Management of Dupuytren's Contracture by Prof Chris Bainbridge

Summary

This script discusses the complexities of managing Dupuytren's disease, emphasizing the importance of patient education and conservative treatment options. It highlights the limitations of surgical interventions and the potential for recurrence, advocating for minimally invasive procedures like needle aponeurotomy. The speaker also addresses various treatment approaches, including the use of radiotherapy and dynamic splinting, and the ethical considerations in obtaining informed consent for surgery.

Takeaways

• 🔍 Dupuytren's disease is challenging to manage, with no cure for recurrence, and can cause pain, contrary to common beliefs that it's not painful.
• 👐 Treatment for Dupuytren's contracture is primarily for functional improvement, not necessarily for a fully straightened finger.
• 💊 Some untested treatments for Dupuytren's are available online, but they lack scientific evidence and should be approached with caution.
• 🧪 Tamoxifen has been studied for its potential in reducing Dupuytren's recurrence post-surgery but is not recommended due to side effects and temporary benefits.
• 🚫 Verapamil gel, though reported to have mild effects, lacks randomized controlled trials and is not widely available, making it an uncertain treatment option.
• 🔬 Ongoing research includes the use of anti-TNF therapy for treating Dupuytren's disease, though its delivery method and systemic effects are concerns.
• 💉 Collagenase injections were once a promising treatment but have been largely discontinued due to risks and complications, except in the United States.
• 🤝 Conservative treatments like splinting and radiotherapy can be effective, but the choice between static and dynamic splinting should be informed by evidence and patient preference.
• 🩺 The Digit Widget is a promising device for straightening fingers, offering a mobile and effective treatment option, though it's not available in all regions.
• ✂️ Needle aponeurotomy is a minimally invasive procedure that can be performed safely with proper technique and is favored for its simplicity and safety.
• 🔄 Recurrence after Dupuytren's surgery is common, and multiple treatments may lead to more complex disease in subsequent procedures.

Q & A

What is Dupuytren's disease and why is it sometimes considered painful despite common teachings?

Dupuytren's disease is a medical condition where nodules form under the skin of the palm and fingers, leading to the thickening and contraction of the fascia, which can cause the fingers to bend. It is sometimes considered painful because many patients report pain, even though it is generally taught that the condition itself is not painful. The pain is likely due to the contracture that can occur as a result of the disease.

Why might patients seek treatment for Dupuytren's disease even if it does not necessarily need surgical intervention?

Patients may seek treatment because they desire a finger that is acceptably straight, even if the level of contracture does not interfere with their function. The psychological impact or cosmetic concerns can lead them to seek medical advice and treatment options.

What is the prognosis for patients with Dupuytren's disease?

The prognosis for patients with Dupuytren's disease varies. Some patients may experience a slow progression of the disease with minimal impact on hand function, while others may have a more rapid progression that significantly impairs hand function. Treatment options, including surgical and non-surgical interventions, can help manage the condition and improve hand function.

Outlines

00:00

🤔 Dupuytren's Disease Management Challenges

The speaker begins by discussing the complexities of managing Dupuytren's disease, emphasizing the difficulty of preventing recurrence even for a genius. They highlight the misconception that the condition is not painful, despite patient experiences to the contrary. The talk also addresses the fact that not all cases require surgical intervention and that contracture, a side effect of the genetic condition, often does not impede function. The speaker uses Bill Nye as an example of someone who has successfully managed with the condition. The paragraph concludes with a discussion about the importance of patient education and the reality that not all conditions require aggressive treatment.

05:01

🧪 Untested and Experimental Treatments for Dupuytren's

This paragraph delves into various untested and experimental treatments for Dupuytren's disease found online, including some with historical roots in treating gout. The speaker mentions drugs like sildenafil, tamoxifen, and verapamil, discussing their limited evidence and side effects. Tamoxifen, for instance, showed temporary benefits that ceased post-treatment, while verapamil gel had mild effects without strong clinical trial support. The speaker also touches on the RID trial from Oxford, which tests anti-TNF therapy for treating the disease, and expresses concerns about its delivery method and potential risks.

10:02

🔬 Clinical Trials and Conservative Treatments for Dupuytren's

The speaker discusses ongoing clinical trials and conservative treatments for Dupuytren's disease. They mention the use of collagenase, which initially showed promise but was later associated with cosmetic use. The paragraph also covers the use of splintage, highlighting the lack of evidence for static splintage post-surgery and the trend towards better outcomes without it. Radiotherapy is presented as a treatment that anecdotally works, with varying degrees of success, and the speaker shares their approach to discussing it with patients. The paragraph concludes with a mention of dynamic splinting as a non-operative treatment, supported by some studies.

15:04

🛠️ Surgical and Post-Surgical Treatments for Dupuytren's

In this paragraph, the speaker focuses on surgical approaches to treating Dupuytren's disease, including dynamic splinting and the Digit Widget, a device used post-surgery to straighten fingers. They describe the process and effectiveness of using the Digit Widget, noting its benefits such as mobility during use and its ability to significantly improve finger positioning. However, the speaker also mentions the unavailability of the Digit Widget in Europe due to a lack of CE mark. The paragraph concludes with a discussion on the timing and importance of surgery in relation to other treatments.

