Hester J. Kan

Extensive percutaneous aponeurotomy and lipografting: A new treatment for dupuytren disease

Background: Surgical resection of Dupuytren contracture is fraught with morbidity and prolonged recovery. This article introduces a novel minimally invasive alternative for Dupuytren disease and its outcome. Methods: The procedure consists of an extensive percutaneous aponeurotomy that completely disintegrates the cord and separates it from the dermis. Subsequently, the resultant loosened structure is grafted with autologous lipoaspirate. After 1 week of postoperative extension splinting, patients are allowed normal hand use and are advised to use night splints for 3 to 6 months. The authors treated and report on their experience with 91 patients (99 hands) operated on in Miami and Rotterdam; from 50 patients, the authors report on goniometry (average follow-up, 44 weeks). Results: The contracture from the proximal interphalangeal joint improved significantly from 61 degrees to 27 degrees, and contracture from the metacarpophalangeal joint improved from 37 degrees to –5 degrees. Ninety-four percent of patients returned to normal use of the hand within 2 to 4 weeks and 95 percent were very satisfied with the result. No new scars were added, and a supple palmar fat pad was mostly restored. Complications were digital nerve injury in one patient, postoperative wound infection in one patient, and complex regional pain syndrome in four patients. Conclusions: This new minimally invasive technique shortens recovery time, adds to the deficient subcutaneous fat, and leads to scarless supple skin. By its ability to treat multiple rays, it addresses the abnormality in the entire hand. The procedure is safe and effective, especially for primary cases. Currently, comparative prospective randomized studies are in process to fully determine its role in the treatment of Dupuytren contracture. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV. Figure. No caption available.

Percutaneous Aponeurotomy and Lipofilling (PALF) versus Limited Fasciectomy in Patients with Primary Dupuytren's Contracture: A Prospective, Randomized, Controlled Trial.

Background: As an alternative to needle aponeurotomy release and limited fasciectomy treatment of Dupuytren’s contracture, the authors introduced an extensive percutaneous aponeurotomy and lipofilling (PALF) procedure. In their previous study, the authors reported that contractures significantly improved and most patients returned to normal use of the hand within 2 to 4 weeks. To establish the safety and efficacy of PALF, the authors compared it to the standard limited fasciectomy in a single-blind, multicenter, prospective, randomized, controlled trial. Methods: Patients with a primary Dupuytren’s contracture were assigned randomly to the limited fasciectomy group or the PALF group. Patients were measured at baseline and at 2 weeks, 3 weeks, 6 months, and 1 year postoperatively. Primary outcome of the trial was contracture correction and convalescence time. Groups were compared using a mixed models approach. Results: Eighty patients were randomized to PALF or limited fasciectomy. In both groups, almost full metacarpophalangeal joint contracture correction was obtained, whereas for the proximal interphalangeal joint, some residual contracture remained. Patients in the PALF group returned significantly earlier to their normal daily activity. At 1 year after surgery, no significant differences in recurrence rate or hand function were present. However, limited fasciectomy seems to have a higher incidence of permanent complications. Conclusions: PALF demonstrates a significantly shorter convalescence, similar operative contracture correction, lower incidence of long-term complications, and no significant difference regarding 1-year postoperative results compared with limited fasciectomy. It is therefore a valuable, minimally invasive alternative to limited fasciectomy in the treatment of Dupuytren’s disease. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Patients' Preferences for Treatment for Dupuytren's Disease: A Discrete Choice Experiment.

Background: Although in modern medicine, patients’ preferences are important, these have never been defined for characteristics of Dupuytren treatment. This study determines these patients’ preferences using a discrete choice experiment. Methods: A multicenter discrete choice experiment study was conducted among patients with Dupuytren’s disease who had been treated previously. Patients were asked about their preferences for attributes of Dupuytren treatments using scenarios based on treatment method, major and minor complication rates, recurrence rates, convalescence, residual extension deficit after treatment, and aesthetic results. The relative importance of these attributes and the tradeoffs patients were willing to make between them were analyzed using a panel latent class logit model. Results: Five-hundred six patients completed the questionnaire. All above-mentioned attributes proved to influence patients’ preferences for Dupuytren treatment (p < 0.05). Preference heterogeneity was substantial. Men who stated they performed heavy labor made different tradeoffs than women or men who did not perform heavy labor. In general, recurrence rate (36 percent) and extension deficit (28 percent) were the most important attributes in making treatment choices, followed by minor complication rate (13 percent). Patients accepted an increase in recurrent disease of 11 percent if they could receive needle aponeurotomy treatment instead of limited fasciectomy. Conclusions: This study confirms the importance of low recurrence rates and complete contracture corrections, but also emphasizes the significance of low complication rates. Convalescence was not an attribute, which scored high. The preference heterogeneity shows that patient consultations need to be targeted differently, which may result in different treatment decisions, depending on patient characteristics and preferences.

Long-term follow-up of flaps for extensive Dupuytren's and Ledderhose disease in one family.

Dupuytrens and Ledderhose disease can be a cumbersome condition in patients with a severe diathesis with a very early onset. Two brothers are described with a reversed radial forearm flap on both hands and two upper lateral arm flaps on both feet with a long-term follow-up ranging from 14 to 25 years. They had multiple procedures of both hands before the flaps were considered. No recurrence occurred under the flap. In very severe diathesis flaps should be considered in an earlier phase to prevent multiple procedures and early recurrence.

