ENDOSCOPIC SURGERY OF COMBINED STAINS OF THE BRUSH AND DISEASE OF DYUPYUTRENE

Thanks to the development of endoscopic hand surgery, the last decade was marked by another explosion of interest of orthopedists to the problem of diagnosis and treatment of degenerative-dystrophic diseases of the hand and wrist joint. Over the past decade, arthroscopy has become one of the fastest growing techniques in orthopedic surgery, also in hand surgery.

The most frequently asked questions on admission from patients:

- I have half-dumb brushes when working on a computer for several months, what do I have?

- My fingers reduce and I can not straighten them, what should I do?

- I can not write with chalk on the board, twist the underwear, twist the screw, hold the child in my arms, what have I got?

- My finger clicks audibly, and now it jammed and doesn’t unbend, what should I do?

I will answer these patient’s questions at the end of the article.

Types of the most common degenerative-dystrophic diseases of the hand and forearm.

1.  Stenoses of the tendon channels of the flexors of the fingers (A.Notta's disease, 1850)
2.  Stenoses of tendon channels of extensors of the fingers (Franz De Kerven's disease of 1895)
3.  Carpal tunnel stenosis (Paget, 1870, Kremer et al., 1953)
4.  Fibromatosis of the hand (A. Cooper, 1822, G.Dupuyitren's disease, 1831)

A subcutaneous endoscopic procedure is described in I.Okutsu et al. (1989) in the "Guide to Endoscopy of Carpal Tunnel Syndrome". Okutsu proposed using a transparent plastic tube, a guide and a standard arthroscope for endoscopic dissection of the carpal ligament.

    We use in our practice our own two-portal technique for surgery for tendon stenosis and palmar fibromatosis.

Types of anesthesia - intravenous and conductive. Mandatory bleeding limb with a tourniquet. Visualization of the operating space is carried out with the help of air, using an air vent tube. The technique can be used in the treatment of all tendon stenosis and palmar fibromatosis:

1. Stenoses of the tendon channels of the flexor of the fingers (A.Notta's disease, 1850)
2. Stenoses of tendon channels of extensor fingers (Franz De Kerven's disease of 1895)
3. Stenosis of the carpal tunnel (Paget, 1870; Kremer et al., 1953)
4. Fibromatosis of the hand (A. Cooper, 1822, G.Dupuyitren's disease, 1831)

Dupuytren's disease (pic. 1 to, pic. 2 during, Pictures 3 and 4 after endoscopic operation on the hand)

Nott's disease or snapping fingers.

    Recognition of Nott's disease in the acute phase is not difficult - the patients paint and describe themselves the main symptom: "clicking", "jumping off", "springs" of the finger when straight, the diagnosis is confirmed by examination and palpation. Prolonged disease is difficult to determine, since the main symptom of "snapping" goes into contracture. We have developed a new, very effective and safe method for the operative treatment of stenosis of the ring-shaped ligaments of the fingers (Knott's disease) (endoscopically, through two accesses at the base of the affected finger conducts a ligamentotomy of the ring-shaped ligament (block A I)  adults and children with a special instrument.

Pic 1. а, b    Stenosis of ring-shaped ligament 1 and 3 of the fingers of the right hand.

We developed a new, very effective and safe method for the operative treatment of stenosis of the ring-shaped ligaments of the fingers (Notte's disease) (endoscopically, through two accesses at the base of the affected finger, a ligamentotomy of the annular ligament (block A I) in adults and children is performed with a special instrument. On the next day, the volume of movements in almost total volume. Pic. 3 a, b, c

Pic. 2 а,b Endoscopic ligamentotomy of ligament A1 of 1 and 3 fingers

Pic.3 а,b,с volume of movements in 1 and 3 fingers of the hand 2 days after the operation

Stenoses of tendon channels of the extensors of the fingers (De Carven's disease).    

The pathology of the first back channel of the extensors tendons of the fingers ( 1st bone-fibrous canal) and its contents - the tendon of the short extensor of the finger 1st and the tendon of the long finger-extending muscle is described by F. De Quervain in 1895 and bears his name - de Quervain's disease (stenosing ligament Ist of the osteo-fibrous canal). This pathology occurs in 80-85% of cases from all stenosing ligament extensors of the fingers of the hand.

Pic.4 а,b De Cervan's disease

     Clinical diagnosis of de Kerven's disease is quite simple - when palpation at the level of the styloid process of the radius, a motionless, smooth and painful tubercle is found.

  

The endoscopic original method of treatment compares favorably with the generally accepted open ligamentotomy with minimal trauma, a relatively short operation time and a significant shortening of rehabilitation.

Pic.5 а,b Open ligamentomy

Pic. 6 а,b,с Endoscopy of the 1 fibrotic canal and the first day after surgery.

Carpal tunnel stenosis or carpal tunnel syndrome.

