Profits vs. care? from cover haps, the practitioner. This has been shown, time and again, in the use of certain orthopedic and cardiac devices (among other culprits) that drive up cost with no proven benefit to patient quality of life, quantity of life, or satisfaction. Yet without new developments that
push the envelope, where would we be today? Without pioneers inoculating common people with smallpox, perhaps against the wishes of the medical establishment, who would drive the innovation? The answers, simply put, are nowhere and no one. We need innovation and medical
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anesthesia fees, facility fees, surgeon fees, and therapy, is likely to cost $5,000–$15,000. Another option is a technique called needle aponeurotA case in point: Dupuytren’s, omy, which involves the use of the Viking disease small needles to cut the conTo illustrate the intersection of tracted cords beneath the skin. profit vs. efficient treatment, let’s This technique was championed take the example of Dupuytren’s in France by a group of rheumatologists and is now used by some surgeons in the United States. The beauty of the technique is its simAll too often, over time we find that these newer, plicity: straight local anesthesia and a handful of nearly always more expensive options serve 25-gauge needles. That’s nothing more than to line the pocket of it. The bevel of the needle is used to sever the conthe manufacturer, sales representative, tracted cords in several or, perhaps, the practitioner. locations, to allow the finger to straighten. It is similar to cutting a rope into multiple sections to remove the itage (it has been called the disease. Dupuytren’s is a genetic tension, whereas open surgery “Viking disease�) and thus is disease process that afflicts the involves removing the rope. very prevalent in the Midwest, hands, causing contracture of Along with the quick recovery and Minnesota in particular. the fingers over the course of and immediate use of the hand, Dupuytren’s causes contracmany years and often leading to the other wonderful thing for ture of the palmar fascia, which the inability to straighten the is the thick fascia underlying the patients is the inexpensive finger(s). In approximately 10 nature of the procedure: It typipalmar skin. As this fascia conpercent of patients, it can also cally costs less than $1,000 tracts into tight cords and nodaffect the plantar surface of the (often only about $500). ules, it causes an inflexible flexAnother technique, recently ion contracture of the digit that released to the health care marprogresses over time. While ket, is an enzymatic treatment trauma (including surgery) may (brand name Xiaflex) in which instigate the formation of this collagenase is injected into the contracture, more often it develcontracted cord to enzymatically ops spontaneously. The diagnosis of this disease break down the tissue and rupture the contracted cord, thereby is fairly straightforward and straightening a previously clinical: You see cords promicrooked finger. This treatment is nently in the palm of the hand similar in theory to the needle that look like errant tendons; technique, but it only treats one nodules in the palm or fingers part of the cord. The real conthat resemble mats of deep scar trast, however, is in the cost: The tissue; or perhaps pits in the injection alone costs $3,200. palm due to the “puckering� of This does not cover the cost of the skin as the contracted fascia administration, manipulation, or pulls the skin inward, while the other professional fees. Thus, fingers are pulled to varying the total cost of treatment for a degrees into flexion. single injection is likely to be at To treat this condition, surleast $4,000. As well, only one gery traditionally has been used injection can be given at a time. for many years. While there are While one treatment is usually many types of surgery persufficient for both needle formed for Dupuytren’s contracaponeurotomy and collagenase ture, in general surgery involves injection, additional treatments removing as much of the diswill come with a similar price eased and contracted tissue as tag. possible, in an effort to straighten the finger(s). The surgery is In today’s health care cliusually successful, but it inmate and in the spirit of saving volves a fair amount of therapy, money while simultaneously recovery, pain, and suffering. offering effective treatment, Such a procedure, including the treatment of choice is obvi-
progress. However, when profits and money enter the equation, their delineation becomes much less clear.
MINNESOTA PHYSICIAN MARCH 2011
feet (Ledderhose’s disease), and in about 1 percent of those males affected, it can cause contracture in the penis (Peyronie’s disease). Named after Baron Guillaume Dupuytren, the surgeon who described an operation to correct the affliction, Dupuytren’s primarily affects those of northern European her-