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OK, great. So hopefully we can just make this a little bit interactive. Um Don't be afraid, it's much scary to do this and have it recorded than in front of people that you don't know are being examined. So conquer your fears early, I would say. So we'll just start off with this case. It's a 48 year old male and this is his left dominant hand. Um So if someone could just tell me what they're looking for in the history and then in the examination, that would be great. So who wants to kick her off? Yeah. So OK. Yeah, go for it. So, yeah. So here we can see a clinical picture of a patient who's finger in a sort of flex attitude at the M CPJ and the P I PJ. So and it's of the right left little finger. So in my history and examination, I want to establish, first of all the diagnosis, I want to establish risk factors. I also want to establish what this patient's occupation and hobbies are and what and how this condition is bothering them and what kind of treatments have been tried already. So, so, yeah, So, when it comes to risk factors, I want to know if they're diabetic. Um, if there's a family history, alcohol has been historically put forward as a risk factor as well and possibly epileptic medications as well as another possible. Yeah, you're doing well. And then what about this patient in particular? You want to know how long this has been going on for and how it's affecting them. So you can see he's got quite a marked deformity. Um And he's starting to go into this type deformity because he's had a longstanding history of this P I PJ deformity. Um So this is his do dominant hand. Um He's uh got a manual job um and he smokes as well. So those things you just wanna hone in on early. Um So I think it's really good to get definitions out early. Um So they'll, the next thing that they may ask you is, um you know, what is this most likely to be? Um And you would have in, in your clinical examination, what would you have done to kind of narrow down on in your diagnosis? So you with his history, he's progressively developed this deformity, there's no history of um obvious trauma. Um And it seems to be a fixed contracture with your examination. Is there anything else that you might be looking for to do specifically? So, do a Houston Table Top test that will help me to establish as ah flexion contractures and you know, individually check the range of motion of the M CPJ and the D I PJ by making sure that the opposite joint is hyperflexed. While I try to possibly extend the joint testing. I also want to palpate to make sure to see if there are any obvious nodules and cords. And then, yeah, if I'm thinking about doing surgery, do a neurovascular exam as well. Ok. Specifically in your neurovascular exam, what would you be doing? So, do a digital test, I did check collateral and also sensation, check the tips on the radium and all the side of the digit. Yeah, brilliant, well done. So. Um so it's a fibroproliferative disease of the palmar fascia. It's about 4% overall in the population and then over 20% in those aged over 65. So I think this is only helpful if they start asking about how common is this. So it's just good to have a few very, very sort of overall uh figures for the disease. Uh So, macroscopically, it's characterized by nodules which is a focus of active disease and they are characterized by myofibroblasts which are the active cells. Um and the cord is very, is relatively late stage in the disease. Um And the the cords are relatively acellular. So um the histological phases were originally described by luck. Um This is I only put this up uh in case anyone finds it of particular interest. But um just quickly, you can describe them as having four histological change phases, the proliferative phase, which is the of a nodule, which is a focus of fibroblasts. And that's relatively low in terms of its collagen content, it's well vascularized. And then the involutional phase where cells align themselves along the line of stress. There's an increase in collagen type three type one ratio. That's more of an M CQ question, but it can um just be something to, to know about. And then the cell number and size decreases and clinically a contracture starts to develop and then there's a residual shape where you have the development of cord tissue. Um I think someone's mic is just still on at the moment. So I don't know. Um I in terms of the histology, the myofibroblasts um express alpha smooth muscle actin and that's how you know that these cells are are myofibroblasts. So, fibroblasts begin expressing a smooth muscle actin as they change from their fibroblasts to myofibroblast er phenotype and then myofibroblast contraction in an actin mediated process. So, genetically um there's a number of different textbooks that refer to this as an autosomal dominant condition with variable penetrance. Uh This is based on two papers, one was published in 1999 the other one in 2005. Um I would say that this is quite an old fashioned way of describing this disease. And I would say the most recent um publications actually have shown that it is not an autosomal dominant um disease. But I think it's not, uh it's not unreasonable to say historically, this was DEA described as autosomal dominant with a variable penetrance. However, newer studies um have focused on polygenic risk scores. So, basically, they did um a very, very big study called a genome wide association study and that identified 26 different er, different areas, so different, er, so called single