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PRESENTATION AT THE AMERICAN SOCIETY OF SURGERY OF THE HAND ON NA(Subcutaneous or Needle Fasciotomy)

 Sept. 8, 2006 Washington, DC

1 A New Look At An Old Solution: Closed (Needle) Fasciotomy

  By Keith Denkler, M.D.

Associate Clinical Professor of Plastic Surgery, UCSF

2 Dogma

Limited fasciectomy with, or without grafting, or open techniques (McCash) remains the treatment of choice for Dupuytren’s contracture since the 1960’s

3 What is the Reconstructive Ladder of Treatment for Dupuytren’s?

4 Dupuytren’s Solutions

Medications or creams: Not yet

Injections Kenalog, collagenase (pending)

Skeletal traction before, or after surgery can help, but invasive

Surgical Release via perforations-Fasciotomy

Open or closed types

Small knives or needles may be used

Surgical Removal via excision-Fasciectomy

Localized, limited, or radical fasciectomies

With full-thickness skin graft (dermofasciectomy)

5 NEEDLE FASCIOTOMY: History and Complications

Subcutaneous fasciotomy was advocated/performed? by Cline 1777 and Cooper in 1822 (first fasciotomies)

Dupuytren 1832 Preferred transverse fasciotomy leaving the skin open

Goyrand 1833 proposed longitudinal subcutaneous fasciectomies with suturing to prevent infection (first limited fasciectomy)

6 "Late 19th surgeons liked the reduced chance of infection and results with closed fasciotomy

Adams 1878 and 1890 published two books on this subcutaneous release

7 Radical Fasciectomy

Technical improvements in surgery and anesthesia allowed in the early 20th century surgeons more extensive removal of diseased Dupuytren’s fascia to prevent recurrence

Radical Fasciectomy

Keen (1906) and Iversen (1909)

Lexer (1931) and McIndoe 1948, McIndoe and Beare 1958

8 Limited Fasciectomy

Extensive post-operative complications led to development of the current limited fasciectomy as recurrence rates are reported to be similar

Hueston 1962 and others

First limited fasciectomy by Goyrand 1833

9 Surgery for Dupuytren’s: Fasciectomies; How are we doing?

Personal fifty-year review on Dupuytren’s surgery

Significant and major injuries may occur after surgery

Are we helping our patients with fasciectomies: yes

Are we hurting our patients with fasciectomies: yes

10 Overall Risk of Digital Nerve Injury

Surgical fasciectomy operations carry a 3% risk of digital nerve injury despite a bloodless field, skilled surgeons, loupe magnification, and an open approach

Tubiana 7.7% of 195 surgeries in 1967 to Coert 7.7% of 558 surgeries in 2006

Major number of cases in the review

Geldmacher 2.8% of 2160 in 1994

McFarlane 1.5% of 1339 in 1990

Overall numbers over 50 years 3.2% out of 6,038 reported in the personal series (Range 0.4% to 7.8%)

Incidence in recurrent cases usually much higher Sennwald 27% of 26 repeat operations in 1990 sustained nerve damage

11 Risk of Digital Artery Injury

If two are injured, may require revascularization or lead to secondary necrosis or gangrene

Major problem before surgery for recurrent disease

Overall rate counting unreported as zero is 0.8% out of 6,038 surgeries in 50 year review

12 Risk of Infection

Most small to moderate, but may be severe despite aseptic technique and antibiotics

Range of infections is 0 to 9.6%

Major number of cases in the review

Geldmacher 2.6% of 2160 in 1994

McFarlane 1.3% of 1339

Overall rate 2.4% of 6038

13 Risk of Hematoma

Formerly a major complication due to more undermining of flaps 15.8% of Tubiana’s series in 1967!

Major studies

Geldmacher 1994 1.16 of 2160

McFarlane 2.2% of 1339

Overall risk 2.1% of 6038 surgeries in 50 year review

14 Reflex Sympathetic Dystrophy and Dupuytren’s Surgery

Highly morbid disease requiring difficult, prolonged, and usually disappointing treatment

Major studies

Geldmacher 2.2% of 2160

McFarlane 4.2% of 1339

Overall incidence 3.5% of 6038 surgeries in 50 year review

15 Reflex Sympathetic Dystrophy and Dupuytren’s Surgery

Very rare in NA Probably because of use of local anesthetic

Use of general anesthetic increases risk of RSD!

