Needle aponeurotomy alternative to open fasciectomy

“Treatment of Dupuytren’s contracture has undergone a seismic shift over the past decade. As surgeons, we are left with more questions than answers on how to treat these problems in the small finger—or in any finger,” said Martin I. Boyer, MD, FRCS, during “Dupuytren’s Contracture of the Small Finger PIP Joint: Treatment Preferences in 2011,” a symposium held during the American Society for Surgery of the Hand annual meeting.

Dr. Boyer, who moderated the session, assembled a panel of thought leaders on Dupuytren’s contracture to discuss different treatment options, including enzymatic fasciotomy, a collagenase injection treatment approved by the U.S. Food and Drug Administration in 2010; dynamic external fixation, or the use of gentle force to stimulate the growth of contracted soft tissues; and open fasciectomy and percutaneous needle aponeurotomy, which are the topics of this article.

Open fasciectomy yields access
According to William B. Kleinman, MD, of the Indiana Hand to Shoulder Center in Indianapolis, open fasciectomy has been the gold standard for treating Dupuytren’s contracture. During open subtotal palmar fasciectomy, the surgeon releases the contracture by excising the fibrous attachments between the palmar fascia and its surrounding tissues. The goal is to eliminate all diseased tissue and attain long-term absence of recurrence and full, painless range of motion (ROM) of the involved digits.

“Open fasciectomy yields access, and access is what it’s all about,” said Dr. Kleinman.

However, the procedure isn’t suited for every patient, or every surgeon. As Dr. Kleinman emphasized, each Dupuytren’s contracture patient differs biologically and with respect to compliance, motivation, anatomic variation, age, and subdermal fascia involvement.

“Open subtotal palmar fasciectomy requires respect for the vast biologic differences among patients,” he said. “It also requires that the surgeon have an intimate knowledge of anatomy, a high technical level of skill, and confidence based on experience—he or she has to be good at the procedure.”

According to Dr. Kleinman, the delicate procedure involves making appropriate incisions to remove all the diseased tissue, designing viable skin flaps, and meticulously performing radical capsulectomies as needed, all while protecting the neurovascular bundles.

“If all goes as planned, the end result is full proximal interphalanged (PIP) extension,” he said. Unfortunately, not all surgeries are that successful. In addition to being technically demanding, open subtotal palmar fasciectomy can also result in complications, such as joint stiffness and hematoma.

“Hematoma is still the biggest complication of open subtotal palmar fasciectomy. Meticulous hemostasis must be achieved by electrocautery before the surgeon closes the flaps, inserts the drains, and applies the dressing,” said Dr. Kleinman.

Successful outcomes also depend on a cooperative patient who is motivated to follow the rigorous postoperative rehabilitation protocol.

“This is a massive operation for a small part—the swelling is considerable. It is very important to elevate the hand immediately after surgery,” said Dr. Kleinman. “The following day, active, active-assisted, and passive ROM exercises are started. Interval splinting of the digit in full extension between exercises continues for 6 weeks postoperative, followed by night splinting for 6 months. This is done to preclude prolonged PIP flexion (eg, during sleep) during the 6 months of healing of fibrous connective tissue. Once tissue quiescence has been reached, night splinting can be discontinued.”

The appeal of needle aponeurotomy
An alternative to surgery, needle aponeurotomy (NA) is a minimally invasive procedure performed under local anesthesia in the surgeon’s office or clinic. During NA, the surgeon uses a small (25 gauge) hypodermic needle to puncture and weaken the cords at multiple locations in the palm and finger (Fig. 1). Once the cords are weakened, the surgeon gently pulls on the finger to straighten it. The entire procedure takes less than 1 hour, requires no incision, and results in minimal pain and swelling.

Used in Europe for many years, NA is a fairly new treatment in the United States. According to Donald Lalonde, MD, a plastic surgeon from St. John, Canada, the popularity of NA is increasing, as evidenced by the literature as well as his own experience.

“My patients love NA. They love that they can be treated in the office and go home right after and are back doing everyday activities—even playing golf—in days instead of weeks,” he said.

Complications such as skin tears, nerve injury, and tendon rupture, however, have been associated with NA.

“To avoid skin rupture, put the needle in loose skin that is not completely adherent to the cord,” Dr. Lalonde recommended. To avoid nerve injury, Dr. Lalonde uses the needle in a perforating (up and down) movement, rather than a sweeping (side to side) movement. “I also use a Doppler ultrasound to make sure there is no nerve/vessel in the loose skin I am perforating.”

Dr. Lalonde admitted that NA is associated with earlier recurrence of Dupuytren’s contracture compared to surgery, but pointed out that neither treatment is a cure for the disease. The goal is to manage the patient’s disability as best as possible.

“When repeat treatment is required, I find that NA is easier and that my patients prefer it to surgery,” he said.

Disclosure information: Dr. Kleinman—Acumed; Dr. Lalonde—ASSI Instruments, American Association for Hand Surgery board, HAND editor, Plastic and Reconstructive Surgery editor.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

Bottom line

• Although frequently considered the ‘gold standard’ for treating Dupuytren’s contracture, open fasciectomy is a technically demanding procedure that can result in complications such as joint stiffness and hematoma.
• Patient compliance with postoperative rehabilitation is essential for the successful treatment of Dupuytren’s contracture with open fasciectomy.
• Needle aponeurotomy (NA) is an office-based procedure that may be more appealing to patients because it requires no incision and results in minimal pain and swelling.
• Associated complications with NA include skin tears, nerve injury, and tendon rupture.

References

1. Beaudreuil J, Lermusiaux JL, Teyssedou JP, et al:. Multi-needle aponeurotomy for advanced Dupuytren’s disease: Preliminary results of safety and efficacy (MNA 1 Study). Joint Bone Spine Feb 2011 (e pub ahead of print).
2. van Rijssen AL, Gerbrandy FS, Ter Linden H, Klip H, Werker PM: Comparison of the direct outcomes of percutaneous needle fasciotomy and limited fasciectomy for Dupuytren’s disease: A 6-week follow-up study. J Hand Surg Am 2006;31(5):717-725.