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

Pre-operative hand therapy management of Dupuytren's disease: A systematic review

Introduction

Dupuytren's Disease is a fibroproliferative disorder of the hand, with a heterogenous pathogenesis, ranging from early-stage nodule development to late-stage digital contractures. Hand therapy intervention is not routinely provided pre-operatively. The objective of this systematic review was to explore the efficacy of hand therapy interventions provided for pre-operative Dupuytren's Disease.

Methods

A systematic review was undertaken of the databases CENTRAL, CINAHL, OVID Medline and OVID EMBASE, PubMed, BNI, Web of Science, with grey literature and reference searches conducted from database inception to April 2022, and confirmed in August 2023. Included studies required non-surgical intervention and outcome data on individuals with Dupuytren's Disease who have not had surgical intervention. Two reviewers conducted the searches, independently assessed eligibility and completed methodological quality assessments. Data were summarised narratively.

Results

Seventeen studies were selected for final inclusion. Interventions included Extracorporeal Shockwave Therapy (ESWT), Corticosteroid Injection (CSI), Splinting, Massage and Stretching, Ultrasound Therapy (US), Temperature Controlled High Energy Adjustable Laser (THEAL). ESWT positively maintained or improved pain, active range of motion (AROM), Disabilities of the Arm Shoulder, and Hand (DASH) scores, and grip strength. US positively maintained or improved ROM and grip. Splinting positively maintained or improved ROM, CSI positively improved nodule size. Cross Frictional Massage positively impacted AROM and THEAL improved pain and DASH scores.

Conclusions

Outcomes from therapeutic interventions for pre-operative management of Dupuytren's Disease were largely positive. However, there is a need for further high-quality research into these interventions to understand their full potential for the management of Dupuytren's Disease.

[Medium-term Results after percutaneous Needle Fasciotomy in Dupuytren's Disease]

BACKGROUND

Dupuytren's disease often leads to an increasing limitation in finger extension in affected patients. As the incidence rises with age, the number of cases is expected to rise in the future due to the demographic change. Therefore, an easy and patient-oriented treatment is required. In the following study, we investigated the short and medium-term results after percutaneous needle fasciotomy (PNF).

PATIENTS AND METHODS

Overall, 65 fingers of 40 patients were treated with PNF. We evaluated the total passive deficit of extension (TPED), the passive deficit of extension of the joints (PED), the Buck-Gramcko score, rate of recurrence, DASH score and patient satisfaction. The average age of the patients was 65,9 years. Most of the patients (82%) were male.

RESULTS

Directly after the PNF, extension in the treated fingers improved significantly (TPED before PNF 74,6°±41,1 SD to 32,8°±29,0 SD after the procedure). By the time of the follow-up examination (30,2±13,9 SD months), TPED had increased again (52,7°±40,2 SD). The rate of recurrence was 29,7%, and a higher Tubiana stage before the procedure correlated significantly with a higher recurrence rate. Nevertheless, patients demonstrated a very high level of satisfaction with the procedure and almost all patients would choose to undergo PNF again.

CONCLUSION

Although it is associated with a relatively high recurrence rate, PNF represents an effective and patient-oriented treatment of Dupuytren's contracture.

Suggesting a mechanism for acupuncture as a global percutaneous needle fasciotomy that respects tensegrity principles for treating fibromyalgia

Acupuncture is a minimally invasive therapeutic method that uses small caliber needles while inserting them through the skin into various areas of the body. Some empirical studies find evidence to support the use of acupuncture as a treatment for certain medical conditions, however, this peculiar practice is widely considered as the domain of alternative and non-evidence-based medicine. Several mechanisms have been suggested in an attempt to explain the therapeutic action of acupuncture, but the way in which acupuncture alleviates chronic non-cancer pain or psychosomatic and psychiatric disorders is not fully understood. A recent study suggested a theoretical model (coined "Fascial Armoring") with a cellular pathway to help explain the pathogenesis of myofascial pain/fibromyalgia syndrome and functional psychosomatic syndromes. It proposes that these syndromes are a spectrum of a single medical entity that involves myofibroblasts with contractile activity in fascia and aberrant extracellular matrix (ECM) remodeling, which may lead to widespread mechanical tension and compression. This can help explain diverse psycho-somatic manifestations of fibromyalgia-like syndromes. Fascia is a continuous interconnected tissue network that extends throughout the body and has qualities of bio-tensegrity. Previous studies show that a mechanical action by needling induces soft tissue changes and lowers the shear modulus and stiffness in myofascial tissue. This hypothesis and theory paper offers a new mechanism for acupuncture therapy as a global percutaneous needle fasciotomy that respects tensegrity principles (tensegrity-based needling), in light of the theoretical model of "Fascial Armoring." The translation of this model to other medical conditions carries potential to advance therapies. These days opioid overuse and over-prescription are ubiquitous, as well as chronic pain and suffering.

