what I think is an excellent topic. I apologize, my moderating slides were replaced with something other than mine, so for the interest of time, I'd like to introduce our faculty, and you'll get a chance to meet all of them, but Dr. Eric Wagner, who's my partner from Atlanta, Georgia, he's gonna be talking a little bit about cost considerations and outcomes. Probably someone that doesn't need any introduction, but Dr. Marco Rizzo is gonna talk to us a little bit about needle aponeurotomy and how to successfully perform this minimally invasive procedure. Dr. Maureen O'Shanese is gonna talk to us about collagenase injections and some technical tips and considerations. Dr. Neil Chen from his hometown is gonna talk a little bit about open fasciectomy and technical pearls and when is skin grafting necessary. I'm gonna talk a little bit about something unique that you may or may not have seen, considering using a continuous torque device for PIP contractures plus open surgery. And then last but certainly not least, Dr. Ryan Calfee's gonna talk a little bit about the Dupuytren contracture and how you analyze outcomes and assess a proper treatment algorithm. So without further ado, I'm gonna ask Dr. Eric Wagner to come talk to us, and hopefully this is the right file. Thank you. Thanks, Mike. So I'm just gonna briefly sort of set the session and then hopefully you'll learn a lot more from our really accomplished colleagues. My name's Eric Wagner, I'm at Emory University. Disclosures are not relevant to this presentation. I'm gonna give a brief history of just Dupuytrens, talk about some outcomes. You're gonna hear probably a lot more about that and then maybe go into a little bit of considerations, at least as you kind of choose between all these different options about what's right for your patient. So it's kind of interesting to look at the history. It dates back to even before BC, there's sort of talks about fingers being bent down. This article on the history in Africa is also kind of interesting looking at the history of it, not just in Northern Europe, as a lot of times we talk about, but it's really rooted in Africa as well. There's kind of stories about finger contractures in Scandinavia with the Viking invasions and even some famous paintings with the fingers being bent down as they're holding swords or not able to hold swords. You look at the in sort of modern or I guess older medical history from 1614 when Plater first bringing it out, the curse of McCribben's and their inability to play the bagpipe, even into Klein actually being one of the first ones that really started kind of talking about it. And then obviously Dupuytren was the one who really popularized this idea. This is kind of a note from Plater talking about contraction of the fingers in this stone mason, very well-known stone mason and not really knowing what to do. Family called the McCribben's that they were sort of this preeminent bagpipe school that they had actually dissolved as many of the members were unable to play the bagpipe because of the bent little fingers. Obviously you've heard of the hand of Benediction and this gesture, and there's some thought maybe that this had a remnant to Dupuytren's with some famous murals like this one that I took outside Madrid. And then you get into some more of the actual medical literature where Klein talked about this contracture, palmar contracture. He noticed both in patients as well as on some cadaveric dissections. And then Dupuytren, the chief surgeon, general surgeon in Paris. And in one of his famous lecture series, buried right after talking about doing amputations of lower extremities, he just briefly mentioned how he's treated all these people with bent fingers and not exactly sure what to do with them over a period of time. Went and visited Ashley Cooper and that's sort of when this really took off about this idea of this problem with these bent fingers. So now you kind of get a setup. There's many different treatments for this. You're gonna hear about all of them or most of them and hopefully get a sense of what to do with all of them, whether it's the fasciectomy. So this is sort of a long rooted history. The needle aponeurotomy, once again, very good large series on this, looking at both recurrence rates and some of the complications associated with it. Collagenase, something that was published actually in the New England Journal for one of the original studies on it and multiple other sort of subsequent follow-up studies looking at its efficacy and some implications of it. So some considerations and I credit my partner, Mike Gottschalk, for a lot of this. When you're listening to these talks, hopefully you can sort of think about a variety of considerations, what your patient's goals are, what their age is. Some patients don't mind if there is recurrence. If they can do something in the office or something relatively minimally invasive, they don't mind if it might recur. Others are gonna mind. If cost is a factor where you work, what are the costs and ultimately kind of what is your patient's priorities? Because ultimately the patient comes first and everybody has different ideas and priorities when it comes to their fingers being bent. Just kind of some food for thought with regards to these commonly debated topics. It's kind of interesting to look at some of the data on it. It's really showing there's not big differences with regards to contracture release. They both do it pretty well. And in general are able to get straight MCPs with relatively little difference in patient-by-outcome measures. You look at QALYs and in general, it's actually very cost-effective in a lot of respects, especially compared to some of the other stuff that our colleagues do. Some of the ones do have pain. Collagenase has been shown to be painful. I think Maureen's gonna talk a little bit about how to avoid that. And then obviously some of the revisions and if you are gonna do an open revision, how difficult it is. And I was lucky enough to be a part of this amazing group led by Mark Rizzo looking at a huge number of interventions over a long-term follow-up period or a long study period. And we were able to sort of elicit out some of the, some or confirm what the literature already talked about is the recurrence in the collagenase and the NELAP. NELAP was a little bit, recurred a little bit later than the collagenase, it seemed like. But both recurred at much higher rates than the open. And when you looked at costs, really NELAP in the office seemed to be a very cost-effective approach to this, assuming that the patient's okay with the recurrences. So it's kind of an interesting take on this, focusing really on a variety of things. One thing to be noted, and Mark, I'm sure, will point this out, that the collagenase group admittedly did have more PIP contracture than the other group. So it's a little bit of a biased study and it should be taken into account when you're looking into this because PIP contractures is one of the more difficult considerations. So ultimately, hopefully you'll get a sense of looking at a patient's both pathology from their MCP and PIP, realizing that the PIP is higher, is more difficult and a little bit more challenging to deal with. Thinking about collagenase and NELAP and some of the risks with it, some of the recurrence risks, but at the same time some of the nice things about the minimally invasive approach. And then obviously from an open standpoint, lowest recurrence, but potentially a little bit longer recovery, and obviously a much more invasive type of approach. So I'll leave you with this quote. I think this is something that maybe you'll think about more so than the patients, especially the ones that don't mind the recurrence. And I'd like to thank you for your time and thank you for the opportunity to be a part of this amazing panel. Thank you. Thanks, Eric. Our next speaker is gonna be Dr. Marco Rizzo, who's gonna talk to us a little bit about needle aponeurotomy. Oh, thanks, Mike. I appreciate the invitation to participate and share and learn. Nice job, Eric. So my charge is to speak a bit about needle aponeurotomy. And you know, as I look back in 20 years now, I sort of feel privileged to be in the throes of a revolution in how we manage Dupuytren's. And some of it's just luck and some of it is just an interest, but it's really nice to be able to offer your patients different options as long as you keep them informed and keep them abreast of what's going on and your concerns. I have no relevant conflicts. And if we start with a case, just right-hand dominant count and who's 62 years old, and we'll come back to that afterwards, but this is a pretty classic pre-tendonist type cord. It's fairly thin, which I think is good. It primarily involves the MP joint. And if I had to think about a cord that would be sort of the ideal cord for needle aponeurotomy, you could argue it's probably an ideal cord for collagenase too, you know. Although, I tend to think the collagenase cords, if they're fatter, you know, might benefit more from collagenase, whereas these thinner cords tend to lend themselves more to the needling. And typically we'll see patients in two groups. You'll