Hospitalization for Dupuytren's disease: a French national descriptive analysis, 2002 to 2009

Application of Near Infrared Spectroscopy to Enhance Safety and Individualize Distraction of Severely Contracted Joints in Far-Advanced Dupuytren's Disease

Background: Slow distraction of contracted joints is a well-established treatment in far-advanced stages of Dupuytren's disease (DD). To assess finger perfusion and avoid malperfusion, we studied near infrared spectroscopy (NIRS) to evaluate the maximum extent of distraction that would not harm microcirculation to the finger. This technique also allows an optimized treatment in accordance with sufficient blood perfusion during distraction. Methods: Eligible patients with stage IV finger contractures who needed treatment for Dupuytren's contracture were included and prospectively investigated. The operation was performed with local anaesthesia. First, the Dupuytren strand of the treated finger was dissected in the palm to allow distraction. Under X-ray control, the distraction device was applied. Then, slow distraction of the treated joint was performed to evaluate the finger perfusion. To assess perfusion of the treated finger, NIRS was used to measure tissue oxygen saturation. If impaired finger perfusion was detected, traction was reduced until sufficient oxygen levels and perfusion patterns were reestablished. Results: NIRS was performed after application of the distraction device in seven cases. We treated six male and one female patient (mean age 70 years, range 51-80 years). Rapid distraction resulted in malperfusion of the treated fingers. Using NIRS proved to render reliable and reproducible information on finger perfusion and oxygenation in all seven patients. Conclusions: Application of NIRS enhances safety in the treatment of far-advanced DD finger contractures with an external skeletal distraction device. It is non-invasive, reproducible, easy to use and allows for an individualized adapted distraction velocity.

Ultrasound-guided aponeurotomy and interphalangeal joint capsular release for treatment of Dupuytren's disease

This study describes a new ultrasound-guided surgical technique for aponeurotomy and interphalangeal joint capsular release in patients with Dupuytren's disease and analyses the clinical outcomes. We carried out a retrospective review of 70 digits in 35 patients who underwent ultrasound-guided aponeurotomy and interphalangeal joint capsular release, with a minimum follow-up of 2 years. The primary outcome was the correction of the deformity and the QuickDASH questionnaire score after surgery and at 1 and 2 years. The secondary outcome was the presence of residual contracture immediately after surgery. The mean QuickDASH score fell from 28 before surgery to 14 after surgery. A significant decrease of -63° was observed for the global contracture, -35° the metacarpophalangeal joint contracture and -28° for the proximal interphalangeal joint contracture. Ultrasound-guided aponeurotomy and interphalangeal joint capsular and palmar plate releases are highly accurate and safe.Level of evidence: IV.

A role for metformin in the treatment of Dupuytren disease?

Dupuytren disease (DD) is a hand-localized fibrotic disorder characterized by a scar-like, collagen-rich cord. Treatment usually comprises surgical removal of the cord, but is associated with a high relapse rate, in some cases requiring finger amputation. There is currently no consensual medical approach for treating DD. Numerous preclinical studies have highlighted antifibrotic properties of metformin, and the aim of this study was to assess a potential antifibrotic role of metformin in DD. Fibroblasts from DD cords (DF) and phenotypically normal palmar fascia (PF) were extracted from surgical specimens and cultured. The fibrotic status of DF and PF was compared at baseline, and under profibrotic (TGF-β stimulation) and antifibrotic (metformin stimulation) conditions, using quantitative RT-PCR, western blot, immunocytochemistry, and a functional fibroblast contraction assay. At baseline, DF showed higher levels of fibrotic markers and contraction capacity compared with PF. Both types of fibroblasts responded to TGF-β stimulation. Treatment of DF and PF with metformin did not affect basal levels of fibrotic markers and contraction but largely prevented their induction by TGF-β. In conclusion, our data show that metformin inhibits TGF-β-induced expression of fibrotic markers and contraction in hand-derived fibroblasts. This supports the case for a clinical trial to assess the repurposing of metformin as an adjuvant to surgery, to prevent, reduce, or delay recurrence in at-risk DD patients.

