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Dupuytren's contracture in the foot

Discussion in 'General Issues and Discussion Forum' started by scottie, Feb 2, 2009.

  1. scottie

    scottie Member


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    Hi. Can anyone advise where I can source more information on Dupuytrene's contracture affecting the feet. My patient thinks the orthopaedic consultant she is being referred to has only performed surgery 3 or 4 times and she is concerned.Where would I find out more about the procedure and treatment? Thanks.
     
  2. jos

    jos Active Member

    Re: Dupuytrene's contracture

    First of all, where in the world are you?
    Second, why does the patient want surgery? Pain? Because the GP said to?
    I have a few Pts with this condition, who have no problems. One has a few nodules though, (which are a bit lumpy) but she says they cause her no pain.
     
  3. scottie

    scottie Member

    Re: Dupuytrene's contracture

    Thanks. In the back of beyond obviously...... patient will require surgery, condition deteriorating rapidly and soon she won't be able to work.
     
  4. drsarbes

    drsarbes Well-Known Member

    Re: Dupuytrene's contracture

    Dupuytren's Contracture is classically seen only in the upper extremities while plantar fibroma/fibromatosis is seen in the feet.

    If your patient, in fact, has symptomatic plantar fibromas which has not responded to conservative treatment, surgery is a viable treatment option.

    How many of these does one need to remove before they are deemed "experienced"???

    Steve
     
    Last edited: Feb 3, 2009
  5. admin

    admin Administrator Staff Member

  6. facfsfapwca

    facfsfapwca Active Member

    Good supportive orthosis not soft non rx orthosis can render plantar fibromas asymptomatic. If the contractures are very severe surgery may be necessary but I would try to use orthosis for 6 months prior to surgery as much less may have to be done.
     
  7. Mark Egan

    Mark Egan Active Member

    Dear Facfsfapwca (can you use an easier name to type?)


    Can you explain a little further by what you mean when you say "not soft non Rx orthosis" I would read that to mean an accomodative innersole rather than an orthotic.

    I currently have a patient with said issues on the plantar aspect of both feet and both hands. The ones on the feet have become more uncomfortable upon rising in the am and after prolonged weight bearing, I have prescribed a full length amfit device with accomodation for the contractures as well as advising him on pre-weight bearing exercises in the am and ice therapy at the end of the day.
     
  8. facfsfapwca

    facfsfapwca Active Member

    Amfit is not an orthosis. It is a ready made non rx over the counter product and it may work but not as likely as acorrectly casted and fabricated Root orthosis.
     

  9. FACFSFAPWCA:

    If Amfit is not an orthosis, what then is your definition of an orthosis???
     
  10. DaVinci

    DaVinci Well-Known Member

    Not true.
     
  11. scottie

    scottie Member


    Thanks. I am in the process of manufacturing functional orthotics to also accomodate the contractures. Patient is waiting for MRI scan to determine other "intervention."
     
  12. facfsfapwca

    facfsfapwca Active Member

    Cast the patient using plaster non weightbearing but hold him in neutral and load the 5th.

    Take forefoot and rearfoot measurements and measure for equinus as well. Leg length is also critical if one foot is worse which it usually is.

    The orthosis must not be made of soft crap it will not support him or correct his gait you can use a soft cover temporarily if lesions are very tender. The tenderness will start to disappear within weeks if the orthosis is made properly.

    Most surgeons only excise PFs in the beginning of their careers.
     
  13. Sarah B

    Sarah B Active Member

    I had a patient only last year with a large nodule just proximal to the 1st MTP joint. It gave her great probelms when walking, but her orthopod surgeon (who operated on her dupuytrens) refused to perform surgery.

    The location of the nodule & the degree of discomfort whe was suffering led to me referring her to a podiatric surgeon, who performed a plantar fasciotomy. I saw the lady several months later, and she was delighted with the results. My surgeon friend tells me that aggressive surgical treatment of such nodules produces very satisfactory results. (He does not, of course have statistically sound data to back up this claim.) He has around 20 years' experience in foot and ankle surgery, by the way.