see patients who have nodules and they're understandably concerned for what's going on. They have, they're not sure what it is and they sort of want to get some information. On rare occasions, they'll complain of it being painful. But the lion's share of the patients, at least I see, are they know what they have. They've had it for years and now it's at a tripping point. And they're at a point where they're frustrated with their functionality. Typically, thank goodness, most of these are pain-free. But when you think about indications, because a lot of patients will ask me, well, Doc, when should I think about treating? And I usually say, well, you can individualize this. Sometimes you'll see a farmer who's down like this and they're like, look, Doc, I've adapted to my deformity. But if you can't lay your palm flat on the table, I think for the treatment of office-based procedures, it's important to have a good sense of the cord and its pathway. There's other indications that have been outlined, MCP contractures greater than 30, PIP. Some argue any PIP contracture is an indication for surgery. And folks who have severe enough deformities where they're abducted and they can't do appropriate hygiene or they're flexed down so much that they can't do hygiene. It's important, in my opinion, to really temporize expectations, especially when you're talking about these office-based procedures. Recurrence is an expectation. And if the PIP joint's involved, it's really a lot more complicated given the unforgiving nature of that joint and the recurrence is more predictable and it tends to be more frustrating to manage for patients. But tubergenes comes in a lot of flavors. There's different types. So individualizing how you treat these as you go through your practice, I think will help you offer your patients different options. And some of them are more daunting to treat in the office. Sometimes patients are pretty fixed on what they wanna do and it challenges you as a caregiver to sort of push your own envelope sometimes. But keep in mind that not all of these need to be treated the same way. Of course, there's surgeon factors, your comfort level, your experience in training, what resources you have available, cost is not always an issue, and your ability to contend with any complications or recurrence. And so when we think about, oh boy, I don't know if my videos are gonna show. They don't. Oh, this is the video. This guy, I hope you can hear this. This is a patient who had surgery on his left hand and he presents to me with a problem on his right hand. And by all measures, this was about eight years ago and he's done great. And by our expectation, yeah, he has a little bit of a DIP lag, but I don't think you can hear that. He is terrified of having another surgery. He has no interest in surgery, despite having a successful surgical outcome. He has no interest in it. So he was talking me into collagenase, which I did for him and he didn't like it. Didn't work out so well. I ended up doing a needle later. So my story starts with this fellow in the lower right hand corner and it was Dr. Eden who emboldened me to sort of look into this. I went and visited him, spent a day. He did about eight cases and I came back feeling pretty good about trying needle aponeurotomies. And I'll talk you through the technique real quick. This is a patient who has a similar cord, a little bit thicker than the one I showed initially. And I typically will mark out evenly spaced intervals along the cord and then the anesthesia. I use Lido with Epi now and I tried to buffer it, but it doesn't seem to help much. And you inject just the skin, just enough to get the skin anesthetized. And then I use a 19 gauge needle in the palm, 19 or 22 in the finger. And I hold that extension force. You see how my left thumb there is pushing on that? That's important to keep the cord taut. And you can do a sweeping or a sewing machine type motion to sort of break the cord. Sometimes I alternate between sweeping and sewing machine. If I feel like I'm sweeping too long, I'll try to needle with the sewing machine motion. Careful, as they start to get more extended, you run more risk of irritating the tendon. And you wanna be cognizant of that, not just the nerve, but worry about the tendon. I've seen people report that the tendon has been severed. So in the finger, it gets a little bit more stressful. And you wanna elicit, if they feel electrical shock sensations or any numbness or tingling ensues, and then you sort of pull on the finger and try to break the cord. And ultimately, it's a process. It takes a while to sort of get a feel. Sometimes you'll feel a tauter part as you start to release. And ultimately, once you feel like you have a satisfactory release and they're completely straight, you can just put some Band-Aids on and they're good to go. Typically, postoperatively, I'll give them a nighttime splint and an LMB if the PIP's contracted. LMB, 30 minutes a spell, three to five times a day. The nighttime splint's a hand-based extension splint. And I ask for three months, but I feel like I'm happy if I get one or whatever they can give me. And there's a couple other cases that illustrate. And some of them are just patient-driven. Some of them, like this next case I'm gonna show you is a patient who had previous surgery. As I talked about already, the ideal cord. Some of these patients have pretty severe contractures. And you can see that you don't always get full improvement. Prosper Benheim talks about never leaving the office without full improvement, but I think it's better just to gradually get the PIP extended. And this is another patient who's from Florida, had numerous previous surgeries. And in the end, you get improvement, the cord's released, and then I lean on the splints to sort of help me. There's been comparison studies, and I won't belabor them, but one is looking at needle aponeurotomy versus fasciectomy. And the results were fairly intuitive. You know, the fasciectomy did a better job long-term, but the needle aponeurotomy had less complications. The recurrence rate in needle ap was 65%. Recurrence is always a moving target, so defining recurrence is important when you're thinking about these studies and having a good sense of what recurrence really means. But they thought needle ap had good short-term results and may be better for sicker, older patients with lesser deformities. There's been a couple studies looking at, looking at needle aponeurotomy versus clostridia and collagenase, and basically, it's a wash. They both are equally effective, they both have equal recurrence patterns. And they both have equal sort of complications. So, and there's been a few of them that highlight this now. So, in conclusion, I would say that I think it's an important treatment, having needle aponeurotomy. I actually am a big fan. The ideal cords are thin, central and in the palm, and patient satisfaction's good, but you have to set expectations. Tell them to think of it like car maintenance every 3,000 miles, you're gonna come back and get the tires rotated and oil changed. The nice thing about recurrence in this setting is that it's no different than when they come the first time. Whereas if they recur after surgery, it's much more complicated. And make it clear to them that that's important for them to know. There are risks, of course. I've had some neuropraxias, but thank God I've never had to reoperate on anyone. And anyone who's complained of numbness has only said it was well worth the trade-off with the mild numbness that they have. And again, expect recidivism in these patients. And this is that patient after a needle aponeurotomy and a basal thumb injection. Thank you. I think I always learn a lot when I hear Dr. Rizzo speak, so hopefully you guys enjoyed that as well. Next I'm gonna ask Dr. Ashensay to talk to us a little bit about collagenase, which may be the counter-argument to what we just saw. Hi. Good evening, everybody. I'm excited to talk to you guys about Collagenase, a couple of technical tips and considerations. So Collagenase is gaining popularity and familiarity. They have a really nice campaign that I'm sure many of you had your patients come in and tell you that they saw the football player on TV and want to know what he had done to him. So that's been kind of a neat campaign to see that come to fruition. As I was preparing this talk, I found this really nice article by Dr. Hens and Dr. Curtin that went through some of the interesting history behind Collagenase. I thought I would highlight really briefly. So Collagenase has been used in lab research to cleave bonds and things. And then in the 60s, in France, they started playing around with an acidic Collagenase to try to treat Dupuytren's. And it was X-rays thermodynamics with a mixture of several different types of Collagenase to try to weaken the cord and then break it. And that allows for manipulation of the contracture. Then McLennan in 1953 started working with the Clostridium Pistoliticum, which is what we have now. And more of the commercially available Collagenases. And this involves the MMP enzymes to create the extracellular matrix. And these two enzymes in the