Dupytren's Contracture of the Hand

Dr. Randale Sechrest: Hello. I am Dr. Randale Sechrest, your host for eOrthopodTV. This morning we will be talking remotely with Dr. Walter Short. Dr. Short is an orthopedic hand surgeon who practices at the Syracuse Hand and Wrist Center in Syracuse, New York. Dr. Short completed his Orthopaedic training at SUNY Health Sciences Center. For many years he served as a professor of orthopedic hand surgery at SUNY Health Sciences Center. Good morning Dr. Short.

Dr, Short. Good morning.

Dr. Randale Sechrest: Dr. Short I thought what we would discuss is a condition called Dupuytren's contracture. This is a problem that occurs in a certain segment of the population. Mostly folks of I think northern European descent. But anyway, lets talk a little bit about that condition, how that condition occurs, and what patients might experience from that condition.

Dr, Short. Dupuytren's contracture is a condition most common in men of Northern European descent. It usually starts in middle age. And, as I said it's more common in men than in women. And what people first notice about Dupuytren's contracture is that they notice thick nodules in the palm if their hand. And as time goes on, over the course of many months, or many years , these nodules start to form together to form cords in their palm which extend into their fingers. Most commonly the ring and little finger. Initially to the patient they look like they are tendons which are sticking out of their skin or bulging the skin. As time goes on, as these cords start to get thicker, they start to pull the fingers down
and the patient notices that he can't extend his fingers or straighten out his fingers, which make it difficult for him to put his hands in his pockets, put gloves on, wash his face, do a lot of daily activities which everybody else takes for granted.

Dr. Randale Sechrest: Do we have any idea as to what causes these nodules? What's the actual problem in the hand resulting in the contractures?

Dr, Short. Theory which seems to be, makes the most common sense, is that the people that develop Dupuytren's contracture have a predisposition to form a different kind of collagen. And collagen is the material that makes up tendons, ligaments, and this specialized tissue in the palm which makes the palm very durable. And this type of collagen in these people that develop Dupuytren's has the unusual property of being able to contract or get smaller.

Dr. Randale Sechrest: Now we talked about how this disease tends to have some sort of genetic predisposition, is this the sort of thing where if your father had this disease, then you are likely to have it? Are you absolutely going to have it, or how does a patient rate their risk if they are from northern European descent, and they have family member that may have Dupuytren's contracture.

Dr, Short. If you have a family history of Dupuytren's contracture, you are more likely to develop Dupuytren's contracture. But it is certainly, definitely not guaranteed that you will have Dupuytren's contracture. But, certainly more than half the people that I see in my practice, who are of northern European descent, if you ask them to go back and talk to their family, they can remember a grandfather or great grandfather that had ah, ah, ah, fingers that were bent or they described the fingers as being bent at an elderly age.

Dr. Randale Sechrest: Now, other than just having the contractures and the problems with using the hand because of the contractures, does this condition cause any pain? I mean is it a painful sort of thing that causes other symptoms?

Dr, Short. Ah, it's not noted to be painful at all. Its ah, just a problem associated with your ability to not being able to extend your fingers and the difficulties associated with that. So when you are trying to put on gloves, as I said, or put your fingers in a narrow spot, the fingers that are involved in Dupuytren's just don't bend the appropriate way.

Dr. Randale Sechrest: Now, how extensive can this get? I mean can this involve the whole hand, does it involve both hands? What's the general presentation that you see as an orthopaedic surgeon in these patients?

Dr, Short. I usually see it, ah, they usually present to me either in two groups. They notice little nodules in their palms and they are concerned that this is something other than a nodule. It may be that they are concerned about tumors. Cancer, and that's usually in it's very earliest stage. And in that stage when it doesn't affect the mobility of the fingers, no treatment is necessary. The next group of patients, those patients are those patients that develop the Dupuytren's and have then gone on to develop contractures of their fingers, such that they can't straighten out their fingers. Those people are bothered, especially in the climate around Syracuse they can't really put gloves on and so their fingers start to become cold because they can't protect their fingers in the cold weather. They can't put their hands in their pockets, those types of activities usually bring them to their family physician and then they are referred to a hand specialist.

