Non-Incisional Day Surgery for Dupuytren's Contracture

What is Dupuytran's contracture?

　Dupuytran's contracture is located under the skin of the palm of the hand,palmaris tendonThis is a disease in which the thin fibrous membrane (collagen) called "collagen" degenerates, overgrows, thickens, and shrinks, causing the fingers to gradually bend.
　The cause is unknown, but it is not malignant. It is more common in middle-aged and older men, and the ring and little fingers are most frequently affected. In the early stages, nodules, indurations, and small depressions appear on the palms of the hands.Skin twitching (Nodule)occurs, and with the passage of timeCable (Code)and the fingers become difficult to extend. It may gradually expand to the middle and index fingers.
　Usually there is no pain, and the ability to bend allows for an approximate lifestyle, but the inability to extend the fingers can cause problems such as difficulty clapping, difficulty putting on gloves, and poking the nose or eyes when washing the face.

　There are racial differences, with Caucasians (Mediterranean periphery) tending to be more affected and Japanese relatively less so. Prolonged alcohol consumption is a risk factor, and diabetics are more prone to Dupuytren's contracture. Dupuytran's contracture can also occur on the opposite side of the body, on the soles of the feet, and on the pubic area.

What are the treatment options?

　The treatment used to break down the collagen and dissolve the cordage.enzyme injectionsAlthough there were2020Since 1949, the supply has been stopped up to the present, so the only current treatment is surgery.

　Surgery has conventionally been performed to release the contracture through a large incision. Palm of the hand.Excision of indurations and cords under the skin through a large zigzag or staircase incisionThe hand is then removed and the hand is then placed under general anesthesia. Because the neurovascular system is wrapped around the cord, this surgery requires advanced skills by a hand surgeon and often requires several hours of surgery, which is often performed under general anesthesia with hospitalization. Because the wounds are large, postoperative problems such as skin adhesion and continued exudation are likely to occur, requiring a longer period of in-patient wound care than is usually required after surgery.
　Therefore, at our clinic, we use ultrasound, which is performed without incision.MINIMALLY INVASIVE SURGERYWe have developed and implemented our own method of releasing contractures by cutting off the induration and cord-like structures with the "MRI" technique. This is a revolutionary surgical technique that eliminates the disadvantages of conventional techniques.day tripIn,Reduced operating time, ,Safety, ,Shorter hospital visits, ,Early return to household chores and workWe are now able to offer benefits such as

　In some cases, surgical therapy was not chosen until the patient was severely ill because of the large and painful surgical incision, but if surgery without cutting could be adapted,Surgery can be selected at an earlier and correct time, andWe believe that the disease can be treated before it becomes serious.

What is non-surgical surgery for Dupuytran's contracture?

　In Dupuytren's contracture, the neurovasculature of the finger wraps around the fibers of the cord and cannot be easily detached, so a large incision is made to expose the nerve broadly, which requires stripping the nerve from the cord and detaching it.
　Our clinic was one of the first to introduce ultra-high definition echo, and we have been performing "surgery without cutting" for other diseases using a method we developed independently. Applying this technology, we have devised a technique to release the contracture without incising the skin to remove the cord-like substance that causes Dupuytren's contracture. In the new technique,Using echo to locate neurovasculatureThe incision is made with a needle, so there is no need to make a large incision. Since the incision of the induration and cord is also made with a needle, we have developed a technique to improve finger contracture without a scalpel incision.
　Specifically, after anesthesia is applied to the palm, the number and location of indurations and cord-like structures in the palm are determined by ultra-high definition echography. At the same time, the location of the surrounding neurovasculature is determined three-dimensionally. Then, the contracture is gradually released by separating the indurations and cord-like structures with a needle, and the same procedure is repeated until the fingers can be straightened. As it is done with a needle,Wound is equivalent to injectionand leave almost no scar. The number of punctures varies from case to case depending on the location, number, and size of the cord-like objects, but basically1It is often not in one place, but in multiple places. Bleeding is minimal, if any, with little swelling and bleeding on the day of and the day after,Immediate use of handsIt is. In difficult cases, stiffness of the joint often develops, and the patient may wear a brace to stretch the finger for a few days only. Once the bleeding has healed, water work can be done.

(Minimally invasive surgery, but some pain and swelling may occur due to the incision in the palmaris tendon. After the surgery, take it easy as much as possible, and do not do any strenuous or unnecessary labor or work.1Avoid for about a month.)

Transmission + local anesthetic injection.
The location of neurovasculature is confirmed by looking at the echo.
While viewing the echo, the needle is advanced to the area of the cord and induration, and the incision is made.
Manually stretch the fingers to release the contracture.
Compression hemostasis is applied and the procedure is completed.

Hospitalization is not required, and "no-cut" surgery is easy to perform after surgery.

　The incisional surgery required a two-week hospital stay, a large wound on the palm of the hand, and a long period of postoperative care (usually 2-3 weeks) for the wound, which necessitated such inconveniences as taking time off work or stopping water work for a certain period of time. The patient also needed to wear a brace for a long period of time to prevent contracture at the incision site and to attend rehabilitation.