current formulation work synergistically to try to break down the Dupuytren's tissue. If there are any residents in the room, we've got an OITE coming up soon. So I thought I would put in here that the Collagenase has no effect on type 4 collagen, which is a very testable question. And the type 4 collagen is highly present in the critical neurovascular structures. So when the Collagenase is selectively not targeting those things that we're trying to avoid damaging, such as the nerve and the artery, this is the, you know, benefit of having the Collagenase now. Trials began in the early 2000s, went through different phases, leading to the New England Journal of Medicine publication in 2009, which then made it more commercially available across the United States. This has been followed up by rigorous studies to evaluate for the efficacy, side effects, complications, and the cordless data that is coming out. The most recent one was from the 2015 data that came out just showing, you know, publishing all of the adverse events and any complications and the rates of recurrence. They did find 47 percent recurrence rate. And we just heard a little bit from Dr. Rizzo about, you know, similar recurrence with the neolaparal neurotomy. One thing I don't think he touched on too much is that the PIP is much more commonly to recur than the MCP. It's just a tougher joint, as we know, from all types of surgery. But it's tougher to manage a duputence contraction while infecting the PIP joint. But important to know about with using Collagenase therapy is that there is almost a 100 percent chance of an adverse effect. So you want your patients to report edema, swelling, pain, and contusion, and that comes from one of, someone that I trained with that said that there was at one point a kind of a bad batch and they didn't have any reaction. If you have no swelling, you think probably your medicine actually wasn't an active medication. So I tell my patients, you know, 100 percent have swelling, pain, you want that. That means that the medicine is working. So you have to set expectations with your patients. Low rate, but important to know about the major complications, which would be tendon rupture, injury, or anaphylaxis. So when should we use it? MCP joint contracture is greater than 30 degrees. PIP arguably of any degrees. The most important thing for Collagenase as well as for the needle-openerotomy is you have to have a palpable cord. You can't treat, you know, a lump or a bump that's causing the contracture. You need something palpable that you can use to inject to target for your manipulation. It can be used for both primary and recurrent disease. So just because somebody has had a prior fasciectomy does not preclude them from having Collagenase. There is a max of two vials per injection per patient at one time. That's FDA regulations. So you could do one, you could do the MCP and PIP in one finger or two neighboring MCP joints, but two vials at a time is the most that you can do. So when should you avoid it in addition to not having a palpable cord? If you have severe recurrent contracture, either after surgery or from other procedure with poor skin, that person's not going to be a great candidate for Collagenase therapy. You do have to, in the United States, get insurance pre-authorization because the medication is very expensive. But it's much more streamlined in the past. And as a matter of fact, the VA now allows it in all of their patients. So if the VA approves it, you know that it's worthwhile. So I think the process has gotten more streamlined, but if you are in private practice, it is a consideration to know that you've got the sort of personnel and bandwidth to go through the process of the prior authorization. You do have to have provider registration. You have to go through a formal training course to be able to give this medication for sort of the FDA requirements, but also just for the safety of your patients. You really should know how to use this medication and be safe about it before you use it. So how do you perform it? So it's an office-based injection procedure. The medication is refrigerated, so you need to make sure that your office would be able to have the equipment for refrigeration of medication. And you mix a sterile diluent with the reconstituting liquid to treat the powder form into the active medication. And there are different concentrations per joint. The manufacturer has really detailed instructions and sort of the measurements within the packet. I have sort of a laminated thing in my office that I can refer to it and make sure you get the exact measurements because it is down to the .01 milliliter. You need to be very careful with the medication. Using a small TB syringe can help you get those really precise measurements. You need to inject the diluent into the powder slowly. Try to get into the sides of the vial. You need to do swirled, not shaken. A little bit shaken, not stirred, but a little bit of difference. You don't want to, you know, aggressively agitate the medication. You want to just slowly dissolve it. So to numb or not to numb, it is not recommended officially to numb your patients for the collagenase injection. You want them to be able to participate. You need to make sure that you're not near a vital structure. And so you do have to tell your patients that the injection hurts. This isn't a great procedure for somebody that has sort of pain catastrophizing behaviors or can't tolerate an injection. And I do think potentially the injection can hurt more the second time a patient sees it. Just sort of anecdotally, I think maybe the body sort of reacts to the foreign body that is. And so their second round of getting a collagenase, they do, you know, tend to say that it hurts a little bit more. So just making sure your patients are aware. So when you go to do the injection, you do want to break it up into three aliquots. You need to pick, you know, confirm the cord, make sure that you've got your right joints that you're doing. And then you're going to inject into three aliquots. It's important to try to really stabilize your hand because you need to inject the medication into the cord. That takes a lot of force. If you can just freely inject, you are not on the cord, you're not doing it right. So you really need to stabilize yourself. A lot of pressure to be able to inject right into the cord. Similar to the neoplatonomy, extending the digit helps bring the cord all the way up to the skin and brings the flexor tendons away from you. And sometimes it's helpful to have your assistant with you also to distract the patient because they want to talk to you. And you need to focus on dividing 3.3 milliliters into three segments in a high pressure, high injection. So I like to bring my nurse in with me to distract the patient. So where should you inject? Important thing is trying to get the best bang for your buck, so finding a place of the cord where you feel like it's the maximum contraction where your injection is going to sort of cleave it in one place. And a lot of times this is where the cord is closest to the skin as well. You want to stay away from callosities or flexion creases because this can increase your rate of tears. So what about the PIP joint? You can do collagenous in the PIP joint, but it is a little bit trickier. So you want to try to avoid injecting within 4 millimeters of the palmodigital crease because that increases your risk of getting the flexor tendon or the neurovascular structures. The small finger does have the highest risk of adverse events with any of the procedures, mostly because the flexor tendons of the small finger are smaller and more variable anatomy. And important to note is that a PIP joint contracture with a huge nodule that fills up the entire proximal phalanx is not a good candidate for collagenase, and that's something you see pretty frequently. So just be sure that you're picking a palpable cord, a non-nodule that's causing the contracture. I kind of went through this. So here is just sort of a diagram showing, you know, using your hand to really stabilize the injection, pulling the finger into extension to bring it away from you, and dividing that into 3 doses. If they do and you can appreciate a Y-shaped cord, the most important, the best bang for your buck spot is to be right at the confluence of the Y. So post-injection, set expectations. I have a handout that the company can provide, but give this to the patients. Tell them about the swelling, the pain, and of course, about the more rare complications. Afterwards, you want them to ice, elevate, and take potentially some Tylenol or Advil as well. Manipulation anywhere from 1 to 10 days post-injection. Check that they didn't self-rupture already. At this point, you can do a local block because the manipulation can hurt, so you definitely want to numb them up. And then once you have a good block, you do a slow extension. You want to make sure to take the pressure off of the flexors by bending the wrist and the digits and working from proximal to distal. So if you've got two cords that you did, if you did the MCP and the PIP, work on breaking your MCP cord first. Because if you go for your