IC27-R: New Revelations or Back to Square One: Dupuytrens Contracture Mgt
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IC27-R: New Revelations or Back to
Square One: Dupuytrens Contracture Mgt
Moderator(s): Marco Rizzo, MD
Faculty: Prosper Benhaim, MD, Douglas M. Sammer, MD, FACS, and Nina Suh, MD
Session Handouts
75TH VIRTUAL ANNUAL MEETING OF THE ASSH
OCTOBER 1-3, 2020
822 West Washington Blvd
Chicago, IL 60607
Phone: (312) 880-1900
Web: www.assh.org
Email: meetings@assh.org
All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement
or presentation made is to be regarded as dedicated to the public domain.
IC27-R: New Revelations or
Back to Square One:
Dupuytrens Contracture Management
Moderator:
Marco Rizzo, MD
Faculty:
Prosper Benhaim, MD
Douglas M. Sammer, MD, FACS
Nina Suh, MD, FRCS(C)
1
DISCLOSURES
Marco Rizzo, MD
Speaker has no relevant financial relationships
with commercial interest to disclose.
2
Dupuytren Contracture: Introduction
IC 27-R: New Revelations or Back to Square One: Dupuytrens Contracture
Management
2020 ASSH Annual Meeting
Marco Rizzo, MD
Department of Orthopedic Surgery
Mayo Clinic
3
1
COI Statement
• I have no conflicts of interest related to this
presentation
4
Learning Objectives
• Epidemiology and Pathophysiology of DD
• Indications for treatment
• Management options
• Outcomes and complications
• Practical considerations from my experience
5
Dupuytrens Contracture
Definition
• Fibroproliferative
disease of abnormal
fascia which forms
nodules and cords
• Results in
characteristic
development of
finger or hand
contracture
6
2
The Curse of the MacCrimmons
Scotland, 16th century
MacCrimmons
Pipers to the chieftains of the
Clan MacLeod
Contracture made playing
bagpipes impossible
Considerable social impediment
Good pipers stood second only to the chieftains!
• Elliot D. The early history of contracture of the palmar fascia (part I). J Hand Surg [Br] 1988; 13-13:246-55.
7
History
• Felix Platter (1614) – First to describe contracture of the digit which
he incorrectly attributed to the flexor tendon “shortening” in his book
Observationum in Hominis in 1614
• Henry Cline (1777) – Described thickening of the “aponeurosis palmaris”
resulting in “many fingers [being] bent into the palm” and the treatment of
sectioning as “efficacious”
• Sir Astley Cooper (1822) – Described palmar aponeurosis thickening and
the treatment with surgical dividing and placement in extension splint in Treatise
on Dislocations and Fractures of the Joints
• Guillaume Dupuytren (1834) – Presented two cases in The Lancet
about patients with palmar fibromatosis and successful surgical
excision and for some reason… his name stuck
Verheyden et al
8
Personal life of Dupuytren
• His teacher was Alexis Boyer,
Surgeon at the Hotel Dieu.
• Boyer’s eldest daughter, Adelaide
• Wedding date January 25, 1810
• Proposal to Gabrielle?
• Eve of wedding dinner
• Wedding celebration
• ”unscrupulous careerist?”
9
3
Interview with Dupuytren
• “Baron, if it is not asking too much - could you tell us
how you would deal with those who say that you are
top of the league as a surgeon, and bottom of the
league as a human being?”
• “I would say that they are fifty per cent right.”
• Traîtrise Orthopédique - January, 2001
10
Prevalence
• Prevalence 2% - 42% (Ross, Hand Clin.1999)
• Prevalence influenced by:
• Age (40-60 yrs.)
• Gender (males)
• Geography
• Ethnicity
Ling R. The genetic factor in Dupuytren’s Disease.
J Bone Joint Surg Br 1963;45:705-718.
11
Etiology
• Likely multifactorial in combination
with genetic disposition
• Proliferation possibly due to
microangiopathy and or tissue
ischemia
• Fibroblasts dedifferentiate into
myofibroblasts, which increase Type
III collagen (usually absent in palmar
fascia)
• Increased free radicals/trauma
increase fibroblasts and
• IL-1 increases myofibroblast
proliferation
Black et al
12
4
Indications for Treatment
• Hueston 's "table top test"
• MCP > 30 degrees
• PIP > 15-30 degrees
• Adduction contracture – skin breakdown
• Hueston JT. Dupuytren's contracture: selection for surgery. Br J Hosp Med 13:361, 1974.
