Why not perform hand surgery before my Dupuytren contracture gets worse, while it is still small?

Hello: I have just recently been diagnosed with Dupuytren’s contracture. I noticed a small hard bump/lump appear in the palm of my right hand, as well as one on the bottom of my right foot. I have just turned 50 and I am female. If the outcome is ‘black and white’, why not perform hand surgery to remove the bump BEFORE it grows into a long band deforming the fingers / toes?  Why wait ?

 

Greetings,

The answer is simple:  Dupuytren contracture recurrence after surgery. For more discussion of this topic see Dupuytren Surgery and Recurrence of Hand Contracture.

You are a little younger than average to develop Dupuytren’s contracture (hand) and Ledderhose disease (foot), and for this reason you are more likely to have an ongoing problem with Dupuytrens; the earlier in life it starts, the more aggressive and difficult the palm lumps and cords tend to be.  Your doctor is trying to delay your surgery for Dupuytren’s contracture to delay the time when your first recurrence starts.

Let’s say you had hand surgery the way that you propose.   If you had your first Dupuytren’s operation at age 50, it is possible to have your first recurrence start within two years.  Following your idea of early surgery to prevent progression of the problem, let’s say you had your  second hand surgery as soon as the recurrence appeared, and the next Dupuytren’s recurrence again appeared within the next two years.   Following your idea of early surgery to prevent progression of the problem, let’s say you had your  third hand surgery as soon as that next recurrence appeared,  and the next recurrence again appeared within the next two years.   Again, you would theoretically have another surgery for Dupuytren’s recurrence, with another recurrence, and so on. 

The above example does not work for three reasons:

  1. Recurrence of Dupuytren’s contracture tends to accelerate with each surgery, so that if the first recurrence did take two years to eventually develop, the net recurrence would be a little faster or sooner; maybe 18 months.  And if you had another hand surgery after that recurrence, the next recurrence would theoretically be even faster or sooner; maybe 12 months.   Of course, all these numbers are just made up, and could be faster or slower depending on your individual characteristics, family history, life history, clinical information and luck.   Some people wait 10 years for their first recurrence of Dupuytren’s contracture, but some people wait just a year – or even less for their first recurrence to appear.  Once the surgery starts, the process of recurrence starts; it is inevitable.   
  2. Each Dupuytren’s surgery “uses up” or removes normal hand tissue.  You cannot have too many hand surgeries without soon having little normal tissue remaining.  Depending on your individual circumstances you might only be able to have one, two or three hand surgeries in your life before your surgeon would inform you that you cannot have any more.   What do you do at that point?  You allow it to get worse, and perhaps become so bad in terms of pain that amputation is your only option. 
  3. No good surgeon would perform an early Dupuytren surgery, such as you have proposed.  Hopefully you would never find a surgeon who would agree to cut early, because he/she would know that this would be a terrible decision that would lead to a terrible result.  

There are drugs that have risks that can be used, and there is surgery as an option for you to consider. I suggest that you should consider trying to avoid Dupuytren’s hand surgery completely.  Since your problem is early and small at this time you are in a good position to try to reverse this process naturally.  I suggest you do some reading to see if this makes sense to you.  You can always try it for 2-3 months of intense natural therapy while you are waiting for your Dupuytren’s to progress.  If it work, fine – look at what you have gained.  If it does not work, as sometimes happens, you can always have your hand surgery when your surgeon thinks you are ready for it.  

For further information about treating Dupuytren’s contracture naturally you can read What is the best therapy to treat Dupuytren contracture?    TRH

What should I change in my Dupuytren treatment plan?

Hi Dr. Herazy,

I am about to place my third order with you. I wanted to let you know about my 5 weeks of treatment so far. I started with your medium Dupuytren’s contracture treatment plan. For 2 weeks I have been taking 5 Neprinol capsules with 2 fundamental sulfur 3 times per day. I find it difficult to find times in the day where I haven’t eaten or plan to eat within 2 hours. I try to take one dose when I wake up in the middle of the night to visit the bathroom. Additionally I am taking your vitamin E and PABA (2 caps ea) once per day. I also try to take Scar X twice per day. Lastly I use topical vitamin E, copper serum with DMSO. This topical Dupuytrens treatment has really softend the surface of my palm. Callouses nearly gone.

I must say, it may be early in treatment but I have not noticed any difference in the dupuytren cords or nodules as far as reduction in size or hardness. I must tell you the unexpected good news about my foot. Plantar Fibroma (aka soft lumps) on the sole of my right foot. they are notably smaller. I have had them for 10 years at least. This to me is proof that your treatment is doing something. These foot lumps are not as hard as the hand dupuytrens lumps.

Additionally I have had 2 dupuytrens surgeries. First one in 2009 needle aponeurotomy. It was quick, some sharp pain during surgery. Results lasted about 3.5 years and grew back. My second surgery was just in Sept 2012. I tried Xiaflex. Dr. injected into the main cord only. It softened the cord enough where he could release it. I could hear and feel it snap like a rubber band. This is when I started your treatment. I am hoping your methods will at least prevent the cord from growing back. I still have cords running up my ring finger and in the web between my ring and pinky.

