SYM07: Dupuytren: Enzyme vs. Needle vs. Fasciectomy: What Should You Do in 2017? Dupuytren Treatment Decision Trees Charles Eaton MD Page 1 of 5

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1 Dupuytren Treatment Decision Trees Charles Eaton MD Page 1 of 5 Primary goal: Minimize lifetime morbidity from both Dupuytren and its treatment What do patients want? Questions: o Will it get worse? (maybe not, but probably) o Doesn t surgery just make it worse? (usually not) o What can I do to keep it from getting worse? (nothing yet) o What can I do to keep it from coming back? (nothing yet) Motivations o Early in disease: Want normal Internet fueled catastrophic thinking common Avoid risk or be proactive? (choose one) o Late in disease: Want better: If I could straighten it enough to be able to Willingness to have more treatment varies greatly o Short term goals: specific Tolerable procedure Quick recovery Dexterity for specific tasks o Long term goals: more general ± Not looking crippled ± Not becoming crippled ± Not losing flexion, feeling or fingers

2 Dupuytren Treatment Decision Trees Charles Eaton MD Page 2 of 5 What do surgeons want? Questions o How do I avoid post-fasciectomy flare/rsd? (loose dressings, treat CTS) o Should diathesis alter treatment? (not if you won t do dermofasciectomy) o What s best for the terrible Dup hand? (be realistic; review salvage options) o How can I better predict who won t do well? (> 2 digits; PIP > 60 ; Ray > 90 ) Motivations o Best interest of the patient o Personal skill/comfort as a technician o Personal comfort creating complications o Logistics / reimbursement How is everything going today in Dupuytren care? Short term: pretty well: new/shiny minimally invasive options o I d rather do this every year than that every ten years o Doctor-shopping more common o Some patients still miss the window for a good result Long term: change without progress o We treat without understanding or treating the biology, which involves Wnt signaling, regulation of focal adhesions, and deposition of ECM o ROM doesn t correlate well with satisfaction o Many patients unaware of minor recurrence/extension o Some patients have inexplicably good long term results o Some patients are inexplicably satisfied with bad hands o Patient satisfaction is dynamic; drops with recontracture o Choice of procedure based more on gut rather than data Case-report mentality Marketing influence Overtreatment or therapeutic nihilism? (choose one) o Serious complications of fasciectomy 4 X other elective hand procedures o Failed Dupuytren surgery most common reason for elective amputation o No improvement in long-term outcomes last 50 years What considerations should influence recommendations? First procedure o Patient Preference o Surgeon Preference o Biology Diathesis factors (If severe, consider primary dermofasciectomy) Anesthetic risk (Too risky for fasciectomy = too risky to treat complications) o Anatomy Dupuytren Palpable cord (No cord? No procedure.)

3 Dupuytren Treatment Decision Trees Charles Eaton MD Page 3 of 5 Nodular skin involvement ( recontracture risk) Number of joints and digits ( risk incomplete correction) Composite ray > 90 ( risk incomplete correction) Secondary pathoanatomy Skin reserve (be ready to graft) Flexor sheath shortening (plan incision for skin to cover release site) PIP > 40 (gentle stretch vs. Digit Widget ; avoid open release) Boutonniere (DIP fusion lasts longer than tenotomy) Sagittal band rupture (fix at same setting) Comorbid booby traps Carpal tunnel (treat) Trigger finger (preserve A1 as for rheumatoid or risk bowstringing) Prior tendon or skeletal injury (ask) Undiagnosed mild spasticity (evaluate) Undiagnosed peripheral neuropathy (evaluate) Undiagnosed ulnar neuropathy (evaluate) Severe contracture: central reorganization/disuse (evaluate) o Postop logistics Self-care arrangements Out-of-town arrangements Next Procedures o Considerations as above o Prior treatment Technical details Early recovery details Timeline of recurrence/extension Redo fasciectomy? Microscope on standby. Procedure Choices o Minimal: dealer s choice, similar results Xiaflex /Xiapex Needle Fasciotomy o Standard: dealer s choice; better correction than minimal for ray > 90 Limited fasciectomy Regional Fasciectomy o Staged: consider for ray > 135 or PIP > 75 Digit Widget then procedure Minimal then procedure Fasciectomy then DIP fusion for boutonniere o Combined / same setting: Fasciectomy and carpal tunnel release (it s OK, really.) Fasciectomy and tendon procedure (e.g. sagittal band reconstruction) Fasciectomy and skin graft gap (for skin shortage without diathesis) Dermofasciectomy and functional unit skin replacement (diathesis) (Dermofasciectomy is not just fasciectomy + skin graft: read up!)