Incidence may be reduced in with more use of axillary block anesthesia in study published this year

Reuben, S.S., et al., The incidence of complex regional pain syndrome after fasciectomy for Dupuytren's contracture: a prospective observational study of four anesthetic techniques. Anesth Analg, 2006. 102(2): p. 499-503.

16 Skin Slough or Separation

Complication of cutting and undermining

Major studies

Geldmacher 1994 4.7% of 2160

McFarlane 1990 4.7% of 1339

Overall incidence is 5.4% of 6038

Dupuytren’s limited fasciectomy under local anesthesia with epinephrine, my own paper, had a 5% incidence:

Denkler 2005

17 Unusual and or Bad Complications of Dupuytren’s Surgery

Hospital re-admission up to 15% incidence

Mandol in UK 2005 Ann RCS

Medical perioperative complications

Tendon injury 0.23% Geldmacher 1994

Digital gangrene 0.1% McFarlane 1990

Prolonged edema and stiffness may occur

Scar sequelae (incisions too straight) Too frequent?

18 Complications of NA

Usually minor complications

Skin tears Could need sutures

Localized infection

More significant complications

Digital nerve injury approx 1%

Tendon 0.1%

Reflex Sympathetic Dystrophy Rate?

19 Complications of NA

Digital nerve injury

1% of 473 overall cases in published series by hand surgeons

JHS (Am) Rijssen 2006

JHS (Br) Foucher 2001

French data Lermusiaux 1997 and 2001

Large numbers (50,000) are anecdotal and not part of series States “nerve as rare as tendon” and “five tendons out of 50,000”

20 Complications of NA

Summarized by Foucher 2001

May be a large number of unreported complications We do not really know the denominator

Foucher 2001 references

Badois data from 1993 3736 aponeurotomies

Two tendon injuries or 0.05% Two nerve injuries or 0.05%

21 My Own Complications 443 Digits

Digital nerve injury 4/443 or 0.9% (one case was after previous surgery for recurrent disease)

A few patients developed temporary neuropraxia from nerve “stretching”

Flexor tendon injury 1/443 or 0.2% (case #20 -60 degrees PIP)

Infection 5/443 or 1.1% (two severe in/around PIP joint 2 severe were recurrent PIP disease needing needle capsulotomies of the PIP joint

22 My Own Complications 443 Digits: RSD

1/443 or 0.2% incidence of Reflex Sympathetic Dystrophy

(patient had previous surgery and RSD after previous surgery)

A second RSD from previous surgery did not develop RSD after my NA procedure!

Skin tears Sutured 10/443 or 2%

Minor, from stretching skin approx 10% and not sutured

FTSG in 1/443 or 0.2% stage 4 finger -145 MCP+PIP total loss of extendion

23 Can We Do Better?

There is no one operation for Dupuytren’s!

Can we take the old, add the new, and help our patients by doing less?

Why not start small?

Repeat as necessary!

TABLE OF LITERATURE ON DUPUYTREN'S SURGERY

Reference

Number

Nerve Injury%

Infection%

Hematoma%

Sympathetic Dystrophy%

Coert[7]

558

7.7

3.6

?

4.5

Rijssen[8] 2006

78

1.2

1.2

1.2

0

Denkler[9]

2005

102

2.9

7

1

0

Bulstrode[10]

2005

253

2.0

9.6

2.0 McCash

technique

2.4

Leclercq[11]

2003

245

2

?

0.4

0

Leclercq[12] 2000

183

2

0.5

1

3

Foucher[13]

1995

54

1.9

?

