Medical Minute 6-20: Undoing Dupuytren's in a Snap

By: Vanessa Welch Email
By: Vanessa Welch Email

When Patrick Bergeron puts his hands to work, he can build almost anything, even an airplane he's got back in the garage.

"I've made a living using my hands my whole life," said Patrick Bergeron.

But for 20 years, there were things his hands couldn't do -- like picking up a jar.

"I couldn't use these two fingers [ring finger and pinky]. I'd have to pick it up with three fingers."

His X-rays tell the story. Patrick had Dupuytren's Contracture -- a build up of collagen that forms thick bands, pulling in the third and fourth fingers on each hand.

Straightening the fingers used to mean invasive surgery and months of rehab. But Doctor Eric George introduced Patrick to a new option.

Day one: Doctor George injects an enzyme called xiaflex at three points to dissolve that tough band in his finger.

"That enzyme over a 25-hour period will basically erode or help to deteriorate this band," said Eric R. George, M.D., Hand Surgeon
Hand Surgical Associates.

24 hours later -- some local anesthetic and a little manipulating to separate the tissue. Then… listen!

One big pop -- and for the first time in 20 years, Patrick's finger is straight.

Now, after having all his fingers straightened, Patrick's got a lot more projects on his list and a lot less to worry about. A handy guy whose hands won't be a problem anymore.

For more information on other series produced by Ivanhoe Broadcast News contact John Cherry at (407) 691-1500,


BACKGROUND: Dupuytren's contracture is a localized formation of scar tissue beneath the skin of the palm of the hand. The scarring accumulates in a tissue (fascia) that normally covers the tendons that pull the fingers to grip. As Dupuytren's contracture progresses, more of the fascia becomes thickened and shortened. Dimpling and puckering of the skin over the area eventually occurs.

SYMPTOMS: Dupuytren's contracture typically progresses slowly over several years. Occasionally, it can develop over weeks or months. In some people, it progresses steadily, and in others, it may start and stop. Dupuytren's contracture usually begins as a thickening of the skin on the palm of the hand. As Dupuytren's contracture progresses, the skin on the palm of the hand may appear puckered or dimpled. A firm lump of tissue may form on the palm. This lump may be sensitive to the touch but usually isn't painful. In later stages of Dupuytren's contracture, cords of tissue form under the skin on the palm and may extend up to the fingers. As these cords tighten, the fingers may be pulled toward the palm, sometimes severely. The ring finger and pinky are most commonly affected, though the middle finger also may be involved. Only rarely are the thumb and index finger affected. Dupuytren's contracture can occur in both hands, though one hand is usually affected more severely than the other.
(SOURCE: Mayo Clinic)

CAUSES: The precise cause of Dupuytren's contracture is not known. However, it is known that it occurs more frequently in patients with diabetes mellitus, seizure disorders (epilepsy), and alcoholism.

REGULAR TREATMENT: If the disease progresses slowly, causes no pain and has little impact on your ability to use your hands for everyday tasks, you may not need treatment. Instead, you may choose to wait and see if Dupuytren's contracture progresses. Treatment involves removing or breaking apart the cords that are pulling the fingers in toward the palm. This can be done in several different ways. The choice of procedure depends on the severity of your symptoms and any other health problems you may have.
(SOURCE: Mayo Clinic)

NEW TREATMENT: The U.S. Food and Drug Administration approved Xiaflex (collagenase clostridium histolyticum) as the first drug to treat Dupuytren's contracture. Xiaflex is a biologic drug made from the protein product of a living organism. It works by breaking down the excessive buildup of collagen in the hand. This enzyme weakens the cord, which then, in a next step, can be pulled and mechanically broken. Bent fingers thus become straight and functional again. One of the early studies proposes enzyme injection as a safe and effective method as an alternative to surgical fasciectomy. The most common adverse reactions in patients treated with Xiaflex were fluid buildup, swelling, bleeding, and pain in the injected area.

Craig Henry, Practice Administrator
Hand Surgical Associates
Metairie, LA


Eric R. George, M.D., a hand surgeon from the Hand Surgical Associates, tells us about a new procedure for correcting Dupuytren's Contracture.

Tell me about the problem that our patient has and what we know about it.

Eric George, M.D.: The condition is referred to a Dupuytren’s Contracture. Dupuytren’s is a condition that we know occurs in people of Northern European decent. The first reporting was Dr. Dupuytren’s stable boy who rode the horses and his fingers were drawn downwards and he thought it was from holding the reins of a horse. People thought that the Popes in the early part of history all had Dupuytren’s Contracture because they came out and waved to the crowds in what ultimately became the sign of the benediction. But we now know that it is a contraction or a thickening of a palmar band that pulls the fingers down in deflection. It occurs in people who are of Northern European decent, Scandinavians, etc.

How do you fix it? Or, how was it fixed in the past?

Eric George, M.D.: In our training, all hand surgeons, the procedure was fairly extensive because in the palmar fascia, or this thickening cord or band in your hand, the cord would spiral around the nerve, and it was a very challenging surgery. We required usually an hour and a half to two hours, depending how extensive. It would require resecting all of this tissue, knowing full well that the condition may very well recur. Post-operatively they were usually put in a big bulky dressing with wound care management for a couple of weeks and then six to ten weeks of therapy for range of motion. The joints became very stiff and it was just a very difficult surgery on the patient and a very difficult procedure.

So, this band is normal and it becomes wider or tougher or what?

