[Percutaneous needle aponeurotomy for Dupuytren's disease]

The ultrasound-guided percutaneous release technique for De Quervain's disease using an acupotomy

Background

This study aimed to compare the effectiveness and safety of the percutaneous first extensor compartment performed by acupotomy procedure with or without ultrasonic (US) guidance.

Methods

The percutaneous release was performed with an acupotomy on 40 wrists of cadavers, which was divided into US guidance operation and blind operation. Each arm was dissected and assessed regarding the amount of release and the extent of neurovascular and tendon injury. An analysis of finite biomechanical elements based on wrists specimen data is analyzed to observe the stress of the first extensor tendon compartment. A prospective study observed the pain visual analogue score(VAS) and Patient-Rated Wrist Evaluation (PRWEB) changes after the ultrasound guidance or blind acupotomy treatment in 30 dQD patients.

Results

The success rate in the ultrasound-guided technique was 85%, and the blind technique was 70% in the cadaver study, both techniques without neurovascular injury. There was no statistically significant difference between the two groups in measuring the distance from the incision marks to the blood vessels and nerves (P > 0.05). According to the biomechanical analysis, the tendon friction rubs when the wrist is upright. When the wrist is flexed, the tendon and tendon sheath is stressed in the bone ridges. In this prospective study, both ultrasound guidance and blind acupotomy treatment achieved well improvements in pain and function (P < 0.05), but the results with no statistically significant between groups (P > 0.05).

Conclusion

Both blind and US-guided percutaneous release by acupotomy of the first extensor tendon compartment can get a good result. US-guided techniques can improve the success rate during acupotomy operations, especially for beginners and followers.

Analysis of recurrence and complications after percutaneous needle fasciotomy in Dupuytren's disease

INTRODUCTION

The partial aponeurectomy for treatment of Dupuytren's contracture represents the gold standard for treatment of Dupuytren's contracture. In selected cases, the alternative is the percutaneous needle fasciotomy (PNF).

MATERIALS AND METHODS

Between 2008 and 2018, 80 rays in 64 patients were treated using PNF. 53 patients (68 rays) were reviewed with a mean follow-up of 31 months.

RESULTS

The recurrence rate was 18.9%. 49 patients with 62 rays had a totally free extension intra-operatively (92.4%). There were no complications. Only one patient reported a transient dysesthesia (1.8%) in the zone of operation. 86% of all patients would undergo the treatment again, if necessary. Patients were able to return to their job in an average of 5.5 days.

CONCLUSIONS

PNF is reliable and relatively simple to perform compared to partial aponeurectomy. Therefore, the PNF could be seen as a serious alternative for selected cases.

Prospective observation of Clostridium histolyticum collagenase for the treatment of Dupuytren's disease in 788 patients: the Austrian register

INTRODUCTION

Since March 2011, the microbial collagenase of Clostridium histolyticum (Xiapex®, Swedish Orphan Biovitrum AB, Stockholm, Sweden) has become available in the European Union for treatment of Dupuytren's disease. The purpose of this study was to evaluate potential safety risks of Xiapex® and to contribute to a better understanding for its use.

METHODS

A prospective, non-interventional, observational study using Xiapex® for Dupuytren's disease named XIANIS was conducted between 1.10.2011 and 01.10.2017. Treatment was conducted in accordance to the manufacturer information. Patients were invited for follow-up after 1 week, 1 month, 3 months and 1 year. Demographic data, treatment data, pain levels, anaesthetic application during passive manipulation, subjective function improvement, subjective satisfaction and adverse events were recorded.

RESULTS

788 patients with 814 treatments were included who suffered from Dupuytren's contracture for a mean of 64 months. The metacarpophalangeal joint was affected in 57% of cases and the PIP joint in 40.8% with a mean contracture of 39° and 56°, respectively. A change in the contracture down to 0°-5° was reported in 66.5% of cases, while 25.5% achieved a partial improvement. The pain during the injection was rated 4.5 and 3.3 during passive manipulation. Adverse events were reported in the majority of treated patients with skin tears being one main common event (26%). Further adverse outcomes were bleeding/hematoma, joint swelling, injection-site swelling, pressure sensitivity, erythema, injection-site pain, peripheral edema, blood blisters, blisters, painless lymphadenopathy, painful lymphadenopathy, axillary pain, arthralgia and sensory abnormality. There were no reported tendon ruptures, anaphylactic reactions or ligament injuries. On 1-year follow-up, 29% showed an increased contracture of a mean of 24° with the need for surgical treatment in 2% of patients. 74% of patients were very satisfied and 72% showed a high functional improvement.