0

9.3

Geldmacher

1994[14]

2160

2.82

2.68

1.16

2.18

Foucher 1992

140

3.2

0.7

7

Sennwald[15]

1990

98

7.8

1

3

19

McFarlane[16, 17] 1990

1339

1.5

1.3

2.2

4.2

Hout[18] 1988

326

5.2

3.4

5.8

1.8

Allieu and Tessier 1986

77

3.6

11.6

Rodrigo 1976

230

0.4

1.3

4

10

Tubiana[19] 1967

195

7.7

2.6

15.8

?

Total with weighted average

6038

3.2

2.4

2.1

3.5

Historical Comments on Subcutaneous Release (Fasciotomy) of Dupuytren's Contracture

Binnie[1] in 1917:   “subcutaneous section is usually followed by recurrence, but the recurrence may be so delayed and the operation is so trivial that many patients prefer repeated section to a more formidable radical operation”

 

Luck[2] from 1959:  "Subcutaneous fasciotomy was first suggested for the treatment of flexion contracture of the fingers by Sri Astley Cooper in 1822.  He wrote "... but when the aponeurosis is the cause of the contraction and the contracted band is narrow, it may be with advantage divided by a pointed bistoury, introduced through a very small wound in the integument. The finger is extended and a splint is applied to preserve it in a straight position".  This procedure fell into disrepute through the years because it was indiscriminately applied to all cases of contracture; but Luck has recently reintroduced it and it has achieved limited popularity.  Having perused 20 papers, published since Skoog's monograph in 1948, on the surgical treatment of flexion contracture, we find that fasciotomy is either not mentioned at all or condemned.  The radical fasciectomy, on the other hand, is given not merely as the procedure of choice but is considered the only satisfactory surgical treatment.  This blind adherence to a single procedure for the treatment of a disease that has many individual variations and several stages of development shows an infatuation with a technical exercise that does not properly answer each patient's need.

 

Howard[3] outlined indications for fasciotomy:

          1) as a preliminary to fasciectomy in severe cases, since it allows the palmar skin to stretch out before the fascia is excised

          2) for older, retired, or non-working patients with limited palmar involvement and cords limited to one or two fingers

          3) for skilled workers with palmar cords who cannot afford the loss of working time associated with fasciectomy, provided they understand that later fasciectomy or repeat fasciotomy will be necessary

          4) for patients who have arthritis or who for other reasons are prone to joint stiffness

          5) for patients who, because of other physical impairment, can only tolerate minor procedures.

 

McFarlane 1988[4]  “no one method to treat Dupuytren’s contracture has been established.  All methods are equally defensible.  One’s choice of treatment becomes a decision based on training, technical skill, and one’s concept of the disease process.” 

 

Neuropraxia has been reported even when the fasciotomy has been limited to the palm and has been attributed to overstretching of the finger after a severe contracture[5]

 

 Bryan[6] confirms the findings of Colville (1983) and Rowley (1984) et al. who suggested that fasciotomy has a role to offer as a corrective procedure in those patients whose contracture is restricted to the MP joints and as a preliminary procedure in those with deformity affecting the PIP joint as well.”…  It may also be stated that 57% of patients with deformity affecting mainly the MP joint will have maintained their correction at five years.

 

Other complications of Open Surgery for Dupuytren's

          Digital gangrene 0.1%[17]

          Myocardial infarction, left ventricular failure, urinary retention[10]

          Arterial injury, gangrene, and amputation[21]

          Emergency revascularization[22, 23]

Secondary amputation 1.30% as a result of malperfusion from divided arteries [14]

          Tendon injury 0.23%[14]

          Inclusion cyst 1.3%[24]

Scar sequelae 1.2% [10]

 

Foucher commenting on needle aponeurotomy[28]:

          Of 65 hands reviewed at an average of 2.5 years, 54% had recurrent lack of extension and 11% necessitated a second surgery procedure for recurring contracture.  From his experience, Foucher states that the best indications for this technique are visible cords adhering to the skin (such as palmar pretendinous cords and digital central cords), whereas retrovascular cords are too dangerous to deal with using this technique.  He advises using the technique in the early stages of the disease (where one would usually advise the patient to wait for an aggravation of the contracture before performing a fasciectomy), in women (because of the increased risk of RSD with fasciectomy), and in an old or unhealthy patient.  He advises against the use of this technique in recurrences after surgery (where the anatomical relationships of the neurovascular bundles may have been greatly modified) and in severe forms in your adults where the dermofasciectomy is best indicated.