20:06

💉 Needle Aponeurotomy: A Minimally Invasive Approach

The speaker introduces needle aponeurotomy as a minimally invasive treatment for Dupuytren's disease, which they have been instrumental in popularizing. They discuss the technique's origins, development, and their personal experiences in refining the method. The paragraph covers various needle types and techniques such as stroking the cord, slicing, and manipulation to break down the diseased tissue. The speaker emphasizes safety, feeling, and precision in performing needle aponeurotomy and shares insights on patient outcomes and the evolution of the technique.

25:07

⚕️ Surgical Techniques and Considerations in Dupuytren's Treatment

This paragraph explores different surgical techniques for treating Dupuytren's disease, including traditional fasciectomy, segmental fascia, and radical fasciectomy. The speaker reflects on the evolution of surgical approaches, moving from minimal to radical and back to more limited procedures. They discuss their personal preferences for incisions and exposure methods, the importance of avoiding damage to neurovascular bundles, and strategies for managing complex disease cases resulting from multiple needle aponeurotomies. The paragraph concludes with a discussion on the importance of patient consent and understanding the potential complications of surgery.

30:08

🩹 Wound Closure and Dermofasciectomy Techniques

The speaker discusses various wound closure techniques after Dupuytren's surgery, advocating for the use of absorbable sutures and the concept of secondary healing. They introduce the dermofasciectomy procedure, highlighting its effectiveness in reducing recurrence rates and detailing the process of performing a full-thickness skin graft from the antecubital fossa. The paragraph also touches on the Stillwell technique, a method for managing severe recurrent Dupuytren's by using the existing scar tissue effectively, thus minimizing tissue waste.

35:08

🔚 Last Resort Options for Dupuytren's Disease

In the final paragraph, the speaker addresses last resort options for managing Dupuytren's disease when other treatments have failed. They discuss the possibility of amputation as a single best option in some cases and the transformation of a three-joint finger into a two-joint finger through surgical procedures like PIP joint excision arthrodesis. The speaker also mentions the importance of considering other potential causes of pain in Dupuytren's disease, such as tender tendon sheaths, and the use of steroid injections as an alternative treatment. The paragraph concludes with a summary of the various complications that can arise from Dupuytren's surgery and the importance of informed consent.

Keywords

💡Dupuytren's contracture

Dupuytren's contracture is a medical condition where one or more fingers are bent and cannot be fully straightened due to thickening of the fascia in the palm of the hand. In the video's theme, it is the central focus, with discussions on its management, misconceptions, and treatment options. The script mentions that 'dupatrans is painful and yet, we generally teach that dupatrans is not, a painful condition,' highlighting the complex nature of the condition and its impact on patients.

💡Needle aponeurotomy

Needle aponeurotomy is a minimally invasive procedure used to treat Dupuytren's contracture by cutting the diseased cord with a needle. It is a key concept in the video, as the speaker discusses its benefits, risks, and techniques. The script describes the 'zen of needle aponeurotomy' and the importance of doing it safely to avoid complications like nerve injury.

💡Fasciectomy

Fasciectomy refers to the surgical removal of the thickened fascia causing the contracture in Dupuytren's disease. It is a fundamental concept in the video, with the speaker discussing various surgical approaches and considerations. The script mentions 'fasciiectomy' in the context of both primary and revision surgeries, emphasizing its role in managing the condition.

💡Collagenase

Collagenase is an enzyme that was once thought to be a promising treatment for Dupuytren's contracture, as it can break down the collagen in the diseased cords. The video discusses its history, efficacy, and side effects. The script notes that 'collagenase... had significant risks,' and its use has been limited, reflecting the ongoing search for effective treatments.

💡Tamoxifen

Tamoxifen is a medication that was trialed for its potential to inhibit the recurrence of Dupuytren's contracture after surgery. The video mentions it in the context of a randomized trial, indicating that while it showed some benefit, the effects were temporary and not significant enough for widespread recommendation.

💡Verapamil

Verapamil is a medication discussed in the video as a potential treatment for Dupuytren's contracture, though its availability and efficacy are limited. The script notes that 'verapamil gel... is reported to have some mild effect,' but also points out the lack of randomized controlled trials to support its use.

💡Splinting

Splinting involves the use of devices to immobilize or apply tension to the affected fingers, aiming to improve the range of motion in Dupuytren's contracture. The video discusses different types of splinting, including static and dynamic, and their effectiveness. The script mentions that 'static splinting or no splinting after surgery, no significant difference,' suggesting that the approach to splinting may not be as crucial as once thought.

💡Dermofasciectomy

Dermofasciectomy is a surgical procedure that involves removing the diseased fascia along with the overlying skin and replacing it with a skin graft. It is highlighted in the video as an effective treatment for recurrent Dupuytren's contracture. The script describes it as 'a well-performed dermo fascictomy... will reduce recurrence more than anything else,' emphasizing its importance in advanced cases.

💡Amputation

Amputation is the surgical removal of a part of the body, such as a finger, and is discussed in the video as a last resort for severe cases of Dupuytren's contracture. The script mentions 'amputation' as 'the single best option' in some cases, indicating that while extreme, it can be the most effective solution for patients with recurrent or severe contractures.

