Needle Aponeurotomy also known as Percutaneous Dupuytren’s Release is a non-surgical procedure performed in a doctor’s office using local anesthesia to help straighten fingers bent by Dupuytren’s contracture.  It is one of several techniques to treat fingers bent by Dupuytren’s disease.

In Dupuytren’s disease, a layer of tissue just under the skin of the palm becomes hard and shrinks. Dupuytren’s may result in a lengthwise tightness beneath the skin of the palm which keeps the fingers from straightening, called a “cord”. With needle aponeurotomy, a physician lengthens a tight cord by cutting it beneath the skin with a small needle, usually at several points along the line of tightness.

Technically speaking, needle aponeurotomy is a type of procedure referred to as a percutaneous fasciotomy. “Percutaneous” means going through the skin with the smallest hole possible, and “fasciotomy” means cutting fascia, which is the layer under the skin affected by Dupuytren’s disease.

DOES NEEDLE RELEASE CURE DUPUYTREN’S DISEASE

No. It helps to relieve the contracture by releasing the tension in the fascia allowing the finger to be straighter. There currently is no medical or surgical cure for Dupuytren’s contracture. All procedures and treatments can result in recurrence.

CAN IT TREAT OTHER CAUSES OF BENT FINGERS

No. It is only used to treat Dupuytren’s contracture. Bent fingers caused by trauma, arthritis, trigger finger, or medical conditions producing hand stiffness such as reflex sympathetic dystrophy, scleroderma, or diabetic stiff hand syndrome cannot be treated with needle aponeurotomy. Considering the number of causes of “bent” fingers, it is important to confirm the correct diagnosis with your physician prior to initiating treatment.

LIMITATIONS OF NEEDLE APONEUROTOMY

NA is usually not appropriate for hands which are persistently painful, tender, or swollen.

NA may not be technically possible when the skin has lost its stretchiness

• The skin itself has shrunk or hardened too much.
• There are tight lengthwise scars from previous surgery.
• There are skin grafts in the middle of the contracted area.
• The skin over the cord is hard, scarred, or nodular (lumpy).

• Nodules are hard lumps in the palm where the Dupuytren’s process is the most active. If a cord is like a string, a nodule is like a bead on that string. Nodules are unfavorable areas for NA, and if nodules involve long areas, it may not be possible to perform NA. However, nodules usually shrink and soften after a cortisone shot, and it may be possible to treat the area with cortisone shots and return in a few months to perform NA.

• PIP contractures are difficult problems for both traditional surgery and NA, and partial rather than complete improvement is to be expected. On the average, PIP contractures over 45 degrees are improved about 50 percent with either NA or traditional surgery.

• Severe contractures or combined contractures of both the MCP and PIP joints may require two sessions, several months apart, in order to gain the maximum benefit. Two sessions are usually required for Stage III and IV contractures. Remember, the goal of NA is improvement without a long recovery period. Severe PIP joint contractures and severe combined MCP and PIP contractures are rarely restored to normal, even with traditional surgery.
• Secondary problems may limit the usefulness of NA. When a finger joint has been too bent too far too long, the joint itself may become stuck, even after the Dupuytren’s cord has been released. This is most common with PIP joint contractures. Also, the tendons which run on the back of the finger which straighten the PIP and MCP joints may stretch out or slide over to the side of the knuckle, no longer able to pull the knuckle straight. If this happens, the contracture will likely recur after NA, and traditional tendon reconstruction surgery should be considered.

ADVANTAGES OF NEEDLE APONEUROTOMY

• Because it’s less invasive, NA can be performed at an earlier stage than surgery.

• Repeat NA after NA is fairly straightforward. Repeat surgery after surgery is not.

• Complications after open surgery are much more common than with NA.

• The biggest advantage of percutaneous treatment is the short recovery time.  Both hands can be treated over a few days and in most cases, normal activities resumed with one to two weeks. This is clearly an advantage over open surgical treatment.

WHEN IS NEEDLE APONEUROTOMY POSSIBLE?

The percutaneous treatment of Dupuytren’s contracture is always an option if the following are present:

• A lengthwise cord is present, and can be felt beneath the skin
• The skin is supple enough for the procedure: not too scarred, shrunk or hardened – the skin has to have some “give” or stretch left.

CAN IT BE USED FOR SIGNIFICANT CONTRACTURES?

As long as the skin is acceptable and clear cords are present Needle Aponeurotomy is an option.  Often in severe cases, two sessions, three months apart, may be needed to achieve the most benefit.

WILL NEEDLE APONEUROTOMY MAKE YOUR FINGERS PERFECTLY STRAIGHT?

In a word – no.  Although there are patients who have achieved perfectly straight PIP joints after Dupuytren’s Contracture release, this is an unsolved mystery in our profession.  Whether the treatment is open surgery, percutaneous treatment, or another approach, we can never fully predict the end position you will achieve.  Just like we cannot predict if and when it will reoccur.

There is no way to guarantee anything in medicine other than the fact that we try our best to achieve optimal results.  Dr Grabow will estimate the likely improvement based on you pre-procedure measurements but even this is only a rough estimate. We have had patients gain full extension over a two-week period after his procedure due to diligent use of a night splint.  Additionally we have had individuals gain full extension at the time of treatment.

