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Dupuytren’s Disease Injection and Manipulation Procedures

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Evolution of Dupuytren’s Disease Injection and Manipulation Procedures

Traditionally, Dupuytren’s disease was treated with surgery to cut out the abnormal tissue and allow the finger(s) to straighten out. This procedure involves fairly large incision(s) on the palm of the hand and is usually done under general anesthesia because the nerves and blood vessels of the hand can be intertwined with the Dupuytren’s tissue, requiring the patient to be perfectly still during the surgery. Because Dupuytren’s patients are often elderly and sometimes have other medical conditions, surgery under general anesthesia may not always be a good option. As such, doctors have long looked for less invasive ways to treat this condition. The question was asked: “What if, instead of cutting out the Dupuytren’s cord, we could just rupture it and then manually straighten the finger back out?”. This led to research into possible ways to rupture the cords of Dupuytren’s tissue. Percutaneous needle fasciotomy/ aponeurotomy involves using a needle to basically saw through the thick tissue in the cord and rupture it. Injectable enzyme treatment involves placing a collagenase enzyme into the tissue of the cord to weaken the tissue and lead to the rupture of the cord.

As mentioned above, Dupuytren’s disease has been traditionally approached with open surgery to excise as much of the abnormal Dupuytren’s tissue as possible, while leaving behind tendons, nerves, blood vessels, and other normal structures. Upon removal of the cord, the affected finger(s) can be manually extended during the surgical procedure. The surgeon then makes sure bleeding is controlled and closes the skin. The hand is inspected to make sure there is good circulation and a bandage and splint are then applied. The patient then wakes up and goes home that same day, usually with a pain prescription. Typical challenges with partial palmar fasciectomy surgery involve patient factors that make anesthesia challenging, and also occasional problems with wound healing after the procedure. Success in correcting joint contractures is the highest with open surgery, and is seen in up to 90% of treated joints. Recurrence is still a problem and occurs in about a third of patients by five years. Complications with open surgery are still uncommon, but can be more severe, including damage to the nerves and blood vessels of the fingers. These are more common in severe disease or during repeat surgery, with rates up to 15% in these situations.

Instead of open surgery, a large bore needle can be used to disrupt the cord. With this in-office procedure, the surgeon cleans the hand, injects local numbing medication with a small needle, and then uses a larger needle in a back-and-forth sawing fashion to divide the Dupuytren’s cord. After the cord has been divided into two pieces, the surgeon applies force to the affected finger(s) to extend the finger(s). The hand is then bandaged, placed in a splint, and the patient is sent home the same day, possibly with a small
number of pain pills. Success rates have been documented to be similar to those of Xiaflex®, while recurrence rates are the highest (and happen the soonest) with this procedure. Complications are rare with this procedure.

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