Needle Aponeurotomy for Dupuytren Disease

Patients' perspectives of collagenase injection or needle fasciotomy and rehabilitation for Dupuytren disease, including hand function and occupational performance

PURPOSE

To describe patients' perspectives of collagenase injection or needle fasciotomy for Dupuytren disease (DD) including hand therapy, and their view of hand function and occupational performance.

MATERIALS AND METHODS

Interviews were performed with twelve patients who had undergone non-surgical treatment and rehabilitation for DD. Data was analysed using a problem-driven content analysis using the model of Patient Evaluation Process as a theoretical framework.

RESULTS

The participants' previous experiences influenced their expectations of the upcoming treatment and they needed information to be prepared for treatment. Treatment and rehabilitation had a positive impact on daily life and were regarded as effective and simple with quick recovery. However, there could be remaining issues with tenderness or stiffness. The participants expressed their belief in rehabilitation and how their own efforts could contribute to an improved result. Despite concerns about future recurrence participants described increased knowledge and sense of control regarding future needs.

CONCLUSION

Undergoing a non-surgical treatment and rehabilitation process for DD was regarded as quick and easy and can meet the need for improved hand function and occupational performance. Taking responsibility for one's own rehabilitation was considered to influence the outcome positively. The theoretical framework optimally supported the exploration of participants' perspective.Implications for rehabilitationTreatment of Dupuytren Disease (DD) with needle/collagenase combined with hand therapy was experienced as giving fast improvement in hand function and occupational performance.An individualized care process which satisfies the need for knowledge about the disease, prognosis, treatment options and rehabilitation can give individuals suffering from DD a sense of security.The need for active participation in the DD care process can vary and it is crucial to listen to individuals' opinions and needs.Individuals can take considerable responsibility for rehabilitation after non-surgical treatment for DD and regard it as important for the outcome.

Recommended Musculoskeletal and Sports Ultrasound Terminology: A Delphi-Based Consensus Statement

OBJECTIVES

The current lack of agreement regarding standardized terminology in musculoskeletal and sports ultrasound presents challenges in education, clinical practice, and research. This consensus was developed to provide a reference to improve clarity and consistency in communication.

METHODS

A multidisciplinary expert panel was convened consisting of 18 members representing multiple specialty societies identified as key stakeholders in musculoskeletal and sports ultrasound. A Delphi process was used to reach consensus which was defined as group level agreement >80%.

RESULTS

Content was organized into seven general topics including: 1) General Definitions, 2) Equipment and Transducer Manipulation, 3) Anatomic and Descriptive Terminology, 4) Pathology, 5) Procedural Terminology, 6) Image Labeling, and 7) Documentation. Terms and definitions which reached consensus agreement are presented herein.

CONCLUSIONS

The historic use of multiple similar terms in the absence of precise definitions has led to confusion when conveying information between colleagues, patients, and third-party payers. This multidisciplinary expert consensus addresses multiple areas of variability in diagnostic ultrasound imaging and ultrasound-guided procedures related to musculoskeletal and sports medicine.

Recommended musculoskeletal and sports ultrasound terminology: a Delphi-based consensus statement

The current lack of agreement regarding standardised terminology in musculoskeletal and sports ultrasound presents challenges in education, clinical practice and research. This consensus was developed to provide a reference to improve clarity and consistency in communication. A multidisciplinary expert panel was convened consisting of 18 members representing multiple specialty societies identified as key stakeholders in musculoskeletal and sports ultrasound. A Delphi process was used to reach consensus, which was defined as group level agreement of >80%. Content was organised into seven general topics including: (1) general definitions, (2) equipment and transducer manipulation, (3) anatomical and descriptive terminology, (4) pathology, (5) procedural terminology, (6) image labelling and (7) documentation. Terms and definitions which reached consensus agreement are presented herein. The historic use of multiple similar terms in the absence of precise definitions has led to confusion when conveying information between colleagues, patients and third-party payers. This multidisciplinary expert consensus addresses multiple areas of variability in diagnostic ultrasound imaging and ultrasound-guided procedures related to musculoskeletal and sports medicine.

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.

Focused electromagnetic high-energetic extracorporeal shockwave (ESWT) reduces pain levels in the nodular state of Dupuytren's disease-a randomized controlled trial (DupuyShock)

