The use of corticosteroid injection for Dupuytren’s disease has been reported in the hand9 and their use for LD in the foot has been discussed (often only in passing) by various authors5,6,10-12. Local steroid injections reduce the rate of fibroblast proliferation and increase the rate of apoptosis13. Ketchum at al14 had previously demonstrated that triamcinolone acetonide softened and flattened hypertrophic scars and keloids and that it degraded the insoluble collagen in hypertrophic scars and keloids to salt-soluble collagen, which was then absorbed and excreted. In a retrospective study9, 63 patients with Dupuytren’s nodules in the early stages of disease underwent a series of triamcinolone acetonide injections. Each injection contained 60-120mg of triamcinolone administered directly into nodule(s) of patients with contracture of less than 15 degrees. 97% (62/63) of patients experienced regression of the disease exhibited as softening or flattening of nodules, with an average of 3.2 injections per nodule reported. Some had complete resolution of the nodule but more (60-80%) experienced definite but incomplete resolution. Although immediate regression of nodules was generally observed, many experienced recurrences and around half of those required further injections 1-3 years after their initial treatment.
Pentland and Anderson11 presented a case study of a patient with bilateral multi-nodular plantar fibromas, recurrent on the right foot after excisional surgery ten years previously. The patient received five intralesional injections of 0.5-1.0ml of triamcinolone acetonide diluted 3:1 with 1% lidocaine hydrochloride to a final concentration of 30mg/ml, at monthly intervals. The reader assumes that each of the lesions had that dose. Considerable softening of the lesions was noted and four months after the final injection the patient was able to resume jogging. They discuss the conflicting results of the effect of corticosteroid injections on in vitro fibroblast collagen production but promote corticosteroid for LD.
A ‘peppering’ technique was first described in 196415 and later popularised clinically for lateral epicondylitis16. Peppering, needling and fenestration are all terms used in the literature across professional groups and across pathologies, in particular plantar fasciitis. We prefer the term fenestration as we aim to create channels within the lesion. We hypothesise that this has the effect of physically breaking down scar tissue while providing an effective portal of entry for the corticosteroid. As such we believe that fenestration confers greater efficacy than use of corticosteroid injection alone. We routinely use 20-30 passes of a 23-gaugue (blue) needle, to patient tolerance, varying depending on the size and turgidity of the lesion and patient discomfort.
Whilst it has been stated that a number of classification systems exist5, the only noted staging system is that developed by Sammarco and Mangone17. They produced a four-stage system incorporating the focal nature of the lesion(s), the extent of fascial involvement, the presence of skin adherence and the depth of tumour extension. The remaining classification systems used for LD are derived from the work of Luck18 in staging Dupuytren’s disease. The proliferative stage is characterised by increased fibroblastic activity and reduced collagen network, followed by the active or involutional stage showing fibroblast maturation, myofibroblast differentiation and increased collagen synthesis. A final residual stage displays both reduced fibroblast and collagen maturation. Whilst it has been opined that corticosteroid injection would specifically help with collagen breakdown at the residual (end) phase of a chronic LD nodule19, corticosteroid injection has been shown to suppress VLA-4 a common integrin integral to cell adhesion in early inflammation20.
The authors have treated over twenty-five patients with the procedure described in the text, whilst outcome data for those patients is anecdotal and/or preserved within medical notes, the authors believe that the majority of patients show significant improvement with the particular combination of fenestrated triamcinolone acetate with a small amount of local anaesthetic. It is recognised that the variability of local anaesthetic as part of the injectate may influence outcomes, as local anaesthetic itself has been shown to cause apoptosis21. Case report two has previously trialled a single injection of methylprednisolone acetate and lidocaine, this was followed by a quick and complete return of symptoms: this is a trend seen anecdotally within our service with the use of methylprednisolone acetate. We have abandoned its use for the treatment of LD.
Whilst a tibial anaesthetic block allowed for procedural anaesthesia in case report one, it should be noted that the majority of patients tolerate local infiltration and fenestration with local anaesthetic added to the injectate only. The use - or not - of concurrent ultrasound guidance is a further matter that is open for debate. Typically, the lesions are sub dermal and easy to identify with the needle tip though Sofka and Adler suggest that ultrasound guidance is useful to help prevent inadvertent injection of corticosteroid to non-target tissues22. With our small case series we are not in a position to state whether the use of ultrasound is an advantage or not. Certainly in those lesions not readily discernible by palpation then the use of ultrasound guidance is helpful.
We have not, to our knowledge, seen a case of fascial rupture or significant tissue atrophy post corticosteroid injection / fenestration but of course this remains a concern. However, given that the surgical option is excision (narrow or wide margin) or sub-total fasciectomy, the occurrence of a partial tear could be considered to be of minimal concern. The authors do however note the mounting evidence to support the use of ultrasound guided injection, particularly in this anatomical region23. Whilst described as an uncommon condition24, Bakotic and Borkowski25 found LD to be the most prevalent of all the plantar lesions identified by histopathology in a series of 401 cases.