NEW LESS INVASIVE TREATMENT FOR DUPUYTRENS
What is Needle Aponeurotomy?
Needle Aponeurotomy is a minimally invasive technique for the management of joint contracture in Dupuytren’s disease. Dupuytren’s contracture is a progressive hand condition that is a result of an abnormal thickening and contracture of tough tissue in the palm (fascia), causing the fingers to curl or bend.
The condition usually begins as a small painless nodule in the connective tissue of the palm that eventually develops into a cord-like band that restricts extension of the fingers, particularly the fourth and fifth digits.
Although fasciectomy, an open surgical procedure requiring anaesthetic, is usually recommended to release the contracture when hand function becomes severely limited, a less incapacitating option – needle aponeurotomy – has recently become available in Canada at the Cambie Surgery Centre.
Needle Aponeurotomy versus Open Fasciectomy
The standard treatment for Dupuytren’s contracture is open fasciectomy, performed as outpatient surgery. After surgery, it often takes 6 to 8 weeks before being able to resume normal activities and not uncommonly 3 to 4 months. Hand therapy 2 to 3 times per week is often part of the recovery program.
Based on published studies, fasciectomy has a 50% recurrence rate about 5 years , and needle aponeurtomy has a 50% recurrence about 3 years. Average improvement depends on the extent of the contracture. Your physician will be able to elaborate during your initial assessment prior to surgery.
Needle aponeurotomy only requires pinhole wounds in the skin and does not provoke the inflammatory flare and long recovery typical of open procedures for Dupuytren’s contracture.
The advantages of Needle aponeurotomy are that it is less invasive, recovery is much shorter and less painful and there is a much lower complication rate. Usually one can return to heavy manual activities within a week of the procedure. For those requiring treatment on both hands they can be treated on consecutive days. Needle Release allows for treatment in patients classified as high risk for surgery or those on anticoagulants.
Needle aponeurotomy is perfomed under minimal surface anaesthesia, which allows the patient to guide the surgeon away from nerves and tendons. The anaesthetic technique greatly reduces the chance of nerve or tendon injury. The puncture wounds are less than a millimetre in diameter and regional tissue trauma is much less from the needle than from a scalpel, which seems critical in preventing the kind of postoperative inflammatory reaction which plagues open surgery.
What does needle aponeurotomy entail?
An initial assessment with your surgeon is necessary to determine if you would be a candidate for this type of procedure.
Appointments are booked at the Specialist Referral Clinic. The initial assessment is about half an hour long. A week or so after your consultation you will be booked for the procedure at the Cambie Surgery Centre.
You will be asked to come a half hour prior to your procedure. The procedure itself is about an hour long and you will need a responsible adult for discharge.
Needle aponeurotomy is performed under local anaesthesia. The surgeon will identify the Dupuytren’s cords by palpation, and Doppler vascular exam is performed when there is a question of neurovascular displacement or “spiral cord. The surgeon will then anaesthetize the skin with a local anaesthetic. The cord is then divided beneath the skin at multiple levels with the tip of a needle. Fingers are straightened with traction to separate the cut ends of the cords beneath the skin, and then a light bandage and a cold pack is applied. Generally bandages can be removed later that day with the resumption of light activities. Post operative pain is uncommon however post operative parathesias are common. They can last for a few days. Strenuous activities are avoided for about a week.
Effectiveness of needle aponeurotomy
With needle aponeurotomy, most patients have an immediate improvement of this measurement in the range of 40 to 80 degrees. The degree or amound of improvement varies with the joint involved, and the severity of the deformity prior to needle aponeurotomy.
Both traditional surgery and needle aponeurotomy are local mechanical treatments for a biophysical problem which has a field effect on the entire hand. Until we have tools to change the underlying biology, all mechanical treatments will continue to have a high long-term failure rate.
As long as the skin remains relatively supple, repeat needle procedures can be performed for recurrent disease.
Risk of needle aponeurotomy
Nerve injury, tendon injury, and infection are each less than 0.1%. This low incidence is due to the anaesthetic technique used, the minimal tissue trauma involved, and the avoidance of tourniquet. Patients with dense skin involvement may sustain a transverse skin tear during release, which heals spontaneously in about 2 weeks.
Which patients are appropriate for this procedure?
Patients who have a measurable loss of motion of their fingers, who have discrete areas of cord or string-like fascia contracted beneath relatively supple palmar skin, and who are mentally and physically able to tolerate the sting of injections into the palm are possible candidates for needle aponeurotomy. Patients who are medically unfit for traditional surgery because of pulmonary disease, anticoagulation, or general ill health are usually candidates as well.