Risks of hand surgery as a limited Dupuytren treatment
Any type of surgery presents risks and can produce unintended side effects. Unanticipated complications following open hand surgery for Dupuytren contracture has been reported in 17% to 41% of cases. Further, these side effects are nearly twice as likely to occur for repeat surgery when Dupuytren’s contracture recurs after a first surgery.
This article will focus on the potential complications of Dupuytren’s contracture surgery, specifically a category called palmar fasciectomy.
Avoid Dupuytren hand surgery with Alternative Medicine
Anyone considering Dupuytren surgery should be encouraged to know that by natural Dupuytren treatment it might be possible to avoid a hand operation.
Medical research by Messina, Loos, and Bulstrod report successful outcomes for Dupuytren contracture after using the non-surgical methods of massage, exercise and traction, yet their work receives little attention. Research interest has always been primarily directed toward high profile profitable surgery and drug therapies. Alternative medicine is not a high profit way to treat hand contracture although the Dupuytren Contracture Institute has been helping people since 2002 deal with their hand problems.
Not all people respond to Alternative Medicine, just as not all people respond well to drugs and surgery. However, the advantage with using simple and low cost natural therapies and remedies is that when they do successfully assist the body to recover from a health problem, the need for drugs or surgery is lowered or eliminated. The idea of attempting a short therapeutic trial of natural remedies first, rather than last, takes advantage of conservative ideas at the beginning of care. Later, if Alternative Medicine fails to assist the healing response then more aggressive drugs or surgery can still be used.
The Dupuytren Contracture Institute is not against hand surgery for Dupuytrens contracture. Obviously there is a need for surgery when natural methods have been unsuccessful.
The risk and limitation of Dupuytren surgery should be considered not only because of the potential permanent consequences (permanent pain and numbness, reduced finger movement, reduced hand strength) that can occur, but also because surgery is not the only option to reduce palm lumps and finger cords.
Hand surgery is not final
Two primary cautions should be kept in mind before submitting to surgery for the hands: First, even when Dupuytren’s surgery is done well by a skilled surgeon, unintended consequences occur that no one can anticipate or explain. Second, Dupuytren surgery is well known to stimulate the recurrence of additional nodule and cord formation in the palm after removal – sometimes as soon as in a single year, often three or four years. Since Dupuytren contracture is famous for recurrence within a few years after surgery, anyone thinking about a surgical option should realize that once the first surgery is done it is just a matter of time before the next surgery will have to be done. The typical pattern is that with each Dupuytren surgery the next recurrence of hand nodules will be a little faster than the last.
The only way to know for sure if Alternative Medicine will stimulate the natural healing process is to use a solid round of natural remedies for a month or two to determine if positive changes occur. If successful, then the patient should consult with her physician to learn if surgery can be avoided. If it does not help, then surgery can proceed knowing any potential risk is justified by the lack of progress with conservative methods. .
To learn about Alternative Medicine self-management, please see Different Way of Looking at Dupuytren Contracture Treatment
New Dupuytren non-surgical and non-drug treatment
Natural Dupuytren contracture treatment
Anyone who has spoken to his family medical doctor, orthopedist or hand specialist about Dupuytren contracture treatment has been told the only options are some form of hand surgery and Xiaflex drug injections. But this is not true.
There is another viable Dupuytren treatment option and that is the use of Alternative Medicine to attempt to increase the healing ability of the body. This is explained that with a better supported healing response the body will have a greater capacity to reduce or eliminate the Dupuytren lumps or cords, as well as reduce the finger contractures that eventually develop.
Avoid hand surgery and drug injections with Alternative Medicine
Dupuytren Contracture Institute has worked since 2002 with those who have had one or more hand operations, and has seen it is possible to eliminate or greatly reduce the need for a second surgery. Many of the people who work with our ideas find their doctors no longer want to do a second surgery after they make significant progress with natural therapies for their Dupuytren hand problem.
For those who never have had a Dupuytren operation, DCI suggests following a conservative treatment option that consists of a short therapeutic trial of Alternative Medicine remedies first – rather than last – in an effort to possibly avoid hand surgery. For those who already have had one or more Dupuytren surgeries, DCI suggests it is still possible to follow the conservative option but with reduced expectation. Either way it makes sense to consider natural Dupuytren treatment as a way to possibly postpone or avoid another hand surgery.
