Q: The little finger on my left hand kinks up into a hook. Is this problem caused by arthritis? I can hardly tie my shoes. Please advise.

Lorraine Butler
Blooming Prairie, Minnesota

A: [Cory SerVaas, M.D., and Wendy Braun, R.N.] Your symptoms match those of Dupuytren’s contracture, a sometimes disabling (but not dangerous) condition that pulls fingers toward the palm and locks them there. It’s unrelated to arthritis. “Dupuytren’s causes painless contraction of fibrous tissue directly under the skin of the palm and fingers, and may be associated with nodules or cords in the palm. Over time, an affected finger may bend into a hook,” notes Dr. Taizoon H. Baxamusa, who is affiliated with the University of Illinois at Chicago and the Illinois Bone & Joint Institute in Morton Grove. “The cause of Dupuytren’s is not known; however, there is a strong hereditary association, especially among people of Northern European or Scandinavian descent. It’s more common in men than women, and risk increases with age.

“Dupuytren’s is sometimes confused with trigger finger, tendonitis, or arthritis. Try this simple test: Place the hand and fingers flat on a tabletop. If you are unable to do so, or the finger curls under, you may wish to seek a formal evaluation by an orthopaedic surgeon.”
New treatments include nonsurgical needling techniques and injections of the biologic drug Xiaflex.

Dupuytren’s Contracture Update The Saturday Evening Post

For the nearly 50,000 Americans seeking relief each 
year for debilitating bone-on-bone ankle pain and disability, there’s good news. Recent advances in arguably the 
most intriguing area of orthopedic surgery—total ankle replacement—are making strides in restoring mobility and quality of life to patients.

Today, four total ankle replacements are used in the U.S.: the Agility, the Inbone, the Salto Talaris Anatomic Ankle, and the Scandinavian Total Ankle Replacement (STAR).

“The technology is light years ahead of where it was a decade ago,” says Dr. Robert Anderson, an orthopedic surgeon in Charlotte, North Carolina, who performed more than 40 Inbone procedures in the past two years and is part of a design team working on a second-generation device.

Hi-tech artificial ankles provide a new alternative to surgery, which permanently fuses worn-out joints. That procedure reduces ankle pain but often limits mobility, causes a limp, and can lead to arthritis in nearby foot joints. An estimated 25,000 Americans underwent ankle fusions in 2009; others considered even more drastic measures.

Reasons for needing an ankle replacement include wear-and-tear over time, accidents, sports injuries, and bone diseases that lead to severe and life-limiting arthritis.

Four years ago, Jeanne St. John’s ankle problems led her to the brink of a difficult decision.

“I was born with deformed ankles and, eventually, was 
so immobilized by arthritis that I considered a double amputation,” recalls St. John, who lives in Oregon. “Then a friend heard about the Inbone. It’s been life-changing for me.”

As with hip and knee replacements, the history of total ankles dates back to the 1970s. Healthy ankles can withstand 1.5 times one’s body weight while walking, but early devices didn’t hold up. Then, Dr. Mark Reiley—who performed St. John’s surgeries in the San Francisco Bay Area—devised a new way to replace the complex joint.

“Dr. Reiley took the proven technology of knee replacements and basically flipped it upside down to be used in the ankle,” Dr. Anderson describes. “The device, now called the Inbone, has very good mechanical advantages and can be used for primary replacements, as well as revisions of failed or previously placed devices. We believe it will be successful 
for a long time.”

Orthopedic surgeons select the specific ankle replacements depending on patient age, anatomy, bone quality, and goals. Long-term success rates on Inbone are not yet available; European data show that 85 percent of modified Salto and STAR devices are functioning well after 10 years.

But Jeanne St. John, now age 67, prefers to focus on how far her new ankles take her.

“I think in terms of steps rather than years,” she says. “I save my steps for selected activities and for travel. Some of my friends are slowing down, but I have this ‘reverse aging’ thing going on, and I’m so thankful.”

Good News for Bad Ankles The Saturday Evening Post

A unanimous decision by an FDA advisory committee on Wednesday, September 16, 2009, paves the way for full approval of a novel and noninvasive treatment to restore hand function (and quality of life) for people with the potentially disabling condition called Dupuytren’s (DEW-peh-trins) contracture. The strong endorsement is based on clinical trial results published earlier this month showing injections of an experimental drug that helped straighten disfigured finger joints in two-thirds of the study participants.

