HAND/PERIPHERAL NERVE Pearls and Pitfalls of Needle Aponeurotomy in Dupuytren’s Disease Michael Morhart, M.D. Edmonton, Alberta, Canada
Background: Dupuytren’s disease is a benign, progressive, fibroproliferative disease, and despite advances in basic science and technology, there remains no cure. To date, open fasciectomy procedures remain the criterion standard for the treatment of Dupuytren’s disease despite a significant complication rate and recovery time. Needle aponeurotomy, a less invasive treatment, is associated with reduced complications and quicker recovery. Methods: A literature review and a compilation of over 700 procedures was performed to highlight the clinical relevance of needle aponeurotomy. A stepby-step description of the author’s technique for needle aponeurotomy is presented, emphasizing the pearls and pitfalls of the procedure. Results: Recurrence rates for open fasciectomy are 5 to 10 percent per year compared with rates for needle aponeurotomy, which are 10 to 20 percent per year. Overall complication rates are much less frequent with needle aponeurotomy, with skin tears being the most common (3 percent). Needle aponeurotomy is cost effective compared with open fasciectomy. Recurrent proximal interphalangeal joint flexion contractures remain the most problematic in terms of correction. Conclusions: Needle aponeurotomy has been shown to be an extremely useful adjunct available to the surgeon in the treatment of Dupuytren’s disease. This procedure can be performed easily in an outpatient setting or office and carries with it dramatic results. Needle aponeurotomy has a lower complication rate and quicker recovery when compared with open fasciectomy and is therefore offered to patients as a first-line treatment. (Plast. Reconstr. Surg. 135: 817, 2015.)
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urgery has been the mainstay of treatment for Dupuytren’s disease, as there is no known cure. Sir Astley Cooper was the first to describe a percutaneous fasciotomy in 1822,1,2 and a plethora of surgical procedures have since been described for Dupuytren’s disease. Although “open fasciectomy” procedures are arguably still considered the criterion standard for the treatment of Dupuytren’s disease today, percutaneous techniques have been enjoying a resurrection in North America now almost 200 years later. The relatively recent enthusiasm was ignited by Lermusiaux and Debeyre in 1979,3,4 when they described a percutaneous fasciotomy using a needle instead of a scalpel. Their main contention was that the procedure allowed patients a quicker recovery and therefore an earlier return to work. They also noted that the technique had a very low complication rate and did From the Department of Surgery, University of Alberta. Received for publication May 29, 2014; accepted September 9, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000961
not require posttreatment rehabilitation therapy. Eaton then introduced the technique of needle aponeurotomy to North America in 2003 when he presented the technique at an instructional course at the annual scientific meeting of the American Society for Surgery of the Hand in 2006.
PATIENT SELECTION Any patient with a palpable cord and a symptomatic contracture caused by Dupuytren’s disease Disclosure: The author is a consultant for Actelion Pharmaceuticals Canada for the product Xiaflex. Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s Web site (www. PRSJournal.com).
www.PRSJournal.com
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Plastic and Reconstructive Surgery • March 2015 is a candidate for needle aponeurotomy. Patients presenting with metacarpophalangeal joint flexion contractures of less than 30 degrees may be considered for needle aponeurotomy, as this procedure is considerably less invasive and associated with fewer complications compared with open fasciectomy. Patients may include those with no prior treatment and those having had prior treatment with surgery, collagenase or needle aponeurotomy. All flexion contractures should be documented at each joint, and photographs should be taken before and after needle aponeurotomy. Additional information such as neurovascular integrity, severity of skin involvement, presence of nodules, and skin dimpling should also be included. Significant time is taken to educate patients on needle aponeurotomy, as there may be reluctance to having a “wide-awake” procedure. They are reassured that although the procedure may be uncomfortable, it is relatively short in duration. Furthermore, the significant reduction in complications and much quicker return to life (work) are strongly emphasized. Patients also appreciate the lack of general anesthesia and potentially shorter booking times for needle aponeurotomy compared with the lengthy wait times for main operating rooms.
PATIENT PREPARATION The procedure may be carried out in an outpatient treatment room or in a private office setting. The hand is prepared with antiseptic solution and draped. No tourniquet is used. A basic surgical tray is used (Fig. 1). All patients are positioned lying in the supine position with the hand resting on an arm board. The patient’s hand is supinated and placed on a
small bump/roll centered over the dorsal metacarpophalangeal joints. All cords are palpated carefully and the skin is examined. A fine felt marker is used to precisely plan out needle entrance points or “portals.” The skin areas best used are those in which there appears to be excess mobile or “redundant” skin. Skin flexion creases are avoided, as these may be prone to skin tears and potential flexor tendon laceration. As many portals as possible are marked, with the goal of maintaining at least 5 mm between each mark. The portals are marked in the center of a palpable cord; however, with very wide cords, one may place two portals at the same level, one on the radial border and the other on the ulnar border of the cord (Fig. 2). It is important to reassure the patient that although the procedure may be uncomfortable, it is imperative that they remain as still as possible. Patients are told to communicate verbally with the surgeon during the procedure, especially if at any time they experience electric shocks or tingling sensations. In addition, patients are instructed to indicate whether they feel an excessive amount of sharp pain, which may result from the needle violating the flexor tendon sheath. This interactive patient communication is critical to maximally reduce the chance of nerve or tendon injury. The patient has a sterile preparation and then approximately 0.1 ml of 1% lidocaine is infiltrated using a 1.0-ml syringe and a 30-gauge needle just in the immediate subdermal plane, creating a small “bleb” in the skin. (See Video, S upplemental Digital Content 1, which demonstrates subdermal infiltration, http://links.lww.com/PRS/B229.) The sequence of the procedure is from distal to proximal. If there are greater than five or six
Fig. 1. Basic setup tray for needle aponeurotomy.
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Volume 135, Number 3 • Needle Aponeurotomy in Dupuytren’s Disease
Fig. 2. Skin markings (portals) for needle aponeurotomy.
Video 1. Supplemental Digital Content 1 demonstrates subdermal infiltration, http://links.lww.com/PRS/B229.