• McFarlane RM. Dupuytren's disease. In McCarthy JG (editor): Plastic Surgery. Philadelphia, 1990, WB
Saunders.
• McFarlane RM. Dupuytren's contracture. In Green DP (editor): Operative hand surgery. New York, 1993,
Churchill Livingstone.
13
Procedural/Surgical treatment
• Treatment options:
• Most common
• Percutaneous fasciotomy/needle aponeurotomy
• Collagenase
• Open fasciectomy
• Goals:
• Release/excise deforming structures
• Improve extension
• Prevent recurrence, especially early, if possible
• Minimize complications
14
Less common and adjuvant treatments
• Treatment options (less common):
• XRT
• Fusion
• Amputation
• Dynamic external extension devices (digit widget)
• Goals:
• Slow progression of dz
• Functional improvement
• Adjunct to faciotomy or fasciectomy
15
5
Treatment Considerations
• Patient expectations must be temporized
• Recurrence is likely
• PIP joint contractures
• Less likely to be fully corrected
• Higher recurrence rate
• Particularly in the small finger
16
Additional Considerations-The many faces of Dupuytren’s
17
Surgeon Factors
• Comfort level with varied treatments
• Experience/training
• Resources available
• Cost
• Ability to contend with complications/recurrence
• Options
• Non-operative
• Operative
18
6
Additional (often unexpected) considerations…
19
Faculty and Outline for ICL
• Prosper Benhaim – UCLA
• Pushing the limits of NA
• Doug Sammer – UTSW
• The future of collagenase
• Nina Suh – University of Western Ontario
• Surgery – Gold standard or Relic
20
Thank You
21
7
8/7/2020
Prosper Benhaim, MD
Speakers Bureau: Endo Pharmaceuticals,
Axogen
Ownership Interests: Cytori
1
NEEDLE APONEUROTOMY
PROSPER BENHAIM, MD, FACS
ASSOCIATE PROFESSOR
CHIEF OF HAND SURGERY
UCLA MEDICAL CENTER
2
DISCLOSURE
Speaker’s Bureau
Endo Pharmaceuticals
3
1
8/7/2020
COMPLICATIONS OF OPEN SURGERY
• Nerve: Pain, CRPS
Numbness
• Joint (recurrent contracture):
inadequate excision
incompetent central slip
resection of annular ligaments
• Artery
• Skin
• Tendon
• Infection
4
Surgical Outcomes
• Stiffness and loss
of ROM
– Not uncommon
– Prolonged
therapy
– Seldom discussed
5
History of Needle Aponeurotomy
1822 - Sir Astley Cooper
“When … the contracted
band is narrow, it may
with advantage be divided
by a pointed bistoury,
introduced through a very
small wound in the
integument. The finger is
then extended, and a
splint is applied.”
6
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Bistoury
7
REDISCOVERY
1959 - J Vernon Luck - JBJS
“Subcutaneous fasciotomy” technique
Theory = nodule is the essential lesion
Fibrous cords hypertrophy in reaction to nodule
Nodules require excision
Cords only require subcutaneous
fasciotomy
8
FRENCH CONNECTION
1979 Jean-Luc Lermusiaux (rheumatologist)
Published in L’actualite Rhumatologique
Described successful NA – “Debeyre
technique”
25 gauge needle
9
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NEEDLE APONEUROTOMY
• Faster recovery • Blind procedure risk
• Fewer wound • ? appropriate for
healing recurrences
complications
• ? applicability at finger
• Less painful level/PIP joint
• Earlier return to • Unable to resect nodules
work
• Skin tears
• Local anesthesia
• Higher recurrence rate
• Affordable
• Steep learning curve
10
Needle Aponeurotomy
• Needle is the “percutaneous scalpel”
• Nodules and cords are not excised
• Cords are transected at multiple levels
11
NEEDLE APONEUROTOMY
Technique
• Only the skin and dermis have pain fibers
Dermal local anesthetic only
“surface anesthesia”
• NO pain fibers on the cords
• Tendons and nerves have pain fibers –
useful for feedback
• CRITICAL IMPORTANCE of Tinel’s sign as a
feedback for close proximity to the nerves
12
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NEEDLE APONEUROTOMY
• Local 1% lidocaine + 1:100,000 epinephrine
+ bicarbonate
• Extremely superficial dermal injection (PPD
test)
• No tourniquet
13
NEEDLE APONEUROTOMY
• Start proximally, progress distally or vice
versa
• Stay central over pretendinous cord
• Avoid deep insertion of needle
• Careful attention to “needle feedback”
• Monitor for Tinel’s sign – continuously!