    Sarah
     
  14. facfsfapwca

    facfsfapwca Active Member

    We do not do surgery that we believe will not have satisfactory results. Occasionally, rarley excision is warranted.
    Fasciotomy as you described did not mean the nodule was excised just the pressure from the tight PF released by the Podiatrist. The Podiatrist did not excise the nodule for the same reason most of us do not unless there is no other alternative.

    Sarah what is your speciality and training?
     
  15. Freeman

    Freeman Active Member

    I have seen many people over the past 25 years with plantar fibromas. Interestingly, quite a few have concurrently had Dupuytron's. I generally encourage patients to relace to the 2nd or 3rd eyelet to reduce strangling effect of laces on the first ray. Insofar as an orthotic is concerned regardless of whether it is rigid, semirigid device, or even soft, I always put in an accommodative groove to reduce the plantar pressure on the fibroma. Addtionally first met cut out even though the frst may not be plantarflexed....and often a 2-5. Anything to reduce the pressure along the arch. I have seen some surgeries go bad... most surgeons I know prefer no to operate on them before trying other non-surgical options.

    Best regards to all
    Freeman
     
  16. I've seen a fair bit of duputryns referred me in the NHS. Got about half a dozen at the mo in ongoing care packages.

    Based on experiance i would say that conservative measures can very definatly be useful and hold off the need for surgery for some time. That said i've had little success with rigid orthoses.

    The dichotomy here, IMO, is that we want to limit the tensile trauma to the vulnerable planter structures (support) whilst at the same time not aggravating the nodules by placing something hard under the area of the foot which is already sensitive!.

    Based on trial and error the best solution i have found is a laminate of 6mm diabet soft (a slow recoil memory foam often used in diabetics with PVD) over 6mm high density EVA for support. I cast the foot in whatever position seems best for that patient which is usually a neutralish position with the windlass engaged (foam box taken with the hallux dosiflexed and the reaerfoot controlled medially). Depending on the prominance of the nodules i will often also mark their position on the foot with a water pencil or lip liner pencil and make an indentation in the foam of about 5 mm to create cavities in the cast where the nodules fall.

    I rarely cover these devices as i feel this detracts from the effectiveness of the memory foam. As such they rarely last more than a year which is fine in the NHS but i can see how this could cause problems in Private Practice.

    Then again if it works, £200 odd quid per year is not a huge sum...
    Hope this helps

    Robert
     
  17. facfsfapwca

    facfsfapwca Active Member

    Last two Dr agree I like the groove idea our lab calls it a "zotch notch"

    We agree the fibroma's are really scarring from tears and we need to keep pressure off effectively.
     
  18. Sarah B

    Sarah B Active Member

    Hello facfsfapwca (hope I spelt it right!)

    To start with I should like to say that I applaud and agree with entirely your philosophy re surgery, and I did not intend to question that.

    As far as I can tell the nodule was excised as well as fasciotomy performed; at least it was no longer present when I saw the patient again (several months after her surgery). As her procedure was carried out privately I was not privvy to the exact details of the surgery carried out.

    To be honest, there was no way I could conceive of achieving a reasonable outcome for her conservatively, due to the site of the nodule itself and its very large size. Her co-existing problems with the other limb made it difficult for her to ambulate with no 'good' limb, and the whole thing was making her life rather miserable. The patient herself is aware that the long-term outcome may not be ideal, but as she is very mature & struggles with her mobility due to the affects of polio on her other leg, was really keen to achieve even a year or two of relief and improved mobility.

    I'm a UK degree-trained podiatrist, and I work partly in biomechanics (but am the first to admit I don't know it all) and partly with a pod surgery team (pre-op triage, intra- & post-op care).

    I do not make any pretension to be a surgeon, & I don't believe that any one of us has all of the answers, but I do believe that most procedures have their place, however limited that may be. (Please note that I say 'most')

    Sarah
     
  19. facfsfapwca

    Firsty, welcome to the arena! Hope you have fun.

