Part two of a two-part series

In our last blog of the Dupuytren Series we discussed the effects of Dupuytren’s Disease and who is most often impacted. This blog is dedicated to the discussion of the promising new treatment for those who suffer from severe Dupuytren contractures that either continue to reoccur following conservative treatment or exceed acceptable degrees of contraction and severely limit hand function.

Traditionally, open surgery to remove Dupuytren nodules and release the contracted palmar fascia, generally at the base of the small and ring fingers, was the last resort measure taken by patients afflicted by severe Dupuytren Contractures. This type of surgery came with the same risks and lengthy recovery time associated with open surgery.

Today, an innovative new procedure first established in Europe is addressing these severe contractures less invasively. Known as the Percutaneous Needle Fasciotomy (PNF), or Needle Aponeurotomy (NA), this new procedure can address the contracture without cutting into the skin and disturbing surrounding soft tissue and nerves. This new minimally invasive surgical approach is an outpatient procedure and entails a local anesthetic and tiny needles.

Needles are applied to the affected areas, which are first identified with small marks. The needles are maneuvered in such a way that “punctures” the contracting tissue. The puncturing process weakens this contracting cord and initiates a breakdown. Fingers are freed from the contraction, allowing the hand to function normally.

Patients are then instructed on rehabilitative exercises in order to ensure full resumption of hand function.

The minimally invasive nature of the needle aponeurotomy procedure allows a faster recovery and more rapid return to activity. The risks associated with traditional open surgery are eliminated and patients report minimal pain following the procedure.

While this procedure is not available in every US city, Dr. Evan Collins is one of the few hand specialist who performs PNF.

One of a Two-Part Series

A little known, though common orthopedic condition affecting the hands and fingers, is called Dupuytren’s Disease. While conditions such as carpal tunnel syndrome, cubital tunnel syndrome, tennis elbow and other types of tendinopathic injuries and conditions are readily discussed, little is written on Dupuytren’s disease and the associated nodules and finger contractures that have the potential to dramatically impact hand function if left untreated.

This blog series will take a closer look at this particular condition and the exciting things that are changing treatment options available to chronic sufferers.

About Dupuytren’s Disease
A progressive condition, Dupuytren’s disease causes the fibrous tissue of the Palmar Fascia in the hand to shorten and thicken, forming scar tissue or nodules. These nodules can grow together and form tight, restricting “cords,” which limits finger extension and results in contractures. Generally located in the palm at the base of the ring and little fingers, a Dupuytren’s Contracture can dramatically impact hand function.

While little is known about what prompts Dupuytren’s disease, it is believed to be a hereditary condition. It is also more frequently seen in men over the age of 40, those of Northern European descent and those who smoke, use alcohol or have diabetes.

While a small percentage of cases can be resolved conservatively, utilizing cortisone injections, heat ultrasound therapy and stretching exercises, those suffering from chronic contractures now have a less invasive option to traditional surgery - Percutaneous Needle Fasciotomy (PNF), or Needle Aponeurtomy (NA).

PNF is considered when Dupuytren contractures cause problems with hand function, either as a result of tightening or contracture of the cords affecting nearby digits, or if there is a fixed flexion contracture of the middle finger joint, known as the proximal interphalangeal (PIP) joint. The procedure is also considered when contracture of the metacarpophalangeal (MCP) joint reaches 30 degrees to 40 degrees.

Until recently, open surgery was the only option for patients suffering from severe Dupuytren contractures. Today, the needle aponeurotomy, first practiced with great success in Europe, is a minimally invasive surgical approach to addressing the contractures and restoring hand and finger function.

More on this procedure will be discussed in Part Two of our Dupuytren Series. Read more now on Dupuytren’s Disease and PNF.

Several years ago a new high-energy shockwave treatment received FDA approval for the treatment of chronic tennis elbow nonresponsive to conservative treatment. This came after a period of clinical trials we performed. This outpatient shockwave therapy is an outpatient procedure known as OssaTron Treatment. Unfortunately, few insurance companies include the treatment in their plan and limited OssaTron facilities make it more difficult to arrange than other treatments proving just as effective.

Most recently, autologous blood injections for the treatment of refractory lateral epicondylitis was introduced and is proving a very effective, less invasive treatment option for chronic tennis elbow. The injection provides the necessary cellular and humoral mediators to promote healing.

The autologous blood is drawn from the dorsal vein of the hand and injected along the supracondylar ridge, into the undersurface of the extensor carpi radialis.

Chronic tennis elbow sufferers remaining symptomatic despite less invasive treatment programs may require a Lateral Epicondyle Release, an outpatient procedure designed to relieve the tension from the extensor tendon at the elbow joint.

Tennis elbow, or lateral epicondylitis, is one of the most common upper extremity conditions seen in orthopedics today. It is a common tendinopathy classified as an overuse or overstress condition and can be the result of a repetitive activity fatiguing the hand, wrist, forearm or elbow.

The fatigue and stress creates an inflammation that grows increasingly worse over time.

There are over nine million reported cases of tennis elbow in the United States alone every year, though most of those diagnosed with Tennis Elbow have never played tennis. While tennis is the sport for which the condition is named, affecting approximately five in 10 recreational and professional tennis players, the most prominent profile of a tennis elbow patient is the average man and woman between the ages of 40 and 60 – performing everyday activities. A smaller percentage of those diagnosed with tennis elbow, approximately 10 to 20 percent, are those sustaining severe injury resulting from a fall or direct hit to the area.