14
NEEDLE APONEUROTOMY
Technique
• 18 gauge needle vs. 25 gauge needle
• Needle moves very slowly
• Stutter step to allow for patient feedback
(Tinel’s sign)
• Avoid extreme hyperextension needling at
MP joint - risk of tendon injury
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16
Technique – Clearing
17
Technique – Perforating
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Technique – Slicing
19
Technique – Sawing
20
21
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22
PL
23
24
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Cross Section
Through
Metacarpal Shafts
25
Cross Section
Through
Metacarpal Heads
? ? ? ?
26
Radial Digital Nerve
Dupuytren Cord
Ulnar Digital Nerve
27
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? ?
? ?
? ?
?
? ?
28
TECHNIQUE
29
30
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32
33
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35
36
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37
NEEDLE APONEUROTOMY
? treatment distal to MP flexion crease - yes
0.5% Marcaine at end of procedure
MP joint hyperextension
“Completion rupture of the cord”
PIP joint closed capsulotomy, if needed
Kenalog injection into nodules and cords
↓ recurrence, ↓ flare reaction
38
NEEDLE APONEUROTOMY
Post-Op Care
Antibiotic ointment for open skin tear
Xeroform + soft dressing
If severe contracture, consider splint
± postop hand therapy and night extension
splint
39
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SAMPLE CASES
40
41
42
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44
45
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50
51
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52
53
54
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56
57
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59
60
208/7/2020
EXPOSED TENDON??
Yup!
61
62
63
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NEEDLE APONEUROTOMY
Evolution in Technique
• Much more aggressive
Release PIP joints routinely
• Much more extensive – release all cords COMPLETELY
Lower recurrence rate
(Eaton – 25 gauge needle for safety, but takes longer and
less extensive)
64
NEEDLE APONEUROTOMY
Evolution in Technique
• Test for sensation repeatedly
• Demonstrate intact sensation to patient prior to
Marcaine block
• PIP joint volar capsular contractures –
controversial – does manipulation work ???
Yes !
65
General Observations
• Many (?most) patients arrive with NA or
collagenase as a conclusion
• If naïve, nearly all choose NA or collagenase
• Physician can “push” a patient to a decision
• I subconsciously push NA vs. collagenase >>
open palmar fasciectomy
66
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NEEDLE APONEUROTOMY
General Observations
• CPT 26040 – per hand, not per finger
• Takes much longer than anticipated
• 25-55 minutes
• Extensive release to minimize recurrence
67
NEEDLE APONEUROTOMY
Bottom Line
• Technically challenging
• Many potential pitfalls
• Patients LOVE it
• Extremely gratifying for surgeon
• ? Ultimate role when compared to
collagenase vs. open palmar
fasciectomy
68
RESULTS
Bryan et al. Journal of Hand Surgery, 1988
Surgical technique = tenotomy knife
43 patients from 1979-1986
Average follow-up was 5.3 years
69
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Results, Bryan et al.
20 patients lost to follow-up (death or
failure to contact), 23 left for study
57% of patients with mainly MCP joint
deformity sustained correction at 5 years
Less successful in patients with PIP joint
involvement
70
RESULTS
Badois Study
Badois et al. Revue du rhumatisme, 1993
90 patients (123 hands), 5 year follow-up
16 gauge needle - “Lariboisière technique”
71
Results, Badois et al.
69% “excellent or good” outcome at 5 years
Complications:
Skin tears (16%)
Nerve damage (2%)
Local infection (2%)
Recurrence rate is 50.4% at 5 years
72
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RESULTS
Foucher et al Study
• Journal of Hand Surgery, 2003
• 211 patients
• 261 hands
• 311 total fingers
• Mean duration of surgery = 8 minutes
73
SHORT-TERM RESULTS
Foucher, et al
Preop Posotop Improvement (%)
Total 65° 15° 76%
(N=311)
MP 48° 10° 79%
(N=296)
PIP 37° 13° 65%
(N=146)
74
LONG-TERM RESULTS (3.2 y)
Foucher, et al.
