Needle Aponeurotomy: A Shifting Paradigm in the Management of Dupuytren's Disease

Objective:

Surgical procedures for Dupuytren's disease include radical dermatofasciectomy, limited fasciectomy, and percutaneous fasciotomy. Of all these options, the limited fasciectomy, as described by Hueston, is probably the most widely used.1 There is a paucity of contemporary reports detailing the use of percutaenous fasciotomy, and of these few, the majority are not in the English language.2-4

Methods:

By reviewing a clinical series of over 400 patients, treated by a single surgeon, the authors review the indications, technique, and complications of palmar needle aponeurotomy.

Results:

The procedure is performed under local anesthesia without the use of a tourniquet. Before the operation commences, patients are instructed to distinguish pain from a Tinel's sign, as the latter could signify close proximity of the needle to critical neurovascular structures. On average, 1.5-3 cc of local anesthetic is infiltrated intradermally with a 30 gauge needle on a 3 cc syringe. Anesthetic below the dermis runs the risk of an inadvertent nerve block, thereby eliminating patient feedback via Tinel's sign.

The surgeon utilizes a free 18-guage needle as a percutaneous fasciatome to divide the palmar fascia in progressive fashion. The depth of the needle and safety of the procedure can be confirmed by a combination of tactile, auditory, and patient feedback. Whereas incisions are usually closed in traditional limited fasciectomy, open wounds after needle aponeurotomy are allowed to heal secondarily, similar to McCash's technique. The senior author (PB) has performed over 400 needle aponeurotomies. Complications were infrequent: one wound infection, one complex regional pain syndrome, one combined flexor digitorum profundus and superficialis tendon laceration in a patient with prior open fasciectomy/scar tissue, one temporary median nerve neurapraxia that fully resolved, and one forearm-level ulnar artery vasospasm in a patient with Prinzmetal's angina. There were no digital nerve lacerations. Six patients required revision surgery, one of which had Dupuytren's diathesis.

Conclusion: In the experienced hands, needle aponeurotomy is a minimally invasive alternative to open fasciectomy in the management of Dupuytren's disease. Advantages include quick functional recovery, low complication rate, and high patient satisfaction.

References:

1. Hueston, J.T. Limited fasciectomy for Dupuytren's contracture. Plast. Reconstr. Surg. 27: 569, 1961.

2. Elliot, D. Pre-1900 literature on Dupuytren's disease. Hand Clin. 15:175, 1999.

3. Lermusiaux JL, Debeyre N. L'actualite rhumatologique 1979 presentee aux praticien. Paris, Expansion Scientifique Francaise, 1980.

4. Badois, F.J., Lermusiux, J.L., Masse, C., et al. Non-surgical treatment of Dupuytren disease using needle fasciotomy [French]. Revue du Rhumatisme, 60:808, 1993.