Video 2. Supplemental Digital Content 2 demonstrates the needle’s sweeping motion, http://links.lww.com/PRS/B230.
portals planned, local anesthesia may be injected at two to three consecutive portals at a time.
form a three-dimensional image as to the anatomy of the cord. This is performed by directing the needle in a vertical direction from volar to dorsal without removing the needle from the skin. The needle is probed using tactile resistance to evaluate the width of the cord (without actually going through cord) as the needle passes along both the radial and ulnar sides of the cord. Once the cord geometry is assimilated within the surgeon’s mind, the sweep is initiated in the subdermal plane. A common mistake is to place the needle too deeply within the cord, which makes it very difficult, if not impossible to perform the “sweep” maneuver effectively. If the needle is positioned correctly, and the sweeping motion is initiated superficially, both the patient and the surgeon will have audible confirmation with a “gritty” sound. (See Video, Supplemental Digital Content 2, which demonstrates the needle’s sweeping motion, http://links. lww.com/PRS/B230.) The use of both hands is critical to the needle aponeurotomy procedure; as one hand uses the needle, the contralateral hand “cradles” and steadies the patient’s operative hand. The surgeon’s fingertips should constantly
GENERAL NEEDLE APONEUROTOMY PRINCIPLES The Needle and Its Basic Motion A 5/8-inch (16-mm), 25-gauge needle loaded onto a 1.0-ml empty syringe is used as a scalpel. Although some advocate the use of an 18-gauge needle, the tactile feedback is not as informative as with a 25-gauge needle. In addition, the incidence of skin tears may increase with an 18-gauge needle, as the cutting surface is larger by comparison. Many descriptions of needle action have been described, including clearing, perforation, and sweeping motions.1,5,6 When performing the procedure in areas of skin excess as suggested above, a vertical sweeping motion is used like a pendulum from one side to the other (radial to ulnar or vice versa, depending on which hand the surgeon is using) and from superficial to deep. One may wish to perform a modified perforation motion to
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Video 3. Supplemental Digital Content 3 demonstrates the audible pop, http://links.lww.com/PRS/B231.
Video 4. Supplemental Digital Content 4 demonstrates cord disruption, http://links.lww.com/PRS/B232.
palpate the cords to monitor the progression of cord disruption. One should assume that once a soft spot has been palpated, disruption of the cord (fasciotomy) has been achieved and a needle is not replaced again at that site. It is imperative that the needle is only inserted over a palpable cord. If a cord disruption is suspected, a gentle manipulation of the finger into extension may be performed at this time. An audible pop may be heard coincident with the finger straightening out under gentle force. (See Video, Supplemental Digital Content 3, which demonstrates the audible pop, http://links.lww.com/PRS/B231.) Another useful maneuver is to simply massage the area (especially when dealing with natatory cords) with a fingertip. It is not unusual to feel the cords separate under light to moderate fingertip pressure. It is important to replace the needles often during a procedure, as they become dull very quickly. Metacarpophalangeal Joint When performing needle aponeurotomy for metacarpophalangeal joint flexion contractures, it should be cautioned that direct pressure on the
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finger into extension during the actual needle aponeurotomy procedure be avoided. Although some recommend this maneuver citing that, with the finger being passively extended, the flexor tendons slacken and displace farther away from the skin.1 However, as the cord lengthens with progressive disruption, the tension in the flexor tendons increases, bringing the flexor tendons closer to the skin. The author’s recommendation is therefore that only skin manipulation be performed for metacarpophalangeal joint release. This is accomplished by stretching the skin distal to the needle in an axial (distal) direction with the thumb or index finger of the cradling hand as the sweeping motion with the needle is performed simultaneously. With successful cord dissection from superficial to deep, one may feel a ratcheting sensation through the skin as the final deeper fibers are transected. (See Video, Supplemental Digital Content 4, which demonstrates cord disruption, http://links.lww.com/PRS/B232.) This will correspond to the finger straightening out with gentle finger manipulation once the needle is removed. Photographs obtained before and after needle aponeurotomy are shown in Figure 3. Proximal Interphalangeal Joint One may apply passive extension force to the finger as the needle aponeurotomy is performed. The dense network of pulleys will not allow as much bowstringing of the flexor tendons compared with the palm. (See Video, Supplemental Digital Content 5, which demonstrates needle aponeurotomy for proximal interphalangeal joint flexion contractures, http://links.lww.com/PRS/B233.) Disease may often be present on both sides and, once the predominant cord is released, further palpation may highlight a cord on the other side not otherwise palpated preoperatively. Although the contracted proximal interphalangeal joint is often much more difficult to straighten, with patience and perseverance the results may often be impressive. If all palpable cords have been addressed but some improvement in proximal interphalangeal joint passive extension is still desired, one may cautiously attempt needle aponeurotomy directly over the volar midline just proximal to the proximal interphalangeal flexion crease. Although the surgeon must be absolutely positive the needle does not violate the flexor tendon sheath, the result may be a significant increase in passive extension. The concern for nerve injury at this level is obvious, as the neurovascular structures are well known to be displaced volar and central.7 However, with constant patient feedback and meticulous technique,
Volume 135, Number 3 • Needle Aponeurotomy in Dupuytren’s Disease
Fig. 3. Photographs obtained (above) before and (below) after needle aponeurotomy of the metacarpophalangeal joint.
The sensation of sharp pain, especially with each sweep, can be a heralding sign of injury to the pulley or flexor tendon. With the needle in place, the surgeon asks the patient to gently flex the finger. If the tendon has been violated, the needle will move with tendon excursion and therefore must be repositioned more superficially. (See Video, Supplemental Digital Content 6, which shows checking for tendon violation, http://links.lww.com/PRS/B234.)
Video 5. Supplemental Digital Content 5 demonstrates needle aponeurotomy for proximal interphalangeal joint flexion contractures, http://links.lww.com/PRS/B233.
the incidence of these injuries can be reduced to a level less than seen with open fasciectomy (see later under Complications of Needle Aponeurotomy). It should be reiterated that the needles are not placed into flexion creases, to avoid injury to either the flexor tendon or the neurovascular bundle (Fig. 4). Constant Monitoring During the procedure, it is crucial to listen to the patient for valuable feedback. Any patient report about a Tinel-like sign may suggest danger and therefore the needle must be resituated. A manual check for fingertip sensation should be performed before and after each portal during the duration of the procedure.
Final Passive Stretch or Manipulation Generally, 3 to 4 ml of 1% lidocaine with epinephrine is mixed with 15 to 20 mg of triamcinolone per digit and injected through the skin portals. A gradual, progressive extension force is applied to the finger, with the endpoint being neutral for the proximal interphalangeal and slight hyperextension of the metacarpophalangeal joint. The wrist may be passively held in slight flexion to allow the flexor tendons to slacken. Caution is exercised, as extensive force on the finger may result in unheralded complications, including fracture of a phalanx, especially in the elderly or frail. In the absence of skin tears, small, round adhesive bandages are placed on the skin portals, and generally no dressing is used. Patients are instructed to elevate their hands and apply cold packs liberally for the first 24 to 48 hours. The patients are encouraged to use their hands for normal activities of daily living but to avoid strenuous activities for 7 to 10 days.