PIP, you won't have the force to create the MCP contracture release. So go from proximal to distal. Go slow. Don't jerk. And the side-to-side motion can be helpful too to help break up the cord. You don't want to do more than three attempts. Sometimes it doesn't work because you don't want to cause any undue harm. Skin tears happen pretty frequently. They heal amazingly well. So just do local wound care. I usually see them back in a week just to kind of see them frequently, make sure things are going well. If somebody has a really high MCP contracture, they're at higher risk of getting those skin tears. Post-inmubilation, I do like splinting in therapy. The interosseic and iatrinsics get really stuck down from having a dupuytens contracture. So I do really enjoy sending them to my therapist, and I think they get great results. This is one that my therapist, Dr. Greg Pitts, created. He calls it the Aquaman. And this is really to help stretch out those intrinsics, which can be really helpful. So if it didn't work, what can you do? You can reinject. You can't do more than three injections at monthly interval. So you can wait a month and try it again. But something I like to add is a needle aponeurotomy. So you've already got the patient numb. Maybe you got a partial release. You didn't get a full release. I say, do you want to try the needle aponeurotomy? And a lot of times it's sort of combining the best of both worlds. You get the, hopefully at least, partial breakage or good release with your collagenase, but then adding in the needle aponeurotomy can be really successful. And we heard about Dr. Rizzo's, you know, tips about that, being a little bit safer in the MCP. Surgery after collagenase, there's no conclusive evidence of increased risk. Anecdotally, I haven't really seen much of a difference in soft tissue planes. That is one thing that people say is that if you do the collagenase, will it make surgery more difficult? And I don't think that it is, but open to debate as well. And I'll just leave with a closing from Dr. Hintz's paper. I thought it was quite interesting when he wrote about collagenase versus surgery. And he said, surgeons do not spend years learning how to plunge a needle up and down like a sewing machine or inject a few tenths of a milliliter of liquid just under the skin. Few hand surgeons experience the same degree of satisfaction after performing either of these procedures as they experience at the end of a successful surgery. But keep in mind that although surgeons enjoy performing surgery, for the patient, surgery is misery to one degree or another. So I will skip my solutions, but thank you very much for your time. All right, that was great. Okay, next we have Dr. Neil Chen, who's going to talk to us about the open technique. Thanks, Mike, for having me. Thanks, Eric. Well, we'll talk about open partial fasciectomy. And I'm going to go over a couple things. And this might bring you nightmares from your hand fellowship, but we'll start with anatomy. I think the important thing to remember is there's a couple different conceptualizations of these cords. And the place we'll start with is the McFarland conceptualization of this. And you've seen this before. But the idea is that you have this central cord and the central band, and it's turning into this central cord. The central cord's coming down, and it's really staying midline. And this is commonly attributed to your MCP flexion contracture. So take a look at that picture and think about it, and we'll go back to it again. But the central cord, when you think about this cord, you want to think about it in three dimensions. You want to think about where is it going as it's passing down the finger. Well, it has three different directions. So one, it goes up into the skin. These are these grapow vertical fibers. And then you have this, again, this is a digital palmar crease. And then you're looking here, and then you have this second expansion. It's going kind of towards the flexor sheath, and you get that big thickening on the flexor sheath. And then you have these fibers going down towards the flexor sheath and extensor hood. So remember that it's a three-dimensional problem, not a two-dimensional problem. And then this is the cord that everybody kind of remembers is this spiral cord. And the spiral cord is coming down and around, and then you can see the neurovascular bundle. The neurovascular bundle is up here, and then the spiral cord kind of grabs it and starts pulling it in. And this schematic here in the books, it always looks perfect, right? And it doesn't look like it's pulling it into the midline. But I've seen it pull it into the midline quite frequently. And then you want to remember there's this natatory cord that comes off here. And so this is the classic description. And when you're dealing with the small finger, you have to remember that there's this contributions from these ulnar aponeuroses and the palmar aponeuroses is contributing. And you have this abductor digiti minimi cord. So when you have this contracture of the small finger, remember that sometimes this cord comes down and you'll see it coming and getting very intimate with that ADM and that you have to get that cord out of there. And Dr. Jupiter used to would just cut out a big chunk of that tendon. So that's that guy right there. All right, so that's the classic conceptualization. Eaton has a slightly different schematic to look at this. And I think this is really valuable in looking at and keeping in mind these two different ways of thinking about it. So you have these central palmar and central digital cords. Okay, so looking right here, this is the central palmar cord, central digital cord. And, you know, this seems pretty similar to what we were talking about before. But he's also talks about these other various cords coming in the web space, so distal first web space, proximal first web space cords. And then on the ulnar side, you have these natatory and hypothenar cords, okay. So natatory between the fingers because the web, like everybody has this Aquaman theme. But the web's going between the fingers. And then you have this hypothenar contribution. Okay, when we get into the fingers, then you start looking at these central palmar cords, the lateral digital cord, you can see that here kind of at the, around the PIP joint or the DIP joint. A retrovascular cord going behind the bundle. You oftentimes don't hear about these in these classic descriptions. As well as the spiral cord, which is the more classic one. So some technique pearls. So this is a patient of mine. She had a family history dupatran. She had a small finger PIP joint contracture. And, you know, we thought she had a spiral, a pretty substantial spiral cord with no prior intervention. And so when we look at this, we start thinking about, well, McFarland, does she have a spiral cord coming up and around? Or is this a central digital cord? Does she have an ADM contribution? We're kind of anticipating and guessing what we're going to see here. And so with incisions, there's a whole bunch of different incisions you can use for this. You can use a Brunner. You can use a straight longitudinal incision followed by Z-plasties. I tend to use the longitudinal followed by Z-plasties. And then what I'll do is I'll bring it longitudinally down. If I have the ring and small finger, I'll come down and then meet at this flexion crease in the palm. And then kind of take a 90-degree turn and then go in the midline to kind of get both sides of it. So I'm just going to walk through a dissection just kind of walking through some of the things that I do stepwise. I don't always do it, but this gives a general outline. So I make this central midline incision down that central cord. And I'm kind of lifting the skin off because there's those contributions that are coming up to the skin and sometimes it's hard to tell where everything is. But you can oftentimes start to develop a layer and then you'll start to see the fat. And then I take my Stevens and I find the arch or the neurovascular bundle on either side. For mild to moderate contractures, I don't separate proximally yet. If I can keep the finger reasonably straight and I can just hold it with the lead hand or whatever instrument I'm going to use, I dissect everything because I like having that tension to work with and to get down that finger. Because once you cut it proximally, then everything's kind of has lost its tension. It's much harder to dissect. In more severe contractures, what I'll do is I'll release it proximally or release it in the middle. And even though I'm giving up that tension, it allows me to get the finger straighter so I can dissect. And then if I've cut it proximally, I'll put an Alice clamp to control that fragment or element just so my assistant can give me a little counter tension if I need it. So again, we talked about this before. This is where this picture comes in play. And then again, there was a study a long time ago showing that if you had a spiral cord, you had a higher likelihood of having the neurovascular bundle being displaced and getting injured. I think this is pretty reasonable and this is similar with my