- Email: [email protected]
Dupuytren's contracture
286
CURRENT
ORTHOPAEDICS-SECOND
OPINION
the nerve could have been anatomically disrupted and in which case there was an absolute indication for amputation. A good femur and a ‘tin leg’ would probably have achieved a much better functional outcome than the present situation in which the patient still has a non-union of the femur for which he will require surgery, bony ankylosis of the knee, infection which could recur in the upper tibia and rather poor quality function in the ankle. If a below knee amputation had been carried out soft tissue cover of the upper tibia could have been obtained. Indeed having decided to preserve the lower leg the decision not to use the medial head of the gastrocnemius, which had been reflected from its origin in order to gain access for the vascular repair, to cover the exposed tibia was another significant error. You will have noted that there was no plastic surgeon present in theatre for the initial treatment. Unless the orthopaedic surgeon has equivalent skills in moving muscles or employing other techniques in which to restore the soft tissue sleeve of the tibia, the plastic surgeon is an essential part of the surgical team. So what then is the profit and loss account. Overall the team did well in preserving the patient’s life. In particular they could have got into severe trouble with myoglobinuria and renal failure. However as regards the leg, a City analyst who achieved this sort of result
Historical review-
References Yamamo Y, Prong Plate Fixation for Displaced Intracapsular Fractures of the Femoral Neck. Bone Joint Surg 1989; 7 1B : 5999601 Caudle J R and Stem P J. Severe Open Fracturesof the Tibia. J Bone Joint Surg 1987; 69A: 801-807 Lange R H, Bach A W, Hansen S Jnr and Johansen K H. Open tibia1 fractures with associated vascular injuries; prognosis for limb salvage. Trauma 1985; 25 : 2033208 Bondurant F J, Cotler H B, Buckle R, Miller Crotchett P, Browner B D. The Medical and Economic Impact of Severely Injured Lower Extremities. J Trauma 1988 ; 28 : 1270-l 273
Addendum
Dupuytren’s Contracture penultimate paragraph of a historical review on Dupuytren’s Contracture (Current Orthopedics 1988 ; 2 : 173-178) referred 2 years ago to the clinical use of allopurinol as an ‘avenue of medical management of Dupuytren’s Contracture’ as possibly ‘another blind alley’. The purpose of this addendum is to report with regret that this clinical trial, albeit limited, seems to have shown no effect on the clinical progress of this condition. Between December 1985 and January 1987 a selected group of 30 patients with Dupuytren’s Contracture were prescribed Zyloprim (allopurinol) 300 mg daily and reviewed personally in January 1988, 1989 and 1990. Apart from 5 patients not operated on, being either too early, too ill, or too old (over 3 years 2 showed very slow progress, 2 remained stationary and 1 died), there were 25 in whom recurrence either had already occurred or in whom a strong family history and personal diathesis made it likely that recurrence could occur within 3 years. A readily admitted personal error in the selection of this ‘at risk’ group may have invalidated the trial from the outset. Of the 25 operated patients, 5 ceased their allopurinol within 1 month but attended for each review. Bilateral progression occurred in 2, with one of these also developing Peyronie’s disease, 2 remained stationary and one declared his palms clearer and ‘definitely improved’. Digital Wolfe grafts had been used in 15 of the 20 patients operated and there was no recurrence in these grafted digits. The
for his fund manager would probably be putting his ‘Yuppie’ BMW car up for sale and looking for another job. As your final reading Second Opinion recommends the article by Bondurant et al.s This addresses the economic effect of these injuries but it also contains some very interesting results. A total of 14 patients who had primary amputations had an average of 1.6 operations and none of them died. The 29 patients who had delayed amputations had an average of 6.9 operations and 6 of the group died. The ISS scores in both groups were similar. Do not forget that surgical zeal in saving legs can not only lose lives but it can destroy them through an excessive period of rehabilitation that quite frequently leaves the patient with a leg whose function is considerably worse than that of a modern below knee amputation.
