Scar-less Day Surgery for De Quervain's Disease
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What is de Quervain's disease?
De Quervain's disease is a tendonitis that occurs on the thumb side of the wrist. In English, it is called De Quervain's tenosynovitis. Pain occurs when twisting the hand or gripping the thumb in a crooked grip. Repetitive motions such as sewing or golfing can cause it, but it can also be caused by aging, changes in female hormones such as after childbirth or menopause, or the shape of the wrist bone. In the case of postpartum, it will begin to improve once breastfeeding ends, but in the case of menopause or when it is caused by the bones, it will not heal easily.
Orthotics and compresses are the first choice of treatment, but they are often ineffective, so injections are the second choice. However, surgery is the last resort for those with conditions that tend to be more severe, as described next.
The severity of the disease will be determined by echo. If the thickening of the tendon sheath is more than 2 mm, if the inflammation by Doppler echo is on both sides of the tendon sheath, if there is a type of tendon sheath that is also between the tendons, or if the tendon is prevented from sliding, it is intractable and surgery will be considered.
Surgery has traditionally only been performed through incisions, but at our clinic, we offer a unique non-surgical method of treatment that allows patients to return to work or home work as soon as possible.
Why can surgery be performed without cutting?
Surgery for non-invasive Duchenne's disease is a minimally invasive procedure that uses echo to improve the condition by cutting through 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.
Echo-guided minimally invasive surgery is still performed only in a few medical institutions in Japan and abroad. Although there are technical difficulties, the reality is that few orthopedic surgeries using echo as a guide have yet been introduced.
Surgery for "non-surgical" de Quervain's disease is,Unique techniques developed at our clinicIt is the first clinic in Japan to introduce this technique. As a pioneer clinic in Japan that introduced this technique early on, we have developed a delicate and precise method that is unmatched by other clinics, reducing the risk of leftover tendon sheath cuts and neurovascular injuries, and advancing safety and certainty.
The clinic hopes to use its overseas experience to serve patients as a local clinic that can provide state-of-the-art treatment.
No-cut" surgery bridges the gap between injections and surgery
Docheruban's disease is relatively common among working and household executives, including postpartum and menopausal women. The pain causes difficulties in life, such as the inability to hold a bottle, but there has been a problem that has not been easily remedied in the early stages.The injections areImmediate but not sustainable,Recurrence is common.The current situation is that Orthotic therapy is not easily accepted by women who often work with water. However, incisionalSurgery isScratches and scratches,Take a break from work or stop working with water for a period of timeIt required inconvenience such as
MINIMALLY INVASIVE SURGERYis to be done with needles only,No scarring, water work can be done on the same day, and work restrictions are less likely to occur due to less pain.Therefore, we recommend this new technique.
Wound size and pain are about the same as injections.
Surgery for de Quervain's disease used to be performed through an incision in the skin, but with the advent of ultra-high definition echo, it can now be treated only by manipulation with a needle. Since it is performed with a needle,Pain is the same as an injection.Of course. Of course.The size of the wound is the same as the injection.No scarring. It does not leave a mark.
Specifically,
(1) Local anesthesia is administered.
(Note 1) Preoperatively, the location of nerves and tendon sheaths are accurately determined by echo.
(2) While watching the echo, insert the needle for tendinotomy.
(iii) The tendon sheath is incised while confirming that the needle is securely between the sheath and the tendon on the echographic image.
Note 2) If there are two separate tendons or a wall between the tendons called a septum, each tendon sheath is incised.
(Note 3) Echocardiographic confirmation that the tendon sheath has been securely incised and softened.
(Note 4) If the tendon and sheath are attached or have synovitis, we also perform an additional procedure to remove adhesions and synovitis by performing a scraping procedure after separating the septum. (This procedure usually requires advanced imaging techniques and careful manipulation of the needle tip, but we perform it after careful intraoperative judgment based on our extensive case experience.)
(4) Remove the needle, apply pressure hemostasis, and finish.
Safe and up-to-date treatment performed by board-certified hand surgeons with expertise in hand surgery
Since the surgery is performed only by manipulating the needle without making an incision, echo manipulation techniques, image evaluation, and tendon shearing techniques using a needle tip are required. At our clinic, surgery is performed by board-certified hand surgeons who are experts in hand surgery among orthopedic surgeons. Specialists with clinical experience in Japan and abroad provide safe and up-to-date treatment methods with minimal complications.