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Fig. 4. Photographs obtained (above) before and (below) after needle aponeurotomy of the proximal interphalangeal joint.
Video 6. Supplemental Digital Content 6 shows checking for tendon violation, http://links.lww.com/PRS/B234.
Triamcinolone Administration The administration of triamcinolone for the treatment of Dupuytren’s nodules has been reported previously, with no long-lasting complications.8,9 The effects of triamcinolone have been well elucidated previously.10,11 A recent study has shown that triamcinolone injection when used in conjunction with needle aponeurotomy resulted in a higher degree of correction at 6 months.12
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Postoperative Hand Therapy and Splinting Splinting postoperatively has never shown any benefit in terms of reducing subsequent flexion contractures in Dupuytren’s disease.13 However, if the proximal interphalangeal joint is passively correctable to neutral but the patient displays an active extensor lag of greater than 10 to 20 degrees, I routinely use a postmanipulation boutonnière splint. Proximal interphalangeal joints with an active extensor lag of less than 20 degrees may correct spontaneously over time, depending on the length of time to treatment. The splint is maintained during the day for 3 weeks, coming off for therapy directed at maintaining both active and passive range of motion. The splint is continued at night for 3 months. Because the extensor lag is caused by attenuation rather than disruption of the central slip, the tone in the extensor tendon usually recovers. Skin Tears It is not uncommon during the final passive stretch maneuver for skin tears to develop.5,6,14–16 The most common sites of skin tearing are over flexion creases and also areas of the skin adherent
Volume 135, Number 3 • Needle Aponeurotomy in Dupuytren’s Disease to underlying cord. Tears may be minimized by performing a dermolysis of the cord’s connection with the overlying dermis. This technique may also be used in conjunction with collagenase just before postinjection finger manipulation. Otherwise, it is not recommended that both needle aponeurotomy and collagenase be performed simultaneously. Although some of the skin tears can appear quite dramatic, including exposure of flexor tendons and the neurovascular structures, they will inevitably go on to heal uneventfully by secondary intention within 2 to 3 weeks, similar to what has been previously described by McCash17 (Fig. 5). Care is taken to prevent tendon desiccation by the liberal application of Polysporin/ Neosporin (Johnson & Johnson, Skillman, N.J.) or medicated ointment one to two times per day. The wound is then dressed lightly with a small gauze and Coban wrap. Patients are instructed on maintaining a gentle active range of motion of the fingers during the wound healing phase. Under no circumstances do these tears need to be closed primarily or have local flap coverage or skin grafting.
RECURRENCE AND OUTCOMES OF NEEDLE APONEUROTOMY Discussion regarding outcomes and recurrence of Dupuytren’s disease continues to be a significant problem in terms of interpretation of the literature because of lack of a universally accepted use of the term “recurrence.”17 There is no cure
for Dupuytren’s, and although the treatment is aimed at decreasing the flexion contractures of the digits, the disease may progress irrespective of the treatment strategy used. Overall, the correction of metacarpophalangeal joint flexion contractures appears superior for the metacarpophalangeal joint in contrast to the proximal interphalangeal joint irrespective of the treatment, surgical or noninvasive,5,13,14,19–22 and can be attributed to an effect of the metacarpophalangeal joint with lengthened collateral ligaments when compared with the proximal interphalangeal joint (shortened collateral ligaments). Van Rijssen and Werker published preliminary results after a 33-month follow-up, citing a recurrence rate of 65 percent using a definition of recurrence with a total passive extension deficit reduction of more than 30 degrees and included both metacarpophalangeal and proximal interphalangeal joint contractures.23 Initial correction was reported as a 71 percent improvement in extension, as the mean preoperative total passive extension deficit was reduced from 62 degrees to 18 degrees. Then, in 2012, the same authors reported an 85 percent recurrence rate after a 5-year follow-up.21 Using flexion of 20 degrees or less over the initial postprocedure correction, Pess et al. reported success in 80 percent of metacarpophalangeal joints and 35 percent of proximal interphalangeal joints at 3-year follow-up in 1013 cases.5
Fig. 5. Skin tear during needle aponeurotomy shown (left) immediately after manipulation with exposure of flexor tendon, (above, right) 8 days after needle aponeurotomy, and (below, right) 18 days after needle aponeurotomy.
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Plastic and Reconstructive Surgery • March 2015 Overall, the recurrence rates are lowest with open fasciectomy. However, one factor rarely reported on is total postoperative flexion. In a 6-week follow-up study directly comparing limited fasciectomy and needle aponeurotomy, 24 percent of patients had a flexion deficit in the fasciectomy group, whereas none occurred in the needle aponeurotomy group.24 Regarding recurrence rates, based on a conservative perusal of the literature and my own experience, I inform my patients as follows: 5 to 10 percent per year for open fasciectomy and 10 to 20 percent per year for needle aponeurotomy. Once patients are educated, the decision for treatment is usually between needle aponeurotomy and collagenase. Although long-term data are not available for recurrence following use of collagenase, the results can be equally impressive. However, collagenase treatment entails at least two appointments, and the cost may be prohibitive.
