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What is Dupuytren's disease?

http://www.handctr.com/Dupuytens%20disease.htm

Dupuytren’s disease is an abnormal thickening of the tissue just beneath the skin known as fascia. This thickening occurs in the palm and can extend into the fingers (see Figure 1). Firm cords and lumps may develop that can cause the fingers to bend into the palm (see Figure 2), in which case it is described as Dupuytren’s contracture. Although the skin may become involved in the process, the deeper structures—such as the tendons—are not directly involved. Occasionally, the disease will cause thickening on top of the finger knuckles (knuckle pads), or nodules or cords within the soles of the feet (plantar fibromatosis). Dupuytren's Disease is named after a French anatomist and military surgeon Baron Guillaume Dupuytren (1777-1835).

What causes Dupuytren's disease?

The cause of Dupuytren’s disease is unknown but may be associated with certain biochemical factors within the involved fascia. The problem is more common in men over age 40 and in people of northern European descent. There is no proven evidence that hand injuries or specific occupational exposures lead to a higher risk of developing Dupuytren’s disease. What are the symptoms and signs of Dupuytren's disease?

Symptoms of Dupuytren’s disease usually include lumps and pits within the palm. The lumps are generally firm and adherent to the skin. Thick cords may develop, extending from the palm into one or more fingers, with the ring and little fingers most commonly affected. These cords may be mistaken for tendons, but they actually lie between the skin and the tendons. These cords cause bending or contractures of the fingers. In many cases, both hands are affected, although the degree of involvement may vary.

The initial nodules may produce discomfort that usually resolves, but Dupuytren’s disease is not typically painful. The disease may first be noticed because of difficulty placing the hand flat on an even surface, such as a tabletop (see Figure 3). As the fingers are drawn into the palm, one may notice increasing difficulty with activities such as washing, wearing gloves, shaking hands, and putting hands into pockets. Progression is unpredictable. Some individuals will have only small lumps or cords while others will develop severely bent fingers. More severe disease often occurs with an earlier age of onset.

What are the treatment options for Dupuytren's disease?

In mild cases especially if hand function is not affected, only observation is needed.

For more severe cases various techniques are available in order to straighten the finger(s). Your treating surgeon will discuss the method most appropriate for your condition based upon the stage of the disease and the joints involved. The goal of any treatment is to improve finger position and thereby hand function. Despite treatment the disease process may recur. Before treatment, your doctor should discuss realistic goals and results.

Types of treatment may include Needle Aponeurotomy, Partial or Complete Fasciectomy, and limited release as well as on Collagenase injections or cortisone injection in a nodule. The rationale behind each treatment depends upon the treating physician and the patient.

Surgical Fasciectomy (Partial or Complete) uses open incisions and the cords and nodules are removed

Incisonal Aponeurotomy or Fasciotomy uses small incisions or portals and the cords are released or perforated

Needle Aponeurotomy (NA) or Percutaneous Aponeurotomy (PA) or Percutanoeous Needle Fasciotomy (PNF)

Needle aponeurotomy uses a small gauge needle or a microblade as a cutting device to sever the abnormal cords of tissue in the palm and digits which cause the fingers to flex down. The tissue is not removed it is essentially perforated or cut in multiple places along the palm to release the contracture (see figure 3) Incisional aponeurotomy fasciotomy is done in some instances.

Collagenase Injection (Xiaflex)

Collagenase is an enzyme that digest collagen a structural protein in tissues. Xiafllex is a collagenase derived from the bacteria Clostridium Histolyticum. Xiaflex is a mixture of several types of collagenase, titrated to achieve digestion of tissue or cords that are present in the hands of those who have Dupuytren's disease. (Figure 4)

Corticosteroid Injection (cortisone shot)

When a steroid or cortisone injection is given to the palm, in a nodule or small cord it will often soften the cord. There are studies that state that this may limit progression of the disease While there have been no large scale prospective double blinded studies or dose dependent studies many surgeons now will attempt to inject a nodule or soft cord that is not ready for surgery in an attempt to treat it.