    Do you mind if i call you facf for short?

    Your comments regarding orthotics, specifically

    And

    Are both interesting and challenging!

    Rather than derail what might become an interesting resource on a tricky condition with a debate on the relative merits of types of orthotics i've started a thread entitled "types of orthotic". Perhaps you might like to enlarge upon your statements there?

    Many thanks

    Robert

    PS, Being pedantic i did'nt actually say i used a groove, i use specific indentations for the nodules. But as i say thats just a point of pedantry.
     
  20. I like this boy/ girl, this post made me get out my potato peeler and a pot of salt.

    Perhaps you'd like to introduce yourself, so we can get an idea of where you are coming from, then please define "soft crap" and tell me all about "correction" and the reliability and predictive value of your measurements. :drinks
     
    Last edited: Feb 9, 2009
  21. LOL! Back to the babies huh?

    Fluffy now, remember? And please lets move the "soft crap" debate to the thread i started on it and keep this one for duputryns;)


    Robert
     
  22. I'll say this once and once only, if people don't like what I write, or the way in which I write it, they should not read my posts. I don't care. You all have a choice. Read or don't read- flip a coin if it helps. I scroll past many posts on a daily basis. When I've said too much, Craig will stop me posting any more. Until that day...

    Now to "soft crap", how soft is too soft? I recall a study recently that demonstrated sham, flat, softy soft soft "orthoses" had a kinematic effect http://www.podiatry-arena.com/podiatry-forum/showpost.php?p=64648&postcount=67

    I'll discuss this wherever you like.:drinks
     
  23. drsarbes

    drsarbes Well-Known Member

    So, Simon, how do you really feel? haha

    My 2 cents on this thread.......PLEASE stop using the term Dupuytren's to describe this lesion on the foot. This is a plantar fibroma.

    Steve
     
  24. Hurt, heartbroken, unworthy, sarcastic.
    AGREED.
     
  25. FACFS:

    I find it interesting that after only 8 posts on Podiatry Arena, and not telling us anything about yourself, you are asking Sarah, who has 31 posts and uses her name in her posts, to tell you her specialty and training. I would think if you want to know more about someone on this forum, you could show them enough respect to tell them what your name is, what your specialty is and what your training is. It would be a lot more easy if you properly introduced yourself to the rest of us so we know where you are coming from when we read your unusual thoughts on foot orthoses and your foot surgery recommendations.:drinks
     

  26. FACFS:

    Amfit is a foot orthosis that is made from EVA (ethylene viny acetate) from a 3D contact digitizer model of the foot. It is not an "over the counter" product. It is likely better than a "Root Orthosis" in many applications since it actually has a forefoot extension as an intergral part of the orthosis.
     
  27. facfsfapwca

    facfsfapwca Active Member

    my credentials are facfs I was also Board certified in Podiatric orthopedics for 20 years.
    my views were not unusual I noticed most respondents did not recommend removal of plantar fibromata as a first choice. They all supported the idea of orthosis and agreed with my opinions.
    Good support takes the strain off plantar fascia. To be supportive it should be custom and support twice the body weight on each foot.

    Since people take offense easily(even when I agree with them) I will not reveal my name. I will no longer trouble you with my "controversial opinions" I will avoid this site.

    I wish you well.
     
  28. Ryan McCallum

    Ryan McCallum Active Member

    Interesting thread.

    Does anybody have any experience of injecting fibromas with corticosteroid?

    I have only recently started doing this (I have injected probably 5-6) and have had good outcomes in all cases- reduction in pain levels and size of the fibroma.

    I find it hard to actually inject into the mass but injecting 'around' and deep to it seems to work well for me. Obviously if injecting superficial to these fibromas, you run the risk of skin breakdown so I avoid this and have thankfully had no complications thus far. Also a painful injection to have done I'm told!!

    Would be interested to hear anyone's thoughts or experience with this.

