Dupuytren’s Disease and Collagenase Injections
Dupuytren’s disease is a common condition in which firm nodules appear beneath the skin of the palm or fingers. Nodules often extend to form cords which can prevent the finger straightening completely. Disease essentially affects a thin fascia which which lies between skin and tendons and exists in every hand. Thickening of this fascia usually starts innocuously and may remain dormant for many years. In some cases, it does never involve fingers. In others, fingers start to bend first, yet the palm is spared (Pictures 1 and 2). Exact course of the disease is impossible to predict. The little and ring fingers are most commonly involved. Disease is often bilateral (affects both hands).
Cause / Risk Factors
There is no single known cause although there are a number of risk factors associated with developing Dupuytren’s disease. These include: genetic predisposition (disease is more common in patients with positive family history), diabetes, epilepsy and/or its treatment, previous hand trauma including surgery and occasionally a liver disease. Dupuytren’s disease does not appear to be associated with manual work.
There is no cure, but fortunately, disease often does not require medical input anyway. Surgery can straighten bent fingers, but it cannot eradicate the disease. Over the longer term, Dupuytren’s disease may reappear in operated digits or in previously uninvolved areas of the hand. People with heavy ‘genetic burden’ are more prone to recurrent disease. Nevertheless, most patients who require surgery and are treated by a person with significant expertise, can expect to benefit from operative improvement for a long time and to require minimal number of interventions.
Occasionally night splinting by a therapist will allow fingers to straighten. However, these are not well-tolerated in the long term. Despite a considerable research worldwide over the last decades, there have been no helpful scientific solutions to the early stages or a useful drug treatment for this condition. Various injections and splintage protocols have proven ineffective. In a very small, selected group of patients, the contracting band may be cut in the palm (fasciotomy) in order to partially straighten the finger. However, this has a very high incidence of recurrence and remains only of a limited clinical value. Once the condition become progressive and contractures have developed, the most predictable treatment is surgery. Without treatment, the fingers get progressively more bent. The speed of such change remains unpredictable.
After many years of research and essential trails on safety and efficacy, a novel enzyme, Clostridium Histiolyticum Collagenase was approved for use in the UK in 2011 for treatment of Dupuytren’s disease.
In hands with early, limited disease (Picture 1) non-surgical management with injection of collagenase enzyme might be a simpler and quicker procedure. Collagenase treatment is done in the clinic, but requires two visits: the first, when injection is administered directly into abnormal cord (Picture 3) and the second one, 24 -48 hours later, when treated finger is gently stretched under local anaesthesia until abnormal cord ruptures and finger is straightened. Within 24-48 hours between two interventions, collagenase enzymatically weakens and breaks down disease tissue. In a very small proportion of cases, more than one injection may be required to straighten the finger adequately.
The most common side effects seen with Xiapex injections are swelling, bruising (Picture 4), bleeding, pain, allergic reaction and small skin tears. These effects resolve within few days and rarely pose problems.
Early results and high patient satisfaction rates suggest that injections are becoming an attractive alternative to surgery in selected group of patients. Personally, I prefer to offer it to patients with disease mainly located in the palm (rather then the digit), when simple, superficial cords are palpable and visible. I do not offer this treatment to patients treated surgically before or with advanced disease as anatomy might not be predictable enough for safe injection. It should be noted that injection is effective in a small area of abnormality and therefore, expectations on its benefits should be reasonable. Extensive disease should be treated with meticulous and pedantic surgery, not just quick outpatient intervention for the sake of convenience, if good long term results are to be obtained. Naturally, each patient should be assessed on its own merits and collagenase injections considered as a new, valid treatment option.
Indications for Operation
Surgery remains a mainstream treatment option for majority of patients. However, indications are clear.
Whilst the fingers are not bent, the palm can be placed flat onto a table, and/or lumps under the skin are not painful, no intervention is required. At this stage operating to remove abnormal tissue might only stimulate abnormal cells of Dupuytren’s disease and trigger worsening. Since there is no loss of hand function, it should be left alone and patient should not be exposed to risks of surgery.
