Needle Aponeurotomy For Clinicians
Needle aponeurotomy is a procedure that aims to divide the fascial cords produced by Dupuytren's disease using the bevel of a needle to safely and effectively release digital flexion contractures with minimal discomfort and downtime for the patient. As more experience of this technique has been gained, so the indications for its use have been extended. It is now possible to successfully treat most of the contractures produced by Dupuytren's disease percutaneously without resorting to major excisional surgery in the first instance. This DVD aims to: 1, introduce the concepts and techniques of needle aponeurotomy; 2, to describe the possible pitfalls and complications that are to be avoided in using the technique; 3, and to describe the post-operative care of patients who are treated by this method. Percutaneous release of Dupuytren's contracture was popular during the 1800's before the advent of anaesthesia.
This was superseded by open fasciectomy and then radical fasciectomy in the 1900's in an effort to reduce recurrence rates and to try to affect a 'cure' for the disease. However, as radical fasciectomy fell out of favour, the concept of percutaneous fasciotomy was reintroduced by the French dermatologist Dr Jean-Luc Lermusiaux in 1979. The technique has been modified since to its present form and it is this technique that is discussed in this DVD. Needle aponeurotomy is best performed for patients with primary disease who have not previously had any form of fasciectomy. Scars from previous operations can greatly reduce the chance of releasing the contracture effectively and may increase the chance of nerve injury as the neurovascular bundles may be in a less predictable location.
Needle aponeurotomy should not be done where a skin graft has previously been done in the involved ray. Fasciotomy is less effective in the presence of an established joint contracture, although it may be difficult to establish the presence of a joint contracture until after the Dupuytren's cord has been divided. Patients with disease recurrence who have previously undergone needle aponeurotomy with good effect and in whom there is a well-defined cord may have further attempts at percutaneous release. Isolated metacarpophalangeal contractures caused by a palmar pretendinous cord are probably the best initial cases to take on for the surgeon who is unfamiliar with needle aponeurotomy. The cord is easily palpable in the palm and the neurovascular bundles are in a predictable position making inadvertent injury less likely when the correct technique is employed. More complex cases involving the natatory cords, and PIPJ flexion contracture may be better left until the surgeon has become more familiar with needle aponeurotomy Percutaneous fasciotomy was originally described with the use of modified scalpel blades, which were associated with higher rates of tendon and nerve injury. The use of hypodermic needles instead of scalpels has not eliminated the risk, but has significantly reduced the chance of inadvertent injury to these structures. As with all surgical procedures, it is extremely important to counsel the patient fully when undertaking needle aponeurotomy.
The patient must not only be aware of the risks of treatment but must have a clear understanding of the likely outcomes of treatment, particularly with respect to recurrence. General complications of hand surgery including: Pain Infection Scarring Bleeding Complex regional pain syndrome and their consequences are explained to the patient. The pain experienced post-procedure is usually controlled with simple oral analgesia such as paracetamol or ibuprofen. Infection is rare, but the patient is warned that approximately 5 patients per year develop a major hand infection that can alter the outcome of surgery and that infection is more common in patients with diabetes. The possibility of a scar no matter how small should be explained and that the scar may become raised, red, itchy or painful for up to 6 months. Complex regional pain syndrome is mentioned as occurring rarely in 1:3000 cases but that the patient's hand could become painful and useless for 2 years if it were to develop following the procedure. Technique-specific complications including: Skin tears Recurrence rates Nerve injury Tendon injury and the likely improvement in range of movement are also emphasized and compared to open fasciectomy. Patients are told that the Dupuytren's disease will recur although the site and timing of recurrence are not known.
The success rate of the procedure is quoted as 85%-90% and that some patients require a further procedure, but that 10% of patients will have a permanent contracture. Recurrence rates of 50% at 3 years for needle aponeurotomy are compared to a recurrence rate of 50% at 5 years for open surgery. Patients are advised that they may use their hand as pain and discomfort allows immediately after the procedure but should avoid activities requiring a tight grip, for example tennis or golf. The patients should expect normal function by the end of the first week following needle aponeurotomy in most, if not all, cases.
We use sterile needle aponeurotomy packs which contain: A 5ml syringe and blunt needle, for drawing up local anaesthetic, A 2ml syringe for injecting anaesthetic, A number of blue (23 gauge) and orange (25 gauge) hypodermic needles for performing the fasciotomies, A sterile towel and swabs, A tray or pot for skin cleansing solution. The concept of a needle portal is important. A portal represents the site of entry of the needle that is used for the fasciotomy. Ideally, a portal should be sited over a cord of disease that is easily palpable and whose margins are easily defined. The skin overlying the portal should be soft and untethered so that when the cord is released the skin can stretch to accommodate the extension produced by contracture release. We've got a pit in the skin there, so that's the point of attachment of the Dupuytren's to the skin. We want to go proximal to that, so we don't want to go through that fold of skin, through that track.
We want to use that as our point that will allow things to straighten out. If we go distal to that then the Dupuytren's will still be attached to the skin and we won't be able to get extension. So we want to go proximal to that, in this very mobile skin where it's not attached to the Dupuytren's. We can see that it's lose there, it's lose down here. There is a point of attachment in the crease, very much attached here and then lose down there. The procedure is performed in a clean or minor procedure room as facilities allow. The patient is semi recumbent with the affected hand resting on an arm table.
