| What to do when NA doesn't work |
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06/25/2013 23:02
Randy_H 
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06/25/2013 23:02
Randy_H
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Re: What to do when NA doesn't work
You don't read too much in the literature about correction expectations but I believe for a PIP it's the same for OS and NA, about 50% improvement on average. It's way better with a MCP. I've seen an MCP put back to near perfect. Some claim better results with the PIP, but I was told by my CHS at pre-op to expect 50%. That's what I got.
Most US CHS wait until the PIP is at about 30 degrees before OS. That results in a average of 15 degree outcome. NA, however, can be done earlier depending on the cords. My OS treated PIP is at about 15 degrees and my NA treated PIP is at about half that at 8-10d. So I'm a big fan of NA....early and often (if necessary).
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06/25/2013 23:12
cokiwi 
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06/25/2013 23:12
cokiwi
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Re: What to do when NA doesn't work
The surgeon I talked to today told me not to expect my pinky PIP to straighten completely. I would be ok with a 30' bend to it rather than the 90' I have now. At least I can still type, put on gloves, etc with 30'. My left hand has about that currently. He said that not only has the skin contracted, but the veins and nerves will have also, and they may not allow the finger to straighten completely.
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06/26/2013 02:06
callie
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06/26/2013 02:06
callie
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Re: What to do when NA doesn't work
Be optimistic. I have seen several surgeries resulting in zero contracture like mine. My little finger was over 90 degrees (in 18 months) before surgery. It has remained zero degrees contracture for over 11 years.
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06/26/2013 06:01
wach  Administrator
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06/26/2013 06:01
wach Administrator
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Re: What to do when NA doesn't work
Hi Randy,
you might have a look at
http://www.dupuytren-online.info/dupuytr...techniques.html
Skin grafting (here called dermofasciectomy) sems to provide good results for specific types of Dupuytren's (("diffuse Duputren's", i.e. without prominent cords). It might not be better in general, i.e. for the "normal" type of Dupuytren's but the evidence is still not very good. Other techniques, like implantation of cellulose firebreaks, seem to improve results equally well and might be aesthetically better.
Wolfgang
Randy_H:
...
However, Wikipedia is reporting twice the recurrence rate with NA Vs OS. That means that normal OS without skin graft will only be 50% better than NA. Considering all the issues with OS (read the above Wiki article) that 50% doesn't seem worth it unless you add a graft. Even then there is no guarantee. I don't know what the recurrence rate is with a graft. Does anyone here know the stats?
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06/26/2013 06:09
wach Administrator
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06/26/2013 06:09
wach Administrator
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Re: What to do when NA doesn't work
Wearing a night splint after NA for 6 months and then on and off might help maintaining the result of NA or at least postponing contracture. There is no proven evidence for that but several patients have reported it and it's also my impression after a Xiaflex injection. Did you wear any night splint after your NA?
Wolfgang
cokiwi:
I just got back from a consultation with a hand surgeon who recommended surgery plus a skin graft to prevent recurrence. About 18 months ago I had N/A done on my little finger of my right hand as my PIP was at 90'. It had contracted to 90' very quickly. The N/A got the finger almost straight but within 3 months it was contracting again. A month or two ago I tried N/A again on the same finger, but the Dr. was unable to straighten the finger, telling me that the fibrous tissue was too deep to get to without damaging nerves etc. He recommended surgery. I had traveled to Arizona for the N/A as no one did it here in Colorado, but I will have the surgery done in CO.
The surgeon I saw today is not a fan of N/A but I don't have that option on this finger any more anyway. I will go ahead with the surgery, and probably the skin graft too as it seems to help prevent recurrence. He wanted to remove nodules in the palm as well, but I am opting just to remove the tissue in the finger itself as the MP joint is not involved. I will have my other little finger done next spring. It is at about 35' right now. I will continue to travel to get N/A as my other fingers contract because I believe in keeping it simple. Surgery should be a last resort, which it is on my pinkies.