nucleotide polymorphisms. So if you remember a long, long time ago, but the er DNA er helix has got uh paired bases. So you've got your A and T base, for example. So if you substitute one of these bases, so that's a single nucleotide polymorphism. So for example, an A to G substitution will give you um this particular polymorphism. Now, some of them me some of these substitutions mean that the actual amino acids are changed. So then you can see how that can potentially affect the structure of various proteins and therefore their function. But to keep it very simple for your um exam purposes, you can say uh the focus is now on multiple genes and a so called polygenic polygenic risk score um after they identified a number of different variants um that contribute to this disease. So, um the most recent um meta analysis of six genome wide association studies um identified 85 single nucleotide polymorphisms in 56 loci. Um And that was a very large um review of a number of different patients. So um 11,000 cases and 47,000 controls, I've only put this up so that um you can start to appreciate that. It's a lot more complicated than just uh a autosomal dominant disease with uh variable pr. So you can say n newer studies have shown that it's actually a number of different genes that work together to get this disease. Um As you quite rightly said, the uh there's been numerous risk factors for dtrans. So increasing age, male gender, a family history of durans and that's been borne out in the studies that I mentioned. But also in, in twin studies, um alcohol consumption, so moderate and high consumption, both in men and in women, um smoking, manual work, so heavy manual labor, um type two diabetes and high levels of triglyceride and HDL and A actually um having an increased BM I is relatively protective against tris, which is interesting. Um But that's been the newer kind of studies that have shown that um one thing to pick up on, as you quite rightly said is um looking for er ectopic lesions. So, um in your history, uh you would want to establish whether there's any um suggestion that this may be d trans diathesis. So, the patient that we had as a case study had relatively early onset of disease, uh it was uh you want to see if there's any bilateral. So in your examination, you would want to have a look at their other hand as well. And in your history, look at, look for positive family history um and ectopic lesions. So, um the image here just shows these um uh nodules on the, on the um back of the er P I PJ. So Garrett's pa pads um is their eponymous name. Um You can also ask for any pain in painful nodules in their feet. Um And PA is also associated with this. Um The, there's a number of, there's three additions that were added in 2006. So, being of male gender, the early disease onset was reclassified to less than 50 years and some people try to include radial involvement in that. Um So I would probably just leave that one out. Um So the palmar fascia is a structure present in all hands, as we know, um there's a number of different cords which make up the various contractures. So, within the D IP joint, you've got the re retro vascular cord um which runs do sort of the neurovascular structures from uh the proximal to the um uh distal phalanx. And then you've got your P I PJ contracture, which is largely due to a spiral cord, um which is a combination of the spiral band, pretendinous cord and Grace's ligament. So, we'll, we'll go through the anatomy for that in a second. Um And then with your MCP joints, you've got the central cord, um which is disease involving the pretendinous bands. Um the web space. Um So in the digits, er you have the metator cord, which is from the metator ligament and I think most people forget or may, may just forget to do an examination of the web space. So web space contractures can be very subtle, but you do want to know about them and that's the commissural cord and then you've got your um A DM cords as well. So this is just a diagram to remind everyone that you've got your radial ulnar and central palmar fascia. Um And it's quite helpful to just have an idea of where all these ligaments. So this is your distal commissural ligament. Um And you've got your proximal commisural ligament as well. So, you've got all these different contributions to your web space contractures, your pretendinous bands, they and then uh a number of, of other um cords which form from, for example, the net atrial ligament. So, um with regards to the longitudinal aspect of the palm of fashion, you've got the lateral digital sheet. So it's a coalescence of the webspace fashion. It runs laterally to the neurovascular bundle in the digits. Um And the lateral digital sheet has a number of coronal extensions that pass from lateral to medial. And then in uh the main part of the LDS into the pharyngeal periosteum and the flexor tendon sheath. So it's just as a reminder that the Grayson's ligaments are involved in GRS, Cleland's ligaments are not involved. Um So Grayson's ligaments are coronal extensions of the LDS which pass var to the neurovascular bundle. Um whereas Cleland's ligament is a coronal extension of the LDS which passes dorsally to the neurovascular bundle. So I think uh you may remember the, the saying Graysons to the ground Cleland's to the ceiling. So that's that relationship with regards to the neurovascular bundle. Um and just as a summary, we know that the spiral cords which contribute to those P IP joint contractures are a combination of the lateral digital sheet, the