💡Consent

Consent in the medical context refers to the process of informing and obtaining a patient's agreement to a treatment or procedure. The video emphasizes the importance of obtaining informed consent, particularly when discussing the potential complications of surgery for Dupuytren's contracture. The script lists 'expected complications' that should be disclosed to patients, highlighting the ethical responsibility of healthcare providers.

Highlights

Dupuytren's disease management can be challenging as it often causes pain and contractures, and patients desire an acceptably straight finger rather than a fully straightened one.

The recurrence of Dupuytren's contracture after treatment is a common issue, highlighting the complexity of the condition.

Some patients with Dupuytren's disease may not need surgery, as the contracture level may not interfere with their functionality.

Untested treatments for Dupuytren's are widespread on the internet, but they lack scientific evidence and should be approached with caution.

Tamoxifen was found to inhibit recurrence of Dupuytren's after surgery in a randomized trial, but its benefits disappeared after ceasing treatment, and side effects are significant.

Verapamil gel has been reported to have mild effects on Dupuytren's when applied topically, but lacks randomized controlled trials to support its efficacy.

The RID trial from Oxford is investigating the use of anti-TNF therapy for treating Dupuytren's disease, marking a significant step in medical research.

Collagenase was once considered a promising treatment for Dupuytren's, but its use has been limited due to significant risks and side effects.

Splintage, both static and dynamic, has varying levels of evidence for its effectiveness post-surgery in Dupuytren's disease management.

Radiotherapy has anecdotal and some study support for its role in treating Dupuytren's disease, though the optimal delivery method remains unclear.

Dynamic splinting has shown promise in non-operative treatment of Dupuytren's disease, with evidence suggesting its effectiveness in straightening fingers.

The Digit Widget is a novel device for treating Dupuytren's disease, offering a mobile and effective solution for straightening fingers pre- or post-surgery.

Needle aponeurotomy is a minimally invasive procedure that has gained popularity for treating Dupuytren's disease, with a focus on safety and minimal risk.

Consent for Dupuytren's surgery is complex due to the range of potential complications, which must be thoroughly discussed with patients.

Dermofasciectomy is considered a highly effective treatment for Dupuytren's disease, particularly in cases of rapid recurrence.

Alternative treatments for Dupuytren's, such as amputation or joint modification, can be considered in severe cases where other treatments have failed.

The importance of considering other causes of pain in the hand, such as tendon sheath inflammation, in addition to Dupuytren's disease.

The Stillwell technique for dermofasciectomy is highlighted as a less wasteful and technically demanding approach to managing severe Dupuytren's disease.

