Dupuytren’s contracture – wikipedia ledderhose disease radiotherapy

Typically, Dupuytren’s contracture first presents as a thickening or nodule in ledderhose disease radiotherapy the palm, which initially can be with or without pain. [8] Later in the disease process, there is painless increasing loss of range of motion of ledderhose disease radiotherapy the affected fingers. The earliest sign of a contracture is a triangular “puckering” of the skin of the palm as it passes over ledderhose disease radiotherapy the flexor tendon just before the flexor crease of the ledderhose disease radiotherapy finger, at the metacarpophalangeal (MCP) joint. Generally, the cords or contractures are painless, but, rarely, tenosynovitis can occur and produce pain. The most common finger to be affected is the ring ledderhose disease radiotherapy finger; the thumb and index finger are much less often affected. [9] The disease begins in the palm and moves towards the ledderhose disease radiotherapy fingers, with the metacarpophalangeal (MCP) joints affected before the proximal interphalangeal (PIP) joints. [10]

In Dupuytren’s contracture, the palmar fascia within the hand becomes abnormally thick, which can cause the fingers to curl and can impair ledderhose disease radiotherapy finger function. The main function of the palmar fascia is to increase ledderhose disease radiotherapy grip strength; thus, over time, Dupuytren’s contracture decreases a person’s ability to hold objects. People may report pain, aching and itching with the contractions. Normally, the palmar fascia consists of collagen type I, but in Dupuytren sufferers, the collagen changes to collagen type III, which is significantly thicker than collagen type I. [ citation needed] Related conditions [ edit ]

People with severe involvement often show lumps on the back ledderhose disease radiotherapy of their finger joints (called “ Garrod’s pads”, “ knuckle pads”, or “dorsal Dupuytren nodules”) and lumps in the arch of the feet ( plantar fibromatosis or Ledderhose disease). [11] In severe cases, the area where the palm meets the wrist may develop ledderhose disease radiotherapy lumps. Severe Dupuytren disease may also be associated with frozen shoulder ledderhose disease radiotherapy ( adhesive capsulitis of shoulder), Peyronie’s disease of the penis, increased risk of several types of cancer, and risk of early death, but more research is needed to clarify these relationships. [ citation needed] Risk factors [ edit ]

Treatment is indicated when the so-called table top test is positive. With this test, the person places their hand on a table. If the hand lies completely flat on the table, the test is considered negative. If the hand cannot be placed completely flat on the ledderhose disease radiotherapy table, leaving a space between the table and a part of ledderhose disease radiotherapy the hand as big as the diameter of a ballpoint ledderhose disease radiotherapy pen, the test is considered positive and surgery or other treatment ledderhose disease radiotherapy may be indicated. Additionally, finger joints may become fixed and rigid.

On 12 June 1831, Dupuytren performed a surgical procedure on a person with contracture ledderhose disease radiotherapy of the 4th and 5th digits who had been previously ledderhose disease radiotherapy told by other surgeons that the only remedy was cutting ledderhose disease radiotherapy the flexor tendons. He described the condition and the operation in The Lancet ledderhose disease radiotherapy in 1834 [24] after presenting it in 1833 and posthumously in 1836 in ledderhose disease radiotherapy a French publication by Hôtel-Dieu de Paris. [25] The procedure he described was a minimally invasive needle procedure.

Because of high recurrence rates, [ citation needed] new surgical techniques were introduced, such as fasciectomy and then dermofasciectomy. Most of the diseased tissue is removed with these procedures. Recurrence rates are high. [ clarify] For some individuals, the partial insertion of "K wires" into either the DIP or PIP joint of the affected ledderhose disease radiotherapy digit for a period of a least 21 days to ledderhose disease radiotherapy fuse the joint is the only way to halt the ledderhose disease radiotherapy disease’s progress. After removal of the wires, the joint is fixed into flexion, which is considered preferable to fusion at extension.

During the procedure, the person is under regional or general anesthesia. A surgical tourniquet prevents blood flow to the limb. [29] The skin is often opened with a zig-zag incision but straight incisions with or without Z-plasty are also described and may reduce damage to neurovascular ledderhose disease radiotherapy bundles. [30] All diseased cords and fascia are excised. [27] [28] [29] The excision has to be very precise to spare the ledderhose disease radiotherapy neurovascular bundles. [29] Because not all the diseased tissue is visible macroscopically, complete excision is uncertain. [28] A 20-year review of surgical complications associated with fasciectomy showed that ledderhose disease radiotherapy major complications occurred in 15.7% of cases, including digital nerve injury (3.4%), digital artery injury (2%), infection (2.4%), hematoma (2.1%), and complex regional pain syndrome (5.5%), in addition to minor complications including painful flare reactions in ledderhose disease radiotherapy 9.9% of cases and wound healing complications in 22.9% of cases. [31] After the tissue is removed, the surgeon closes the incision. In the case of a shortage of skin, the transverse part of the zig-zag incision is left open. Stitches are removed 10 days after surgery. [29]