spiral bands um from the pretendinous bands and gras liga ligament but not Cleland. So it's really helpful to have that visual um aid there. Um There's a number of er vertical extensions of the palmar fascia. So, these ligaments I don't expect anyone to know, but if you do come across them, um they're basically vertical septations within the palmar fascia. Um And then you also have some transverse extensions of the palmar fascia, which is the notator ligament um which causes your web space contractures. Um And you've got your superficial transverse ligament. So, um we mentioned within your examination, what you'd be looking for. Um So, uh ectopic disease and ask for plan nodules um on palpation. You want to check if there's any nodules and cores and remember the web spaces as well, including the thumb. Um See if the contracture is correctable and to what degree you could say that you would like to measure this er degree of contracture formally with a goniometer. However, we know that there's quite high intra and inter observer variability. So you could say this is approximately X number of er degrees. Um and you mentioned Houston's stable top test. So um special tests, I think digital islands tests are very important to do that. Um whether it's primary or revision surgery, I would do it for both. And then tests don't ask for sensation. So you can do your um seams Weinstein monofilament test for cutaneous sensation and you can do your two point discrimination test. So, um I think it's really worthwhile just being able to show how to do a digital Allens test. So you occlude um both the radio ulnar digital arteries and then um ask the patient to flex their fingers to draw, draw out um all the, all the uh blood and then subsequently release one side and then repeat and subsequently release the next side um with your cutaneous sensation, um just being able to recognize what these things are. So this is your Seam Weinstein one filament test. So I think the main thing to be able to do is I don't think anyone will ever ask you to do this, but I think it's important to be able to at least know what it is. So, um it's a way of testing cutaneous sensation. Um You have a number of these monofilaments which increase in size and the smallest is 2.83 millimeters. Um I think before you do it, just warn the patient that it's not, it's not sharp, it doesn't hurt, ask them to close your eyes and make sure that their hand is supported. So that when you do press on their finger, you don't get any proprioception, um which may help them if they, if they have actually got some cutaneous sensory loss. So we want to make sure that you're not pushing their finger down as you're testing it. Um with regards to two point discrimination, this is a disc discriminator. Um And the norm was five millimeter discrimination um for the digit. So you, you would normally start um with that if it's any. Um if, if that's not intact, then uh you may move to larger um distances. Um If you don't have any of these, you could also say, or you can also test with a paper clip where you just um fashion that distance in the paper clip. So that's just a very rudimentary way of doing it. Um And in terms of your consideration for treatment. Um so your MCP joint contracture over 30 degrees and P IP joint contracture over 15 degrees um and web space contractures. Um It's important to note that the um metacarpophalangeal joint usually can um correct following surgery. Um It's got a cam shape. So it will usually straighten following excision of the tissue with your P IP joint. Um You may have um a flexion contracture which with an associated uh shortening of the fola plate. So you may find that you may have quite an extensive release that might be required if you've got more than 70 degrees of contracture. So your checking ligaments and accessory collaterals. I think the main thing is just be careful with what degree of release you do. Um So your plate release is not recommended. Um because the scarring and loss of flexion is usually more disabling than the flexion form of deformity, the fixed selection deformity. Um So I think in terms of uh fasciectomy, say the obvious, I think when they're asking you what you would consent patients for just, just say um the obvious and er don't be afraid to repeat things or really embellish things. So, um your aim is to improve their range of movement. You do have the risks of wound healing problems, scar infection, neurovascular injury and injury to the surrounding structures. Um Specifically, I would mention cold intolerance, incomplete correction and recurrence, um complex regional pain syndrome and uh need for additional procedures. So, in this patient, you would consent them for a skin graft. Um And I would mention the risk of amputation, so that also increases um as you uh have an increased risk. Um a as you have uh potentially revision surgery, um in terms of numbers to quote, I would say probably a 90 day risk, um, of serious local complications at 1.2% and serious systemic uh complications at less than 1%. Um, there's a number of different numbers that have been thrown out of a number of studies, but I would probably stick with that one. Um, there's a number of studies that have shown uh, various percentage er, risks. I think patients would be very reluctant to undergo surgery if you said that your digital nerve injury risk is 3.4%. This is the most recent um review. Um So they reviewed over 20,000 patients um in the 2018 review. Um and the overall complication rates are 17.4 for