Transcripts

so i'm talking about the management of

dupatrons tonight

and

i thought i'd start off with a few

aphorisms a couple of notes so

any full straighten a finger

but even a genius cannot currently

prevent recurrence and i think it's

important to remember that

it's sometimes painful

and patients often get very cross about

this because many patients will tell you

that their dupatrons is painful and yet

we generally teach that dupatrons is not

a painful condition

and dupatrons does not need to be

treated with surgery dupatron's

contracture is treated and that is

really just a side effect of the

underlying genetic condition

and for many patients they live with

a level of contracture that does not

interfere with their function

and so it's not that they want a

straight finger but they want a finger

that is acceptably straight

and we have to remember that a fully

flexed finger is actually less of a

problem than one that is locked or fixed

in a half extension

if we think of bill nye the actor with

his two fingers bent permanently down

into the palm he has managed to win

multiple accolades as an actor with

these fingers locked into his palm

frequently patients come to us because

they don't know what is wrong they don't

know what the prognosis is and they

don't know what the options are they

want advice and we offer them treatment

we need to remember not everything needs

treatment

and also we need to remember that often

for these patients

loss of flexion after surgery is more of

a functional problem

than their previous loss of extension

so what treatments are there what things

can you offer patients well

you probably don't want to offer them

any of these

these are the things that you can find

as untested treatments listed

all over the internet

and i'm sure that i haven't got all of

them

other peonal interestingly came from a

time when gout and dupatrons were

thought to be almost identical diseases

and there is now

some

evidence that there are links between

them

um

i don't know of any evidence that uh

sildenafil is of great benefit

um tamoxifen uh we'll talk about in a

moment and

verapamil as well

so tamoxifen interesting drug and

there's one

randomized trial

using tamoxifen

a very high dose

showing that it did inhibit the

recurrence of dupatrons after surgery

the problem sadly

was that this beneficial effect

disappeared within two years of ceasing

the tamoxifen and the side effects are

not insignificant

so

not something that you should really be

recommending to patients

the verapamil gel isn't available in the

uk it is available i believe in the

united states i don't know about europe

and you could if you can get it as a 15

gel rubbed into the affected palm and

fingers then it is reported to have some

mild effect

however i was unable to find any

randomized controlled trials

so what things are currently being

tested

well the rid trial from oxford

repurposing anti-tnf for treating

jupiter's disease

um is

a proper

randomized trial

um

one could be cynical and say that it was

a way of extending the patent on

anti-tnf therapy

which has probably earned oxford many

millions of pounds but i wouldn't ever

dream of doing that

my worry about it is how it's going to

be delivered

um

at the moment it's being injected into

the nodule and that certainly reduces

the systemic effect but

use systemically i think would be

associated with

risks that would really outweigh the

possible benefits in terms of a

seriously

dangerous drug

for a benign condition

so shin shin mentioned collagenase which

we

thought was the great hope of dupatrons

at one point

until uh it became the great hope of uh

smoothing out your buttock creases and

your

various other

cosmetic problems

um i remember that when this

was first mentioned uh many many years

ago and we got a

an email

in the early days of email

from the manufacturers

and it came to the consultant meeting

and it said would we be interested in a

medical treatment for dupatrons

and there was a sort of

nah

never going to work

and those that know me know that my view

is

jump onto it see what it's like and it's

better to do a trial of something and

prove it doesn't work

than to allow it to get into the wild

and let other people

try and see if it works

so we we used it it it worked it's not

perfect it had significant risks

you can tear the skin you can

rupture tendons you can damage

arteries when you try to extend it i

certainly had patients who had bruising

all the way up the arm and down onto the

side wall of the chest which was rather

scary

we moved from doing the snap at 24

hours to doing the snap at a week

and the advantage of that was that

the swelling that occurred in the in the

week or the first

48 hours after the uh

injection acted as a

tissue expander

allowed

the skin to stretch and soften and then

as the swelling went down

um the skin stayed stretched so when you

came to

snap the collapse the

collagen the dupatrons at

seven days you didn't get the skin tears

and that was very helpful

unfortunately as i said it's been

removed from worldwide use apart from in

the states where it is uh highly

expensive

um

but there are multiple other carginases

that have been uh

characterized

and it wouldn't surprise me if we see

another collagenase coming along in the

future

so

that's the the things that are unproven

the things that are in trial uh in drug

treatment

and the things that have disappeared

what conservative treatment can you do

well

splintage there are papers all over the

place of splintage

and we've got to differentiate between

static splintage and dynamic

and really after surgery there is no

evidence for static splinting

uh the

paper by christina jerich really was a

landmark paper in this

as a pragmatic paper

static splinting or no splinting after

surgery

no

significant difference between the

splinted and the non-splinted groups

but a trend towards a better outcome

with no splintage

and i think this resonated with many

people my

impression is that

our nordic cousins haven't splinted for

donkeys years and certainly

uh my view has been to move away from

splintage and this really pushed me away

from splintage completely

i now don't even split my demo

fasciaexmiz unless i have to

so

other conservative treatment

radiotherapy

anecdotally and from the studies that

are available it does work

i'm not an expert on radiotherapy and my

view is that if a patient wants to

discuss radiotherapy i will put them in

touch with the radiotherapist

and leave it to the radiotherapist to

discuss the pros and cons

my understanding is that there are

different ways of delivering the dose of

different

sources for the for the dose of

radiation and i wonder whether that

makes a difference to the outcome

because certainly some people seem to

get very prolonged benefit whereas

others report little if any benefit

i remember when radiotherapy was first

suggested for treating dupatrons those

surgeons especially plastic surgeons who

had

an interest in or a previous experience

of head and neck surgery were vehemently

against it remembering the skin damage