　Surgery without cutting is performed using only a needle, so there are no scars and the surgery can begin early in the postoperative period.take a bathResults,Less painThe advantage is that work restrictions are also less likely to occur.Reduced duration of orthotic wear, ,Shortened outpatient rehabilitationThe result is a significant advantage over incisional surgery in many ways.

Advantages of surgery for Dupuytran's contracture without incision

Downward risk	Advantages
Hemorrhage/hematoma	Improved safety (nerves and blood vessels can be visualized and protected preoperatively)
infection	Less pain from anesthesia injections
Swelling, edema	No need to wear a painful tourniquet
Anesthesia solution volume	Shortened disinfection visits
drug allergy	No stitches required
neurovascular injury	Leaves no scarring
pain	Bathing is possible from almost the next day.
CRPS	Short operating time
Skin induration/keloids	Less postoperative pain
range of motion limitation	No rehabilitation required (except for severe cases)
skin adhesion	Postoperative brace is not necessary or short term

The greatest advantage is safety

　Dupuytren's contracture surgery without cutting is our clinic's unique minimally invasive surgery that uses echo to improve the condition by incising the targeted tissue using only a needle. The use of echo allows us to target tissues in the body that could not be done before without cutting. The greatest advantages arePre- and intraoperative nerve and blood vessel locationThe neurovascular system is located in the Until now, the location of the neurovascular system was not known until the incision was made. Although we know the approximate location of the neurovascular system through anatomical knowledge, there are individual differences, and we inevitably left the risk of damaging the neurovascular system.

　Echo-guided minimally invasive surgery allows the location of the neurovasculature to be ascertained before surgery begins and at any time during the operation, thus reducing the risk of injury as much as possible. The dilemma is that minimally invasive surgery increases the risk of neurovascular injury,Echo-guided surgery is a new technique that improves safety and is minimally invasive (reduces the burden on the body)It is.

　At present, echo-guided Dupuytran's contracture surgery is rarely performed in Japan. Although there are some technical difficulties, the reality is that orthopedic surgery using echo as a guide has hardly been introduced yet. Our clinic hopes to be of service to patients as a local clinic that can provide state-of-the-art treatment.

Comparison of Dupuytren's contracture by technique

	Normal incision. surgery to do	Using echoes." MINIMALLY INVASIVE SURGERY
Wound size	4-5 cm or larger	1mm
pain	strong	few
Skin and subcutaneous damage	ant	Almost never
removal of sutures	necessary	unnecessary
Operation Time	2-3 hours	1 hour
safety (Less nerve/tendon damage)	◯	'good work' (equiv. of silver star awarded to children at school)
certainty (Less leftover/overcutting)	'good work' (equiv. of silver star awarded to children at school)	'good work' (equiv. of silver star awarded to children at school)
anesthesia	General anesthesia is common (requires hospitalization)	Local Transmitted Anesthesia (day case)
Bathing after the day following surgery	✖️	◯
rehabilitation	necessary	Not required except for severe cases
Postoperative hospital stay	2-3 weeks (wound treatment and suture removal required)	Every 1-3 weeks

Safe and minimally invasive treatment performed by "specialists" who are well versed in hand surgery

　Because the surgery is performed only by manipulating the needle without making an incision, echo manipulation techniques, image evaluation, and precise manipulation of the needle tip are required. Our clinic is one of the best in the field of orthopedic surgery,Board-certified hand surgeon with expertise in hand surgeryThe treatment will be performed by Our specialists, who have accumulated clinical experience both in Japan and overseas, provide safe and minimally invasive treatment methods that minimize complications to the greatest extent possible.

Ultra-high definition echoes are used

　It is essential for safe and reliable surgery,0.1Ultra-high definition echo with a resolution of mmWe believe that the most important thing is to check the images. Above all, we believe that it is most important to confirm with images. Therefore,At our clinicNot the standard echo used in regular orthopedic surgery, but only employed at some university hospital levelsEcho specialized for hand surgeryequipment.

Standard resolution echo commonly used in orthopedics

Characteristics of Dupuytren's contracture surgery

　Dupuytran's contracture is characterized by the following features

Characteristics of surgery for Dupuytran's contracture without incision
day trip
Less pain
Leaves no scars
Less bleeding.
Low risk of infection
You can take a bath the next day.
No need for postoperative disinfection visits from early on
Can be treated before it gets worse.
Safe for monitoring by echo
Can use fingers from an early age.
Get back into sports faster.

Dupuytran's contracture surgery without cutting is suitable for the following patients

　Most patients with Dupuytran's contracture are middle-aged men and are in their prime socially. The "non-surgical" Dupuytren's contracture surgery allows for a fast postoperative recovery and earlyBack to the daily routine,Get back to work fasterTherefore, it is suitable for the following

(i) Those who cannot take time off work

2) Water workers and housewives

(iii) Those who play sports that require the use of their hands

4) Those who are sensitive to pain

(5) Those who do not want to leave scars

⑥ Those who wish to reduce the number of hospital visits

7) Musicians and musicians

Are there any disadvantages of incisionless surgery?