observations. And then after I start tracing the cord distally, I'm thinking about all the different anatomic patterns and I'm just freeing everything off and making sure I know where the bundle is, going back to the band that I'm working on and going back and forth. Once I've excised my bands and I'm remembering sometimes the band goes to the extensor and I'm being careful not to injure the flexor sheath so I don't get bow stringing. Or I'm remembering how the, on these different schematics, where is this cord going to go? Is it going to dive laterally? I'm thinking about these pathways. So I'm thinking, I'm also thinking about how am I going to get coverage. So what I do after I've made this longitudinal incision, I'll do Z-plasty. So I'll make a cut here, a cut here. And the tricky part is remembering how to make all these cuts. And basically what I'll do is I'll say, well, here's the flexion crease. And I'll make a Z around this flexion crease. And I'm ignoring everything distally. But what I'll remember is, okay, I make a Z and I make another Z, I make another Z. And so these are three Zs in a row, okay? And then I can basically just take one flap, bring it up, one flap, bring it down. And that's the way I remember it. Because I think if you try to not think about it as three separate Zs, then you can get confused. So more problematic cases, sometimes you can get dorsal involvement. And that's that retrovascular cord. You have to remember these atypical anatomies. And you can get these boutonniere deformities or swan neck deformities. When you see those secondary deformities, start thinking that your cord is involving an atypical pathway. This is a quote from Dr. Jupiter to me. And basically, regardless of what the textbooks state, vascular involvement can extend along both sides of the PIP joint to the dorsal surface. And you'll sometimes read like that's impossible. And so I think it's possible. Bow stringing, really be careful. Don't take out your pulleys. Sometimes you get into them by accident, but just don't take out a lot of them if you recognize it. This is a problem that's very hard to fix. Especially in the setting of Dupuytren's. Okay. PIP joint contracture. I think Mike's going to talk about this a bit. He's going to talk about the digit widget. But some of the things that you can do are cut the capsule, cut the collateral ligaments. And then basically, if the joint kind of pops into hyperextension, you want to check your lateral cords. Make sure you don't have anything funny back there. Sometimes you'll release the PIP joint and the finger's super unstable. And in that situation, it's okay to pin it in extension and then pull the pin after a couple weeks just to try to let it heal a little bit so you don't have this, you've unleashed the secondary problem. And finally, with skin grafting, don't be afraid to skin graft. I do it fairly liberally. I used to be afraid to do it. There's a good historical precedent for it. And basically, Houston had initially described skin grafting being a fire break because he would say there's a lack of recurrence under the graft. I try to do my skin grafts here oftentimes where this palmar flexion crease is and I'm putting the skin graft here. But sometimes, if you don't have enough skin, sometimes you're doing it on the finger. I try to avoid the flexion creases. That's not an absolute rule. Okay. So basically, I'll use some glove paper, use a template, lift the skin off the form or off the antecubital fossa, and then basically perforate this with a knife so then I can have a little bit of drainage. I put it on as a full thickness graft and trim it and then I put this bolster on. I'll secure it with some silks. And you take a big mineral oil-soaked cotton, you put some Xeroform and then wrap it like a present and then you stick it in these after, because you've already put all these silks as a parachute and then you just drop that little package in there and tie it down. I take the bolster off about a week after surgery and start moving the other adjacent joints and then basically the bolster comes off in week one and generally heals pretty well. Here's an example of what a skin graft looks like. It looks kind of funny as it's healing sometimes and then it gets this more mature. This is skin graft hiding over here. It gets more mature, but it does contract a bit. So thanks very much and I'll pass on the mic. That was great. Thanks, Dr. Chen. All right, hopefully this works this time with the correct PowerPoint presentation. Okay, great. There we go. So I'm going to talk a little bit about either recurrent disease or PIP contractures, which can be pretty substantial issues as it relates to getting a sustainable result. So one of the things that I've come across after seeing multiple recurrent patients come through my office, either of my own or from someone out in the community, is having recurrent contractures of the PIP is common. And for patients that have extreme contractures of both the MCP and PIP, I was hoping there's got to be something easier than me trying to release this every time and doing a large open release and saying, oh, geez, you know, it's recurred already and within a few weeks because of a flare or for whatever reason. So these are my disclosures. Luckily, none of them are relevant to this talk. So what exactly are we talking about? So the term that you may see in the literature is actually called a continuous extension technique, also known as a AG digit widget. I have no involvement with the company except for the fact that I think that device works reasonably in certain scenarios. It is fairly simple. You're essentially putting a small external fixator attached to the middle phalanx with a large boom arm and rubber bands that creates a generalized torque over a period of time. And it's not like it's, oh, one rubber band, you leave it on, it takes a little bit more than that. So you have to have a patient that has some understanding that they're going to be changing out rubber bands over a period of several weeks. It's similar if any of you have ever put on a multi-planar X-Fix. If you get someone that doesn't know how to turn the knobs in the right way, you theoretically could end up with the deformity looking exactly worse than it started. So what are my indications? The reason I put this up there is that you can see this patient has substantial contractures and I'll argue hand X-Rays are not the greatest when you're looking for Dupuytren's. Ideally you want finger X-Rays that are looking at the PIP joint to see if there's arthritis or some sort of bony deformity. But the indications, someone that's had a prior release, they've had collagenase, they could be a needle apneurotomy, could be an open, someone that has a predominantly PIP contracture, less so of an MCP. So I will put on here, and I should have a star next to it, a boutonniere deformity with a plan to reconstruct it down the road. And I say that because if you do a boutonniere deformity and you do this technique and don't correct the boutonniere, you're going to be staring right back at the boutonniere within a certain time frame after this. So I should really star that just that you're aware. And then honestly a primary significant contracture where it may be 90 degrees at the MCP and 90 degrees at the PIP, this device will make your life 1,000 times easier in the operating room. When would I not do it? So central slip attrition without plan to reconstruct, arthritis or bony deformity. If you're pulling through someone that's got an arthritic PIP joint, you probably should be looking at an arthrodesis or an arthroplasty, depending on your skill set. Any sort of prior fracture or prior bony deformity, someone that you don't think is going to be compliant, potentially neurologic compromise, and then obviously someone that's got a fusion, theoretically I would hope you're not going to consider doing this on. So what do you need in the OR? It's actually not a lot. You really just need a pin driver, some sort of mini C-arm, a hand table, and really just a small sterile area. You don't actually have to have a full sterile OR. You can use a Mayo stand. We're lucky enough, we use our stretcher and we literally bring the patient in, put a little arm board on, put a little couple towels or sometimes we'll just use a drape. But it's a pretty quick setup. So here's a technique. I always feel like the videos will help this, so I obviously have been examining them here. This person's got a 90-90 contracture. You can do these under straight local, believe it or not. So here I'm just injecting lidocaine and marcaine combined. You can use epi if you choose for this. I don't typically use epinephrine for my revisions or for my primary open releases. This is a positioning jig, and you'll see here I'm just using a portable mini C-arm. I'm going to look here and kind of make sure that the jig is centered over the PIP, and that I'm going to be distal to the joint itself. Here, simple. It's got a stepwise progression. It'll tell you step one, step two, step three, and you kind of just follow the steps and various off-the-plastic piece that comes with it. And here you can say, okay, look, you're