from head and neck radiotherapy for skin

cancer for

intraoral cancer

but this is very different much lower

and the skin does become dry

i think that's a universal

skin is a sort of dry feeling

but i've certainly seen no problems with

wound healing after radiotherapy

not large numbers because it does seem

to

reduce the rate of progression

but uh

probably half a dozen somewhere between

half dozen and 10 patients over the

years

it doesn't

cause regression of the dupatrons so you

need to discuss with your radiotherapist

how you're going to manage any existing

contracture are you going to do a needle

upon your otomy are you going to do open

surgery are you going to do collagenase

if you have it available and then decide

uh at the timings of the radiotherapy

um

what i've done is discuss with the

radiotherapist when they want to give it

and then we will schedule a patient for

a simple needle of ponerotomy get the

patient the finger straight or the

fingers and then deliver them to the

radiotherapist a few weeks later

so dynamic splinting

there are a number of studies of dynamic

splinting from

simple occupational therapy splints

uh to more complex

and

one study showed that uh of the three

groups uh three different types of

splinting

it did not influence the natural course

of the disease after operation

but others

uh this one from aniline bronze uh luke

the smear etc

showed that

tension and compression orthotic devices

can be used as a non-operative treatment

of dupatron's disease

in both early untreated and aggressive

post-surgery

so there is evidence that dynamic

splints will work and straighten fingers

in terms of

surgically applied dynamic splinting

this i think was in some ways the

landmark paper

uh from messina and messina

um this rather complex

erection of meccano

slightly more

streamlined on the right hand side

and they were able to confirm complete

extension of the severely contracted

fingers

my personal experience is that it's

difficult to apply

i certainly found difficulty in getting

these two pins into the fifth metacarpal

on a reliable basis

um

i think i remember one metacarpal

fracture from perhaps too many pins

being inserted

and i know of other surgeons that also

had fractures

this was in the days before we had small

mini c arms so it may be different today

but

something that demonstrated the utility

of dynamic traction but really hasn't

stood the test of time

perhaps of more interest currently

is the digit widget now those of you

that have been to the american han

society meetings uh will have seen

the hand innovations uh

installed and the

multiple different devices developed by

the team there

but this digit widget is fascinating

uh you put two pins into the dorsal of

the middle metacarpal

there's a jig for doing this

you do it under fluoroscopy

and then you have a

wrap

of lycra and

um

sticky back plastic

on the back of the hand and this uh

device is uh then applied to it and

these are

mandibular

bands used after intraoperative surgery

and

as you can see

we take a post-surgery um

jupiter's and over a period of uh six

weeks get it to a virtually straight

position

and then at about

10 weeks operate on the finger with a

flashy ectomy or skin graft and then

they recommend leaving it on for a

further period after that

the beauty of this of course is that

it's mobile so the patient can still

keep their movement

whilst they've got it on

and uh

it's very effective i was fortunate to

be able to get two of these devices uh

some years ago and i can confirm that

they will straighten any finger

so i

put one of them on to a patient with a

third time recurrent dupatrons of the

little finger uh down into the uh the

palm and over eight weeks we managed to

get it out completely straight

and then i went ahead with a

dermafasciaectomy

unfortunately it's not available in

europe

there's no ce mark

so

not currently available but the concept

is there

the problem

with with the dynamic traction though is

that if you take the

diatraction off before you do the

surgery it will very rapidly recur

now whether that's because the extensor

tendon is incompetent or whether you

stretch the dupletrons and then it

fights back against you when you take

the traction off i'm not sure

but fundamentally it's a pre-surgery

treatment or a post-surgery treatment

not an alternative to surgical treatment

so we've covered the various drugs that

you can

look up on google if you are a patient

we've covered the various forms of

conservative treatment and the

pre-surgery treatment

but what else can you do

a needle upon eurotomy shin chin said

that i have popularized it

i've certainly been keen on it

and

it's one of those things that

wasn't invented by surgeons much to our

discomfort it was uh really

i suppose invented by baron dupatron

this is what he did he did a needle upon

neurotomy but with a bishopri um a

jeweler's knife

bisjutri

but it was re reinvented or rediscovered

by a group of rheumatologists in

paris

there was certainly a dermatologist in

london doing needlepoint rotary very

successfully for many years

but

was associated in the mind of most

surgeons with a high risk of pref

digital nerve injury

incomplete release and complications

so i started doing needle apology

around the time of collagenase

just before collagenase became available

and we started the trials

and

really it just took off

um i think i'd had a patient that said

they'd been to paris

had had it done there would i do their

other hand and i said oh well okay let's

give it a try

started in the palm

and then gradually moved out into more

complex cases

and

patients just talked to each other and

within a few months i had a queue out

the door of patients wanting needle upon

your offspring which meant that i had to

get very good at it very quickly

then

venus and i

prepared a video

one for patients on

what they need to know and the second

one for

surgeons

my

view is that

treat the parma chords and you can do

this even in the context of doing a

fasciectomy you know that the palmer

chords in primary disease will be

superficial to the

transverse fibers the nerves are going

to be safe

and so

with an anaesthetised patient just

before you start doing the fasciectomy

practice your needle upon your otomy in

the palm

see the benefit it gets and then go

ahead with your fasciaectomy exploring

waved under your

your needle upon your otomy confirming

the release or seeing how you've

missed parts of it

and then as you get uh

better at it you could perhaps do needle

a ponyotomy in the palm for a complex

disease patient prior to surgery

help straighten the finger out partially

and then bring them in for a more

limited fasciaectomy in the finger for

example

and then you can work your way out

towards the pip joint and even towards

the dip joint

on this side you can see a range of

needles

i use blue needles

almost universally

i don't use green needles except

occasionally in the palm i think they're

slightly too big

and i use orange needles at the pip

joint and beyond just because they're

shorter and they're more precise

be careful that you don't get given