IMPORTANT considerations:

The presence of a lump in the palm does not mean that surgery or treatment is required or that the disease will progress. Correction of finger position is best accomplished with milder contractures and contractures that affect the base of the finger. Complete correction sometimes can not be attained, especially of the middle and end joints in the finger. no matter what method is used. Skin grafts are sometimes required to cover open areas in the fingers if the skin is deficient during open fasciectomy or open removal of cord tissue.. The nerves that provide feeling to the fingertips are often intertwined with the cords and may be affected by any treatment Splinting and hand therapy are often required after surgery or other treatment procedures in order to maximize and maintain the improvement in finger position and function. All treatments for Dupuytren's may involve the risk of tendon, nerve, joint, skin: injury, infection, and stiffness. as well other conditions that may negatively affect the result.

Figure 1: Dupuytrens disease may present as a small lump, pit, or thickened cord in the palm of the hand

Figure 2: In advanced cases, a cord may extend into the finger and bend it into the palm

Figure 3: In Needle Aponeurotomy , a cord may be released or perforated without the need for standard incisions.

Figure 4: , Xiaflex is a collagenase, a drug that is injected into a cord to dissolve a small segment of that cord, to treat the contracture.

These pictures are before and one day after injection (just after manipulation). Xiaflex treatment requires that a manipulation take place the next day

*Based on Phase I clinical trials, collagenase injections work better for metacarpophalangeal (MP) joint contractures than for proximal interphalangeal (PIP) joint contractures, and for lower severity contractures than for higher severity contractures.

*Ideally, patients for collagenase injection should have a well-defined, palpable cord, ideally one that is strung away from the flexor tendon system. The worst patient is probably someone who has a small finger IP contracture that’s more than 50 degrees and has been there for 5 or 10 years. Collagenase can only affect the cord itself; it won’t be able to act on the secondary tissues that have changed. *(source; http://www.aaos.org/news/aaosnow/oct10/clinical2.asp)

More information, links and documents

Collagenase and Needle Aponeurotomy for Dupuyten's Disease ; a 2010 Article discussing reported data

Dupuytrens (.PDF) from ASSH

New treatments for Dupuytren contracture from AAOS Needle aponeurotomy Dupuytren's Bibliography Xiaflex injection photos from AAOS (PDF)

XIAFLEX SIDE EFFECTS Xiaflex pdf handout ( long)

Xiaflex 2 page hand out

portions © 2009 American Society for Surgery of the Hand. Developed by the ASSH Public Education Committee

taken modified from ASSH and other sources including AAOS by www.handctr.com

XIAFLEX® is a registered trademark of Auxilium Pharmaceuticals, Inc. 0510-013.c WARNING: THE INFORMATION offered in links from this page IS TAKEN FROM pages that include AN AUXILIUM SPONSOREDSITE BY WWW.HANDCTR.COM for PATIENT EDUCATION way to offermore information from its DUPUYTREN'S DISEASE UPDATE WEB PAGE . It is meant only as a starting point for education does not represent medical advice or the opinion of handctr.com. It is manufacturers information and may also not be current. In addition all content may be subject to previous copyright, warnings and disclaimers t at its sources. THE HAND CENTER OF WESTERN MASSACHISETTS HAS NO FINANCIAL RELATIONSHIP WITH AUXILIUM AND IS NOT INTENDING TO REPRESENT ITSELF AS AUXILIUM. THE SOLE PURPOSE OF PRVODING THIS IS FOR INFORMATION ONLY . ANY AND ALL DECISONS SHOULD BE MADE BY AN INFORMED PERSON IN CONJUCTION WITHTHEIR HEALTH CARE PROVIDER(s)

http://www.nlm.nih.gov/medlineplus/druginfo/natural/895.html

Bromelain is reported to havr an anitinflammatory and analgesic effect. There are similar medications that may also relieve symptoms of inflammation and swelling but you should pay attention to hte information available on these over the counter remedies much like you would for a prescription medication. Just because it is "natural" doesnt mean it isnt harmful

