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DUPUYTREN’S DISEASE

CONSERVATIVE TREATMENT NEEDLE APONEUROTOMY
Christian Dumontier, MD, PhD
Guadeloupe

WHAT’S CERTAIN

Genetic trait
Caucasian (3-6%); 8 cases over 6 years in a black
population with an incidence of 0,00007%
Sporadic cases in asiatic people (595 cases- 96 chineses,
19 thais, 1 vietnam, 15 india, 474 Japan - age 67 yrs, familial history
9% - Risk factors 65%)

Slattery. ANZ J Surg 2010;80: 495-499

WHAT’S CERTAIN
Links to other pathologies
Diabetes - OR 1,75 - type I > 2
Epilepsia - OR 1,12
Tobacco - OR 2,8
Alcohol - OR 1,9
Others: HIV, Hypertriglyceridemia, work, ...
Loos, BMC 2007;8:60 ; Geoghegan JHS 2004; 29B: 423-426 ; Burge JBJS 1997; 79B: 206-210

WHAT’S CERTAIN
Unpredictable evolution after
surgery
Reccurences will occur if the patient
lives long enough
Surgical complications should be
limited if possible (per-op ; early ;
late complications)
Nerve and arterial injuries
(1-1,5%Skin tears, skin necrosis (5-10%),
RSD, Flare reaction (5-10%)

CONSERVATIVE TREATMENT

Observation ?
Nodules followed-up for 9 years

Reilly JHS 2005; 30A:1014-1018

50% increased to a cord (European origin
43%, younger (<50 yrs), Bilateral 30%, Relatives
involved 23%, Ledderhose 13%)

The table top test is an easy, cost-free
technique to follow the evolution

CONSERVATIVE TREATMENT
Have been abandoned: cytolytic agents,
Radiotherapy (Keilholz, 1996), Interferon,...
Not validated: acupuncture, mesotherapy,
homeopathy, vit E (Thomson, 1949), phytotherapy,
physiotherapy (Stiles, 1966),...
Had proven not useful: Steroid injection (Baxter, 1952; Ketchum,
2001), Allopurinol,
Yet to be proven: Isoptine, Imiquimod (Namazi. Med Hypotheses.
2006;66(5):991-2.), shockwave therapy (Knobloch. Med Hypotheses 2011;76(5):
635-7), Antifibrotics (Knobloch. Med Hypotheses 2009; 73(5):659-61),...

HISTORICAL OF NEEDLE
APONEUROTOMY
De Seze & Debeyre: 1957, Rev Rhum - 70 cases
Lermusiaux: 1984, Rev Prat.
Badois: 1993, Rev. Rhum.
Lermusiaux: 1997, Rev. Rhum.
Foucher: 1998, Ann. Chir. Plast. -2001, Chir. Main

NEEDLE APONEUROTOMY

To turn old into new !
That’s what Astley-Cooper and Dupuytren did !
The idea is to break that «f...ing» cord
Already many variations

«ORIGINAL» TECHNIQUE
Done during consultation
Local anesthesia
Steroid Injection into nodules under pressure
To and Fro mvts with a fine needle
Finger extension - mechanical rupture
Extension splint

1 to 5 aponeurotomies - 1 to 3 sessions to get extension
CCAM: MJPB001 (41,54€) + MZMP001 (steroid = 15,68€)

2 SESSIONS

MULTIPLE APONEUROTOMY

«SURGICAL» TECHNIQUE

Day surgery, under loco-regional anesthesia +/tourniquet
One seance
From proximal to distal
Section of the cords with a 21 gauge needle,
tangent under the skin

CLINICAL SERIES (LENOBLE)

123 pts (108 males)
58,7 yrs (42 – 78)
167 aponeurotomies (103
palmar, 64 digito-palmar)
Follow-up: 5,9 yrs minimum 3 yrs

Stage

Finger

1

36

2 + 17 W1

2

91

1

3

22

17

4

18

78

5

25

COMPLICATIONS
Tendon

0

Nerve

0

Infectious 1
RSD

0

Stiffness

0

Pain

84%

Minimal

76%

Severe 8%
> 1 month 6%

CUTANEOUS COMPLICATIONS

Ruptures

57%

« skin bruising » 46%
Skin rupture
Skin grafts

11%
2

EVOLUTION OF RESULTS
3 yrs

5,5 yrs

Reccurence

38 (22,7%)

66 (39,5%)

No TTT

29 (17,4%)

42 (25,1%)

TTT

9 (5,4%)

24 (14,4%)

Aponeurotomie

7 (4,2%)

9 (5,4%)

Fasciectomy

2 (1,2%)

17 (10,2%)

CONTRA-INDICATIONS ?

The thumb
Nodules, skin infiltration

HOW SAFE IS IT ?
No complications (8 cases - Cheng J Orthop Surg 2008; 16(1):
88-90 / 74 cases van Rijssen. JHS Br 2006;31(5):
498-501)
1 nerve injury (211 cases - Foucher Chir Main 2001;20(3):
206-11

)

18 minor problems (160 cases) - 1 drainage
treated surgically

HOW EFFICIENT IS IT ?

Improvement MP 70%, PIP 41% (Cheng) MP 79%
IPP65% (Foucher Chir Main 2001;20(3):206-11)
Improvement 86% (160 patients), and 72,5% at 5
yrs (38°)

HOW LONG WILL IT LAST ?

24% re-operation and 58% recurrence at 3,2 yrs
33% recurrence at 5 years, 10% re-operated
65% recurrence at 32 months (van Rijssen. JHS Br
2006;31(5):498-501) and 84,9% at 5 years (van
Rijssen. PRS 2012;129(2):469-477) vs 20,9% (limited
fasciectomy)

IS IT BETTER ?

Less efficient (63 vs 79%) in Tubiana’s stage 3 and
4 at 6 weeks but less major complications (0 vs 5%)
than limited fasciectomy (van Rijssen. JHS Am
2006;31(5):717-725)