needles that are too long if you get a

blue or orange needle that's too long

then it'll be too whippy and you won't

actually get feedback from the tissues

as to what you're doing

choose your portal site for the needle

of ponerotomy with care

you don't want to do it where the skin

is adherent to the underlying

dupertron's chord if you do

you'll get a skin tear because there's

no possibility of extension

so what you want to do when you're

starting

is to put tension on the finger and look

for where the skin remains pink

so

stretch it the finger out

get most of it to blanch and you'll see

where the skin is not under tension

by it remaining pink and that's where

you put your portal

you can start approximately obviously i

prefer to start distally

that means that

if i do happen to anesthetize the

digital nerve

when i come to the next most proximal

portal the nerve will not be

anesthetized at that point and i'll

still get

an electric shock

from sensation in the patient if i touch

the nerve

but that is relatively rare um

the important thing is to

only have a short part of the needle in

the finger so you know what you're doing

these pictures were drawn by a medical

student who is working with us and uh to

show the various methods

if you've got a lovely mature jupiter

trans chord then simply

putting the neat the chord under tension

and pushing the needle into the cord

will start to cut it and you'll

sometimes feel the cord just giving way

as you push the needle in and it's a

lovely feeling

and you can feel the finger

straightening out each time you do it

and this is what the

french rheumatologists were doing they

were simply

putting the knee pushing the needle into

the cord hundreds of times

but frankly it doesn't work for every

chord and it gets boring very quickly

and we're surgeons so we can do better

so the next uh technique that i

developed was to stroke the chord

if you put the tip of the needle on the

very surface of the cord and just slide

it backwards and forward so you're just

tilting the needle side to side no

pressure at all

um then it will just scratch its way

through the cord

i call this the zen of uh needle of

plenty there's no force to it it just

flows

uh and again

if you aren't just feeling that scratchy

nature of the chord

stop

needle ponyotomy is supposed to be safe

it's a minimally invasive procedure

stop whenever you're not sure what

you're doing

not sure what you're cutting and you're

not sure where the needle is any one of

those if you don't stop will lead you

into disaster

so stroking the cord

very helpful

the next one is is what i call the slice

now if you've got a cord that is uh thin

um then you can't stroke across the top

of it

but if you put the needle down the side

and then just put a little bit of

tension on the needle so that as it

comes up

it flicks

then it will start to cut through a

narrow cord

and that's what we're trying to

demonstrate here so you can see that

i've got a little bit of bowing on that

needle not very much just a slight

amount

so that as it lifts up it will slice its

way across it

and you just keep on repeating that

doing it from each side in turn until

you uh feel the cord go

and then manipulation and this is either

the most scary part of needle ponyotomy

or the most enjoyable part of needle

upon rotary

or both

you get to the point where you know that

you've got through the vast majority of

the chord with your needle you know that

you're not really feeling

clearly any more

called to be cut but it hasn't quite

come straight

is this

the joint that's stiff or is it still

called

if you can't feel a defect in the chord

then there's still some remnants of the

chord

and if you isolate the joint so you uh

you if you're doing a pip joint flex the

mp joint and then straighten just the

pip joint

you will get this

snap as we call it if you're lucky it

will sound like like a ripe carrot just

snapping in half and everybody in the

room will jump

otherwise it will just ease out i don't

think there's any difference in the long

term outcome between the two

um and then as soon as you've done that

you'll be able to feel a defect between

the ends of the cord

and when you stretch the finger

the skin that was under that wasn't

under tension

and

stayed pink when you stretch the finger

will now go white showing that you've

taken up all of the elasticity in the

skin

so that's uh needle upon neurotomy

um for me it's one of the most enjoyable

uh parts of dupatron's treatment it's

simple

it's safe

and i always say to patients that if i

can't feel what i'm doing safely or i

get lost in the finger we will stop

we will reassess

and we'll either go for surgery or the

patient can live with what we've already

achieved i'm not there to get perfection

in complete extension i'm there to get

an improvement

with minimal risk and minimal damage

so let's move on to the more traditional

uh

surgery

and

there's a variety of these from

segmental fascia to me limited

fascictomy and even radical fascictomy

now um radical fasciectomy has really

fallen out of uh

favor

very much like most other forms of

radical surgery and i

i look at uh almost all forms of surgery

as going through this evolution from

pre-anaesthetic days of minimal surgery

that was often very fast

get the minimum necessary done

and then with the introduction of

anaesthesia

we saw

surgeons moving into radical surgery so

with breast cancer we moved from

mastectomy to the radical to the whole

sense mastectomy

and then we realized it didn't work

and so we now see things changing back

and with chemotherapy and

radiotherapy we can move back to

more limited surgery but equal cure

rates or better cure rates even

and similarly with dupatrons uh we went

from uh

small

treatments with uh dupatron

the introduction of anesthesia allowed

fasciaectomy and then radical fascictomy

where the whole of the skin of the palm

was

elevated

and the fascia

excised on block

often associated with a real

high incidence of wound necrosis

long-term healing

but also associated with

very highly successful treatment

my grandfather had a radical fascectomy

probably back in the 30s or

40s

uh healed perfectly never had any

long-term problems never had recurrent

dupatrons

um

thankfully for me it didn't pass down

the family and at the moment touchwood i

have no signs

but we have to

think what do we mean by jupiter's what

do we think of the disease process

are we looking at a disease of specific

parts of the fascia in which case we

want a narrow margin around the cord or

are we say seeing this as a disease of

the whole fascia in which case we want a

radical excision

we want to look at recovery for the

patient the time to recovery versus the

recurrence rate and there's very little

information on which to based any

decisions we talk about the dupatron's

diathesis

but we don't really know what that means

and one of the problems from needle upon

your other me and those of you that do

need a leuponorotomy and do it regularly

and have been around for the 27 years

that shinshin reminded me that i've been

a consultant for thank you shinchan