fasciectomy. However, you can say again, there's a risk of having a very mild complication and um a a serious local complication. So I would probably stick with the ones that are quoted uh in the nice quote lines. Um One thing to mention is you may be asked about skin closure um and just be able to draw Az Plasty um and explain the various um advantages. So, um your advantages with Z Plasty is that you, you gain length. So with a 60 degree angle, um you gain a 75% increase in length and just practice drawing um and converting a, a straight incision to AZ plasty. So you'd start your straight incision and then draw a dotted line um at 90 degrees to the incision and then mark your flaps at 60 degrees to that dotted line and then cross over the flaps. So I think just be really happy to, to be able to draw that if they do ask you to do that. Um And with the brunners, it's a, this is the exact incision. Um um just make sure that you do say that the apex should be at 60 degrees to prevent flap necrosis um and avoid the neurovascular bundle at the apex. Um Dermofasciectomy. So, um if you may need to take a full thickness skin graft, if there's an increased um contracture. Now, that's usually from the forearm. Um Again, just remember the digital allens test. Um And although you will probably try to make it um the most sort of hairless part of the forearm, um just warn them about the potential for hair follicles to grow within the graft. Um With revision surgery, there is an increased risk of nerve and vessel damage. Um So the nice guidelines um population based study uh show an 8% amputation rate for reoperation with limited fasciectomy following dermofasciectomy. So that's um repeat operation after a primary dermofasciectomy. Um Again, I think it's just important to say that that isn't necessarily in every center, but you do have an increased ri risk um with revision surgery. So, um should we just have another go with this case? Uh So if anyone wants to have a go with this case, just shout. Um I don't mind if no one else is. That's pretty. Um So this is a clinical photograph of a 58 year old male um where there seems to be evidence of a nodule um in line with the ring finger, uh and a cord uh suggesting a possible pretendinous cord. But I would want to obviously examine the patient uh to assess this further. Yeah, great. And um with your history, what would you be looking for? So, again, um similarly to what Simon mentioned earlier, I'd want to get a history about how long they've noted the nodule to be present, whether they had any pain associated with it, um whether they have any other risk factors. So past medical history, um social risk factors, family history, um and also how much it's affecting their quality of life. Um looking at the digit from what I can see, it doesn't look like there's any obvious contracture associated or any significant contracture associated at present. But obviously, you'd want to look at the lateral projection and assess what the range of motion was like um actively as well as passively at the joints. Um brilliant. And so with your examination, you already you already mentioned. So, um so this is a 58 year old gentleman. Um he's uh works with um at, at a desk based job, so he works with the computer. Um He doesn't have any contracture of his fingers. Um It is a solitary nodule you can't see anything on his, uh, contralateral side. Um He denies any ectopic features. Um He says, uh, his dad also had Dre's disease, um, and he is a nonsmoker. Um And, uh, so hasn't had any treatment up to this date. What, what sort of, um, uh, management would you be thinking of offering him? So, in this particular case, I kind of earn more towards non operative management at present. Um But obviously, I would explain to this patient that unfortunately, this most likely looks like Dutton's disease, um which is a chronic disease um where there is no um treatment for the disease, but that any procedures or treatment that we off, no treatment is probably the wrong word, but no kind of um curative treatment for the disease. But that any treatment that we would offer in the long run would be more to maintain function of the hand. And therefore, we do not tend to operate on these patients unless there is significant deformity that impacts their quality of life because we want to try and preserve surgical operations for the future. I would probably inform them of what to expect and say that everyone has a variation as to how quickly the disease progresses. Um and that what kind of signs and symptoms to look out for. Um and probably leave them either with the patient initiated, follow up or discharge them back to the care of their doctor with that advice. And say that we'd be more than happy for them to be re referred back to us if any of the kind of things we've discussed were to occur. Yeah, very good. So, um I think it's very reasonable to discuss that uh you know, f what the future may hold with them. Um I think in this particular case, um you may think about um and again, a non operative way of managing this and this is very much dependent on what's being offered in their sort of re region. So um that's very good, well done. Um So, uh you may have radiotherapy that you can offer them. So this is um recommended by nice only to be used with special arrangements for clinical governance. Um So you'd, you'd really want to know what your local set up is to offer this. Um not everywhere um offers this. So, um if you do have um uh this in your local hospital, um you may, you may want to