What is needle aponeurotomy or palmar fasciotomy and what are the risks?

Alternative Medicine: Safer alternative than needle aponeurotomy  

Before discussing the Dupuytren contracture surgery known as needle aponeurotomy (NA) and its inherent risks, it is important for the reader to know there is a conservative alternative therapy that avoids the possible side effects and adverse reactions of needle aponeurotomy, also called palmar fasciotomy.  Any Dupuytren’s surgery, even when done well, can have bad unintended consequences as well as stimulate the recurrence of additional nodule and cord formation within a year or two.

Needle aponeurotomy, and other kinds of Dupuytren surgery, is not the only treatment option available.   Alternative Medicine is a conservative and essentially risk free alternative that could make surgery unnecessary.   Most people agree that it makes more sense to use conservative options first, followed by more aggressive and risky options if they are still needed.  However, in the case of Dupuytren contracture most patients are unaware they have other options outside of surgery.

Since 2002 this website has suggested that anyone with Dupuytren contracture should first consider the conservative non-surgical and non-drug treatment options before attempting irreversible surgery.  To learn about Alternative Medicine self-management, please see Different Way of Looking at Dupuytren Contracture Treatment

While all medical websites approach the subject of Dupuytren treatment as though hand surgery and Xiaflex injections are the only options to consider, they intentionally avoid the many diverse Alternative Medicine options that are easy to incorporate and can be used with practically no risk at all. Please read Conservative Philosophy for Dupuytren Therapy

Medical doctors discuss Dupuytren surgery risks

For verification of the risks associated with Dupuytren surgery simply read what hand surgeons have to say.  If the reader goes to the website of a surgeon who specializes in needle aponeurotomy you can read about the dangers of open hand surgery like fasciectomy or even Xiaflex injections.   And, if the reader goes to the website of a surgeon who specializes in open hand surgery you can read about the dangers of needle aponeurotomy.

Each surgical procedure obviously has pros and cons about it, and it us up to the informed patient to know the best option to use.  The intention of this article to simply say that all surgery has a certain level of built-in risk that is best avoided if at all possible.

Risks of needle aponeurotomy

The surgeon cannot see the tip of the needle or the actual tissue being sliced and torn during a needle aponeurotomy, since there is no surgical incision made when performing a needle aponeurotomy.  The surgeon inserts the needle that is used to do the cutting and slicing, and must rely on a high level of skill to only contact and destroy the Dupuytren cord – and nothing else.

There are two risks involved. The first risk is that normal and healthy tendon, ligament, blood vessel and nerve tissue can be accidentally cut instead of the intended targets of palmar fascia contracture and Dupuytren cords.

However, the second risk is greatest.  After a palmar fasciotomy or needle aponeurotomy is done, the cutting and tearing of the Dupuytren contracture tissue accelerates the time for recurrence of another episode of Dupuytren’s contracture when compared to conventional open hand surgery.   The reality of this hand problem is that the contracture will come back at some point after any Dupuytren intervention, and recurrence is statistically faster after needle aponeurotomy than after other types of hand surgery.

Difference between needle aponevrotomy and needle aponeurotomy

There is a simple reason for the difference in terminology encountered while learning about Dupuytren treatment.  Many people find it confusing to occasionally see aponeurotomy spelled a little differently, as in the phrase “needle aponevrotomy.”

Needle aponevrotomy is not an accidental misspelling of needle aponeurotomy. It is simply a matter of a French word being used because the earliest and most innovative development of needle aponeurotomy was done in France, hence the occasional use of the French terminology needle aponevrotomy; both words refer to the same procedure.

Needle aponeurotomy is Dupuytren surgery  

In medical terminology an “-otomy” is a surgical procedure in which the body is cut into, but nothing is removed.  Familiar examples are: tracheotomy, laparotomy, phlebotomy.

The reader will occasionally come upon another –otomy, the term palmar fasciotomy to describe needle aponeurotomy.  In a fasciotomy a type of tissue called fascia is cut but not removed.   Fascia is a kind of thin but tough layer of connective tissue that surrounds, covers and lines all major organs, tissues and cavities of the body.  There is fascia – a lot of it – under the skin on the palm of hand.  During a needle aponeurotomy fascia is cut but not removed, qualifying for this surgery to be called a palmar fasciotomy.

Further, in medical terminology an “-ectomy” is a surgical procedure in which the body is cut into, and something is removed.  Familiar examples are:  Tonsillectomy, appendectomy, and vasectomy.

The reader will also occasionally come upon another –ectomy, as in palmar fasciectomy which is an open hand surgery during which an incision is made to allow for removal of part or all contracted fascia of Dupuytren contracture.   During a palmar fasciectomy sometimes so much fascia and skin is removed that sometimes a skin and fascia graft must be done.

