Needle Aponeurotomy for Stage IV Dupuytren Contracture: A Wide-Awake First Step Approach in 204 Consecutive Rays.

SUMMARY: Severe forms of Dupuytren disease are difficult to treat. Surgical fasciectomy is often the first choice, despite its high complication rate. At times, amputation is recommended. The authors evaluated the efficacy of minimally invasive needle fasciotomy (needle aponeurotomy) as the first and only treatment for severe (stage IV) Dupuytren contracture using a retrospective chart review of a single surgeon's consecutive experience over 8 years. A total of 204 rays from 165 patients with severe Dupuytren disease with total passive extension digit contracture of 135 degrees or greater were included in the study. Mean follow-up was 22.3 months. Standard goniometric measurements of finger joint contractures were taken before needle aponeurotomy and at follow-up visits. Total passive extension digit and flexion contracture improved significantly at each finger joint. Before the procedure, median flexion contractures were as follows: at the metacarpophalangeal joint, -70 degrees (interquartile range, -80 to -55); at the proximal interphalangeal joint, -75 degrees (interquartile range, -85 to -65); and at the distal interphalangeal joint, -5 degrees (interquartile range, -20 to 0); median total passive extension of digit was -145 degrees (interquartile range, -160 to -135). Flexion contractures after the procedure improved with 74 percent gain at the metacarpophalangeal joint, 32 percent gain at the proximal interphalangeal joint, and 46 percent gain at the distal interphalangeal joint, with 55 percent gain of total passive digit extension overall ( p < 0.001). The study shows that needle aponeurotomy led to significant improvements in joint contractures at all finger joints with minimal adverse effects. Needle aponeurotomy is an effective and safe first-line treatment for severe Dupuytren disease as the sole treatment or as a preliminary step for more invasive procedures if needed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Fasciectomy under local anaesthetic and adrenaline for Dupuytren's contracture in a community setting in the UK with a cost analysis.

AIMS: In the UK, fasciectomy for Dupuytren's contracture is generally performed under general or regional anaesthetic, with an arm tourniquet and in a hospital setting. We have changed our practice to use local anaesthetic with adrenaline, no arm tourniquet, and perform the surgery in a community setting. We present the outcome of a consecutive series of 30 patients. METHODS: Prospective data were collected for 30 patients undergoing open fasciectomy on 36 digits (six having two digits affected), over a one-year period and under the care of two surgeons. In total, 10 ml to 20 ml volume of 1% lidocaine with 1:100,000 adrenaline was used. A standard postoperative rehabilitation regime was used. Preoperative health scores, goniometer measurements of metacarpophalangeal (MCP), proximal interphalangeal (PIP) contractures, and Unité Rheumatologique des Affections de la Main (URAM) scores were measured pre- and postoperatively at six and 12 weeks. RESULTS: The mean preoperative contractures were 35.3° (0° to 90°) at the metacarpophalangeal joint (MCPJ), 32.5° (0° to 90°) at proximal interphalangeal joint (PIPJ) (a combined deformity of 67.8°). The mean correction was 33.6° (0° to 90°) for the MCPJ and 18.2° (0° to 70°) for the PIPJ leading to a combined correction of 51.8°. There was a complete deformity correction in 21 fingers (59.5%) and partial correction in 14 digits (37.8%) with no correction in one finger. The mean residual deformities for the partial/uncorrected group were MCP 4.2° (0° to 30°), and PIP 26.1° (0° to 85°). For those achieving a full correction the mean preoperative contracture was less particularly at the PIP joint (15.45° (0° to 60°) vs 55.33° (0° to 90°)). Mean preoperative URAM scores were higher in the fully corrected group (17.4 (4 to 31) vs 14.0 (0 to 28)), but lower at three months post-surgery (0.5 (0 to 3) vs 4.40 (0 to 18)), with both groups showing improvements. Infections occurred in two patients (three digits) and both were successfully treated with oral antibiotics. No other complications were noted. The estimated cost of a fasciectomy under local anaesthetic in the community was £184.82 per patient. The estimated hospital theatre costs for a fasciectomy was £1,146.62 under general anaesthetic (GA), and £1,085.30 under an axillary block. CONCLUSION: This study suggests that a fasciectomy performed under local anaesthetic with adrenaline and without an arm tourniquet and in a community setting is safe, and results in favourable outcomes regarding the degree of correction of contracture achieved, functional scores, and short-term complications. Local anaesthetic fasciectomy in a community setting achieves a saving of £961.80 for a GA and £900.48 for an axillary block per case. Cite this article: Bone Joint J 2020;102-B(10):1354-1358.

