Dr Nick Wallwork | Shoulder, Elbow, Wrist and Hand Surgeon

Dupytren’s contracture is a well recognised progressive condition that develops in the palm of the hand. It involves the development of fibrous nodules that coalesce into a cord of scar tissue that eventually limits movement. The fingers become contracted with a loss of active and passive extension in the metacarpophalangeal joints and interphalangeal joints. The condition is generally painless but individual nodules can be tender. The most common cause is due to a genetic predisposition but environmental factors can contribute to the rate of progression.

In the thick skin of the palm there is a supporting fibrous anatomic mesh that anchors the skin. This is the layer that becomes contracted by a proliferation of myofibroblasts. The skin tendons and joints themselves are not directly involved by the process but become tethered and scared and lose function. The abnormal tissue is similar to a scar and is composed of collagen. Collagen is an essential building block of all tissues and is found in greatest density in structures such as tendons and bones.

Dupytren’s contracture requires treatment when there is a functional loss in the hand. This can vary due to individual demands, as some individuals tolerate the deformity without impediment, but others have early difficulty with specific tasks, such as applying gloves. The traditional patient examination involves assessing the degree of flexion deformity in each joint, and the sensory and vascular supply of the digit. Intervention is recommended when the palm cannot be placed flat on a table, termed the table top test.

Standard surgical treatment involves careful excision of the contracted cord and releasing the skin and joints that have become secondarily involved. The tendons and nerves of the finger are protected to preserve function. This can be very successful in restoring function and reducing deformity. Frequently skin may be taken as a graft or flap to release the tension over the joints of the hand. The range of movement within the MCPJ generally recovers rapidly, but a fixed contracture in the PIPJ is more recalcitrant to treatment.

The surgical procedure requires day surgery admission and several weeks to heal and involves the small risks of infection and inadvertent nerve or vessel injury. A splint is often worn at night for several months to help prevent recurrence. This option is always selected for more advanced disease and any recurrence.

A new form of treatment to dissolve the fibrous cord is available for adult patients, using a collagenase protein. The collagenase protein is an enzyme produced by the clostridium histolyticum bacteria and is commercially available as Xiaflex injections. This treatment is not appropriate for all patients and careful clinical assessment needs to be made prior to a decision to offer this therapy. The injection is administered in an outpatient setting directly to the contracted cord. The cord will then by lysed by the enzyme and at a review appointment 24-72 hours later a manipulation of the finger is performed under local anaesthetic. The injection may need to be repeated on up to three occasions at four weekly intervals to achieve the best results.

This treatment is indicated where there is a palpable cord producing a moderate contracture in one or two fingers without advanced disease. There are risks involved in the process with all patients experiencing some pain, redness, itchiness and swelling at the site of injection. More serious side effects include skin necrosis, injury to the flexor tendons or digital nerves due to the effects of the enzyme. In the little finger the risks are higher due to the proximity of these structures. Prior clinical experience in the treatment of Dupytren’s and specific training and certification are required before being able to administer the injection, due to these risks.

The injection is a bacterial product and incites an immune response in most patients (90%3) and allergic reactions (1%) can occur. It is recommended that the injection be administered in a location where the patient can be monitored and treated for any allergic response. The reported outcome following injection in trial patients1,2 showed 44-64% gained full movement (0-5 deg) in the MCPJ and PIPJ contracture, with up to three injections. This was significantly better than placebo and the overall gain in range of motion was significantly improved.

Xiaflex is currently not listed on the PBS and hence incurs an out of pocket expense, but some contribution may be available from private insurers.

At sportsmed, we aim to provide the most appropriate, effective and safe patient care. Our surgeons will be happy to discuss treatment options with your patients. For all appointments and enquiries with Dr Wallwork, contact 08 8130 1279.

References

1. Hurst, Lawrence C.; Badalamente, Marie A.; Hentz, Vincent R.; Hotchkiss, Robert N.; Kaplan, F. Thomas D.; Meals, Roy A.; Smith, Theodore M.; Rodzvilla, John (2009). “Injectable Collagenase Clostridium Histolyticum for Dupuytren’s Contracture”. New England Journal of Medicine. 361 (10): 968–79.

2. Gilpin D, Coleman S, Hall S, Houston A, Karrasch J, Jones N. xiaflex “Injectable collagenase Clostridium histolyticum: a new non-surgical treatment for Dupuytren’s disease.”J Hand Surg Am. 2010 Dec; 35(12):2027-38.e1.

3. Badalamente, Marie A.; Hurst, Lawrence C. (2007). “Efficacy and Safety of Injectable Mixed Collagenase Subtypes in the Treatment of Dupuytren’s Contracture”. The Journal of Hand Surgery. 32 (6): 767–74.