bicortical. You probably shouldn't be as bicortical as I am on the second one there. And then here you swap out the distal pin first. You'll put a little screw in device here, and then you'll, you know, as I talked about, you can check it once or twice depending on how often you do it, but you can get it deep far enough that it's stable, put this in, and it takes a little bit of force to get these to go, so sometimes you're like, oh, I'm far enough, or you're typically not. Ideally you want a double-action bolt cutter, which you'll see I swap out for for this one. Otherwise, I make the fellows do it so I look better after the fact. And then you take the jig off, and you'll see there's this little device, what we call the pin clamp. Typically you just want it far enough off the skin that it's not going to irritate, and you attach it here, and then, as I said, here's the double-action pin cutter, which is much easier. And then you kind of repeat the steps for the next digit, and then here you'll see us applying the actual device over the hand. So it's got two sizes, it's got a large and a small, and this is pretty easy to put on. And then occasionally, the reason there's co-band is I'll add a little either needle appenrodomy or something if I need to get the MCP out of some extension just to help. Interestingly enough, if the MCPs hyperextend, there is a strap that you can use to prevent the MCPs hyperextending in this case. And then here we're just putting on the rubber bands. And interestingly enough, I try and keep always an extra set of rubber bands and an extra set of a key. These rubber bands work great if any of you use dynamic fixators for PIP joints. So for whenever when I do a Suzuki frame, I use these rubber bands as well, and they've got different tensioning. So this is kind of what it looks like immediately in the recovery room. And once you're done, obviously at around six weeks, they look like this. So this is a different patient. Typically the device will stay on for about six weeks or until the contracture is corrected. I don't put them on any prophylactic antibiotics or anything like that. I'll have them clean around the area with hydrogen peroxide every day. And then the key to this is technically a second procedure. So people always ask me, can I get away with just doing this? And the most common question I get about that is actually for people that have a pseudo boutonniere, no dupatrans, and say, look, I can get your finger perfectly straight without having to do a check brain release or any of these other fancy procedures. And I will tell you, it's typically not enough, right? So if you just do the device and there's not a second procedure, and I'll show you the outcomes of one, it will recur. And that is unfortunately a typical process. Even though the skin and the tissue is pliable, it's got this memory to it. So I will do the second procedure around six weeks afterwards. And typically I will say, as everyone knows, hand therapy, hand therapy, hand therapy, hand therapy. So that just means that you want them in a splint at night just to help make sure, because obviously resting it with the hand flexed is more comfortable. There's data to suggest that it may or may not work, but for me, it seems to be pretty helpful. And then after six weeks, I just say, look, you can go to nighttime splinting. So this is someone that had 90 degree contractures of their PIP joints. I'm here now doing a second stage. And this was actually recurrent disease from prior open procedures. Whenever you're doing recurrent dupatrans, I highly, highly, highly recommend you Doppler the bundles. I cannot tell you the amount of times that you let down the tourniquet or you're doing something, you go, oh, there's a white finger. And then you sit there pouring warm water, warm water, sometimes Fentolamine or whatever it is, and you're just praying that they're going to pink up. And so I always tell everybody, there's a digital Allen's test. If you've ever done that, it's the same thing as a normal Allen's. You crush both of the digital arteries at the finger, you let off one and see if it pinks up, vice versa. But I will say having a Doppler in the operating room if you do recurrent dupatrans is a must. So outcomes, and Dr. Kalfi is going to talk about this, and he's an expert in patient report outcomes and reviewing the literature, and he's saying no, but he is, as far as a deputy editor. And the truth is, how do you measure the outcomes for this, right? Is it, what do you define as recurrence? How much of an angle is recurrent? At what time point is there a recurrent? I used to joke about reading aspiration of ganglion cysts and saying, okay, you aspirate the cyst, it doesn't come back. Yeah, at one month that may be the case, but four or five years later they almost all recur. So time to recurrence is important to what degree is the contracture and what were the other available alternatives, right? So I can't tell you the number of people that come see me that the surgeons in the community or someone said, look, you need an amputation. And I say, well, look, if you're willing to try a two-stage procedure, I'll do this, and then I'll do a revision open. And they come back and they're like, I'm surprised I was able to keep my finger. So it's something out there. There's two papers that are reasonable. Keep in mind, one of them is the inventor of the device, so you always have to be cautious about that. But ideally what they showed was that continuous extension plus a secondary release was better than just open fasciectomy and check brain release alone. And that data is good. So I'll leave you with this. These are some patient outcomes. Some of them are good. So this lady had a 90-degree contracture of her PIP. She's three weeks out. This is her second release. Her motion's pretty reasonable. It's not perfect, but she can get her hand flat and she's happy. And then this is a guy who refused the second procedure. And you can see he's got a boutonniere deformity, but he's super happy because his hand is no longer completely contracted and he can do something. So sometimes it's patient expectations and they'll tell you what they want. And sometimes, as always, as a physician, you just have to listen. But thanks for attending. And last but not least, I'm going to have Dr. Kalfi come up and talk to us a little bit about outcomes. Well, thank you guys. I'm honored to be here. I was sitting here in half terror waiting to be the last speaker, hoping I wasn't going to present something totally different than what everybody else just said, but I feel a lot better now. So something about outcomes and treatment algorithms. So here's my disclosure. Here's the thing. I hope you're not disappointed. I was asked to assess the treatment algorithms. I don't know the right treatment algorithm and I don't think anyone does. So I thought I'd give very quickly, which I do think agrees with just about everybody that's talked, things I do by the textbook. Basically if you don't have a contracture, just observe it. Don't do things to the patient. Any type PIP, I kind of follow that. If it's bothering them, I'll offer something. MP joints for actual open surgery, like Dr. Chen talked about, 30 degrees seems fair to me to take the risk. Things I do that may not be textbook, MP joints, really anything that feels tight or bothersome, if they want a needle release, I'll offer it because I just think it's so minimal and they're very happy. Needle releases to release PIP contractures I think are fine, as long as you can feel the cord. I really like to make sure that you can feel it sub-Q. It's right there. There's not a bunch of tissue in the middle. Sorry, Maria. I don't do collagenase. I just don't. I like needle releases. Is that even after my talk? Maybe after the talk, but I just don't have any experience with it. And then also when you examine the patient in the office, I really like having the residents and fellows flex the MP and see what the PIP does. Those people that when you flex the MP, the PIP gets better, those people do great. They're not the bad PIP actors. Those are the people I feel real confident about. And then led up by the last talk by Mike, I really love this device. I was going to try to stay away from the name, but dynamic fixator. It's a digit widget. I have no ties to the company. It's a brilliant device. When I started practice, I would have these anxiety provoking, nausea provoking surgeries where you're trying to get the artery and the nerve out. No more. Anything bad like this, I put that on. This lady actually, they usually take six weeks for me. This lady at three weeks was already straight, and I did her open release just as Michael talked about just this Monday. Makes it way easier. You have enough skin. You have enough vision. Everything works. Okay. Talking about outcomes now. I do get asked to talk a lot about patient reported outcomes, and I'm usually talking about this little alphabet soup of all these outcome measures that we use that are patient reported. The problem is, is I don't think these work well for Dupuytren's. Why is that? Well, here we've got a disease now that doesn't cause any pain really. It