In the coming months you may hear about a new drug for treating cellulite, called Xiaflex. The pharmaceutical manufacturer that makes it just began clinical trials of its effects in January. I am not recommending Xiaflex for treatment of cellulite because I’m not a cosmetic surgeon. I am familiar with Xiaflex, however, because it was originally developed to treat a hand disorder called Dupytren’s contracture. Normally, I hesitate to use words like “revolutionary” when describing medical advancements; few things truly change the way we do something. The arthroscope was revolutionary; it completely changed the way people have surgery, and ultimately not just in orthopedics. But Xiaflex really belongs in that revolutionary category because it has helped us treat Dupuytren’s patients in a much less invasive way.
Dupuytren’s contracture is a disease that causes a person’s fingers to curl down toward their palms. It can also affect the feet but it’s far more prevalent in the hands. There’s a layer of tissue just below the skin called fascia, which gives your skin the flexibility to move and grab things without disrupting or damaging the tendons, nerves, arteries and muscles underneath. Dupuytren’s turns fascia from being soft and pliable into hardened scar tissue that adheres to the skin, tendons, nerves and arteries. It feels like thick cords or nodules under your skin. The fingers can curl all the way down to the palm if it goes untreated, causing a person to completely lose function in the affected digits. You can’t grip anything. You can’t even get your hand in your pocket. It can be a very debilitating disease. In fact, one of the recommendations if the small finger becomes flexed all the way down is amputation.
The surgical treatments for Dupuytren’s are pretty extreme. In the early 1960s, a Scottish physician named McCash introduced a technique that removed all skin from the palm. The operation restored partial functionality to the fingers. But can you imagine what rehab must be like when you’re waiting for the skin to grow back on your hands so you can use them again? The more traditional surgery has been to make a series of zigzag incisions running from palm to finger, and then remove the cords and nodules. This procedure is fraught with risks of stiffness and nerve or artery damage, however, and the recovery time can be as long as a year.
I started reading about Xiaflex and hearing about it in professional development meetings sometime in 2009. It was being used with good success in Australia, New Zealand and Europe, and I was advising some of my patients to hold on until it was approved by the Food and Drug Administration. When that finally happened in 2010, I went through the training to do the injections. A lot of injections in orthopedic surgeries are made into spaces. Xiaflex is injected directly into the tissue and it essentially eats away at the cord or nodule in that spot. After waiting anywhere from 24 to 48 hours, you numb the hand and manipulate it until you hear a pop. I still jump every time I hear that pop because it’s so loud. But after the pop you can generally straighten the finger all the way out, though it depends on how severe the contracture was to begin with. There is physical therapy afterward to strengthen the hand, and you might wear a splint at night. But it really surprised me how quickly it resolves compared to surgery. You can be using your hand normally within a month.
The other thing that surprised me was the amount of swelling and bruising the injections cause. It looks like somebody has taken a sledgehammer to your hand, and in some people the bruises track all the way up the arm. The swelling subsides as you recover. Risks include the chance of rupturing the flexor tendons in your fingers. There have not been many reports of this happening fortunately, and it is occurring mostly in the pinky finger. Longer term studies may eventually show that there is more risk than benefit to using Xiaflex in smaller finger joints due to the potential for a ruptured tendon. Other risks include incomplete release, need for further injections, skin tears, nerve or blood vessel injuries, or even fracture of the finger. It should be stressed that all Dupytren’s disease, no matter how it is treated, will recur.
We do see a fair amount of Dupytren’s here in southern Vermont. It’s a genetic disease that happens most frequently in males of northern European descent. The condition can also be brought on by excessive alcohol use or certain types of seizure medication; but by and large, it’s a condition passed down from generation to generation. The trouble is most people aren’t diagnosed. They think they’ve sustained an injury to their hand and don’t get it looked at soon enough, which means the disease progresses and makes treating it much harder. We talk about it with primary care physicians when we do presentations on orthopedic issues to make them aware of it.
It’s very easy for an individual to determine whether they need treatment for Dupuytren’s. Try putting your palm flat down on the table. If you can’t do that then you need to get medical attention. The key is not to wait and let it get worse.
Xiaflex is not a cure for Dupytren’s. It could always return in a person who is genetically disposed. But unlike the surgeries, Xiaflex can restore a person’s quality of life faster and with far less risk. Think about a carpenter grabbing a hammer, an office worker typing on a keyboard, or any of the hundreds of other things we do with our hands each day and it’s really exciting that we have this kind of cutting edge treatment available in our community.
Elizabeth McLarney, MD is a board-certified orthopaedic surgeon at BMH Orthopaedics & Sports Medicine, a department of Brattleboro Memorial Hospital.