SPLINTING The best non-surgical, non-drug treatment for carpal tunnel syndrome is a wrist splint. This is especially true for early mild carpal tunnel syndrome with occasional activity related symptoms and night time or nocturnal tingling. By keeping the wrist in a neutral position the median nerve has less pressure placed upon it from the surrounding tissues. It is pressure that exceeds the normal capillary pressure within the nerve itself that forces blood out of the nerve and leads to the changes in the nerve that are seen in carpal tunnel. In early carpal it is just a transient temporary loss of blood to the nerve. This is why when one wakes up with numb fingers form carpal tunnel that hanging hands down or shaking works, it forces the blood back into the nerve.

When we sleep, the fluid in our body that spends the day finding it way into our feet ( that may feel tired and swollen) at the end of the day now redistributes itself when we lie down. At night when we also flex our wrists or extend our wrists into awkward positions it also puts pressure on the nerve. The extra swelling in the nerve and the position can often be lessened by using a simple night time wrist splint. Only a small increase in pressure is needed to push the blood out of the median nerve. Think about when you push on your own palm or fingertip skin and it goes flat or changes color, that's al it takes. Now imagine you put pressure on that same spot every night for a few hours and that area was also subject to increased pressure form local swelling.

Later if the carpal tunnel progresses, the splint is not as effective. Splinting alone shouild not be the only treatment for all cases of carpal tunnel, antinflammatories, injections, and surgery as well as correcting any metabolic or endocrine issues all are very useful....but splinting should be the answer for the best non-surgical, non-drug treatment

A cortisone injection may be used to reduce the swelling in the carpal canal and thereby reducing the pressure on the median nerve that causes the acute symtpoms of carpal tunnel syndrome. IN early mild cases, the injection alone when combined with splinting may be enough to reverse the disease and "cure" the carpal tunnel of its disease. In more moderate to severe cases symptoms may be reduced or erased but recurrent symptoms may occur. A ressponse to an injection however is a favorable sign for eventual success of surgery if surgery is offered at a later date. Failure of an injection to work does not mean that surgery is not indicated but success of an injection is another positive factor associated with a better outcome for surgery. For some a cortisone injection is pallitive atbest but "buys one time" so that pain and numbness is reduced in anticipation of surgery at a later date. Injections oare just one of the arms of treatment for carpal tunnel and like spliintng, NSAIDs or surgery should not be thought of as the only way to treat carpal tunnel symptoms. There is no one treament algorithm that applies to everyone.

Let me add that even with injection I often prescribe a splint to be worn at night and the biggest mistake I seeis that when someone feel better from an injection, they abandon their splint causing the wrist to flex at night and adding again to the irritation in the carpal canal. The best non-surgical, non-drug treatment for carpal tunnel syndrome is a wrist splint. This is especially true for early mild carpal tunnel syndrome with occasional activity related symptoms and night time or nocturnal tingling. By keeping the wrist in a neutral position the median nerve has less pressure placed upon it from the surrounding tissues. It is pressure that exceeds the normal capillary pressure within the nerve itself that forces blood out of the nerve and leads to the changes in the nerve that are seen in carpal tunnel. In early carpal it is just a transient temporary loss of blood to the nerve. This is why when one wakes up with numb fingers form carpal tunnel that hanging hands down or shaking works, it forces the blood back into the nerve.

When we sleep, the fluid in our body that spends the day finding it way into our feet ( that may feel tired and swollen) at the end of the day now redistributes itself when we lie down. At night when we also flex our wrists or extend our wrists into awkward positions it also puts pressure on the nerve. The extra swelling in the nerve and the position can often be lessened by using a simple night time wrist splint. Only a small increase in pressure is needed to push the blood out of the median nerve. Think about when you push on your own palm or fingertip skin and it goes flat or changes color, that's al it takes. Now imagine you put pressure on that same spot every night for a few hours and that area was also subject to increased pressure form local swelling.