Both hands may be operated at the same visit, if indicated. The skin is prepared with alcoholic chlohexidine and sterile drapes are used to give a sterile field. 5mls of 1 % lidocaine are drawn up into a 5 ml syringe using a blunt needle and 2mls are taken from this syringe into a 2ml syringe. As a general rule, a blue needle (23 gauge) is used for palmar cords and an orange needle (25 gauge) is used for digital cords. The bevel of the needle that is to be used for the aponeurotomy is positioned so that the opening is in line with the gradations on the syringe to facilitate positioning.
This ensures the surgeon is able to maintain the needle bevel perpendicular to the direction of the cord fibres once it is inserted into the hand. Skin wheal anaesthesia is used. It is extremely important to restrict the local anaesthetic injection to only the skin. This ensures that the digital nerves are not anaesthetised because the patients' perception of nerve irritation is an important indicator of the location of the digital nerves. This in turn helps to avoid digital nerve injury. The patient is asked to report any feelings of pins and needles or electric shocks during the procedure.
After injection of the anaesthetic, the affected digit is held under constant tension and the fasciotomy performed. Cords are treated in a distal to proximal direction. In doing so, the nerve is less likely to become anaesthetised as different parts of it are released and so remains stimulable during the procedure, reducing the chance of inadvertent injury. There are 3 basic manoeuvres that can be used to divide the cords: 1, Perforating the cord. This helps the surgeon establish the depth and width of the cord.
It is often necessary to pass the needle quite superficially and laterally around the cord to ensure the whole width of the cord is perforated by the needle. This manoeuvre also helps to clear the subdermal septae from around the cord. 2, Stroking the cord. The cord can be gently stroked from side-to-side using the tip of the needle. Care must be taken to ensure that the needle is not placed too deeply as the flexor tendon may be injured with this manoeuvre.
Asking the patient to move the finger and looking for movement of the needle may help to define the depth of the needle tip. 3, Slicing the cord. With the needle placed against the side of the cord, it is withdrawn whilst applying pressure across the cord, but not so much as to produce a bend of the shaft of the needle, so dividing the fibres of the cord. Whilst applying these manoeuvres, the surgeon can appreciate a 'crunching' of the cord as it is divided. This is both audible and palpable. It is important to change the needle regularly if it appears to be becoming ineffective as a sharp bevel is required for effective needle aponeurotomy. Once the cord has been divided as much as possible with the needle, the finger is extended to help break any remaining fibres of the cord and reduce the flexion contracture. It is important to isolate the joint being treated and to direct the manipulation force specifically across it.
Then stretch the finger out and a definite defect there in the cord. We can feel an opening. The wounds are dressed with simple adhesive dressings after the area has been cleaned with antiseptic solution. The patient may find application of an ice pack for the first 24 hours useful, especially if a large area has been treated.
The patient is advised to use the hand as pain allows for the first week, but to avoid strenuous activities such as golf, tennis or gardening. A night splint may be used depending on surgeon preference. We generally use static splints for those patients with longstanding contractures and skin tightness. We use dynamic splints for those patients who have incomplete release and a soft endpoint to the contracture suggesting ligamentous tightness, and is fitted on the day of surgery and worn for 3-6 months. The patient is discharged with an open appointment and advised to return as and when further contractures develop. This patient has just undergone needle aponeurotomy.
He had previously had an open fasciectomy twenty years earlier for Dupuytren's disease effecting the little finger ray. His needle aponeurotomy was performed for Dupuytren's disease effecting the thumb, index and middle fingers in the same hand. You're quite unique in some respects that you've had both the faciectomy and the needle in the same hand. So considering the benefits of the previous operation which lasted you twenty years set against the time it has took you to get over that operation and the needle which takes you very little time to get over but doesn't last as long. Which procedure would you prefer? The needles, every time.
Why is that particularly do you think? Well, you get over it quicker, invasive, well it is invasive but hardly. The recovery time is instantly. The results to me are excellent and my hands have been bad and I am very impressed with it. You can have it done several times, it isn't a one of that's it.
As I say, recovery rate, less trauma, no scar tissue, for me it's the way to go. How did you find having the needle aponeurotomy because it does involve putting a needle in your hand several times? Is it particularly sore or uncomfortable? No not really, the worse bit is the anaesthetic when they put that in to start off with. It's just a prick in your hand but that's the most painful bit. Once it's in there you don't feel anything.
Sorry, you do feel the needles in there, get that right. No pain, but you can feel them on the internals of your hand working away. There isn't any pain, just a strange feeling really. Dupuytren's disease is an incurable problem that greatly impacts on the function of patients' hands. All surgical methods of treatment are complicated by recurrence of the condition. Needle fasciotomy offers patients the benefits of a minimally invasive procedure with low complication rates that allows them to use the hand soon after the procedure. Although the recurrence rate is higher than with more radical excisional procedures, subsequent fasciotomies do not compound the initial surgical insult of a needle aponeurotomy and will help to preserve the function of the hand for the duration of the patient's life.
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