1. Mr G Shyamalan (Shyam) Hand Surgeon HEFT
Dupuytren’s Disease
Mr G Shyamalan (Shyam)
Hand Surgeon HEFT

2. So Much Choice!

3. Definition of Dupuytren’s
Benign proliferative disease
Fascia of digits and palm
Nodules, cords and contractures

4. Procedures of Limited Clinical Effectiveness (POLCE)
Need yes to one of the questions to approve
Moderate MCPJ contracture >30 degrees
Any PIPJ contracture
First web contracture

5. Risk Factors
Age
Ancestry
Sex FH
Diabetes
Smoking and Alcohol
Epilepsy

6. Dupuytren’s Nodules 50% progress 10% require surgery

7. Non-Dupuytren’s Disease
Trauma
Surgery
Diabetes
No FH
Any race
Generally non-progressive

8. Dupuytren’s Diathesis
Male
<50
Affected siblings/parents
Ectopic Disease ‘Garrod’s pads’
Bilateral Disease

9. Treatment options 1. Do nothing 2. Radiotherapy – early disease
3. Steroid Injection
4. Percutaneous Needle Fasciotomy
5. Collagenase/Xiapex
6. Limited Fasciectomy
7. Dermato-fasciectomy and skin graft
8. Amputation

10. Treatment options & cost(2011)
1. Do nothing £0
2. Radiotherapy – early disease £2500 (10 visits)
3. Steroid Injection (£ Steroid vial +OPD)
4. Percutaneous Needle Fasciotomy (£ OPD +needle +/- theatres)
5. Collagenase/Xiapex (£760 per vial/digit)
6. Limited Fasciectomy (£2500 plus therapy)
7. Dermato-fasciectomy and skin graft (>£3000 plus therapy)

11. Personal thought process
1. Age/Retirement
2. Occupation
3. Hand Dominance
4. Pain
5. The speed of progression of disease
6. Recurrence Vs Extension
7. Extent of contracture PIP joint
8. Diathesis (bilateral, radial side, male)
9. General Systemic Health
10.Patient expectations

12. Radiotherapy 3 Gy x5 days - repeat 8 weeks later (potential delayed side effects due to radiation)

13. Steroid for nodules Triamcinalone 50% softening
50% recurrence one year

14. Percutaneous Needle Fasciotomy
Mostly clinic based
Splint 6 – 12 weeks at night
Low complication rate
Early return to work
5% early failure – akin to a failed injection for CMC joint arthritis!
Long-term 50% recurrence in 5 years but not always requiring surgery

15. Collagenase - Xiapex Good option for early rehabilitation
Less time off work
Less recurrence than needle release
Recurrence rate akin to surgical fasciectomy
Has side effects as a drug (see next slide)

16. Collagenase - Xiapex Side Effects
Paraesthesia ,Complex regional pain syndrome (CRPS)
Hypoaesthesia 
Monoplegia
 Burning sensation
 Tremor
 Lymphadenopathy
 Crepitus
 Arthralgia
 Hyperhidrosis
 Myalgia /Muscle weakness and spasm
 Wound dehiscence
 Joint swelling
 Tendon rupture
 Injection site reactions
 Ligament injury
 Ecchymosis

17. Limited Fasciectomy Procedure with known results
Good for limited disease
Can be performed under local anaesthesia
Recurrence rates higher than skin grafts

18. Dermato-fasicectomy Lowest recurrence rate
Best choice for young patient
Increase time to wound healing (diabetics and smokers take longer)
Longer rehabilitation time

19. Dermato-fasicectomy post op

20. Recurrence Extent of the pre-surgical contracture of the finger
Longer you live, the higher the recurrence!

21. Conclusion
Refer early
Tailor treatment to patient

22. Mr G Shyamalan gunaratnam.shyamalan@heartofengland.nhs. uk
Solihull Hand Clinic
Heartlands Fracture Clinic
Good Hope Hand Clinic
Spire Parkway
Spire Little Aston