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Suggest treatment for dupuytrenes contracture

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Posted on Wed, 9 Jul 2014
Question: I have dupuytrenes contracture in both hands. I was told not to ever do anything as long as I could lay my hands flat on a table. The condition has worsened over time however, my fingers have not drawn up in a frozen position like my Mother. My daughter has inherited dupuytrenes and told me today about an injection that she will have to hopefully cure her rigid (frozen) finger. The name of the medicine that will be injected is Xiaflex or Ziaflex? I am not sure of the spelling. I would be most interested in this treatment and would appreciate information.I question if a hand surgeon would be the specialist to answer this? Thank you.XXXX
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Answered by Dr. Shafi Ullah Khan (5 hours later)
Brief Answer:
All options including xiaflex mentioned, consult

Detailed Answer:
Thank you for asking!
Let me first explain in detail what this contracture is and all about it and then i will give you management options including the one you mentioned. But one thing before all that i want you to have realistic expectations that surgery can relieve some disability but that it cannot cure Dupuytren disease. Discuss all potential complications of the procedure, including complex regional pain syndrome with your doctor. In addition, intense rehabilitation with an occupational therapist is necessary postoperatively for an optimal outcome.
Dupuytren disease is a fibrosing disorder, which results in slowly progressive thickening and shortening of the palmar fascia leading to debilitating digital contractures, particularly of the metacarpophalangeal (MCP) joints or the proximal interphalangeal (PIP) joints. This condition usually affects the fourth and fifth digits (the ring and small fingers).
I want you to know that Dupuytren contracture belongs to the group of fibromatosis that include plantar fibromatosis (Ledderhose disease), penile fibromatosis (Peyronie disease), and fibromatosis of the dorsal PIP joints (Garrod nodes or knuckle pads)
Males are 3 times as likely to develop disease and are more likely to have higher disease severity. Male predominance is related to expression of androgen receptors in Dupuytren fascia.
In order for its management it depends on its stages and grades. lower once can get cured conservatively.
Proliferative phase - During this phase, myofibroblasts proliferate and a nodule develops. In early disease, some patients may report tenderness and discomfort associated with the nodules. The associated pain is thought to be due to nerve fibers embedded in the fibrous tissue or compression of local nerves. Upon physical examination palmar skin blanching is seen with finger extension.
Involutional phase - In this phase the disease, spreads along the fascia and into the fingers resulting in the development of a cord. Myofibroblasts are the predominant cell type during this phase and align themselves along tension lines within the nodule
Residual phase – During the residual phase, the disease continues to spread into the fingers and the cord tightens creating a contracture. The nodular tissue disappears as do the myofibroblasts and acellular tissue with thick bands of collagen remain.
The ratio of type III collagen to type I collagen increases, the reverse of the normal pattern, in the palmar fascia.Grades of severity The grading system for Dupuytren disease severity is as follows

Grade 1 - Thickened nodule and band in the palmar aponeurosis; may have associated skin abnormalities
Grade 2 - Development of pretendinous and digital cords with limitation of finger extension
Grade 3 - Presence of flexion contracture
Lets talk about different management option including the one you mentioned of xiaflex injection.
1)Rehabilitative options
a-Physical therapy ...Stretching with the application of heat and ultrasonographic waves may be helpful in the early stages of Dupuytren contracture.you should wear a custom splint or brace to stretch the fingers further. ROM exercises should be performed several times a day.Even if you opt for surgery you will need physiotherapy consisting of wound care, massage, passive stretching, active ROM exercises, and splinting.
b-Occupational Therapies..........learn adaptive techniques and begin to use assistive devices that enhance functional abilities. For example, adaptive equipment can help you to open jars, despite contractures.
2)Corticosteroid injection
Intralesional triamcinolone acetonide (Kenalog-40) injections of 40 mg/mL have yielded subjective improvement in the size of Dupuytren nodules in some patients.However, corticosteroids are associated with a high risk of complications, including fat atrophy and skin discoloration.In addition, intralesional injection of corticosteroids can result in tendon rupture. Weigh the pros and cons with your doctor for this.
3)Radiotherapy
It will be effective only in early stages of disease and not in advanced one , thats why i focussed on stages and grading of the contractures.
4)Now Your option of collagenase Injection:
I want you to know that Prior to February 2010, surgical intervention was the mainstay of treatment for Dupuytren disease despite a high rate of recurrence and complications. In February 2010, the US Food and Drug Administration (FDA) approved collagenase Clostridium histolyticum (Xiaflex) at a dose of 0.58 mg per injection for the treatment of Dupuytren contracture in a single digit during a 30-day treatment cycle. Injected collagenase extracted from C histolyticum weakens and dissolves the Dupuytren cord.
SO yes it is a valid option and you can opt for it too.