Eric George, M.D.: Great question. The palmar fascia we all have is normally very soft and supple, but in patients with Dupuytren’s, no one knows exactly what causes it, but there’s a thickening of that palmar band and it runs a single strand down to the digit and causes the joints to flex, permanently flex. So, you’ll notice that the patients will come and greet you or shake your hand with their fingers contracted. It most commonly occurs in the small and ring fingers.

What’s this new treatment that you did today for Patrick?

Eric George, M.D.: The treatment today is called Xiaflex. It’s a new injectable and it’s an enzymatic solution. It’s an enzyme. And basically, it’s injected in three spots along this cord and that enzyme over a 24-hour period will erode or help to deteriorate this band. The patient returns 24 hours later and we stretch it and pop it and effectively the finger can return back to function.

Can the Dupuytren’s come back after that?

Eric George, M.D.: It’s new so, theoretically, in their clinical trials they have not seen that the banding has recurred. And they believe that it’s because the enzyme is effectively deteriorating the band.

Is this FDA approved now or is it still considered experimental?

Eric George, M.D.: No. It started off in clinical trials and now it is fully FDA approved.

How long does the swelling last?

Eric George, M.D.: When we first inject them, and it’s a pretty painful injection, it stings and it burns because it’s enzymatic and that night the hand is swollen and very tender. You’ll even see some bruising around the area of the hand. Basically, what it’s doing is like Liquid Plumber on your pipe. It’s eroding the tendons. When they return the next day and when we release them they are swollen for about two to three days after that and then we usually make them a little splint to help keep the fingers out and then we start them in range of motion. So, two weeks and they should be back to full speed ahead.

But immediately the finger is straight?

Eric George, M.D.: Absolutely. Some people that are really contracted, you may need two. Single shot; stretch a little more, another shot. But, in most cases, as in Mr. Bergeron and our other patient, we inject them, stretch them and they can come almost fully back to extension.

How long have you been doing this and how amazed were you when you first saw this?

Eric George, M.D.: I’ve been practicing for 20 years and for 19 years we’ve done this surgery. It’s part of our armamentaria of the care of the hand. And when they first introduced it to us, as you would expect, we were very critical. “OK, so you’ve come up with a shot that’s going to make Dupuytren’s go away?” It was like saying, “here’s a shot and you won’t have arthritis anymore.” For us, we want to see it. So, as you would expect we were very critical, very cautious, and it has been remarkable. It really has. And as you can tell from the patients, they are elated. It’s such a simple procedure with such good results.

Are there any other alternatives that have this kind of result that are this easy?

Eric George, M.D.: No. Not in Dupuytren’s care at this point. There is nothing out there. It tells you though that it’s opening the windows for enzyme or enzyme-based drugs to do things in the future for similar problems.

How excited are you to be able to help these patients? I’m sure that when you had to offer them surgery it was very difficult.

Eric George, M.D.: Exactly. It’s very discouraging because you have to tell them that this is going to be three months of your life. This is going to be a very difficult undertaking. There could be a chance of nerve injury; you could rupture your tendons. So, you have to tell them all of those things and they know they are going under a general anesthetic. Now, you say, “Come in and let’s try the shot. It should get you out to a pretty good length.” Talk about smiles on their faces when they leave. Many of these patients for twenty years have had their fingers contracted because they are fearful of the surgery. So, it’s extremely rewarding.

Anything else about Dupuytren’s and this procedure I should know?

Eric George, M.D.: It’s fairly expensive.

Does insurance cover it?

Eric George, M.D.: Yes. It’s a fairly expensive drug. The insurance companies cover it. In order for the insurance company to cover it, you need to dictate. I think it’s only covered for hand surgeons use. You have to describe the degree of contracture and the banding but then they usually authorize it. It takes about a week or two to get the medication in and then we do the injection. But, for the insurance company, it is an expensive drug, but no comparison to an operation, eight to ten weeks of therapy, etc.

How did the idea of formulating the enzymes come about?

Eric George, M.D.: The concept, or the idea of trying to find something that could help alleviate this contracture, started with people trying what’s called needle aponeurotomy, fancy name, but basically, what they were doing was they would put a needle in with a point and just try to cut one of the cords to try to stretch it out. And then some physicians thought, ”Well, what if we could inject something like cortisone to help break up the cord so that we could then stretch it out. And we started thinking, why do we have to go cut all this? The enzymes developed do exactly that except they are specifically directed to that Dupuytren’s type of condition.

Obviously, you can have something that’s too powerful because than you could cut the whole cord and you’ve got a big problem.

Eric George, M.D.: Exactly, or erode through the cord and into the tendon or into the nerve. That’s exactly right. It has to be specific for this type 3 fiber blast is what we call them or for this condition.

I assume we are born with this cord. What happens? Does it get thicker and harder? What if you got rid of it? Would that be detrimental to the hand?

Eric George, M.D.: No, you don’t see the cord until you reach about 25 or 30 and they start with a single palmar pith. It looks like a little pith. What happens is as we age it develops and causes more and more contracture. Some people believe the earlier it shows up the more problematic it’s going to be for you. But the cord is something that you don’t need. It’s an excess of this palmar fascia. So once it’s gone it doesn’t change anything. In fact, it gives them a hand just like patients that don’t have Dupuytren’s.

If you are in the early stage do you wait until it gets really bad?

Eric George, M.D.: Answer is: you want to do it earlier. You don’t want to do it unless there is a little bit of contracture, but if you wait until the fingers are so pulled down even though we release the band, the patient can get stiff joints. Thirty years of having their fingers in a flexed contracture, yes we can break the band, but how do we solve the stiff joints now? So, if you wait to the point where they are so down and so stiff, you may not be able to get the extension you need secondary to the joint contracture.

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