discuss this with them. Um And also refer to your um radiology team, for example, um your clinical radiologist, they may be able to have that discussion with them and, and assessment either. So, um overall um radiotherapy in the early stages, um 40% have had a regression of symptoms or lack of progression. Um And about 12 to 31% have a recurrence and that's over a four year follow up. Um Some people would argue that it's still better than no treatment. So you'd really want to have quite a specific, um, reason for offering this. So, no contracture. They've had a, a progression of their disease in terms of their palma nodules um, quite recently. Um So, uh they've tried various different protocols. So there's a review article which is quite helpful, just tells you that, um, they've tried various different protocols. Um, but the, the two articles that are, um, kind of the main ones for this, um, was uh one in 2001 and one in 2012. Um, both by, er, with the main Ortho of Siegen Schwitz. So, um, they did a comparative study. So the first one, they looked at 100 and 98 hands, um, group A got a total of uh 30 grades in two series. So they did five lots of three grades in one week, then they had an eight week break and then another five, lots of three grades in one week. Group B had a total of 21 grades, but in one series. So they basically had 77 times, three grades over two weeks. So group two was much more intense than group one. Um, and at 12 months, approximately 50% showed regression at one year. Um, that was 56% in group A and 53% in group B. Um, over a third remained stable. So in group A uh was 37% and uh in group B, it was 38%. Um And the overall disease progression was 8%. Um They did also did a follow up study, um which is a five year follow up. Um And they noticed that um actually the acute toxicity was more common in the single series group as we would expect. Um, the control group did worse than the um radiotherapy group. So, in their, in their further study, um, they also had an observational only control group, but um, the control group for that one did worse than both of the, the radiotherapy groups. So, um, you can see that actually, that's quite a good study to show that radiotherapy can be very useful. Um, if you er, target um, your patients, uh well, and the take home message, um, in terms of toxicity is that a total of 30 grays over two series is better to minimize the side effects. Um So your side effects that you may warn patients about are erythema, erythema dryness, um, desquamation within six weeks of radiotherapy. Um And again, that was more frequent with a single dose, um, than the interval dose. Um, you may get some chronic dryness. Um, and that's again, more common common with a single dose than the, with the interval one, um, no increase of risk of cancer. Um, anecdotally, people may say, well, do you find operating on these people more difficult? Um, after they've had radiotherapy, I think so. Far there's no evi evidence of that. Um So it might just be anecdotally. Um People have thought about postoperative radiotherapy. But again, I think um the risks of wound healing would not be uh taken on by this, you know, that, that, that is a risk if you do postoperative radiotherapy. So at the moment, that's not something that people would consider. Um So, and currently the nice guidelines are that there's no major safety concerns. Um And it's indicated for early disease, but again, uh something that you have to find out locally, what's um what's on offer. Um There is uh another, another study which looked um at radiotherapy for Leder Hoer's disease. Um And again, that was quite well tolerated. Um And most of the side effects resolved in 18 months. Um So that brings us to our next case. Uh Does anyone want to have a go at this one if no one's speaking? Come on, guys, be brave. It's almost almost over if no one is brave. I don't mind. You go very good. Ok. So this is um a 62 year old plumber. Uh He's got an, this is his hand. Um And he's really keen not to take time off work. So just again, just run through what you, what you'd want to look for with this gentleman. So again, patient examination to establish diagnosis, his occupation, how long he's had symptoms for how it's affecting him. Risk factors as discussed before as well and risk factors for serious or progress, progressive or recurrent disease. Um, here to the table top test. I'm again checking individual joint range of motion. Um And then in my history, I'd want to explore what his job is, whether he's self-employed as well because that might sort of have a bearing on why he doesn't want to take time off work. Um, and also risk factors for any surgical procedure. So I want to know if he, if he's got cardiovascular disease or if he's had anesthetic before, if there's been any adverse events from that, um, uh, and also if he's again a smoker or diabetes, any cardiovascular disease. So, having taken all that and going through and establishing what sort of treatments he may have had, whether they've worked or not. Um, ii then, yeah, my management, ah, my management would take into consideration the fact that he doesn't want to take time off work. He's got a major contracture at the N CPJ. So that would be amenable to no fasciotomy, which can be done under local anesthetic. Some centers don't even take these procedures to theater. They can potentially be done in a clinic or just be done as a day case. And that again, obviously would allow him to get back to work pretty, pretty early, maximum off work if