Dupytrens Disease

Dupuytren's disease is an extremely common condition, particularly in men from the sixth decade of life onwards but it does also occur in women. It is believed that patients inherit a genetic tendency to this condition and indeed some patients present with a strong family history, with many other family members affected too. Patients with Dupuytren's disease may present with similar types of conditions in other parts of the body including the instep of the foot (Lederhose's disease). In men, the penis is rarely affected (Peyronie's disease) and is managed by urologists.

Dupuytren's disease is characterised by thickening of the palmar and digital fascia, tissues which are present in the hands of all people. As the affected fascia thickens up, the progression is from an initial nodule or thickening to the presence of a string-like cord of tissue underneath the skin, which has a tendency to contract. Because the affected tissues are present on the palmar aspect of the hand, contraction has a tendency to pull the fingers into a bent position, which in turn means that patients lose the ability to straighten their fingers, compromising their grip. Pain is seldom a problem.

For most patients, Dupuytren's is a slowly progressive condition. Treatment centres around two issues, namely, when to treat and how to treat. As far as the timing is concerned, it is not appropriate to operate in most patients unless there is an established contracture, which translates to an inability to place the hand flat on a desktop or table. It is not helpful to wait until the fingers are profoundly flexed because this compromises the prospects of achieving a good outcome. Until very recently the only reliable treatment available was surgical, which ranges from simple division of a cord (fasciotomy) through to excision of all the affected tissues (fasciectomy) or, in some selected cases, dermofasciectomy, in which skin is also removed from the finger and replaced with a skin graft, a procedure which significantly reduces the risk of the problem coming back again.

A new treatment has recently become available to patients with Dupuytren's disease, namely, Xiapex injection. Xiapex is produced by Sobi and is an enzyme derived from bacteria, which is injected in very small volume into affected tissues in which it then produces a molecular degradation and weakening that allows the finger to be manipulated into a position of straightness, 24 hours after injection.

Early results appear to be very encouraging but, as ever, with new treatments, what we don't know is how patients will do in the long-term. At the moment, my own practice is to continue to offer surgery and for those cases who may benefit from Xiapex, I will discuss this option with them.

Surgery and Xiapex injections both require post-operative therapy to achieve good outcomes. Complications of surgery include, as ever, infection, bleeding, stiffness, pain, recurrence of the Dupuytren's disease, recurrence of a bent position in the finger due to joint contracture and possible numbness if the digital nerves, which are encased in Dupuytren's disease, are damaged during surgical excision. The latter is rare, with a risk of approximately 1%.

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