Bulstrod, Loos and Messina are well respected medical researchers who report successful Dupuytren treatment outcomes with exercise, massage and traction, all without surgery. In spite of good clinical results their work is not given much interest because research funding is always directed toward innovative surgery and high profit drugs. There is almost no financial incentive to research or document the value of the combined use of low cost natural Alternative Medicine treatment for Dupuytren contracture with, minerals, herbs, traction, massage or exercise that a person use at home.
Only a short therapeutic trial of aggressive natural treatment is needed to learn if your body can reduce or even eliminate the palm lumps of Dupuytren contracture. To learn about the wide variety of natural self-management ideas that DCI has been developing since 2002, visit Different Way of Looking at Dupuytren Contracture Treatment.
Three primary reasons to avoid surgery for Dupuytren contracture
DCI has never suggested anyone not have hand surgery when it is recommended by a treating doctor. But, DCI always recommends a patient learns the pros and cons of any therapy. There are three fundamental things about Dupuytren surgery in all its forms or the use of Xiaflex injections that should be of special interest to anyone thinking about using them.
- Recurrence of Dupuytren contracture does occur after surgery. No surgery or drug stops this problem, but delays it. Eventual return of the nodules, lumps and cords, with gradual flexion contracture of the involved finger, develops again at the rate of 50% of people five years after surgery. In later years that percent of recurrence continues to rise over time. It is commonly held that eventually any9one who has had Dupuytren surgery will experience a return of the problem.
- Dupuytren surgery removes both normal and abnormal tissue from the hand and forever changes the physical relationship of tissue that remains, therefore after surgery the hand cannot return to a fully normal state and sometimes worsens. Pain, stiffness, numbness, tissue hypersensitivity, reduced blood flow can all start – or worsen – after the kind of surgery that is done to remove Dupuytren lumps, nodules, cords and joint contracture. Common and simple activities of daily living (washing, dressing, shopping, typing) can continue to a problem after surgery because normal tissue must be removed along with abnormal tissue of the hand. Very often people who have had Dupuytren surgery learn they have simply traded one kind of hand problem for another; sometimes the new problem is less than the original one and sometimes it is worse. Anyone who thinks the hand will be like new after having a Dupuytren hand surgery will be disappointed. The hand is always compromised in some new way that can be large and small, even though the immediate problem of finger contracture is usually improved for a few years after surgery.
In conversation with hundreds of people over the years who have had Dupuytren hand surgery, the two most frequent comments are: 1. “My finger is straighter, but now I have new hand problems.” 2. “I was definitely better for a year or two, and then the hand problem came back worse than before. I think I would not have had the first surgery if I knew it would only lead to a second one so soon, and so little genuine improvement.”
No Dupuytren surgery can make the hand as good as new, although everyone I have ever spoken to about their hand surgery has told me this is what they expected as the outcome of their hand surgery.
It is true that needle aponeurotomy (fasciotomy) is less invasive than different types of open hand surgery (fasciectomy), however NA still carries the problem of a much faster recurrence rate and presents the possibility of surgical error since it is done blindly because the surgeon is not able to see the tissue he is slashing with the needle tip. For this reason, in this type of surgery the skill of the surgeon is extremely important.
- With each hand surgery that is done, the next hand surgery will be more complicated and subsequent risks greater because there is less normal tissue remaining in the hand and the increased development of scar tissue. The younger a person is when the first Dupuytren surgery is done, the more likely that person will need a second, then third, hand surgery. If enough surgeries are performed it could happen that eventually no additional surgery can be done – no matter how painful or useless the hand becomes. When this point is reached sometimes patients opt for finger amputation.
The Dupuytren Contracture Institute estimates that at least 80 percent of the people experience a moderate to marked degree of improvement of their hand problem within the first two to three months of Alternative Medicine treatment, when they faithfully follow our treatment suggestions for use of an aggressive therapy plan, using the therapy products found within this website. Substituting bargain brand or questionable products while trying to treat this kind of deep soft tissue problem is not wise, and usually leads to disappointing results.
What is the difference between Dupuytren contracture and Dupuytren syndrome?
Occasionally the term Dupuytren syndrome appears when researching the subject of Dupuytren contracture. It might appear to those who do not know the actual meaning of the term syndrome that a Dupuytren syndrome might be something different – perhaps less serious or more serious – than the more conventional terms of Dupuytren contracture or Dupuytren disease.
A good place to start is with a discussion of these different words.
Syndrome – generally, a collection or group of signs (objective findings that are observed by someone else) and symptoms (subjective complaints that are felt or experienced that cannot be proven by the person who is feeling them) that are known to commonly appear together, but without a known cause to explain their occurrence.
