Selective Fasciectomy in Dupuytren’s Contracture: An Experience of A Specialized Tertiary Hospital in Bangladesh

Background: Dupuytren’s disease is a benign yet disabling, irreversible, progressive fibroproliferative condition affecting the palm and fingers, leading to flection contracture of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints.Objective: To evaluate results of selective fasciectomy to correct the deformity of MCP and PIP joints and observe the complications.Methods: This crosssectional study was done on 30 patients of Dupuytren’s contracture treated by selective fasciectomy, between January 2015 and December 2018, in Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Selective fasciectomy was done under brachial plexus block, tourniquet control and loupe magnification. Brunner zigzag incision was used. Indications for surgery was MCP flection contracture more than 30⁰ and any degree of PIP flection contracture. Postoperatively hand was immobilised in extension of MCP and PIP joints for 2 weeks and then active and passive movements were encouraged and intermittent splinting for 10 weeks (only at night in last 6 weeks).Results: Among 30 patients, 24 (80%) patients were male, 6 (20%) were female; mean age was 62 years (56-74 years). 12 (40%) cases were bilateral, ring and little fingers involvement were seen in most cases (92%). Mean MCP correction was 53⁰ and mean PIP correction was 34⁰ (p<0.001). There were 3 digital nerve injuries peroperatively which were repaired/reconstructed and protective sensation regained in repaired nerve area at 1 year and 3 (10%) marginal skin loss postoperatively which healed secondarily. Superficial wound infection developed in 3 (10%) patients which healed on dressing and antibiotics. Complex regional pain syndrome developed in 2 (6.66%) patients which were mild and resolved on conservative management. 3 (10%) patients developed scar sequilae which were mild and resolved on conservative treatment. Radial digital artery injury was observed in 1 (3.33%); however, no ischaemic insult was observed postoperatively. 2 (6.66%) patients developed recurrence of the disease who were more than 70 years old; however, they declined further intervention.Conclusion: Selective fasciectomy is an easy and effective procedure with less complication to correct the deformities and improve the gripstrength significantly in Dupuytren’s contracture patients.International Journal of Human and Health Sciences Vol. 06 No. 01 January’22 Page: 41-46

Dupuytren’s interventions surgery versus collagenase (DISC) trial: study protocol for a pragmatic, two-arm parallel-group, non-inferiority randomised controlled trial

Background Dupuytren’s contracture is a fibro-proliferative disease of the hands affecting over 2 million UK adults, particularly the white, male population. Surgery is the traditional treatment; however, recent studies have indicated that an alternative to surgery—collagenase clostridium histolyticum (collagenase)—is better than a placebo in the treatment of Dupuytren’s contracture. There is however no robust randomised controlled trial that provides a definitive answer on the clinical effectiveness of collagenase compared with limited fasciectomy surgery. Dupuytren’s intervention surgery vs collagenase trial (DISC) trial was therefore designed to fill this evidence gap. Methods/design The DISC trial is a multi-centre pragmatic two-arm parallel-group, randomised controlled trial. Participants will be assigned 1:1 to receive either collagenase injection or surgery (limited fasciectomy). We aim to recruit 710 adult participants with Dupuytren’s contracture. Potential participants will be identified in primary and secondary care, screened by a delegated clinician and if eligible and consenting, baseline data will be collected and randomisation completed. The primary outcome will be the self-reported patient evaluation measure assessed 1 year after treatment. Secondary outcome measures include the Unité Rhumatologique des Affections de la Main Scale, the Michigan Hand Questionnaire, EQ-5D-5L, resource use, further procedures, complications, recurrence, total active movement and extension deficit, and time to return to function. Given the limited evidence comparing recurrence rates following collagenase injection and limited fasciectomy, and the importance of a return to function as soon as possible for patients, the associated measures for each will be prioritised to allow treatment effectiveness in the context of these key elements to be assessed. An economic evaluation will assess the cost-effectiveness of treatments, and a qualitative sub-study will assess participants’ experiences and preferences of the treatments. Discussion The DISC trial is the first randomised controlled trial, to our knowledge, to investigate the clinical and cost-effectiveness of collagenase compared to limited fasciectomy surgery for patients with Dupuytren’s contracture. Trial registration Clinical.Trials.gov ISRCTN18254597. Registered on April 11, 2017.

Limited palmar fasciectomy for bilateral Dupuytren’s contracture

Dupuytren’s disease is a fibro-proliferative condition affecting the palmar and digital fascia. This disease is very common in Northern Europe but in India it uncommon as there are only a few cases reported, hence also called as ‘Viking Disease’. Surgical fasciectomy is the standard surgical treatment of choice for Dupuytren’s disease. Complications following surgery are high but there is no definitive cure for Dupuytren disease (DD), and recurrence of finger contractures after treatment is common.