5)5 Fluorouracil
cause a dose-dependent, selective and specific decrease in collagen production by fibroblasts and inhibit fibroblast proliferation and myofibroblast differentiation. this treatment may be useful as an adjuvant therapy to surgery in reducing extracellular matrix production and recurrence of Dupuytren contracture

6)Imiquimod
It works just like 5 fluorouracil by controlling the contractures growth.
7)Botulinum toxin
8)Ilomastat
9)Splinting
10)Hyperbaric oxygen
valid option. Fibroblast and myofibroblast production may cease if hypoxic conditions are reversed by high tissue oxygenation
11)Surgical options like fasciotomy and fasciectomy.
Seek a plastic or an orthopaedic hand surgeon and discuss all these 11 options with your doctor and let them decide what is best for you from all the options on the table.
I hope it helps.Take good care and dont forget to close the discussion please.
may the odds be ever in your favour.
Regards
Khan


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Answered by
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Dr. Shafi Ullah Khan

General & Family Physician

Practicing since :2012

Answered : 3613 Questions

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Suggest treatment for dupuytrenes contracture

Brief Answer: All options including xiaflex mentioned, consult Detailed Answer: Thank you for asking! Let me first explain in detail what this contracture is and all about it and then i will give you management options including the one you mentioned. But one thing before all that i want you to have realistic expectations that surgery can relieve some disability but that it cannot cure Dupuytren disease. Discuss all potential complications of the procedure, including complex regional pain syndrome with your doctor. In addition, intense rehabilitation with an occupational therapist is necessary postoperatively for an optimal outcome. Dupuytren disease is a fibrosing disorder, which results in slowly progressive thickening and shortening of the palmar fascia leading to debilitating digital contractures, particularly of the metacarpophalangeal (MCP) joints or the proximal interphalangeal (PIP) joints. This condition usually affects the fourth and fifth digits (the ring and small fingers). I want you to know that Dupuytren contracture belongs to the group of fibromatosis that include plantar fibromatosis (Ledderhose disease), penile fibromatosis (Peyronie disease), and fibromatosis of the dorsal PIP joints (Garrod nodes or knuckle pads) Males are 3 times as likely to develop disease and are more likely to have higher disease severity. Male predominance is related to expression of androgen receptors in Dupuytren fascia. In order for its management it depends on its stages and grades. lower once can get cured conservatively. Proliferative phase - During this phase, myofibroblasts proliferate and a nodule develops. In early disease, some patients may report tenderness and discomfort associated with the nodules. The associated pain is thought to be due to nerve fibers embedded in the fibrous tissue or compression of local nerves. Upon physical examination palmar skin blanching is seen with finger extension. Involutional phase - In this phase the disease, spreads along the fascia and into the fingers resulting in the development of a cord. Myofibroblasts are the predominant cell type during this phase and align themselves along tension lines within the nodule Residual phase – During the residual phase, the disease continues to spread into the fingers and the cord tightens creating a contracture. The nodular tissue disappears as do the myofibroblasts and acellular tissue with thick bands of collagen remain. The ratio of type III collagen to type I collagen increases, the reverse of the normal pattern, in the palmar fascia.Grades of severity The grading system for Dupuytren disease severity is as follows Grade 1 - Thickened nodule and band in the palmar aponeurosis; may have associated skin abnormalities Grade 2 - Development of pretendinous and digital cords with limitation of finger extension Grade 3 - Presence of flexion contracture Lets talk about different management option including the one you mentioned of xiaflex injection. 1)Rehabilitative options a-Physical therapy ...Stretching with the application of heat and ultrasonographic waves may be helpful in the early stages of Dupuytren contracture.you should wear a custom splint or brace to stretch the fingers further. ROM exercises should be performed several times a day.Even if you opt for surgery you will need physiotherapy consisting of wound care, massage, passive stretching, active ROM exercises, and splinting. b-Occupational Therapies..........learn adaptive techniques and begin to use assistive devices that enhance functional abilities. For example, adaptive equipment can help you to open jars, despite contractures. 2)Corticosteroid injection Intralesional triamcinolone acetonide (Kenalog-40) injections of 40 mg/mL have yielded subjective improvement in the size of Dupuytren nodules in some patients.However, corticosteroids are associated with a high risk of complications, including fat atrophy and skin discoloration.In addition, intralesional injection of corticosteroids can result in tendon rupture. Weigh the pros and cons with your doctor for this. 3)Radiotherapy It will be effective only in early stages of disease and not in advanced one , thats why i focussed on stages and grading of the contractures. 4)Now Your option of collagenase Injection: I want you to know that Prior to February 2010, surgical intervention was the mainstay of treatment for Dupuytren disease despite a high rate of recurrence and complications. In February 2010, the US Food and Drug Administration (FDA) approved collagenase Clostridium histolyticum (Xiaflex) at a dose of 0.58 mg per injection for the treatment of Dupuytren contracture in a single digit during a 30-day treatment cycle. Injected collagenase extracted from C histolyticum weakens and dissolves the Dupuytren cord. SO yes it is a valid option and you can opt for it too. 5)5 Fluorouracil cause a dose-dependent, selective and specific decrease in collagen production by fibroblasts and inhibit fibroblast proliferation and myofibroblast differentiation. this treatment may be useful as an adjuvant therapy to surgery in reducing extracellular matrix production and recurrence of Dupuytren contracture 6)Imiquimod It works just like 5 fluorouracil by controlling the contractures growth. 7)Botulinum toxin 8)Ilomastat 9)Splinting 10)Hyperbaric oxygen valid option. Fibroblast and myofibroblast production may cease if hypoxic conditions are reversed by high tissue oxygenation 11)Surgical options like fasciotomy and fasciectomy. Seek a plastic or an orthopaedic hand surgeon and discuss all these 11 options with your doctor and let them decide what is best for you from all the options on the table. I hope it helps.Take good care and dont forget to close the discussion please. may the odds be ever in your favour. Regards Khan