Dupuytren’s disease is a progressive fibroproliferative disorder of the hand. In the nodular stage of Dupuytren’s disease, pain might limit daily hand activities and progress to finger contractures. Focused electromagnetic high-energetic extracorporeal shockwave therapy (ESWT) may reduce pain in Dupuytren’s nodules (Tubiana N). In this prospective, randomized, blinded, placebo-controlled single center trial, we enrolled 52 patients (mean age, 58.2 ± 9.2) with painful nodular Dupuytren disease Tubiana N. Randomization was done to either (group A) 3 treatments with focused electromagnetic high-energetic ESWT (2000 shots, 3 Hz, 0.35 mmJ/mm²/hand, Storz Duolith SD1, n = 27) or (group B) placebo ESWT (2000 shots, 3 Hz, 0.01 mJ/mm²/hand, n = 25) in a weekly interval. Primary outcome was the level of pain on a visual analogue scale (VAS 0–10) at 3/6/12/18 months, secondary outcomes were patient-related outcome measures (DASH score, MHQ score, URAM scale), grip strength, patient’s satisfaction, and Dupuytren’s disease progression over 18 months follow-up. Focused ESWT significantly improved outcomes. Pain was reduced from 3.6 ± 1.8 to 1.9 ± 1.2 at three, to 1.4 ± 0.7 at six, to 1.7 ± 1.6 after 12 months and 1.9 ± 0.8 after 18 months in the intervention group (47% reduction, p < 0.05). In the placebo group, pain on VAS increased from 2.2 ± 1.4 to 3.4 ± 1.7 at three, to 3.4 ± 1.8 at six, to 3.4 ± 1.4 at 12 and 3.1 ± 1.1 at 18 months (35% increase, p < 0.05). Quality-of-life score tended to improve in the intervention group (MHQ, 77 ± 19 to 83 ± 12; DASH, 12 ± 18 to 10 ± 9) while it deteriorated in the placebo group as Dupuytren’s disease was progressing (MHQ, 79 ± 15 to 73 ± 17; DASH, 6 ± 10 to 14 ± 13). The strength of the affected hand and fingers did not change significantly in either of the groups. Patients’ satisfaction was higher in the intervention group for symptom improvement (56% vs. 12%) and reduction of disease progression (59% vs. 24%). Any Dupuytren-related intervention was performed in 26% in the intervention group and in 36% in the placebo group within 18 months of follow-up (n.s.). Focused electromagnetic high-energetic ESWT can significantly reduce pain in painful nodules in Dupuytren’s disease in an 18-month perspective. (ClinicalTrials.gov Identifier: NCT01184586).

Vibrotactile perception in Dupuytren disease

PURPOSE

Dupuytren disease (DD) has been associated with enlarged Pacinian corpuscles (PCs) and with PCs having a greater number of lamellae. Based on these associations, we hypothesized that subjects with DD would have altered sensitivity to high-frequency vibrations and that the changes would be more prominent at 250 Hz, where healthy subjects demonstrate the highest sensitivity.

METHODS

A novel device was created to deliver vibrations of specific frequencies and amplitudes to the fingers and palm. Using a Psi-marginal adaptive algorithm, vibrotactile perception thresholds (VPTs) were determined in 36 subjects with DD and 74 subjects without DD. Experiments were performed at 250 Hz and 500 Hz at the fingertip and palm. The VPTs were statistically analyzed with respect to disease status, age, gender, location tested, and frequency tested.

RESULTS

We found that VPT increases with age, which agrees with findings by others. Women showed greater sensitivity (i.e. lower VPT) than men. Men exhibited lower sensitivity in DD versus healthy subjects, but the results were not statistically significant. In subjects with DD presenting unilaterally, the unaffected hand was more sensitive than the affected hand, in particular for a 250 Hz stimulus applied to the finger.

CONCLUSIONS

The data on vibration sensitivity obtained from a large group of subjects with and without DD present interesting trends that may serve as a useful reference to future DD researchers. Understanding additional symptoms of DD may facilitate development of novel diagnostic or prognostic protocols.

Percutaneous needle fasciotomy in Dupuytren contracture: a register-based, observational cohort study on complications in 3,331 treated fingers in 2,257 patients

Background and purpose - Percutaneous needle fasciotomy (PNF) is a minimally invasive treatment option for Dupuytren contracture, which has gained momentum worldwide in recent years. However, evidence regarding safety and severe complications associated with PNF is sparse. Thus, we evaluated safety of a specific PNF method in the largest cohort reported in literature.Patients and methods - This is a single-center, register-based, observational study on PNF treatments between 2007 and 2015. The study cohort was identified by the Danish National Patient Registry, and diagnosis codes and procedure codes were used to identify potential severe postoperative complications such as: tendon rupture, nerve damage, infection, amputation, and reflex dystrophy for all index treatments. The Danish National Prescription Registry was used to identify non-hospital-treated infections. All index treatments and postoperative complications were verified by review of medical records.Results - 2,257 patients received PNF treatment of 3,331 treated finger rays. Median follow-up was 7.2 years (interquartile range: 4.9-9.5 years, range 1-12 years). 4 patients sustained flexor tendon rupture. 1 patient had digital nerve damage. 2 patients had an infection treated in hospital, while 31 patients received antibiotics in the primary sector for an infection or based on suspicion of an infection after PNF. None of the infections required surgical intervention. No finger amputations or ipsilateral upper limb reflex dystrophy cases were registered in relation to the procedure.Interpretation - Percutaneous needle fasciotomy for Dupuytren contracture is a safe procedure with a low rate of severe postoperative complications when a specific PNF method is applied.

[Non-surgical treatment of Dupuytren's disease by using percutaneous needle aponeurotomy: A 10-year experience]

INTRODUCTION

Dupuytren's disease is a fibroproliferative disorder of the palmar aponeurosis that leads to digital flexion contractures. This disabling condition can be treated with a minimally invasive procedure, called percutaneous needle aponeurotomy (PNA).

OBJECTIVE

To report the results of 10 years of experience treating Dupuytren's contracture by PNA in the rheumatology hand unit of our department.

METHODS

We conducted a retrospective study with a description of method to perform PNA and analysis of post-procedure results.

RESULTS

There were 197 patients with Dupuytren's disease. Ninety-eight patients (49.7%) underwent PNA, corresponding to 117 treated fingers. Good immediate results were achieved in 84% of the patients, with results being better in those with less advanced stages. Recurrences occurred in 12% of the patients. The complication rate was 1.7%.

CONCLUSION

Our results confirm the value of this technique especially in the early stages of Dupuytren's disease, with immediate satisfactory results and a low rate of complications.