David J. Slutsky


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3475 Torrance Blvd., Ste F
Torrance, CA 90503


Appointments: 310.792.1809
Fax: 310.792.1811

Office hours: M-F, 9am – 5 pm

Worker’s compensation, Medicare and most insurance plans accepted.

In September 2008, we will be moving to a beautiful new 4,400 sq ft, state of the art dedicated hand center located at 2808 Columbia Ave in Torrance, CA., which will feature onsite nerve conduction studies, occupational hand therapy and digital x-ray.
 


PROCEDURES

DUPUYTREN'S

Dupuytren’s contracture is a condition where normal connective (i.e. fascial) tissue in the palm becomes infiltrated with scar tissue in a very characteristic manner, resulting in progressive finger flexion contractures. The condition is named after Baron Guillaume Dupuytren who gave his famous lecture describing a palmar fasciotomy for the treatment of a subcutaneous contracture in 1831, even though the disorder was described by others as early as 1777.

Anatomy
The palmar aponeurosis is a triangular facial layer in the palm which is just underneath the skin and subcutaneous fat , and covers the nerves, arteries and tendons. It splits into Y-shaped extensions pretendinous bands, that travel from the transverse crease at the end of the palm (distal palmar crease) to the base of the finger, and then splits into 3 layers which merge with the fascial tissue of the fingers and the webspace.

Pathophysiology
The 2 cells responsible for Dupuytren's disease are the fibroblast which is the normal cell which lays down collagen or scar tissue, and the myofibroblast which appears identical to a fibroblast but has contractile properties. McFarlane implicated the myofibroblast as the cell responsible for contracture formation.
The diseased tissue of Dupuytren's presents as nodules and cords, each of which has a distinctive appearance under the microscope and which attach to the skin. Electron microscopic studies have shown that contracture of the myofibroblasts in the nodules is responsible for the finger flexion contracture. Nodules pull on cords that have extended past adjacent joints. This contracture across joints produces the pathologic flexion contractures of Dupuytren's disease. The cords may insert centrally along the midline of the finger (central cord) or they may spiral around the side of the finger, intertwining with and displacing the nerves and arteries (spiral cord).

Causes
Many factors have been considered to predispose an individual to Dupuytren's disease. Alcohol consumption, smoking, diabetes, epilepsy, genetics, and manual labor all have been implicated as potential etiologic factors, however, there is little conclusive evidence regarding these risk factors.
The exact role that alcoholism plays in the development of Dupuytren's contracture is not clear. There are no studies that show the quantity of alcohol that leads to Dupuytren's disease or what the cumulative affect is of alcoholism on Dupuytren's. There has long been an association between epilepsy and Dupuytren's disease which may be related to the antiepileptic medication. There has been little conclusive evidence to support manual labor as the cause for most cases of Dupuytren's disease. There is a higher incidence of Dupuytren’s disease in people of Northern European descent. It is significantly less common in Mediterranean populations and in Asia. Inheritance appears to follow an autosomal-dominant model with variable penetrance.

Diagnosis
The earliest sign of Dupuytren's disease is a nodule or incomplete cord that appears in the palm. After the nodule development other changes including thickening and pitting of the skin and scarring of the subcutaneous fat.

The formation of cords occurs as the nodules regress, although they may both be present simultaneously. The cords may remain in the palm or progress into the fingers. The ring finger is the most commonly affected digit followed in order of frequency by the small finger, thumb, middle finger, and index finger. Pretendinous or central cords form in the palm and cause flexion contractures of the metacarpophalangeal joints (the first joint at the base of the finger), as they mature and contract. Cords extending into the fingers cause proximal interphalangeal joint contractures (the middle finger joint).

Dupuytren's disease may affect other tissues through out the body. The knuckle overlying the proximal interphalangeal joint may show subcutaneous fibrosis termed knuckle pads or Garrods nodes. Prominent subcutaneous cords may develop on the the soles of the feet (Lederhose disease) or cause a deviation and contracture of the subcutaneous fascia of the penis (Peyronie’s disease).
The term Dupuytren's diathesis refers to a patient with a more rapid progression of the disease, who usually present at a younger age and have involvement of both hands as well as other sites of involvement.

Nonsurgical Treatment
A variety of nonsurgical treatments have been attempted including radiation therapy, dimethyl sulfoxide, physical therapy, and steroid injections but unfortunatley they have not been found to provide a long-term solution. Recently, direct cord injection with a collagenase, which is an enzyme that dissolves collagen, followed by manual rupture of the cord has been studied by investigators in New York and Stanford with encouraging results. This treatment is still awaiting FDA clearance in the US and may hold some future promise in selected patients.

Surgical treatment
Paradoxically, surgical treatment may lead to a faster progression and quick return of the disease hence as a general rule Dupuytren’s is observed until there is a significant joint contracture. A surgical release is considered when the patient is no longer able to get their hand flat on a table. The typical indications include a metacarpophalangeal joint contracture of greater than 30° and proximal interphalangeal (PIP) joint contractures of any degree due to its resistance to full extension after Dupuytren's excision. Most PIP contractures will improve by only about 50% after surgery hence the more contracted the finger joints prior to surgery, the more residual contracture can be expected.

There are a variety of surgical techniques available. The goal of surgery is to remove the diseased fascia while protecting the nerves and arteries (i.e. neurovascular bundles) that run along each side of the finger and thumb. (link to Dupuytrens video) These structures are most at risk with advanced contractures and may limit the amount of correction since they are prone to stretch injuries with long standing finger contractures. A partial fasciectomy in which the Dupuytrens tissue that has formed cords or nodules is excised. Normal-appearing fascia is left behind. Recurrent contractures may require skin grafting, since the skin is part of the disease process. Dupuytrens rarely recurs under a skin graft, but the disadvantages of skin grafting including hyperpigmentation and a loss of sensation over the graft. Postoperative therapy is important to achieve the maximum correction of the joint contracture but to regain finger flexion as well. Static progressive splinting with the use of an external fixator such as the Agee Digit widget over a period of 6-8 weeks can markedly improve a resistant contracture.