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Mr G Shyamalan (Shyam) Hand Surgeon HEFT

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Presentation on theme: "Mr G Shyamalan (Shyam) Hand Surgeon HEFT"— Presentation transcript:

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

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