Preop Immediate Follow-up
postop
# with - - 58
recurrence
MP + PIP 52° 14° 16°
(N=100)
MP (N=100) 38° 8° 10°
PIP (N=25) 26° 11° 17°
75
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Results, Foucher et al.
Complications
2 failures
5 temporary paresthesias
1 digital neuroma
1 hemorrhage
19 skin tears (avg. healing = 11 days)
1 CRPS
76
RESULTS
van Rijssen and Werker
Van Rijssen, Werker. JHS (Br), 2006
74 patients (123 hands), 32 month follow-up
77% initial improvement
65% recurrence (>30 degrees of recurrent
contracture)
77
UCLA NEEDLE APONEUROTOMY STUDY
• Retrospective review: 2008 to 2010
• 525 digits
• 193 hands
• Mean age 65 year (range = 37 – 88)
• 138 patients were male
• Mean preoperative TPED was 41o
78
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Results
• Mean postoperative TPED was 1o
– Mean residual MP contracture 15o at the PIP joint
• Observed in 62 digits (12%)
80
Results
• Complications (7 major)
− Persistent triggering - 1
− Infection - 3
– Delayed flexor tendon rupture - 1
– Complex regional pain syndrome -1
– Persistent numbness - nerve exploration - 1
81
278/7/2020
• Skin tears noted in 68%
of patients.
– Treated with local
wound care
– Does not alter
postoperative
recovery
– Not considered an
operative
complication
82
NEEDLE APONEUROTOMY
Updated UCLA Results - Complications
• > 950 procedures
• 1 trigger finger
• 3 infections
• 1 small finger FDS/FDP tendon laceration
• 1 CRPS
• No digital nerve lacerations; 1 median nerve neurapraxia
• 48 redo cases – 12 in Dupuytren’s diathesis patients
83
Needle Aponeurotomy
What patients should know:
Recurrence rate 50 % at 3 years
compared to 50 % at 5 years with
traditional surgery
Complication rate 5 – 10 times higher
with traditional surgery
Length of recovery 10 times longer
with traditional surgery
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References
Luck JV. Dupuytren's contracture; a new concept of the pathogenesis correlated
with surgical management. J Bone Joint Surg Am. 1959 Jun;41-A(4):635-64.
Lermusiaux JL, Debeyre N. le traitement medical de la maladie de Dupuytren, In:
De Seze S, Ryckewaert A, Kahn MF et al. (Eds). L’actualite Rhumatologique.
Paris, Expansion Scientifique, 1979: p. 338–343.
Bryan AS, Ghorbal MS. The long-term results of closed palmar fasciotomy in the
management of Dupuytren's contracture. J Hand Surg [Br]. 1988 Aug;13(3):254-
6.
Badois FJ, Lermusiaux JL, Masse C, Kuntz D. [Non-surgical treatment of
Dupuytren disease using needle fasciotomy]. Rev Rhum Ed Fr. 1993 Nov
30;60(11):808-13.
Foucher G, Medina J, Navarro R. Percutaneous needle aponeurotomy:
complications and results. J Hand Surg [Br]. 2003 Oct;28(5):427-31.
http://www.eatonhand.com
Van Rijssen, A.L., Werker, P.M.N. Percutaneous Needle Fasciotomy in
Dupuytren’s Disease. JHS (Br). 31B (5): 498, 2006
85
SPIRAL CORD
• Spiral relationship with NV bundle
• Volar to NV bundle in palm
• At MCP passes deep (dorsal) to NV
bundle
• Continues distally, lateral to NV
bundle (lateral digital sheath)
• Becomes volar to NV bundle distal
digit (Grayson’s)
Greens Operative Hand Surgery
86
SPIRAL CORDS
• Responsible for
superficial and medial
displacement of NV
bundles as cord
contracts
• HUGE surgical
significance
• Also contributory in PIP
contractures
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88
Drawing derived from
Bojsen-Moller and Schmidt, 1974
89
90
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Drawing derived from
Bojsen-Moller and Schmidt, 1974
91
Drawing derived from
Bojsen-Moller and Schmidt, 1974
92
RESULTS
• Wide range of recurrence rates in literature
75-80% correction of contracture initially
35% - 60% recurrence at 5 years
• UCLA approach – aggressive
> 950 cases
98% correction of contracture
< 20% recurrence rate
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Douglas M. Sammer, MD, FACS
Speaker has no relevant financial relationships
with commercial interest to disclose.