SO an injection and a night splint are synergistic

Carpal Tunnel Surgery: Patient Questions and their Answers from a Hand Surgeons Perspective Carpal Tunnel Surgery is one of the most common operations done today. Of course there are many questions that arise. While a lot has been written about what carpal tunnel is, it is rare to get a surgeon’s answers to these questions. Here are some common questions asked by our patients every day at the Hand Center of Western Massachusetts and their answers

Can I see a demonstration of the endoscopic method?

You can watch a video from You tube. ( see below)

Will my sensation come back or be normal after surgery?

While the goal of carpal tunnel surgery is to relieve the pressure on the nerve not everyone will respond the same to surgery

Some patients will have immediate return of sensation while some will take longer. Some will notice an improvement right away but still feel tingling and will describe this as “numb” The return of sensation is dependent on many factors including age, general health, duration of symptoms, circulation and the actual mechanical severity of compression.

In very severe cases while decompressing the nerve stops the carpal tunnel syndrome from getting worse, full recovery of sensation may not be possible. Often this is seen in patients who have muscle wasting noted prior to surgery and in those with longstanding complete numbness and elevated two-point discrimination. Of course there are many in these categories that improve despite having very severe cases.

Having a severe case where you are not sure if you’d have full recovery is not a reason to put off surgery, as progression is likely if nothing is done.

How about my strength?

This is a very difficult question as there are many reasons why a hand with carpal tunnel may not feel as strong. It may be that the decreased sensation in the fingers prevents someone from knowing how tight to hold and object and that object is dropped more easily. With return of sensation or even a slight improvement in sensation, dropping objects becomes less of a problem. Some severe cases of Carpal Tunnel can be associated with atrophy in the muscles of the hand. In some severe cases, this muscle will never fully recover. However despite loss of muscle, function can still be preserved. In very severe cases a suregon may recommend a tendon or muscle transfer to improve function.

What do you actually do?

What is actually “released” is the hard ligament in your palm that covers the median nerve. Together with the bones in your wrist this ligament forms a ring or tunnel that surrounds the median nerve and the tendons to your fingers and thumb. When this “release” is done it is much like making a ring bigger and there is less pressure on the median nerve. The body heals the cut in this enlarged ring. But it takes time until your palm feels comfortable. With the pressure reduced on the nerve, healing can occur. How the nerve heals is different in everyone.

Is there more than one way to have carpal tunnel surgery?

There are two methods that are in use here in Western Massachusetts. One method is the traditional open palm method and the other is an endoscopic limited incision method?

What is the difference between these two methods?

In a standard open carpal tunnel release the surgeon carefully makes an incision in the proximal portion of the palm. Exposing the togh tissue in the palm called palmar fascia which is then released. Deeper down is the transverse carpal ligament which is then released to take pressure off the median nerve.

Endoscopic carpal tunnel release uses an endoscope, an instrument attached to a video monitor to visualize the undersurface of the transverse carpal ligament. This avoids the need to make an incision in the palm. Instead the surgeon makes the incision in the wrist crease near the base of the palm.

The endoscopic carpal tunnel view gives the surgeon performing carpal tunnel release a detailed magnified high resolution view. Here, below to the left, a simple gauze bandage as viewed through the endoscope. The surgeon has control over variables to allow a full release under direct visualization. On the right is a series of pictures from inside the carpal canal as the endoscope is used to divide the transverse carpal ligament. Here the fibers of the transverse carpal ligament form the roof of the carpal tunnel. Note the partial release in the first three frames going clockwise and the full release in the last frame. The cut edge of the ligament is seen.

The surgeon essentially releases the ligament from the inside out, avoiding damaging the tough tissues called fascia in the palm that give the palm its shape and contour. In addition the palm skin incision is avoided. For many this reduces the immediate problem of using the hand more fully in the early post operative period. It does not mean that there will be absolutely no discomfort but many feel it is less. Typically however one must realize that there are many people who undergo so called regular open carpal tunnel release who have very little pain and many do not need to take pain medicine at all. However those who have endoscopic release who do well, do well a little bit sooner.