COMPLICATIONS OF NEEDLE APONEUROTOMY It is well established that the incidence of complications of needle aponeurotomy is significantly lower compared with open fasciectomy. Chen et al. reported on a systematic review of the literature and an overall complication rate of 14 to 67 percent with open partial fasciectomy, with the most common complications consisting of nerve injury, infection, and complex regional pain syndrome.13 In contrast, Pess et al. found the overall complication rate to be very low with needle aponeurotomy, with the most common being skin tears (3.4 percent).5 All tears healed with local wound care. There were no reports of tendon laceration, infection, or complex regional pain syndrome. Neurapraxia was noted in 1.2 percent of patients. In the author’s own experience, 723 needle aponeurotomy procedures in a hospital outpatient clinic were performed over a 5-year period. One flexor tendon laceration occurred, and skin tears were noted in 14 fingers (all healed within 3 weeks). One patient had a wound infection that settled with oral antibiotics. No nerve injuries were noted. Seven digits were treated open for uncorrectable proximal interphalangeal flexion contractures. Needle aponeurotomy was repeated in 42 digits for recurrent flexion contractures at the metacarpophalangeal joint (>20 degrees) and 57 digits for proximal interphalangeal contractures (>5 degrees). Cost of Needle Aponeurotomy Recently, studies looking at the cost effectiveness of surgical and nonsurgical treatment
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strategies have been performed.25,26 Both studies, using different models, concluded that needle aponeurotomy was considerably more cost effective compared with open fasciectomy. However, one of the primary factors associated with increased costs in both studies is based on the assumption that all open fasciectomies are performed in the operating room with either regional or general anesthesia. Certainly, with the trend of wide-awake surgery, these procedures may be performed in an outpatient clinic under local anesthesia, thereby lowering costs.27 Advantages and pitfalls of needle aponeurotomy are listed below. Advantages of Needle Aponeurotomy • Patients love it • Extremely low complication rate • Performed in outpatient setting or in private office • Benefits of wide-awake surgery with dramatic results • Quick recovery • Cost effective • Excellent for metacarpophalangeal joint contractures with palpable cords • Easy to repeat at any time Pitfalls • Steep learning curve • Skin tears • Difficulty in correcting proximal interphalangeal flexion contractures
CONCLUSIONS Ultimately, it is up to the surgeon and patient to tailor a treatment protocol for Dupuytren’s disease. It is the surgeon’s responsibility to educate the patient regarding the treatment strategies and the subsequent outcomes. The author’s belief is that open fasciectomy should be offered as a last-resort intervention, with the most common indication being the uncorrectable proximal interphalangeal flexion contracture. Therefore, patients should at least be offered needle aponeurotomy as a potential first-line treatment option because of its low complication rate, cost effectiveness, and quicker recovery. Michael Morhart, M.D. 303 Coronation Plaza East Tower 14310 111 Avenue Edmonton, Alberta T5M 3Z7 Canada [email protected]
Volume 135, Number 3 • Needle Aponeurotomy in Dupuytren’s Disease REFERENCES 1. Diaz R, Curtin C. Needle aponeurotomy for the treatment of Dupuytren’s disease. Hand Clin. 2014;30:33–38. 2. Hutchison RL, Rayan GM. Astley Cooper: His life and surgical contributions. J Hand Surg Am. 2011;36:316–320. 3. Lermusiaux JL, Debeyre N. Le traitement medical de la maladie de Dupuytren. In: de Seze S, Ryckewaert A, Kahn MF, et al., eds. L’actualite rhumatologique. Paris: Expansion Scientifique Franchaise; 1980:338–843. 4. Badois FJ, Lermusiaux JL, Masse C, Kuntz D. Non-surgical treatment of Dupuytren disease using needle fasciotomy (in French). Rev Rhum Ed Fr. 1993;60:808–813. 5. Pess GM, Pess RM, Pess RA. Results of needle aponeurotomy for Dupuytren contracture in over 1,000 fingers. J Hand Surg Am. 2012;37:651–656. 6. Eaton C. Percutaneous fasciotomy for Dupuytren’s contracture. J Hand Surg Am. 2011;36:910–915. 7. McFarlane RM. Patterns of the diseased fascia in the fingers in Dupuytren’s contracture: Displacement of the neurovascular bundle. Plast Reconstr Surg. 1974;54:31–44. 8. Ketchum LD, Donahue TK. The injection of nodules of Dupuytren’s disease with triamcinolone acetonide. J Hand Surg Am. 2000;25:1157–1162. 9. Ketchum LD, Robinson DW, Masters FW. Follow-up on treatment of hypertrophic scars and keloids with triamcinolone. Plast Reconstr Surg. 1971;48:256–259. 10. Ketchum LD, Robinson DW, Masters FW. The degradation of mature collagen: A laboratory study. Plast Reconstr Surg. 1967;40:89–91. 11. Al-Qattan MM. Factors in the pathogenesis of Dupuytren’s contracture. J Hand Surg Am. 2006;31:1527–1534. 12. McMillan C, Binhammer P. Steroid injection and needle aponeurotomy for Dupuytren contracture: A randomized, controlled study. J Hand Surg Am. 2012;37:1307–1312. 13. Chen NC, Srinivasan RC, Shauver MJ, et al. A systematic review of outcomes of fasciotomy, aponeurectomy, and collagenase treatments for Dupuytren’s contracture. Hand 2011;6:250–255. 14. Donaldson J, Goddard N. The re-emergence of percutaneous fasciotomy in the management of Dupuytren’s disease. Open Orthop J. 2012;6:83–87.
15. Foucher G, Medina J, Navarro R. Percutaneous needle aponeurotomy: Complications and results. J Hand Surg Br. 2003;28:427–431. 16. Henry M. Dupuytren’s disease: Current state of the art. Hand (N Y) 2014;9:1–8. 17. McCash CR. The open palm technique in Dupuytren’s contracture. Br J Plast Surg. 1964;14:53–58. 18. Werker P, Pess GM, van Rijssen AL, et al. Correction of contracture and recurrence rates of Dupuytren contracture following invasive treatment: The importance of clear definitions. J Hand Surg Am. 2012;37:2095–2105. 19. Becker GW, Davis TR. The outcome of surgical treatments for primary Dupuytren’s disease: A systematic review. J Hand Surg Br. 2010;35:623–626. 20. Dias JJ, Braybrooke J. Dupuytren’s contracture: An audit of the outcomes of surgery. J Hand Surg Br. 2006;31: 514–521. 21. van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: Percutaneous needle fasciotomy versus limited fasciectomy. Plast Reconstr Surg. 2012;129:469–477. 22. van Rijssen AL, Werker PM. Percutaneous needle fasci otomy for recurrent Dupuytren disease. J Hand Surg Am. 2012;37:1820–1823. 23. van Rijssen AL, Werker PM. Percutaneous needle fasciotomy in Dupuytren’s disease. J Hand Surg Br. 2006;31:498–501. 24. van Rijssen AL, Gerbrandy FS, Ter Linden H, Klip H, Werker PM. 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;31:717–725. 25. Baltzer H, Binhammer PA. Cost-effectiveness in the management of Dupuytren’s contracture: A Canadian cost-utility analysis of current and future management strategies. Bone Joint J. 2013;95:1094–1100. 26. Chen NC, Shauver MJ, Chung KC. Cost-effectiveness of open partial fasciectomy, needle aponeurotomy, and collagenase injection for Dupuytren’s contracture. J Hand Surg Am. 2011;36:1826–1834. 27. Lalonde DH. Reconstruction of the hand with wide awake surgery. Clin Plast Surg. 2011;38:761–769.