doesn't disrupt sleep. It doesn't mess up your feeling. It doesn't change your grip strength. So therefore, what bothers people, just that little bit of lost extension in a finger doesn't show up on a lot of those things. So I think we have to look elsewhere for outcomes. But if we think about it simply, right, everyone in here knows if we're treating Dupuytren's, what are we just trying to get? We're trying to restore finger extension without causing numbness or a loss of flexion, and then we're trying to maintain it. That seems pretty simple. Restoring extension, if you look at a lot of papers, usually success is that getting full extension or within five degrees of it. Okay, but I think very much like the other talks you've heard, I've got a lot of patients that are happy. If I can just get the MP out, they're willing to tolerate 40 degrees at a PIP joint. It's not in their palm. They can grab something. They can put their hand in the pocket. So I think in clinic, success is different than research success and studies. Also, maintaining extension, as was mentioned, we have a lot of studies focused on, was it a needle? Was it collagenase? Was it an open release? Did it involve skin grafting? Probably what matters more than what we did to treat it are all these other factors about the patient. You know, which disease? Was it small fingers? Did they have strong family history? Did they also have it in their feet? That's going to dictate the ultimate outcome probably, as opposed to how I broke the cord. And I'll just tell you that there is no consensus definition of recurrence, and actually in a lot of studies, do we know if it's recurrence? Is it really new disease? I've certainly seen new cords form on the other side of fingers that we've taken out, you know, previous cords on one side. So here's a quick example from one of the systematic reviews recently published. This is just looking at three randomized trials, right? Randomized trials are like the most controlled thing that we have. None of these three agree on the primary outcome. They're all different. Secondary outcomes overlap a little bit, and the recurrence definition, one didn't report any recurrence, one didn't define it, and one said greater than 30 degrees. So you can't compare the literature that's out there currently in terms of outcomes. There are some outcome measures. This one's not patient-reported, but there are some that are specific to Dupuytren's. So if you're going to be doing research on Dupuytren's, you may want to think about these. This was a classic, the Tubiana score basically gives a rating to how much contracture each finger has. You add it up, you get a score from 0 to 23. And then there's a couple of patient-reported ones that are specific to Dupuytren's. There's the Southampton Dupuytren scoring scheme. Basically if you look at the tasks they're asking and asking people, you know, how hard is it to do this, they're trying to get tasks that relate to Dupuytren's, you know, things like shaking hands. And this has been shown to correlate with amount of Dupuytren contracture. Similar, there's the URAM. I'm not going to pronounce the rest of the words because I will butcher it. But look, you know, the things they're asking about are shaking hands, washing your face. I have so many patients, they hate washing their face because the finger keeps hitting them in the eye, clapping your hands. So these are probably more specific and are going to pick up more of the both impairment as well as the response to treatment than are other general ones that I usually use. And then most recently in one of the hand therapy journals just a couple of years ago, this is a scale that's getting developed. It's the Dupuytren impact on function. And the second part is a hospital in Montreal. Basically judging multiple aspects of function and Dupuytren's impact on it, this may be a little bit more complicated. It also incorporates a bit more of a patient-directed give three functions that are really impaired but are important to you. They're still developing scoring. But just want you to know it's out there. So my summary for my talk is just for current Dupuytren's research, we really would be benefited if people in this audience are doing research on this topic. If you guys could come up with some standardized definitions of success and recurrence, some consensus outcome measure that probably includes one of those patient outcome measures would be great. And some defined time intervals and duration of intervals that we would need to say, hey, this should be published. And then ultimately, guys, Dupuytren's treatment, I think the big step forward is not gonna be how we break up the cord. It's gonna be how do you change the biology or the genetics in the way that rheumatoid arthritis has been changed. And if you have expertise in that area or are interested, contact Charles Eden because he's spent a lifetime doing it. If you want to read more and get in the weeds of this, those are great reviews that really get into patient-reported outcomes of Dupuytren's. Thanks, guys. I'm gonna ask Dr. Kalfi to come sit up here or stand up here is fine. And then Dr. Chen, if you'll come up as well just for panel discussion. You can stand if you want or someone can stand. Neil, I'll ask you to stand. So just to, we have a few minutes left, probably about 10 or so, just a poll of the audience. How many of you do needle aponeurotomy? So a wide number. What about collagenase? It's also a good number. And I'm assuming you all still do open as well? Very good. How many of you are aware of the DigitWidget? So a pretty large number, actually. Okay, good. I guess one of my questions, which maybe the panelists can opine on, is what do you do for prevention of a Dupuytren's flare and how often do you feel like you see it? Go ahead. I'd be on an island somewhere if I could prevent a Dupuytren's flare. You mean like the recurrent, do you? No, so I don't know how many of you have seen it, but you've done a release on them and it hasn't been that long of a time. It could be open, it could even be needle, and then all of a sudden you look at their hand two weeks later and it's not, it's almost like it's like post-traumatic, right? So if you've ever seen it after distal radius, carpal tunnel, that they've got this palmar fibromatosis, things of that nature, that they get this really abundance like, hey, there's a signaling pathway that really flared it up. So I don't even want to admit this in the microphone, I guess I haven't seen it. I mean, I've read about it, haven't seen it, and I'll watch my patient from Monday who's going to come back in three weeks and look like that. Yeah, I haven't seen it that much either. I do know the nodularity after distal radius fracture, definitely have seen that. And probably what I would say is we're, we've always been fairly minimalist with regards to this and our, like our, my senior attendings and what I've learned. So that's kind of my experience. Let me ask you another question then. For people that you're revising Dupuytren's on, and that could be an open revision fasciectomy, is there anything that you consider doing or giving that you think will, you know, technically prevent recurrence? I don't think I have anything that will prevent recurrence on that. I mean, I think I do like you do, and I offer a staged approach more frequently because a lot of times they come in with such severe recurrent contraction, and I say, let's do something different and really stretch it out and try to get everything. But I'm not confident that I have anything that can eliminate recurrence. So I may be a little bit biased, well, we have a, I may be a little bit biased based off of some recent publications that I've had, but I've started giving recurrent patients steroids, interestingly enough, granted I do worry a little bit about infection, but with the hopes that maybe it will reduce some inflammatory response post-surgical to it. But I know that we had a comment from the audience too. Well, in a few patients where they've had really frequent recurrence or bad recurrence, sometimes a whole thick of skin cramping, dermatofasciitis. That's great. How many, sorry, another comment? to have a smaller amount of, you know, the higher concentration, a smaller amount too. And just for a smaller joint, a smaller anatomy at the PIP versus the MCP. So the concentrations increase though you said? The... Yes, the concentration increases because you do less of the diluent into the... so the concentration increases and the dose decreases. So... Another question right in the back. I was actually about to ask that. just to rephrase in case everyone didn't hear that the questioner was asking about radiation therapy. It's very popular in Europe. There was just a randomized controlled trial of all the sort of literature that's published and it hasn't been shown to have any effect and so the official recommendation is that it probably should not be considered. I know that most kind of American radiation oncologists don't necessarily know that the risk of radiation outweighs some of the benefit. But I still talk to my patients about it and I think a lot of Dupuytren's, especially