Markian Hawryluk
The Bulletin

Richard Finch just wants to shake hands normally again.

“People look at me kind of funny when I shake hands with two fingers,” the 73-year-old retired Navy man from Redmond said. “If I don't keep my fingernails short, it sticks them in their palms.”

For more than 40 years, he hasn't been able to straighten more than a pair of fingers on his right hand due to an inherited condition known as Dupuytren's contracture . The fingers on his left hand won't straighten at all.

He's had multiple surgeries to correct it, and had a finger amputated because of the condition. Each time, the surgery allowed him to extend his fingers a little more, but soon after, his hands would slowly curl again.

“It's difficult to do almost everything,” his wife, Annie Finch, said. “The more crippled they become, the harder it is just to button his shirt. He can't button those little collars any more, his fingers just won't do those little buttons.”

His hands won't open beyond a loose fist, as if he were perpetually grasping a pool cue. In fact, shooting pool is one of the few things he can still do.

“It would be nice if I could wear a ring again,” Finch said. “Simple things.”

As many as 300,000 people are diagnosed with Dupuytren's in the U.S. each year, and until recently they had to choose between surgery or living with the disability. But last year, the Food and Drug Administration approved a innovative treatment that uses an injectable enzyme to dissolve the build up of collagen that prevents the fingers from straightening. In most cases, the treatment works overnight and allows those affected to resume the normal use of their hands within a week.

“The results are amazing,” said Dr. James Verheyden, a hand surgeon with The Center: Orthopedic&Neurosurgical Care&Research in Bend, who's treated more than 80 patients with the enzyme. “I've had good results from everybody.”

Collagen build-up

Dupuytren's contracture forms in connective tissue known as fascia below the palm. For unknown reasons, some people get an abnormal build-up of collagen in the fascia in their hands, creating a nodule. Over time, those nodules become a braided cord, and as the cord contracts, it pulls the finger down toward the palm.

The condition affects men seven times more often than women, and usually crops up for men in their 40s or 50s and women in their 60s. It's much more prevalent among people of northern European descent and there's a strong familial pattern to the disease.

Once the nodules and cords start to develop, they only get worse.

“People come in when their fingers start contracting,” Verheyden said. “They can't put their hand flat on the table. They can't put their hands in their pockets or in gloves. It really starts affecting the quality of their life.”

The standard treatment has been to slice open the palm and cut away the cord with a scalpel, leaving patients with a large Z-shaped scar and often weeks of physical therapy to return to normal function. Some surgeons offered a alternative procedure, sticking a needle through the skin and slowly moving it back and forth to severe the cord.

Verheyden learned about the enzyme treatment more than a decade ago, but it took years for Auxilium Pharmaceuticals to get through the FDA approval process. The Xiaflex enzyme is produced by bacteria that causes gangrene, and is being tested by the company for several other similar conditions. The day it was approved for Dupuytren's in February 2010, Verheyden called the company's representative and said, “I've got some patients lined up. When can I do my first injection?”

He's now treated more patients with Xiaflex than any other doctor in the Pacific Northwest.

The injection is done in an office setting. Technically, a single vial of the enzyme is supposed to be used to treat one contracture. Verheyden uses a somewhat different approach, using all of the enzyme provided in the vial and injecting it into multiple locations in the hand. His goal is to inject it directly into the cord.

“If you inject it into the wrong spot, you could dissolve good collagen and damage the tendon that bends your finger,” he said. “So people tend to inject it superficially between the skin and

this cord because they don't want to inject it deep near the tendon. But you have to inject it into the cord.”

The cord, which can be felt through the skin, is like a rope made up of intertwined fibers, and at first, it is difficult to inject the liquid into the cord. But the enzyme starts to eat away at the fibers immediately, opening up room for more of enzyme to be injected. After 15 to 30 seconds, Verheyden can feel the pressure on the syringe lighten up and can inject more of the enzyme into the cord.

After injection, patients typically come back 24 hours later. The doctor will then numb the hand and try to straighten the finger.

A day after Finch's injections, Verheyden stretched his ring finger, resulting in an audible pop when the cord snapped, and straightened the finger completely. That surprised even Verheyden, who said Finch's contractures were so bad, he did not expect to get the finger completely straight.

“That's the first time I've seen that in close to 30 years,” Finch said with a smile.

Verheyden had injected the enzyme into two cords affecting the adjacent finger, and the finger released with a double pop as both cords snapped. After years of contracture, the skin on Finch's hand was so tight, it tore open when the little finger was extended. It's a common occurrence and will soon heal, Verheyden said.

“There's a little swelling and bruising, but that goes away,” Verheyden said. “Normally when you operate, you get a bunch of scarring. With the enzyme, there's no scar tissue so the hands are soft and supple and smooth. You'd never know that they've had the disease or any operation done on their hand.”

Out of the 80 patients that Verheyden has treated, only three were not able to straighten out their fingers completely after one treatment. Only one patient required any physical therapy afterward.

Within a week, Finch should have full use of his right hand, and then can come back for injections to loosen up his left hand. He also avoided the risks associated with anesthesia but going with the nonsurgical approach.

“Oh I'm happy. I don't remember when they were straight,” Finch said. As incredible as the treatment might seem, Finch realizes it has its limitations.

“It won't improve my pool,” he said.

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