Carpal tunnel syndrome, caused by compression of the median nerve inside the carpal tunnel, requires surgical dissection of the transverse palmar ligament. Until recently, this procedure was conducted in an open way. The dissection of the skin and subcutaneous tissue by several centimeters in the area of ​​the wrist was necessary to avoid damage to the median nerve during open surgery. Endoscopic access to the carpal tunnel was a satisfactory substitute for open surgery. A subcutaneous endoscopic procedure is described in I.Okutsu et al. (1989) in the "Guide to Endoscopy of Carpal Tunnel Syndrome". Okutsu proposed using a transparent plastic tube, a guide and a standard arthroscope for endoscopic dissection of the carpal ligament. We use in our practice our own two-portal technique for operations concerning the stenosis of the carpal canal. Types of anesthesia - intravenous and conductive. Mandatory bleeding limb with a tourniquet. Visualization of the operating space is carried out with the help of air, using an air vent tube. (Рic.7 a,b)

Pic. 7 а,b Endoscopic ligamentotomy of the carpal ligament and the type of brush at the end of the operation

Dupuytren's disease.

This is one of the most ancient, interesting and mysterious diseases so far. And it makes sense to learn the history of acquaintance with her humanity.

The history of Dupuytren's contracture.

Dupuytren's disease, even after more than 170 years since the first generally recognized recorded description of this disease, stirs the minds of scientists and continues to be a secret to us its etiology and pathogenesis. I must admit that Dupuytren was not the first to mention this disease in his works. In the scientific archives of Europe there are the works of Felix Platter, Henry Cline, and Sir Astley Cooper, who also described this suffering. Guillaume Dupuytren was the first to recognize the important role of pathological changes in the palmar aponeurosis in the development of this disease. He was the first to use the term "affectation" (change) of the palmar aponeurosis. Thurston A. (2003) studied the Astley Cooper’s works stored in the collection of historical medical books in the library of the Cowlishaw College and claims that in 1822 Astley Cooper was the first to describe in detail the contracture of the palmar aponeurosis and recommended therapeutic fasciotomy. His book "A Treatise on Dislocations and Fractures of the Joints" contains this description of Dupuytren's contracture, is in the Cowlishaw collection. On the other side of the Channel, Baron Dupuytren made lectures repeatedly incorrectly quoting Cooper and stating that Cooper believed that the disease was incurable.

Early in 1962 was the first to suggest the origin of Dupuytren's disease in one particular racial group of Scandinavians and explained the distribution of the disease to other parts of the world on the basis of migration from the Scandinavian group in Europe to the British Isles during the Viking Age in the 9th-13th centuries. In the 9th century, this disease in Scandinavia and Europe was known as the Viking disease, in Scotland as the curse of the Grimmon family, in Italy - as the blessed hand of Pope Benedict or the papal sign of blessing. Dupuytren's disease has a "northern origin", i.e. affects the overwhelming majority of people of the Caucasoid race (up to 19.2% of the population) and casuistically rare in representatives of the Mongoloid and Negroid races.

Conservative treatment of Dupuytren's disease.

A number of authors inject triamcinolone, superoxide dismutase, collagenase into the fibrous parts, while achieving a clinical improvement. However, Weinzierl admit that the effect of using enzyme preparations is short-lived and quickly become relapse of the disease. Enzyme preparations have a rather high cost. Of the means of general medicamental therapy, it is recommended to use non-steroidal anti-inflammatory drugs, colchicine, gamma-interferon, nifedipine and veropamine

Surgical treatment of Dupuytren's disease.     

For several hundred years, the only treatment for Dupuytren's disease was surgical treatment and as the perfection of the surgical instruments and the accumulation of our knowledge of Dupuytren's disease, not one dozen methods of surgical treatment of Dupuytren's disease were tried. Brushes of patients in search of optimal operational access crossed along and across, zigzagging and wave-like. The surgical technique of treatment of Dupuytren's disease reached its perfection in the 20th century, but the number of relapses and complications after surgical treatment decreased not much and now amounts to 30%.

    

Since 2000, we have successfully used endoscopic two portal technology in Dupuytren's contracture operations in an original technique protected by several patents for invention and utility model. (Pic. 8,9)

Pic.8 а,b,с Endoscopic aponevrectomy of the hand

Pic.9 After surgery in a few weeks

Answers on questions:

Question: I have half-dumb brushes when working on a computer for several months, what do I have?

Answer: It is quite possible that you have a compression-ischemic neuropathy of the median nerve in the carpal canal or the ulnar nerve in the Guyon canal. Consultation of the orthopedist is necessary.

The question is: My fingers reduce and I can not straighten them, what should I do?

Answer: You probably have developing palmar-finger fibromatosis, with the formation of contracture in metacarpophalangeal and inter-flank joints. It is necessary to consult an orthopedist and decide on the type of treatment.

Question: I can not write with chalk on the blackboard, twist the underwear, twist the screw, hold the child in my arms, what have I got?

Answer: De Quervain's disease. It is necessary to consult an orthopedist and decide on the type of treatment.

Question: my finger clicked, when bending, and now it is jammed and does not straighten out, what should I do?

Answer: At this stage, conservative treatment is meaningless and surgical treatment is required

Question: I want to get rid of the disease on the hand, but I'm afraid to perform the operation, because it's a brush and there's little that can happen after an open surgery through the skin incisions. Can you offer me an alternative?

Answer: An endoscopy of the hand has been an alternative to the open surgery involving skin incisions for 18 years already. The operation is performed through punctures in the skin, movements in the fingers of the brush begin on the day of the operation. The patient can start working 4 to 5 days after the endoscopic operation. For many years of these operations, no serious complications have been reported.