1	Dupuytrens Disease Chris Bainbridge
2
3	History Plater 1614 Cline 1808 Cooper 1822 Dupuytren 1831
4	Basic Science
5	Basic Science Normal Fascia – 95% Type I collagen – 5% Type III collagen Dupuytren’s Fascia – 40% Type III collagen
6	Basic Science Local ischemia leads to fibroblast proliferation Myofibroblasts responsive to growth factors
7	Normal Anatomy • Palmar Aponeurosis • Septi of Legueu and Juvara • Superficial Transverse Palmar Ligament • Pretendinous Band
8	Normal Anatomy • Spiral Band • Natatory Ligament • Lateral Digital Sheath • Cleland’s Ligament • Grayson’s Ligament • Retrovascular Band • Neurovascular Bundle
9	Pathoanatomy • Pathologic change in normal fascia Bands Cords • Myofibroblast produce contractile behavior
10	"MP contracture" MP contracture Pretendinous Cord Thumb web Palmar Aponeurosis Web space Natatory Cord
11	PIP joint Lateral Digital Cord Grayson’s Ligament Central Cord Spiral Cord Retrovascular Cord
12	DIP Joint Lateral Digital Cord Retrovascular Cord
13	Demographics Viking heritage Genetics Complex Multifactorial Mitochondrial element Particular loci now identified
14	Clinical History Age 40 to 60 years (can start younger) Male:Female is 7:1 Pathognomonic Nodule Often tender Usually at base of ring finger
15	Clinical examination Flexion Contractures MP, PIP Bilateral Ectopic Deposits
16	Associated Disease Smoking Alcohol Diabetes Epilepsy
17	Trauma NOT related to manual work MAY appear after a single episode of trauma
18	"• Family History" • Family History • Early Onset • Bilateral - Radial • Ectopic Deposits
19	Treatment Indications • “Table Top” Test • MP > 30 degrees • PIP - any contracture
20	Table top tests - Normal
21	Table top tests
22	Assessment Stage 1: 0-45 Stage 2: 46-90 Stage 3: 91-135 Stage 4: 136-180
23	Treatment options • Needle Aponeurotomy • Segmental Fasciectomy • Fasciectomy • Radical Fasciectomy Dermofasciectoy
24	Needle Aponeurotomy Least invasive technique Simple division of the cords Endorsed by NICE Low risk of complications Local anaesthetic out patient procedure No need for physiotherapy Recurrence rate 50% at 5 years
25	Downside to NA Risk of early recurrence Chance of nerve damage, vessel damage (as in all surgery) Possible small skin tears
26	Advantages of NA No risk of skin necrosis No sutures Return to work the next day Much less stiffness No need for a full anaesthetic
27	Segmental fasciectomy Moermans 1990 Very simple technique Remove small segments of the cord to release the contracture Low complication rate 23% recurrence at 3 years Local anaesthetic / Axillary block procedure
28	Fasciectomy / Dermofasciectomy Radical surgery Aims to remove all disease High risk of nerve and vessel damage (46% Dias et al) Always needs physio Prolonged recovery (6 weeks +) Recurrence rates 20-40% (3-5 years) 19% feel the problem is as bad after surgery as before
29	Incisions Brunner (zig-zag) Skoog (straight line with Z-plasty) Zig-zag with V-Y extension
30	Wound closure Direct closure with Z-plasty Open palm technique Skin graft
31
32	Recurrent Disease 26 to 80% of patients will get recurrence after surgery depending on author Young patients with a high risk Dermofasciectomy with FTG (low risk of recurrence and extension) Further surgery carries a high risk of Nerve damage Cold intolerance Stiffness Needle Aponeurotomy can be repeated for extensions and possibly for recurrent disease
33	New Advances Collagenase injection This is a bacterially derived enzyme which when injected into a Dupuytrens band will cause rupture without any surgical intervention “AA4500 achieved a 91% success rate for the primary endpoint of less than 5° of contracture in treated joints, including both PIP joints and MP joints, after up to three injections. The placebo group had a 0% response rate (P < 0.001). “