Magnetic resonance imaging of diffusion characteristics following collagenase clostridium histolyticum injection in Dupuytren’s contracture

Purpose We aimed to evaluate the extent of collagenase clostridium histolyticum (CCH) diffusion in Dupuytren’s contracture (DC) for tissues outside of the contracture cord using Magnetic Resonance Imaging (MRI) immediately after CCH injection. Methods: 10 male patients aged 57–79 with DC of the metacarpophalangeal (MCP) joints were examined. Extension deficits were 10–60°(mean, 34.3) and 0–60°(mean, 26.6) in the MCP and proximal interphalangeal (PIP) joints, respectively. CCH injection was performed according to the standard method. MRI was performed within 15 min of CCH injection. Results: In all 10 cases, the extended area of high-intensity signal change outside of the cord was observed on short-T1 inversion recovery images (STIRs). Continuity from the insertion site was observed in the area of signal change involving the flexor tendon and neurovascular bundle. The signal change area spanned distally and proximally beyond the injection level. The signal change area expanded along the tendon sheath but no signal changes were observed inside the flexor tendon, suggesting the tendon sheath serves as a protective barrier from the CCH solution. After 1 week of injection, the mean decrease in contracture was 32.5°(94.7%) for the MCP joint and 19.8°(74.4%) for the PIP joint. In nine out of 10 cases, the extension deficit was within five degrees of full extension in the affected finger. There was no neurovascular injury or tendon rupture at 3 months of observation. Conclusions: MRI indicated the possible leakage of the drug outside of the cord during the early phase after administration, suggesting that CCH could persistently affect healthy tissues until CCH inactivates its enzyme process.

PATHOMORPHOLOGIC CHARACTERISTICS OF PALMAR APONEUROSIS IN PATIENTS WITH DUPUYTREN’S CONTRACTURE AND VIRAL HEPATITIS

Objective. To establish pathomorphologic peculiarities of palmar aponeurosis in the patients with Dupuytren’s contracture and concomitant virus hepatitis B and C. Methods. The data analysis of histomorphometric studies of the operation samples of 122 patients with Dupuytren’s contracture («Control» group, n=100) and Dupuytren’s contracture with virus hepatitis B and C («Hepatitis» group, n=22) were analyzed. Results. In patients of the «Hepatitis» group, the content of adiposed tissue in the palmar aponeurosis was 40.9% less (p <0.01) than in the «Control» group, and the content of dense connective tissue was 18.9% higher (p <0, 05). In all patients, arteries with the diameter up to 150 µm prevailed in the palmar aponeurosis, but in the «Hepatitis» group their percentage was reduced by 20%, with higher proportions of vessels with the diameter of 150-450 µm and the absence or recalibration of the largest arteries. In the «Control» group, the arteries had diameters from 50 to 660 µm, in the «Hepatitis» group they did not exceed 370 µm. Vessels less than 300 µm in diameter in both groups had comparable values of the Kernogan’s index. Arteries with a diameter of more than 300 microns in the «Hepatitis» group had higher values of the Kernogan’s index, which indicated a low conductance capacity compared to the vessels in the «Control» group. Most of the nerve trunks of the palmar aponeurosis in the patients of «Hepatitis» group showed signs of necrobiotic changes, i.e. fibrotic or swollen perineurium, withinflammatory cell infiltration, sometimes lost lamellar structure, and nerve fibers with signs of Wallerian degeneration. Conclusion. Obtained histomorphometric data of the tissue composition of palmar fascial fibromatosis, less amount of adiposed tissue and higher amount of dense connective one and more pronounced disorder of hemodynamics and innervation of the palmar aponeurosis in the group with concomitant virus hepatitis indicate significant effect of the liver pathology on the progression of the disease. What this paper adds For the first time, the pathomorphological features of the palmar aponeurosis have been studied in 122 patients with Dupuytren’s contracture and concomitant viral hepatitis B and C.It has been found that in patients with Dupuytren’s contracture and hepatitis in the palmar aponeurosis, the amount of adiposed tissue is reduced and the amount of dense connective tissue is increased; hemodynamic and innervation disorders are more pronounced.

Validation of a Handprint for Clinical Evaluation of Dupuytren’s Contracture

Objective We have developed a handprint-based method for visualizing and quantifying the palmar contact of patients with Dupuytren’s contracture. The purpose of this study was to examine whether the generated handprint was useful for assessing the severity of flexion contracture of the fingers and for evaluating the therapeutic effects of collagenase clostridium histolyticum (CCH) injection for Dupuytren’s contracture. Methods The handprint was created by applying medical-grade ethanol-containing hand sanitizer over the entire palmar surface of the affected hand and then pressing it on thermal paper for word processors. The reliability of the handprint was evaluated through test–retest of 10 healthy volunteers at an interval of 10 days, and the validity of the handprint was assessed using a flexion contracture model in which the little finger was fixed in an Alfence splint. In addition, we obtained handprints of the affected hand in 33 patients with unilateral Dupuytren’s contracture both before CCH injection and at the final observation after injection to investigate the contact area of the hand (CAH) and the length of the hand (LH). The relationships between CAH, LH, total extension deficit angle (TEDA), and patient-reported outcome measures (Japanese Society for Surgery of the Hand Version of the Quick Disability of Arm, Shoulder, and Hand Questionnaire [Quick DASH-JSSH] and Hand20) were examined. Results The test–retest correlation coefficient was 0.9187 (p < 0.001) for CAH and 0.9052 (p < 0.001) for LH, indicating high reliability of the handprint. The ratios of CAH and LH decreased gradually as the contracture angle of the splinted finger increased. The handprint revealed a marked improvement of palmar contact after CCH injection for Dupuytren’s contracture. Furthermore, the ratios of CAH and LH were strongly correlated with TEDA, Quick DASH-JSSH, and Hand20 before treatment. Conclusion Our handprint-based assessment method was extremely useful for clinical evaluation of CCH treatment for Dupuytren’s contracture. Type of Study/Level of Evidence Therapeutic.