Ultrasound evaluation of the pretendineous cord in patients with Dupuytren's disease

Transcription

1 Ultrasound evaluation of the pretendineous cord in patients with Dupuytren's disease Poster No.: P-0083 Congress: ESSR 2016 Type: Scientific Poster Authors: P. Vanek, J. Strömberg, J. Friden, Y. Aurell ; Gothenburg/SE, Mölndal/SE Keywords: Tissue characterisation, Connective tissue disorders, Surgery, Localisation, Ultrasound-Colour Doppler, Ultrasound, Musculoskeletal soft tissue, Extremities, Anatomy DOI: /essr2016/P-0083 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 17

2 Purpose Dupuytren's disease (DD) is a condition characterised by a localised fibromatous hypertrophy of the palmar fascia, which eventually develops into a cord causing contracture of one or more fingers. Morphological characteristics of DD, especially from a radiological perspective, are not completely described although the clinical appearance of the disease is well recognisable. Dupuytren's disease can be treated locally, by needle fasciotomy or by the recently developed percutaneous collagenase-injection-method. Nerve damage is a wellrecognised complication to the procedure. The purpose of this study was to describe the ultrasound characteristics of the cord as well as its relation to both the flexor tendon and the neurovascular bundle in order to assess the usefulness of US as guidance on the minimally invasive procedure. Methods and Materials Thirty-nine fingers in thirty-seven consecutive patients (32 men and 5 women) scheduled during the period from November 2012 to November 2014 for local treatment were included in the study. Inclusion criteria: at least 20-degree contracture of the metacarpophalangeal joint well-palpable Dupuytren's cord no surgical treatment of the contracture before One radiology resident performed all examinations, partially under supervision of radiologist experienced in musculoskeletal radiology. In the sonographic evaluation the patient was seated at an examination table with the elbow in flexion resting on the table, the forearm supinated and the hand resting on a cushion. The affected finger was also kept extended passively during the examination. Used US-system was a "point of care-system" BK Medical flex Focus 500 owned by the Department of Hand surgery where all examinations took place. A 18-6 MHz linear-array transducer, "hockey stick", and a 15-6 MHz linear-array transducer were used for the Page 2 of 17

3 examinations. Standoff gel pads were used in all cases in order to ensure the optimal contact between the transducer and skin and in this way minimize artifacts. To ensure correct positioning of the transducer and standardisation of ultrasound projections a tape measure was applied on the patients' finger prior to the examination. Scanning in both sagittal and transverse plane in B-mode as well as colour Dopplermode was performed and frozen representative images stored. All images in the sagittal projection included the MCP-joint. Images in the transverse plain was obtained over the MCP-joint as well as one centimetre proximally and distally to the MCP-joint, Fig. 1 on page 3. Aspects of interest: echogenicity of the cord echostructure of the cord topography of the cord in relation to the flexor tendon and the neurovascular bundle Images for this section: Page 3 of 17

4 Fig. 1: Standard image projections obtained in each patient, here emphasised by the red lines. A standoff gel pad and a tape measure were always applied. Page 4 of 17

5 Results Echogenicity and overall echostructure It was possible to clearly distinguish the pretendineous cord in all 39 patients. The echogenicity of the cord varied interindividually and in 24 cases (62%) was showing inhomogeneity in the individual patient and then two or three echo-patterns were presented in the cord. In relation to the flexor tendon the cord was hyperechogenic (10/39) Fig. 6 on page 9, isoechogenic (4/39) Fig. 4 on page 7 or had mixed echogenicity (24/39) Fig. 2 on page 6, Fig. 3 on page 6. No strictly hypoechogenic cord was found in the cohort. The overall echo-structure of the cord could be described as nodular (15/39) Fig. 5 on page 8, fibrillar (6/39) Fig. 4 on page 7, Fig. 6 on page 9 and mixed (17/39) Fig. 2 on page 6, Fig. 9 on page 13. In eight cases out of seventeen the cord of mixed type consisted of two rather homogeneous portions of different type giving a layered appearance of the cord Fig. 3 on page 6, Fig. 10 on page 13. In one case echogenicity and echo-structure could not be assessed. The correlation between the echogenicity and the structural pattern of the Dupuytren's cord was 0,5 (p<0,004). No correlation was found between patients' sex or age and echogenicity or echostructure respectively. Cord topography - position in relation to the neurovascular bundle and the flexor tendon: The position of the cord in relation to the underlying tendon and the digital nerves and vessels varied. In twenty-eight cases (72%) the cord followed the flexor tendon on the palmar site. In eleven cases (28%) the cord was switching from one side of the tendon to the other crossing the tendon plain. No cases with a cord lying exclusively lateral or medial to the tendon were found. In the transverse projection the digital vasculature was visualized Fig. 7 on page 10, Fig. 8 on page 11. Digital nerves could be seen in three cases Fig. 8 on page 11. Page 5 of 17

6 It was possible to show unilateral or bilateral digital vessels being surrounded by the Dupuytren's cord in six cases out of thirty-nine (14%). No correlation between patients' sex or age and position of the cord was found. Images for this section: Fig. 2: Dupuytren's cord with both a fibrillary-isoechogenic and a nodular-hyperechogenic portion, longitudinal projektion. Page 6 of 17