Dr. Randale Sechrest: Well, as a hand specialist, how do you evaluate a patient with Dupuytren's contracture? Is this something that is pretty obvious when you see the patient? Is there anything special that you need to do in terms of either X-rays, imaging of some sort, or any type of lab test that are needed?

Dr, Short. To a trained professional, Dupuytren's contracture is relatively obvious, because we see it very commonly in our practice. To other specialists who see it rarely, they may have a somewhat of a relatively more difficult time because it's not as common in their clinical practice. There's no blood tests that need to be done, there is really no genetic counseling at the present time that I am aware of, that is necessary. If a patient comes that has severe contraction of the fingers, where the fingers are bent way down, and you are contemplating treatment, I'd get X rays. And the reason to get X rays is to make sure that there is no deformity of the bones or the joints secondary to the long-term contractures, which may have deformed the joints, and therefore not allow relatively normal motion after you have treated the Dupuytren's contracture. So, if the contracture is severe, then I do get X rays, but other than that there is no blood tests, or other tests that really need to be done.

Dr. Randale Sechrest: Well, lets talk a little bit about treatment. When you sit down with a patient that has Dupuytren's contracture, what sort of discussion are you having with that patient in terms of what you are going to propose to them? You mention that in some cases the patient may not need surgery, may not need treatment, may not need anything right now. Do you anticipate that the condition is going to progress to the point to where you do need to consider treatment? How do you have that discussion with the patient?

Dr, Short. When I see the patient I evaluate the hand, I take a history to see if there's other family members that may have Dupuytren's contracture. And then I counsel the patient, I tell then, after I evaluate their hand, and if they have no contracture, I tell them just to watch these nodules and these cords or bands. And there is a test called a “table top” test and I ask them on a relatively regular interval to put their hand flat on a table and if they can see sunlight between their hand and the table, then I'd tell them that is the time to start to consider treatment for the condition. And when there is sunlight underneath the palm of your hand that means that there's a contracture, and the fingers are bent to the point where it might be worthwhile to consider treatment for the Dupuytren's contracture. If a patient comes and has contractures already, I measure the severity of the contracture. I also determine what a which fingers are involved. It is known that if the contracture involves the knuckle, the metacarpophalangeal joint, that is usually somewhat easier to treat and has a better result than if it involves the joint following the metacarpophalangeal joint, or the proximal intraphalangeal joint. If that joint is involved, then I encourage the patient to treat that a little more aggressively. Because if the finger is left bent at that position then they would have less than normal motion.

Dr. Randale Sechrest: You know I think there are a lot of patients that are going to wonder if there is anything that can slow down this process that they can do - something like physical therapy or braces or anything that can be used as a prevention. Are you aware of anything that can effect the natural progression of the disease?

Dr, Short. I know of a lot of patients that try braces and try stretching, but to my knowledge and the literature seems to support the fact that bracing and stretching really don't effect the long-term natural history of this condition.

Dr. Randale Sechrest: Well, we talked a little bit about treatment in terms of general philosophy, let's move on and talk a bit about specifics in terms of treatment. When you've decided that a patient is actually needing something active done, what options do they have?

Dr, Short. There are actually two, well actually there are three options. One is surgery, where an incision is made in the skin, and this band of tissue is surgically removed. The second option is what they call a needle aponeurectomy, which is a medical term where basically a hypodermic needle is placed through the skin and the sharp edge of the needle is used to cut or break apart the cord or the band of Dupuytren's contracture. And, recently, over the past approximately 9 months to a year, medication has become available, which has been in development for approximately ten years, which dissolves portions of this cord and breaks apart the cord so that normal motion is restored.

Dr. Randale Sechrest: Well, lets discuss how you make the decision whether a patient is better off having either full-blown surgery to remove the cord versus when you decide to do either the mechanical release, I believe you termed that aponeurectomy?

