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Keith Denkler M.D.
Plastic and Reconstructive Surgery
415-924-6010
275 Magnolia Ave.
www.PlasticSurgerySF.com
Larkspur, CA 94939
kdenklermd@hotmail.com
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- Photographs of Dupuytren's Needle Release
- Needle Aponeurotomy, a Simple Fasciotomy for Dupuytren's Contracture
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Needle Aponeurotomy
Ten month follow-up after needle release (needle aponeurotomy) of Dupuytren's contracture. This patient with stage four disease and 175 degrees of bend had more than 120 degrees of improvement in finger extension. This required one treatment under local anesthesia. The other fingers showed significant gains in extension also. |
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Stage IV Dupuytren's
This before and after view is a 3 day follow-up of a stage 4 (greater than 135 degree total contracture) patient with Dupuytren's. This successful release shows marked improvement in extension with a simple in office needle aponeurotomy release under local anesthesia. |
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NA Needle Aponeurotomy
Immediate before and after photos of multiple finger NA procedure for Dupuytren's contracture |
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Multiple Finger NA for Dupuytr…
This shows the before and after treatment of Dupuyten's contracture with Boutonniere of the little finger. This requires release of not only the fibrous Dupuytren's, but also the contracted joints and tendons |
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Before, And Three Months After…
Stage IV Dupuytren's contracture three months after needle aponeurotomy |
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Needle Aponeurotomy for Stage …
This patient had a loss of 70 degrees of straightening at his first joint (MCP) and a loss of 65 degrees at the middle joint (PIP). The total loss of extension was 135 degrees or stage IV. The bottom pictures show the significant improvement eight months later. There is a residual bend of 35 degrees at the PIP joint, but the first joint has maintained extension. |
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Lariboisière Hospital
Hospital in France where Dr. Denkler learned the French needle technique for release of Dupuytren's contracture. |
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Anatomy of Dupuytren's Contrac…
On the back of the hand, after skin removal, the tendons are seen. On the palm of the hand, after skin removal, a sheet of fibrous gristle or fascia is seen. This fascia is tightly adherent to the skin of the palm and aids in grabbing things (try to grab something with the skin on the back of the hand: it rolls). In the disease of Dupuytren this fibrous gristle or fascia grow and tightens pullling the fingers into a contraction and limiting ability to straighten out the fingers. Underneath this sheet of fibrous tissue on the palm of the hand are the flexor tendons. |
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Severe Stage III PIP (middle) …
This patient had 95 degree contracture of his index PIP (middle) joint. He had had no previous surgery, so this difficult contracture could be improved with needle technique to the tendon tightening and joint capsule. These difficult PIP contractures require physical therapy afterward to prevent readherence of the Dupuytren's via serial splinting. |
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Needle Aponeurotmy for Dupuytr…
The contractures at the PIP (middle) joint can be very difficult to treat. However, in some patients, dramatic improvement can occur. This patients hand is seen one month after Dupuytren's needle release of the little finger. Significant gains in extension of the little finger have occured after needle (subcutaneous) fasciotomy for the contracture of Dupuytren. The usual improvement is usually only about 50%. That is, a 90 degreee contracture such as this would be expected to only improve to about a 45 degree contracture. These lesser results are due to tight muscles and stiff joints due to lack of use. |
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NA, Before and After
Subcutaneous fasciotomy, or needle aponeurotomy (NA) before and after. Release of the middle joint involves a more difficult recovery as the muscles that extend the finger are weak from non-use and it takes time to build up the strength to extend the finger fully. It is important to activly straighten the finger often, in order to help maintain the result. |
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14 month follow-up
This patient with multiple finger Dupuytren's including a stage four contracture of the little finger. The follow-up photo is 14 months later. |
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Multiple Needle Release--Dupuy…
This patient had several digits released from Dupuytren's contracture. The blue dots are midline markers for central cord release. The lateral lines are for lateral cords or spiral cords. These lateral cords are near the ulnar and radial digital sensory nerves. Smaller needles and more judicious incising of the cords is necessary to prevent numbness of the fingertip. |
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NA after Previous Surgery