will know that

multiple needle upon your ottomans will

lead to more complex disease

and so

whilst needle upon your otomy is i think

excellent and patients like it

you have to be aware that

if you've done it two or three times or

even four times in a finger

when you finally come to do the

fasciectomy

you will have a long job it will be

complex you'll have more retrovascular

chords you'll have more spiral bands and

you'll be working hard for your money

get uh two surgeons together to talk

about dupatrons and you'll probably end

up with three different uh approaches

um i personally like them akash

and scoob but then i'm old-fashioned

i used to think that the bruno approach

was

not a good approach for dupatrons

but many of my colleagues

who i really respect uh have used the

bruno incision and made it work for them

the lateral approach

donald summit is i think very

much in favor of the lateral approach

and i think it does have its place i

think if you've got a unilateral cord

with an

inexperie sorry with an experienced

surgeon

then

distal to proximal

through a lateral incision can be very

effective

but if you're an inexperienced surgeon

then i would still recommend

the skoog approach i think it's more

extensile

in its exposure than the bruner

and the makash now why the mccash

and it's it's one of those exposures

that comes and goes in and out of

fashion

for those of you that aren't aware of

what the cash is it's a transverse

incision in the palm

somewhere around the distal palmar

crease

and you just

open it up raise your skin flaps

and then carry on with either a brunner

or a screw and you leave it open at the

end of the procedure

you have to warn the patient you've left

a great big hole in the palm of their

hand otherwise they and your nursing

staff get very upset uh later on

when they come for their first dressing

change but it will heal in about 10 days

to a fortnight and

fascinatingly it leaves

virtually no scar you cannot see where

it is

where it has happened

i think it has uh

three advantages

firstly it allows you to have a drainage

portal so that you won't get

hematomas uh i know that they aren't

common in uh dublin surgery but it just

gives me that little bit of extra

sleep at night

secondly it takes the tension out of the

fingers so that

this you get a little bit of movement of

the web spaces

into the fingers

because all of this skin has moved

forwards so i think it aids

extension of the finger at the end of

the procedure

and

finally i think it takes tension off the

sutures

so that when you ask the patient to

extend their fingers they don't get that

tension from the from the sutures

but finally on this slide we've got to

talk about what you're going to do with

the neurovascular bundles now the

neurovascular bundles

we know are

collateral damage in jupiter surgery two

patrons is not about the neovascular

bundles but we have to know where they

are

in order to exercise the duplicates

safely and every trainee is told that

they have to look out for spiral bands

and that if they cut the digital nerve

whilst we

uh through a spiral band they will be

damned forever and the drummed out of

hand surgery uh and it will be a big

black mark

well

my view is that actually

doing dupertrons i just don't want to

see the neurovascular bundle unless i

have to

so in primary disease i will be doing

everything i can not to see the

neovascular bundle

the neovascular bundle's

surrounded by fat it's under no tension

in jupiter's disease

so even if you push your knife against

the neovascular bundle you won't damage

it

and if you can leave that perineural fat

alone it will prevent scar tissue

forming around the nerve

and mean that when you come to do your

revision surgery

you will still have a virtually pristine

nerve to dissect out a functioning

artery

if you make it your life's work to

demonstrate the neurovascular bundle

even in primary cases

you will be very sad when you come to do

the revisions because it will already be

scarred

so

know where the digital the neurovascular

bundles are

but just leave them there let sleeping

dogs lie

and then closure

well there's as many different ways of

closing a wound as there are

different surgeons

uh zed plasti or v to y

um clearly as a proponent of the skoog

approach i like z plastics

one single large zed plasti in the

proximal compartment uh nothing fancy

don't move

skin from the palm into the finger so

it's not

formed on the palmer digital crease it's

formed in the middle of the proximal

compartment

then close all gaps or allow secondary

healing um

when i was uh a young surgeon

um

then i was taught that you had to close

all gaps

so everything had to be closed

and if the gap couldn't be closed

you had to put a skin graft on it

and then i think

coming from the congenital hand surgery

world we had the

concept of secondary healing especially

for

syndactyly release where people were

simply joining the apices of their

zigzags

and now

i'm really very happy to leave gaps in

dupatrons if i will close the apc's i

might do a running stitch but if it's

tight just leave it

i use absorbable sutures

i think there's a number of reasons

firstly patients like absorbable sutures

patients dislike having sutures removed

and if you've ever had sutures removed

from a slightly gooey wound it's painful

secondly

in times when

nurses in clinic are in short supply run

off their feet

why give them extra work

it takes hours sometimes to take sutures

out of that jupiter patients

absorbable doesn't matter

dressings

whatever you like

plaster of paris no

splints no

further dressings

whatever you like

um increasingly i'm thinking that what

we should be doing to these patients

is treating them like either burn scars

or

hypertrophic scars

and that we should be in the immediate

post-operative period once everything's

healed

putting them into

compression orthoses compression gloves

with

silicon

inserts to control scarring

but that's something that

when we have limited therapists is again

difficult

and then we come on to the uh

the

big daddy of them all the

dermofascictomy

um so andy logan in

norwich uh produced a lovely paper a

number of years ago showing that a

well-performed dermo fascictomy

will reduce uh recurrence

more than anything else

and here we can see a series of

photographs there's the dupatrons um

the skin graft are switched into place

the tie of addressing

and then

final appearance

it works it's a brilliant treatment

um

and

there are

some people who think that it should be

done fairly early i prefer to keep the

patient's natural skin and so i'll often

keep it for the

third revision but

if i get

rapid recurrence so if i get recurrence

after surgery at three to six months

which does happen

so

uh there's a

a feeling i think among surgeons that uh

if they see that uh rapid recurrence the

patient that you've done a beautiful

operation on and they've come back three

months later to your clinic and their

fingers back down again

oh

what do i do

they're the ones to do a dermal fascia

etch me on even if it's the first

recounts just do a dermal fascia