immediate range of motion, the caveat is that there is an increased risk of recurrence if he is to go down that route. So he may have to come back for another procedure wave and a fasciectomy further down the line. Yeah. And another thing that you absolutely, you've hit the nail on the head there. Really nice sort of the discussion of, of all your considerations that you're guiding this patient through. Um What in his um clinical examination would you sort of make you lean more towards having um doing a needle fas fasciotomy? So, the fact that it's affecting his M CPJ more than the P if you can't do a fasciotomy, when the P I PJ is majorly affected because you're more at risk of damaging neovascular bundles that's affected by the spinal cord that pushes your neurovascular bundles, media. Lovely. Yeah, absolutely. And you've got this really nice well defined cord there that is very obvious. Um And that would be amenable and to uh percutaneous needle faso well done. That's really good. So, um I should say fio me there. Um So you've got a palpable cord um with lots of, with sufficient skin, you've got a cooperative patient. Um You've got a more pronounced um MCP joint contracture, um not uh P IP joint because of the higher risk of neovascular injury, as you said, um it can be done in clinic. Um and you've got a reduced recovery time compared to um uh fasciectomy. So, um you can advise him that he may be, he, he can uh go back to work potentially one week um post procedure. Um You may get um a more rapid recurrence, as you said. Um And you can't correct uh skin shortage. Um So you just want, you want some Lignan C and a 25 gauge needle, um your needle is used to release the fascia um and then you go into pass finger extension um and you want to just minimize the complications. So um use uh intradermal an anesthesia and monitor your d distal sensibility. So, as you're doing this, um you can monitor that active finger motion while the needle is in is in proximity to the flexors. Um So it's quite good little summary of, of the technique um by eating. So it's an aseptic technique, just get the patient um nice and comfortable. Um Make sure that they've got some support under their metacarpals to facilitate that um MCP joint ex extension um and make sure that you just warn them about skin tears um and a very small chance of nerve um or tendon injury. Um when you're planning the portals, just look at the cord, which in this case is very well defined. Um And you just want to make sure that your portals are about five millimeters apart um and avoid the skin creases. Um And that's because it's more likely to be in proximity of the flexor. Um So you again increase that risk of skin tears. Um You want to try and put your portals in uh areas where there is soft skin and it doesn't blanch, so pink, nice nicely. Um Well, through skin, that's why you want to put your portals. Um And in terms of sensory innervation, um you've got innervation to the skin, the deep dermis, the joint capsule, the digital nerves and the flexing tendon sheath. Um but your subdermal fat and your palmar upper neurosis really isn't, isn't innervated. Um and just be careful with dimpling. So, pimples may be deeper than they appear and they may distort the structures underneath. Um So, and pure calls are only palpable under tension. Um So you just put in your Ligna cane and then you release very slowly with your 25 gauge needle. Um So, in a sort of clear, perfect and sweet motion. Um So, in terms of results, um we already mentioned that there is an increased risk of recurrence. Um I think depending on which study you look at that recurrence risk really does vary quite dramatically. Um I think the main thing to look at is um that it even if it does recur not every recurrence actually requires treatment. Um And if you do end up doing a second PNF, then that is quite effective. So it can still be very effective. Um And your return to work is about 5.5 days, which is pretty good. So this patient I think would really benefit from that. Um They are doing various other randomized controlled trials. So they're doing something called like filling. This is mainly for just those that are interested. I probably wouldn't mention this. I would just stick to saying that this is a very useful mode of treatment with a high success rate in the initial short term and allows patients to go back to work fairly quickly. So overall low complication rate, high satisfaction and you can treat again with if required and that is very successful. Just a quick mention on collagenase. So that was previously used with quite high success. And they did a, a prospective randomized controlled trial and it was shown to be very effective in terms of allowing treating contractures 30 days. However, the drug is no longer available in the UK and it has been withdrawn. So they do still use it in America and it's increasing in popularity. Um But uh it's not available in the UK. Um And actually, it's being used in America for cosmetic treatment. So I don't think it will come back um If at all, to be honest. Um So what do we tell patients? I would say it's not Viking's disease. They have shown that in a study which uh unfortunately, um has this proven that theory, I think patients just like having that. So you can say to them, it's actually not. But um you know, they, they probably will continue telling people that um it is related to the Vikings. Um It's caused by a number of genes that work together to give each person's individual disease characteristic. So the