1
ASSH 2020
The Future of Douglas Sammer, MD
Collagenase UT Southwestern Medical
Center at Dallas
2
Disclosure
Statement
None
3
17/29/2020
Aux‐I and Aux‐II
Collagenase
(CCH)
Mechanism Bind ‐> unwind ‐> lyse
of Action
Synergistic in‐vitro
4
Therapeutic dose
Type I
Collagenase
(CCH) Type III
Mechanism Higher doses
of Action
Type IV
5
Treatment with Collagenase
• Day 1
• Injection
• Day 2
• Manipulation
Image source: Endo pharmaceutical
6
27/29/2020
Preparation of Medication
Image source: Endo pharmaceutical
7
Injection
Technique
Image source: Endo pharmaceutical
8
Manipulation
Technique
Image source: Endo pharmaceutical
9
37/29/2020
Tips
• Denkler K JHS 2014
• Use of all collagenase in bottle
• Massage of skin to release tethering
• Delaying manipulation 1‐2 weeks
• Stretching of all 5 digits longitudinally and
transversely
• Concurrent needle subcision for skin
release
10
Tips
• Meals JHS 2014
• Use all of collagenase in bottle (0.9mg)
• Use 0.58mg for primary cord
• Use ‘extra’ for secondary cords
• Inject cord obliquely
• Inject cord under tension
• 3‐5 aliquots
• Transverse orientation of aliquots for very
thick cords
• 4‐step manipulation
11
Therapy, Splinting and Follow‐up
Skirven et al. JHS 2013
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13
14
15
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16
17
CORD I
CORD II
Outcomes
Studies
CORDLESS
MULTICORD
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CORD I
1 2 3
CCH did better than MCP did better than Low severity did better
placebo PIP than high severity
64% vs. 7% 77% vs. 40% 89% vs 58% at MCP
Hurst et al. NEJM 2009
19
CORD II
1 2 3
CCH did better than MCP did better than Low severity did
placebo PIP better than high
44% vs. 5% 65% vs. 28% severity
70% vs 60% at MCP
Gilpin et al. JHS 2010
20
2 concurrent injections
Manipulation at 1‐3 days
MULTICORD No impact of manipulation delay
0.1% tendon rupture
Increased skin tear (22% vs 9% in CORD I
and II)
Coleman et al. JHS 2014
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CORDLESS
Peimar et al. JHS 2015
22
97% Adverse Event
Rate
CORD I study
23
• Edema
• Contusion
• Injection site
Most Common hemorrhage
• Injection site reaction
25% or more
experience these • Pain
complications
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9% in CORD I and II
Skin Tears 22% in MULTICORD
Image source: Endo Pharmaceutical
25
CRPS
Serious
Complications Anaphylaxis
Can Occur
Tendon Rupture
26
CORD I and II
2/372 = 0.5%
Tendon MULTICORD
Rupture 1/715 = 0.1%
Rate
Phase 3 trials
2/506 = 0.3%
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Other Issues
28
Use of entire vial
Grandizio LC et Successful, similar
al. JHS 2017
complication
profile
29
30 day result
RCT ‐ 1 vs 7 day
manipulation
Increased Pain
interval No difference
injection to in
manipulation Skin tear
No ruptures
Mickelson DT, et al. – JHS
2014
30
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Collagenase • Dickson D, et al. – JHS 2015
Injection on • If INR7/29/2020
Prior successful
51 patients
CCH
CCH for
Recurrence
Adverse event
57% primary profile consistent
endpoint with previous
studies
Bear BJ, et al. – JHS 2017
34
Hay DC, et al. – PRS 2015
Survey of 9 physicians, 15 patients
• 7 of 9 – no distortion, technically unchanged
• 1 – altered anatomy, difficult dissection
Fasciectomy
after CCH Eberlin KR, et al. – JHS (Eu) 2014
11 patients
• Disruption of normal architecture, extensive
scar
• Successful, but increased technical difficulty
35
?
What is the future of
collagenase?
It depends on
comparative results, and
cost‐effectiveness.