A Personalized Approach to Treat Advanced Stage Severely Contracted Joints in Dupuytren’s Disease with a Unique Skeletal Distraction Device—Utilizing Modern Imaging Tools to Enhance Safety for the Patient

Background: While surgical therapy for Dupuytren’s disease is a well-established standard procedure, severe joint flexion deformities in advanced Dupuytren’s disease remain challenging to treat. Skeletal distraction has proven to be an additional treatment option. Methods: We analyzed the surgical treatment algorithm, including the application of a skeletal distraction device, in patients with a flexion deformity due to Dupuytren’s disease, Iselin stage III or IV, who were operated on from 2003 to 2020 in our department. Results: From a total of 724 patients, we included the outcome of 55 patients’ fingers in this study, who had undergone additional skeletal joint distraction with our Erlangen device. Additional fasciotomy or fasciectomy, in a one- or two-staged procedure, was performed in all patients, according to the individual findings and necessities. The range of motion of the PIP joint improved from 12° to 53°. A number of complications, in all steps of the treatment, were noted in a total of 36.4% of patients, including the development of fractures (16.4%), followed by vessel injury, pin infections, and complex regional pain syndrome (5%). Conclusions: Additional skeletal distraction improves the range of motion of severely contracted joints in Dupuytren’s disease. Nevertheless, careful patient selection is necessary, due to the moderate rate of complications.

Scoping review and interpretation of myofascial pain/fibromyalgia syndrome: An attempt to assemble a medical puzzle

BACKGROUND

Myofascial Pain Syndrome (MPS) is a common, overlooked, and underdiagnosed condition and has significant burden. MPS is often dismissed by clinicians while patients remain in pain for years. MPS can evolve into fibromyalgia, however, effective treatments for both are lacking due to absence of a clear mechanism. Many studies focus on central sensitization. Therefore, the purpose of this scoping review is to systematically search cross-disciplinary empirical studies of MPS, focusing on mechanical aspects, and suggest an organic mechanism explaining how it might evolve into fibromyalgia. Hopefully, it will advance our understanding of this disease.

METHODS

Systematically searched multiple phrases in MEDLINE, EMBASE, COCHRANE, PEDro, and medRxiv, majority with no time limit. Inclusion/exclusion based on title and abstract, then full text inspection. Additional literature added on relevant side topics. Review follows PRISMA-ScR guidelines. PROSPERO yet to adapt registration for scoping reviews.

FINDINGS

799 records included. Fascia can adapt to various states by reversibly changing biomechanical and physical properties. Trigger points, tension, and pain are a hallmark of MPS. Myofibroblasts play a role in sustained myofascial tension. Tension can propagate in fascia, possibly supporting a tensegrity framework. Movement and mechanical interventions treat and prevent MPS, while living sedentarily predisposes to MPS and recurrence.

CONCLUSIONS

MPS can be seen as a pathological state of imbalance in a natural process; manifesting from the inherent properties of the fascia, triggered by a disrupted biomechanical interplay. MPS might evolve into fibromyalgia through deranged myofibroblasts in connective tissue ("fascial armoring"). Movement is an underemployed requisite in modern lifestyle. Lifestyle is linked to pain and suffering. The mechanism of needling is suggested to be more mechanical than currently thought. A "global percutaneous needle fasciotomy" that respects tensegrity principles may treat MPS/fibromyalgia more effectively. "Functional-somatic syndromes" can be seen as one entity (myofibroblast-generated-tensegrity-tension), sharing a common rheuma-psycho-neurological mechanism.

Cost-Effectiveness and Patient Outcomes of Injectable Collagenase to Treat Dupuytren’s Contracture

Introduction

Dupuytren’s contracture is a disabling and progressive flexion contracture of the hand that is often treated by a surgical release. Collagenase clostridium histolyticum injection (CCH-I) was introduced to the UK in 2011 as an alternative and less invasive treatment for contracture. The purpose of this study was to evaluate the cost-effectiveness and patient-reported outcome measures (PROMs) of treating Dupuytren’s contracture with collagenase compared to surgery.

Methods

A retrospective review identified 151 patients who underwent CCH-I (n=94), limited fasciectomy (LF; n=38) and percutaneous needle fasciotomy (PNF; n=19). Outcomes included PROMs (satisfaction, QuickDASH), complication rates (recurrence, reintervention) and direct costs.

Results

Standardised treatment costs for CCH-I, LF and PNF were £1,125.82, £3,438.28 and £1,143.32 respectively. Collagenase presented a cost-benefit of £88,205 had the LF/PNF group undergone CCH-I. At a mean six-year follow-up, there were no significant differences in complication rates (=0.621) or QuickDASH scores (p=0.157). Collagenase-treated patients reported the highest satisfaction and lowest recurrence rates.

