Should I have a third Needle Aponeurotomy surgery for my Dupuytrens?

Dr. Herazy,

I have dupuytren contracture in my little finger on my left hand and have had needle aponeurotomy done on it twice.   It is aggressive and I was considering the procedure a third time  and just heard about you.  I’d like to try an aggressive treatment with you instead–have I missed an opportunity to improve my situation because of the needle aponeurotomy sessions (because of  scar tissue,etc)?

I’d like to speak to you about it if possible – I have a third needle aponeurotomy session scheduled two months from now (28 Nov) that I’d like to cancel…the contracture comes back quickly and the finger is a bit thicker.  Any advice??

Thank you in advance for your attention to this,

Scott Riviere

 

Greetings Scott,

Needle aponeurotomy is well known for rapid recurrence of Dupuytren contracture.   Although you did not say how quickly your Dupuytren’s returned after your first and second hand surgery, it is not uncommon for the palm lumps and cords to come back back in two years or so, with the rate of recurrence increasing after each NA surgery. 

The increased thickness of your finger could be due to chronic swelling or edema that is the result of scar tissue that prevents normal drainage of blood and lymph fluid out of the hand.   Or, it could be directly due to scar formation from the internal cutting that is part of the NA technique.  Either way, this is a frequent side effect of hand surgery for Dupuytrens.   

The rapid recurrence of Dupuytren contracture after needle aponeurotomy and scar tissue build-up are two of the nasty consequences of this kind of hand surgery simply because, as you have found out, the technique not only solves nothing but it can leave you worse off than before it was done.      

My advice is that you be extremely cautious about undergoing a third needle aponeurotomy.   What has your surgeon told you about the possible outcomes of a third NA if the first and second did not help you and resulted in undesirable side-effects?    Did he/she say why you should expect the results of this third surgery to be any different than the first two?   Did he/she warn you about further acceleration of the rate of recurrence with each succeeding NA procedure?   Did he/she warn you about the increasing risk of possible injury to blood vessels, nerves and tendons that occurs with each succeeding hand surgery?    Did he/she warn you that these hand surgeries would eventually have to stop?   Did he/she speculate what the eventual condition of your hand might be if you had 4-5-6 surgeries, and how useful, painful, numb or flexible your hand might be?   did he/she discuss with you what your options might be when you can no longer have additional NA surgeries?

Please be even more cautious if you are told that this next surgery will be more extensive to reverse or clean up the problem scar tissue that resulted from the others.  I have never heard of any  “clean-up surgery’ that goes well for the patient; usually it goes in the opposite direction and creates more problems.   Mind you, I am not saying to not have the surgery and I am not saying to not listen to your doctor, I am just saying to use the highest level of caution and prudence when you make this decision.

Time will tell how effective an aggressive Alternative Medicine treatment plan might be to help your current condition.  I have worked many times with people who have a history of past hand surgery who find their problem worse than when they started; some make great improvement, while most make at least a small to moderate amount of change; very few do not at least make some small level of improvement.   I cannot answer you directly about how effective natural therapy might be for you, but considering your options I suggest you consider undergoing an intense round of therapy for 2-3 months to determine how much change your body can make.   You will only know for sure when you give it your best effort.   

I would be pleased to speak to you about your Alternative Medicine treatment options.   The important thing is to not make matters worse at this point.   Simply call me at 847-670-8800.     TRH

 

 

 

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.

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