Day trip and can be wet from day one.
Many patients with de Quervain's disease are lactating, middle-aged, and socially active. Surgery for "no-cut" de Quervain's disease is a minimally invasive procedure for those who have been unable to have surgery in the past because of work or childcare commitments that prevented them from taking time off.You can quickly return to your daily routine without having to miss work.(Minimally invasive surgery. (Minimally invasive surgery, but some pain and swelling may occur due to the incision in the tendon sheath. To repair the tendon sheath1~ (after a number N)2It will take about 3 months to complete the surgery, so take it easy as much as possible and do not do any strenuous or unnecessary labor or work after the surgery.1~ (after a number N)2Avoid for a period of months.)
- Characteristics of surgery for non-surgical de Quervain's disease
- day trip
- Less pain
- Leaves no scars
- Less bleeding.
- Low risk of infection
- You can take a bath from that day
- No need for postoperative disinfection visits
- Can be treated before it gets worse.
- Safe for monitoring by echo
- You can use your fingers from day one.
- Get back into sports faster.
Surgery for non-surgical de Quervain's disease is recommended for the following patients
Patients with de Quervain's disease are often young postpartum women, middle-aged and older adults, and are in their prime socially. Surgery for "non-surgical" de Quervain's disease is,Return to daily life immediately without having to miss work.Therefore, it is suitable for the following patients. In addition, since the surgery can be performed with only a small amount of local anesthetic, it is possible for nursing mothers to undergo the surgery.
(1) Those who cannot take time off work (can return to work early)
(2) Those who work with water, housewives (ready access to water)
(iii) Those who play sports that use their arms (can move them earlier)
(4) Those who are sensitive to pain (scarring is less likely to be painful)
(5) Those who do not want to leave scars (no scarring)
(6) Those who wish to reduce the number of hospital visits (no need for stitches)
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 confirmation with images is of the utmost importance. Therefore, at our clinic,Not the standard echocardiography used in regular orthopedics,Only adopted at the level of some university hospitals.Echo specialized for hand surgeryequipment.
Standard resolution echo commonly used in orthopedics
Comparison of different surgical procedures for de Quervain's disease
Normal incision. surgery to do | Using echoes." MINIMALLY INVASIVE SURGERY | |
|---|---|---|
Wound size | 2-3 cm | 1mm |
pain | strong | few |
Skin and subcutaneous damage | ant | Almost never |
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) |
Response to additional tendon sheath incision | Incision needs to be enlarged | Possible from the same puncture site |
Bathing on the day of surgery | ✖️ | ◯ |
Confirmation of tendon sheath sliding | under one's direct observation | sub-echo |
Preoperative, intraoperative, and postoperative tendonitis Pathological condition check of | ✖️ | 'good work' (equiv. of silver star awarded to children at school) |
Are there any disadvantages?
It was thought that surgery for non-surgical Docheruban's disease could cause more damage to invisible tissues than if performed under direct vision. However, in fact, important nerves and blood vessels can be seen by echocardiography, so damage can be avoided in advance. Still, the usual orthopedic surgical techniques used18MHzThe probes of the "Mere Old Man" may not have been able to see very small nerves and blood vessels. Therefore, our clinic specializes in orthopedic ultrasound diagnostic treatment,24Mhzof ultra-high definition probes (in echo, the higher the frequency, the higher the resolution) are introduced to reduce the risk as much as possible.24MhzThe ultra-high-definition probes of the "K" series have only been introduced at the university hospital level, and our clinic is one of the few medical institutions in Marugame City, and even Kagawa Prefecture, that uses these probes.
Even in the unlikely event that the tendon sheath is left uncut, a complete release can be obtained with an additional injection procedure. The introduction of high-definition echo has nearly eliminated this problem, and we believe that this is a safe treatment with results comparable to surgery to insert the incision and with less pain and scarring. If the tendon sheath cannot be cut by any means or if there is a large septum, we will move to an incisional procedure.
In addition, because any surgery or procedure is generally 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.
Advantages of surgery for non-surgical de Quervain's disease
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 | No need for disinfection visits |
drug allergy | No stitches required |
neurovascular injury | Leaves no scarring |
pain | Possible to take a bath from the same day |
CRPS | Short operating time |
Skin induration/keloids | Less postoperative pain |
Limited range of motion, skin adhesion | No rehabilitation required (except for severe cases) |
About tendonitis with preoperative inflammation
We always perform a preoperative ultrasoundMicrovascular blood flow assessment (SMI)to confirm the degree of "tendonitis". Tendonitis implies dilation of inflammatory blood vessels. Recently, this inflammatory vessels have beenmoyamoya vesselsand has been shown to cause prolonged pain.