CONCLUSION

The injectable collagenase Clostridium histolyticum (Xiapex®) proved to be effective and safe in patients with Dupuytren's disease. Minor adverse events disappeared within 30 days and the need for surgical treatment within 1 year was very low (2%). No major complications or rare side effects were seen in this prospective observational study.

Range of motion, postoperative rehabilitation and patient satisfaction in MCP and PIP joints affected by Dupuytren Tubiana stage 1-3: collagenase enzymatic fasciotomy or limited fasciectomy? A clinical study in 52 patients

INTRODUCTION

In Switzerland, collagenase Clostridium histolyticum therapy (CCH) for Dupuytren's disease was introduced in 2011. This study analyzes possible differences between CCH and limited fasciectomy (LF) in terms of range of motion, patient satisfaction and postoperative rehabilitation.

MATERIALS AND METHODS

This retrospective study included 52 patients with Dupuytren's disease stage 1-3 according to Tubiana, treated with CCH or LF between January 2012 and December 2013. Complications were analyzed for each patient. The contracture of each treated joint measured on average at the 3 months and up to 2 years follow-up was compared with the preoperative values. The Michigan Hand score was evaluated at 2 years and the patients were asked to subjectively evaluate the outcome of the treatment and whether they would repeat it if necessary. Postoperative rehabilitation was also precisely quantified.

RESULTS

11 minor complications were reported for a complication rate of 29% in the CCH group. No major complications were reported in both groups. In the CCH group, mean MCP joint contracture was, respectively, 44° ± 20°, 9° ± 2° (gain of mobility compared to the preoperative situation 35°, P < 0.001), and 10° ± 3° (gain 34°, P < 0.001), respectively, before, at the 3 months' control and at the 2-year clinical control. In the LF group, mean MCP joint contracture was, respectively, 30° ± 21°, 2° ± 0.5° (gain 28°, P < 0.001), and 1° ± 0.5° (gain 29°, P < 0.001) for the same control periods. In the CCH group, mean PIP joint contracture was, respectively, 51° ± 21°, 18° ± 3° (gain of mobility compared to the preoperative situation 33°, P < 0.001), and 32° ± 4° (gain 19°, P < 0.001), respectively, before, at the 3 months' control and at the 2-year clinical control. In the LF group, mean PIP joint contracture was, respectively, 30° ± 20°, 2° ± 0.5° (gain of mobility compared to the preoperative situation 28°, P < 0.001), and 11° ± 4° (gain 19°, P < 0.001) for the same control periods. Outcomes were compared across the LF and CCH groups: surgery performed better than collagenase for PIP joint treatment at early (P < 0.001) and 2-year follow-up (P = 0.004) controls. However, patient satisfaction was higher in the CCH group: 92% were satisfied or very satisfied of the treatment compared to 71% in the LF group. All patients would reiterate the treatment in the CCH group if necessary compared to only 71% in the LF group. Rehabilitation was highly reduced in the CCH group compared to the LF group.

CONCLUSION

In this study, surgery performed better than collagenase at early and 2-year follow-up in PIP joints and similar in MCP joints. While surgery seems to achieve better results, collagenase is considered in Switzerland as an off-the-shelf therapy that provides consistent results without scars, with shorter rehabilitation time, minor hand therapy, shorter splinting time, and applicability.

LEVEL OF EVIDENCE AND STUDY TYPE

Level III.

