Wednesday, April 2, 2014

Treating Dupuytren's - Acoustic Shockwave Therapy

Treating Dupuytren's

In many cases no treatment is necessary if the condition lies dormant, causes no problems and and does not progress.
Surgery to straighten bent fingers has long been the
established method of treatment, but in recent years new treatments have
become available to deal with the earlier stages of the disease. Some
of these treatments, such as Radiotherapy and Collagenase injections
might not yet be available on the NHS, but all are available from
private clinics in the UK.
You can view an image of our treatment comparison table or download a PDF of our patient leaflet.


Recommended Treatments

Stage N, N1 - nodules and cords, slight or no contracture

Radiotherapy - shows promising results of halting or
slowing any progression of the disease, but has minor side-effects, such
as dry skin and is not always effective. It is only effective during
the active or proliferation phase when nodules are growing and cords may
be developing. This is often accompanied by symptoms of soreness,
tingling, aches, and so on.
If there are no signs of activity then you
should wait and see, but examine and possibly photograph your hands
regularly for signs of changes.
Corticosterod injections - such as Triamcinolone have been used with some success by some Doctors.


Stage 1 and 2 - slight to moderate contracture

Needle Aponeurotomy - is a good option if any
contracture is not too severe and if the cord is well away from tendons
and nerves in the hand.
Collagenase injection ( Xiapex) - Has good
results for contracture but carries a small risk of tendon rupture. It
works by dissolving the strands of tissue in the cords or strings. Some
patients need may a second injection. In most cases the contracture is
straightened by the Doctor the following day or a few days after the


Stage 3 and 4 - severe contracture

Surgery - there are different types and your
your surgeon will decide which is needed. Surgery is advised when the
MCP joint (the one that connects the finger to the hand) is more than
40% bent, or the PIP joint (second finger joint from the tip) is more
than 20% bent.


Other treatments (not in general clinical use)

Tamoxifen - (Acts as Growth hormone beta inhibitor)
not used because of potential serious side effects such as stroke-risk.
More promising is the idea of converting the presentation to a gel or
ointment for local application.
Cortisone - (steroid) injection into the nodule
or cord. This lessens pain and inflammation (in theory). Temporary
benefits only for most patients but some have seen a lasting reduction
in nodules.
the application of extreme cold to the tissues. The nodule has to be
big enough (1 cm) to place the probe in it. It freezes the cells and
thus shrinks theb nodule, and it freezes the nerve ending around the
nodule and reduces the pain.
Verapamil - A calcium channel
blocker, applied as a gel. Reported as effective in some cases but the
cost is prohibitive. Not available on the NHS as far as we know.
Penetration of Verapamil into the affected tissues has not been proven
so the effect of the drug applied this way is questionable.
5 fluoro-uracil - injected into the wound area after surgery can limit scarring.
Acetyl -L - Carnitine - This is an essential
amino acid, taken as tablets is reported to have good effect in some
Peyronie’s cases.
Allopurinol - Xanthine oxidase inhibitor used
as gout medicine. Hypoxanthine is found in high concentrations in
Dupuytren’s tissue, and allopurinol can reduce this, thus reducing the
amount of free radicals in the tissues. However clinical results are not
very promising, and some suggest the people who benefited did so
because their gout improved, not their Dupuytren’s.
Ultrasound - The idea is that it can break the
disulfide bonds in the cords, and produces heat to increase the oxygen
and bloodflow. Not proven very successful but some patients can have
reduction aof pain and increased movement after treatment.
Hyperbaric Chamber - As the etiology of the
nodules suggests tissue damage by hypoxia (lack of oxygen) this has been
tried. One report of patient improvement.
Vitamin E ointment - Does not appear to be very successful. The idea is to ‘mop up free radicals’.
Interferon - injected into the nodule or cord. Not proven successful.
Extracorporeal Shockwave Therapy (ESWT) - a non
invasive drug free treatment that takes about 5 minutes. Sudden brusts
of sound are directed into the palm and fingers to loosen the tightening
cords. The vital characteristic of a sockwave is that from zero
decibels to high must happen in a few nanoseconds. The fast moving sound
wave hits the tightened cord and stretches it. Moreover it also
activates stem cells to migrate to the site because through the nerves
the brain has detected a problem and instructs white blood cells to make
a repair. the patient will feel the treatment as uncomfortable, maybe
even painful, but giving a (local) anaesthetic would prevent this repair
process from setting in. The treatment may need to be repeated after
two weeks. Improvements can take place for up to a year after treatment
due to the response of cells to repair the tissues. In over 40 years of
use ( also forproblems such as idneys stones) no side effects have been
gel or injections, reduces the production of collagen and increases the
bodies own enzyme activity to break down collagen strands.

Recent developments:

Botox injection : apart from an enzyme to smooth out wrinkles Botox
also contains another enzyme, that is capable of  reducing contractions,
adhesions and  fibrosis, after surgery.

Halozyme: an injection  ( recombinant hyaloronidase) presently
in use for dissolving blood clots in thrombosis patients ( so already
been tested for safety), it is being trailed for cellulite but could
potentially help Dupuytren's patients in a way similar to Collagenase,
as it degrades collagen.

Alteplase  injections- a compound that stimulates cells in the nodules
and cords to produce their own collagenase. So far it has been tried on
a few Dupuytren's and Lederhose patients who were happy about the
results, but the patent for the drug is pending, so it is a long way
from being widely available, if it ever gets so far.

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