 

 

Recurrence and extension modified from Geldmacher[30]

Author

Year

Procedure

Number

Follow-up yrs.

Extension

Recurrence

Luck[31]

1959

SQ Fasciotomy

?

?

?

71%

Millesi[32]

1965

SQ Fasciotomy?

9

5

?

78

Tonkin[33]

1984

Dermofasciectomy

100

36

?

4% under graft, 33-42% under original skin

Schneider[34]

1988

Fasciectomy

Open palm

49

5

48

32

Allieu[35]

1988

Fasciectomy open palm?

164

3

19

30

Ketchum[36]

1987

Dermofasciectomy

36

3.9

8

0

Norotte[37]

1988

Fasciectomy

58

10

?

71

Sennwald[15]

1990

Radical Fasciectomy

256

0.5

?

21

Foucher[38]

1992

Fasciectomy Open palm

140

5

39

40

Moermans[39]

1996

Segmental excision

240

3

16

23

De Maglio[40]

1996

Fasciectomy

124

33

26

24

Lermusiax[29]

1997

Needle Fasciotomy

799

?

?

50

 

Notes on recurrence from Leclercq[41]:

          Mantero et al. (1986) followed their patients for up to 30 years and reported a global rate of 63% recurrence

          Norotte[37] et al. (1988) followed 58 patients for more than 10 years.  Of 69 hands operated on, 71% had recurrence after 10 years.

          Foucher[38] et al.’s series (1992) showed a lower incidence of recurrences (46%) but his 54 patients were reviewed at 5.6 years on average

          An average of 30% of patients experience a recurrence during the first and second postoperative years, then another 15% during the 3rd to 5th years, 10% between 5 and 10 years, and less than 10% after 10 years.  Thus, even though patients are free of recurrence at 5 years, there is still a 10-15% chance that they develop one later on.  From Norotte et al.’s series it appears that the most severe recurrences (Stages II and above in Tubiana’s grading) occurred early, whereas recurrences appearing later usually remained discrete (Stages I or II).

RSD or complex regional pain syndrome occurs more from general or bier block anesthesia for Dupuytren’s than axillary block anesthesia[42]:

 

Significantly  (P < 0.01) more patients developed postoperative CRPS in the general anesthesia group (n = 25; 24%) and the (IVRA Bier Block) lidocaine group (n = 12; 25%) compared with either the axillary block group (n = 5; 5%) or the IVRA lidocaine and clonidine group (n = 3; 6%)

 

Hospitalization rate of 14.5% after limited fasciectomy for Dupuytren’s as an outpatient surgery[43].  Usually bleeding or nausea and increased risk factors included males, age over 80, BMI over 30, surgery lasting greater than 45 minutes, or a surgical delay over 2.5 hours.

 

 

 

 

 

 

 

 

 

 

 

 

References

1. Binnie, J.F., A treatise on regional surgery. Vol. 3. 1917, Philadelphia,: P. Blakiston's son & co. p.315.

2. Kelly, A.P., Jr. and R.H. Clifford, Subcutaneous fasciotomy in the treatment of Dupuytren's contracture. Plast Reconstr Surg, 1959. 24: p. 505-10.

3. Howard, L.D., Jr., Dupuytren's contracture: a guide for management. Clin Orthop, 1959. 15: p. 118-26.

4. Green, D.P., Operative hand surgery. 2nd ed. 1988, New York: Churchill Livingstone. 1-2458.

5. Berger, A., Dupuytren's disease : pathobiochemistry and clinical management. 1994, Berlin ; New York: Springer-Verlag. p. 741.

6. Bryan, A.S. and M.S. Ghorbal, The long-term results of closed palmar fasciotomy in the management of Dupuytren's contracture. J Hand Surg [Br], 1988. 13(3): p. 254-6.

