By Dr. Benjamin D. Sutker, MD
Dupuytren's contracture is a benign condition which causes a tightening of the flesh beneath the skin of the palm and can result in permanently bent fingers. There is a sheet of tissue under the skin of the palm which is stuck to the undersurface of the skin of the palm. This layer, called fascia, reinforces the skin of the palm.
The fascia looks like cloth and has fine threads which run length-wise from the palm into the fingers. Dupuytren's disease makes these length-wise threads shrink and they become too short to let the fingers straighten all of the way. Trying to straighten the fingers pulls the threads taught and they feel like a string under the skin called a cord. The taught cord holds the fingers bent like the string on a bow. The cord may feel like a tendon but it is actually between the tendon and the skin.
CAUSES & TRADITIONAL TREATMENT
Other possible reasons for people to develop bent fingers include arthritis, trigger finger or the after affects of injury, but these conditions are not Dupuytren's disease and are treated differently. Dupuytren's is felt to be inherited but does not necessarily show up in every generation. About half the people with Dupuytren's know of a close relative with it but half do not know anyone in the family with the disease. The natural history of Dupuytren's is progressive contracture in the hand, although prediction of the rate of progression is difficult. The younger a person is when they first develop Dupuytren's, the more likely they will develop a contracture requiring surgery. Overall, finger contractures develop in about 1 in 20 people with Dupuytren's disease. If finger contractures develop, eventually function is lost; however, function and dexterity can be improved with correction of the contractures.
Traditional treatment for Dupuytren's disease involves fasciectomy or surgical excision of the diseased cords and nodules. In this procedure, the surgeon makes extensile incisions in the finger and into the palm elevating skin flaps, protecting the nerves and vessels, and removing the diseased tissue. Occasionally the skin of the palm is left open to heal in secondarily or, in more severe cases, may require a skin graft. Postoperatively, patients require supervised hand therapy and recovery can be anywhere from six to 12 weeks. The irony of Dupuytren's disease is that in the hand that has Dupuytren's contracture, the normal reaction to wounding can be greatly exaggerated resulting in increased swelling, stiffness, tenderness and difficulty using the hand. This reaction can drag on for much longer than it would without Dupuytren's. The reaction to open surgery can result in permanent complications even if surgery is technically perfect.
A MINIMALLY INVASIVE ALTERNATIVE
An alternative to open surgery, Needle Aponeurotomy (NA) is a minimally invasive treatment for Dupuytren's contracture. In contrast to surgical treatment, Needle Aponeurotomy allows a more rapid recovery. In most cases it is possible to return to near normal activities without bandages within a few days of treatment.
The NA technique was developed in Paris by Dr. Lermusiaux, and has been performed in France for nearly 30 years. NA has been performed in the United States since 2003.
The NA procedure is performed as an outpatient under local anesthesia. During the NA procedure, the physician lengthens the tight cord by cutting it beneath the skin with a small needle, usually at several points along the line of tightness. From a technical standpoint, Needle Aponeurotomy is a type of procedure referred to as a percutaneous fasciotomy, meaning entering the skin through a tiny hole and cutting the fascia affected by Dupuytren's disease. The needles may be used both to cut the tight fascia and to inject Dupuytren's nodules with cortisone. After the procedure, the injections sites are merely covered with bandages, a small ice pack and small dressing. Patients are encouraged to elevate the hand as much as possible for 48 hours. Most patients are able to eat, change clothing, go to the restroom and drive a car without assistance immediately after the procedure. In addition, patients are advised to avoid gripping a golf club, tennis racket or carrying heavy objects for 10 to 14 days after Needle Aponeurotomy. Pain medication is rarely required and most patients do very well with an occasional over-the-counter anti-inflammatory.
ADVANTAGES OF NEEDLE APONEUROTOMY
The advantages of Needle Aponeurotomy are obvious, most notably the quicker recovery of two to seven days as opposed to two to three months for traditional surgery. Postoperative therapy is not usually needed and the procedure can be repeated in a very straight forward fashion if there is possible recurrence. Because Dupuytren's is a medical condition, recurrence is common whether treated with open surgery or with percutaneous techniques. Correction of contractures are more difficult for both traditional surgery and Needle Aponeurotomy if there is significant involvement of the PIP joint or severe combined contractures of both the MCP and PIP joints. Recurrence rates, which may merely be the brief formation of a cord and may not necessarily mean significant contracture, are estimated at approximately 50% of patients at five years postoperative from open surgery and 50% postoperatively at three years from Needle Aponeurotomy.
Results of the NA procedure compare favorably with traditional open surgery, with the advantage being improvement of contracture without a long recovery period. Data from the Paris group revealed approximately 90% good or excellent results in over 3,700 NA procedures, with only a 3.7% minor complication rate which compares favorably to open surgery. The degree of postoperative correction correlates with the severity of the contracture.
For those patients who have a contracture of the hand that is confirmed to be Dupuytren's disease and for whom the contracture is impairing normal function and use of the hand, Needle Aponeurotomy offers a minimally invasive treatment with a quick recovery time and rapid return to normal activities.
A native of Charlotte, Dr. Benjamin Sutker specializes in elbow, hand and wrist at OrthoCarolina Rock Hill. He has a special interest in wrist and elbow trauma, arthritic reconstruction of the hand/wrist, nerve and tendon injuries, wrist/elbow arthroscopy, total elbow arthroplasty and needle aponeurotomy for Dupuytren's disease.
Outside of the office, Dr. Sutker enjoys spending time with his wife Lisa, their twin teenagers and their Goldendoodle, Finley, and likes to burn off steam fishing and road biking.