Promising Results with Less Invasive Treatment of Dupuytren's Disease
Dupuytren's disease is a condition where the tissue just under the skin in the palm of your hand becomes thick and shrinks, pulling very tight. In some cases, this causes lumping or unevenness of the palm of the hand and in others, it can cause a significant flexion contracture, making the hand look as if it is permanently holding on to something.
The regularly accepted treatment for Dupuytren's has been surgery. But there is a high recurrence rate (the problem comes back) and there is always the risk of complications from surgery. Researchers are looking for alternate noninvasive ways to treat this problem. In this report, two new treatment options are presented. The first is collagenase injection. The second is a minimally invasive procedure called percutaneous aponeurotomy.
Let's take a look at each one of these treatment techniques separately. First, collagenase injection: collagenase is an enzyme that can be injected directly into the problem area. If you remember the little Pac-men in commercials for laundry detergent or the game Pac-man, you know that enzymes break down substances like dirt. In this case, they are being used to break down the collagen fibers that cause the tendon thickening.
Studies done so far have used up to three injections, 30-days apart. Follow-up has shown that collagenase injections works best for patients who have the most problems at the metacarpophalangeal joints (MCPs). The MCP joints are what we more commonly refer to as the knuckles across the back of the hand. The injections have been used successfully for the proximal interphalangeal (PIP) joints but with less improvement of motion. The PIP joints are the joints in the middle of the fingers.
It looks like collagenase injections work best for mild-to-moderate Dupuytren's disease. More severe cases improve but not by as much. Contractures (joint is stuck and can't move any farther) of 50-degrees or more don't seem to loosen up as much as contractures less than 50-degrees. Fingers that are contracted 40-degrees or less have the best results with more motion and fewer complications.
Uh-oh. There's that word "complication". But don't panic yet -- these potential side effects of the treatment seem to be short-lived. For most patients, they go away within one-to-three weeks. Physicians refer to these adverse effects as self-limiting. The most common problems include swelling of the fingers, bruising at the injection site, swollen glands, and skin itching. Although 85 per cent of the patients tested developed antibodies against the collagenase, these symptoms were not considered allergic responses.
Are collagenase injections going to replace surgery for Dupuytren's disease? Not yet -- short-term results are good but the long-term benefits are still unknown. And if patients end up with a recurrence of the disease, no one knows if having collagenase injections first will affect the success of surgery later. More studies are needed before we have some answers to these kinds of questions.
Now, what about that second potential treatment of percutaneous aponeurotomy? What is that and how well does it work? Percutaneous means the procedure is performed through the skin without an open incision. After numbing the skin, the surgeon passes a small needle through the skin to the tight cords and makes several cuts. Cuts are made until the finger can be moved by the surgeon through its full range-of-motion.
Just like with the collagenase injection treatment, percutaneous aponeurotomy seems to work best on the metacarpophalangeal joints (MCPs). When these joints are affected, it's possible to get 100 per cent improvement. Likewise, patients with milder disease (smaller contractures) have the best results.
Anytime a surgeon is cutting through tissue, it's possible to develop nerve damage or even rupture of the tendon. Fortunately, these complications are rare. The most common complications reported with percutaneous aponeurotomy are skin fissures and numbness of the finger. Both of these problems are also self-limiting and go away in time.
The biggest disappointment with percutaneous aponeurotomy is the high recurrence rate (65 per cent). Open surgery has a lower recurrence rate but the percutaneous method may still be preferred when the patient is older, less active, or has small contractures that don't require open surgery.
Studies comparing these two new treatment options for Dupuytren's disease were not reported by these authors. The promising results of these two less invasive procedures will ensure that future studies will be done. Long-term follow-up for patients already enrolled in current studies will also be pursued. Having safe and effective (and less invasive) surgical procedures for Dupuytren's disease could speed up recovery and eliminate the need for a formal rehab program.
Ramesh C. Srinivasan, MD, et al. New Treatment Options for Dupuytren's Surgery: Collagenase and Percutaneous Aponeurotomy. In The Journal of Hand Surgery. August 2010. Vol. 35-A. No. 8. Pp. 1362-1363.