My questions to you are: what should I change? More Neprinol? or something else? I know you say its trial and error. I was just wondering if you had any comments or recommendations. I am sure these hard firm bands will take more time. But question the treatment plans effectiveness.

Also. When I wake I take my morning Neprinol dose with coffee. I know you say water but I can’t find three times per day where I can commit to 3 doses for 2 hour periods without some kind non-water intake. does caffeine negate the enzymes?

What about wine in the evening? Is that a no-no too?

Thanks for you help.

Jim VH

 

Greetings Jim,

Congratulations on the early progress you are making with the several problems you are dealing with. Five weeks is not a lot of treatment time and your therapy levels apparently have made some good tissue changes for you to be able to notice them so soon.  

What you have going on that puts you in a slightly different (and more difficult) category than a lot of people is that you have had multiple surgeries and you have more than just a Dupuytren’s contracture problem to correct. People who have had Dupuytrens hand surgery tend to take longer to recover while using Alternative Medicine, bu then again people who have had Dupuytrens surgery need this work a lot more since they have seen that recurrence of the lumps on the palm and cords is a real problem.  You cannot continue to have hand surgery when the problem will always come back, because a surgery or two more you will run out of tissue for the surgeon to work with.  At that point you will be worse off than before the surgery.  

I have worked with many people in the past who had plantar fibromas just as you do and I find that this tissue drains a lot of the Dupuytren treatment products away since it competes for them at the same time you are attempting to reduce the nodules and cords on your hand.  The more of these soft tissue problems that are present, the more therapy products that the body will need to address them all.  There is no way, other than the topical or external therapies that you use, to direct or select where the internal therapies will be used by the tissue; the rule apparently is an equal distribution since they travel in bloodstream.  I am confident that if you only had Dupuytren’s contracture and not the plantar fibromas to deal with, your current plan would be giving you greater improvement with the hand contracture problem. 

I suggest that you reduce the vitamin E to two capsules daily, total.  Also, I suggest that you consider taking perhaps three Neprinol more than your current dosage, and that you add these additional three to the end of the day when they will stay in your stomach and bloodstream longest while you go the longest time without eating.  You might also consider adding in acetyl-L-carnitine to your plan, starting at 3-4 capsules daily. 

Taking your Neprinol with coffee is not a great problem since caffeine does not influence the enzymatic activity or availability in any way.  Limited wine intake is also OK.    TRH   

Is my hand problem a cyst or Dupuytren contracture?

dear dr. herazy, 

my name is mark c, and  i have a question concerning my hands.  on my left hand, immediately under my ring finger, it look’s like i have a cyst! very hard to open my hand fully. in the middle of the hand i see something like a tendon sticking out and it appears to be  connected to the cyst. i also have a little one starting on my left hand. i can’t fully extend my left hand flat out because of the cyst.  i have heard there are alternative procedures for my ailment, like cortisone shots, etc. i do not know if i have a cyst or dupuytrens.

thank you for your time,

 mark c.

 

Greetings Mark C,

Thank you for writing to ask about the problem with your hand.

Based on the way you describe your hand problem, and the fact that you did not say so, I will assume that you have not seen a doctor at this time for the problem you are having with your hand.  This is a mistake.  You should see a doctor in your area about your hand so you will know exactly what the problem is that is causing your complaints.

Further, since you are having a problem of a mass located near the base of your ring finger and trouble flattening your hand and cannot open your hand fully, along with the appearance of what looks like a tendon connected to the palm lump, your description does make it sound like you have Dupuytren’s contracture.   

If it turns out that you do have Dupuytren’s contracture it would be helpful to determine if you can increase the ability of your body to remove the dense fibrous tissue that is developing in both of your hands by using Alternative Medicine methods as are outlined on the DCI website.  Many people find improvement after aggressively following a plan of treatment for a few months of self-administered care.   If after this time you do not see improvement in your problem then you can always consult with a surgeon to discuss hand surgery, although Dupuytren surgery is always eventually followed by recurrence of the same problem – usually within a few years.

Once you know the exact cause of the problem you will know how to proceed.    TRH

My Dupuytren’s surgery lately is going badly; do you have any suggestions for me?

Hello Doctor,

I had Dupuytren’s surgery on my right hand on August 3, 2012. Most of the surgery involved the area below my little finger with the incision extending upwards to the adjoining ring finger. A nodule on my palm was also removed from the base of my thumb. I began therapy on August 31, after complaining about the pain. After 3-4 sessions, the therapist felt I was progressing well enough that it wasn’t necessary for them to check my progress.

My concern is that lately I am experiencing some numbness in my fingertips, wrist pain, and a shooting pain up my right arm. Also, I am unable to make a fist when I wake up. It generally takes 2-3 hours before I can make a normal fist without too much pain. I continue to do the prescribed exercises and wear an Isotoner glove each night.

It appears to me that my healing process is going in the opposite direction it should be going after surgery, as the pain and lack of range of movement and poor flexibility were not that apparent 3 weeks after surgery. I’m regretting the surgery already, as I can no longer workout with weights or anything that requires squeezing.  Do you have any suggestions for me?

Thank you for any help or ideas you can provide.

