Cambridge Plastic Surgery

Plastic and reconstructive surgery, hand surgery and aesthetic surgery


Dupuytren’s Disease

Dupuytren’s disease is a benign progressive thickening of the soft tissues below the skin of the hand. Dupuytren’s disease can also less commonly affect the feet and very occasionally in some male patients the penis.

Dupuytren’s disease most commonly presents as hard nodule in the palm, associated with cords, which radiate out towards the fingers and across the first web-space to the thumb. Dupuytren’s disease can also vertically pull on the palm skin creating pits.

Treatment

Most patients will consider intervention when the disease causes a finger to become bent to a degree that impinges upon their ability to use their hands. The threshold for considering intervention varies from one individual to another, and depends upon the patient’s own expectations and circumstances.

The most appropriate treatment is dependent upon the severity of the disease and the patients personal and vocational needs. There are a spectrum of operations, the smallest of which is needle fasciotomy (division of a cord using a needle under local anaesthetic) the largest of which is dermofasciectomy (removal of the diseased fibrotic tissue and replacement of the skin over the base of the finger with a skin graft). Smaller procedures are associated with a shorted down-time, but a more rapid recurrence, bigger procedures are associated with a longer down-time, but a slower rate of recurrence. Patients with a single symptomatic cord are suitable for Xiapex injection.

Patients with proximal inter-phalangeal joint contractures, or patients with significant post-operative stiffness or swelling can benefit from hand therapy after surgery.

Contractures of the proximal phalangeal joint of the finger are more difficult to treat than contractures of the meta-carpo-phalangeal joint, and can require post-operative splinting

Dupuytren's disease

Images from patients treated with Surgery and Xiapex in 2012/2014

Surgery
Before surgery

12 days after surgery

Xiapex™​
Before Xiapex™ injection

6 days after injection

Before Xiapex™ injection

​8 days after injection

Cause

Recent studies looking have implicated abnormalities in at least nine genes in the Wnt-signaling pathway. It is likely that a predisposition to develop Dupuytren’s disease is passed down from one generation to the next. . Most commonly patients request help in their fifties, but some patients (with a particularly aggressive form of the disease) will develop contractures earlier in life.The disease is probably more rapidly progressive in diabetics, but is not commonly associated with any particular profession or activity.

Xiapex™ for Dupuytren’s Disease

Xiapex is an out-patient injection treatment to correct the hand problems caused by Dupuytren’s disease. This treatment was approved for use in the UK after more than a decade of extensive research and clinical trials. Xiapex is not currently available within the NHS to patients from Cambridgshire and Peterborough.

The drug is injected into Dupuytren’s tissue, and slowly breaks down the large protein fibres responsible for the disease. Patients return to the clinic two days later in-order to have the finger stretched into a flatter posture. Xiapex consists of an enzyme (clostridium histiolyticum collagenase), which has a high level of specificity for the cords of protein which cause Dupuytren’s disease.

The potential advantages of Xiapex
Treatment with Xiapex avoids surgery, the skin and soft-tissues of the hand seem to recover quicker than after equivalent surgery. The most compelling feature of this treatment, compared to surgery, has been the rapid recovery of the soft tissues of the hand. A video of this treatment showing some of my patients at one week can be seen on:  www.cambridgemedicalconsultants.co.uk/page2.htm

Duputren’s disease can return after any treatment. Initial clinical studies of six hundred patients, three years after treatment suggests that the recurrence rate after Xiapex-treatment, is equivalent to the recurrence rate after surgery. Treatment with Xiapex injection does not stop a patient having surgical treatment at a later date.

The risks
Xiapex does not cure Dupuytren’s disease. Patients will experience recurrence. For most patients the pain after injection is mild or moderate, for some the pain is more intense. There is also a small risk of failure, and a small risk of nerve or tendon damage. Some patients develop a small skin split that usually heals within days. Xiapex is a drug, some patients may develop an allergic reaction to Xiapex.

What is involved in Xiapex treatment?

Visit 1: The injection
I carry out the injection in the out-patient clinic at the Spire Lea hospital Cambridge. This is not an operation, there is no incision, the drug is injected with a small syringe, using a very fine needle. This is not particularly pain-full. After injection the hand is wrapped in a bulky bandage.

Patients need to be prepared to stay at the hospital for 30 minutes after the injection and should not drive themselves home.

Visit 2: The manipulation
Patients are asked to return two days later. Most patients are aware of an ache and bruising or swelling in the hand. Patients who take aspirin will have more bruising.

The dressings are removed and a small amount of local anaesthetic is injected into the palm. I then stretch the finger into a flatter posture, snapping any remaining tight cords of Dupuytren’s tissue. This maneuver can cause a small split in the skin (which almost always heals in less than one week).

Patients need to be prepared to stay at the hospital for 75 minutes and should not drive themselves home after the manipulation.

The hand is wrapped in a light dressing to support the fingers in an extended posture. Most patients remove the dressings 5 days later.

More information about Dupuytren’s disease
Patients can look at the BSSH website: www.bssh.ac.uk/patients/conditions/25/dupuytrens_disease or the Dupuytren’s society website: www.dupuytrens-society.org.uk

To make an appointment
please call 01223 550 881 or email: igrant@uk-consultants.co.uk

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