Sometimes the word syndrome is applied to a condition or disorder when there is strong agreement about a cause, when there are multiple alternative or contributing factors that it is not possible to isolate the cause to one single factor. This is true of Dupuytren contracture since it is commonly agreed that there is a strong genetic cause of the condition there are also several contributing and overlapping issues that cloud the causation of the problem (liver cirrhosis, diabetes, trauma, lung disease, etc.)
Because of the way the word syndrome is used, laypeople might get the impression that a syndrome is something less serious than a disease or that it is a made-up or imagined problem. That is not the case. The last part of the definition explains that the most important point is that a syndrome will not have a known cause or reason to explain the problem.
Some examples: Carpal tunnel syndrome, Gulf War syndrome, Premenstrual syndrome, Reye’s syndrome, Down’s syndrome, etc.
Disease – a health disorder in a system, organ or part of the body that adversely affects the body’s function, and fulfills at least two of the following criteria:
- Known group of signs and symptoms
- Known and identified cause
- Consistent anatomic or physiologic changes due to the disease
In regard to Dupuytren contracture is simple to see that the term Dupuytren disease is accurate since it does fulfill all of the definition requirements.
Contracture – a chronic and unrelenting state of tightening or shortening of muscle, tendon, ligament, or skin that prevents a normal range of movement of the involved area.
Therefore, there is nothing wrong with the term Dupuytren syndrome, it is a legitimate term for this problem; the same can be said for the term Dupuytren disease. All of these are legitimate terms to use. However, on this website we have maintained the use of the term Dupuytren contracture as the preferred term because it is a more descriptive term that accurately defines the palmar and finger contracture as the central aspect of this hand condition.
No confident answer can be given to this question based on this single finding of fingers that are stuck in the bent position. One of the possible reasons for fingers that won’t straighten out is Dupuytren contracture.
Good news about Dupuytren contracture treatment and those bent fingers
Surgery is not always necessary to restore the limited finger movement of Dupuytren’s contracture. Since 2002 the Dupuytren Contracture Institute has helped people from all parts of the world use natural Alternative Medicine therapy to help those who can’t extend their fingers because of DC. Our position has always been that while hand surgery is always an option, it makes sense to first attempt non-surgical treatment and therefore possibly avoid the inherent risks of surgery.
What is Dupuytren’s contracture?
Dupuytren’s contracture is a soft tissue problem of thickening and shortening of the deep supporting tissue of the hand (palmar fascia), found immediately above the bones and tendons and below the skin of the hand. This thickening and shortening that takes place below the skin surface causes lumps on the palm of the hand that results in constricted fingers that are bent down toward the palm preventing the hand from being opened without pain.
Dupuytren hand contracture is slowly progressive as the nodules or lumps on the palm of the hand cause the involved fingers to not straighten out and permanently get stuck in the flexed position with the fingertips toward the palm. Both hands are affected half of the time, and the right hand is more often affected when only one hand develops the problem. One or more fingers can be affected at the same time; usually the ring finger won’t extend or the pinky finger won’t extend – or both fingers can’t open normally.
The cause of Dupuytren’s contracture is unknown, but it does appear to have some strong genetic association since seven out of 10 people who are diagnosed with Dupuytren contracture have a family history of the condition. Further supporting the genetic input of these hand nodules is the finding that those people who have a Scandinavian or North European ancestry (Ireland, England, Wales and Scotland), are far more likely to develop hand nodules than dark skinned people. It is more common in those over 40 years of age, and men (70%) more often women (30%). There is still controversy and diverse opinion about the unclear relationship of other disease and environmental factors and the development of Dupuytren contracture:
- Liver disease
How do I know it is Dupuytren that is causing my fingers to not straighten out?
As discussed above, there are more than one reason to explain why the pinky and ring finger won’t extend. The reader can develop a fairly confident conclusion if the hand stiffness is due to Dupuytren contracture when several of these factors are present:
- Age 40+
- Family descended from England, Ireland, Scotland, Wales, or a Scandinavian country
- One or more family members have Dupuytren contracture
- Palm lump at the base of the pinky and/or ring finger
- Treated for epilepsy
- Alcohol abuse or liver disease
Is this the only thing that could cause my ring finger to not straighten out any more? Why do I have a bent little finger now?