polygenic risk score, um there are a number of nongenetic risk factors implicated. Um And these ones I've highlighted because they're ones that can potentially be uh impacted um through patient management. And it's difficult to predict the individual course, but work is being done, um probably about 21% progression over seven years. Um And again, it really does depend on the individual patient characteristics. Um family history and ectopic disease are positive predictors of progression. Um And if we want to look at the various complication rates, uh I think the main sort of take home message from this study was that um primary surgery uh for, for, for this disease. So having a fasciectomy is a lot lower, lower risk than having a dermofasciectomy. But again, that's more that a re reflection of the complexity of the disease that you're treating because of course, you wouldn't be doing a dermofasciectomy unless you had quite marked contracture. Um in terms of serious local complications, um you can just see uh they're all very, very low risk. So um surgical site infection, they're all, they're all coming in under um less than one. So, wound assistance, wound complications, neurovascular injury, tendon injury, uh amputation, they're all fairly low risk. Um in terms of revision surgery, uh risk of amputation at 90 days following um an operation um depending on what your primary operation was if your primary operation was a dermofasciectomy. Um, and your further procedure is a, um, limited fasciectomy. You've got an 8% risk derma fasciectomy. Um, 2%. So I think this is just to highlight that you really do want to be quite careful about what, um, second operation you, you pick and just be really clear about um, what, what has been done initially. Um, so careful consideration of options for revision surgery. Um And as we said, there is a huge difference in, in what your recurrence risk is. Um But overall, um 33.7% following um PNF and then you've got your uh limited fasciectomy and derma fasciation, which are about 20%. So, um I think those are kind of a good, that's a good summary of the options. So uh do take a detailed history um and throw in occupation and hand dominance really early. Um risk factors and previous treatment. Um Some people heal really well. So they may not remember that they've had an operation on that particular hand. They may think that they've had it on the other side. Um especially people that have had multiple operations. So just be careful about um examination because some people heal very well. Um make it really obvious that you're looking for signs of ectopic disease, um web space contractures and do your special tests. Um And then I think these are just some very, very straightforward numbers to remember, um and just a couple of um key bits of literature that might help you. Um if you were asked for further questions on that. Um So yeah, that's, that's pretty much it. I think one of the things to, to kind of be aware of is learning how to learn. Um So just be quite unapologetic about what's helpful to you. Um And then don't be afraid to repeat lots of stuff in the actual exam. Um And don't worry, even if you think you haven't done very well. Uh I think that's probably not the case. So yeah, train hard fight easy. Thank you, Mia. Um I was just wondering, um uh like you Lucy Aron, anybody who's on the floor who sees quite a bit of Dutton's disease. Um What your thoughts were about referring patients for Radiotherapy for nodule disease because I personally, I guess we don't see a lot of them in clinic because by the time we see them, they have quite advanced disease uh where you're either going down, either a needle fasciotomy as like your most basic procedure all the way down to doing a fasciectomy or dermofasciectomy. So I was just wondering whether any of you had actually referred patients for Radiotherapy cos it's not something that I've done before. So I just wanted to kind of get some feedback on that. I think, I think you, you have to sort of have that discussion with them because if they're not being debilitated by the, the nodules. Then as we've said, radiotherapy is not without its risks. So, um I think it's worth just finding out what your local policy is. The other thing is um maybe some people would not even uh come to clinic as you said, um without a contracture. So having less than 30 degree contracture, they may not have even been uh been been referred to the orthopedic clinic. So I think just raising awareness that this is a potential treatment which can exist and knowing your local guidelines is what I would I would say is the key thing. It's really dependent on er regional availability. So I know where Aaron previously worked in Norfolk, Norwich, there is a service available for this. The indications are fairly limited as you described. But if you have a patient who you think might be eligible and you mention it to them and they are keen, then you can refer them over to that center and there's a certain radiologist who will administer this. So it's, it is an option and it can be mentioned in an exam, but in practice and in most centers it's not commonplace. Yeah, just because I've been sending any of them back home with like a few in the future if there's a problem. So I just thought it's worth knowing because it's not something I really talk to them about. So that's useful to know. Thank you. Yeah, I think as, as Lisa said, it, it's something that it's worth being aware of but locally it's very dependent on where you are. Yeah. Perfect. No.