Opinions differ somewhat, but in general, most surgeons would agree that operation in indicated once a finger(s) fail to go flat on the table and/or when nodules in the palm are painful enough that gripping is affected unfavourably. If bent finger is left untreated for too long, correction becomes more difficult as anatomy of finger joint becomes permanently affected and joints become stiff. In advanced, long standing cases, even successful and radical surgical removal of Dupuytren’s tissue which triggered the deformity, may fail to correct joint contracture and straighten the finger fully.
Dupuytren’s disease can, occasionally recur. If it does so, it can be re-operated with a more complex type of operation which involves use of a skin graft in order to overcome skin shortening and provide long term benefit.
The surgery is usually carried out as a day care procedure and takes between 60 and 90 minutes, depending on the extent of the disease. Operation can be done under either general or regional (upper limb only) anaesthesia. A tourniquet (a blood pressure like cuff around the upper arm) is used during operation; it prevents blood from obscuring the surgeons view in the hand during surgery. If the whole arm is not anesthetised, this tourniquet can be painful after 15-20 minutes and this is the main reason why the surgery for the Dupuytren’s disease is not carried out under the local anaesthesia in vast majority of cases.
The surgery is performed through the straight or zigzag incision in the palm and/or along the finger. The tissues are resected with a great care not to injure nerves and blood vessels to the finger running in direct proximity to diseased tissue. Once all abnormal tissue is removed and joint is straightened (with or without additional intervention on joint ligaments itself), wound is closed. This can be done with absorbable or non-dissolvable sutures. Each method has its advantages, so I discuss this with the patient in advance taking into account individual circumstances and preferences.
If significant contracture has been overcome surgically, there is often a shortage of skin at the operated site (a proof that surgery was truly indicated !). In such circumstances, a skin graft may be required to cover the wound completely (operation know as dermofasciectomy). This is particularly case in advanced, extensive and recurrent diseases. The skin is taken from the inner forearm, through a small, additional incision close to the elbow crease (my preferred site). Wound is closed neatly, so that subsequent scar is rarely of any cosmetic concern, often hardly visible. The tourniquet is then released and any bleeding controlled. Local anaesthetic is infiltrated into the skin. A bulky dressing is applied with a Plaster of Paris slab for immobilization. Cast prevents finger re-curling inwards in an immediate postoperative period as is worn between 3-6 weeks postoperatively.
Although operations which require use of skin grafts are more complex and technically demanding, patients usually do very well for a long time after surgery. Improvements are often dramatic and greatly appreciated by people who often find a great relief to have straight finger again! Many patients seek an operation on the contralateral hand very soon after marked improvements obtained with the first operation (Picture 5). Published evidence suggests that grafting is associated with excellent long term results, often better then any other type of surgery for Dupuytren’s disease. This is due to the fact that the skin graft literally acts as a barrier and prevents formation of recurrent disease.
Please be aware that it is not always possible to guarantee complete straightening of the finger by surgery. This particularly applies to the middle joint of the finger (proximal inter-phalangeal joint) which is prone to contractures of the ligaments around the joint if it has been bent for a long time.
Recovery and Rehabilitation
You can expect to go home soon after the operation. The anaesthetic wears off after approximately 6 hours. Simple analgesia usually controls the pain, but in many cases, no painkillers are required postoperatively at all. The hand should be elevated as much as possible for the first 5 days to prevent the hand and fingers swelling. After surgery you can begin to practice finger exercises straight away, once out of the cast. Your wounds may show some blood staining for the first 24 hours, This is quite normal and nothing to worry about. There may be some bruising which usually clears within two weeks.
You are likely to be reviewed by the hand therapist first, within the first 4-7 days after surgery. At that time, physiotherapist will remove original cast and bandage, check the wound, clean it and reapply lighter dressings. He/she will also make a custom made (light weight) splint which will be much easier to manage at home for the next few weeks. It is usually secured by Velcro straps and is easy to put on and remove at home. Finger straightening with a cast is required for 4-6 weeks, depending on preoperative deformity, but you will be encouraged to mobilise fingers as much as possible in the meantime, to prevent stiffness and contractures.
