Dupuytren’s Contracture Radiation Oncology Grand Rounds

Omar Nazir M.D.

Overview

• Background

• Pathology

• Anatomy

• Treatment

• Questions

History

• A fifteenth century altar cloth from the cathedral of Holar in North Iceland

History

• First described in 1614 by Felix Plater

• Progressive contracture of a digit

• Henry Cline (1808)

• Contracture and thickening of palmar aponeurosis

• Guillaume Dupuytren (1834)

• Hypothesized overuse

• Defined anatomy, natural history and treatment of disease

History

• Baron Guillaume Dupuytren

DUPUYTREN’S CONTRACTURE Epidemiology

• Prevalence

• 2 – 42%

• Autosomal dominant with variable penetrance

Epidemiology

• Common in Scandinavia, Great

Britain, Ireland, Australia and

North America

• “Nordic disease”

• Rare in Blacks, Asians and North

American Native Indians

Clinical History

• Usually appears in

middle age (40-60)

• 50% > age 60

• More common in

males – 7X – 10X

Predisposing Factors

• Diabetes mellitus

• Alcohol consumption

• Cigarette smoking

• Epilepsy

• Other Factors

Nomenclature • Nodule

• fundamental lesion of the disease

• palpable subcutaneous lump

• a collection of cells in a whorled pattern

• consists predominantly of myofibroblasts

Nomenclature

• Band

• normal palmar fascial structure

• Cord

• a diseased band

• contains no myofibroblasts

• organized collagen structures similar to tendons

Myofibroblasts

• quintessential cell

• characteristics of fibroblasts and smooth muscle cells.

Anatomy – Palmar Fascia

•Fibrous skeleton

•Retinacular restraint for tendons

•Connects skin to underlying static structures

•Palmar skin does not ‘slide’

PL

Anatomy

•Triangular fascial layer

•Fibers are oriented longitudinally

•Pretendinous cords

•Natatory ligaments

The MCP Joint

• Pretendinous cord

• Adjacent pretendinous cord (Y cord)

• Natatory cord

The PIP Joint

• Central cord

• Spiral cord

• Lateral cord

• Retrovascular cord

• Subdermal-level

contracture

NATATORY CORDS

•Originates from natatory ligament

•Contracture of second, third or fourth web spaces

NV Bundle Involvement

Ask About Related Conditions

• Knuckle pads (Garrod pad):

• deposits on dorsum of PIP joint

• Peyronie’s disease (3%):

• deposits on dorsum of penis

• Ledderhose’s disease (5%):

• deposits on plantar fascia

Clinical Presentation

• Differential diagnosis

• Epithelioid sarcoma

• hyperkeratosis and callous formation

• localized PVNS

• atypical contractures

• soft tissue giant cell

Differential Diagnosis: non-Dupuytren's contracture

• Associated with trauma and surgery

• 2 to 3 months after incident

• Resembles a pretendinous cord

• In line with a single digit without digital involvement

• Unilateral

Nonoperative Treatment

• creams, lotions, steroid injections, PT, and splinting • are ineffective

• educate patient

• When evaluating surgical candidates must consider • Rate of Progression

• Loss of Function (usually PIP/MP contracture>30o)

Indications for Intervention

•Progressive contracture (hand can no longer be placed on a flat surface)

•Goal of surgery is to regain maximal hand function

•Cure is not always attainable

Indications

•MCP contracture >30

•Any PIP contracture

Enzymatic Lysis - Collagenase

•Approved by FDA in February 2010

•“Adults with Dupuytren’s contracture

with a palpable cord”

•Less morbidity compared to surgery

•Less time off work

Collagenase - Xiaflex

• Mixture of 2 purified collagenases

• Clostridium histolyticum

• The two collagenases increase the enzymatic degradation of collagen

• Relatively rapid effect

Badalamente MA et. al. JHS 2000

Day 7 Day 5

Day 33

Day 14 Day 20

Day 26

Operative Treatment

•3 Concerns

•Skin Incision

•Management of Palmar Fascia

•Management of Volar Skin

Management: Surgical Options

• Primary surgical options include:

• Percutaneous fasciotomy

• Segmental aponeurectomy

• Dermofasciectomy

• Partial fasciectomy

• Total fasciectomy

• Extensive fasciectomy

Percutaneous Fasciotomy

• Done through a stab

• #11 blade is administered horizontally and then turned perpendicular to the cord

Percutaneous Fasciotomy

•Highest risk of injuring the neurovascular bundle

•Highest potential for recurrence

•Approximately 45 % recurrence within 5 years

•Palmar cords and for MP joint contracture

•Not indicated for patients with PIP contracture

Segmental Aponeurectomy

• C-shaped incisions

• Limits wound complications and joint stiffness associated with wide dissections.