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Background: Dupuytren’s disease is a benign, progressive, fibroproliferative disease, and despite advances in basic science and technology, there remains no cure. To date, open fasciectomy procedures remain the criterion standard for the treatment of Dupuytren’s disease despite a significant complication rate and recovery time. Needle aponeurotomy, a less invasive treatment, is associated with reduced complications and quicker recovery. Methods: A literature review and a compilation of over 700 procedures was performed to highlight the clinical relevance of needle aponeurotomy. A stepby-step description of the author’s technique for needle aponeurotomy is presented, emphasizing the pearls and pitfalls of the procedure. Results: Recurrence rates for open fasciectomy are 5 to 10 percent per year compared with rates for needle aponeurotomy, which are 10 to 20 percent per year. Overall complication rates are much less frequent with needle aponeurotomy, with skin tears being the most common (3 percent). Needle aponeurotomy is cost effective compared with open fasciectomy. Recurrent proximal interphalangeal joint flexion contractures remain the most problematic in terms of correction. Conclusions: Needle aponeurotomy has been shown to be an extremely useful adjunct available to the surgeon in the treatment of Dupuytren’s disease. This procedure can be performed easily in an outpatient setting or office and carries with it dramatic results. Needle aponeurotomy has a lower complication rate and quicker recovery when compared with open fasciectomy and is therefore offered to patients as a first-line treatment. (Plast. Reconstr. Surg. 135: 817, 2015.)
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urgery has been the mainstay of treatment for Dupuytren’s disease, as there is no known cure. Sir Astley Cooper was the first to describe a percutaneous fasciotomy in 1822,1,2 and a plethora of surgical procedures have since been described for Dupuytren’s disease. Although “open fasciectomy” procedures are arguably still considered the criterion standard for the treatment of Dupuytren’s disease today, percutaneous techniques have been enjoying a resurrection in North America now almost 200 years later. The relatively recent enthusiasm was ignited by Lermusiaux and Debeyre in 1979,3,4 when they described a percutaneous fasciotomy using a needle instead of a scalpel. Their main contention was that the procedure allowed patients a quicker recovery and therefore an earlier return to work. They also noted that the technique had a very low complication rate and did From the Department of Surgery, University of Alberta. Received for publication May 29, 2014; accepted September 9, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000961
not require posttreatment rehabilitation therapy. Eaton then introduced the technique of needle aponeurotomy to North America in 2003 when he presented the technique at an instructional course at the annual scientific meeting of the American Society for Surgery of the Hand in 2006.
PATIENT SELECTION Any patient with a palpable cord and a symptomatic contracture caused by Dupuytren’s disease Disclosure: The author is a consultant for Actelion Pharmaceuticals Canada for the product Xiaflex. Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s Web site (www. PRSJournal.com).
www.PRSJournal.com
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Plastic and Reconstructive Surgery • March 2015 is a candidate for needle aponeurotomy. Patients presenting with metacarpophalangeal joint flexion contractures of less than 30 degrees may be considered for needle aponeurotomy, as this procedure is considerably less invasive and associated with fewer complications compared with open fasciectomy. Patients may include those with no prior treatment and those having had prior treatment with surgery, collagenase or needle aponeurotomy. All flexion contractures should be documented at each joint, and photographs should be taken before and after needle aponeurotomy. Additional information such as neurovascular integrity, severity of skin involvement, presence of nodules, and skin dimpling should also be included. Significant time is taken to educate patients on needle aponeurotomy, as there may be reluctance to having a “wide-awake” procedure. They are reassured that although the procedure may be uncomfortable, it is relatively short in duration. Furthermore, the significant reduction in complications and much quicker return to life (work) are strongly emphasized. Patients also appreciate the lack of general anesthesia and potentially shorter booking times for needle aponeurotomy compared with the lengthy wait times for main operating rooms.
PATIENT PREPARATION The procedure may be carried out in an outpatient treatment room or in a private office setting. The hand is prepared with antiseptic solution and draped. No tourniquet is used. A basic surgical tray is used (Fig. 1). All patients are positioned lying in the supine position with the hand resting on an arm board. The patient’s hand is supinated and placed on a
small bump/roll centered over the dorsal metacarpophalangeal joints. All cords are palpated carefully and the skin is examined. A fine felt marker is used to precisely plan out needle entrance points or “portals.” The skin areas best used are those in which there appears to be excess mobile or “redundant” skin. Skin flexion creases are avoided, as these may be prone to skin tears and potential flexor tendon laceration. As many portals as possible are marked, with the goal of maintaining at least 5 mm between each mark. The portals are marked in the center of a palpable cord; however, with very wide cords, one may place two portals at the same level, one on the radial border and the other on the ulnar border of the cord (Fig. 2). It is important to reassure the patient that although the procedure may be uncomfortable, it is imperative that they remain as still as possible. Patients are told to communicate verbally with the surgeon during the procedure, especially if at any time they experience electric shocks or tingling sensations. In addition, patients are instructed to indicate whether they feel an excessive amount of sharp pain, which may result from the needle violating the flexor tendon sheath. This interactive patient communication is critical to maximally reduce the chance of nerve or tendon injury. The patient has a sterile preparation and then approximately 0.1 ml of 1% lidocaine is infiltrated using a 1.0-ml syringe and a 30-gauge needle just in the immediate subdermal plane, creating a small “bleb” in the skin. (See Video, S upplemental Digital Content 1, which demonstrates subdermal infiltration, http://links.lww.com/PRS/B229.) The sequence of the procedure is from distal to proximal. If there are greater than five or six
Fig. 1. Basic setup tray for needle aponeurotomy.
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Volume 135, Number 3 • Needle Aponeurotomy in Dupuytren’s Disease
Fig. 2. Skin markings (portals) for needle aponeurotomy.
Video 1. Supplemental Digital Content 1 demonstrates subdermal infiltration, http://links.lww.com/PRS/B229.
