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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
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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
Solihull Hand ClinicHeartlands Fracture ClinicGood Hope Hand ClinicSpire ParkwaySpire Little Aston
Mr G Shyamalan