This photo illustrates a common problem in those that have had previous surgery or have severe PIP joint Dupuytren's contracture. NA has been partially effective on the immediate postoperative active motion of the little finger. However, the finger can be passivly fully extended as seen in the right middle picture. All the contracting scar tissue, joint ligaments and Dupuytren's cords have been released. The finger extensor muscles are so weak from years of non-use, they do not have the strength to fully extend the finger as seen in the left middle picture. Active stretching, surgical pinning, physical therapy, or night splinting can help prevent recurrence of the contracture. Fingers with previous surgery are also more likely to have skin tears during needle release requiring sutures for closure. The bottom two photos show improved results at post-op day number four with only the patients active extension. Multiple puncture wounds show the aggressive release that is necessary in these difficult problems. |
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Multiple Dupuytren's Needle Re…
This three finger Dupuytren's contracture needle release showed immediate improvement under local anesthesia. |
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Needle Release of Dupuytren's …
Photo at surgery before and after NA, or needle aponeurotomy (aponevrotomy)of Dupuytren's contracture. Instead of a scalpel, small hypodermic needles are used to cut the firm, contracted Dupuytren's cord. |
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Needle Aponeurotomy for Dupuyt…
Full frontal and side views of needle aponeurotomy for Dupuytren's contracture. Notice that the Dupuytrens cords that prevented the little finger from spreading apart (natatory ligaments) have also been released opening up the hand significantly. |
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Needle Release of Dupuytren's
Before and after photos of Dupuytren's contracture release using NA or needle aponeurotomy (Aponevrotomy)technique. |
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Needle Aponeurotomy
Immediate result of NA or Needle Aponeurotomy for Dupuytren's contracture of the finger under local anesthesia. |
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Fasciectomy for Dupuytren's
Surgical removal of diseased fascia in Dupuytren's is a traditional surgical approach. It removes the diseased fascia entirely and may help prevent recurrence. It may be performed as an office surgery using local anesthetia with epinephrine and no constricting tourniquet. It's safety and efficacy has been published in the Journal of Plastic and Reconstructive Surgery in March of 2005.
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Dupuytren's cord contracture
Notice the pulling of the Dupuytren's cord brings the digital nerve into a dangerous postion for injury with needle release or traditional surgery. In the area of the PIP joint, the lateral contracted tissues may prevent full needle releases of the Dupuytren's cords. In this situation, gentle superficial sectioning, plus firm traction into extension is necessary to ruputure the cord with less risk to the digital nerve. |
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Needle Release Problem
This before after needle release of Dupuytrens shows the problem of weak and contracted intrinsic muscles that limit post-operative ability to regain extension. Notice on the preoperative photo upper Dupuytrens contracture the little finger. There is MCP and PIP joint disease that limits extension of the little finger. Plus MCP joint disease of the ring and middle fingers that prevent full extension. After NA, the MCP joint disease is corrected on all three fingers in the bottom left picture. In the upper right picture the intrinsic muscles are relaxed via MCP joint forced flexion and there is improvement in PIP extension over the bottom left view. In the final bottom right photo one can see that the dupuytrens contracture is all released and there is full PIP extension with passive extension by the physician. These photos demonstrate the need for postoperative exercises to improve intrinsic muscle strength as these muscles have atrophied due to non-use. On a positive note, it notice the immediate, excellent improvement of MCP extension of the little, ring, and middle fingers |
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Recurrent Dupuytren's
This patient had two previous open surgeries by a top local hand surgeon. With residiual contracture of 65 degrees after two surgeries, the patient was told that nothing more could be done. NA after previous open surgery has higher complications and poorer results, but this before and immediate after photo shows a very good immediate result. If recurrence is rapid due to scar tissue from the previous open surgeries, then a repeat NA with skin grafting would be the next option. |
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Hand Plastic Surgery
This patient disliked the large veins and shrunken tissues on the back of the hand. The photo is a 3 month before and after photo of Radiesse injections into the back of her hand. Radiesse is a filler that helps bulk up tissues such as the nasolabial folds in the face or wrinkles of the face and hands. |
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Melanoma removed by Dupuytren
The melanomas depicted in the lower right and center were actually removed by Dupuytren in 1826. The large hand melanoma was removed as an amputation by Drs Marjolin and Blandin in 1828. The photo is from the book by Cruveilhier published in between 1828-1842 Anatomie Pathologique du Corps Humains. Reference: Denkler, Keith M.D.; Johnson, Jann M.D.Plastic & Reconstructive Surgery: Volume 104(7) December 1999 pp 2149-2153 A Lost Piece of Melanoma History. |
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Dupuytren
Dupuytren, now known mostly due the the eponym Dupuytren's contracture left an incredible legacy in medical history. The Dupuytren's museum in Paris is across the street from the medical school he founded. http://www.planetware.com/paris/musee-dupuytren-f-p-mudu.htm |
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Office in Larkspur
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