Between 2003 and 2012, I had the privilege of being able to do 800 to a thousand percutaneous haponeurotomies for Dupuytren's contracture in my practice. And during that time, I tried to develop and refine and kind of standardize an approach. And I'd just like to share some of that with you. I have nothing to disclose. The entire process of percutaneous fasciotomy for Dupuytren's can be accomplished in a single office visit from meeting the patient for the first time, doing the procedure, and instructing them on post-op care, which is essentially all self-care. It uses intradermal anesthetic. The bandages can be taken off the same day. You do one hand one day, the next hand the next day, and you have to be nice to your hands for about a week. And splinting is an area for which we still are lacking data. I'm going to show you a video with a voiceover that is a typical patient with typical kinds of issues that you run into doing this type of approach, and hopefully examples of how to address these. Enjoy. This 75-year-old man with a low diathesis score had a fasciectomy on the other side last year, ring finger MCP45, PIP65. Central cord in the palm, two lateral digital cords, and a natatory cord. The needle approach can be directly over the cord with a single portal or tangentially offset as dual portals. The ideal anesthetic is purely intradermal, avoiding a conduction block. This block works instantly. Measure a plane superficial to the cord and then divide it by repeatedly perforating into it or by sweeping or scoring over the surface of it with the bevel of the needle. Out in the digit, you can use dual portals to stay more superficial to both sweep and perforate. You plan portals by feel. You'd like to identify a cord beneath supple skin, which feels hard when you pull on the finger but soft when you let it relax. I mark all of my portals with a marking pen ahead of time, but you can alternatively mark them as you go. Avoid portals and creases where the skin is really tethered down and stay distal to Kaplan's line to avoid pillar pain type tenderness in the palm. Here are the cords and here's the chart. Document everything with diagrams and photos. Here I'm using a dental floss passer to see how deep the dimple is just distal to the natatory cord. In this patient, it shows that you can paint some Betadine on and it'll mark the dipstick so that you can avoid putting portals where you might transect a dimple. You can use a Doppler to evaluate a potential spiral cord pre-op. Listen where you don't expect to hear a pulse, like here. But if you don't hear a pulse, that may mean that the cord is blocking it. A spiral cord should be suspected when there's a soft, fleshy mass over the cord somewhere between the distal palmar crease and the PIP flexion crease. Here I'm going to listen directly over the cord where I wouldn't expect to hear a pulse. Make your best fist. Straighten them out all the way again. Turn sideways. Lift your fingers all the way back. And then, there we go. And then just let your hand relax all the way. And you feel me touch you here on your fingertip? And you feel me touch you over here? So there's this up in here and that I'm going to go up here for. A retrograde approach addresses the fact that PIP cords often extend distal to the flexion crease. Check to make sure you're not in the tendon and then release the cord. Here's a different patient who's just demonstrating that maneuver. I'm going to give you a buzz. Pinch right here. One, two, three. Sorry about that. A little sting. There we go. Am I getting you with that? Does that feel sharp? Septal fibers at the base of a crease can pull the sensitive dermis into the line of fire. Fix this by injecting the base of the crease. Yeah. Oh. That one did. Now, is that right up your fingertip? Or... No, just in that spot. Okay. Let me give you a little bit more anesthetic. Okay. Just in that crease. Yeah, with that fold there, it might be that that's... Pinch right here. One, two, three. That's the stinker. Boop. Here are the three basic maneuvers. Clear a plane in front of the cord. Then perforate into the cord. Make sure you're not near a nerve vascular bundle. And then you can sweep progressively through the cord. There you go. You feel me touch out here on your fingertip? Yes. Good. All right. So that was good. Okay. Thanks. One, two, three. Sorry. Here I'm using three portals to release the two lateral cords. This effectively amounts to two double portals that share one middle portal. Stay superficial. Repeatedly check nerve and tendon status. And connect the dots under the skin. It's common to have to go back and forth from one side to the other and back again before the entire level is released transversely. Here I'm giving the joint a pull, but it's really not releasing. So I've got to go back and feel what areas still have tensionable cords. You work until the joint releases or you can't feel any more tensionable cord. Check your nerve status before each injection and also at regular intervals during the procedure. Here at the next proximal level I'm using dual portals to release this fairly broad central cord at the base of the finger. At this point it usually hurts to pull on the PIP joint, so some intra-articular anesthetic is helpful. You can inject right through the vulvar plate distal or proximal to the flexion crease depending on the finger geometry. Put a little anesthetic into this knuckle as well. This will burn on the back of your knuckle. There. That will make it much more comfortable. Now here I've gone proximal and I have again paired dual portals. A little bit different this time because I have a central cord going up to the finger and a natatory cord over to the middle finger. Sweeping and poking. Longitudinal sweep for the natatory cord which is transverse. Once you've released proximal to the PIP joint there are four maneuvers to help manipulate it. Flex the MP for an isolated pull on the PIP and then in each direction dorsal lateral as if to stretch the accessory collaterals. This is because the cords are palmar lateral. Then a composite stretch of everything. So here an isolated PIP stretch and then a dorsal radial stretch and then a dorsal ulnar stretch for those ulnar palmar cords. And then stretching in a composite direction you can see that the skin blanches and that means that the cord has been fully released beneath the skin at that level. Once you get into the palm, sweeping is the go-to move. Here's another little fiber release there and blanching on stretch. Cords are much more two-dimensional and planar in the proximal palm compared to the digits where they're more of a cylindrical geometry. Final stretches are of the PIP but also of composite of all the fingers to break up the confluence of the central palm cords. There's a 1-2-3. That's good. A 1-2-3. That was great. No problem. And this one I'll be gentle on. 1-2-3. At the end of the procedure I inject a few milligrams of Kenalog at each portal level. Available evidence suggests that this ought to improve results of percutaneous fasciotomy. Great. Make your best fist. Straighten them all the way out again. Great. And then turn sideways and lift your fingers back as far back as you can. Great. And palm back up. And that's good. Final measurements. A little over 90 degrees of composite improvement. If you do these, it's critical that you document these. That's the only way that we can continue to improve our understanding of Dupuytren's. And that's it. I wish you luck if you're interested in doing this. It's a nice technique to have in your armamentarium. And until we come up with a better medical treatment for Dupuytren's, this is the kind of thing that it's nice to be able to offer patients. I've got forms and videos at docsna.com and if you're interested in the Dupuytren Foundation, which you should be, go to dupuytrens.org. Thank you very much.

video

percutaneous haponeurotomy

Dupuytren's contracture

intradermal anesthesia

Kenalog injections