You need to take it easy and get plenty of rest when you get home for the first 2-3 days. You can start to do your usual activities, as you feel comfortable and are able to do so unless I advise you that postoperative plan indicates otherwise. When you return to work will depend on the work you do. Most patients return to work within two weeks, but if your job involves physical activity of lifting it may be longer. Taking part in any strenuous activities and return to sport should be avoided for at least 4-6 weeks.
The goal of physiotherapy is to restore full motion, strength, and function. The rehab program will be geared towards your needs at home, work, and play. Please note that postoperative physiotherapy and compliance with its requirements is as important as surgery itself. Allowing tissues to heal and mend, manage inevitable postoperative swelling and stiffness, stretch, yet not disrupt the scar is an art in itself and will require a lot of your patience. If conduced properly, it will in return, leave you with improved hand outcome and will prove worth focusing on for a short period of time.
For two days following a general anaesthetic you should not: drive a car or ride a motorbike, do not attempt to drive until you are in complete control of your hand. If you are unsure at all you should discuss this with me. It is also advisable to check with your car insurance company, as some policies state that you must not drive for a specified period of time after an operation.:
It always helps to plan things in advance of surgery and adjust work and life activities accordingly. Therefore, please consider the following issues prior to your operation:
- Anticoagulation medication (Aspirin, Brufen, Warfarin, Clopidrogel) should ideally be stopped few days before the operation to reduce the risk of bleeding, but advise from the clinician who prescribed them is wise beforehand. I would strongly advise you to stop smoking prior to surgery as this can badly affect the outcome of surgery and increase complication rates.
- Please make sure that you arrange to be collected from the hospital as you will not be able to drive after the surgery.
- Plan your time off school / work / sports.
- Allow at least few weeks after surgery before considering a holiday.
Risks and side effects of surgery
Complications are rare, but as with any surgical procedure, there are general and carpal tunnel release -specific risks which patients should be aware of:
- Adverse reaction to general anaesthetic
- Skin/wound infection (less then 1%)
- Lumpy scars
- Reflex Sympathetic Dystrophy – RSD (up to 2% – a bad reaction to surgery with painful and stiff hands – this can occur with any hand surgery from a minor procedure to a complex reconstruction)
- Nerve injury resulting in either; Numbness or Neuroma (painful nerve lump extremely sensitive to touch)?, Temporary loss of sensation along the operated finger is inevitable
- Artery damage resulting in devascularisation of the finger which might require immediate microsurgical repair). This is particularly the case in repeated surgery with a lot of scar tissue
- Recurrence is part of the normal disease process, depending on age of onset, family history, alcohol intake and other factors, so it is not really a complication of the surgery as such. The disease will always recur, however, most patients have a long lasting result that they are happy with
- Hypertrophic scarring (especially in the forearm where skin graft has been harvested from)
- Graft loss (with delayed wound healing)
Things to look out for
- Disproportionate swelling and pain in your hand
- Signs of infection in vicinity of the operated area i.e. hand/wrist are very hot, prominent redness, pain, swelling, puss collection
- Grazing of the skin (and possibly fluid leaking/oozing from the wounds)
- Increased temperature in the area
- Strange smells coming from the wounds.
If you notice any of above symptoms in the first few days, feel free to contact the team on numbers below.
This leaflet provides only basic and generic information, but full details and explanations are provided at the consultation as no two patients are the same and each person’s circumstances are highly individual.
If you have any concerns following your surgery please contact:
Ashtead 01372 221 442; St Anthony’s 020 8337 6691; Parkside 020 8971 8000
|Hospital stay||Day care|
|Anaesthetic||General or Regional (the whole arm is numbed)|
|Surgery time||60-90 minutes|
|Wound healing||2 weeks|
|Hand therapy||between 4-8 weeks depending on severity|
|Washing||from week 2|
|Time off work||2-3 weeks for office based work; 6-8 weeks for manual work|
|Sports and exercise||from week 2|
|Driving||from week 1 please check details with your insurance company|
|Full recovery||4-6 weeks|
Picture 1: Early / mild disease
Picture 2: Advanced disease
Picture 3: Collagenase injection
Picture 4: Bruising/swelling 24h after collagenase injection
Picture 5: The improvement that can be achieved: right little finger operated 3 months ago; awating surgery for the left ring finger