Treating Dupuytren's disease

There's some correlation between Peyronie's disease and Dupuytren's contracture, though the structures involved are fairly different. So this treatment for Dupuytren's, a disorder for which there's been no good treatment, is at least of passing interest:

Straightening Bent Fingers, No Surgery Required - New York Times

Keith Felcyn, a retired senior editor of BusinessWeek magazine who lives in Greenwich, Conn., had not been able to fully extend the little and ring fingers of his left hand for 20 years. But last month, it took 20 minutes for a doctor in Ontario, Ore., to reverse his Dupuytren’s disease, a benign but ultimately disabling disorder in which the fascia of the hand thickens and draws the fingers permanently into the palm.

The disabling disorder causes patients’ fingers to become fixed in a bent position.

“When he finished and I could lay my hand flat,” Mr. Felcyn recalled, “I said, ‘My God, this is a miracle.’ ”

The procedure, called needle aponeurotomy or percutaneous fasciotomy, involves using the bevel of a hypodermic needle to essentially shred the ropes of constricting fascia characteristic of Dupuytren’s disease. The disorder, named for Baron Guillaume Dupuytren, a 19th-century French surgeon who wrote about it, afflicts up to 25 percent of people over 40 in Western countries and is most common in men of northern European descent. Ronald Reagan had it; so does Margaret Thatcher. Risk factors for the disease include hand or wrist trauma, repetitive strain, alcoholism, smoking and diabetes.

Needle aponeurotomy, which leaves only superficial puncture wounds, was developed 30 years ago by a group of French rheumatologists and is now being practiced in the United States by fewer than a dozen physicians. Thousands of patients like Mr. Felcyn are flocking to these doctors every year, many against the advice of hand surgeons who say open hand surgery is more effective.

“Surgery has a lower recurrence rate,” said Dr. Richard Gelberman, chairman of the department of orthopedics at Washington University in St. Louis, and president of the American Society for Surgery of the Hand. The recurrence rate for needle aponeurotomy is around 50 percent after three years, according to several studies published in French medical journals. Studies in the British and American medical literature indicate that the recurrence rate for fasciectomy, or surgical removal of the diseased fascia, is 40 percent after five years.

But surgery carries a significantly higher risk of complications like nerve and vascular injury, infection, inflammation and something called a flare reaction in which the hand gets very swollen, red and stiff.

“Fasciectomy is a delicate procedure that requires meticulous technique,” said Dr. Steven Z. Glickel, director of the C.V. Starr Hand Surgery Center at St. Luke’s-Roosevelt Hospital Center in New York. Moreover, he added, “Patients have to be committed to physical therapy” for six weeks to four months before they can expect to regain full function of the hand.

Mr. Felcyn played tennis the day after his needle aponeurotomy, which, unlike surgery, can be easily repeated should he have a recurrence.

Dr. David Kline, who performed the procedure using a mild local anesthetic, had the same thing done to both his hands five years earlier in France.

“I cried the day I had it done,” Dr. Kline said. “I was so happy to be able to use my hands.” As an emergency room doctor, he had thought his career was over until an Internet search turned up a group of rheumatologists at the Hôpital Lariboisière in Paris offering an alternative to surgery.

Dr. Kline paid 40 euros, about $55, to undergo the procedure. He returned to Paris in 2005 to receive training in the technique. Dr. Kline said he had since performed more than 600 needle aponeurotomies, in addition to continuing to practice emergency medicine, at Holy Rosary Medical Center, in Ontario, Ore.

There is little competition because so few doctors offer it in the United States; a list can be found at http://www.dupuytren-online.info/needle-aponeurotomy.html.

The cost is $500 to $650 per affected finger and is covered by Medicare.

Dr. Charles Eaton, a hand surgeon in Jupiter, Fla., said the technique had been slow to gain acceptance by other American surgeons because “it sounds crazy to work on the delicate structures of the hand without cutting it open to see what you are doing,” especially when Dupuytren’s disease often distorts the anatomy of the hand.

But because patients are awake for the procedure, he said they can report a tingling sensation if the one-half millimeter needle gets too close to a nerve, and they can move their fingers to reveal the location of tendons.

“It took a long time for arthroscopy to take hold, too,” Dr. Eaton said.

It would be interesting to understand exactly how and why this works. I was surprised by the cited prevalence for Dupuytren's. If it's really that common (25%?! of all men over 40?) then any historic association with Peyronie's may be completely coincidental.

Update 8/4/07: The prevalence of contractures is not 25%. Amongst Caucasian European males over age 40 it's probably 1-4%, and maybe 5%+ in Scandinavians.