Needle Aponeurotomy for Dupuytren's Contracture

dupuytrens disease contracture needle
Dupuytren's disease causes contractures in the palm and fingers. Image © John Mahoney, M.D.

Dupuytren's contracture is a condition of the hand that affects almost 3% of the population.  Historically, the only options for treatment were either nothing, or major surgical procedure.  Over the past decade, some other less-invasive options have emerged as possible treatments.  One of these modern treatments is a minimally invasive procedure called a needle aponeurotomy. 

Dupuytren's Contracture

Dupuytren's contracture is a condition affecting the hand; it is found in people who have Dupuytren's disease.

It causes the tissue just under the skin on the palm side of the hand to become thickened and contracted. This tissue, the palmar fascia, normally provides strength and support for the skin. However, in Dupuytren's contracture, the palmar fascia can dramatically shorten, making it impossible to straighten the fingers. The condition is most common in men of Northern European ancestry over the age of 50.

Treatment is of Dupuytren's contracture depends on the severity of symptoms.  Most patients affected have either nodules that form firm balls of scar tissue in the palm, or cords that form tight bands that run up the palm side of the finger.  Dupuytren's nodules can be treated by cortisone injection or can be monitored with no specific treatment.

A Dupuytren's cord can be more problematic as these can start to pull the fingers downwards towards the palm of the hand.  Over time, if the contracture progresses, patients will be unable to fully straighten the fingers.

  This can make simple activities such as washing your face, shaking hands, or wearing gloves, nearly impossible.

Treatment of Dupuytren's Contracture

The standard treatment of Dupuytren's contracture is a surgical procedure called partial palmar fasciectomy. The palm and affected finger are surgically opened through large incisions.

The abnormally contracted palmar fascia is then removed. Because of the wide surgical exposure, scar tissue will form in the hand and fingers. Surgery can require prolonged rehabilitation. Some patients may need to take one to two months off from work, depending on their jobs.

Needle aponeurotomy (NA) is a minimally invasive procedure used to treat Dupuytren's contracture. In NA, the surgeon uses the tip of a needle to divide the contracted palmar fascia. This is done through microscopic puncture wounds. Unlike open surgery, the hand is not widely opened, and there is minimal scar tissue formation. The procedure is performed in the doctor's office under local anesthesia. NA was first developed in France in the 1970s and was brought to the United States by Dr. Charles Eaton of Jupiter, Florida. 

Needle Aponeurotomy

When performed by a trained surgeon on an appropriate patient, NA is very safe and effective. The rate of complications, such as tendon or nerve injuries, is less than with traditional surgery.

There most common complication is a small tear in the skin, which typically will heal with simple bandages.

The rate of Dupuytren's recurrence after NA is higher when compared to traditional open surgery. After open surgery, 50% of patients will have recurrence at five years. This compares to 50% recurrence after three years with NA. Dupuytren's disease will likely come back with either treatment, just slightly sooner after NA.

Generally, formal hand therapy is not required after NA. Patients are asked to keep their operated hand elevated for two days after the procedure. Patients can return to light work activities immediately. Strenuous work, sports, or hobbies are not allowed for one week. Occasionally, a splint is made to be worn at night after NA.

Sources:

Eaton C, The Hand Center © 2007.

Mahoney JD, Personal Communication, Midwest Orthopaedic Center, Interviewed 11/2007.

Murphy K, "Straightening Bent Fingers, No Surgery Required" The New York Times July 24, 2007.

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