7. Coert, J.H., J.P. Nerin, and M.F. Meek, Results of partial fasciectomy for dupuytren disease in 261 consecutive patients. Ann Plast Surg, 2006. 57(1): p. 13-7.

8. van Rijssen, A.L., et al., 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(5): p. 717-25.

9. Denkler, K., Dupuytren's fasciectomies in 60 consecutive digits using lidocaine with epinephrine and no tourniquet. Plast Reconstr Surg, 2005. 115(3): p. 802-10.

10. Bulstrode, N.W., B. Jemec, and P.J. Smith, The complications of Dupuytren's contracture surgery. J Hand Surg [Am], 2005. 30(5): p. 1021-5.

11. Leclercq, C. and F. Hildo, Complications following fasciectomy with primary closure in Dupuytren's disease. Journal Hand Surgery (Br), 2003. 28B(Supplement 1): p. 12.

12. Leclercq, C. and R. Tubiana, Personal Series, in Dupuytren's Disease, R. Tubiana, et al., Editors. 2000, Martin Dunitz: London. p. p. 250.

13. Foucher, G., et al., A modified open palm technique for Dupuytren's disease. Short and long term results in 54 patients. Int Orthop, 1995. 19(5): p. 285-8.

14. Geldmacher, J., Limited Fasciectomy, in Dupuytren's disease : pathobiochemistry and clinical management, A. Berger, Editor. 1994, Springer-Verlag: Berlin ; New York. p. 257-63.

15. Sennwald, G.R., Fasciectomy for treatment of Dupuytren's disease and early complications. J Hand Surg [Am], 1990. 15(5): p. 755-61.

16. McFarlane, R.M., D.A. McGrouther, and M.H. Flint, Dupuytren's disease : biology and treatment. The hand and upper limb ; v. 5. 1990, Edinburgh ; New York: Churchill Livingstone. 348-64.

17. McFarlane, R.M. and D.A. McGrouther, Complications and their management. The hand and upper limb ; v. 5, ed. R.M. McFarlane, D.A. McGrouther, and M.H. Flint. 1990, Edinburgh ; New York: Churchill Livingstone. 377-382.

18. Hoet, F., et al., Dupuytren's disease. Review of 326 surgically treated patients. Ann Chir Main, 1988. 7(3): p. 251-5.

19. Tubiana, R., J.M. Thomine, and S. Brown, Complications in surgery of Dupuytren's contracture. Plast Reconstr Surg, 1967. 39(6): p. 603-12.

20. Skoog, T., Dupuytren's contraction. Acta Chir Scand, 1948. 96 (Suppl 139)(1): p. 1-190.

21. Michon, J., Operative difficulties and postoperative complications in the surgery of Dupuytren's contractrue, in Dupuytren's disease, J.T. Hueston and R. Tubiana, Editors. 1974, Grune & Stratton: New York. p. 101-7.

22. Jones, N.F. and J.I. Huang, Emergency microsurgical revascularization for critical ischemia during surgery for Dupuytren's contracture: a case report. J Hand Surg [Am], 2001. 26(6): p. 1125-8.

23. Chung, K.C. and K.A. Segalman, Microvascular solution for vascular complication in surgery for Dupuytren's contracture: a case report. J Hand Surg [Am], 1996. 21(4): p. 711-3.

24. Rodrigo, J.J., et al., Treatment of Dupuytren's contracture. Long-term results after fasciotomy and fascial excision. J Bone Joint Surg Am, 1976. 58(3): p. 380-7.

25. van Rijssen, A.L. and P.M. Werker, Percutaneous needle fasciotomy in dupuytren's disease. J Hand Surg [Br], 2006.

26. Foucher, G., J. Medina, and K. Malizos, Percutaneous needle fasciotomy in dupuytren disease. Tech Hand Up Extrem Surg, 2001. 5(3): p. 161-4.

27. Lermusiaux, J.L., F.J. Badois, and H. Lellouche, Maladie de Dupuytren. Rev Rhum Ed Fr, 2001. 68: p. 542-7.

28. Leclercq, C., L.C. Hurst, and M.A. Badalamente, Treatment, in Dupuytren's Disease, R. Tubiana, et al., Editors. 2000, Martin Dunitz: London. p. 121-131.