    Regards,
    Ryan
     
  29. Let's clear some things up here so we can make this a useful thread for those interested in this fairly common foot pathology.

    First of all, there is no such thing as Dupuytren's disease that affects the foot. Fibromas that occur within the central component of the plantar aponeurosis (i.e. plantar fascia) describe the condition that is called Ledderhose (or Ledderhose's) disease, first described in 1894 by a German surgeon, Georg Ledderhose (Ledderhose G: Über Zerreisungen der Plantarfascie. Arch Klin Chir 48: 853–856, 1894). Duputren's disease is named after Guillaume Dupuytren (1777-1835) a French surgeon that first described in 1832 a surgery to correct the contracture of fingers in the hand that occurs with this disease.

    Both Ledderhose disease and Duputren's disease are forms of palmar-plantar fibromatosus, the most common type of fibromatosus in adults (Allen RA, Woolner LB, Ghormley RK: Soft-tissue tumors of the sole: With Special Reference to Plantar Fibromatosis, JBJS, 37:14-26, 1955) [see article attached below].

    The lesions of the palmar and plantar fibromatosus are grossly and histologically nearly identical to each other. In the foot, the lesions of Ledderhose disease are also known as plantar fibromas. Treatment of plantar fibromas generally involves accommodation of the insole (cutting out the insole of the shoe around the fibroma) or making an orthosis with a plantar accommodation for the fibroma. Intralesional injection of long-acting cortisone solution, such as Depo-Medrol, with multiple punctures throughout the substance of the fibroma will shrink the lesions approximately 50% within 4-6 weeks, from my clinical experience. Also, transdermal verapamil 15% gel has been used for the last 10 years to treat plantar fibromas, which I have not had any personal experience with.

    I have treated many of these cases of plantar fibromatosus both conservatively and surgically. Care must be taken when these fibromas are surgically excised in the foot since regrowth of new fibromas may occur within the fascia post-excision. If multiple, large fibromas are present and conservative care has not made them non-painful, then a radical plantar fasciectomy (excision of nearly the whole central compenent of the plantar aponeurosis with a long plantar incision) is indicated which, in my experience, has been a very gratifying surgery for my few patients that have required it. Of course, the patient may expect some lowering of the arch of the foot post-surgically, but since these patients typically have a higher than normal medial longitudinal arch height, the surgery does not normally seem to cause abnormal biomechanical effects on the foot.

    Hope this helps.
     

    Attached Files:

    Last edited: Feb 10, 2009
  30. Ooops. We've done it again! Somebody call the waaaambulance!

    [​IMG]

    Seriously though. This is a discussion forum. The key word being "discussion". If you just make sweeping statements as fact and refuse to discuss them what is the point?!:bang:

    How boring would this forum be if it was comprised of one member stating an opinion and everybody else simply agreeing? I get the impression that many who post here are not used to being challenged and find it threatening.

    I suppose we are doomed to never know what is meant by

    Unless anyone else can enlighten me.

    Thanks for the information Kevin and Steve. Useful as always. I must admit i was taught this as simply "duputryns" in both hands and feet. Correct and accurate terminology vital if we are to progress our understanding.

    Kind regards

    Robert
     
  31. This is just another American podiatric surgeon that is more used to being the true authority on all podiatry-related subjects rather than being a willing student. These individuals make broad, sweeping statements that are inaccurate, they don't like being corrected and thinks that Root biomechanics is still the one and only way to make "correct" foot orthoses. I have met hundreds of these individuals over my last 24 years of teaching here in the States.
     
  32. drsarbes

    drsarbes Well-Known Member

    "Since people take offense easily(even when I agree with them) I will not reveal my name. I will no longer trouble you with my "controversial opinions" I will avoid this site."

    Well there is a self fulfilling prophesy.

    Kevin, I liked your post, very educational and thorough, as usual.