Tennis elbow actually causes the tendons around the elbow to become inflamed and results in pain at the outside, or lateral side, of the elbow – as opposed to the inside, or medial side, of the elbow associated with a condition known as Golfer’s Elbow, or medial epicondylitis.

Tennis elbow often occurs in the dominant arm. If left untreated, the affected tendon can tear and cause scar tissue to develop. Those suffering from the condition may experience moderate to debilitating pain as the tendon becomes increasingly weaker over time.

Some of the common symptoms of tennis elbow include:

• Pain along the outside of the elbow of the dominant arm – radiating or traveling into the forearm and possibly the hand.
• Pain and subsequent weakness with reaching or grabbing activities.
• Nagging ache and discomfort during rest following activity.

Treatment for tennis elbow can vary depending on the severity of the pain and length of time a patient has suffered from the condition. In Tennis Elbow Part 2, the treatment options available today for tennis elbow sufferers will be discussed – including new autologous blood injections.

Repetitive stress conditions of the hand, wrist and elbow affect the office worker, athlete, and musician alike.  And increasingly the condition is affecting the young limbs of children whose daily tasks meld as seamlessly with cell phones, keyboards and game controllers as they have traditionally with pencils and toothbrushes.

Such repetitive stress conditions include tendonitis, carpal tunnel syndrome, cubital tunnel syndrome, tennis elbow (lateral epicondylitis) and golfer’s elbow (medial epicondylitis). Playing-related musculoskeletal disorders (PRMD) also fall within this category and are those conditions associated with professional musicians.

The key in staying strong and pain free is recognizing irritation when it occurs and adjusting activity accordingly, in order to prevent a more extensive problem.  A series of rehabilitation exercises have been developed for the specific conditions and both serve as part of a treatment program as well as a preventative exercise program.

Some of the rehabilitation exercises for common repetitive stress condition Carpal Tunnel Syndrome include the median nerve glide, tendon glide and a neutral wrist splint.

A series of rehabilitation exercises, called the Musician 6 Pack, developed specifically for the demands of professional musicians entails stretching and core strengthening exercises, in order to reduce the chance of developing tendinopathic injuries and conditions, as well as reduce the duration of symptoms in those suffering from such.

Part 2 of 2 part series.

Carpal Tunnel Syndrome, a continued discussion

Last week, a discussion on Carpal Tunnel Syndrome began, as it has become one of the most commonly seen orthopedic conditions affecting the hand today – second only to osteoarthritis.

Those at greatest risk include:

• Women (three times more likely to be affected than men), as CTS affects those subject to high hormone-related conditions such as pregnancy, breastfeeding, menopause and hypothyroidism.
• Those on certain medications such as birth control pills, high blood pressure drugs and cortisone pills or shots.
• Medical conditions such as arthritis, diabetes, Raynaud’s disease and cysts and tumors within the carpal tunnel.

And today’s technologically savvy society seems to be increasingly predisposed to such “overstress” conditions as a result of the handheld device error cementing an electronic dependency that has been growing over the years.  Recognizing that which predisposes us to CTS makes it easier to take preventative measures.

Such preventative CTS steps can be as simple as taking anti inflammatory medication such as Ibuprofen, reducing the amount of time on an activity aggravating the condition and purchasing ergonomic aids for work environments, or as complex as adjusting other medications taken and addressing a primary condition to which it is frequently secondary.

While chronic CTS conditions nonresponsive to conservative treatment may require Dr. Collins’ minimally invasive endoscopic carpal tunnel release, rarely does the condition return once treated.

The endoscopic carpal tunnel release involves a tiny incision made at the base of the hand.  A scope that is inserted illuminates and magnifies the view of the area.  The scope has a small camera attached, which projects images onto a small monitor and guides the doctor through the carpal tunnel.  The transverse carpal ligament forming a band across the wrist is cut slightly in order to relieve the pressure placed on the median nerve as it passes beneath the ligament.

Rehabilitation exercises then help patients quickly return to activity.

Carpal Tunnel Syndrome - Part I

Carpal Tunnel Syndrome (CTS) is one of the most common hand conditions seen in orthopedic medicine today.  Traditionally related to occupational activities, it is today becoming increasingly more prevalent as a result of everyday activities – as computers serve as the primary tool of written communication, blackberries and cell phones grow in sophistication and functionality, and game controls keep the youth just steps away from the ultimate challenge.

Known as an “overstress” condition, Carpal Tunnel Syndrome is the inflammation of the median nerve.  This median nerve travels down the arm and through a narrow passage way in the wrist, called the carpal tunnel.

Irritation resultant of a repetitive activity will cause irritation and contraction within the tunnel, applying pressure to the median never passing through it.  This constriction further inflames the area and causes pain and discomfort.  The nerve is surrounded by nine tendons and covered with a tight ligament called the transverse ligament.  When the membranes responsible for lubricating the tendons as they glide in the tunnel swell, the condition is identified as CTS.

Since the median nerve provides feeling to the thumb, index and middle fingers, as well as a portion of the ring finger and some hand muscles, the impact of the constriction can be prominent and cause a great deal of pain.

The first course of action is to refrain from the activity suspected of prompting the condition.  Creating different environments can also be productive, as a number of ergonomic computer keyboards and gaming devices have been developed over the years to help prevent the strain on many of the hand positions linked to CTS.

Depending on the severity of the condition and other related diseases or genetic factors prompting the condition in patients, other treatment options may be indicated.