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RCT, 156 pts, 2 year f/u
MCP only
CCH vs. PNF
at MCP Joint
No significant difference
• MCP contracture, ROM, pain, or
QuickDASH
Stromberg J, et al. ‐ JBJS 2018
37
RCT, 50 pts, 2year f/u
32% PNF and 8% CCH maintained
improvement at 2 years
CCH vs. PNF No difference in “clinical success” rate at 2
at PIP Joint years
No difference in recurrence rate at 2 years
No difference in PED at 2 years
Skov ST, et al. – JHS 2017
38
RCT, 93 patients, 3 year
follow‐up
CCH vs. PNF
No significant difference in
recurrence at 3 years
Sherman et al – JHS Euro 2018
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37 patients, MCP and PIP Joints
Non‐randomized, 2 year f/u
LF
CCH vs. LF • 91% PED correction at MCP
• 87% PED correction at PIP
CCH
• 83% PED correction at MCP
• 32% PED correction at PIP
Tay TK, et al. – Hand Surgery 2015
40
Non‐randomized
132 pts, 3 month f/u
MCP CCH = LF
CCH vs. LF
PIP LF 10 degrees better than CCH
Fewer serious adverse events with CCH
CCH better MHQ scores
Zhou C, et al. ‐ PRS 2015
41
Non‐randomized
52 patients, 2 year f/u
2 year ROM better in surgical group
CCH vs. LF
Satisfaction higher in collagenase group
All collagenase patients would repeat
71% surgical patients would repeat
LeClere et al – Arch Orthop Trauma Surg 2018
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DRITSAKI M, ET AL. ‐ BMC META‐ANALYSIS 4 HIGH QUALITY STUDIES
MUSC. DISORD. 2018
Cost
Effectiveness
2 STUDIES SHOWED 2 STUDIES SHOWED
FASCIECTOMY TO BE NOT FASCIECTOMY TO BE THE
COST‐EFFECTIVE MOST COST‐EFFECTIVE
43
350 patients
Compared direct cost of NA, collagenase,
LF
Cost
Effectiveness Collagenase most expensive
More re‐intervention than collagenase
NF least expensive
Less re‐intervention than collagenase
Leafblad et al. – JHS 2019
44
Direct vs indirect costs
Challenges in Regional and institutional variables
Determining
Cost‐ Clinic set‐up, pace, procedure room, etc.
Effectiveness Other
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The future of collagenase?
Concluding thoughts…
46
Thank you
Douglas Sammer, MD
UT Southwestern Medical Center at Dallas
ASSH 2020
47
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Nina Suh, MD
Speaker has no relevant financial relationships
with commercial interest to disclose.
1
Gold Standard or Relic:
Open Surgery
Nina Suh MD, FRCSC
Assistant Professor
Division of Orthopaedic Surgery
University of Western Ontario
2
External Forces
• Discontinuation of collagenase
• Canada
• Europe
• Asia
3
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Functionally Disabling,
No Discrete Cord
4
Progressive Nodular Tissue
5
Indications for Intervention
• MP Joint Flexion >30o
• PIP Joint Flexion >30o or >20o with progression
• Revision/Recurrence
• Dupuytren’s Diathesis
• (Ectopic Knuckle Pads)
• (Palmar Nodules)
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Surgical Options
• Fasciotomy
• Open
• Closed (Needle, Enzymatic)
• Segmental Open Fasciectomy
• Limited Fasciectomy
7
More Options
• Open Radical Fasciectomy
• Dermofasciectomy
• McCash Technique
8
Salvage Options
• Joint Fusion
• External Fixation
• Amputation
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Skin Incisions
• Bruner Incision
• Hemi-Bruner Incision
• Longitudinal
• Mid-Lateral
• Transverse
10
Principles of Surgery
• Set realistic patient expectations
• Pick an appropriate skin incision
• Avoid avascular flaps yet try not to leave pathologic
tissue behind
11
Principles
• ALWAYS be aware of the
NV bundle
• Start proximally and work
distally to excise pathologic
tissue
• Bipolar cautery essential
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Significant Contractures
• >30o residual joint contracture
after fascial excision,
consider joint release
13
Pathologic Tissue
• Central Cord
• Pretendinous band and palmar superficial
fascia
• Often responsible for joint contractures
• Spiral Cord
• Pretendinous band, spiral band of Gosset,
lateral digital sheath, vertical band, and
Grayson’s ligament
• Responsible for PIP contracture and draws NV
bundle proximally, centrally, and superficially
14
Pathologic Tissue
• Lateral Cord
• Lateral digital sheath
• Natatory Cord
• Natatory ligament
• Responsible for webspace contractures
15
57/29/2020
Pathologic Tissue
• Retrovascular Cord
• Dorsal digital fascia
• Responsible for DIP extension
contracture
• ADM Cord
• ADM tendon
• Draws NV bundle to midline
16
Results
• MCP Correction
• Almost always correctable
17
Results
• MCP Correction