Dr, Short. Correct.

Dr. Randale Sechrest: Or whether they may be a candidate for the new treatment with the medication – How do you make that decision?

Dr, Short. I make the decision based on the severity of the contracture. If people come to me and the metacarpophalangeal joint is only contracted, and they have an isolated cord to one or two fingers, then I feel that they would be a candidate for the injection of the medications which dissolves the band of tissue. This medication is a chemical which basically dissolves or weakens the band or cord in the hand. Another option when it's at this relatively earlier stage is the needle aponeurectomy. And of those two, my preference at the present time, is to inject the medication, which in my experience has given a somewhat a better result. As the disease progresses and they have contractures which approach a degree where the joint is at a right angle, then I feel that surgery is probably a better option because not only is the cord involved, you need to cut the cord and remove the cord, but you also have to release the contracture around the joint because the joint has been bent at such a severe angle for such a long time that ligaments and the tissues which support the joint are also contracted and they need surgical attention also.

Dr. Randale Sechrest: Well, it sound like that patients would be better off treating this earlier rather than later. I'm assuming that what we just discussed is that this condition progresses at a slow rate and you don't just all of a sudden wake up with your fingers flexed at 90 degrees. So, am I correct in assuming that patients should be a little more aggressive in looking at some of these less aggressive techniques earlier on in the disease process rather than just letting this go and trying to ignore it?

Dr, Short. Absolutely. The earlier, the treatment is sort of to observe the condition until that point where the fingers just start to contract, and where they can't put their hand flat on the table. Once they can't put their hand flat on the table, that's the time when it's the easiest to treat non-surgically, either with the medication, which is injected into the cord or the use of the needle which breaks apart the cord – and that requires no surgery. It requires much less treatment after the injection, and the patient has to spend a lot less time involved in post operative, or post treatment care of their hand.

Dr. Randale Sechrest: Now, in these two treatments, the aponeurectomy and the medication that is injected, are these procedures done in the office? Is there anything special that has to be done? Or do they have to be done in an operating room or a surgery center?

Dr, Short. No, my preference is the medication, which is ordered from the company. And what is done is the medication, which is called Xiaflex, is reconstituted, and then it is injected into the cord at the level of the joint. Afterward, the patient starts using his hand and trying to stretch the finger out so it becomes straight. In cases where the contracture is mild, the patient usually can break up the cord all by himself. I have made it a point to see the patient 24 hours after the injection, and if the cord is not broken apart, or he still has a contracture, then I numb the finger up with Novocaine or Xylocaine and then stretch the finger under some local anesthetic. Which in the vast majority of cases breaks apart the cord and the patient then has full motion of the finger.

Dr. Randale Sechrest: What about treatment in any of these techniques in terms of progression of the disease? I am assuming all of these techniques treat the contracture. Does the contracture, or the disease process continue after treatment? Does this recur?

Dr, Short. Ah, by removing the tissue or breaking apart the tissue, you haven't cured the disease process. The tissue that forms these bands continues on. And yes, there can be recurrence. The fact in a patient's favor is that it progresses so slowly that it may be years before this has to be done again. So, surgery, or the injection, or the needle, is not a cure but it restores the function of the hand and it may be years before this starts to contract again. So, it may need to be repeated again, but usually not for many years.

Dr. Randale Sechrest: Lets talk a little bit about the surgical treatment of the disease. I mean it obviously sounds like if you can get to this disease process early and you are able to do the injection, or possibly do the release that you talked about, that you may be able to avoid major surgery. In the cases where you do surgery, however, can you talk a little about how extensive that procedure is and what you're concerned with as a surgeon when you go in and do that type of surgery?