29. Lermusiaux, J.L., et al., How should Dupuytren's contracture be managed in 1997? Rev Rhum Engl Ed, 1997. 64(12): p. 775-6.

30. Geldmacher, J., Dupuytren's disease : pathobiochemistry and clinical management. Dupuytren's disease : pathobiochemistry and clinical management, ed. A. Berger. 1994, Berlin ; New York: Springer-Verlag. p.204.

31. Luck, J.V., Dupuytren's contracture; a new concept of the pathogenesis correlated with surgical management. J Bone Joint Surg Am, 1959. 41-A(4): p. 635-64.

32. Millesi, H., On the pathogenesis and therapy of Dupuytren's contracture. A study based on more than 500 cases. Ergeb Chir Orthop, 1965. 47: p. 51-101.

33. Tonkin, M.A. and W.P. Lennon, Dermofasciectomy and proximal interphalangeal joint replacement in Dupuytren's disease. J Hand Surg [Br], 1985. 10(3): p. 351-2.

34. Schneider, L.H., F.M. Hankin, and T. Eisenberg, Surgery of Dupuytren's disease: a review of the open palm method. J Hand Surg [Am], 1986. 11(1): p. 23-7.

35. Allieu, Y., [The "open palm" in the treatment of Dupuytren's disease. Technic and indications]. Rev Chir Orthop Reparatrice Appar Mot, 1988. 74 Suppl 2: p. 46-9.

36. Ketchum, L.D. and F.P. Hixson, Dermofasciectomy and full-thickness grafts in the treatment of Dupuytren's contracture. J Hand Surg [Am], 1987. 12(5 Pt 1): p. 659-64.

37. Norotte, G., A. Apoil, and V. Travers, A ten years follow-up of the results of surgery for Dupuytren's disease. A study of fifty-eight cases. Ann Chir Main, 1988. 7(4): p. 277-81.

38. Foucher, G., C. Cornil, and E. Lenoble, Open palm technique for Dupuytren's disease. A five-year follow-up. Ann Chir Main Memb Super, 1992. 11(5): p. 362-6.

39. Moermans, J.P., Long-term results after segmental aponeurectomy for Dupuytren's disease. J Hand Surg [Br], 1996. 21(6): p. 797-800.

40. De Maglio, A., R. Timo, and G. Feliziani, Dupuytren's disease: recurrence and extension treated by selective aponeurectomy. A clinical review of 124 cases. Chir Organi Mov, 1996. 81(1): p. 43-8.

41. Leclercq, C., Fasciotomy, in Dupuytren's Disease, R. Tubiana, et al., Editors. 2000, Martin Dunitz: London. p. 132-38.

42. Reuben, S.S., et al., The incidence of complex regional pain syndrome after fasciectomy for Dupuytren's contracture: a prospective observational study of four anesthetic techniques. Anesth Analg, 2006. 102(2): p. 499-503.

43. Mandal, A., et al., Unplanned admissions following ambulatory plastic surgery--a retrospective study. Ann R Coll Surg Engl, 2005. 87(6): p. 466-8.






Keith Denkler, M.D.  |  Contact Info  |  Kybella  |  Common Procedures  |  BOTOX® for Wrinkles  |  Dupuytren's and XIAFLEX Pictures  |  Dupuytren's Contracture (Maladie de Dupuytren)  |  Dupuytren's for Patients  |  FAQ/Needle Aponeurotomy  |  XIAFLEX for Distal Joint Dupuytren's Contracture  |  ASSH Hand Society Presentation of NA  |  AAPS Presentation on Needle Aponeurotomy for Severe Dupuytren's  |  Dupuytren's Boutonniere Deformity Treated with XIAFLEX  |  XIAFLEX Boutonniere Treatment  |  2011 ASSH Dupuytren's Needle Presentation  |  Credentials  |  Curriculum Vitae  |  Directions/Office Hours  |  Links  |  News Articles  |  Needle Release for Beauty

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