What Happens to the cut ligament?

The cut ligament heals. The gap fills in with new tissue. It is a lot like taking a ring or in this case because it your wrist, a bracelet, and making it bigger. By preserving normal tissue in the palm, less tissue has to fill in, in order for your palm to feel like it hasn’t had surgery. A number of studies have shown that palm pain in the early postoperative period is reduced.

Can I use my hand right away?

After surgery you may be able to use your hand right away, especially your fingers to do light things. You must keep your dressing dry until it is changed or removed in the office. For showers or baths keep your dressing covered with a plastic bag. Using your fingers to do light things right away is important. While the dressing will cover your palm, your fingers will be free to use.

How long will it take to heal?

The time for healing is variable as no two people are alike and no one heals exactly the same. However most feel comfortable doing light activities that require palm pressure in 2 – 3 weeks and very heavy activities 4 -5 weeks. Those with lighter sedentary jobs can often go back sooner. Those with very heavy jobs may take longer. Other conditions such as arthritis, tendonitis and fibromyalgia may delay comfort after surgery. Sometimes you do not complain of or notice other problems until after your carpal tunnel is better. For example, if you have arthritis in your wrist or thumb, it may not seem to be an issue becasue you have been using your hand less and your attention has been focused on the carpal tunnel symptoms. While 5-6 weeks down the line most patients with either an open or endoscopic release are at nearly the same place with respect to activities, the endoscopic released hands seem to be more comfortable sooner. . While endoscopic release may feel better earlier it is still advisable not to overdo it. Doing too much too early can delay full recovery, while not doing enough with hand can have the same effect. It is important to use your hand but not overdo it.

Do I need to go to sleep to have the surgery?

The type of anesthesia used is typically is known as “local with monitored anesthesia care “(or IV sedation). This means that you get an intravenous dose of medicine to relax or lightly sedate you. An anesthesiologist, a physician, who is in charge of this part of your operation, gives the sedation. Then the surgeon injects your palm to “numb it up”. The sedation usually makes you forget that you had the palm injection. When the surgery starts you do not feel the incision but you know that something is going on because the back of your hand and your fingers still are awake (Some fall gently asleep at this point but many stay awake and are indifferent to what is happening.)

Does it have to be done in the hospital?

Most carpal tunnel is done as day surgery and most patients can have it done at the surgicenter without the need to go to the hospital. It is usually a 20 -25 minute procedure with total time in the surgery center about 2 hours. You need to have a ride from surgery and cannot drive for 24 hours. After 24 hours you may drive as long as you feel safe and are not taking pain medicine, which can impair your judgment. The requirement of insurance carriers and some people because of other medical problems or sometimes because of scheduling need to go to the hospital for surgery. Then you would expect to spend about 4 – 5 hours at the hospital. The surgicenter has you arrive 80 minutes prior to your scheduled surgery time while at the hospital you need to get there 2 hours ahead of the surgical time.

Will I be in a lot of pain?

While typically everyone who has carpal tunnel surgery gets a prescription for pain medicine, most state that they did not need it or used it minimally. Many get by with Tylenol, Advil, Alleve or a similar over the counter medication. Others feel the need to take pain medication such as codeine or percocet for a few days. Remember that everyone will not respond to surgery the same way with respect to pain after the surgery.

Overall carpal tunnel surgery can work well. While these answers do not apply to everyone and everyone will not react the same way to surgery, they represent a more common experience. For more information you can come to our website at http://www.handctr.com.

Additional resources

WIKIPEDIA: ENDOSCOPIC CARPAL TUNNEL RELEASE SURGERY

http://www.handctr.com/articles.htm

ON FACEBOOK: THE HAND CENTER OF WESTERN MASSACHUSETTS

http://www.youtube.com/user/HANDCenter

This answer is not a substitute for professional medical advice. This answer is for general informational purposes only and is not a substitute for professional medical advice. If you think you may have a medical emergency, call your doctor or (in the United States) 911 immediately. Always seek the advice of your doctor before starting or changing treatment.