As with many other surgical disciplines there is motivation to decrease invasiveness of treatments of hand disorders. Decreased invasiveness of these treatments offers the potential of decreased morbidity of and faster recovery from the procedure, but carries with it the risks of increased adjacent structure injury due to narrower areas of exposure and of less durable results of treatment. New studies regarding less invasive treatment of Dupuytren’s disease and cubital tunnel syndrome (ulnar nerve entrapment at the elbow) have been reported in the past two years and have begun to influence treatment selection for these conditions.
Collagenase from C. histolyticum has been under investigation for many years as a potential injectable treatment for Dupuytren’s contracture. Results of the first prospective, multicenter, phase 3 clinical trial of C. histolyticum versus placebo were reported in 2009.[1] Hurst and colleagues demonstrated significant improvement in range of motion of joints affected by Dupuytren’s cords after cord injection with collagenase as compared to placebo (from 43.9 to 80.7 degrees versus from 45.3 to 49.5 degrees, p < 0.001). The majority of complications were minor, such as bruising or swelling. In comparison, surgical fasciectomy for Dupuytren’s disease has a higher risk of more severe complications such as numbness and even vascular compromise.[2] However, fasciectomy has been demonstrated to provide durable correction of the contracture with 66-86% of patients reporting full or near-full maintenance of contracture correction at up to four years. In comparison, the collagenase injection group results were reported for 90 days after treatment.[1]
Multiple techniques exist for the treatment of cubital tunnel syndrome (ulnar nerve entrapment at the elbow). Treatments range from simple in-situ release of Osborne’s fascia to resecting the medial epicondyle of the humerus or transposing the ulnar nerve anterior to the elbow in either the subcutaneous or submuscular plane. The latter surgeries required more time to complete and more postoperative time for recovery, but are believed by many authors to provide better results.
Recent reports have suggested that simple in-situ release of the nerve may produce equivalent results to the more invasive procedures.[3] Based on this information, techniques for endoscopic in-situ decompression have been developed. Preliminary data suggests that endoscopic cubital tunnel release provides the same durability of symptom relief as open in-situ release.[4] However, as with all minimally invasive procedures, there is a learning curve to the technique. Risk of injury to the ulnar nerve and/or medial antebrachial cutaneous nerve as well as risk of incomplete decompression of the ulnar nerve are both notable concerns regarding the endoscopic procedure, and no multicenter prospective studies have been reported regarding this technique as of yet. In addition, some authors believe that ulnar nerve transposition, which cannot be performed via endoscopic technique, provides superior results to in-situ release.[5]
Minimally invasive treatments for disorders of the hand continue to develop. Both of the techniques described above show promise. As larger, prospective, multicenter studies with long-term results become available, hand surgeons will better be able to determine what role collagenase injection into cords and endoscopic in-situ release of the ulnar nerve at the elbow should play in the treatment of Dupuytren’s disease and cubital tunnel syndrome, respectively.
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Cite this: Advances in Minimally Invasive Treatment of Hand Disorders - Medscape - Feb 25, 2010.
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