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Office-Based Percutaneous Fasciotomy for Dupuytren Contracture
J. Stephen Chambers, MD1 Taylor Pate, MD2 James H. Calandruccio, MD1
1 University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering Memphis, Tennessee 2 Eastern Virginia Medical School Norfolk, Virginia
Corresponding Author
James H. Calandruccio, MD
1400 S. Germantown Road Germantown, TN 38138 P: 901-759-3210 F: 901-759-3195 jcalandruccio@campbellclinic.com
Dupuytren disease is a chronic progressive disorder that a ects connective tissue in various areas and can cause functional issues when significant contractures develop in the palmar and digital fascia. The disease has an autosomal dominant inheritance pattern with variable penetrance, with family history cited as a strong predictor of the disease. The disease is most commonly diagnosed in Caucasian men, with increasing prevalence in men older than 65. Dupuytren disease often is tolerated for many years before the patient presents for evaluation when skin tightness and contour changes progress to form nodules, typically on the palmar aspect of the hand. These nodules produce tension in pretendinous and other cords of the palm and fi ngers resulting in joint fl exion contractures. The contractures occur most often on the ring and small fi ngers with the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints most commonly a ected. Treatment usually is begun for patients when the contractures are signifi cant enough to interfere with daily activities. Primary treatment goals are to completely straighten the a ected ray(s) while reducing the risk of recurrence and avoiding complications. Treatments options are of 2 general types: minimally invasive and open surgical procedures. Minimally invasive procedures include percutaneous needle fasciotomy (PNF), cordotomy, and enzymatic fasciotomy. These options typically are more cost-e ective, but have higher rates of recurrence compared with open procedures. Open surgical procedures have higher complication rates but lower rates of recurrence and often are preferred as a second line of treatment. Although fasciotomy was described more than 200 years ago, it was seldom used until French rheumatologists described fasciotomy with a percutaneous needle technique (PNF). The technique gained more widespread acceptance after the report by Foucher and colleagues. In 2003, a series of 100 patients treated with PNF resulted in few complications, reoperation rate of 24%, and recurrence at 3-year follow-up of 58%. More recent studies have shown that 79% of patients retain a straight joint after 2 years, but recurrence of the contracture(s) remains frequent, regardless of treatment method. Pess and colleagues reported a recurrence rate of 48% in 1,013 fi ngers followed for a median of 3 years. In their randomized controlled trial, van Rijssen and colleagues found a recurrence rate of 22% with PNF compared with 5% with limited fasciectomy. Because it is a simple procedure with few complications, PNF can be done repeatedly if necessary. The e ectiveness of treatment of Dupuytren contractures can be subjectively assessed using patient-reported outcome measures (PROM). Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) is a commonly used PROM in upper extremity research including Dupuytren disease. It consists of 11 questions that focus on severity of symptoms and
This article reproduced with permission from Orthopedic Clinics of North America. Chambers JS, Pate T, Calandruccio JH. O ce-Based Percutaneous Fasciotomy for Dupuytren Contracture. 2020 Jul;51(3):369-372. doi: 10.1016/m.ocl.2020.02.008. Epub 2020 Apr 1.
Fig. 1: (A) A #15 scalpel blade is placed between the skin, parallel to the underlying cord. (B) The fi nger is extended to deliver the taut cord to the blade, which is then directed perpendicular to the cord. The knife is gently pushed against the underlying cord with the fi nger held in forceful extension. (C) The scalpel is removed and force-ful extension is used to get as much correction as possible.