4 Dupuytren Treatment Decision Trees Charles Eaton MD Page 4 of 5 o Fasciectomy and biologic barrier implant (diathesis) Salvage PIP fusion (current standard for recurrent severe PIP) Amputation (only if patient suggests it)? Middle phalangectomy (length same as PIP fusion for 90, keep flexion arc) ± Dorsal angulation osteotomy (sometimes accomplishes nothing) ± PIP Joint replacement (requires good luck) More materials at: References Armstrong JR, Hurren JS, Logan am. (2000). Dermofasciectomy in the Management of Dupuytren s Disease. J Bone Joint Surg Br 82 (1): Cantero-Téllez R, Cuesta-Vargas AI, Cuadros-Romero M. (2015). Treatment of Proximal Interphalangeal Joint Flexion Contracture: Combined Static and Dynamic Orthotic Intervention Compared with Other Therapy Intervention: A Randomized Controlled Trial. The Journal of Hand Surgery 40 (5); Craft RO, Smith AA, Coakley BB, Casey 3rd WJ, Rebecca AM, Duncan SFM, Casey WJ. (2011) Preliminary Soft-Tissue Distraction versus Checkrein Ligament Release after Fasciectomy in the Treatment of Dupuytren Proximal Interphalangeal Joint Contractures. Plast Reconstr Surg 128 (5): Degreef I, De Smet L. (2009). Dupuytren s Disease : A Predominant Reason for Elective Finger Amputation in Adults. Acta Chirurgica Belgica 109 (4): Ghidella SD, Segalman KA, Murphey MS. (2002). Long-Term Results of Surgical Management of Proximal Interphalangeal Joint Contracture. The Journal of Hand Surgery 27 (5): Goodman AD, Gil JA, Starr AM, Akelman E, Weiss APC. (2016). Incidence of Serious Complications in Hand Surgery: A 10-Year Review. The Journal of Hand Surgery 41 (9). Elsevier Inc: S Logan AM, Brown HG, Lewis-Smith P. (1985). Radical Digital Dermofasciectomy in Dupuytren s Disease. Journal of Hand Surgery (Edinburgh, Scotland) 10 (3): Terry Michael J, Sue Gloria R, Goldberg Carolyn, Narayan Deepak. (2014). Hueston Revisited: Use of Acellular Dermal Matrix Following Fasciectomy for the Treatment of Dupuytren s Disease. Annals of Plastic Surgery 72 (3): 2 4. Roush TF, Stern PJ. (2000). Results Following Surgery for Recurrent Dupuytren s Disease. The Journal of Hand Surgery 25 (2): Teboul F, Sabri E, Goubier JN. (2012). Case Report: Middle Phalanx Resection as an Alternative Treatment to Amputation of Recurrent Dupuytren s Contracture of the Fifth Digit. European Journal of Plastic Surgery 35 (12): Tonkin MA, Burke FD, Varian JP. (1985A). The Proximal Interphalangeal Joint in Dupuytren s Disease. Journal of Hand Surgery (Edinburgh, Scotland) 10 (3):

5 Dupuytren Treatment Decision Trees Charles Eaton MD Page 5 of 5 Tonkin MA, Lennon WP. (1985B). Dermofasciectomy and proximal interphalangeal joint replacement in Dupuytren s disease. 1985/10/01, 10 Journal of hand surgery (Edinburgh, Scotland) Moberg E. (1973). Three Useful Ways to Avoid Amputation in Advanced Dupuytren s Contracture. Orthop Clin North Am 4 (4): Verjee LS, Midwood K, Davidson D, Essex D, Sandison A, Nanchahal J. (2009). Myofibroblast Distribution in Dupuytren s Cords: Correlation with Digital Contracture. J Hand Surg Am 34 (10):