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July 25, 2011

Therapy for hand disease gives patients non-surgical option

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Robert Newman likes to make his bed every day. It might seem a simple task, but it was one that was problematic for him for years.

“My little finger was always in the way,” says the 84-year-old. “I couldn’t use my flat hand. There are many times you need to use your flat hand to do something, and you probably don’t even realize it.”

Newman’s little finger had curled into the palm of his left hand due to Dupuytreyn’s disease, an abnormal thickening of the connective tissue beneath the skin of the palm.

Until recently, the only way to treat the condition effectively had been surgery. But a new, less invasive treatment used by James Long, M.D., associate professor of plastic and reconstructive surgery at UAB and chief of plastic, reconstructive and hand surgery at The Veteran Affairs Hospital, offers patients a non-surgical option.

An injection of a collagenase enzyme into the affected area has proven to have the same quality and quantity of correction as surgery and does not require extended therapy.

“The treatment consists of an initial injection followed in 48 hours by a manual release,” Long says. “That just means we apply traction to the cord 48 hours after the procedure. During that two-day span, the collagenase has an opportunity to break up the cord to the degree that enables us to rupture it. We were able to do that with Mr. Newman, and he has gone on to have some occupational therapy and has achieved a quite good result.”

Newman found out about the procedure from his daughter Barbara Steele, a nurse in Michigan. When she heard about the injection treatment, she immediately told her dad. Newman was excited, largely because he had surgery for Dupuytreyn’s in his right hand in 1984. The surgery was a success, but it wasn’t something he was excited about repeating in his advanced age.

After he had his first hand operated on, Newman says he can remember his heart pounding if he dropped the hand below his chest. So, he says he walked around for five days with his hand above his heart.

“They were calling me the Pope,” he says with a laugh. “I was walking around blessing everybody.”

The collagenase injection he had in May was much quicker, less painful and provided a speedier recovery.

“I much prefer the injection procedure,” Newman adds. “I had my hand wrapped just one day. They told me I should put the splint on every night, otherwise I could use my hand. And I’ve been able to do just that.”

History of Dupuytreyn’s

Dupuytreyn’s is an inherited disease; Newman’s father also suffered from it.

The Vikings brought it from northern Europe to England, Ireland and Scotland early in the first millennium. Dupuytreyn’s disease is found predominantly in Caucasians, especially men of Western and Northern European descent, and is prevalent in certain areas of the world, especially Australia.

Scientists don’t know why the disease causes the tissue in the hands to change. They do know it changes in a certain population that has certain genetic markers.

“The cord is normally present as a non-diseased structure in the hand,” Long says. “However, it becomes pathologic when the cord begins to contract. It starts to shorten. And the pathogenesis of that process is not completely understood.”

The first treatment for Dupuytreyn’s occurred in 1831 by Baron Guillaume Dupuytreyn, who was Napoleon’s general and a famous French physician.

Dupuytreyn’s is not painful in itself, but laborers or others who use their hands for their occupations or hobbies can experience pain.

“If someone tries to hold a hammer, wrench or any number of tools they might use for their job, that force transmission through the tool can sometimes cause nerve compression pain,” Long says.

Surgery — a full hand fasciotomy and the less-intrusive needle aponeurotomy in affected tendons — has been the most widely available treatment. But with the introduction of the collagenase injection, Long says a new patient population that couldn’t be treated before now has an option.

“Most off those with Dupuytreyn’s are older gentlemen who often have associated medical conditions,” Long says. “They may be on blood-thinning medications, a life-long or current smoker or have a heart condition or other medical conditions that make them a poor candidate for surgery. Before this injection therapy, patients who weren’t candidates for surgery had to live with it. Now they have an alternative.”

The injection has worked wonders for Newman. He can carry a pail of water to his backyard, put his hands in his pockets, button his shirts and, most important, make his bed to near perfection.

“I love it when I make my sheets in the morning; I can straighten them out,” he says. “It makes me feel good.”