First, let’s consider the obvious cause for a lump or density to appear on the palm of anyone’s hand, so you do not have to worry this common and normal palm nodule. If you have recently begun using your hands in a new way (a new job in a factory or construction, recently started a hobby like gardening or wood working, or heavy housework for a few days in the springtime), that small painful palm lump might be a callus. Think back to what new activities, or greater work associated with old activities, that could prove your hand nodule is nothing abnormal.
If you cannot otherwise account for the new lumps on the palms, then it could be a rather common condition called Dupuytren’s contracture.
Let’s also consider another explanation why the hand will not open as it once did: trigger finger (stenosing tenosynovitis). This is really not anything more than a swollen tendon in the palm of the hand that periodically locks up finger movement when it encounters a narrowed part of the tendon sheath that surrounds it. Any finger or thumb can display a trigger finger reaction in which the affected digit suddenly catches while in a bent position and just as suddenly releases the hold – like a trigger when it is pulled and suddenly snaps as it is released. Trigger finger can be occasional or frequent, mild or severe, locked in a bent position for a short or prolonged time, and mildly or severely painful.
The great differentiation between the locked finger of trigger finger and Dupuytren contracture is the trigger finger has a very sudden onset and release with a popping sound, and it is apparently normal between episodes. While the stuck finger of Dupuytren contracture is slowly progressive, and does not release because it is constant.
Let’s explore this problem through a few questions commonly asked by people who want to know more about their inability to extend their fingers.
Are the Dupuytren nodules or cords a type of tumor of the hand?
No, Dupuytren’s contracture is not a cancerous tumor, although certain hand problems that also cause hand pain, reduced finger movement and swelling are cancers (giant cell tumor or epitheliod sarcoma). This is the reason it is strongly suggested to have your doctor evaluate your hand complaints and determine a clear diagnosis of the condition that is causing the problem straightening out the fingers and making it so you cannot open your hand without pain.
What keeps my fingers bent all the time and why won’t my fingers straighten out?
Dupuytren contracture begins as a thickening of the deep tissue of the palm (palmar fascia), located below the skin and above the bones and tendons of the palm. This thickened state slowly progresses and the involved tissue also shortens at the same time, gradually allowing less and less movement until the fingers are constricted completely into a modified fist. In the early stage of Dupuytren contracture as the palm lumps develop, it is not possible to flatten the hand on a tabletop and pain accompanies it. Later as cords develop from the nodules, the reduced finger movement makes the stiff fingers more pronounced until they come closer to the palm of the hand.
Is this why my pinky finger and ring finger won’t extend open?
Exactly. People comment that when their Dupuytren contracture starts they can’t open the hand without pain and they experience great clumsiness. Over time this changes to gradually prevent the involved finger so it won’t straighten out completely, sometimes eventually constricting finger movement completely.
Is this the reason I can’t open my hand without pain?
Pain is a common complaint when Dupuytren contracture begins, often described as constant stinging and burning pain wherever there are lumps on the palm of the hand. Over time as each finger gets stuck in a constant bent position, less pain is felt usually.
Generally, Dupuytren contracture is not thought of as a very painful condition; it is known mostly for the bent fingers, inability to fully open the hand, and the palm lumps.
What does “recurrence rate for Dupuytren contracture” mean?
Dupuytren contracture is famous for the fact that in about half of the cases the problem returns about five years after hand surgery. For some people the reappearance is as soon as one year after an invasive operation to remove the cords, nodules and contracted hand tissue. Many people are disheartened to learn that surgery and Xiaflex injections are not a final answer to their hand problem because of Dupuytren recurrence.
Consider a brief delay of Xiaflex injections to see if natural remedies might help
The Dupuytren Contracture Institute is not against Xiaflex injections or surgery for Dupuytren’s contracture. Since 2002 our position has always been to recommend surgical intervention in those cases that have not responded to an aggressively applied round of conservative Alternative Medicine therapy. If a brief therapeutic trial of natural Alternative Medicine treatment has limited results, we then advise to have an evaluation from two doctors who specialize in Dupuytren’s contracture for possible surgical or Xiaflex intervention.
However, there are those who approach the management of their Dupuytren contracture in the reverse order: They first have hand surgery for their Dupuytren’s problem and only after the problem recurs do they consider conservative treatment.