a younger patient that has a family history, comes down to education. They come to you because they want to, we don't have a solution, we can't cure Dupuytren's, but if you can give them all the information and I'll give them the paper, I'll say here's what they do in Europe, if you want to meet with a radiation oncologist please have the meeting. Nobody's taken me up on it, but I think it does help somebody when they have a disease that doesn't have an answer to just give them all the tools in our toolkit too. So that's a great question. We have a radiation oncologist that's been interested in doing this and she's done a number of patients. We haven't really followed them, but she says they've had good results so far. So, but I think it's pretty early. Yeah, so typically I'll use some sort of graft and then I'll just pull the lateral bands as much as I can, tie them together and then do like a figure of eight with almost a palmaris type weave for a boutonniere. Do you do that at the same time? No, so what I'll do is they have to get passive motion back first and you have to have a very, very compliant patient. So theoretically they're getting a stage procedure where we get them straight first, then they're still a little bit stiff. I wish I could say like look, you put the device on, you take it off and day one they're moving it, but that's not the case. So essentially I'll have them go straight into what they call an LMB splint, which I don't know if you guys know what it looks like, but it's got a little spring and it kind of keeps the PIP joint open, but still allows you to bend and I'll have them do that with therapy and then I'll normally wait a few weeks after and then do a boutonniere recon. Yeah, the question was using ultrasound guidance for collagenase, or I suppose for needle opanoratomy as well. And I don't think Dr. Rizzo touched on that, but he does, at least he used to use the ultrasound to identify the neurovascular structure. So I don't use it, but if you've got it at your disposal, I think it's a great addition. It helps treat you and make sure that you're kind of in the right place. Short answer is yes. So while I say primary procedures, the last one I did, which was probably a couple months ago, was for a recurrence. Interestingly enough, after a trigger finger release and a small Dupuytren's release, right, and theoretically it came back and there was a lot of skin adherence. And I told her, I said, look, she was flexed down at the MPs. The only way you're going to do that is, as they mentioned before, excise the skin with it, take out the diseased tissue, and then do a Palmer skin graft, which works well. I don't typically do it as a formal primary, not to say that you can't. Sometimes you're staring at a lot of open tissue, but, you know, the open McCache technique, which is where for the residents or fellows, which is often a test question, is you used to just leave the palm open, right, and the fat and everything else would come in. And I do that still. So sometimes, as long as there's no tendon or vascular bundle exposed, I don't mind leaving tissue exposed and it slowly heals in and it looks pretty good, so. I think that if, as you're doing it, and I don't do a lot of them, but as you're doing it, if you, if you've given anesthesia and then I check the finger, I say, can you feel this periodically? If someone's like, hasn't had a zinger, but they're not feeling it anymore, I'll stop because I don't, I don't know, I don't have any feedback to know if I've cut the, I'm injuring the nerve at that point. I don't want to say that I'm too cavalier. I guess I can't remember the last one that I've stopped for that. I do keep asking for the zinger and I don't think I'm doing a whole lot of spots in the finger. I'm usually maybe doing like one over a PIP and then several in the palm. Zingers will make me back away from an area, but usually that little bit of lidocaine in the dermis, infrequent that they say, oh, you know, I'm totally numb out there, but I agree with checking. So unfortunately, Dr. Rizzo is not here, so I was going to ask him, I don't do as many locations on the finger as, as he showed in his technique video and Marco is an incredible person. So if you ever have the opportunity to watch him do it, it's, it's pretty neat. I normally will only do two or three spots and I actually, it sounds weird, I actually like the skin tearing mainly because I like the fact that there typically there's a fair amount of skin adherence to the cord and some of these patients, and I find that if you get the skin to tear there, I feel as though that there are corrections a little bit better. And maybe that's why they don't, I don't feel like I need five or six. I just do two or three large spots, get them to open and then I leave it open. Yeah, this is totally low level evidence. I'll personally, I think in the beginning I'd get those easy ones. You do one spot and it opens up. I don't think those do as well. So I'd usually, I'd now would at least go to a second or third spot and get a little, you'll usually can feel it give a little bit more. The skin, I don't know if I've noticed as much of a difference, but I'm kind of more like you. I usually am doing kind of two to four spots, not six or seven up the finger. Why do you say the one spot? I don't know. I feel like I do some, you release it and you feel a nice zing and the finger kind of comes neutral and now that I'll usually still go to one or two others, you usually still feel like, oh wait, the finger just went even more. It just, it feels like you get a little extra, there's always extra little bands or something. I actually, I have to, I used to just do, I wouldn't say just one, but what happened is I would do such an aggressive one on the first one that it would make it hard to get the second tension. So now what I do is I actually use a larger gauge needle on the skin just to get it started and then I'll do two or three spots, identify them before and numb them and then I'll come back with a smaller needle so I can feel it and then kind of slowly do it and then manipulate afterwards. Yeah. Okay. So what are your indications to releasing a PIP capsule for the trichromatic microlase? Like when do you say the station? So I do it infrequently. I do it when I go to the OR maybe for that PIP joint and I've taken out the dubatrons and it's really like, wow, that's not looking very different. I mean, I could make up a number, like it's gotta be 30 degrees or something, but if it started at 70 and it's 30, I might just like leave it alone. In my limited experience, I would say that when I do that PIP release, those people come back more swollen, more sore to rehab. They just have a tougher time. So in my mind, um, in training and fellowship, Peter Stern used to say it was the birdie moment where once you got the dupatrons out, he's like, oh, look over there. And then he'd like pull really hard and just kind of bluntly get it. I think that works really well. But if I have to open the flexor sheath, release that, they don't do as well in my hands. So I'm only doing it if it feels like it's a really frustrating experience in terms of what I think the outcome will be if I leave it alone. And two, with a good, you know, a good therapist afterwards and good patient compliance, you can get more extension once you get the dupatrons cord out of the way. With any of the procedures, needle op, neurotomy, collagenase, or surgery, you can still get more, you know, with splinting afterwards. I would say sometimes when you, when you're starting off with these really bad contractors, like they're at like 90 degrees, and you've cut out all this stuff, and it's, you still, as you're stretching it out, and you kind of hit this very, very firm end point, and you just can't get any further, and you've excised everything you think you've gotten, that's when it's reasonable to do that. But it's, I know it's very nebulous. So I used to do it all the time, and that was probably close to 10 years ago when I first started. But now I do it 0% of the time, and I just do a heavy manipulation, relatively speaking, and then I normally splint them. Typically now I will say, if there's anything greater than 60 degrees to make my life easier, I just say, look, we're going to put a little device on you, and I'm going to see you in six weeks. It just, I don't have to worry about skin graft. I don't have to worry about neuropraxy of the nerve. And the results so far have been reasonable, is what I would tell you. We haven't written up our series. It's coming. It just takes some time. The editors always just want too much. Oh, jeez. Well, now we have some good Dupuytren-specific outcomes. But if you're having it high over, like, 10 or 15 or 20 degrees at the PIP, just push on it, stretch it, send it to therapy later. Don't go opening more. I wanted to thank everybody for attending. It is 6.15, and true to word, we stayed on time. And thank you all again. Thank you.

Dupuytren's contracture

treatment options

needle aponeurotomy

collagenase injections

open surgery

ultrasound guidance

steroids

recurrence prevention

patient education

outcome measures

treatment success