Management of Dupuytren's Contracture by Prof Chris Bainbridge
Summary
TLDRThis 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
- π 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.
- π Treatment for Dupuytren's contracture is primarily for functional improvement, not necessarily for a fully straightened finger.
- π Some untested treatments for Dupuytren's are available online, but they lack scientific evidence and should be approached with caution.
- π§ͺ 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.
- π« Verapamil gel, though reported to have mild effects, lacks randomized controlled trials and is not widely available, making it an uncertain treatment option.
- π¬ Ongoing research includes the use of anti-TNF therapy for treating Dupuytren's disease, though its delivery method and systemic effects are concerns.
- π Collagenase injections were once a promising treatment but have been largely discontinued due to risks and complications, except in the United States.
- π€ 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.
- π©Ί 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.
- βοΈ Needle aponeurotomy is a minimally invasive procedure that can be performed safely with proper technique and is favored for its simplicity and safety.
- π 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
π€ 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.
π§ͺ 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.
π¬ 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.
π οΈ 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.
π 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.
βοΈ 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.
π©Ή 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.
π 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.
Mindmap
Keywords
π‘Dupuytren's contracture
π‘Needle aponeurotomy
π‘Fasciectomy
π‘Collagenase
π‘Tamoxifen
π‘Verapamil
π‘Splinting
π‘Dermofasciectomy
π‘Amputation
π‘Consent
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
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