Dupuytren Disease Flashcards
Moreaggressive (invasive) treatment options may reduce rate
ofrecurrence, but may be accompanied by increased risk
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there is no cure for
this chronic disorder
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most prevalent in persons of Caucasian descent.
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DD has been described in nearly every ethnicity
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F>M
F Men are affected
more often than women,
most common in the sixth decade of life
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When the incidence of DD became equal between M and F
beyond the eighth decade, the incidence of DD in men and women
becomes nearly identical
Reports of DD in infants and children
are very rare.
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There are no genetic factor in development of DD
F DD has both a genetic and an
environmental component
genetic factors must be playing a major
role. The authors concluded that the heritability of DD was approximately 80%
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What gene responsible for DD?
no single gene has been implicated
Etiology must be multifactorial
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DD CAN EASILY be DIAGNOSED BY genetic test
F there is currently no genetic test
for DD
manual labor cigarette and alcohol consumption have been linked with
increased prevalence of DD
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liver disease increased risk of DD
F Despite the increased prevalence of DD in alcoholics, for example, patients with liver disease due to other causes do not have an increased risk of DD
increased risk of DD in patients with seizure disorders
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Increase the incidence of DD with antiseizure medication wich medics?
the common antiseizure drug, phenobarbital
another risk factor for DD
diabetes mellitus, human
immunodeficiency virus, hypercholesterolemia, hypertriglyceridemia, frozen shoulder, and rock climbing
negative risk factor for the development of DD
is the
presence of rheumatoid arthritis
the common pathway
for development of DD is the transformation of fibroblasts to myofibroblasts
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DD stages
■ Proliferative stage: nodules form as fibroblasts proliferate
■ lnvolutional stage: contractures form, collagen is produced, cellularity reduced
■ Residual stage: nodules regress, hypocellular cords remain
Why increased ratio of type Ill to type I collagen
reaction to the increased fibroblast density in this disorder
pretendinous cords cause PIP contractures
F pretendinous cords cause metacarpophalangeal joint
(MCP) contractures
whereas central and spiral cords cause proximal interphalangeal joint (PIP) contractures
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Wich cord cause contracture in the web space
Natatory cords can lead to
webspace contractures; this may be referred to as a commissural cord
at the thumb-index web.
Cause of contracture in the DIP
Deep retrovascular cords and extensions
of lateral cords have been implicated in the distal interphalangeal joint
(DIP) contractures
the DIP joint sometimes becomes contracted in hyperextension, as these cords are often dorsal to the axis
of rotation of that joint.
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Spiral cords are particularly notorious in that they displace the
neurovascular bundle as they contract
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as
the spiral cord contracts, it displaces the neurovascular bundle proximally, centrally, and superficially related to its native position
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digital nerve appears to be spiraling around the cord, leading some authors to prefer the term spiral nerve
rather than spiral cord
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What is the isolated digital cord?
This unique cord originates
from the fascia or tendon of the abductor digiti quinti muscle, and it
can cause PIP and sometimes DIP contractures of the small finger.
factors that might predict a greater risk of early recurrence
■ Bilateral palmar disease
■ Family history of DD
■ Ectopic disease
■ Ethnicity
Ectopic disease ?
Ledderhose disease (plantar fibromatosis), Garrod pads (knuckle pads over the
dorsum of the PIPjoints),
and Peyronie disease (fibrotic disease causing curvature of the penis).
male patients
and younger patients also tended to have increased risk ofrecurrence
and/or extension
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the risk associated
with Garrod pads was higher than that associated with other forms of
ectopic disease
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modern definition ofDupuytren
diathesis
■ Male gender
■ Bilateral disease
■ Family history
■ Garrod pads
■ Age of onset less than 50
Staging systems
have been developed based on degrees of contracture is useful in planing of the surgfery
F these are rarely used in practice, as they are not really
helpful in determining a course of treatment
tabletop test is often
used as a simple tool to help patients monitor their disease:
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isolated MCP
contractures are easily corrected by many methods, why?
because that the collateral ligaments do not become pathologically shortened
when these joints are fixed in flexion for significant periods of time
PIP joints positioned in flexion for long periods of time
develop intrinsic joint contractures, which limit the overall success
rates of treatment
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mild MCP contractures (less
than 30°) can be observed safely, but progressive PIP contractures
should have earlier intervention to obtain the best outcome.
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Hyperbaric oxygen used in DD treatment
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Seriod used topically only
■ Intralesional steroid injection
■ Topical steroids
■ Oral steroids
■ Intramuscular steroids
External beam radiation can be used in treatment of DD
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steroid injection and radiotherapy appeared to offer some benefit
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Needle aponeurotomy asdvantages?
as the advantage of a rapid recovery, minimal
discomfort, high patient satisfaction, and lower cost
a steep learning curve and most studies
have shown higher and faster rates of recurrence compared to other treatments. There is also a small risk of tendon and/or digital nerve injury.