Dr, Short. If the patient has severe contractures, where the finger is bent to an extreme angle – say 90 degrees or more, then that requires a surgical intervention. That is done in an operating room. Although the patient should be able to go home after the surgical procedure, so it is considered an out-patient
procedure. It is usually done by blocking the arm with a block done by an anesthesiologist or general anesthesia. In many cases a zigzag incision is made over the cord of the Dupuytren's contracture. In these cases where the patient has ignored the problem for several years, multiple fingers may be involved. So, an incision has to be made essentially over each contracted cord that goes to each finger. And then there has to be meticulous dissection of the Dupuytren's cord to distinguish it from relatively normal tissue. To the untrained eye, the diseased tissue almost looks almost identical to the normal tissue. In addition, because the cord has become so contracted, the anatomy of the blood vessels and the nerves have become distorted and the nerves and the blood vessels can become entwined with this Dupuytren's tissue, so it becomes a long and relatively involved process to separate the cord from the blood vessels and the nerve. To separate the two so that the Dupuytren's tissue can be excised and not damage the nerve and the blood vessel. After the cord or the Dupuytren's tissue is removed, if the patient has ignored the problem for a long time, the joint capsule or the ligaments of the joint may be stiffened or contracted and therefore the surgeon may need to cut or release this tissue in order to allow the finger to straighten up normally. A third problem is that if the finger has been bent for a very long time, the tendon which straightens out the finger may have become stretched out or elongated . In that case they would need to do physical therapy. They need to be very vigorous in their attempts to move the finger following the surgery. So, after all of the tissue is removed, the blood vessels and the nerves are protected, and make sure that they aren't damaged during the surgery. Afterward the patient is then, usually sent to physical therapy to start moving the hand and making sure that they regain relatively normal motion of the finger.

Dr. Randale Sechrest: Lets talk about something that surgeons don't like to think about, and that's what might go wrong? Can you give me an idea what the complications are?

Dr, Short: As far as the surgery goes, the complications can be several. One is that the surgeon can inadvertently cut a small nerve that gives you feeling at the tip of the finger. And that is due to the fact that the nerve may spiral around this cord of Dupuytren's, and it is very difficult to distinguish one from the other in some circumstances. Another problem is that once you make all of these incisions in the skin, you may develop what they call a hematoma, which is a collection of blood underneath the skin flaps, which can drain or result in an infection. The skin flaps can die because of the multiple areas of skin that have to be moved while you cut out this Dupuytren's band. So there can be loss of skin. And, in addition, if the contracture is left for a long period of time by the patient, it is more than likely that he may not get full motion as an end result. Following the surgery, there is a recurrence rate, and the recurrence rate can vary from 10% to 70 or 80% depending upon the severity of the contracture and how long you wait after the surgery to determine if there is a recurrence rate.

Dr. Randale Sechrest: What about the other two procedures, the needle procedure and the medication injection? Are you worried about complications with either of these two procedures?

Dr, Short: I worry about complications after any procedure. And the complications that have been reported after the Xiaflex injection are - in rare cases, you can inject it into a spot where there's not a cord and you may damage the tendon which moves the finger. You may damage a nerve or blood vessel if it is not injected directly into the cord. The procedure where you use a needle to cut or break apart the cord, can in some cases, damage a nerve or a blood vessel. And in both those cases there is some instances where the cord is not completely broken apart, and the patient regains full extension. So there is a failure rate of removing the cord in those two cases.

Dr. Randale Sechrest: Well, this has been an excellent comprehensive discussion of Dupuytren's contracture. Is anything else that you feel like patients should know that we have not discussed up to this point?

Dr, Short. I think people have to realize that it is a condition which needs treatment, not initially when
the little nodules are noted, but it is a condition which is easily treated once they start to develop a slight contracture of their finger. And if they choose to ignore it, the problem gets worse and worse and the treatment involves more time on the patient's part, and the results are less likely to be satisfactory to the patient the longer he ignores the problem.

Dr. Randale Sechrest: Well I think that's excellent advice, Dr. Short and I want to thank you for an excellent discussion and some great information about Dupuytren's contracture So, thank you for joining us today.

Dr, Short. Thank you.