Needle Aponeurotomy - Clinical Results

What are the known results of needle aponeurotomy?

• Comparison of NA vs. limited fasciectomy
• Three year follow-up for NA
• NA complications and results
• NA results of the Paris group

A comparison of the direct outcomes of percutaneous needle fasciotomy and limited fasciectomy for Dupuytren's disease: a 6-week follow-up study. J Hand Surg [Am]. 2006 May-Jun;31(5):717-25.

van Rijssen AL, Gerbrandy FS, Ter Linden H, Klip H, Werker PM.

PURPOSE: The demand for percutaneous needle fasciotomy (PNF) as treatment for Dupuytren's disease is increasing because of its limited invasiveness, good outcome, limited number of complications, quick recovery, and overall patient satisfaction. This randomized controlled trial was designed to test whether these short-term expectations are sound by comparing this treatment with limited fasciectomy (LF) with regard to these aspects. METHODS: We treated 166 rays: 88 by PNF and 78 by LF. Total passive extension deficit (TPED) improvement at 1 week and at 6 weeks were the primary outcome parameters; patient satisfaction, hand-function recovery, and complication rate were secondary outcome parameters. We used the Disabilities of the Arm, Shoulder, and Hand questionnaire to measure disabilities of the upper extremity before and after treatment and all adverse effects and complications were recorded.
RESULTS: Overall TPED improvement was best at 6 weeks. In the PNF group TPED improved by 63% versus 79% in the LF group; this difference was statistically significant. Results at the proximal interphalangeal joint were worse than those at the metacarpophalangeal and distal interphalangeal joints for both the PNF and LF groups. The rays classified before surgery as Tubiana stages I and II showed no difference between these treatments, but for rays higher than stage II LF clearly was superior to PNF as a treatment modality. The rate of major complications in the LF group was 5% versus 0% in the PNF group. Patient satisfaction was almost equal but direct hand function after treatment was considered better in the PNF group, as was the degree of discomfort that patients experienced. This was underscored by the Disabilities of the Arm, Shoulder, and Hand scores in the PNF group, which were significantly lower than those in the LF group at all time points measured.
CONCLUSIONS: In the short term and in cases with a TPED of 90 degrees or less PNF is a good treatment alternative to LF for treatment of Dupuytren's disease.
TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level I.

Percutaneous needle fasciotomy in Dupuytren's disease. J Hand Surg [Br]. 2006 Oct;31(5):498-501.

van Rijssen AL, Werker PM.

The aim of this study was to examine our results of 74 percutaneous needle fasciotomies for Dupuytren's contracture. Pre-operative and postoperative total passive extension deficit was measured. Patients were seen at the outpatient clinic at 32 months for final follow-up. Extension deficit and sensibility were measured and flexor tendon function assessed. Recurrence, defined as an increase of the passive extension deficit of 30 degrees or more compared to the immediate postoperative measurement, and other complications were also noted. Immediate outcome was excellent with an average improvement of 77%. After 32 months, we reviewed 55 rays. Their recurrence rate was 65%. Two patients experienced a slightly diminished sensibility on one side of the finger. There were no flexor tendon injuries. This procedure has a good short-term effect. It may be suitable for patients who want a minimally invasive treatment and to whom long-term results are less important. It may also have a place in delaying fasciectomy.

Percutaneous needle aponeurotomy: complications and results. J Hand Surg [Br]. 2003 Oct;28(5):427-31.

Foucher G, Medina J, Navarro R.

Recently French rheumatologists have repopularized fasciotomy using a percutaneous needle technique. This blind approach has been claimed to be plagued by numerous complications. We reviewed the charts of 211 patients treated consecutively on 261 hands and 311 fingers to assess the rate of postoperative complications. The first 100 patients were evaluated with a mean follow up of 3.2 years to assess the rate of recurrences and extension of the disease. In the whole group the mean age was 65 years and delay between onset and treatment was 6 years. Division of the cords were performed only in the palm in 165 cases, in the palm and finger in 111 and purely in the finger in 35. Complications were scarce without infection or tendon injury but one digital nerve was found injured during a second procedure. Postoperative gain was prominent at metacarpophalangeal joint level (79% versus 65% at interphalangeal level). The reoperation rate was 24%. In the group assessed at 3.2 years follow up, the recurrence rate was 58% and disease "activity" 69%. Fifty nine hands need further surgery. The ideal indication for this simple and reliable technique is an elderly patient with a bowing cord and predominant MP contracture.

Results of Paris Group

The group that first described Needle Aponeurotomy reported their results of a prospective study "managed in 1995."  The original text of the study is reported at http://www.dupuytren.org/html/gbresultats95.html.  My summary of the results is presented below.

799 patients were studied. A total of 992 hands were treated.  Some patients were treated on more than one occasion. Some had more than one than one finger treated. There were 1557 treatments, and 3736 aponeurotomies.

Complications reported were mostly minor. There were a total of 138 complications, which is 8.9% of sessions, or 3.7% of aponeurotomies.

Summary of Clinical Results

Results are Correlated to Clinical Stage

Patients with earlier stage disease (less severe contracture) had a greater correction compared to patients with more severe disease.  Complications were not broken down according to clinical stage.