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Needle aponeurotomy indication
Needle aponeurotomy can be considered for any symptomatic MCP
or PIP joint contracture with a palpable cord
not a good choice
for patients that have experienced rapid recurrence following treatment
or in patients with severe scarring or skin shortening
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The effectiveness
of needle aponeurotomy is increased by corticosteroid (triamcinolone)
injection
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Collagenase injection, requires two separate visits
T one for injection
of CCH, and one for manipulation of the digit into extension
two cords in the same hand simultaneously can injected at the same time
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Collagenase injection use in the treatment of Peyronie disease
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CCH injection frequently causes localized bruising and pain, and
occasional lymphadenopathy and manipulation-related skin tears
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IN fasciectomy removes just the diseased fascia (limited fasciectomy) or remove both diseased
and nondiseased fascia (radical fasciectomy)
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In modern practice,
radical fasciectomy is uncommonly performed due to its increased
morbidity
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Dissection of the diseased cord proceeds from proximal to distal in most cases,
starting in the proximal palm
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the deeper, transverse
fascia! fibers may become disease
F the longitudinal fascia! fibers may become diseased, but the deeper, transverse fascia! fibers remain disease-free.
Once dissection
reaches the distal third of the palm, the transverse fascia
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In case of joint contractures persist in spite of the complete release of the cord what you can do?
In practice, it may be best to proceed with
PIP joint capsulotomy and/or ligamentous release in select cases,
Ifcomplete skin closure is not possible, skin grafting can be performed, or
wounds can be left open to heal by secondary intention.
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McCash open palm technique
advocated transverse incisions in the palm and digits to perform the
required fasciectomy, followed by weekly dressings with nonadherent
gauze until healed
STSG can be used in case of the wound canot closed
F small full-thickness skin
grafts when skin closure is not possible without tension
that full-thickness skin graftscouldact as afirebreak
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wide excision ofdiseased fascia and involved skin (dermofasciectomy), especially in recurrent cases can be employed
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Option of treatment of recurrent cases
Recurrent cases pip capsulotomy ligaments release and dermofasictomy and steroid injection
patients closed with Z-plasty
to those closed using small full-thickness skin grafts at the intended
Z-plasty site. No difference in recurrence was noted between the two
groups
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Skin can’t involve directly with DD
T Because the fibers ofthe palmar fascia attach to the skin in multiple locations, it is not surprising that the skin can become directly involved with DD
Soft tissue distraction has been used to treat Dupuytren contractures, relying on slow steady stretch to help overcome problems
T Digit Widget*
gradual tissue lengthening can be accomplished slowly over a period
of weeks or months, making subsequent surgery easier and more
successful
Benefit of preliminary distraction
T skin deficiency Vascular compromise due to stretched arteries, and intrinsic PIP joint contractures can be overcome with the preliminary distraction
better degree of contracture correction
Ligament release is better than preliminary, destruction
When compared to fasciectomy and checkrein ligament release, preliminary, destruction
was shown to provide a better degree of contracture correction
Percutaneous aponeurotomy and lipofilling (PALF) has been
advocated by some as a viable alternative to standard limited fasciectomy
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Benefit of lipoaspirate (lipojilling)
■ Reduction in myofibroblast density and cell-to-cell contact
■ Inhibition of myofibroblast proliferation mediated by adiposederived stem cells
■ Prevention of recurrence by replacing the deficient subdermal fat
risk of surgery dramatically increases for each subsequent
surgery on a digit
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risk of nerve injury in
a primary limited fasciectomy operation is around ……….
3%
Percentage of some disturbance of sensation
68%
For patients with early,
severe recurrence, PIP arthrodesis is one option that can stabilize the finger
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Amputation is considered only as a last resort in DD
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Chronic pain can decrease with an amputation of the involved digit.
F Phantom sensation
and phantom pain after surgery cannot be predicted easily, and sometimes pain related to complex regional pain syndrome is not eliminated with an amputation ofthe involved digit.
needle aponeurotomy
has early results equivalent to fasciectomy for cases of mild contracture, but may not be as effective for contractures involving the PIP
joint.
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limited fasciectomy has better durability, but greater
short-term disability, compared to the minimally invasive options
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Salvage Procedures
■ Arthrodesis
■ Amputation
the Delphi method to establish a definition of
recurrence in 2014
They defined recurrent contracture as passive extension deficit ofmore than 20° for at least one treated joint, in the presence
ofa palpable cord, compared to the result obtained at time 0. Time O was
further defined as between 6 weeks and 3 months after an intervention
The Cleland ligaments are not typically
involved in Dupuytren contracture. The oblique retinacular
ligament is a component of the extensor mechanism and is not
involved in Dupuytren disease
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enzyme CCH (collagenase Clostridium
histolyticum) preferentially targets collagen types I and III, but
has less effect on collagen type IV
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This isimportant because type
IV collagen is a major structural component of the connective
tissues surrounding arteries, veins, and nerves.
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The structures that contribute to the spiral cord
include the pretendinous band, spiral band, lateral digital sheet,
and Grayson ligament
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Although cigarette smoking has been associated
with increased prevalence of Dupuytren disease, it has not been
linked to Dupuytren diathesis,
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