di culty in completing specifi c tasks. The QuickDASH score has 2 additional modules, work and sports/art, which focus on the patient’s disability while playing a sport/musical instrument or at work. There is limited evaluation of these additional modules in patients with Dupuytren disease. Percutaneous office-based cordotomy is an e ective treatment for Dupuytren contracture; however, given that the cords are divided rather than excised, recurrence is frequent. There have been many di erent definitions of recurrence causing inconsistencies among studies and data, with rates ranging from 2% to 86%. In 2017, Kan and colleagues as part of the Dupuytren’s Delphi group, addressed this problem with an expert consensus of recurrence as “an increase in extension defi cit of 20 at 1 year compared to at 6 weeks post-procedure.” Identifying risk factors associated with recurrence of contracture is important because this information may change treatment plans. Degreef and De Smet, in a study of more than 300 patients, showed that rates of recurrence are high for patients younger than 50 years and those with Ledderhose disease, family history, and male sex. The variable penetrance of the disease plays a confounding role in identifying specifi c risk factors. E ectiveness of treatment also can be assessed from a patient’s perspective using PROM. Budd and colleagues showed an improvement in QuickDASH Score from 15.1 before procedure to 8.0 afterward at a mean of 110 days. The QuickDASH survey has 2 additional modules that focus on the ability to work (Work Module Score or WMS) and to play a musical instrument/sport (Sport Module Score or SMS). MacDermid and colleagues studied upper extremity conditions and showed a reduction in QuickDASH score of 15 points or more to appreciate a change in function; their study, however, did not include Dupuytren disease. The correlation between improvement of contracture and patient-reported outcomes after treatment for Dupuytren disease has been shown to be weak or nonexistent. Budd and colleagues showed that the change in QuickDASH score and change in extension defi cit did not correlate. Post-procedure patient satisfaction also contributes to the patient’s perceived function of the digit(s). Most patients are satisfied with the outcomes of the procedure at 1 year. Patient satisfaction outcomes following fasciotomy and collagenase treatment showed rates of 84% at an average of 10 months and 73% at 3-year follow-up. Complication rates are low after percutaneous fasciotomy. Pess and colleagues reviewed more than 1000 percutaneous releases and found skin tear to be the most common complication, occurring in only 3.4%; nerve laceration occurred in 0.1%. Skin ruptures have been reported in from 5% to 38% of patients. Nerve injuries (<0.5%) and tendon injuries (<0.05%) are rare.
Percutaneous Fasciectomy Technique
• Under sterile conditions, 3.0 mL of 1% lidocaine without epinephrine is injected into the skin and subcutaneous tissues proximal to the intended site of cord division. • A #15 scalpel blade is placed between the skin, parallel to the underlying cord (Fig. 1A). • The fi nger is extended to deliver the taut cord to the blade,
which is then directed perpendicular to the cord (Fig. 1B). • The knife is gently pushed against the underlying cord with the fi nger held in forceful extension. The cord tissue when being divided yields a palpable gritty sensation and usually produces a predictable audible pop when the cord gives way. • The scalpel is removed and forceful extension is used to obtain as much correction as possible (Fig. 1C). • Occasionally additional sites along the cord are released, sometimes using a 25-gauge needle mounted on a syringe. After the procedure, a soft dressing is applied and patients are instructed to begin range of motion exercises immediately. The soft dressing is removed the day after the procedure, and wound healing monitored daily for closure and home-based range-ofmotion exercises are continued.
Outcomes
In 52 patients (65 digits) followed prospectively from the time of the office-based procedure to 1-year follow-up, the rate of recurrence was 33%. The average metacarpophalangeal joint correction in active extension was from 39.6 to 9.3 (P = .001), and passive extension correction was from 25.4 to 3.6 of hyperextension (P = .001). The average QuickDASH score decreased by 8, the WMS score by 12, and the SMS score by 9 compared with preoperative scores, and these decreases were statically signifi cant. The improvement in patient-reported outcomes (WMS and SMS) did correlate at 6 weeks and 1 year with active extension improvement. Also, SMS at 1 year correlated with passive extension improvement. On average, the wound closed by 7 days and pain resolved by day 2. The average highest pain score was 2.3 on a scale of 10. None of patients who had the procedure sustained a sensory defi cit. At 1 year, 82% of patients were satisfi ed with the outcome of their procedure, and 87% considered the procedure worth having done. A much shorter recovery time with this o cebased procedure is appealing and is useful in patients with welldefi ned cords, especially with MP joint contractures.
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J. STEPHEN CHAMBERS, MD
Hometown: McDonough, Georgia Undergraduate Institution: Georgia Institute of Technology Medical School: Mercer University School of Medicine-Savannah Dr. Chambers has a younger brother and is the fi rst in his family to choose medicine as a career. When asked why he chose medicine as a career: I chose a career in medicine because the human body is the world’s best machine, and I wanted to learn more about it. And why he chose orthopaedics as a specialty: The ability to restore a patient’s function is what I fi nd truly special, and I believe orthopaedics best fosters this. Plans After Campbell: Dr. Chambers will complete a Hand/Upper Extremity Fellowship at University of Pittsburgh Medical Center.
Dr. Chambers adds: Thank you to my fellow classmates. These past fi ve years have been unforgettable, and I couldn’t have done it without your support. Thank you to all the Campbell Clinic faculty and the staff (especially Karen and Tonya) for the countless hours of education and support you provided. Thank you, Dr. Cal, for introducing me to the best subspecialty. I am grateful for my experience here and proud to call myself a Campbell Clinic graduate.
