Collagenase injections to treat Dupuytren's disease
Written in association with:
Orthopaedic surgeon
Published: 25/04/2019
Edited by: Laura Burgess
Dupuytren’s contracture is a very common condition where one or more fingers are permanently bent in a flexed position and as it worsens over time, it means that the fingers can no longer be straightened. In this article below, we asked consultant orthopaedic surgeon, Ms Anna Moon, to explain how the condition can be treated through the use of collagenase injections.
What’s the history of the condition?
Dupuytren’s contracture is named after the French army surgeon Dr Guillaume Dupuytren who first described the condition and its underlying mechanisms in 1883. In fact, there are earlier reports of the condition in 1777 by an Englishman called Mr Hunt, meaning that the condition was recognised before. But to this day it carries the name from the 18th-century description.
When you take into account migration and different races, the condition is more prevalent where the Celtics, Vikings or later, where the northern Europeans moved and therefore it's quite common in northern Europe. It's also quite common in Japan but very rare in other Asian countries and extremely rare in people of African-Caribbean descent.
What is Dupuytren’s contracture?
Although it is described as a pain-free condition, it usually starts with small nodules in the palm, which might be mildly tender at the beginning. If you imagine that you take the skin off you have palmar fascia just under the skin which protects the nerves and the vessels. It also fixes the skin to the palm, so at the back of our hand our skin is fairly mobile but on the palm, it's quite fixed, which helps us to hold objects and it gives us a good grip.
If you are genetically predisposed and have the Viking genes, there may be some thickening of the palmar fascia that appears as a nodule or two in the palm, which could be mildly tender. With time the condition progresses into a cord, which is like a string running usually at the base of the little and ring finger and starts bending the finger into the palm. Over time, it could become quite debilitating and it becomes cumbersome to put gloves on or go into the pocket or even wash your face and shave.
In that case, we can treat Dupuytren's contracture although we cannot get rid of it as it is a genetic condition that's likely to come back. We can strengthen the fingers and improve the function but unfortunately whatever treatment you choose, it's likely to return.
What are collagenase injections?
Collagenase injections (also known as Xiaflex) consist of an enzyme derived from Clostridium bacteria that dissolves a certain type of collagen. Dupuytren's contracture is the thickening of the palmar fascia and it also consists of collagen, which the collagenase injection can dissolve. This is one of the treatment options for Dupuytren's contracture and is usually done in an outpatient setting. It's less invasive than an operation, but there is a recurrence rate following the injection as well as an operation.
However, some patients choose to have an injection for the easiness of it and if they know they will require repeated treatment, an injection is preferable over an invasive operation.
What happens on the day and after the procedure?
The patient comes for a half an hour appointment where the collagenase is injected carefully into the cord. Following the injection, the patient is advised to keep their hand elevated and keep it still so the injection can work and weaken the cord. Within three days, the patient returns to the clinic and under local anaesthetic the cord is then ruptured and the fingers strengthened. We can do two fingers at a time and we make two injections in two separate cords. The most common side effects of the collagenase injection are usually swelling, bruising, skin tear, enlarged lymphatic nodes, and potential allergy.
Following manipulation, there is no limitation of movement or using the hand. Apart from keeping the hand elevated to reduce the swelling and moving the fingers, you may need hand therapy, so if the joints are badly stiff and you're struggling with movement, we can send you to the hand therapist who can make a custom-made splint to be worn in the night and exercise during the day. If there is any skin tear, this is usually treated just with a change of dressing and the skin heals nicely within a week or two.
After the manipulation and local anaesthetic, we don't advise the patient to drive. Once the anaesthetic wears off, there are no restrictions on driving or doing usual daily activities. If there is a skin tear, this needs to be treated with a change of dressing and is to be kept dry and clean. Again, it's far less restrictive than having surgery.
Do not hesitate to book an appointment with Ms Anna Moon if you are interested in collagenase injections.