Dupuytren's disease in a child: a long-term evolution after surgery.

We report the case of a 13-year-old girl who presented with a fibrous nodular lesion on the palm of her hand. After ultrasonographic examination, surgical resection of the skin (dermofasciectomy) was performed, and a nodular phase mass was recovered, characterized as fusocellular fibroblast proliferation in a dense collagenous stroma with a cell population consisting of parallel fascicles of densely packed fusiform cells of a fibroblast strain. No signs of encapsulation or malignant changes were observed, all of which was consistent with Dupuytren's disease. This lesion is exceptional in childhood. Sixteen years later, the patient has not relapsed, and retains full active and passive mobility. Dupuytren's disease in childhood must be considered in the differential diagnosis of any hard palmar lesion. Diagnostic uncertainty and the fact that a hard palmar lesion in children may be clinically indistinguishable from a malignant process mean that resection of the lesion and histological examination are required.

Hand surgery using local anesthesia.

Most hand traumas and elective surgical disorders of the hand can be treated quickly, easily, inexpensively, and effectively in an outpatient clinic. Although many surgeons prefer general anesthesia, the senior author routinely uses local anesthesia without sedation almost exclusively for carpal and cubital tunnel release, fasciectomy, arthrodesis, arthroplasty, synovectomy, and trauma, including the repair of tendons, nerves, ligaments, fractures, and soft tissue defects. After completing more than 10,000 procedures, the authors have found great benefits through the use of local anesthesia, which are detailed in the article.

[Experience with percutanous needle fasciotomy]. / Erfahrungen mit der Perkutanen Nadelfasziotomie (PNF).

The role of percutanous needle fasciotomy (PNF) in Dupuytren's disease is still discussed. Technique and own experience are shown. Due to our own experience and a brief review of the literature we recommend percutanous needle fasciotomy for patients who can't get surgery because of restricted general conditions. Furthermore the PNF is also useful in younger patients with a well defined visible and palpable cord which is responsible for flexion contracture of MP joint to avoid or delay the operation.

Management of Dupuytren contracture with ultrasound-guided lidocaine injection and needle aponeurotomy coupled with osteopathic manipulative treatment.

Dupuytren contracture is a debilitating disease that characteristically presents as a firm nodularity on the palmar surface of the hand with coalescing cords of soft tissue on the webs and digits. With few nonsurgical modalities providing clinical benefits, open surgical procedures are the standard of care for patients with this condition. However, recent studies have associated surgical intervention with many complications, necessitating further exploration of nonsurgical treatment options. We describe the case of a 64-year-old woman who presented with decreased extension of the fourth and fifth digits on the upper extremities bilaterally; previous conservative treatment regimens had been unsuccessful. After a diagnostic ultrasound, the patient was diagnosed as having Dupuytren contracture and underwent 5 treatments consisting of ultrasound-guided dry-needle aponeurotomy, lidocaine injections, and osteopathic manipulative treatment. During the fifth treatment session, the patient experienced dramatic relief of her symptoms after a palpable release during the manual manipulation portion of her therapeutic regimen. At 2-week follow-up, the patient was symptom-free. Based on this desirable outcome, the authors suggest future research be directed at minimally invasive therapeutic options in the management of Dupuytren contracture.

[Dupuytren's contracture: percutaneous needle aponeurotomy is an alternative to surgery]. / Maladie de Dupuytren : l'aponévrotomie percutanée à l'aiguille est une alternative à la chirurgie.

Dupuytren's contracture is a retractile fibrosis of the superficial palmar aponeurosis of the hand, resulting in a progressive and fixed flexion of the fingers that may result in severe limitation of hand function. It affects several millions of people in Europe and North America. Risk factors are genetic and sometimes related to mellitus diabetes. There is no spontaneous remission. Until recently, surgery was the only treatment, but now needle aponeurotomy emerges as a therapeutic alternative. It should be performed as first line treatment by a trained practitioner. Short and long-term results of needle aponeurotomy appear identical to those of surgery, with milder complications. It is indicated in palmar, palmo-digital, as well as in strictly digital forms of the disorder. The "table-test" is used to assess the loss of extension of the digit and to select the indication to needle aponeurotomy. A medico-surgical consensus should define the optimum treatment strategy in this affection.

Screening of potential prodrugs on cells derived from Dupuytren's disease patients.

