Proliferation of myofibroblasts with laying down ofcollagen 3and contractile proteins leading to formation of cords and nodules
Pathogenesis as proposed by Al-Qattan - genetic predisposition triggered by ischemic effects of smoking/ DM/ trauma/ aging/ Alcohol ➔ increases free radicals ➔ increases fibroblast proliferation
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Risk factors?
Males (japanese, caucasians, scandinavians), Diabetes, Liver Disease, Smoking, AIDS
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Classification and Stages of Duputryen's?
Tubiana Staging based on the composite contractures of PIPJ and MCPJ
Luck stages - PIR
Proliferative ➔ involutional ➔ residual
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What is Dupuytren's Diasthesis? Implications?
BERRYS - bilateral, Ectopic, Radial side, Recurrence, Young, Sex - male
Young onset < 40, bilateral, Ledderhose disease (plantar fascia), Peyronie’s disease (Dartos fascia of penis), Garrod Disease (knuckle pads over PIPJ dorsum)
Implications - higher recurrence rates, likely skin involvement, may need dermatofasiectomy, conservative unlikely to work
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Ligaments of the Finger and the pathological change?
Pathoanatomy is not well understood and no clear consensus
According to JAAOS review in 2013, there are 6 Cords in Duputryens
1. [MCPJ Contracture] Pretenditnous band ➔ Pretendinous cord
2. [PIPJ contracture] Extension of pretentinous band in palm ➔ Central cord
3. [PIPJ contracture + NVB centralization] Spiral band + Lateral Digital sheet + Grayson ➔ Spiral Cord
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4. [PIPJ and DIPJ contracture] Lateral Digital Sheet ➔ lateral cord
(VOC) cannot differentiate spiral and lateral cord clinically. Only intraop. But cord in the lateral part of the finger is spiral unless proven otherwise due to the risk of vascular compromise.
5. [DIPJ contracture]Digital Fascia dorsal to neurovascular bundle ➔ Retrovascular cord
The patient can receive up to a maximum of three injections per cord, limited to two digits (one at a time) at 4-week intervals.
Dose is 0.58mg based on the UK CORDLESS trial
The complications of this treatment include swollen lymph nodes, itching, pain, swelling, injection site bleeding, tenderness and bruising.
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How will you consent for surgery?
I will consent by explaining to her the
“Indications, alternatives and Risks”
indications - loss of function…
Alternatives - therapy, will not reverse
Risks, other than anaesthetic risks
Specific
Early
Injury to NVB
Correction not 100%
Cosmesis may be poor
Risk of infection/ delay wound healing/ need for skin grafts
Late
Recurrence 30-50% at 10 years; Diasthesis - almost 100%
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What incision? Draw!
“Longitudinal Z-plasty incision” will allow me to achieve more length
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Most important complication to be aware of?
BEWARE NVB that is more midline now due to spiral cord pushing it more central
I will also start my dissection in the palm where the NVB is more easily identifiable
Checkdigital allen testbefore op
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How do you protect the NVB?
Trace NVB proximally and distally towards the contracture
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Is dermatofasiectomy better?
Controversial
Previous Armstrong study JBJS 2000 if 143 fingers retrospective case series. Found recurrence rates to be 8% as compared to fasciectomy which can be as high as 27-66%
Why is PIPJ contracture more difficult to correct?
The presence of check-rein ligaments at the volar plate of the palmar plate further worsens the contracture ➔ needs to be released other than the central cord
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Have you heard of the open palm Maccash technique?
Yes. Transverse incisions in skin creases
Division of fascial bands
Splint fingers in extension for 4 weeks after operation
Wounds left open and allowed to heal by granulation.