 

Greetings,

While you did not name the type of Dupuytren hand surgery you had, based on your very brief description and commentary I will assume (but feel rather confident) that you had some type of palmar fasciectomy, with several different types possible depending on the amount of tissue removed during hand surgery. 

To understand this hand surgery it would be good to first explain the term, palmar fasciectomy. The word palmar refers to the palm of the hand, that broad area of the hand that is in contact with anything being held and to which the fingers are connected.   The word fasciectomy refers to surgery that is performed to remove fascia from the body.  Fascia is a thin but tough layer of soft fibrous tissue that covers, surrounds and lines all tissues, organs, structures and cavities of the body.  Fascia is as thin as, and in a way is used in the body like, the plastic Saran wrap that is used to cover and protect food.  You can see fascia as the pearly white thin tissue membrane found in cheaper grades of roasts and steaks.  There is normally a considerable amount of fascia tissue in the palm of the hand to provide extra strength, durability, support and protection during the heavy work done by the hands. 

The “-ectomy” ending of the word fasciectomy indicates the surgery is done through an opening in the skin, and that something is removed during the surgery – fascia in the case of a fasciectomy. 

The exact course and degree of tissue removal performed during a palmar fasciectomy is based on the patient’s age, occupation, family history of the Dupuytren’s contracture, duration, location and severity of finger  contracture or degree of reduced range of motion, level of disability, general health, as well as history of previous hand injury and prior hand surgery. 

With that explanation out of the way, let us discuss your situation. 

It is probably important to DCI readers that your email was received on October 15, 2012, approximately two and a half months after your hand operation.  This means that for approximately the first three weeks or month after your Dupuytren’s surgery your progress was good, but you are saying during the next six weeks you are having new hand and arm symptoms and that you now feel you are regressing.

You did not mention if this was your first Dupuytren’s surgery; this is important in regard to how you decide to manage your hand problem.  Since you did not mention prior hand surgery I will assume there was none. 

Your description of a very brief period of improvement – in your case about a month   followed by gradual appearance of numbness in the fingertips, wrist or hand pain, shooting pain in your  arm, stiffness and weakness in the involved arm is not uncommon for someone undergoing the rapid recurrence of Dupuytren’s contracture. There are many adverse things that can and do sometimes happen after even small or simple hand surgery that are totally unintended and unexpected.  Please see Dupuytren’s surgery risks for palmar fasciectomy for further discussion. 

I have no way of knowing if that is what is happening with you, but your flare up of symptoms fits in with the way that DC will always recur after surgery. On the other hand you could be going through some temporary complaints that are easily explained and common and consistent for the kind of Dupuytren’s surgery you had.  At this point I think you need to get some answers from someone who has direct knowledge and experience with the kind of surgery you had.

I suggest you go back to your surgeon and tell him exactly what you explained in your email to me.  If you receive a response that does not make sense to you, or you get brushed off with a hasty and unsatisfying reply, I suggest that you go for another opinion from a surgeon that is not associated with the surgeon who did your operation.     

Your story is a lot like many people who send me emails or call to discuss their results and side effects after Dupuytren hand surgery; I hear of bad results frequently and some much worse than what you are reporting.  From my perspective in doing this work since 2002 I observe that poor surgical results and aggravation or worsening of the original hand problem happen much more often than patients are being told prior to surgery; it seems that surgeons downplay the poor results and permanent pain, increased scarring, numbness and weakening that can happen.  They also seem to downplay the speed of Dupuytren recurrence; for some people it is never mentioned although it always recurs.   This is an unfortunate situation I hear about frequently.     

Lastly, I suggest that you consider doing your best to avoid additional hand surgery if at all possible.  The DCI site is all about the successful use of Alternative Medicine to support an encourage the natural healing of the Dupuytren’s nodules and cords.  Please spend some time looking over this information to see if it makes sense to you.  Let me know if I can assist you in any way.   TRH

 

How are the Dupuytren contracture therapy products used?

Hi Dr Herazy. I have Dupuytren contracture on both hands. I had surgery to cut the contracture and my Dr applied a Digit Widget on my right ring finger. Once my finger gets straighter I will then have surgery to remove all of the cording. I am very interested in your treatment plan to hopefully eliminate the need for that surgery. Which plan do you recommend and how are the products used? Are they all applied topically? Thanks – I’m looking forward to your response. Regards, Vee Cluley.

 

Greetings Vee,

You are wise to want to avoid Dupuytren’s surgery since none of the operations will cure the problem, and the hand contracture will always come back in a few years.

I always recommend that a person uses the most aggressive plan they can afford, since the more variety and depth of therapy that is used offers greater opportunity for improvement.  The Dupuytren medium plan is the most popular, but the large plan gets best results.  The greatest cost difference is just getting started, and after that the medium plan averages about $90-105/month to continue and the large plan averages $95-110/month to continue. 

Full instructions come with the order that you place; whatever you order we include detailed instructions to use all items so you are comfortable you know what to do. 

Some items are applied topically (DMSO, vitamin E oil and Copper peptide, Genesen pens) while the others are taken orally. 

Let me know if I can help you in any way.  TRH