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06/26/2013 12:30
cokiwi
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06/26/2013 12:30
cokiwi
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Re: What to do when NA doesn't work
I wore a splint day and night as long as I could. The finger still contracted anyway. It was a spring loaded splint and it would sometimes come off at night, so I wore it during the day too. But after a while the finger was so bent that it wouldn't stay on.
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06/26/2013 12:56
wach Administrator
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06/26/2013 12:56
wach Administrator
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Re: What to do when NA doesn't work
That's too bad really! How long did you actually wear your splint? BTW, I am not sure whether a spring loaded splint is better than a passive splint. The spring will constantly pull on the finger, might cause pain and forming of new cords. Wearing a splint day and night is not optimal because then your joints will probably get pretty stiff. To me a passive night splint seems to be a good compromise.
When you had NA, did the cord snap or was it just elongated? Did you achieve full or partial correction with your NA? Another possibility is that you had more than one cord and only one was broken. I had a PIP contracture on my littel finger and that seemed to be caused by two cords.
Wolfgang
cokiwi:
I wore a splint day and night as long as I could. The finger still contracted anyway. It was a spring loaded splint and it would sometimes come off at night, so I wore it during the day too. But after a while the finger was so bent that it wouldn't stay on.
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06/26/2013 13:52
cokiwi
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06/26/2013 13:52
cokiwi
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Re: What to do when NA doesn't work
I wore the splint the doc gave me to wear. I lost it after a couple of months and ordered a new one online. While I was waiting for it to arrive I even used two popsicle sticks and a rubber band, that is how dedicated to wearing it I was! By that time I knew it was contracting again and was trying to keep it from happening.
The doc worked on cords on both sides of the finger but I never did hear a pop, and I wondered at the time if they broke or only were partially cut. The finger was not quite straight, but not bad for being at 90'. Now the cords are so thick that my finger looks swollen, although it is not. I understand from my research that the PIP with the MP hyperextended is the most difficult to treat with N/A and among the most likely to recur, so I can't really blame the doc. I will still use N/A on my other fingers as it is needed. Surgery is a last resort for me, but it looks like I do need it now.
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06/26/2013 14:26
wach Administrator
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06/26/2013 14:26
wach Administrator
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Re: What to do when NA doesn't work
I was curious because I suspect that breaking a cord or not makes a big difference with respect to recurrence. Your experience seems to confirm that. If your cord was damaged but still in place the constant pulling by the spring might have contributed to quick recurrence. But who knows. In their 5-year paper about a trial of NA vs. surgery van Rijssen et al. report faster recurrence after incomplete correction (it's not in the abstract but here is a link to the abstract anyway http://journals.lww.com/plasreconsurg/Ab...l_Trial.30.aspx). This might have the same reason; after incomplete correction a the cord might still be in place.
Wolfgang
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06/26/2013 15:59
mikes 
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06/26/2013 15:59
mikes
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Re: What to do when NA doesn't work
Perhaps I was just plain "lucky" or perhaps my NA practitioner (Dr. Denkler) was just that "good" but my small finger PIP contracture which he classified as 95 degrees (90 degrees to me) was reduced to 15-20 degrees in November 2006 and is still there - maybe slightly better. As advised by the doctor, I followed a regimen of physical therapy until discharged (about 3 months - the limit covered by insurance) and night splinting as prescribed by the therapist. The therapist made a series of passive night splints (they'd deteriorate after some time) which I initially wore 7x/week, later 5x/week, then 2-3x/week after a few years, and finally discontinued. For some time, if I went on vacation or otherwise slacked off for a week or so I could detect a marginally increased contracture. When this sensation stopped, I stopped using the splint - maybe after 3-4 years.
So.....it can be done....with a highly skilled practitioner and some luck.....
Unfortunately I do have other symptoms, including a 20-30 degree contracture on the PIP joint of my opposite hand small finger, but have not yet quite had the "guts" to opt for my next NA. Someday (soon?), I'll likely have to face up to it.
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