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Do Xiaflex injections really have a low Dupuytren recurrence rate?

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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.

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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:

  1. 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.
  2. 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.

Should I have a third Needle Aponeurotomy surgery for my Dupuytrens?

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Dr. Herazy,

I have dupuytren contracture in my little finger on my left hand and have had needle aponeurotomy done on it twice.   It is aggressive and I was considering the procedure a third time  and just heard about you.  I’d like to try an aggressive treatment with you instead–have I missed an opportunity to improve my situation because of the needle aponeurotomy sessions (because of  scar tissue,etc)?

I’d like to speak to you about it if possible – I have a third needle aponeurotomy session scheduled two months from now (28 Nov) that I’d like to cancel…the contracture comes back quickly and the finger is a bit thicker.  Any advice??

Thank you in advance for your attention to this,

Scott Riviere

 

Greetings Scott,

Needle aponeurotomy is well known for rapid recurrence of Dupuytren contracture.   Although you did not say how quickly your Dupuytren’s returned after your first and second hand surgery, it is not uncommon for the palm lumps and cords to come back back in two years or so, with the rate of recurrence increasing after each NA surgery. 

The increased thickness of your finger could be due to chronic swelling or edema that is the result of scar tissue that prevents normal drainage of blood and lymph fluid out of the hand.   Or, it could be directly due to scar formation from the internal cutting that is part of the NA technique.  Either way, this is a frequent side effect of hand surgery for Dupuytrens.   

The rapid recurrence of Dupuytren contracture after needle aponeurotomy and scar tissue build-up are two of the nasty consequences of this kind of hand surgery simply because, as you have found out, the technique not only solves nothing but it can leave you worse off than before it was done.      

My advice is that you be extremely cautious about undergoing a third needle aponeurotomy.   What has your surgeon told you about the possible outcomes of a third NA if the first and second did not help you and resulted in undesirable side-effects?    Did he/she say why you should expect the results of this third surgery to be any different than the first two?   Did he/she warn you about further acceleration of the rate of recurrence with each succeeding NA procedure?   Did he/she warn you about the increasing risk of possible injury to blood vessels, nerves and tendons that occurs with each succeeding hand surgery?    Did he/she warn you that these hand surgeries would eventually have to stop?   Did he/she speculate what the eventual condition of your hand might be if you had 4-5-6 surgeries, and how useful, painful, numb or flexible your hand might be?   did he/she discuss with you what your options might be when you can no longer have additional NA surgeries?

Please be even more cautious if you are told that this next surgery will be more extensive to reverse or clean up the problem scar tissue that resulted from the others.  I have never heard of any  “clean-up surgery’ that goes well for the patient; usually it goes in the opposite direction and creates more problems.   Mind you, I am not saying to not have the surgery and I am not saying to not listen to your doctor, I am just saying to use the highest level of caution and prudence when you make this decision.

Time will tell how effective an aggressive Alternative Medicine treatment plan might be to help your current condition.  I have worked many times with people who have a history of past hand surgery who find their problem worse than when they started; some make great improvement, while most make at least a small to moderate amount of change; very few do not at least make some small level of improvement.   I cannot answer you directly about how effective natural therapy might be for you, but considering your options I suggest you consider undergoing an intense round of therapy for 2-3 months to determine how much change your body can make.   You will only know for sure when you give it your best effort.   

I would be pleased to speak to you about your Alternative Medicine treatment options.   The important thing is to not make matters worse at this point.   Simply call me at 847-670-8800.     TRH

 

 

 

Can Dupuytren contracture recur after I have hand surgery?

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Recurrence of Dupuytren contracture is common and impossible to predict

In general, Dupuytren contracture recurrence means that is spite of hand surgery, the shortened, thickened tissue appears to return to the area of previous surgery, but actually is a continuation of the extension or progression of the disease into tissue previously unaffected.  Many surgeons openly speculate that Dupuytren contracture surgery accelerates the rate and extent of the disease progression.

In broad terms, the rate of Dupuytren’s recurrence after needle aponeurotomy (palmar fasciotomy) is considerably higher than for traditional open hand surgery (palmar fasciectomy).

Avoid surgery if possible with natural Dupuytren treatment

Any type of hand surgery done to release the contractures of Dupuytren disease can eventually result in the return of more contractures.  This recurrence if followed by another hand surgery can result in the return of more contractures eventually.  While this cycle of surgery and reappearance of more contractures proceeds, the patient is exposed to the potential risks of hand surgery each time it is done: permanent numbness, reduced finger movement, reduced hand strength, reduced sensations and pain.

To avoid this cycle the patient should consider the use of a brief therapeutic trial of Alternative Medicine as a conservative and essentially risk free option that could make surgery unnecessary.