Dupuytren's disease (DD) is a fibroproliferative disorder, the cure for which is still limited to surgical excision of the affected fascia, often leading to high recurrence rates. Due to this fact, non-surgical treatments are being investigated, among them those targeting molecular processes of proliferation and differentiation in Dupuytren's cell cultures. Drugs with antiproliferative action may be valuable in DD treatment. Through characterization of changes on DD-specific cells, we, therefore, decided to test the therapeutic potential of new cytostatic drugs for DD treatment and/or for reduction of post-operative recurrence rates. The N-sulfonylpyrimidine derivative, amidino-substituted benzimidazo[1,2-a]quinoline, and amidino dihydrothienothienyl[2,3-c]quinolone hydrochloride, known to affect proliferation processes, were tested for their antiproliferative activity on primary fibroblasts/myofibroblasts cell cultures derived from the palmar fascia of patients with DD. Only amidino dihydrothienothienyl[2,3-c]quinolone hydrochloride acted in a highly specific manner on cells derived from diseased fascia of DD patients and exhibited a low cytotoxic effect. This result might be a consequence of its specific activity on cytoskeleton changes occurring in differentiating cells. A similar short-term differential antiproliferative effect was observed by the N-sulfonylpyrimidine derivative that was, however, completely lost after 6- and 14-day treatments. The amidino-substituted benzimidazo[1,2-a]quinoline exerted a strong non-specific, dose-related antiproliferative activity on cell types.

Splinting after contracture release for Dupuytren's contracture (SCoRD): protocol of a pragmatic, multi-centre, randomized controlled trial.

BACKGROUND: Splinting as part of the overall post-surgical management of patients after release of Dupuytren's contracture has been widely reported, though there is variation in practice and criteria for using it. The evidence on its effectiveness is sparse, of poor quality and contradictory with studies reporting negative and positive effects. METHODS/DESIGN: A multi-centre, pragmatic, randomized, controlled trial is being conducted to evaluate the effect of static night splinting for six months on hand function, range of movement, patient satisfaction and recurrence at 1 year after fasciectomy or dermofasciectomy. Using a centrally administered computer randomization system consented patients will be allocated to one of two groups: i) splint group who will be given a static splint at approximately 10 to 14 days after surgery to be worn for 6 months at night time only as well as hand therapy; ii) non-splint group, who will receive hand therapy only. The primary outcome measure is the patient-reported Disabilities of the Arm, Hand and Shoulder Questionnaire (DASH). Secondary outcomes are total active flexion and extension of fingers, patient satisfaction and recurrence of contracture. Outcome measures will be collected prior to surgery, 3 months, 6 months and 1 year after surgery. Using the DASH as the primary outcome measure, where a difference of 15 points is considered to be a clinically important difference a total of 51 patients will be needed in each group for a power of 90%. An intention-to-treat analysis will be used. DISCUSSION: This pragmatic randomized controlled trial will provide much needed evidence on the clinical effectiveness of post-operative night splinting in patients who have undergone fasciectomy or dermofasciectomy for Dupuytren's contracture of the hand. TRIAL REGISTRATION: Current Controlled Trials ISRCTN 57079614.

The effect of 5-fluorouracil on Dupuytren fibroblast proliferation and differentiation.

INTRODUCTION: Dupuytren's disease is a proliferative disease with contractile properties, prone to recur after surgery. Intra-operatively applied 5-fluorouracil has been used to avoid scar problems in the eye after glaucoma filtration surgery and was therefore investigated as a means to inhibit proliferation and myofibroblast differentiation in Dupuytren fibroblasts in vitro. METHOD: Primary cell lines were obtained by explants from Dupuytren's tissue (n = 6), non-diseased palmar fascia from patients with Dupuytren's disease (n = 3) and carpal ligament from patients undergoing carpal tunnel release (n = 3). The effect of 5-fluorouracil on proliferation was assessed by cell counting. Myofibroblast differentiation, an intergral part of Dupuytren's contracture, was investigated by staining for alpha smooth muscle actin, a marker for contractile cells, using immunohisto-chemical methods. RESULTS: A single exposure to 5-fluorouracil caused a sustained inhibition of proliferation in Dupuytren's and non-diseased fascia cultures, whilst the effect on carpal ligament cultures was transient. Untreated Dupuytren's fibroblasts exhibited the highest myofibroblast differentiation, whilst differentiation in non-diseased fascia cultures was shown to be proportional to cell density and virtually non-existent in carpal ligament cultures. After 5-fluorouracil exposure, the differentiation was significantly reduced in Dupuytren's fibroblasts cultures, reduced at high cell densities in non-diseased fascia and unchanged in carpal ligament cell cultures. DISCUSSION: 5-fluorouracil inhibits both proliferation and myofibroblast differentiation in Dupuytren's cell cultures and may have a potential use as an adjuvant treatment to Dupuytren surgery in order to reduce the rate of recurrence and contracture.