Dupuytren Surgery: Needle Aponeurotomy (Needle Fasciotomy)

Dupuytren contracture surgery risks

Dupuytren surgery is the standard medical treatment of Dupuytren contracture and the  lumps on palms and contractures of fingers it causes; it is known as partial palmar fasciectomy.  In this more invasive approach the palm and affected finger(s) are cut open on the palm side through a large zig-zag incision to enable removal of the abnormally thickened and contracted palmar fascia (thin tissue layer just below the skin).  There are two primary disadvantages of this technique.  The large surgical exposure favors the development of additional scar tissue at the incision site at the lump in palm and related fingers. Secondly, again related to the large incision pattern, intense rehabilitation is necessary to promote adequate recovery, often requiring one to two months of rest during which manual activities are avoided.

Needle aponeurotomy

In the late 1970s a far less invasive surgical procedure, called needle aponeurotomy (NA), or percutaneous needle fasciotomy (PNF), was developed that intended to avoid these problems.  However, while successful in one regard, NA gives rise to other problems for the patient with Dupuytren contracture.

Needle aponeurotomy is a minimally invasive form of Dupuytren surgery performed in the doctor’s office under local anesthesia.   During NA a specially trained surgeon works through the opening of a series of tiny puncture incisions to avoid opening the palm of the hand.   The technique uses needles to puncture and tear the contracting Dupuytren cord and thus weaken it until it can be broken by an abrupt mechanical force delivered by the surgeon, usually accompanied with a loud characteristic “pop.”

As the surgeon uses the tip of a needle to lacerate and divide the thickened and drawn up Dupuytren contracture, that involves a type of tissue called the palmar fascia.  Since there is no major incision there is reduced chance of additional contracture from scar tissue formation or post-surgical infection.

Is needle aponeurotomy a safe procedure?

When performed by a surgeon specially trained in needle aponeurotomy on an appropriate patient, NA is considered very safe. The rate of post-surgical complications (tendon and nerve injury, infection, chronic pain), is approximately five to ten times less likely with NA than with traditional direct and open Dupuytren surgery.  Needle aponeurotomy presents a five percent risk of a skin tear at the surgical site, although these usually require simple bandages for adequate control for skin healing.  Risk of a flare reaction developing after needle aponeurotomy is rare, unlike open incision surgery where this is seen five percent of the time.

Compare needle aponeurotomy and traditional Dupuytren surgery

This brief discussion shows the fallacy or weakness of the needle aponeurotomy procedure.

The frequency of Dupuytren’s contracture reappearing again after needle aponeurotomy is considerably higher than after traditional open hand Dupuytren surgery.  After traditional open hand surgery 50% of patients will experience recurrence within five years time.  This compares to 50-65% of needle aponeurotomy patients who will experience recurrence within just three years time.  It is postulated that the recurrence rate is higher for NA than traditional open surgery because the larger contracting cords are not removed.

While the results of NA are better than conventional open hand surgery for Dupuytren contracture, it does not fully off-set the problem of not only a much higher rate of recurrence of Dupuytren’s contracture after NA but this recurrence appears within a shorter period of time .

Dupuytren’s contracture is likely to return after either surgical procedure, but will return in about half the time if a needle aponeurotomy is performed.  Lastly, since needle aponeurotomy is a fairly new procedure, the scientific literature is just beginning to publish early reports about the long-term effects of this procedure.  These early reviews suggest that when the Dupuytren contracture returns within three years after the NA, the Dupuytren contracture is usually more severe and more widespread than the original condition and does not respond as well to a second needle aponeurotomy.

Post-surgical rehabilitation of needle aponeurotomy

Generally, because it is a less invasive procedure, much less formal hand therapy is needed after NA.  Patients are permitted to return to light work activities immediately, if the work environment allows for limited, gradual and protected work reintroduction; they are urged to keep their hand elevated for two days after NA.  Strenuous manual work and use of the hands, sports, and hobbies are to be avoided for at least one week post-surgery. When there are signs of complications, a customized hand splint can be worn at night and especially during the day until full recovery occurs.

Dupuytren surgery not as safe as Alternative Medicine

Based on the experience of the Dupuytren Contracture Institute using Alternative Medicine methods since 2002 to treat Dupuytren contracture, it is our opinion that a brief therapeutic trial of care be attempted before any surgical intervention is used.   Typically, when an aggressive therapy plan is used in an appropriate manner as described in this website, for those cases that will be successful with non-surgical and non-drug care, progress will be seen 6-8 weeks into care.  For more information, click on Dupuytren contracture treatment options.