Dupuytren's disease: A reality in Black Africa

Long regarded as a disease exclusively found amongst Northern Europeans, Dupuytren's disease was seldom studied amongst Black Africans. Thus, we sought to study the impact of Dupuytren's disease, its etiological, clinical and evolutionary peculiarities on a segment of the Senegalese population. This study analyzed data derived from clinical observations carried out between January 2006 and December 2018. It involved Senegalese subjects with Dupuytren's disease, the patients' history, profession, habitus, clinical findings, therapeutic modalities and disease staging. The population included 20 men and 6 women averaging 63.5 years of age (range 45-77). None of the patients reported a family of Dupuytren's disease. Twelve patients had diabetes, 11 were smokers and 22 were engaged exclusively in manual labor. The condition was bilateral in 14 cases. Tubiana stages N, I, II, III and IV were found in 31, 15, 9, 5 and 6 rays, respectively. Conservative treatment was done in 11 patients. Surgical treatment was carried out in the other 15 patients: needle fasciotomy (N=10) including two bilateral involvement and open fasciectomy (N=7). Functional outcomes were satisfactory. Lesions were all stable in the short and medium term. Two patients had progressive lesions on a longer-term basis. Dupuytren's disease is real among Afro-descendants from Senegal even though it is seldom studied. Based on the patients' recollection of Dupuytren's disease in their families, heredity is not yet a proven factor. The early forms are more common, and the lesions remain stable for a long time.

Segmental aponeurectomy with Z-Plasty as a treatment option in Dupuytren's disease: A retrospective cohort study

BACKGROUND

Aponeurectomy remains the reference standard treatment for digit tethering by palmar fascial cords in Dupuytren's disease but is associated with a substantial complication rate. An alternative technique decreases metacarpophalangeal joint (MCPJ) flexion contracture by combining palmar segmental aponeurectomy with Z-plasty skin closure. The primary objective of this study was to assess range of motion of the operated ray after the procedure. The secondary objectives were to assess the complication rate and to determine the recurrence rate after at least 1 year.

HYPOTHESIS

Palmar segmental aponeurectomy with Z-plasty closure may provide the advantages of aponeurectomy while decreasing the surgical risk and recurrence rate.

MATERIAL AND METHODS

A retrospective study was conducted in 16 patients with predominant MCPJ flexion contracture due to a well-defined palmar fascial cord. Anaesthesia was loco-regional. The Z-plasty design involved a longitudinal incision along the palmar cord with an oblique incision at each end at a 60° angle to the longitudinal incision. The length of the aponeurectomy was about 1.5cm, to allow full MCPJ extension.

RESULTS

In all, the 16 patients-13 males and 3 females-had 17 segmental palmar aponeurectomy procedures with Z-plasty closure. Mean operative time was 18minutes. Before surgery, mean loss of extension was 47° at the MCP joint and 15° at the corresponding proximal interphalangeal joint (PIPJ). Immediately after surgery, a 97% improvement in MCPJ extension was noted, leaving a mean extension deficit of 1.25°. Mean follow-up was 18.9 months. No complications occurred. Two patients experienced a recurrence.

DISCUSSION

Segmental palmar aponeurectomy as described by Moermans in 1991 improves extension similarly to extensive aponeurectomy but has a lower complication rate. Z-plasty provides good exposure of the pedicles and takes advantage of the greater pliability of the skin on either side of the cord to lengthen the skin by 75%, thereby limiting the risk of the complications seen with needle aponeurotomy. Segmental palmar aponeurectomy with Z-plasty has a role in the management of Dupuytren's disease with flexion contracture predominantly involving the MCPJ.

Impact on costs of switching one-ray aponeurectomy to percutaneous needle aponeurotomy in Dupuytren's disease: A model analysis

OBJECTIVE

To assess the cost of switching surgical aponeurectomy to percutaneous needle aponeurotomy in one-ray Dupuytren's disease.

METHODS

A model analysis was performed with a cross-sectional national survey of public and private French hospitals in 2012. All stays for one-ray aponeurectomy were "virtually" replaced with 1, 2 or 3 outpatient sessions of percutaneous needle aponeurotomy. The costs were based on the hospital cost (tariff per disease-related group) and on common classification of medical procedures performed in outpatient care for 2013.

RESULTS

Dupuytren's disease represented 18,707 hospitalizations (€26 million [2013 euros]) in France in 2012, 8534 hospitalizations for one-ray aponeurectomy (€11.9 million). By replacing surgical aponeurectomy with percutaneous needle aponeurotomy for one-ray Dupuytren's disease, 91% to 97% and 56% to 59% of the treatment costs could be saved using hospitalizations for one-ray aponeurectomy or total hospital costs, respectively, as reference.

CONCLUSIONS

Replacing aponeurectomy with percutaneous needle aponeurotomy for one-ray Dupuytren's disease could greatly reduce the treatment costs for all Dupuytren's disease. Effective alternatives to surgery for Dupuytren's disease, such as needle aponeurotomy in an outpatient setting should be considered in the economic perspective.