Recurrence of Dupuytren's contracture: A consensus-based definition

Purpose One of the major determinants of Dupyutren disease (DD) treatment efficacy is recurrence of the contracture. Unfortunately, lack of agreement in the literature on what constitutes recurrence makes it nearly impossible to compare the multiple treatments alternatives available today. The aim of this study is to bring an unbiased pool of experts to agree upon what would be considered a recurrence of DD after treatment; and from that consensus establish a much-needed definition for DD recurrence. Methods To reach an expert consensus on the definition of recurrence we used the Delphi method and invited 43 Dupuytren’s research and treatment experts from 10 countries to participate by answering a series of questionnaire rounds. After each round the answers were analyzed and the experts received a feedback report with another questionnaire round to further hone in of the definition. We defined consensus when at least 70% of the experts agreed on a topic. Results Twenty-one experts agreed to participate in this study. After four consensus rounds, we agreed that DD recurrence should be defined as “more than 20 degrees of contracture recurrence in any treated joint at one year post-treatment compared to six weeks post-treatment”. In addition, “recurrence should be reported individually for every treated joint” and afterwards measurements should be repeated and reported yearly. Conclusion This study provides the most comprehensive to date definition of what should be considered recurrence of DD. These standardized criteria should allow us to better evaluate the many treatment alternatives.

Sirolimus-related dyspnoea, airway obstruction and pleural effusion after lung transplantation

Renal insufficiency remains a major side-effect of the treatment with calcineurin inhibitors after organ transplantation and when it appears, switching to a calcineurin inhibitor (CNI)-free regime including sirolimus or everolimus may be a favourable possibility. Sirolimus is a mammalian target of rapamycin (mTOR) inhibitor, which has been reported to exhibit less renal toxicity than calcineurin inhibitors [1,2]. However, sirolimus can have other serious side-effects such as dose-dependent myelosuppression, hypertension, hyperlipidaemia, glucose intolerance, dehiscence of the bronchial anastomosis, interstitial pneumonitis and pulmonary vasculitis [3–6]. In this report, we describe a patient who showed deterioration of lung function, after being switched from tacrolimus to sirolimus. A 47-year-old female, with a smoking history of 20 pack-years, underwent bilateral sequential lung transplantation because of pulmonary emphysema. After transplantation, she was treated with an immunosuppressive regimen including tacrolimus (initial trough levels 15–20 lg/l), mycophenolate and prednisolone combined with induction therapy with daclizumab (1 mg/kg body weight) on days 0 and 10. After discharge, her clinical course was unremarkable without signs of acute or chronic rejection. Her FEV1 increased from 0.40 l (16% predicted, pre-transplantation) to 2.50 l (102% predicted, 9 months post-transplantation). However, a gradual decrease of renal function developed. Two years postoperatively, her serum creatinine had increased to 223 lmol/l and her calculated serum creatinine clearance had dropped to 22 ml/min. At this point, we decided to prescribe sirolimus (initial trough levels 10–15 lg/l) instead of tacrolimus. Her renal function improved significantly, illustrated by a decrease in serum creatinine level to 131 lmol/l (calculated creatinine clearance 40 ml/min) 35 days after the switch. Unfortunately, 21 days after the switch, she presented with shortness of breath. At that time a drop in the FEV1 was seen, with the lowest FEV1 of 53% suggesting bronchiolitis obliterans syndrome (BOS) stage 2. Lung function was obstructive as the Tiffeneau index (FEV1/FVC) decreased from 88% (110% of predicted) to 73% (91% of predicted). Chest X-ray and CT-scan revealed bilateral pleural effusion (see Fig. 1 panels A and D). Furthermore, slight peripheral oedema and proteinuria were observed. We considered five main causes for the decline in FEV1 and appearance of pleural effusion. First, we considered acute rejection because sirolimus is generally regarded as a less powerful immunosuppressive agent than calcineurin inhibitors. Although we could prove neither rejection nor interstitial pneumonitis by biopsy, we decided to give high doses of methylprednisolone (1000 mg/day for three consecutive days). This did not result in significant improvement in lung function and therefore the drop in FEV1 and the pleural effusion were unlikely to be a result of acute rejection. Second, we considered infection. At the time of admission her C-reactive protein (CRP) was 32 mg/l (reference value <9 mg/l). Elevated CRP-levels have been described earlier possibly attributable to sirolimus therapy, although the authors underlined that CRP remains an unspecific marker [6]. She did not have a productive cough and there was no evidence of bronchitis. On the chest X-ray, there were no signs of pneumonia. Her bronchial lavage fluid showed Haemophilus influenzae, but lung function did not improve upon treatment with either amoxycillin or cefuroxime. Therefore, infection was considered an unlikely cause of the drop in FEV1. Unfortunately, no thoracentesis was performed. Third, hypoproteinaemia may be a cause of pleural effusion. However, the proteinuria was not in the nephrotic range (maximal protein loss 4.08 g/l) and lowest serum albumin level was 37 g/l. Fourth, cardiac dysfunction may result in pleural effusion, but in this patient cardiac evaluation was unremarkable. Despite polypragmatic treatment, her FEV1 did not improve and eventually her decline in FEV1, the appearance of bilateral pleural effusion, in combination with the development of proteinuria and peripheral oedema were all regarded as secondary to sirolimus. Therefore, after 63 days of treatment with sirolimus, we decided to reconvert her to tacrolimus. Thirty-five days after this conversion, her FEV1 had increased significantly to 84% (BOS