Video 2. Supplemental Digital Content 2 demonstrates the needle’s sweeping motion, http://links.lww.com/PRS/B230.
portals planned, local anesthesia may be injected at two to three consecutive portals at a time.
form a three-dimensional image as to the anatomy of the cord. This is performed by directing the needle in a vertical direction from volar to dorsal without removing the needle from the skin. The needle is probed using tactile resistance to evaluate the width of the cord (without actually going through cord) as the needle passes along both the radial and ulnar sides of the cord. Once the cord geometry is assimilated within the surgeon’s mind, the sweep is initiated in the subdermal plane. A common mistake is to place the needle too deeply within the cord, which makes it very difficult, if not impossible to perform the “sweep” maneuver effectively. If the needle is positioned correctly, and the sweeping motion is initiated superficially, both the patient and the surgeon will have audible confirmation with a “gritty” sound. (See Video, Supplemental Digital Content 2, which demonstrates the needle’s sweeping motion, http://links. lww.com/PRS/B230.) The use of both hands is critical to the needle aponeurotomy procedure; as one hand uses the needle, the contralateral hand “cradles” and steadies the patient’s operative hand. The surgeon’s fingertips should constantly
GENERAL NEEDLE APONEUROTOMY PRINCIPLES The Needle and Its Basic Motion A 5/8-inch (16-mm), 25-gauge needle loaded onto a 1.0-ml empty syringe is used as a scalpel. Although some advocate the use of an 18-gauge needle, the tactile feedback is not as informative as with a 25-gauge needle. In addition, the incidence of skin tears may increase with an 18-gauge needle, as the cutting surface is larger by comparison. Many descriptions of needle action have been described, including clearing, perforation, and sweeping motions.1,5,6 When performing the procedure in areas of skin excess as suggested above, a vertical sweeping motion is used like a pendulum from one side to the other (radial to ulnar or vice versa, depending on which hand the surgeon is using) and from superficial to deep. One may wish to perform a modified perforation motion to
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Video 3. Supplemental Digital Content 3 demonstrates the audible pop, http://links.lww.com/PRS/B231.
Video 4. Supplemental Digital Content 4 demonstrates cord disruption, http://links.lww.com/PRS/B232.
palpate the cords to monitor the progression of cord disruption. One should assume that once a soft spot has been palpated, disruption of the cord (fasciotomy) has been achieved and a needle is not replaced again at that site. It is imperative that the needle is only inserted over a palpable cord. If a cord disruption is suspected, a gentle manipulation of the finger into extension may be performed at this time. An audible pop may be heard coincident with the finger straightening out under gentle force. (See Video, Supplemental Digital Content 3, which demonstrates the audible pop, http://links.lww.com/PRS/B231.) Another useful maneuver is to simply massage the area (especially when dealing with natatory cords) with a fingertip. It is not unusual to feel the cords separate under light to moderate fingertip pressure. It is important to replace the needles often during a procedure, as they become dull very quickly. Metacarpophalangeal Joint When performing needle aponeurotomy for metacarpophalangeal joint flexion contractures, it should be cautioned that direct pressure on the
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finger into extension during the actual needle aponeurotomy procedure be avoided. Although some recommend this maneuver citing that, with the finger being passively extended, the flexor tendons slacken and displace farther away from the skin.1 However, as the cord lengthens with progressive disruption, the tension in the flexor tendons increases, bringing the flexor tendons closer to the skin. The author’s recommendation is therefore that only skin manipulation be performed for metacarpophalangeal joint release. This is accomplished by stretching the skin distal to the needle in an axial (distal) direction with the thumb or index finger of the cradling hand as the sweeping motion with the needle is performed simultaneously. With successful cord dissection from superficial to deep, one may feel a ratcheting sensation through the skin as the final deeper fibers are transected. (See Video, Supplemental Digital Content 4, which demonstrates cord disruption, http://links.lww.com/PRS/B232.) This will correspond to the finger straightening out with gentle finger manipulation once the needle is removed. Photographs obtained before and after needle aponeurotomy are shown in Figure 3. Proximal Interphalangeal Joint One may apply passive extension force to the finger as the needle aponeurotomy is performed. The dense network of pulleys will not allow as much bowstringing of the flexor tendons compared with the palm. (See Video, Supplemental Digital Content 5, which demonstrates needle aponeurotomy for proximal interphalangeal joint flexion contractures, http://links.lww.com/PRS/B233.) Disease may often be present on both sides and, once the predominant cord is released, further palpation may highlight a cord on the other side not otherwise palpated preoperatively. Although the contracted proximal interphalangeal joint is often much more difficult to straighten, with patience and perseverance the results may often be impressive. If all palpable cords have been addressed but some improvement in proximal interphalangeal joint passive extension is still desired, one may cautiously attempt needle aponeurotomy directly over the volar midline just proximal to the proximal interphalangeal flexion crease. Although the surgeon must be absolutely positive the needle does not violate the flexor tendon sheath, the result may be a significant increase in passive extension. The concern for nerve injury at this level is obvious, as the neurovascular structures are well known to be displaced volar and central.7 However, with constant patient feedback and meticulous technique,
Volume 135, Number 3 • Needle Aponeurotomy in Dupuytren’s Disease
Fig. 3. Photographs obtained (above) before and (below) after needle aponeurotomy of the metacarpophalangeal joint.
The sensation of sharp pain, especially with each sweep, can be a heralding sign of injury to the pulley or flexor tendon. With the needle in place, the surgeon asks the patient to gently flex the finger. If the tendon has been violated, the needle will move with tendon excursion and therefore must be repositioned more superficially. (See Video, Supplemental Digital Content 6, which shows checking for tendon violation, http://links.lww.com/PRS/B234.)
Video 5. Supplemental Digital Content 5 demonstrates needle aponeurotomy for proximal interphalangeal joint flexion contractures, http://links.lww.com/PRS/B233.
the incidence of these injuries can be reduced to a level less than seen with open fasciectomy (see later under Complications of Needle Aponeurotomy). It should be reiterated that the needles are not placed into flexion creases, to avoid injury to either the flexor tendon or the neurovascular bundle (Fig. 4). Constant Monitoring During the procedure, it is crucial to listen to the patient for valuable feedback. Any patient report about a Tinel-like sign may suggest danger and therefore the needle must be resituated. A manual check for fingertip sensation should be performed before and after each portal during the duration of the procedure.
Final Passive Stretch or Manipulation Generally, 3 to 4 ml of 1% lidocaine with epinephrine is mixed with 15 to 20 mg of triamcinolone per digit and injected through the skin portals. A gradual, progressive extension force is applied to the finger, with the endpoint being neutral for the proximal interphalangeal and slight hyperextension of the metacarpophalangeal joint. The wrist may be passively held in slight flexion to allow the flexor tendons to slacken. Caution is exercised, as extensive force on the finger may result in unheralded complications, including fracture of a phalanx, especially in the elderly or frail. In the absence of skin tears, small, round adhesive bandages are placed on the skin portals, and generally no dressing is used. Patients are instructed to elevate their hands and apply cold packs liberally for the first 24 to 48 hours. The patients are encouraged to use their hands for normal activities of daily living but to avoid strenuous activities for 7 to 10 days.