　The most difficult part of the Dupuytren's contracture surgery is to find the most difficult part of the contracture in the cord-like object.spiral cordis that there is one that exists that wraps around the neurovasculature called the This spiral cord is the first of the fingers.2Joints and No.3It can be present between joints and must be carefully operated on, whether through an incision or a nonincisional procedure.Nerve and blood vessel damageThis can cause a Since the spiral cord wrapped around the nerves and blood vessels cannot be removed by the non-surgical method, the second2If joint contractures are strong (severe cases), a mildResidual contractureThere are times when the For this reason, the Clinic has established the first2In the case of Dupuytren's contracture, in which the joints have lost their elongation, surgery is recommended as soon as possible.

　It is often thought that surgery for Dupuytren's contracture without incision has a higher risk of damaging important tissues such as nerve vessels than surgery with incision because the inside cannot be seen, but as mentioned earlier, important nerves and blood vessels can be seen with echo, so damage can be avoided in advance. Rather, we believe that the incision method, in which incisions are made without seeing the interior, may be more dangerous in some cases.

　Still, the usual orthopedic use of18MHzThe probes of the "Mere Old Man" may not have been able to adequately see the very small nerves and blood vessels. Therefore, our clinic introduced orthopedic ultrasound treatment,24MhzUltra-high definition probe of(In echo, the higher the frequency, the higher the resolution) is introduced to reduce this risk as much as possible.

　Surgery for Dupuytran's contracture without incision does not involve an incision, so the cord-like substance cannot be completely removed. Therefore, an incision is made.Remnants of cord-like material (skin lumps) remain. It is important to exercise the fingers early in the process, as they can become stiff if not moved after surgery.

　If the cord-like object remains, the contraction will be less severe than with the incisional method, which removes the cord-like object.Possibility of recurrenceis considered to be high.3The likelihood of recurrence within a year is3about ten percentreported that the contracture can be improved by the same technique (non-cutting method) in case of recurrence.

　If there are many cords, the needle may cause some skin problems due to the increased puncture site. (If skin contracture is strong, the needle may cause slight skin irritation when it separates the cord and stretches the skin.break one's skinThe skin will repair itself in a few days to a week or so.) In any case, the skin is likely to be less damaged than through an incision.Surgery without incision is a safe treatment that offers the same results as surgery with incision placement and less pain and scarring.We believe that this is the case.

Other Surgical Complications

　Because any surgery or procedure is invasive to the body, there is a risk of complications. Specifically, there are the following risks: (1) allergies due to drugs; (2) complications due to swelling, bleeding, or hematoma; (3) infection; (4) nerve or blood vessel damage; (5) pain or resulting movement disorders; (6) thrombosis or embolism; (7) skin scars, keloids, or wound pain; (8) joint contracture or joint instability (when joints are manipulated); (9) other complications (CRPS) and other unforeseen complications (e.g., problems not only in the affected area but in other parts of the body as well). Since the future can be unpredictable, we will take the best possible measures (administration of drugs, additional surgical procedures, additional treatment, resuscitation, emergency medical care, etc.) depending on the situation. In case of emergency, we may perform the surgery without your consent, but we ask that you understand this before accepting the surgery.

About the cost of treatment

　Surgery for non-surgical Dupuytran's contracture is not covered by insurance. The cost of treatment is as follows

＊指1本目 240,000円（税込： 264,000円）
＊指2本目以降1本につき（同側手に限ります） 180,000円（税込：19,8000円）

(Surgical fees include all anesthesia, costs, pre- and post-operative medications, surgical drugs, and surgical technique fees.)

　Although we have introduced this treatment to reduce the pain and burden of surgery on patients, there are some advanced and sophisticated medical treatments that are not fully covered by the current Japanese insurance system. We explain to patients that they should choose this treatment with the understanding that the quality and content of the treatment provided by the current Japanese insurance system is limited.

　When patients are asked to choose whether to receive treatment covered by insurance or at their own expense, we explain the advantages and disadvantages of these treatments to them and let them make their own choice. We will then do our best to provide the treatment that the patient chooses. We believe that a relationship of trust with our patients is of utmost importance. We cannot provide treatment without mutual trust. Please feel free to contact us if you have any questions.

[On the cost of self-funded treatment.

　Self-funded treatment not covered by insurance may not be covered by life insurance or accident insurance benefits. In addition, benefits from workers' compensation insurance, liability insurance, and various public subsidies are also not available.

However, since it is a medical expense, it is deductible.

For Patients Considering Surgery

　Due to the magic of the word "surgery," there are many cases in which the appropriate treatment is not given at the right time, the disease progresses, and surgery is chosen only after the nerve cells have become irreversible. We have devised this non-surgical procedure in the hope that if we can minimize the pain and fear as much as possible, the patient will be able to undergo surgery at an earlier stage, recover well, and return to his or her life.
　The "no-cut" carpal tunnel syndrome surgery is a unique technique developed at our clinic. As a pioneer clinic in Japan that introduced this technique early on, we have evolved a delicate and precise method that is not available at other clinics, reducing the risk of inadequate nerve decompression and neurovascular damage, as well as safety and certainty.

Responsible for writing Orthopedic Surgeon, Hand Surgery Specialist/Instructor
Yuki Toya