    FACFS...no need to leave, really. A bit of thicker skin and don't be afraid to put your name to your posts and this site can be very informative and somewhat addictive (and yes, fun too)

    If you are board certified with experience, it would be a shame not to share your knowledge with others.

    Steve
     
  33. Steve The Footman

    Steve The Footman Active Member

    I have a number of patients currently with plantar fibromas. Some have had surgery previously but this has not given complete resolution of the lesions.

    Like Robert, I like to mark the lesions on the casts to accommodate them. I prefer to use a casted Cad/Cam orthotic from generally low density 260 EVA. I get the orthotics back uncovered then deepen and lengthen the cavity for the lesion. I have the patient try them uncovered first to gage comfort and then cover them with multiform (a very low density EVA cover).

    I have found that most patients will get significant relief just by reducing the pressure on the lesions. The orthotic otherwise is prescribed based on their structure, biomechanics and extra pathology.
     
  34. You put it far more elegantly than I!

    Out of interest what to you use to deepen / lengthen the cavities? I use a finger grinder on a high speed power drill to modify orthotics directly but i'd be lying if i said i was happy with it! Polyprop is of course easier to do with a heat gun.

    Kind regards
    Robert
     
  35. Jbwheele

    Jbwheele Active Member

    I loved the "softy soft soft " part and I Learned something new. I never new about the Ledderhose guy . Thanks Dr Kirby! I even think we called it duputryns of the foot in Uni? I must tell my Viking friends.

    Cheers

    Joe
     
  36. Jbwheele

    Jbwheele Active Member

    Is it common to get ledderhose (plantar Fibrosis) and severe inversion/ cavus of the foot? I had a client who had that and Diab Neuropathy (which may have caused the Cavus foot as well) But you would think the tension on the PF would increase cavus..ness..(poor grammar)

    He had nodules which didnt bother him due to neuropathy however developed an ulcer which we offloaded as described with a softy soft soft EVA heat moulded device / orthosis ......crap thingy? lol it worked well........

    Cheers

    Joe
     
  37. Steve The Footman

    Steve The Footman Active Member

    Hi Robert,

    I use a small hand drill called a Dremel. You hold it like a fat pen. The main thing about it is the shape of the sandstone block on the end. It has a gentle curve into a blunt end. It just takes a little practice to create a smooth cavity. The hand action is more of a graceful sweep then a grind. I let the rotation of the drill carry it along and control the pathway. You use more of the point to get the depth and then more of the edge to smooth it out. I used to fill the cavity slightly with Poron but have found that is not necessary in most cases if you can get the cavity in the right place.

    I have found the width does not seem to be an issue but the length needs to have a more gentle skive. The 1.6mm cover does help to cover up any rough edges.
     
  38. David Smith

    David Smith Well-Known Member

    Robert, Robert! Robert! Robert! Robert! Robert!


    Aha bit o Fighting spirit next:boxing:

    Sharpen your pencil and poke him in the eye, you'll be peeling babies next.

    Is Simon rubbing off on you?

    OOH!Suit you sir

    Nice one :drinks

    LoL Dave
     
  39. scottie

    scottie Member

    Thanks. Since I initiated the thread this is the explanation I was hoping for. As a non-academic,I find this forum useful although sometimes over my head! But you guys do the academia stuff and I'll simplfy it in my clinic and continue to get good results!
     
  40. musmed

    musmed Active Member

    Dear Ryan

    I have been performing and referring fibromas for steroid injection for 20 years. I use a combination of steroid and L/A in and around the fibroma under ultrasound guidance only.

    I only inject the fibroma that hurts. Often there are several seen on U/Sound and the smallest may be the most painful.

    I tell them that their foot will be needle sore for a few days and most accept that.
    Prio to injection I spray ethyl chloride to the site and this numbs the skin so entry is accurate because the patien does not move.
    Finally I aks them to bring two pairs of thick socks. They wear 2 on the sore side and one on the normal for 2 days.

    Results excellent despite the problem may have been driving the patient nuts for years on and off.
    Regards
    Musmed.
     
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