Dupuytren’s affects as many as 27 million people in the United States and Europe and tends to run in families. Over time, a rope-like cord of collagen forms under the skin and around the tendon of a finger, bending it toward the palm and “locking” it in place.

Ken Nelson, who—along with his 91-year-old father and 30-year-old son—has Dupuytren’s, was unwilling to gamble on conventional surgery to treat the condition. He first noted unusual growths developing in the palm of his left hand in the early 1960s.

“I was eventually referred to the Indiana Hand Center, and they knew almost immediately that I had Dupuytren’s,” Ken tells the Post. “The doctor described extensive surgery to open up the palms of the hands and delicately remove the abnormal tissue. I basically fled.”

Over time, his condition progressed.

“About 10 years ago, the problem also appeared in my right hand,” Nelson recalls “The small fingers and the ones next to them began to contract to the point that the tips of my fingers were jammed into the palm of my hand. Both thumbs also began to bend over.

“It was very disruptive to me. I could no longer play the piano, which I enjoy. Putting on a pair of gloves became almost impossible. I had to hunt and peck at the keyboard and even bought a voice-activated program so that I could write by speaking into a microphone on my computer. But I continued to tell my doctors, ‘Maybe one day medical science will develop something that is not going to be as intrusive as surgery.’ It was a trade-off for me, and I decided to not do anything.”

Recently, Ken’s wife saw a notice in the local newspaper seeking candidates to test an injectable treatment for Dupuytren’s. He applied, went through the lengthy approval process, and was accepted into the study.

During the experimental procedure, doctors inject Xiaflex (collagenase clostridium histolyticum made by Auxilium Pharmaceuticals) into Dupuytren’s cords in the hand, taking care to avoid the surrounding area. The cord gradually weakens and then ruptures, releasing the tendon and helping to restore the finger’s normal position and movement.

“Dr. Thomas Kaplan injected one cord in my left hand,” Ken reports. “The next day, he started to gently pull back on the affected finger. I felt a stinging sensation and then heard the cord popping and snapping. I had to look away. But then he said, ‘OK, we’re done. I’m happy.’ I looked at my hand, and, for the first time in 10 years, my finger was straight. I got tears in my eyes and hugged the doctor. It was like a miracle to me.”

Phase III data show the promising treatment significantly reduced the angle of contracture of the finger joint closest to the palm of the hand (called the metacarpophalangeal or MP joint) and the middle joint (or proximal interphalangeal or PIP joint), regardless of severity. Multiple treatments may achieve the best results.

“Xiaflex is an enzyme that comes from the bacterium called Clostridium histolyticum,” study investigator Dr. Thomas Kaplan, who treated Ken Nelson at the Indiana Hand Center in Indianapolis, explained to the Post. “In Dupuytren’s disease, multiple fibers of collagen run along the cord. When the enzyme is injected into the cord, it starts ‘cutting’ the fibers into progressively smaller fragments, weakening the cord in that section.”

Investigators believe that many patients with Dupuytren’s may benefit from the first-in-its-class treatment option. Early intervention may prove to be the most effective approach.

“Multicenter study results published in The New England Journal of Medicine show that 89 percent of MP joints with contracture less than 50 degrees were fully corrected, and 81 percent of PIP joints less than 40 degrees were fully corrected by the experimental treatment,” explains Dr. Kaplan, who is also clinical assistant professor of orthopaedic surgery at Indiana University School of Medicine.
A final FDA decision on Xiaflex is expected within three months. Once approved, experts predict the drug could hit the market next spring.

“Hopefully, this research will represent a whole new treatment paradigm for Dupuytren’s that will be more tolerable and provide patients a better experience than we have been able to offer them with surgery,” adds Dr. Kaplan. “It is really exciting.”

Nelson, now 65, enthusiastically agrees.

“I can play the piano again,” he says. “A quality of life has been returned to me that I had never expected to experience again. I am thrilled with the outcome and my wife is happy too—I can do more chores!”

New Hand Therapy The Saturday Evening Post