As some new treatments have offered a less-invasive way to manage Dupuytren’s contracture, there are some healthcare providers who now recommend early treatment. With collagenase injections and needle aponeurotomy, repeat treatment is not as much of a concern. Therefore, early treatment when the condition is less severe is becoming popular. And, by not waiting, the likelihood of fully correcting contractures is much better which, in turn, makes waiting on treatment much less popular.
Cortisone injections are occasionally used to inject the nodular type of Dupuytren’s (not the cords) and it can help to shrink down nodules. The downside is that these nodules typically return over time to their pre-injection size, so this treatment is rarely performed. In addition, there are possible side-effects of cortisone shots that may cause problems for some people.
Stretching and splinting are sometimes used after treatment to increase joint mobility and prevent recurrence of the contracture. But, this is really only effective as a post-surgical or post-release treatment. At that time, stretching and splinting may commonly be recommended. Stretching as a treatment used on its own is generally not helpful.
Collagenase injections, sold under the trade name of Xiaflex, has become popular as it is relatively simple to perform and therefore many types of healthcare providers now offer it. The procedure can be done entirely within a healthcare provider’s office, although it does require the person being injected to return between one to three days.
The downside is that collagenase has fairly specific indications, meaning that it is not a useful treatment for everyone with Dupuytren’s. Some healthcare providers feel they can help patients more with a needle aponeurotomy or surgery, which are generally more versatile procedures. In addition, there is a high cost of collagenase and many insurance plans will not cover the medication.
The proponents of this procedure tout several benefits:
It is very safe. Complications can occur, but serious complications are unusual. It is inexpensive. Compared to other treatments, needle aponeurotomy generally costs much less than collagenase or surgery. It is easy. This is comparative, meaning that it may not be simple for everyone, but it can usually be performed in less than an hour and follow-up is seldom necessary.
There are possible downsides to needle aponeurotomy. Not everyone has a type of Dupuytren’s that will be effectively treated with the needle procedure. Furthermore, recurrence of the condition can be common. And while repeating the procedure is generally not a problem, the recurrence tends to occur more quickly after the needle procedure compared to surgical treatment.
The advantage of surgical treatment is that, even in the most advanced stages of Dupuytren’s, there is usually something that can be done from a surgical standpoint. More extensive Dupuytren’s may require a more extensive surgery, but it almost always can be addressed through an incision.
In addition, while all of these procedures address the contracted tissue of Dupuytren’s, none of them cure the underlying condition called Dupuytren’s disease. Therefore, recurrence of the contracture is always a possibility, no matter what treatment is performed.
The major downside of surgery is that the recovery from the procedure can involve discomfort and can be prolonged. People may have bandages on for weeks and splints for months. There is often physical therapy involved in the treatment. Compared to the collagenase or needle procedure, the recovery from surgery is much more involved. The trade-off is that your surgeon may be able to address more surgically than through those less invasive options.
Someday, we expect that we will be able to offer a medication to people with Dupuytren’s to prevent progression or recurrence of the contractures. However, until that time, we are stuck with treatments for the symptoms of Dupuytren’s disease only. For that reason, Dupuytren’s can, and almost always will, eventually come back. In those cases, further treatment can be considered.
Repeat surgery can be tricky and definitely not as straightforward as initial surgery for Dupuytren’s. Because of scar tissue formation, the normal anatomy and tissue planes within the hand become distorted, making revision (repeat) surgery much more prone to complication. In fact, some studies have shown a complication rate up to 10 times higher in revision surgery situations.
A salvage procedure is a treatment that is not used to fix a problem, but rather to make the situation as tolerable as possible. Some of the salvage procedures rarely performed in the treatment of Dupuytren’s contracture include:
Joint fusion: A joint fusion is a surgery to permanently set a joint in a position and have bone grow across it so that it will never bend again. When the joint is fused, it will no longer contract, even if the Dupuytren’s progresses. External fixation: An external fixator is a device attached to the bone that can stretch soft-tissues around the joint over long time periods. In people with very contracted tissues, stretching for weeks or months may help. Amputation: Amputation of a finger is rarely performed in Dupuytren’s, but it can be helpful in the most challenging situations. Particularly in small fingers—and in people with significant limitations in the functions of the hand—removal of a digit can be helpful in some rare situations.
Again, salvage treatments are reserved for the most severe situations that have typically failed more traditional treatments. However, there are possible steps to take in these difficult circumstances.
