Dupuytren’s Disease

1. Dupuytren’s Disease Mr G Shyamalan (Shyam) Hand Surgeon HEFT

2. So Much Choice!

3. Definition of Dupuytren’s • Benign proliferative disease • Fascia of digits and palm • Nodules, cords and contractures

4. Procedures of Limited Clinical Effectiveness (POLCE) Need yes to one of the questions to approve • Moderate MCPJ contracture >30 degrees • Any PIPJ contracture • First web contracture

5. Risk Factors • Age • Ancestry • Sex • FH • Diabetes • Smoking and Alcohol • Epilepsy

6. Dupuytren’s Nodules 50% progress10% require surgery

7. Non-Dupuytren’s Disease • Trauma • Surgery • Diabetes • No FH • Any race • Generally non-progressive

8. Dupuytren’s Diathesis • Male • <50 • Affected siblings/parents • Ectopic Disease ‘Garrod’s pads’ • Bilateral Disease

9. Treatment options • 1. Do nothing • 2. Radiotherapy – early disease • 3. Steroid Injection • 4. Percutaneous Needle Fasciotomy • 5. Collagenase/Xiapex • 6. Limited Fasciectomy • 7. Dermato-fasciectomy and skin graft • 8. Amputation

10. Treatment options & cost(2011) • 1. Do nothing £0 • 2. Radiotherapy – early disease £2500 (10 visits) • 3. Steroid Injection (£ Steroid vial +OPD) • 4. Percutaneous Needle Fasciotomy (£ OPD +needle +/- theatres) • 5. Collagenase/Xiapex (£760 per vial/digit) • 6. Limited Fasciectomy (£2500 plus therapy) • 7. Dermato-fasciectomy and skin graft (>£3000 plus therapy)

11. Personal thought process • 1. Age/Retirement • 2. Occupation • 3. Hand Dominance • 4. Pain • 5. The speed of progression of disease • 6. Recurrence Vs Extension • 7. Extent of contracture PIP joint • 8. Diathesis (bilateral, radial side, male) • 9. General Systemic Health • 10.Patient expectations

12. Radiotherapy 3 Gy x5 days- repeat 8 weeks later (potential delayed side effects due to radiation)

13. Steroid for nodules • Triamcinalone • 50% softening • 50% recurrence one year

14. Percutaneous Needle Fasciotomy • Mostly clinic based • Splint 6 – 12 weeks at night • Low complication rate • Early return to work • 5% early failure – akin to a failed injection for CMC joint arthritis! • Long-term 50% recurrence in 5 years but not always requiring surgery

15. Collagenase - Xiapex • Good option for early rehabilitation • Less time off work • Less recurrence than needle release • Recurrence rate akin to surgical fasciectomy • Has side effects as a drug (see next slide)

16. Collagenase - Xiapex Side Effects • Paraesthesia ,Complex regional pain syndrome (CRPS) • Hypoaesthesia • Monoplegia •  Burning sensation •  Tremor • Lymphadenopathy • Crepitus • Arthralgia • Hyperhidrosis • Myalgia /Muscle weakness and spasm •  Wound dehiscence •  Joint swelling •  Tendon rupture •  Injection site reactions •  Ligament injury • Ecchymosis

17. Limited Fasciectomy • Procedure with known results • Good for limited disease • Can be performed under local anaesthesia • Recurrence rates higher than skin grafts

18. Dermato-fasicectomy • Lowest recurrence rate • Best choice for young patient • Increase time to wound healing (diabetics and smokers take longer) • Longer rehabilitation time

19. Dermato-fasicectomy post op

20. Recurrence • Extent of the pre-surgical contracture of the finger • Longer you live, the higher the recurrence!

21. Conclusion • Refer early • Tailor treatment to patient

22. Mr G Shyamalan • gunaratnam.shyamalan@heartofengland.nhs.uk • handelbowsurgeon@googlemail.com Solihull Hand Clinic Heartlands Fracture Clinic Good Hope Hand Clinic Spire Parkway Spire Little Aston