Dermofasciectomy is a surgical procedure that is mainly used in ledderhose disease radiotherapy recurrences and for people with a high chance of a ledderhose disease radiotherapy recurrence of Dupuytren’s contracture. [28] Similar to a limited fasciectomy, the dermofasciectomy removes diseased cords, fascia, and the overlying skin. [36] The skin is then closed with a skin graft, usually full-thickness, [28] consisting of the epidermis and the entire dermis. In most cases the graft is taken from the antecubital ledderhose disease radiotherapy fossa (the crease of skin at the elbow joint) or the inner side of the upper arm. [36] [37] This place is chosen, because the skin color best matches the palm’s skin color. The skin on the inner side of the upper arm ledderhose disease radiotherapy is thin and has enough skin to supply a full-thickness graft. The donor site can be closed with a direct suture. [36]

The graft is sutured to the skin surrounding the wound. For one week the hand is protected with a dressing. The hand and arm are elevated with a sling. The dressing is then removed and careful mobilization can be ledderhose disease radiotherapy started, gradually increasing in intensity. [36] After this procedure the recurrence of the disease can be ledderhose disease radiotherapy low [28] [36] [37] but the re-operation and complication rate may be high. [ vague] [38] Segmental fasciectomy with/without cellulose [ edit ]

The person is placed under regional anesthesia and a surgical ledderhose disease radiotherapy tourniquet is used. The skin is opened with small curved incisions over the ledderhose disease radiotherapy diseased tissue. If necessary, incisions are made in the fingers. [39] Pieces of cord and fascia of approximately one centimeter are ledderhose disease radiotherapy excised. The cords are placed under maximum tension while they are ledderhose disease radiotherapy cut. A scalpel is used to separate the tissues. [39] The surgeon keeps removing small parts until the finger can ledderhose disease radiotherapy fully extend. [39] [40] The person is encouraged to start moving his or her ledderhose disease radiotherapy hand the day after surgery. They wear an extension splint for two to three weeks, except during physical therapy. [39]

Needle aponeurotomy is a minimally-invasive technique where the cords are weakened through the insertion ledderhose disease radiotherapy and manipulation of a small needle. The cord is sectioned at as many levels as possible ledderhose disease radiotherapy in the palm and fingers, depending on the location and extent of the disease, using a 25-gauge needle mounted on a 10 ml syringe. [41] Once weakened, the offending cords can be snapped by putting tension on ledderhose disease radiotherapy the finger(s) and pulling the finger(s) straight. After the treatment a small dressing is applied for 24 ledderhose disease radiotherapy hours, after which people are able to use their hands normally. No splints or physiotherapy are given. [41]

The advantage of needle aponeurotomy is the minimal intervention without ledderhose disease radiotherapy incision (done in the office under local anesthesia) and the very rapid return to normal activities without need ledderhose disease radiotherapy for rehabilitation, but the nodules may resume growing. [45] A study reported postoperative gain is greater at the MCP-joint level than at the level of the IP-joint and found a reoperation rate of 24%; complications are scarce. [46] Needle aponeurotomy may be performed on fingers that are severely ledderhose disease radiotherapy bent (stage IV), and not just in early stages. A 2003 study showed 85% recurrence rate after 5 years. [47]

A comprehensive review of the results of needle aponeurotomy in ledderhose disease radiotherapy 1,013 fingers was performed by Gary M. Pess, MD, Rebecca Pess, DPT and Rachel Pess, PsyD and published in the Journal of Hand Surgery April ledderhose disease radiotherapy 2012. Minimal followup was 3 years. Metacarpophalangeal joint (MP) contractures were corrected at an average of 99% and proximal interphalangeal joint (PIP) contractures at an average of 89% immediately post procedure. At final follow-up, 72% of the correction was maintained for MP joints and 31% for PIP joints. The difference between the final corrections for MP versus PIP ledderhose disease radiotherapy joints was statistically significant. When a comparison was performed between people aged 55 years ledderhose disease radiotherapy and older versus under 55 years, there was a statistically significant difference at both MP and ledderhose disease radiotherapy PIP joints, with greater correction maintained in the older group. Gender differences were not statistically significant. Needle aponeurotomy provided successful correction to 5° or less contracture immediately post procedure in 98% (791) of MP joints and 67% (350) of PIP joints. There was recurrence of 20° or less over the original post-procedure corrected level in 80% (646) of MP joints and 35% (183) of PIP joints. Complications were rare except for skin tears, which occurred in 3.4% (34) of digits. This study showed that NA is a safe procedure that ledderhose disease radiotherapy can be performed in an outpatient setting. The complication rate was low, but recurrences were frequent in younger people and for PIP ledderhose disease radiotherapy contractures. [48] Extensive percutaneous aponeurotomy and lipografting [ edit ]