[The fibrous skeleton of the hand : Changes with Dupuytren's contracture]

The exact knowledge of the anatomy of the fibrous skeleton of the hand is an absolute prerequisite for any treatment of Dupuytren's disease. The fibrous skeleton does not only include the palmar aponeurosis, but also numerous retinacula cutis, which are not found in current anatomy books. Here, eponyms facilitate the otherwise difficult and over-pronounced names of the fiber systems. Skoog, Legueu and Juvara, Gosset, Grapow, Grayson, Cleland, Thomine, and Barton are the most important. This systematic review of the fibers and strands is designed to help reduce iatrogenic complications.

[Percutaneous needle aponeurotomy for Dupuytren's contracture]

Dupuytren disease is a benign fibroproliferative disease of the palmar aponeurosis, which can cause considerable functional deficiencies for the person concerned. Partial aponeurectomy is the gold standard in primary surgery. Because it is minimally invasive and has short recovery and low complication rates, the importance of needle aponeurotomy under specific indications has been increasing in the last years. Needle aponeurotomy is a cost-effective treatment with low complication rates. The revision rate compared to partial aponeurectomy is higher. Under consideration of specified indications, needle aponeurotomy is an alternative treatment option.

[Treatment of Dupuytren's disease with collagenase Clostridium histolyticum]

BACKGROUND

Dupuytren's disease as a benign fibroproliferative disease leads to hyperplasia of the collagen fibers of the fascia of the palm, which can result in severe impairment of the functionality of the hand.

OBJECTIVES

Examination of the significance of non-operative treatment of Dupuytren's disease with injectable collagenase clostridium histolyticum (CCH) METHODS: Observation of 120 patients treated with injectable collagenase. Documentation of the range of motion before the intervention, 12 months after the intervention, and documentation of any adverse events.

RESULTS

All in all, 120 patients were treated (107 male, 13 female) (mean age 62 years, range 30-84 years). In 49% the little finger, in 44% the ring finger, in 4% the middle finger, and in 3% the index finger were treated. Full release was accomplished in 71%, partial release in 26%, and no change in 3% of the patients. The median contracture before the treatment was 37° for the metacarpophalangeal (MP) joint (range 25-100°) and 51° for the proximal interphalangeal (PIP) joint (range 30-97°). After 12 months, the mean contracture for the MP joint was 9° (range 0-25°) and 21° (range 10-36°) or the PIP joint. Adverse events occurred in 96% of patients within 3 months after treatment. No tendon ruptures, anaphylactic reactions, nerve, or ligament injuries were observed.

The efficacy of open partial aponeurectomy for recurrent Dupuytren's contracture

INTRODUCTION

To evaluate the efficacy of open partial aponeurectomy for recurrent Dupuytren's contracture.

METHODS

Eighteen patients with recurrent Dupuytren's contracture of 22 fingers were retrospectively assessed with a mean follow-up time of 94 months (range: 70-114 months). Examination parameters included the determination of range of motion (ROM), grip strength, pain and subjective outcome (disabilities of the arm, shoulder and hand (DASH) questionnaire).

SURGICAL TECHNIQUE

Dissection with special regard to former skin incision and expected wound defect. Modified incisions after Bruner (Mini-Bruner incisions) were facilitated. Dissection started at the palm. Fibrous tissue was resected proximally within the palm including vertical fibrotic septae. Direct preparation of the neurovascular bundles (NVB) was facilitated from proximal to distal. If the anatomy of the neurovascular structures became unclear around the natatory ligament preparation of the NVB at the distal end of the fibrous cord was performed. After complete preparation of a NVB, dissection was continued from medial to lateral until the other bundle was completely released. Transposition flaps and skin transplants were often used for sufficient wound closure.

RESULTS

Recurrence rate was 36 % applying the definition of van Rijssen et al. Fifteen patients had a grip strength of 90 % or higher in comparison to the contralateral side. Ten patients had a pinch strength of 90 % or higher in comparison to the contralateral side. All patients except for one had pain reduction or none postoperatively. Fifteen patients had a DASH score of 15 or lower (range: 0-47). An unrelated ray amputation was suffered due to wound healing complications.

CONCLUSIONS

Open partial aponeurectomy performed by a board certified hand surgeon proved to be safe. The postoperative functional outcome seemed to be related to the individual course of the disease.