Inflammation can occur in the following ways The tendon sheath becomes too narrow and the tendon or tendon sheath is scraped by rubbing as the tendon passes through it. To repair itimmunoreactionThis leads to vasodilatation of the nourishing blood vessels, which in turn leads to synovitis. Inflammation leads to edema and further swelling of the tendon sheath and tendon, creating a vicious cycle that makes it difficult for the tendon to pass through.
This inflammation gradually improves after surgery to open the tendon sheath, as friction is reduced, but in some cases the inflammation may persist and swelling of the affected area continues after surgery.
The clinic has reviewed past cases,(1) Chronic cases that are more than 6 months old, ,(2) Osteophytes present on the radius near the tendon sheath, ,(iii) Strongly positive wrist flexion test, ,Inflammation tends to be prolonged when any one of the following is met (intractable tenosynovitis).
When prolonged inflammation (refractory tendonitis) occurs
If the tendon snagging has improved but the patient still experiences lingering tendinitis after surgery (refractory tendinitis), two options are available.
(i)steroid injection: Anti-inflammatory steroids are injected into the affected area. Caution should be exercised because of side effects such as tendon rupture, infection, and worsening of diabetes mellitus. If the disease recurs when the effect of steroids wears off, treatment (2) should be considered.
(2)Embolization of Abnormal Blood Vessels: This is a treatment that embolizes (packs) the inflamed blood vessels and eliminates the blood vessels altogether. It is highly effective, more durable than steroids, and safer than steroids because it does not cause tendon rupture, a side effect of steroids. This treatment is not covered by Japanese insurance and must be paid for by the patient.
Specifically, the arteries of the elbow and hand are injected with a chemical solution containing microparticles that have the property of embolizing only in the inflamed vessels, eliminating the inflamed vessels in the hand.
If the patient is diagnosed with high inflammation before surgery, the tendon is in poor condition and prolonged gliding problems can be expected. In our clinic, when prolonged inflammation is expected in this way, inflammatory vascular treatment is performed simultaneously with surgery(non-surgical D'Quervain's disease surgery + inflammatory vascular therapy)to improve their performance.
To avoid prolonged inflammation
After a tendonotomy, the tendon sheath is partiallyCeiling deficientI will do so. With the current echocardiographicTendon sheath regeneratesIt is known that it will be In order to regenerate1~ (after a number N)2About a monthBecause it takes a lot of time1~ (after a number N)2It is safe to avoid finger flexion and extension exercises for a month. Although non-surgical surgery has no scar, too much finger movement in the early postoperative period can lead to prolonged inflammation, as in intractable tendonitis.
About the cost of treatment
Surgery for non-surgical Docheruban disease is not covered by insurance. The cost of treatment is as follows
(1) Normal de Quervain's disease: 88 per hand,000suffix for names of swords, armour, musical instruments, etc.(Excluding tax) (Tax included) 96.800(Yen)
(2) Refractory Dochterban's disease(Severe cases with high inflammation)Hand1per book118,000suffix for names of swords, armour, musical instruments, etc.(Excluding tax) (Tax included) 129,800(Yen)
(iii) Doerkelvin's disease complicated by ganglions: 98 per hand,000suffix for names of swords, armour, musical instruments, etc.(Excluding tax) (Tax included) 107,800(Yen)
(in Japanese history)Surgical costs include all anesthesia, fees, pre- and post-operative medications, drug costs, and surgical technique fees).
earnestSurgery for Dochterbang's disease, which is not covered by insurance, is performed at our own expense. Although we have introduced this treatment in order to reduce the pain and burden of surgery on patients, there are some aspects of advanced and sophisticated medical treatment 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.
Finally.
When providing treatment, we try to suggest treatments that patients would want to receive if they were their own family members.If you have any questions, please feel free to ask them during the consultation. We believe that it is important for you to be satisfied with your treatment so that you can undergo the surgery. We will provide you with thorough explanations as needed so that you can undergo the surgery with as little anxiety and peace of mind as possible.
Responsibility: Dr. Yuki Toya, Orthopedic Surgeon, Hand Surgery Specialist/Supervisor
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