A technique introduced in 2011 is extensive percutaneous aponeurotomy with ledderhose disease radiotherapy lipografting. [42] This procedure also uses a needle to cut the cords. The difference with the percutaneous needle fasciotomy is that the ledderhose disease radiotherapy cord is cut at many places. The cord is also separated from the skin to make ledderhose disease radiotherapy place for the lipograft that is taken from the abdomen ledderhose disease radiotherapy or ipsilateral flank. [42] This technique shortens the recovery time. The fat graft results in supple skin. [42]

Before the aponeurotomy, a liposuction is done to the abdomen and ipsilateral flank ledderhose disease radiotherapy to collect the lipograft. [42] The treatment can be performed under regional or general anesthesia. The digits are placed under maximal extension tension using a ledderhose disease radiotherapy firm lead hand retractor. The surgeon makes multiple palmar puncture wounds with small nicks. The tension on the cords is crucial, because tight constricting bands are most susceptible to be cut ledderhose disease radiotherapy and torn by the small nicks, whereas the relatively loose neurovascular structures are spared. After the cord is completely cut and separated from the ledderhose disease radiotherapy skin the lipograft is injected under the skin. A total of about 5 to 10 ml is injected ledderhose disease radiotherapy per ray. [42]

Radiation therapy has been used mostly for early stage disease, but is unproven. [6] Evidence to support its use as of 2017, however, is poor; efforts to gather evidence are complicated due to a poor ledderhose disease radiotherapy understanding of the how the condition develops over time. [6] [53] It has only been looked at in early disease. [6] Alternative medicine [ edit ]

Besides hand therapy, many surgeons advise the use of static or dynamic splints ledderhose disease radiotherapy after surgery to maintain finger mobility. The splint is used to provide prolonged stretch to the ledderhose disease radiotherapy healing tissues and prevent flexion contractures. Although splinting is a widely used post-operative intervention, evidence of its effectiveness is limited, [57] leading to variation in splinting approaches. Most surgeons use clinical experience to decide whether to splint. [58] Cited advantages include maintenance of finger extension and prevention of ledderhose disease radiotherapy new flexion contractures. Cited disadvantages include joint stiffness, prolonged pain, discomfort, [58] subsequently reduced function and edema.

The presence of all new Dupuytren’s diathesis factors increases the risk of recurrent Dupuytren’s disease by 71% compared with a baseline risk of 23% in people lacking the factors. [22] In another study the prognostic value of diathesis was evaluated. They concluded that presence of diathesis can predict recurrence and ledderhose disease radiotherapy extension. [59] A scoring system was made to evaluate the risk of ledderhose disease radiotherapy recurrence and extension evaluating the following values: bilateral hand involvement, little finger surgery, early onset of disease, plantar fibrosis, knuckle pads and radial side involvement. [59]

• ^ a b c Brazzelli, M; Cruickshank, M; Tassie, E; McNamee, P; Robertson, C; Elders, A; Fraser, C; Hernandez, R; Lawrie, D; Ramsay, C (October 2015). "Collagenase clostridium histolyticum for the treatment of Dupuytren’s contracture: systematic review and economic evaluation". Health Technology Assessment. 19 (90): 1–202. doi: 10.3310/hta19900. PMC 4781188. PMID 26524616.

• ^ a b c d Kadhum, M; Smock, E; Khan, A; Fleming, A (1 March 2017). "Radiotherapy in Dupuytren’s disease: a systematic review of the evidence". The Journal of Hand Surgery (European Volume). 42 (7): 689–692. doi: 10.1177/1753193417695996. PMID 28490266. On balance, radiotherapy should be considered an unproven treatment for early Dupuytren’s disease due to a scarce evidence base and unknown ledderhose disease radiotherapy long-term adverse effects.

• ^ a b c d e Van Rijssen, Annet L.; Gerbrandy, Feike S.J.; Linden, Hein Ter; Klip, Helen; Werker, Paul M.N. (2006). "A Comparison of the Direct Outcomes of Percutaneous Needle Fasciotomy ledderhose disease radiotherapy and Limited Fasciectomy for Dupuytren’s Disease: A 6-Week Follow-Up Study". The Journal of Hand Surgery. 31 (5): 717–25. doi: 10.1016/j.jhsa.2006.02.021. PMID 16713831.

• ^ Bainbridge, Christopher; Dahlin, Lars B.; Szczypa, Piotr P.; Cappelleri, Joseph C.; Guérin, Daniel; Gerber, Robert A. (2012). "Current trends in the surgical management of Dupuytren’s disease in Europe: An analysis of patient charts". European Orthopaedics and Traumatology. 3 (1): 31–41. doi: 10.1007/s12570-012-0092-z. PMC 3338000. PMID 22611457.

• ^ a b c Hurst, Lawrence C.; Badalamente, Marie A.; Hentz, Vincent R.; Hotchkiss, Robert N.; Kaplan, F. Thomas D.; Meals, Roy A.; Smith, Theodore M.; Rodzvilla, John (2009). "Injectable Collagenase Clostridium Histolyticum for Dupuytren’s Contracture". New England Journal of Medicine. 361 (10): 968–79. doi: 10.1056/NEJMoa0810866. PMID 19726771.