Mr G Shyamalan (Shyam) Hand Surgeon HEFT. So Much Choice!

Dupuytren’s DiseaseMr G Shyamalan (Shyam)

Hand Surgeon HEFT

So Much Choice!

Benign proliferative disease

Fascia of digits and palm

Nodules, cords and contractures

Definition of Dupuytren’s

Need yes to one of the questions to approve

Moderate MCPJ contracture >30 degrees Any PIPJ contracture First web contracture

Procedures of Limited Clinical Effectiveness (POLCE)

Age Ancestry Sex FH Diabetes Smoking and Alcohol Epilepsy

Risk Factors

Dupuytren’s Nodules 50% progress10% require surgery

Trauma Surgery Diabetes No FH Any race Generally non-progressive

Non-Dupuytren’s Disease

Male <50 Affected siblings/parents Ectopic Disease ‘Garrod’s pads’ Bilateral Disease

Dupuytren’s Diathesis

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

Treatment options

1. Do nothing £0 2. Radiotherapy – early disease £2500 (10

visits) 3. Steroid Injection (£ Steroid vial +OPD) 4. Percutaneous Needle Fasciotomy (£ OPD

+needle +/- theatres) 5. Collagenase/Xiapex (£760 per vial/digit) 6. Limited Fasciectomy (£2500 plus therapy) 7. Dermato-fasciectomy and skin graft

(>£3000 plus therapy)

Treatment options & cost(2011)

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

Personal thought process

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

Triamcinalone 50% softening 50% recurrence one year

Steroid for nodules

Mostly clinic based Splint 6 – 12 weeks at night Low complication rate Early return to work 5% early failure – akin to a failed injection

for CMC joint arthritis! Long-term 50% recurrence in 5 years but

not always requiring surgery

Percutaneous Needle Fasciotomy

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

Collagenase - Xiapex

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

Collagenase - Xiapex

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

Limited Fasciectomy

Dermato-fasicectomy Lowest recurrence rate Best choice for young patient Increase time to wound healing (diabetics

and smokers take longer) Longer rehabilitation time

Dermato-fasicectomy post op

Extent of the pre-surgical contracture of the finger

Longer you live, the higher the recurrence!

Recurrence

Refer early Tailor treatment to patient

Conclusion

gunaratnam.shyamalan@heartofengland.nhs.uk

handelbowsurgeon@googlemail.com

Solihull Hand ClinicHeartlands Fracture ClinicGood Hope Hand ClinicSpire ParkwaySpire Little Aston

Mr G Shyamalan