The goal of the NA procedure is to get your fingers noticeably straighter without the risks and the ordeal of traditional open surgery.

WHY IS IT HARD TO GET THE PIP JOINT STRAIGHT? SHOULD YOU HAVE SURGERY INSTEAD?

PIP joint stiffness is the toughest problem facing a hand surgeon. If it involves the little finger, you may even see us shed a tear.  There is currently no solution to this difficult problem. The way the joint is shaped on the inside makes it prone to getting stuck with a bend if it sustains any injury or chronic condition. You can develop a permanent bend in the joint from a sprain, tendonitis, or from having surgery on the joint itself. When the joint is bent close to ninety degrees, surgery may give a better improvement than NA, but it is very unpredictable.  If a patient’s primary goal is a straight finger, and motion (bending) is not that important, there are several options available to provide a straight finger.  Unfortunately,  if you need the finger to be able to straighten AND bend (like most of us do) we are faced with a challenge.  You can see that this is a complex topic and is best addressed individually.

NEEDLE APONEUROTOMY vs SURGERY: WHICH IS BETTER?

Unfortunately there is no clear answer to this common question. It depends on your goals and expectations with treatment, your interest or willingness to participate in therapy, and your patience with the post-operative recovery process.

Dr.Grabow offers several forms of treatment for Dupuytren’s Contracture including surgical fasciotomy, limited fasciotomy and external fixation, as well as needle aponeurotomy. After a thorough exam and discussion of treatment options, a treatment plan is chosen.

When a patient being a good candidate for both surgery and percutaneous release, here are the facts:

• Because it’s less invasive, NA can be performed at an earlier stage than surgery.

• Recurrence is a problem with any treatment, but is more likely following NA than surgery. 50% recurrence at 5 years with open surgery and 3 years following percutaneous release.

• Contractures of the proximal interphalangeal joint (the knuckle in the middle of the finger) are more reliably treated with surgery than NA. However, most studies show that complete correction of PIP contractures, especially for the little finger is usually only 50% and that recurrence is extremely high with all forms of treatment.

• Repeat NA after NA is fairly straightforward. Repeat surgery after surgery is not. The complication rate for secondary open surgery for Dupuytren’s is much higher than primary surgery, in many studies double the rate. Which is somewhere between 30 – 40X the rate of complications with needle aponeurotomy.

• Complications after open surgery are much more common than with NA.
• The biggest advantage of percutaneous treatment is the short recovery time.  Both hands can be treated over a few days and in most cases, normal activities resumed within one to two weeks. This is clearly an advantage over open surgical treatment.

WHAT ARE THE RISKS OF NEEDLE RELEASE?

There is no cure for Dupuytren’s contracture. Nodules, cords, and contracture have a 50% recurrence in 5 yrs with open surgery and a 50% recurrence with Needle Aponeurotomy (Percutaneous Release) after approximately 3 years.  That does not mean it will come back,  but there is a good chance. Our treatment goal is to achieve straighter, more functional fingers.

Stiffness

Since Dupuytren’s more often effects older men, the presence of arthritis or hand stiffness in this population is not uncommon. This hand stiffness will not be improved with Needle Aponeurotomy.

After any hand procedure, some inflammation does occur. Needle Aponeurotomy (Percutaneous release) is no different. When a patient already has a reason for finger stiffness, an increase in inflammation of the hand can make the stiffness worse until the inflammation resolves. This is similar to someone with an arthritic hip or knee having pain and stiffness after a lot of walking.

Skin Cracks or Tears

The most common problem with Needle Aponeurotomy is that the skin of the palm may crack open when the finger is straightened. This happens in about one out of twenty procedures. This is easily treated with a small adhesive bandage (Band-Aid®) on the palm until it heals, typically in 7 to 10 days.

Nerve Injury

The Paris group reviewed their results of nearly four thousand Needle Aponeurotomy procedures in 1995 and found a less than one percent incidence of nerve injury. Infection, bleeding and tendon injury were also reported, but in much less than one percent of the procedures. These results compare favorably with the risks associated with open procedures for Dupuytren’s contracture.

Infection

Any procedure that involves breaking the skin with a needle or knife has a potential for infection. The hand is cleansed with alcohol and iodine prior to the procedure and all equipment is sterilized.  However, infection is always a risk, although statistically less than 1% in all procedures.  In general, post-procedure infection in hand surgery is extremely low, even when one considers bigger surgeries with large open wounds.  Considering the minimally invasive approach utilized, infection is uncommon.

Tendon injury

Injury to soft tissue structures such as tendons, nerves, and blood vessels is a risk for all surgical procedures. Tendons can be partially cut or injured with a potential risk of rupture if they are weakened significantly. Like in all hand procedures, we take every precaution to minimize or eliminate these risks.

COMPARISON OF RISKS WITH OPEN SURGERY

Statistically, all the risks listed are over ten times more likely to occur with open surgery than with Needle Aponeurotomy.  Additionally, the significant risk of wound breakdown is almost twenty times more likely with open surgery versus almost zero risk in Needle Aponeurotomy, due to the lack of an incision.