activity

full thickness versus split it's got to

be full thickness

um there's papers about using integra

and they're split skinny graft on top um

but just do a full thickness

i use the anti-cubital fossa it's thin

mobile skin there's plenty of it

uh it leaves a scar in the lines of

election that's invisible uh i think

taking uh full thickness grasp from the

side of the forearm is a horrible scar

it's a tight wound it's uh it's

um hypothena eminence

equally but even more

so for me full thickness and a cubital

fossa

if you want to show off how good you are

then you take it

leaving the reety pegs behind so you can

see the

the uh

the tracery

and you don't d-fat a couple of fat

globules on your skin grafts will make

no difference to the take

whereas taking your scissors and uh

meticulously taking off every bit of fat

from your skin graft will certainly

crush and damage it

so sharp knife

lots of tension

and lift the skin graft in one piece

but the standard description of

demofascectomy

is to excise

the original scar

but then you've thrown away tissue

and

my personal preference

uh that i've done for

27 plus years is what i call the

stillwell technique

uh those of you that work in the north

of england

or certainly the north west

may remember john stillwell a plastic

surgeon

who taught me this technique uh

during

his time and my time at writington

it's a difficult technique it's

technically demanding

it protects the pip joints

particularly

and it comes i think uh from the concept

of burn scar management and this is a

picture that i found under the

management of burn scar

on a neck where we don't cut out

this whole scar

we simply incise it

let it retract

and then fill in the gap

this is a picture of a burn scar and a

finger in a child and you can see the

similarity to severe

recurrent dupatrons with this shortage

of skin

and here

traditionally you would open this up

you would release these

flaps of scar tissue back to the

mid-lateral line

and then you would in layer graft

what uh

i do um and i i don't have a picture of

this i've gone through all my slides and

it it's something that i do so routinely

that i've never thought to photo it or

to photograph it

so if you start in the middle of the uh

middle phalanx at the mid lateral line

and

draw your incision

right down into the palm and you want to

be proximal or just proximal to the edge

of your previous scar tissue

and then down the

other mid-lateral line

by being just proximal to your level of

scar tissue this allows you to go down

and find your neurovascular bundles in

good tissue

and then you lift this whole flap of

skin scar dupertrons whatever

off the neovascular bundles off the

tendon sheath

just sliding it distally

now this looks as if it's going to be a

massive flap that is

far more than one to one um it's going

to have very poor blood supply and it's

made of scar tissue and deuterons

well it does in this picture but if you

imagine doing it in this hand

it's going to be a very short

piece of tissue

it is virtually going to be one to one

by the time you've raised it

and it always survives if you're worried

you can let down the tourniquet

and inspect the proximal edge of it and

it will bleed

the big advantage is that as you dissect

this out

and you start releasing the pip joint

and you open the tendon sheath as we

always end up doing

and then you're worried about putting

your uh

skin graft on it will it take over the

tendon

this flap

always just sits

over the pip joint crease and then you

put your big skin draft

down in here

so you have the advantage that you

haven't thrown any tissue away

you've kept and used that tissue and

you've used it where your skin graft

will have the poorest take

so it's demanding

it's not something to jump into unless

you're very happy with dissecting out

along the neovascular bundles but i

think it actually gives a much better

result in terms of derma fashion ectomy

and is less wasteful

so

what are the last rites of dupatron's

amputation

and sometimes it is the single best

option

sometimes just amputate the finger

amputate the finger keeping a long

dorsal flap

and fold that dorsal flap down into the

palm resurfacing

previously scarred tissue in the palm

uh dorsal tissue

doesn't have dupertrons well yeah it

does uh the pads but

effectively it doesn't so folding it

down into the palm gives you lots of

skin

and gives you a fire break if nothing

else

the other one that

people don't think about but which i

think can be very useful

is to turn a three finger joint and a

three finger three joint finger

into a two joint finger

and you can do this in uh two ways

what i prefer to do is a pip joint

excision arthrodesis and

what i

do is open from the back so you're going

through

virgin territory

and you excise proximal phalanx and

middle flanks

until the finger will come straight

again

and then you simply put a plate on it

reef your extensor tendon close up and

you've shortened the finger

usually by about a phalanx in length

but you've got a finger that is straight

all the jupiters is relaxed

and it's got one joint at the

appropriate place for the finger to

function

an alternative that i have come across

is that in a situation like this

you'd

take out the middle phalanx

keeping all of the collateral ligaments

to keep the collateral ligaments at the

dip joint on the distal phalanx

the pip joint on the proximal phalanx

and you bring the distal phalanx to sit

on top of the proximal phalangeal head

repair your collateral ligaments

[Music]

refuel extensor tendon and again produce

a two-joint finger

of a shorter length

but removing the contracture

um

i think that's more complicated than my

one but my one has an occasional

non-union rate

so

uh two options

one of the big problems i think in

duplicate surgery is consent

and the complications

this is the list of expected

complications

from limited fascictomy surgery in the

disc trial

amputation arterial injury bleeding

complex regional pain syndrome delayed

healing infection instability nerve

injury pain parasthesia scar pain

scarring

medicine ecosystem carpal tunnel

syndrome tina synovision trigger finger

um so

if you're not

telling patients about these risks

then you aren't telling them

about what a nationally funded ethically

approved study

considers expected complications

mention of trigger finger reminds me

of another slide which i thought i had

or a point that i've missed out which is

that

whilst dupatrons may be painful not all

pain in dupatrons

is dupatrons think of other things

and my colleague dan armstrong has

really brought home to me in his

discussions

that a tender nodule in the palm in the

line of the ring finger

is frequently a tender tendon sheath and

a1 pulley rather than a tender nodule

and

dan has had great success with some of

these patients with a steroid injection

into the tendon sheath

rather than injecting

nodules

and that reminds me we've not talked

about injecting nodules

probably because i don't like it and i

think it's a waste of time

and i think it's very very painful

and that seems to brought me to the end