• Almost always correctable
• PIP Correction
• Better results when 60o
18
67/29/2020
Results
• MCP Correction
• Almost always correctable
• PIP Correction
• Better results when 60o
• DIP Correction
• Almost always difficult
19
Complications
• NV Injury
• Wound Closure Issues
• Vascularity concerns
• Recurrence
20
Literature
• 2015 Cochrane Review
• 14 articles
• 11 single center studies + 2 multi-center studies
• 944 hands of 940 participants total
21
77/29/2020
Cochrane
• DASH scores lower after NA compared to fasciectomy
• Fasciectomy improved contractures more effectively in
more severe disease
• 5-year satisfaction was higher in fasciectomy group
compared to fasciotomy group
22
Cochrane
• Recurrence greater after fasciotomy
• Skin grafting did not improve outcomes compared to
fasciectomy alone
• Splinting was not found to be effective
23
Conclusions
• Insufficient evidence to show relative superiority of
various procedures
• Needle fasciotomy vs fasciectomy;
• Interposition firebreak skin grafting vs z-plasty
closure of fasciectomy
24
87/29/2020
Final Conclusions
• Surgery is a viable treatment
25
Final Conclusions
• Surgery is a viable treatment
• Understanding anatomy paramount for surgical
dissection
26
Final Conclusions
• Surgery is a viable treatment
• Understanding anatomy paramount for surgical
dissection
• Limited fasciectomy most commonly performed but
salvage procedures should be considered
27
97/29/2020
THANK YOU!
28
10DISCLOSURES
Marco Rizzo, MD
Speaker has no relevant financial relationships
with commercial interest to disclose.
1
Recurrent Dupuytren Contracture and
Cases for Discussion
IC 27-R: New Revelations or Back to Square One: Dupuytrens Contracture Management
ASSH Annual Meeting
October 2020
Marco Rizzo, MD
Mayo Clinic
Rochester, MN
2
COI Statement
• I have no conflicts of interest related to this
presentation
3
1Case example: 76F, RHD, Retired
4
Case example: 76F, RHD, Retired
• Underwent NA
• Limited minimal improvement
• Numbness and tingling
• Resolved over time
• Returned at 6 months
• Options?
5
Dupuytren Disease
• “Dupuytren contracture is a
frustrating condition both for hand
surgeons, because the surgery
can be difficult, and for patients,
because the rehabilitation can be
lengthy. Both surgeons and
patients are often frustrated by
complications and poor results,
with fingers that remain
contracted even after multiple
attempts at correction.”
Amadio PC. JBJS [A], 2008:90; 453-458
6
2Recurrence of Dupuytren Disease
• Recurrence rates (26% to 80%)
• Higher risk of recurrence
• Diabetics
• Dupuytren’s diathesis
• Greater severity of disease
7
Personal Experience
Outcomes and Cost Analysis of Needle Aponeurotomy,
Collagenase Injection, and Fasciectomy in the Treatment of
Dupuytren’s Contracture
Leafblad et al, JHS, 2019
8
Results: Rates of repeat intervention*
Rate of repeat intervention Needle Collagenase Fasciectomy
aponeurotomy
Any repeat intervention at 2 years 24% 41% 4%
Any repeat intervention at 5 years 61% 55% 4%
Mean time to repeat intervention (years)
1.8 0.95 0.92 **
*estimates derived from Kaplan‐Meier analyses
** based on 4 patients
9
3Results: 5‐year rate of repeat intervention by type*
5‐yr rate of repeat interventions by Needle Collagenase Fasciectomy
type aponeurotomy
NA 42% 13% 1%
Collagenase 29% 46% 1%
Fasciectomy 5% 6% 2%
*estimates derived from Kaplan‐Meier analyses
10
Procedural/Surgical Rx for Recurrent DD
• Treatment options:
• Percutaneous fasciotomy/needle aponeurotomy
• Collagenase
• Open fasciectomy
• Adjunctive
• Dynamic extension devices
• Radiation
• Salvage options
• Amputation
• Arthrodesis
11
Indications for Surgery
• Individualized with patient
• Inability to lay palm flat on
table
• PIP contracture
• Pain
• Skin breakdown or matted
disease
• Diathesis
• Recurrent disease
12
4Treatment Considerations
• Patient expectations must be temporized
• Correction amount is less likely
• Higher risk of NV injury
• PIP joint contractures
• Less likely to be fully corrected
• Higher recurrence rate
• Particularly in the small finger
13
Surgeon Factors
• Comfort level with varied treatments
• Experience/training
• Resources available
• Cost
• Ability to contend with complications/recurrence
• Options
• Non-operative
• Operative
14
Needle Aponeurotomy
15
5Case: 61M s/p prior surgery
16
Collagenase Injection Day #1
Day #2
3wks later…
17
48M, RHD, Small finger
18
648M, RHD, Small finger, injection
19
48M, RHD, Small finger, 3wks post-
injection
20
Surgical Fasciectomy
• Options:
Shaw et al.
