Needle Aponeurotomy

Gary M. Pess, MD, FACS, FAAOS

Dr. Pess or an immediate family member has received royalties from Biomet and is a member of a speakers’ bureau or has made paid presentations on behalf of Endo Pharmaceuticals.

INTRODUCTION

Dupuytren disease is a benign fibromatosis of the fascia of the hand and fingers. It begins with a palpable mass or nodule. This is usually located between the proximal palmar crease and distal palmar crease, but the nodule may first present in the finger. Enlargement of the nodule leads to the development of pathologic cords which thicken and contract, causing contracture of the metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints. Other areas affected include the distal interphalangeal (DIP) joint and web spaces.

The most commonly affected digits are the ring finger and little finger (50% to 60%), followed by the thumb, middle finger, and index finger. Dupuytren disease is often bilateral (Figure 1).

FIGURE 1 Photograph of severe untreated Dupuytren disease.

SECTION 1: PATIENT SELECTION

Indications for Treatment

There is no “cure” for Dupuytren disease. Once a contracture occurs, it will not resolve spontaneously. Attaining a perfect correction is not necessary, especially when treating a disease that has a significant recurrence rate. Patients appreciate improvement of function and increase in range of motion, even without achieving full extension. A patient should have palpable cords causing the contracture (Figures 2 and 3).

When considering needle aponeurotomy (NA) for treatment of Dupuytren disease, there are a few helpful principles to be aware of. Specifically, treat early and repeat early. Since there is low morbidity and risk with NA compared with open fasciectomy,¹ it is not necessary to wait for an MP or PIP contracture to reach 30 to 40°. The highest efficacy and lowest recurrence rates are in patients with early contractures and minimal arthrofibrosis of the PIP joint, and thus the principle to treat early. Furthermore, NA can be performed for recurrent contracture after previous treatment with NA,
collagenase, or fasciectomy.² If a contracture recurs, NA should be repeated early.³

FIGURE 2 Photograph of mild Dupuytren disease.

FIGURE 3 Photograph of complete correction of mild Dupuytren disease with needle aponeurotomy (NA).

Contraindications

NA is contraindicated for the release of contracted skin, skin grafts, and scar tissue from prior fasciectomy or dermofasciectomy. It is not used to treat contractures secondary to spasticity or ulnar nerve palsy. When severe, long-standing contractures are present, the patient’s expectations need to be reasonable, and they should be aware of the limited goals of treatment (Figures 4 and 5).

Dupuytren disease consists of a combination of nodules, skin pits and cords. Common cords include (Figure 6):

Pretendinous cord—originates from pretendinous band; begins proximal to the proximal finger crease; contracts the MP joint of fingers or thumb.

FIGURE 4 Photographs of the area of maximum bowstringing is the best location for needle aponeurotomy (NA) portals. A, Before. B, After.
Central cord—located midline between neurovascular bundles and distal to the proximal finger crease; is a continuation of the pretendinous cord, contracts the PIP joint.
Lateral cord—composed of diseased lateral digital fascia; located superficial to neurovascular bundle; contracts PIP joint.
Retrovascular cord—located deep to neurovascular bundle; can contract both the PIP and DIP joints.
Natatory cord—contracts the second, third and fourth web spaces.
Commissural cords (proximal and distal)—contracts the first web space; may be rope-like in consistency.
Abductor digiti minimi cord—contracts the little finger MP and PIP joints; can displace the neurovascular bundle in a volar, midline, and distal direction.
Spiral cord-contracts PIP joint, usually a combination of pretendinous cord, diseased lateral digital fascia and Grayson ligament; can displace neurovascular bundle in a volar, midline, and distal direction.

SECTION 2: PREOPERATIVE (DIAGNOSTIC) IMAGING

There is no special imaging necessary to treat Dupuytren disease with NA. For long-standing severe contractures, especially of the PIP joint, plain radiograph is useful to evaluate the articular surfaces. A radiograph is required if there is a history of an old injury or dislocation. Ultrasonography is not needed preoperatively.

SECTION 3: PROCEDURE

Room Setup/Patient Positioning

Needle aponeurotomy is usually performed in an outpatient treatment room under local anesthesia with
the patient recumbent or sitting up.⁴ For patients with a low pain tolerance, light monitored anesthesia care (MAC) sedation can be utilized in a surgery center or hospital setting. If sedation is used, an experienced anesthesiologist is essential, so that it can be assured that the patient remains responsive to stimuli and communication with the patient is sustained. A tourniquet is not used. Prophylactic antibiotics are not needed. Patients are asked to stop anticoagulation, if possible, but continued use of anticoagulants is not considered a contraindication to the procedure.

FIGURE 5 Photograph shows that needle aponeurotomy (NA) can be performed as long as a palpable cord is present and the contracture is not just due to scar.

FIGURE 6 Illustration of anatomy of pathologic cords. 0 = central cord; 1 = pretendinous cord; 2 = distal commissural cord; 3 = abductor digiti minimi cord; 4 = lateral cord; 5 = natatory cord; 6 = proximal commissural cord; 7 = retrovascular cord; 8 = spiral cord; 9 = thumb pretendinous cord. (Redrawn from an illustration provided courtesy of Charles Eaton, MD.)

Special Instruments/Equipment

A 5cc syringe is filled with 3cc lidocaine 1% plain and 1cc methylprednisolone acetate injectable suspension 40 mg (Depo-Medrol, Pharmacia & Upjohn Co., New York, NY) and prepared for injection via a 25 g needle. Corticosteroid is not used for those patients with diabetes mellitus. Short 25-gauge, 16-mm (5/8-in) length needles are used⁵ (Figure 7). An 18-gauge, 40-mm (1.5-in) needle can be bent to 90° and used for subcision. A clamp or needle holder is useful for safe removal of used needles. Used needles are placed in a basin or needle pad and are not recapped.

Surgical Technique

The patient’s hand and wrist are prepped with antiseptic solution. A stack of folded towels is placed under the hand to aid in extension of the MP and PIP joints. A sterile
surgical towel or surgical drapes can be used to cover the wrist and forearm.

FIGURE 7 Photograph of a short 25-gauge, 16-mm (5/8-in) needle with which needle aponeurotomy is performed.

All abnormal cords should be identified by palpation and marked with a surgical marker (Figure 8). Portal sites are carefully chosen in areas of definite cords and are marked 5 mm apart. Skin creases, clefts, and pits should be avoided for needle insertion, and supple skin is preferable. To minimize the chance of a skin tear, portal sites are chosen over areas of maximum skin mobility.⁶ The ideal locations for NA insertion are areas where the cord is maximally bowstringed, which increases the distance between the cord and the flexor tendons and neurovascular bundles. Care should be taken to avoid the neurovascular bundle when a spiral or abductor digiti minimi cord is present. Only pathologic cords are released.

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