Dupuytren Roundtable Discussions

Here are links to two recently published roundtable discussions by experts in the field of Dupuytren's. Although these were discussions by surgeons for surgeons, they are really just conversations and quite readable. They highlight the current challenges both surgeons and their patients face with Dupuytren's disease and provide insight into future efforts to develop a biological cure.

American Association of Hand Surgeons (go to page 6): http://www.dupuytrenfoundation.org/DupPDFs/2010_AAHS.pdf

American Academy of Orthopaedic Surgeons: http://www.dupuytrenfoundation.org/DupPDFs/2011_AAOS.pdf

Coming up: What is known about Dupuytren's and Chondroitin/Glucosamine?

Dupuytren's: it's not just the fascia.

Dupuytren's contracture is a local manifestation of a systemic process, and although the palmar fascia is the usual focus, what happens in the hand is a regional process, affecting the skin and the fatty layer under the skin as well as the fascia: it appears to be something which brews between the skin and the fascia, not just in the fascia. This concept and its consequences were eloquently reviewed by the late, great John Hueston in "The role of the skin in Dupuytren's disease" (full text: http://www.dupuytrenfoundation.org/DupPDFs/1985_Hueston_1125.pdf). His observations regarding the anatomy ("A nodule is never found on the dorsal aspect of a palmar aponeurosis..."), the biology ("...obsession with the collagenous structure of the palmar tissues is at present being replaced by the more logical study of the cellular origins..."), and the logic of dermofasciectomy and full thickness skin graft for aggressive or recurrent Dupuytren's are even more relevant today than when the article was published 25 years ago.

Fasciectomy: Unsafe at any Speed?

Fasciectomy, invented by Goyrand just a few years after Dupuytren's initial demonstration of open fasciotomy, has been the main treatment option for Dupuytren's for nearly 200 years. There have been many refinements, but the central theme of removing fascia is unchanged. With so much time and experience, one might assume that all of the wrinkles had been ironed out. Not so. Fasciectomy has inherent, unavoidable dangers even in experienced hands because of both technical difficulty and biologic reaction. In this recent report, "Surgical Complications Associated With Fasciectomy for Dupuytren's Disease: A 20-Year Review of the English Literature" (full text: http://www.dupuytrenfoundation.org/DupPDFs/2010_Denkler.pdf), the numbers are notable. On the average, one out of six fasciectomy patients experience a major complication; more if the procedure is for recurrent disease; even more if one asks the patients rather than the surgeons. This risk is hard to justify for the treatment of a benign condition. We need better treatment options to straighten out bent fingers, but also to prevent contractures from progressing or recurring.

Flare reaction after fasciectomy for Dupuytren's

Flare reaction refers to a disproportionate degree of swelling, pain and stiffness developing after surgery for Dupuytren's contracture. Although commonly known, there is relatively little published on this. Flare shares some features with reflex sympathetic dystrophy, another poorly understood condition which is seen more often after Dupuytren's surgery than other hand procedures. Flare reaction appears to be triggered by some combination of skin incisions and mechanical tension on the skin: it does not occur after needle aponeurotomy when a minimum number of portals are used. Flare reaction greatly prolongs recovery and may result in permanent stiffness of the hand. This article documents a case of flare reaction after fasciectomy for Dupuytren's and reviews the difficult issues it presents: (full text: http://www.dupuytrenfoundation.org/DupPDFs/2008_Fournier_1045.pdf)

Dermofasciectomy reconsidered

There are three mechanical approaches for Dupuytren's. In order of both increasing problems and long term effectiveness, these are: fasciotomy (cut fascia); fasciectomy (remove fascia); dermofasciectomy (remove both skin and fascia). The popularity of dermofasciectomy and skin grafting has been limited by concerns regarding complications of wound healing and loss of flexion. Some of these concerns stem from the historical use of dermofasciectomy as a revision procedure after failed fasciectomy, a group biased toward poor results. Dermofasciectomy as the primary or first operation is a different story. This study reviews technical tips for dermofasciectomy and shows that for patients with diffuse skin involvement, primary dermofasciectomy and skin grafting has a better chance of long term control than fasciectomy. http://www.dupuytrenfoundation.org/DupPDFs/2000_Armstrong_1046.pdf