Discussion

Collagenase presents a significant cost reduction with superior PROMs relative to surgery for treating single-digit contracture.

Conclusion

Outpatient CCH-I is a cost-effective treatment with fewer clinical encounters, a similar risk profile to LF/PNF and high levels of patient satisfaction, which warrants serious consideration in light of overburdened waiting lists due to COVID-19.

Modified dynamic high-frequency ultrasound-guided needle aponeurotomy for Dupuytren's contracture

The aim of this report was to introduce the use of modified dynamic high-frequency ultrasound-guided needle aponeurotomy for Dupuytren's contracture. From January 2014 to February 2019, the technique was used in 42 consecutive patients who suffered from Dupuytren's contracture: 38 male and 4 female; mean age, 57 years (range, 32-80 years). Assessments comprised total active extension deficit and total active flexion of the fingers, active range of motion, Disabilities of the Arm, Shoulder and Hand (DASH) score, and EQ-5D index. Recurrence was defined as ≥20° flexion contracture. Compared to the opposite hand, preoperative total active extension deficit and total active flexion were 105° ± 32° and 221° ±  33°, respectively. The mean active range of motion of the metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints was 42° ± 24°, 37° ± 26° and 62° ± 14°, respectively. Mean follow-up was 27 months (range, 24-35 months). There were no cases of tendon rupture or neurovascular injury. Total active extension deficit and total active flexion at the final follow-up were 17° ± 11° and 225° ± 32°, respectively. The mean active range of motion of metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints was 73° ± 28°, 89° ± 24° and 63° ± 16°, respectively. The pre- and post-operative DASH scores were 18 ± 10 and 5 ± 2, respectively. Health-related quality of life on EQ-5D index improved from 0.72 ± 0.28 pre-operatively to 0.88 ± 0.72 post-operatively (p < 0.05). Recurrence rates in the metacarpophalangeal joint and proximal interphalangeal joint were 7% and 11%, respectively. The modified dynamic high-frequency ultrasound-guided needle aponeurotomy is a safe and effective way to treat Dupuytren's contractures. Ultrasound visualization ensures that the cords can be completely transected. Dynamic ultrasound decreases the risk of iatrogenic injury to the neurovascular bundles and tendons, and decreases the recurrence rate. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Versatility of percutaneous needle fasciotomy for Dupuytren's disease across a spectrum of disease severity: A single-surgeon experience of 118 rays

Background

Percutaneous needle fasciotomy (PNF) represents the only minimally invasive approach for treatment of Dupuytren's disease in Europe since withdrawal of collagenase from European markets. Though well-established, surgeon preference and uncertainty regarding safety and efficacy, results in limited provision in favour of open fasciectomy.

Methods

A retrospective review of 74 patients who self-opted to receive PNF between 2017 and 2020 was conducted. Demographic data, complications and degree of release achieved were compared across three cohorts based on contracture severity as per Tubiana staging (TS): Stage 1, 0-45°; Stage 2, 46-90°; Stage 3, 91-130° with χ² analysis.

Results

One hundred and eighteen rays were treated amongst 74 patients (mean age, 68 years (R, 32-86), males: 74%) with mean follow-up 51 weeks (IQR 28-76 weeks) with no significant difference in baseline characteristics across cohorts. No cases of permanent sensory disturbance, flexor tendon rupture, arterial transection nor infection were observed. Neuropraxia was seen in six patients, resolving with mean recovery of 6 weeks. 86% (n = 166) of joints had satisfactory release (residual passive extension deficit (PED) ≤10°) with full release in 67%. Full release was most likely in metacarpophalangeal joint (MCPJ; 93%) than distal interphalangeal joint (DIPJ; 67%) or proximal interphalangeal joint (PIPJ; 45%; p<0.0001). Mean release was 54° in MCPJ and 56° in PIPJ. All TS1 patients achieved release with ≤10° residual PED versus 75% of TS2 patients and 22% of TS3 patients (p<0.05), the latter of whom had a mean residual PED of 12° Ninety-two percent of patients stated they would undergo PNF again if necessary, in preference to open fasciectomy.

Conclusion

We find PNF to facilitate a safe, effective yet minimally invasive approach amongst patients of varying disease severity, across different age groups, with recurrent disease, associated comorbidities or concurrent anticoagulation therapy. Patients reported high satisfaction in preference to open procedures. We, therefore, intend to recommend PNF first-line to all patients regardless of disease severity.

Dupuytren's Contracture - Current Concepts

Dupuytren's contracture is a common condition that has the potential to be debilitating. It presents in a variety of manners and can be mild or more aggressive in its progression. There are a large number of management options currently available. In this review of the evidence, non-operative and operative management options are examined, with a consideration of post-operative rehabilitation and complications. A summary of the current concepts in the management of Dupuytren's contracture is presented.