Percutaneous Needle Aponeurotomy major modality for treating Dupuytren contracture and postponing fasciectomy: Study

Percutaneous Needle Aponeurotomy in Dupuytren's Contracture: the technique

Dupuytren's contracture (DC) is a progressive fibroproliferative disorder of an unknown origin affecting palmar fascia, causing irreversible finger flexion contractures. The metacarpophalangeal (MCP) and proximal interphalangeal joints (PIPJs) are the most affected. Contractures can cause hand deformities and poor hand function, resulting in lower quality of life.

Numerous treatments for symptomatic contractures have been proposed. Physical therapy, steroid injection, radiation, 5 fluorouracil injection, and oral tamoxifen are conservative treatments.

Surgical treatment of dupuytren's disease includes open fasciotomy, partial fasciectomy, radical fasciectomy, dermofasciectomy and percutaneous needle aponeurotomy (PNA). Percutaneous needle fasciotomy has gained popularity in the past three decades which has many potential advantages over open surgery. Nerve injuries are avoided with wide local anesthesia as distal sensibility monitoring is possible during the procedure. The chance of tendon injuries is minimized by monitoring active finger motion. Patients can use their hands and return to work earlier.

The technique by Navaneeth et al:

The procedure of needle aponeurotomy was performed using wide awake local anesthesia with no tourniquet, with an 18 G needle. The cord was palpated by applying pressure and marked using a skin marker.The needle was meticulously inserted in a parallel manner to the skin, with the bevel oriented upward into the cords. Applying stress to the cord moved the needle in both upper and downward directions to sever the cords. Precautions were taken to prevent neurovascular bundles and flexor tendon injury. As the procedure was performed under local anesthesia, any intraoperative injury to the digital nerve could be identified by the tactile withdrawal of the patient. Additional punctures were administered in the same manner along the cord. Following its release, the finger was immobilized in extension using splints. Active mobilization was initiated on first post operative day with an 8 week night splint.

PNA can serve as a major modality for treating Dupuytren contracture or as a means to postpone fasciectomy. Patient results and satisfaction rates are comparable to those of collagenase injection. The recurrence rate is higher as compared to open fasciectomy, especially for younger patients (under 35 years old) and for contractures in the PIPJ. It is cost effective compared to open fasciectomy and collagenase injections. However, it has a steep learning curve, moderate recurrence rate, and faster time to recurrence for PIPJ contracture, with complications including digital nerve injury, neuropraxia, hematoma, skin tears, flexor tendon injury, infections, and recurrence.

Further reading:

Percutaneous needle aponeurotomy in Dupuytren’s contracture.

Navaneeth PK, Bhat AK, Pai GM, Acharya AM.

J Orthop Trauma Reconstr 2024;1:10-3.

DOI: 10.4103/OTR.OTR_9_24