Therefore, a needle aponeurotomy is a surgical procedure that is performed by inserting a needle into a site of deep palmar fascia contracture and nothing is removed.  Instead, once under the skin of the palm, the needle tip is moved blindly around in a variety of directions to intentionally slash, weaken and otherwise disrupt the contracted palmar tissue that causes the reduced finger movement and flexion contracture of Dupuytren’s disease.

Dupuytren Surgery and Recurrence of Hand Contracture

Dupuytren surgical treatment temporary relief

After speaking to well over a thousand people about their Dupuytren surgery options, fewer than a handful knew that surgical repair is only a temporary relief of the palm nodules and finger contractures. Only a few knew surgery for Dupuytrens is NOT a one-time and permanent solution.

Recurrence of a second episode of Dupuytren contracture after the first surgery takes approximately five years, sometimes sooner and  sometimes later.  For every example where someone might have a recurrence after as long as ten years, there are many others who have a return in one or two years; five years is a good average.

Here are important ideas to have in mind when you think about having any kind of Dupuytren surgery:

  1. Once you have your first Dupuytren surgery, you will have others because the problem will return.
  2. There is no such thing as cutting the Dupuytrens tissue out and being done with it.  Some surgeon’s refer to cutting out a large and deep mass of tissue as creating a  “firewall of tissue” to keep the problem from returning, but it is only a delay technique.  It will always return; it is just a matter of time.
  3. If you have Dupuytren surgery and your problem recurs in (let’s say) three years, if you have another or second surgery for the first recurrence of the problem your second recurrence will happen in less than three years.   After each Dupuytren surgery the next recurrence happens faster each time.  The return of your hand contracture will be faster after the second surgery, even faster after the third surgery, and even after the fourth surgery, and so on.
  4. After each hand surgery your recovery will be longer and more complicated with greater chance for side effects.  Just like the recurrence problem increasing with each surgery, the amount of numbness, stiffness, pain, scar build up, reduced hand and finger movement and general limitation increases each time you have Dupuytren surgery.
  5. If  your hand has been so scarred, and so much tissue removed by prior surgeries, and pain and limited use of the hand develops, a common solution is to amputate the offending finger(s).

Here is a brief explanation of the different types of Dupuytren surgery and how each rates in terms of recurrence after the first surgery.

  • Regional Fasciectomy: Most common Dupuytren surgery.  The contracted fascia of the palm and involved fingers are surgically removed, requiring general anesthesia or a nerve block.  Requires extended rehabilitation and wound care. Recurrence of Dupuytren contracture – somewhat more frequent than after other types of Dupuytren surgery.
  • Fasciotomy: Less common Dupuytren surgery.  Requires single or multiple incisions (usually in a zig-zag pattern) using widespread dissection over the Dupuytren’s cord, but the diseased tissue is not removed.  Also requires general anesthesia or a nerve block.  Requires extended rehabilitation and wound care. Recurrence is slightly more frequent than a regional fasiectomy.
  • Dermofasciectomy: Less common Dupuytren surgery.  Surgical removal of diseased skin and fascia overlying Dupuytren cords, in which diseased soft tissue of palm is replaced with a skin graft from patient’s forearm.  Requires very long rehabilitation and wound care.  Recurrence is somewhat less frequent than regional fasciectomy.
  • Needle Aponeurotomy (NA): Very popular – and almost faddish – in-office procedure.  While needle aponeurotomy is a minimally invasive Dupuytren surgery in which a needle is inserted and slashed around under the skin of the palm to shred, lacerate and weakened the Dupuytren cords.  After being so weakened, each cord is broken by hyperextending or pulling each finger straight.  Only local anesthesia is needed.  Requires short rehabilitation and minimal wound care.  Recurrence is about average.
  • Collagenase injection: Early in 2010 the US Food and Drug Administration (FDA) approved inject able collagenase extracted from the bacteria Clostridium histolyticum to be used in treatment of Dupuytren contracture.  Collagenase erodes the Dupuytren cords when they are injected with small amounts of this enzyme, breaking the peptide bonds in the cords of collagen.   Recurrence of hand and finger contractures seems to be most frequent with this technique.

None of these surgical procedures has proved to be a way to stop or cure Dupuytren contracture permanently.  It is said that if a patient lives long enough, the finger contractures and palm lumps will return and additional Dupuytren surgery will be needed.

In extreme cases, amputation of fingers may be needed for severe or recurrent disease, or after complications in surgery.

Alternative therapies, such as advocated by Dupuytren Contracture Institute, have received almost no evidence-based research by the large pharmaceutical companies or university medical programs because of their limited profit potential and easy access by laypeople, and so have little support from the medical profession.

♦    Click here to learn more about natural Dupuytren treatment