Palo Alto Hand Surgery

Dr. Andrew Gutow 

Dr. Jennifer Schneider


Dupuytren's contracture

General Information:

Dupuytren's contracture (also known  palmar fibromatosis) is a non cancerous disorder where thickening of the fascia (connective tissue) of the palm and fingers causes nodules, cords and sometimes contractures of the fingers.  In its earliest stages there are nodules in the palm, then there can be rope like cords and in more advanced stages the cords bend the fingers toward the palm so that the fingers cannot be fully extended.  The disorder is hereditary and most frequently occurs in individuals of Northern European descent.  The disorder progresses slowly and usually is not painful.  As this a non cancerous benign process treatment is only needed when the nodules, cords or contractures begin to interfere with function.

 

As Dupuytren's is not a cancer, but rather a disorder of all of the cells which make the fibrous connective tissue of the palmar fascia, excision of one area of Dupuytren's does not prevent growth in another area.  Similarly all patients are prone to recurrence of the disorder if they live long enough whatever treatment is used.

Treatment Options:

 We offer three treatments for Dupuytren's contracture.

 

1.  Traditional Open Surgery (Partial or complete palmar and digital fasciectomy), where we excise the abnormal cords or portions in the operating room to allow the fingers to straighten.  This method can remove all of the bumps, and provide for the longest time before recovery.  It also has the longest post operative recovery with the need for dedicated hand surgery.

 

2.  Needle Aponeurotomy which is an in office procedure performed by using local anesthetic on the skin and then using 25 gauge needles to disrupt the thickened cords allowing the fingers to straighten.  This procedure has a small risk of damage to the sensory nerves to the finger tips, and also has the highest recurrence rate.  It is also the simplest and fastest treatment. In reviewing our experience with 40 procedures over the past year we have had no infections, nerve injuries or significant skin tearing, we have had recurrence or failure of complete release requiring revision or other treatment.

 

3. Clostridium Histolyticum (XiafleX tm) Injection. This is a two day office procedure where the cord  dissolving agent  Clostridium Histolyticum is injected on the first day into the cord, and then on the next day  the finger is stretched in the office (with the use of a local anesthetic injection).  There is a small risk of tendon rupture from the injected agent which dissolves the collagen of the cords and can also dissolve the collagen of tendons.  There also can be allergic reactions to the agent.  With the manipulation to stretch the finger there can be skin tears requiring suturing which has occured in about 10% of our patients.    We have also had a few patients have pain requiring strong medications on the day of injection.

EXAMPLE OF PATIENT TREATED WITH NEEDLE APONEUROTOMY (NA)

Patient with Ring finger Dupuyutren contracture

Same patient after in office release via needle aponeurotomy.  Note small point of injection and release in palm.

EXAMPLE OF PATIENT TREATED WITH XIAFLEX INJECTION

Top image: one day after injection with Xiaflex.  Note bruising.

Middle image: immediately after manipulation under local block (bandaid at site of injection of anesthetic).

Bottom image: three weeks later with good motion