28.11.2011
2 Disclosures
Controversies of surgical versus
non-surgical treatment in
Dupuytren's disease.
Vincent R. Hentz, MD
Robert A Chase Center for Hand and Upper Limb Surgery
Stanford University. Stanford California
Clinical investigator for Auxilium
sponsored clinical trials
I am first and foremost a surgeon who
loves to operate
Patient preference
Question # 1
Which are the main factors influencing
my decision to adopt a non-surgical
procedure ?
Surgery!!! Anything but surgery!!
Some patients will only consider
non-surgical or less invasive treatment
Fear: They are afraid of surgery, anesthesia, the hospital, costs
1.Patient preference
Knowledge: They know someone who had a poor surgical outcome
2.Disease presentation
Experience: They have already had surgery
3.Co-morbidities
Personal environment: Too busy for surgery - sports, job, events
4.Previous response to surgery (CRPS, “flare reaction”)
Recurrence – unconcerned
Disease presentation
Co-morbidities
Very amenable to non-surgical treatment – high expectation for successful outcome
Some examples: isolated 5th finger PIP contracture in a woman – they get stiff
Simple pretendinous cord causing
MPJ contracture
Pretendinous to central cord causing dynamic
MP + PIPJ contracture
 Old -
won’t live long enough to have a recurrence
 Sick –
arguments from your anesthesiologist
 Can’t stop their anticoagulants
 Can’t take proper care of themselves
postoperatively – stroke on opposite hand
Note that these are also presentations where surgery also likely to succeed.
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28.11.2011
Previous response to surgery
(
Question # 2
What are the circumstances where a non surgical
approach would be contra-indicated ?
CRPS, “flare reaction”)
Stiff hand
Disease presentation – non surgical likely to fail
High risk of complications
Patient preferences/desires
END
Where it is likely to fail
Previously operated digit with poor skin – poor candidate
The young patient with diathesis – multiple joints, aggressive
disease, high expectation of recurrence - deserves aggressive
surgery
Where it is likely to fail
Long-standing severe PIPJ contractures with periarticular
changes
Where it is likely to fail
PIPJ contractures associated with large nodules occupying most of the
proximal phalanx
MPJ contractures where there is no discrete cord, only nodules
Where the risk of complications is too great
Needle aponeurotomy
Lateral digital cords causing PIPJ contractures –
risk of nerve injury
Central cord- risk of tendon injury
Collagenase
Central cords causing PIPJ contractures (5th
digit) – risk of tendon injury
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Question # 3
Patient preference/desire/inconveniences
My preferred treatment for this healthy patient with a 30°
MPJ contracture and an 80° PIPJ contracture?
Wants all diseased fascia removed
Too many joints involved – for collagenase, 1
injection/month
What I want to know: Age? Desires and expectations?
Priorities re the “bargain”: Immediate inconvenience vs durability of correction
END
The deciding factors
The deciding factors
or, what I believe I know from the reported experience of others and my
own experience (1975-2011)
or, what I believe I know from the reported experience of others and my
own experience (1975-2011)
For MPJ contractures:
For PIPJ contractures > 60°:
•Surgery remains most predictable, most durable procedure
•Recovery often prolonged
•Needle/enzyme “aponeurotomy” equally initially effective
•Recovery much quicker than following surgery
Surgery yields superior initial results in terms of PIPJ extension.
Often at expense of PIPJ flexion – too aggressive surgery
My patients are happy with 50-60% improvement at PIPJ
Risk of nerve injury: higher with NA than enzyme aponeurotomy
•Enzyme aponeurotomy more durable than NA
I would recommend: discussing benefits and risks of
all 3 procedures
2 similar cases
Before treatment, contractures were 45˚ in
the MP joint and 75˚ in the PIP joint
When patient asks: “What do you recommend?”
What he is really asking is “What would you do if this were
your hand?
Today: Collagenase injection
.
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28.11.2011
1 day post-injection
30 days post-injection
Contracture status (after finger extension
procedure (24 hrs post injection))
30 days after the last (3rd) injection, (1 MP
cord injection, 2 PIP cord injections)
*Only the cord affecting the MP joint was injected.
.
55 year old man, pre-injection MP=45o, PIP = 700
9/10/11
Inject MP cord
9/17/11
Manipulate – MP cord ruptures, PIP=60
10//10/11 Inject PIP cord
10/17/11 Manipulate PIP = 20 Begin therapy
11/14/11 MP = O, PIP =0
4