New Drug Treatment for Dupuytrens Disease May Replace Surgery
Almost 400 years have passed by since Dupuytrens disease of the hand was first described by a Swiss physician. Since that time, surgery has been the only successful treatment. That may all change with the recent FDA approval of Xiaflex, an injectable drug designed to weaken the diseased tissue.
Dupuytrens disease is a fairly common disorder of the fingers. It most often affects the ring or little finger, sometimes both, and often in both hands. Although the exact cause is unknown, it occurs most often in middle-aged, white men and is genetic in nature, meaning it runs in families.
The palm side of the hand is affected. This is where a type of connective tissue, called fascia that surrounds and separates the tendons and muscles of the hand is involved. Just under the palm is the palmar fascia, a thin sheet of connective tissue shaped somewhat like a triangle.
This fascia covers the tendons of the palm of the hand and holds them in place. It also prevents the fingers from bending too far backward when pressure is placed against them. The fascia separates into thin bands of tissue at the fingers.
These bands continue into the fingers where they wrap around the joints and bones. Dupuytrens disease causes tightening called contracture. When the palmar fascia tightens, the fingers curl into a bent position and stay there.
The condition commonly first shows up as a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger. More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened. Dupuytrens contractures usually only affect the ring and little finger.
Heating and manually stretching the tight tissues doesn't solve the problem. Cutting the hand open and releasing the tight cords has been the only effective treatment. Now, according to this report, there is a nonsurgical approach to this problem.
By injecting an enzyme directly into the cords formed by the disease, the tissue dissolves and starts to weaken. Then the surgeon can manually pull the fingers straight and rupture the cord. That sounds dramatic -- it's not! The treatment is safe and effective.
There are a few possible (minor) side effects but very few major or long-term complications with this new treatment. During the control trials conducted with patients, most people had a local skin reaction (redness, skin tears, itching or stinging) where the injection went into the skin. A small number of more serious problems developed in a few patients including tendon rupture, finger deformity, and hives that had to be treated with medication.
Treatment of this type (called enzymatic fasciotomy) may eventually replace surgery. But further study is needed to assess the long-term effects, especially recurrence rates. Until then, surgical release of the cords will likely remain the gold standard.
The criteria for when to have surgery are joint contractures of 30 degrees or more, significant impaired function, and/or disease that is getting worse over time. There are several different surgical procedures possible. Each one has the same purpose -- to release the cording and restore joint and finger motion.
The least invasive approach is called needle aponeurotomy. Under local anesthesia, the surgeon inserts a very thin needle under the skin. The sharp needle cuts a path through the cord, weakening it enough to stretch and extend or rupture it.
The advantage of this procedure is that it can be done on older adults who have other health issues that might make surgery under general anesthesia too risky. The disadvantage is a high recurrence rate and the potential for nerve injury, infection, and hematoma (pocket of blood) formation.
Future studies will be needed to compare final results for different treatments. Conservative care with Xiaflex (or other similar) injections must be compared to surgical treatment. The various surgical approaches should all be included as well.
For now, just developing a collagen enzyme injection and getting it on the market is a big step in moving from a surgical to nonsurgical approach to Dupuytrens disease. Cost considerations among the different treatment options will have to be considered along with the long-term effects and recurrence rates.
Shaunak S. Desai, MD, and Vincent R. Hentz, MD. The Treatment of Dupuytren Disease. In The Journal of Hand Surgery. May 2011. Vol. 36A. No. 5. Pp. 936-942.
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