• Comparable to other techniques

• Recurrence rate of 21 percent

• Recurrence plus extension of 14 percent.

Dermofasciectomy

• Skin and diseased tissue removed

• Indicated for recurrent and severe primary cases

• No evidence of recurrence of cords when combined with skin grafting • controversial

Partial Fasciectomy

• Excision of diseased tissue only

• unaffected fascial tissue left behind

• Reported surgery for recurrence in 43 % after fasciotomy and 15 % after fasciectomy.

Extensive fasciectomy

• Involves the removal of a large area of diseased tissue, sparing the normal fascia.

• Indicated for extensive involvement of the palmar fascial complex.

Total Fasciectomy

• Total excision of the palmar aponeurosis (both diseased and adjacent normal fascia, including involved skin).

• “mentioned to be condemned because of the frequent profound postoperative morbidity”

Residual Joint Contracture • Pretendinous cords

• deformity at the MP joint

• do not cause residual joint contracture

Digital cords • cause PIP joint flexion

• result in residual joint contracture

• Gentle passive manipulation helps • Pull on it

• Associated with attenuation of the central slip • Intraoperative tendondesis test confirms imbalance.

Capsulotomy / Splinting

• Done in combination

• residual deformity is greater than 45 degrees.

• PIP extension splinting can help restoring central slip function.

• Attempts to fully correcting severe deformity

• dorsal dislocation of the joint.

Salvage procedures • Indicated for

• severe PIP deformities greater than 70 degrees

• recurrent

• Options • Osteotomy of proximal phalanx

• Arthrodesis of the PIP joint combined with resection • Decreases tension on NV structures.

• Arthroplasty of the PIP joint using silastic implant

• Amputation

Wound Management Options

• Primary closure

• Open-palm method

• Skin grafting

• Flap coverage

Primary Closure: Incisions

Most common incisions: • Bruner zigzag incisions +/- Y-V-plasties

• longitudinal incision closed with multiple Z-plasties.

Primary Closure: Z-plasty

V-Y plasty Y-V plasty

Open-Palm Method

• Heal by secondary intention

• Good results and low complication rate including hematoma, skin necrosis, and infection.

• Dupuytren was the first to leave the wound open after placing a transverse palmar incision.

Open-Palm Method

Local Flap / Skin Graft

Postoperative Therapy

• Goals

• Maintain correction

• Reduce scarring and edema

• Restore flexion and strength

• OT begins 2 days after surgery

• Volar forearm-based splint with fingers in extension

• Start active and passive motion immediately

• Daytime splinting 2 weeks

• Nighttime splinting 6 months

COMPLICATIONS OF OPEN SURGERY

• Nerve injury

• Complex regional pain syndrome

• Recurrent contracture

• Finger ischemia

• Skin necrosis

• Tendon injury

• Infection

Disease Recurrence

• Disease is controlled at genome level

• Surgical excision

• Not a true cure

• Recurrence is more common in those with diathesis and earlier presentation

• New foci from area that has not been treated?

• Incomplete excision?

Conclusion

• Genetic condition

• Multiple options depending on severity

• Room for improvement

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reaction and tissue complications in Dupuytren's disease

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emerging insight into a Viking disease. Hand Surg.

2014;19(3):481-90.

3: Povlsen B, Povlsen SD. What is the better treatment for

single digit dupuytren's contracture: surgical release or

collagenase clostridium histolyticum (Xiapex) injection?

Hand Surg. 2014;19(3):389-92.

4: Engstrand C, et al. Hand function and quality of life before

and after fasciectomy for Dupuytren contracture. J Hand

Surg Am. 2014

Jul;39(7):1333-1343.e2.

Thanks!

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Dupuytren's disease. Clin Genet. 2014 Apr 22. doi:

10.1111/cge.12410.

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contracture. Instr Course Lect. 2014;63:131-42.

8: Toppi JT, et al. Dupuytren's contracture: an analysis of

outcomes of percutaneous needle fasciotomy versus open

fasciectomy. ANZ J Surg. 2014 Jan 20.

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Percutaneous Needle Aponeurotomy for Treatment of Dupuytren Contracture.

Ann Plast Surg. 2013 Mar 11.

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