No further activity occurred in the operated hand in 5 of the 20 patients still on allopurinol, 5 developed extension requiring surgery either in the operated hand or in the opposite hand, and 2of these showed true but mild recurrence in ungrafted operated areas. Extension or slow progression occurred very mildly in one or both hands of the remaining 10 patients, not requiring surgical relief. The small size of this series prevents any firm conclusion but the fate of those operated patients who early ceased allopurinol is interesting to note and compare with the main body of patients. Surprisingly emphatic were 4 operated patients insistent that their hands feel ‘freer and more supple’ since starting allopurinol-despite any clinical evidence of regression, indeed 3 of these showed very mild progression. In such a diverse group where skin grafts had been freely used to prevent recurrence, only a sublime optimist could claim that allopurinol had reduced recurrence from the expected 503; to lOo,O.It is impossible to state whether the patients remaining clear of disease owe this to the drug when 2 of the 5 who stopped the drug also remain clear. But since the possibility exists that allopurinol may just ‘dampen the diathesis’ it is reasonable to consider a bigger and better trial. If the first postoperative six months is the period most likely to show signs of renewed Dupuytren‘s activity, the search for a ‘dampening’ agent to cover this period is surely worth pursuing. John Hueston
CURRENT
ORTHOPAEDICS-SECOND
OPINION
the nerve could have been anatomically disrupted and in which case there was an absolute indication for amputation. A good femur and a ‘tin leg’ would probably have achieved a much better functional outcome than the present situation in which the patient still has a non-union of the femur for which he will require surgery, bony ankylosis of the knee, infection which could recur in the upper tibia and rather poor quality function in the ankle. If a below knee amputation had been carried out soft tissue cover of the upper tibia could have been obtained. Indeed having decided to preserve the lower leg the decision not to use the medial head of the gastrocnemius, which had been reflected from its origin in order to gain access for the vascular repair, to cover the exposed tibia was another significant error. You will have noted that there was no plastic surgeon present in theatre for the initial treatment. Unless the orthopaedic surgeon has equivalent skills in moving muscles or employing other techniques in which to restore the soft tissue sleeve of the tibia, the plastic surgeon is an essential part of the surgical team. So what then is the profit and loss account. Overall the team did well in preserving the patient’s life. In particular they could have got into severe trouble with myoglobinuria and renal failure. However as regards the leg, a City analyst who achieved this sort of result
Historical review-
References Yamamo Y, Prong Plate Fixation for Displaced Intracapsular Fractures of the Femoral Neck. Bone Joint Surg 1989; 7 1B : 5999601 Caudle J R and Stem P J. Severe Open Fracturesof the Tibia. J Bone Joint Surg 1987; 69A: 801-807 Lange R H, Bach A W, Hansen S Jnr and Johansen K H. Open tibia1 fractures with associated vascular injuries; prognosis for limb salvage. Trauma 1985; 25 : 2033208 Bondurant F J, Cotler H B, Buckle R, Miller Crotchett P, Browner B D. The Medical and Economic Impact of Severely Injured Lower Extremities. J Trauma 1988 ; 28 : 1270-l 273
Addendum
Dupuytren’s Contracture penultimate paragraph of a historical review on Dupuytren’s Contracture (Current Orthopedics 1988 ; 2 : 173-178) referred 2 years ago to the clinical use of allopurinol as an ‘avenue of medical management of Dupuytren’s Contracture’ as possibly ‘another blind alley’. The purpose of this addendum is to report with regret that this clinical trial, albeit limited, seems to have shown no effect on the clinical progress of this condition. Between December 1985 and January 1987 a selected group of 30 patients with Dupuytren’s Contracture were prescribed Zyloprim (allopurinol) 300 mg daily and reviewed personally in January 1988, 1989 and 1990. Apart from 5 patients not operated on, being either too early, too ill, or too old (over 3 years 2 showed very slow progress, 2 remained stationary and 1 died), there were 25 in whom recurrence either had already occurred or in whom a strong family history and personal diathesis made it likely that recurrence could occur within 3 years. A readily admitted personal error in the selection of this ‘at risk’ group may have invalidated the trial from the outset. Of the 25 operated patients, 5 ceased their allopurinol within 1 month but attended for each review. Bilateral progression occurred in 2, with one of these also developing Peyronie’s disease, 2 remained stationary and one declared his palms clearer and ‘definitely improved’. Digital Wolfe grafts had been used in 15 of the 20 patients operated and there was no recurrence in these grafted digits. The
for his fund manager would probably be putting his ‘Yuppie’ BMW car up for sale and looking for another job. As your final reading Second Opinion recommends the article by Bondurant et al.s This addresses the economic effect of these injuries but it also contains some very interesting results. A total of 14 patients who had primary amputations had an average of 1.6 operations and none of them died. The 29 patients who had delayed amputations had an average of 6.9 operations and 6 of the group died. The ISS scores in both groups were similar. Do not forget that surgical zeal in saving legs can not only lose lives but it can destroy them through an excessive period of rehabilitation that quite frequently leaves the patient with a leg whose function is considerably worse than that of a modern below knee amputation.
No further activity occurred in the operated hand in 5 of the 20 patients still on allopurinol, 5 developed extension requiring surgery either in the operated hand or in the opposite hand, and 2of these showed true but mild recurrence in ungrafted operated areas. Extension or slow progression occurred very mildly in one or both hands of the remaining 10 patients, not requiring surgical relief. The small size of this series prevents any firm conclusion but the fate of those operated patients who early ceased allopurinol is interesting to note and compare with the main body of patients. Surprisingly emphatic were 4 operated patients insistent that their hands feel ‘freer and more supple’ since starting allopurinol-despite any clinical evidence of regression, indeed 3 of these showed very mild progression. In such a diverse group where skin grafts had been freely used to prevent recurrence, only a sublime optimist could claim that allopurinol had reduced recurrence from the expected 503; to lOo,O.It is impossible to state whether the patients remaining clear of disease owe this to the drug when 2 of the 5 who stopped the drug also remain clear. But since the possibility exists that allopurinol may just ‘dampen the diathesis’ it is reasonable to consider a bigger and better trial. If the first postoperative six months is the period most likely to show signs of renewed Dupuytren‘s activity, the search for a ‘dampening’ agent to cover this period is surely worth pursuing. John Hueston