Needle aponeurotomy 14,15
Needle aponeurotomy was invented in 1972 by JL Lermusiaux. This technique was made possible by the technological progress in single-use medical needles, with their double sharp bevel being used as micro scalpels (see Figure 1). The technique is ambulatory and can be performed in an ordinary medical clinic. The principle consists in one or several percutaneous sections of aponeurotic cords with the bevel of a needle (16-5/10th in Europe, 25G x 5/8 in the US). The same needle is used for the injection of local anaesthetic, 1-3 cc of lidocain 2%, inside and around the cord after a thorough disinfection of the skin by 1% iodized alcohol. A little amount of prednisolone acetate 2.5% can be added to the solution in the syringe (1ml per 5ml of lidocain) to prevent painful reactions posterior to the treatment. In contrast to other non-surgical techniques of Dupuytren’s contracture treatment still in development16,17, no enzyme is injected in the cord. Section of the cord is obtained by to- and fro- movements of the needle perpendicular to the palm, completed by a firm extension of the treated finger. A dry bandage protected by an elastic tape (Tensoplast®) should be kept on for two days. One to four aponeurotomies can be performed in a single session and the procedure repeated with a delay of seven days. Between one and two sessions are needed to treat Tubiana stage 1 and 2 diseases18 (see Figure 2). Treatment is always initiated from palmar to distal cords and from P1 to P2 in the finger. A thermoplastic splint worn at night is sometimes necessary in long-standing proximal interphalangial forms with capsular retraction. Apart from dirty work, full use of the hand is allowed immediately. Two-week sick-leave is only necessary for those employed in manual labour.
Complications of Needle Aponeurotomy:
Serious adverse effects are uncommon after needle aponeurotomy. However, in less than one in 1,000 cases, rupture of one of the flexor tendons may occur within a few days of the procedure and requires prompt surgical repair. Section of collateral nerve happens in less than one in 1,000 cases. No complex regional pain syndrome involving the entire hand has occurred in our centre, and only 3 focal forms were reported over 35 years of experience. Phlegmon is exceptional. Minor incidents occur in 1% of procedures including skin breaks, temporary hypoesthesia, superficial infections and haematoma. This should be balanced with the high rate of complications following surgical management of Dupuytren’s contracture19-21: section of nerve: 5.2%, section of tendon: 2%, section of artery: 1.8%, C.R.P.S.: 1.8%, infections between 1 and 2%, amputations: 0.1%, and scars: 100%.
Immediate and 5 year follow-up results are comparable to surgical results15,21. The immediate results are excellent with Tubiana stage 1 and 2 (89-92 % reduction of the degree of contracture), good with stage 3 (83%) and intermediate with stage 4 (48%) disease, with no aggravation or failure, unlike in surgical series. After 5 years, results are sustained in stage 1, 2 and 3 (92%, 74% and 57% respectively), but 38% in stage 4. Recurrence rate reaches 50% in all series but the safety, the ambulatory mode and the low cost of the technique make retreatment easy in case of recurrence. Stage 4 treatment still have insufficient results, which suggest that treating in earlier states is preferable, and needle aponeurotomy should be offered as first line treatment in stage 1, 2 and 3. Technical improvements have allowed treatment of digital forms10. Needle aponeurotomy can be used on postoperative reoccurrences of Dupuytren’s contracture, with the exception of retractile scars and capsular retractions of the proximal interphalangeal joint (PIPJ)22.
We must emphasise that needle aponeurotomy is a medical technique of delicate learning that should be performed by trained practitioners only, with the appropriate tools. Using a blade or troncular anesthesia increases risks of tendon damage, skin scar and nerve lesion23.