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Fig. 4. Photographs obtained (above) before and (below) after needle aponeurotomy of the proximal interphalangeal joint.
Video 6. Supplemental Digital Content 6 shows checking for tendon violation, http://links.lww.com/PRS/B234.
Triamcinolone Administration The administration of triamcinolone for the treatment of Dupuytren’s nodules has been reported previously, with no long-lasting complications.8,9 The effects of triamcinolone have been well elucidated previously.10,11 A recent study has shown that triamcinolone injection when used in conjunction with needle aponeurotomy resulted in a higher degree of correction at 6 months.12
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Postoperative Hand Therapy and Splinting Splinting postoperatively has never shown any benefit in terms of reducing subsequent flexion contractures in Dupuytren’s disease.13 However, if the proximal interphalangeal joint is passively correctable to neutral but the patient displays an active extensor lag of greater than 10 to 20 degrees, I routinely use a postmanipulation boutonnière splint. Proximal interphalangeal joints with an active extensor lag of less than 20 degrees may correct spontaneously over time, depending on the length of time to treatment. The splint is maintained during the day for 3 weeks, coming off for therapy directed at maintaining both active and passive range of motion. The splint is continued at night for 3 months. Because the extensor lag is caused by attenuation rather than disruption of the central slip, the tone in the extensor tendon usually recovers. Skin Tears It is not uncommon during the final passive stretch maneuver for skin tears to develop.5,6,14–16 The most common sites of skin tearing are over flexion creases and also areas of the skin adherent
Volume 135, Number 3 • Needle Aponeurotomy in Dupuytren’s Disease to underlying cord. Tears may be minimized by performing a dermolysis of the cord’s connection with the overlying dermis. This technique may also be used in conjunction with collagenase just before postinjection finger manipulation. Otherwise, it is not recommended that both needle aponeurotomy and collagenase be performed simultaneously. Although some of the skin tears can appear quite dramatic, including exposure of flexor tendons and the neurovascular structures, they will inevitably go on to heal uneventfully by secondary intention within 2 to 3 weeks, similar to what has been previously described by McCash17 (Fig. 5). Care is taken to prevent tendon desiccation by the liberal application of Polysporin/ Neosporin (Johnson & Johnson, Skillman, N.J.) or medicated ointment one to two times per day. The wound is then dressed lightly with a small gauze and Coban wrap. Patients are instructed on maintaining a gentle active range of motion of the fingers during the wound healing phase. Under no circumstances do these tears need to be closed primarily or have local flap coverage or skin grafting.
RECURRENCE AND OUTCOMES OF NEEDLE APONEUROTOMY Discussion regarding outcomes and recurrence of Dupuytren’s disease continues to be a significant problem in terms of interpretation of the literature because of lack of a universally accepted use of the term “recurrence.”17 There is no cure
for Dupuytren’s, and although the treatment is aimed at decreasing the flexion contractures of the digits, the disease may progress irrespective of the treatment strategy used. Overall, the correction of metacarpophalangeal joint flexion contractures appears superior for the metacarpophalangeal joint in contrast to the proximal interphalangeal joint irrespective of the treatment, surgical or noninvasive,5,13,14,19–22 and can be attributed to an effect of the metacarpophalangeal joint with lengthened collateral ligaments when compared with the proximal interphalangeal joint (shortened collateral ligaments). Van Rijssen and Werker published preliminary results after a 33-month follow-up, citing a recurrence rate of 65 percent using a definition of recurrence with a total passive extension deficit reduction of more than 30 degrees and included both metacarpophalangeal and proximal interphalangeal joint contractures.23 Initial correction was reported as a 71 percent improvement in extension, as the mean preoperative total passive extension deficit was reduced from 62 degrees to 18 degrees. Then, in 2012, the same authors reported an 85 percent recurrence rate after a 5-year follow-up.21 Using flexion of 20 degrees or less over the initial postprocedure correction, Pess et al. reported success in 80 percent of metacarpophalangeal joints and 35 percent of proximal interphalangeal joints at 3-year follow-up in 1013 cases.5
Fig. 5. Skin tear during needle aponeurotomy shown (left) immediately after manipulation with exposure of flexor tendon, (above, right) 8 days after needle aponeurotomy, and (below, right) 18 days after needle aponeurotomy.
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Plastic and Reconstructive Surgery • March 2015 Overall, the recurrence rates are lowest with open fasciectomy. However, one factor rarely reported on is total postoperative flexion. In a 6-week follow-up study directly comparing limited fasciectomy and needle aponeurotomy, 24 percent of patients had a flexion deficit in the fasciectomy group, whereas none occurred in the needle aponeurotomy group.24 Regarding recurrence rates, based on a conservative perusal of the literature and my own experience, I inform my patients as follows: 5 to 10 percent per year for open fasciectomy and 10 to 20 percent per year for needle aponeurotomy. Once patients are educated, the decision for treatment is usually between needle aponeurotomy and collagenase. Although long-term data are not available for recurrence following use of collagenase, the results can be equally impressive. However, collagenase treatment entails at least two appointments, and the cost may be prohibitive.
