The document discusses strategies for treating benign versus aggressive Dupuytren's disease. For benign disease with palmar cords, options include fasciotomy for elderly patients and fasciectomy for younger patients, with open palm procedures for large involvement. Recurrence rates are lower but depend on the extent of involvement. Aggressive disease may require more extensive surgery like dermofasciectomy and skin grafting, with higher morbidity but lower recurrence rates. Treatment selection balances function preservation and recurrence risk based on disease severity and patient factors.

1. The different strategies for aggressive VS benign disease Caroline Leclercq Institut de la Main Paris,France

2. What is our goal ? Cure the disease? : we cannot

4. The patient’s goal ? May not necessarily be identical Full function, not full motion Quick treatment Resume activities rapidly Less worried about recurrence

5. What do we know? In some patients the disease follows a more severe course, and recurs more after surgery -> Benign VS aggressive

6. - Ethnicity -Family history -Ectopic lesions -Bilateral involvement *Young age of onset Dupuytren’s diathesis Hueston 1963 Institut de la Main

7. Abe 2004 Hindocha & Stanley 2006 - 322 patients -Ethnicity -Family history : less significant -Ectopic lesions : knuckle pads -Bilateral involvement -Young age of onset < 50 yo - Male gender -Alcohol consumption > 28 U/w *1U = 10ml pure ethanol = 1 small glass of wine Diathesis revisited Institut de la Main

8. Hindocha & Stanley 2006 Diathesis revisited Institut de la Main

11. Non surgical treatment Vitamin E Corticoids Radiation-therapy (Germany) Seegenschmiedt 2007, 419 hands Reduces progression of disease, less surgery Shockwave therapy ?? Knnobloch 2011 (Germany) Institut de la Main

12. Fasciotomy - open /closed / needle Regional fasciectomy - skin closure / open palm Dermo-fasciectomy (collagenase) Institut de la Main

13. Surgical -open -closed Needle De Seze 1957 Popular in France Institut de la Main

18. Needle fasciotomy Recurrence *Diffcult to assess Institut de la Main Recurrence delay 1993 50% 5 years FOUCHER 2003 58%* 38 mths VAN RIJSSEN 2006 65% BADOIS RAIMBEAU 2008 100% 5years

19. Satisfaction rate is high!!! But so is it with other procedures… Roush & Stern (2000) results of treatment for recurrent contractures: 18/19 satisfied despite limited results Needle fasciotomy Subjective results

22. literature personal s. BULSRODE 2003 2005 nb patients 155 253 COMPLICATIONS 30 to 50% 14% 18% Nerve lesions % 1 to 9 2 2 Arterial lesion % 0.8 to 9 3.3 0.8 Hematoma % 4 to 15 0.4 2 Skin necrosis % 5 to 11 2 delayed healing % 0 to 10 3.2 } 2.4 infection % 0 to 6 0 9.6 lack of flexion % 6 6.5 ? CRPS % 4 to 9 / 2.4

23. MP : full correction PIP :depends on initial contracture MISRA 2007 Correction 67° to 6° , and at one year 25° 5th finger : worst results GOUBIER 2001 MP 65% improvement PIP 46% Institut de la Main

24. GELBERMAN / 1982 Bruner Z plasties open palm nb patients 26 30 27 healing w 2,5 2,5 3,9 skin necrosis % 11 7 0 hematoma % 4 0 0 infection % 4 0 0

25. Wound healing 4 to 6 wks + Long term splinting Stiffness

26. Not much difference between skin closure and open palm at middle term and long term Institut de la Main

27. Problem : definition… - finger lack of extension ? - reappearance of palpable cords ? - « reappearance of DD tissue in an area previously cleared of all disease » Institut de la Main

29. Institut de la Main

30. Bulstrode 2005 = 31% - no definition - average follow up 9 years (4 – 16 years) Institut de la Main

31. Recurrence is independant of the type of skin closure GEM 1992 Citron 2005 Institut de la Main

32. Segmental fasciectomy MOERMANS 1991 CLIBBON & LOGAN 2001 well localized palmar cords Probably the closest to collagenase Institut de la Main

33. The most common treatment -MARAVIC 2005: French National Hospital Data 14200 primary surgeries : 88% fasciectomies Institut de la Main

34. EU Chart Audit study (2009) 687 European surgeons Institut de la Main

35. All stages of DD Large palmar involvement : transverse incision and open palm PIPj release as needed Skin replacement as needed Institut de la Main

36. Institut de la Main

37. -Specific indications -A specific group of patients Complications are expected to be more frequent : -Nerve lesion 4 .5% -Arterial lesion 13.5% index and Vth finger -Graft necrosis : partial 10% -Stiffness 12% Institut de la Main

38. No recurrence under skin graft Tubiana & Leclercq 1986 Kelly & Varian 1992 Searle & Logan 1992 Brotherston 1994 Institut de la Main

39. Hueston 1969 Tonkin 1984 3.2y 33% Armstrong 2000 5.8y 11% CL 2008 5.6y 21% -outside grafted area Institut de la Main

40. Recurrent disease +++ Strong diathesis ++ Significant skin involvement 5th finger, radial involvement Institut de la Main

42. Decision making Benign versus aggressive disease

51. BENIGN DISEASE Palmo-digital cord Standard procedure Fasciectomy (Collagenase?) - Large palmar involvement Open palm

52. BENIGN DISEASE Palmo-digital cord Several rays Fasciectomy+++

53. BENIGN DISEASE Palmo-digital cord Several rays Fasciectomy+++

54. BENIGN DISEASE Palmo-digital cord Several rays Fasciectomy+++ - and large palmar involvement Open palm

58. BENIGN DISEASE Palmo-digital cord Results depend largely on the extent of finger involvement

59. BENIGN DISEASE Palmo-digital cord Results depend largely on the extent of finger involvement Severe PIP contracture : worst results

64. 2 weeks

65. 6 months 2 weeks

68. 2 months

70. Female 62 y.o. 4 years post-fasciectomy + skin grafting Palmar recurrence: much easier to operate

79. Rate of recurrence (years)