People from around the world report they rushed into having a hand operation, not knowing of the possible side effects and recurrence issues that develop after invading the area of Dupuytren’s disease. It is DCI‘s opinion that it is safe and reasonable to attempt to improve the body’s ability to heal and repair the problem of Dupuytrens contracture by aggressively using several conservative Alternative Medicine treatment measures for a short time. We strongly suggest that anyone with Dupuytren contracture works with what is known and what is available – even if it is not perfect – before submitting to potentially risky surgery. If DCI’s conservative concepts do not improve or eliminate the hand lump, Dupuytren’s surgery can always be done later.
How low is the Dupuytren recurrence rate after Xiaflex treatment?
Auxilium Pharmaceutical, manufacturer of Xiaflex collagenase injections, boasts that in a two-year study Xiaflex had a recurrence rate of 19.3 percent, a considerably lower rate of return than those who used surgical procedures to treat their hand problem.
The answer to the question “Is the Xiaflex recurrence rate for Dupuytren low?” is a qualified yes and no.
Yes, Xiaflex or collagenase treatment results in a considerably lower Dupuytren recurrence rate than hand surgery. However, this does not necessarily mean that the rate of recurrence is actually low; it only means the problem will come back slower than what happens after invasive hand surgery. The reality is that hand surgery has a tremendously high recurrence rate, so a non-surgical therapy option by comparison will look favorable.
Every child learns that pointing to someone who has done something worse than you does not diminish his crime. When you told your mother that the child next door stole 25 cents from his mother, you were trying to make yourself look pretty good for stealing only 10 cents from her purse. Your mother was not swayed by the faulty logic of a scared child. In the final analysis, even though the numbers were different, both children did something wrong.
And along a similar line of thought, 19.3% recurrence is still a high rate for Dupuytren contracture to come back after being subjected to an invasive medical procedure that carries risks, even though there are other treatment methods that have a considerably higher rate of recurrence.
Most surgeons will admit that any type of physical invasion into the palm (like with surgery or injections) seems to accelerate the progression of Dupuytren’s disease. Patients note that their previously slow progressing hand contracture not only recurred after surgery but worsened at a faster rate.
Perhaps a better question to ask is, “Would you want to undergo an invasive medical procedure like a Xiaflex injection series, knowing that 20 out of 100 people will have to do it again in two years?” The answer should take into account that more injections might not be as simple and uneventful as receiving the first Xiaflex injection.
Xiaflex has a short history of treatment of Dupuytren contracture
Since Xiaflex was given FDA approval for Dupuytren contracture treatment in early 2010, not enough time has lapsed and not enough patients have used this procedure for the FDA to know sure what will happen to those 19.3% of patients who have recurrence within two years after receiving a second – or third or fourth – injection series.
For example, recent research information released about Xiaflex at the three year follow-up shows that 34.8% of joints with initial clinical success experienced recurrence, considerably higher than the 19.3% recurrence rate reported at the two year mark. It is reasonable to speculate that the Xiaflex recurrence rate will continue to increase at the four and five year follow up marks, bringing Xiaflex recurrence much closer to the frequency of hand surgery.
There are two valid issues to consider about repeated injections with a new drug like Xiaflex:
- When Xiaflex is injected to dissolve the collage cord of Dupuytren’s contracture it carries the risk of physician error and unintended drug consequences, such as injection into a nerve or artery, accidental leakage causing destruction of tendons or muscles, or drug side effects.
- No one knows the long term consequences of multiple Xiaflex injections over time into the same area. After all, 70% of people who receive their first Xiaflex injections find that the Dupuytren cord does not break as it should; they must return one month later for another series of injections; if this does not work, they again must return in one month later. The manufacturer does not recommend that anyone receives more than three series of Xiaflex injections if it did not dissolve the cord by that time. In this way the manufacturer of Xiaflex is admitting there is a reasonable limit to how often and how much this drug can be used for the same cord.
Return of Dupuytren after hand surgery
There are two common types of Dupuytren hand surgery. The first is palmar fasciectomy (cutting the palm open to remove the deep connective tissue of the palm and collagen cords) with a 35% recurrence rate after two years. The other is needle aponeurotomy or palmar fasciotomy (inserting a needle into the palm and blindly slashing at the Dupuytren cords wit h the tip of that needle) with an 85% recurrence rate after two years.
By comparison, yes, the Xiaflex return rate of 19.3% recurrence at two years is lower than aggressive surgery. However, this recurrence rate for Xiaflex is said to be low only because the recurrence rates for the other types of surgery are so terribly high by comparison.
At the Dupuytren Contracture Institute we take the position that it is better to avoid the risk the hand problem will return after undergoing any kind of hand surgery by first attempting Alternative Medicine natural Dupuytren treatment.