COMPLICATIONS OF NEEDLE APONEUROTOMY It is well established that the incidence of complications of needle aponeurotomy is significantly lower compared with open fasciectomy. Chen et al. reported on a systematic review of the literature and an overall complication rate of 14 to 67 percent with open partial fasciectomy, with the most common complications consisting of nerve injury, infection, and complex regional pain syndrome.13 In contrast, Pess et al. found the overall complication rate to be very low with needle aponeurotomy, with the most common being skin tears (3.4 percent).5 All tears healed with local wound care. There were no reports of tendon laceration, infection, or complex regional pain syndrome. Neurapraxia was noted in 1.2 percent of patients. In the author’s own experience, 723 needle aponeurotomy procedures in a hospital outpatient clinic were performed over a 5-year period. One flexor tendon laceration occurred, and skin tears were noted in 14 fingers (all healed within 3 weeks). One patient had a wound infection that settled with oral antibiotics. No nerve injuries were noted. Seven digits were treated open for uncorrectable proximal interphalangeal flexion contractures. Needle aponeurotomy was repeated in 42 digits for recurrent flexion contractures at the metacarpophalangeal joint (>20 degrees) and 57 digits for proximal interphalangeal contractures (>5 degrees). Cost of Needle Aponeurotomy Recently, studies looking at the cost effectiveness of surgical and nonsurgical treatment
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strategies have been performed.25,26 Both studies, using different models, concluded that needle aponeurotomy was considerably more cost effective compared with open fasciectomy. However, one of the primary factors associated with increased costs in both studies is based on the assumption that all open fasciectomies are performed in the operating room with either regional or general anesthesia. Certainly, with the trend of wide-awake surgery, these procedures may be performed in an outpatient clinic under local anesthesia, thereby lowering costs.27 Advantages and pitfalls of needle aponeurotomy are listed below. Advantages of Needle Aponeurotomy • Patients love it • Extremely low complication rate • Performed in outpatient setting or in private office • Benefits of wide-awake surgery with dramatic results • Quick recovery • Cost effective • Excellent for metacarpophalangeal joint contractures with palpable cords • Easy to repeat at any time Pitfalls • Steep learning curve • Skin tears • Difficulty in correcting proximal interphalangeal flexion contractures
CONCLUSIONS Ultimately, it is up to the surgeon and patient to tailor a treatment protocol for Dupuytren’s disease. It is the surgeon’s responsibility to educate the patient regarding the treatment strategies and the subsequent outcomes. The author’s belief is that open fasciectomy should be offered as a last-resort intervention, with the most common indication being the uncorrectable proximal interphalangeal flexion contracture. Therefore, patients should at least be offered needle aponeurotomy as a potential first-line treatment option because of its low complication rate, cost effectiveness, and quicker recovery. Michael Morhart, M.D. 303 Coronation Plaza East Tower 14310 111 Avenue Edmonton, Alberta T5M 3Z7 Canada [email protected]
Volume 135, Number 3 • Needle Aponeurotomy in Dupuytren’s Disease REFERENCES 1. Diaz R, Curtin C. Needle aponeurotomy for the treatment of Dupuytren’s disease. Hand Clin. 2014;30:33–38. 2. Hutchison RL, Rayan GM. Astley Cooper: His life and surgical contributions. J Hand Surg Am. 2011;36:316–320. 3. Lermusiaux JL, Debeyre N. Le traitement medical de la maladie de Dupuytren. In: de Seze S, Ryckewaert A, Kahn MF, et al., eds. L’actualite rhumatologique. Paris: Expansion Scientifique Franchaise; 1980:338–843. 4. Badois FJ, Lermusiaux JL, Masse C, Kuntz D. Non-surgical treatment of Dupuytren disease using needle fasciotomy (in French). Rev Rhum Ed Fr. 1993;60:808–813. 5. Pess GM, Pess RM, Pess RA. Results of needle aponeurotomy for Dupuytren contracture in over 1,000 fingers. J Hand Surg Am. 2012;37:651–656. 6. Eaton C. Percutaneous fasciotomy for Dupuytren’s contracture. J Hand Surg Am. 2011;36:910–915. 7. McFarlane RM. Patterns of the diseased fascia in the fingers in Dupuytren’s contracture: Displacement of the neurovascular bundle. Plast Reconstr Surg. 1974;54:31–44. 8. Ketchum LD, Donahue TK. The injection of nodules of Dupuytren’s disease with triamcinolone acetonide. J Hand Surg Am. 2000;25:1157–1162. 9. Ketchum LD, Robinson DW, Masters FW. Follow-up on treatment of hypertrophic scars and keloids with triamcinolone. Plast Reconstr Surg. 1971;48:256–259. 10. Ketchum LD, Robinson DW, Masters FW. The degradation of mature collagen: A laboratory study. Plast Reconstr Surg. 1967;40:89–91. 11. Al-Qattan MM. Factors in the pathogenesis of Dupuytren’s contracture. J Hand Surg Am. 2006;31:1527–1534. 12. McMillan C, Binhammer P. Steroid injection and needle aponeurotomy for Dupuytren contracture: A randomized, controlled study. J Hand Surg Am. 2012;37:1307–1312. 13. Chen NC, Srinivasan RC, Shauver MJ, et al. A systematic review of outcomes of fasciotomy, aponeurectomy, and collagenase treatments for Dupuytren’s contracture. Hand 2011;6:250–255. 14. Donaldson J, Goddard N. The re-emergence of percutaneous fasciotomy in the management of Dupuytren’s disease. Open Orthop J. 2012;6:83–87.
15. Foucher G, Medina J, Navarro R. Percutaneous needle aponeurotomy: Complications and results. J Hand Surg Br. 2003;28:427–431. 16. Henry M. Dupuytren’s disease: Current state of the art. Hand (N Y) 2014;9:1–8. 17. McCash CR. The open palm technique in Dupuytren’s contracture. Br J Plast Surg. 1964;14:53–58. 18. Werker P, Pess GM, van Rijssen AL, et al. Correction of contracture and recurrence rates of Dupuytren contracture following invasive treatment: The importance of clear definitions. J Hand Surg Am. 2012;37:2095–2105. 19. Becker GW, Davis TR. The outcome of surgical treatments for primary Dupuytren’s disease: A systematic review. J Hand Surg Br. 2010;35:623–626. 20. Dias JJ, Braybrooke J. Dupuytren’s contracture: An audit of the outcomes of surgery. J Hand Surg Br. 2006;31: 514–521. 21. van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: Percutaneous needle fasciotomy versus limited fasciectomy. Plast Reconstr Surg. 2012;129:469–477. 22. van Rijssen AL, Werker PM. Percutaneous needle fasci otomy for recurrent Dupuytren disease. J Hand Surg Am. 2012;37:1820–1823. 23. van Rijssen AL, Werker PM. Percutaneous needle fasciotomy in Dupuytren’s disease. J Hand Surg Br. 2006;31:498–501. 24. van Rijssen AL, Gerbrandy FS, Ter Linden H, Klip H, Werker PM. 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;31:717–725. 25. Baltzer H, Binhammer PA. Cost-effectiveness in the management of Dupuytren’s contracture: A Canadian cost-utility analysis of current and future management strategies. Bone Joint J. 2013;95:1094–1100. 26. Chen NC, Shauver MJ, Chung KC. Cost-effectiveness of open partial fasciectomy, needle aponeurotomy, and collagenase injection for Dupuytren’s contracture. J Hand Surg Am. 2011;36:1826–1834. 27. Lalonde DH. Reconstruction of the hand with wide awake surgery. Clin Plast Surg. 2011;38:761–769.
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