Dupuytren’s surgery, even when done well, can have bad unintended consequences as well as stimulate the recurrence of additional nodule and cord formation in the palm.  Since 2002 this website has suggested that anyone with Dupuytren contracture should first consider conservative treatment options before attempting irreversible surgery.  To learn about Alternative Medicine self-management, please see Different Way of Looking at Dupuytren Contracture Treatment

What is Dupuytren contracture recurrence?

The wide range of recurrence rates represent only gross estimates because there is no formally accepted definition of this term, so what characterizes a reappearance of Dupuytren contracture varies from one study or doctor to the next.  Recurrence of Dupuytren contracture can be:

  1. A finger or hand that received a prior Dupuytren surgery had to be operated on again for any one of a variety of reasons.
  2. The condition of a finger or hand worsened after hand surgery, without evidence of even initial improvement.  Sometimes the worsening is determined to be any degree of flexion deformity greater than prior to surgery, and sometimes must be a 5-10 degree increase.
  3. The condition of a finger or hand was initially good after Dupuytren surgery, but after time some degree of finger flexion returned to that finger or hand.  Sometimes the return is determined to be any degree of flexion deformity greater than the level of correction initially provided after surgery and sometimes it must be a 20-30 degree increase greater than the level of correction initially provided after surgery.

“The greatest French surgeon of the 19th century,” Guillaume Dupuytren, battled with the problem of reappearance of this disease after surgery. He experimented with a variety of tactics and methods to minimize the return but none were totally successful, just as it is today.

How often does Dupuytren contracture come back after hand surgery?

The general consensus is that after having conservative surgery by needle aponeurotomy, 50% of patients see a return of the same or worse contracture just three years later.  But after having more invasive open hand Dupuytren surgery, 50% of patients will notice a reappearance of the same or worse contracture five years later.  It seems that Dupuytren contracture will tend to come back over time to the same 50% group, but for needle aponeurotomy patients it happens much sooner.

In 2011 the partial fasciectomy is still the most common surgery for Dupuytren contracture.  In this operation the diseased tissue is completely removed and perhaps parts of the palmar aponeurosis might also be excised.  In 1990 McGrouther reported after this kind of surgery anywhere from 2 to 63% of surgery patients will have their Dupuytren tissue changes  reappear, while in 2007 Schwartz reported 44% recurrence after these same surgeries.

MedScape News Today reported in February of 2011 that contracture recurrence rates range from 27% to 80% after palmar fasciectomy (open hand surgery), and are highest  when this technique is used on  the PIP joints of the fingers. This same Medscape commentary reported 65% to 85% contracture problems recur after palmar fasciotomy (needle aponeurotomy).

Little information for laypeople about Dupuytrens returning after hand surgery

Many patients research on the web or elsewhere for information about Dupuytren contracture surgery.  Usually they find little information explaining that the palmar nodes and cords often   reappear a few years, sometimes as soon as one year, after surgery.  While attempting to learn about Dupuytren surgery from a medical website – and recurrence in particular – the reader will often encounter only a single sentence that mentions the word “return” or “recurrence,” with rarely any discussion or statistics to explain the scope or frequency of the problem.  A large medical website promoting palmar fasciectomy or needle aponeurotomy might only comment, “After surgery, a therapy program of massage, wound care, exercises and night time splinting is important to get the best possible result and prevent recurrence.”

While it can be said that such a website does inform people about the possible return of Dupuytren contracture after surgery, the usual mention is so vague and casually presented that a potential surgical patient will not understand the rather high rate at which the nodules and cords come back after being surgically removed.  With limited information being the norm it is difficult for anyone to develop a clear understanding of how often, how quickly, and how problematic is this return of the Dupuytren’s contracture problem after undergoing a surgical release of the constricted fingers.

It is almost as though the popular medical information sources are reluctant to reveal that while Dupuytren surgery can improve the palm and finger contractures for the short term, the results are somewhat temporary and have no beneficial effect on the eventual progression of the disease.

This would explain why over the years the majority of people I encounter through the Dupuytren Contracture Institute are completely surprised and unprepared when they have a reappearance of their hand contractures after surgery; most thought that once they had the  hand operation their problem was solved and would not come back again.  Over and over I learn these people were not told about Dupuytren’s recurrence by their surgeon, or that the idea of needing a second operation was presented as a genuine rarity.  It is a serious problem when patients cannot provide informed consent for their hand surgery because they have not been given adequate information about the post-surgical return of Dupuytren nodules and cords.

Final comment, Dupuytren reappearance after hand surgery

In 1964 Weckesser stated. “In general, the longer the follow-up period [after Dupuytren’s disease surgery], the lower the percentage of good results.”  This means, of course, that surgery for Dupuytren’s contracture does not stop the disease process or prevent its return, but only provides a temporary break from the contractures. This would not be too bad if the time between surgeries was longer or if side effects, or complications from surgery did not make the problem worse for some patients over time.

Better to avoid the first hand surgery if possible.