7 Fig. 3: Dupuytren's cord with both a hyperechogenic and an isoechogenic portion, transverse projection in between the MCP-joint and the PIP-joint. Page 7 of 17

8 Fig. 4: Dupuytren's cord of fibrillar type, which is isoechogenic with the tendon, longitudinal projection. Page 8 of 17

9 Fig. 5: Dupuytren's cord of nodular type, which is isoechogenic with the tendon, longitudinal projection. Page 9 of 17

10 Fig. 6: Dupuytren's cord of fibrillar type, which is hyperechogenic to the tendon, longitudinal projection. Page 10 of 17

11 Fig. 7: Dupuytren's cord consisting of two different portions. The digital vessels are depicted by colour Doppler. Transverse projection in between the MCP-joint and the PIPjoint. Page 11 of 17

12 Page 12 of 17

13 Fig. 8: Dupuytren's cord which is hyperechogenic to the flexor tendon. B-mode and the colour Doppler-mode depict the digital vessel and nerve on one side of the finger. Transverse projection in between the MCP-joint and the PIP-joint. Fig. 9: Dupuytren's cord with both a fibrillary-isoechogenic and a nodular-hyperechogenic portion, longitudinal projektion. Page 13 of 17

14 Fig. 10: Dupuytren's cord with both a fibrillary-isoechogenic and a nodularhyperechogenic portion, longitudinal projektion. Page 14 of 17

15 Conclusion By ultrasound the echo-pattern of the Dupuytren's cord and its relation to the flexor tendon can be described which might be useful in planning of the minimal invasive surgical procedure and thus avoid complications. However, with the point-of-care US-system used in this study, the neurovascular bundle could not be assessed in majority of cases, which might be overcome with another technical platform. References Badois FJ, Lermusiaux JL, Massé C, Kuntz D. Non-surgical treatment of Dupuytren s disease using needle fasciotomy. Rev Rhum Ed Fr 1993:60(11): Hurst LC, Badalamente MA, Hentz VR, Hotchkiss RN, Kaplan FT, Meals RA, Smith TM, Rodzvilla J. Injectable collagenase clostridium histolyticum for Dupuytren's contracture. N Engl J Med. 2009; 361: Foucher G, Medina J, Navarro R. Percutaneous needle aponeurotomy: complications and results. J Hand Surg Br 2003:28(5): Chen NC, Srinivasan RC, Shauver MJ, Chung KC. A systematic review of outcomes of fasciotomy, aponeurotomy, and collagenase treatments for Dupuytren s contracture. Hand (NY) 2001;6: Uehara K et al. Ultrasonographic Evaluation of Displaced Neurovascular Bundle in Dupuytren Disease. JHS 2013; 38A:23-8. Créteur V, Madani A, Gosset N. Apport de l'échographie dans la maladie de Dupuytren. J Radiol 2010;91: Teefey S A, Middleton W D, Boyer M I. Sonography of the Hand and Wrist. Seminars in Ultrasound, CT, and MRI, Vol 21, No 3 (June), 2000: pp Lam W L, Rawlins J M, Karoo R O S, Naylor I, Sharpe D T. Re-visiting Luck's classification: A histological analysis of Dupuytren's disease. JHS (European Volume 2010) 35E: 4: Kloen P. New insights in the development of Dupuytren's contracture: a review. British Journal of Plastic Surgery (1999), 52, Page 15 of 17

16 Alfonso-Rodríguez C A, Garzón I, Garrido-Gómez J, Ximenes Oliveira A C, Martín-Piedra M Á, Scionti G, Carriel V, Hernández-Cortés P, Campos A, Alaminos M. Identification of Histological Patterns in Clinically Affected and Unaffected Palm Regions in Dupuytren's Disease. PLOS ONE, November 2014, Issue 11. Yacoe M E, Bergman A G, Ladd A L, Hellman B H. Dupuytren's Contracture: MR Imaging Findings and Correlation Between MR Signal Intensity and Cellularity of Lesion. AJR: 160, April 1993, Verjee L S, Midwood K, Davidson D, Essex D, Sandison A, Nanchahal J. Myofibroblast Distribution in Duouytren's Cords: Correlation With Digital Contracture. JHS, Vol 34A, December 2009, Wilbrand S, Ekbom A, Gerdin B. The sex ratio and rate of reoperation for Dupuytren's contracture in men and women. JHS (British and European Volume, 1999) 24B: 4: Leclére F-M, Mathys L, Vögelin E. Traitement de la maladie de Dupuytren par collagénase injectable, évaluation de l'échographie assistée. Chirurgie de la main 33 (2014) Sakellariou V, Brault J, Rizzo M. Ultrasound-assisted percutaneous needle fasciotomy for Dupuytren's contracture. Orthopedics, 2015, 38(5): Personal Information Petr Vanek Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden. petr.vanek@vgregion.se Joakim Strömberg Department of Hand surgery, Sahlgrenska University Hospital, Gothenburg, Sweden Centre for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Sweden Page 16 of 17

17 Jan Friden Centre for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Sweden Ylva Aurell Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden Page 17 of 17