21
7Open Palm Technique
• Described by McCash
• Transverse incision across
palm assists in correcting
MP joint contracture
• Allow to granulate with
meticulous wound care
• Unsightly to patients and
may make rehab more
challenging
22
McCash technique
• Advantages
• No hematoma
• No skin necrosis
• Less postoperative pain
• Disadvantages
• Poor visualization of N-V
structures
• Open wounds (3-4 weeks)
• Infection
• Patient factors
23
Fasciectomy
• Types
• Limited
• Radical
• Incision types
• Bruner
• Longitudinal with z-plasties
• Advantages
• Skin “Lengthening” (Y-
V, Z-plasty)
• Excellent Exposure
• Disadvantages
• Hematoma
• Skin Necrosis
24
8Fasciectomy
• Technique
• Anesthesia
• Regional anesthesia
• WALANT
• Thick skin flaps
• Proximal to distal
dissection
• Loupe magnification
25
Fasciectomy
• Closure
• Meticulous hemostasis
• Primary
• Local flaps
• Skin Grafting
• Skin Shortage after Surgical Correction
• Skin Necrosis after Surgical Correction
• Skin Devitalized during Surgery
• Dupuytren’s Diathesis
• Re-do
• Splint is position of function
• Rehabilitation
• Aggressive ROM (especially flexion)
26
Surgery – recurrent spiral cord
27
9Complications
• Nerve injury
• spiral cords in digits cause digital nerve
displacement in a proximal, superficial, and
midline direction*
• Best to identify nerve proximal to finger and
follow it into digit
28
Complications
• Vascular injury
• ALWAYS let tourniquet
down at conclusion of
fasciectomy before closure
• Digital artery spasm due to
release of contracture
• Digital artery laceration
29
Complications
• Postoperative hematoma
• Wound dehiscence/Skin necrosis
• RSD/Flare
• Higher rate in females
• Active therapy plus NSAIDs and sympathetic
blocks may help
• Extension/Recurrence
• Loss of flexion
30
10Surgery for Recurrent Dupuytren’s
• Higher risk of neurovascular injury
• PIP joint contracture may be fixed
• More difficult dissection due to scar tissue
31
Surgery on Recurrent Dupuytren’s
• Roush & Stern, JHS, 2000
• 19 patients/28 fingers
• Avg f/u 4 years
• Three groups/types of treatment
• A: Limited fasciectomy and arthrodesis (7)
• B: Dermatofasciectomy and skin grafting (8)
• C: Fasciectomy and local grafting (13)
• Results
• Group C was the only one to maintain improved ROM
• Skin grafting did not improve outcomes
• Significant nerve dysfunction
• Overall patient satisfaction was high (18/19)
32
Additional surgical options
• Dynamic extension device
• Digit Widget
• Arthrodesis
• Amputation
• Cross-finger flaps
• Hyperextension of the DIP joint
33
11Adjunctive Treatments
• Dynamic extension devices
In OR After 2 weeks
34
Back to our patient… Digit Widget
35
Back to our patient… 5 wks Digit Widget
36
12Back to our patient… 6 wk s/p fasciectomy
37
Summary
• Recurrence in DD is common
• Treatment options similar to initial presentation
• Optimal treatment individualized
• Regardless of treatment decided upon
• Prognosis is more guarded
• Higher risk of complications
38
Thank You
39
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