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Percutaneous needle fasciotomy for Dupuytren's: Further insights
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Journal of Plastic, Reconstructive & Aesthetic Surgery (2016) xx, 1e3
CORRESPONDENCE AND COMMUNICATION Percutaneous needle fasciotomy for Dupuytren’s: Further insights Dear Sir, Percutaneous needle fasciotomy (PNF) is a simple technique to release Dupuytren’s cords and achieves the same functional outcome as more invasive fasciectomy procedures for Dupuytren’s contracture.1,2 It also has a similar or lower complication rate compared to fasciectomy procedures.2 In a randomised trial Van Rijssen et al. found needle fasciotomy to be the preferred treatment amongst the elderly who were willing to accept a possible early recurrence.1 The senior author has made a number of clinical observations in a consecutive series of 150 cases of PNF. In this letter, we discuss and illustrate a few pearls that he has learnt which may be useful to surgeons thinking of introducing PNF into their practices. The procedure is performed under wrist block supplemented with digital anaesthesia. The cord is released in a skin crease and the digit is held under tension to make the cord easier to palpate and to facilitate division of the cord.
A 16G (white-hub) needle is held in a tripod grip using the thumb, index and middle fingers to provide optimal control of the needle point (Figure 1). The bevel of the needle should be oriented so that it acts like a small blade. The Dupuytren’s cord is progressively divided by stroking the tip of the needle transversely across the cord (Figure 1). The aim should be to cause a partial division of the cord with the needle-tip. The digit is then passively extended with more force to tear the remainder of the cord (Figure 1). If this cannot be done easily at the first attempt, then more of the cord should be divided before trying to passively extend the finger again. Otherwise, there is a risk of more serious damage to the digit (e.g. fracture of the phalanges). In the senior author’s practice, skin tears are frequent after passive manipulation, especially when the proximal interphalangeal joint (PIPJ) flexion deformity is significant (>60 ). In many cases, 1 cm2 or more of the flexor tendon may then become exposed. Similarly, the neurovascular bundles (NVBs) will become exposed. In such a scenario, many hand surgeons might feel compelled to cover the defects with a full thickness skin graft or a flag flap from the adjacent digit to expedite healing and/or avoid a rapid recurrence of the flexion deformity. Instead, the senior author uses an approach similar to the McCash technique for the palm,3,4 leaving any digital wounds open and allowing
Figure 1 Demonstration of the important steps in PNF (A e palpation of cord under tension, B e tripod grip to control needle tip, C e passive manipulation to break the cord, D e full correction on table e with skin tearing. http://dx.doi.org/10.1016/j.bjps.2016.04.023 1748-6815/ª 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Nikkhah D, Kang N, Percutaneous needle fasciotomy for Dupuytren’s: Further insights, Journal of Plastic, Reconstructive & Aesthetic Surgery (2016), http://dx.doi.org/10.1016/j.bjps.2016.04.023
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Correspondence and communication
Figure 2 Demonstration of PNF. A and B e recurrent flexion deformity after five previous fasciectomy procedures (plan to release little, ring and index fingers). C e Intra-operative view showing release of little and ring fingers with exposed NVBs and flexor tendons, D e 10 days after release showing granulation tissue covering tendons and NVB of little and ring fingers. E and F e good correction of flexion deformity (little, ring and index fingers) and satisfactory scar at 6 months.
Please cite this article in press as: Nikkhah D, Kang N, Percutaneous needle fasciotomy for Dupuytren’s: Further insights, Journal of Plastic, Reconstructive & Aesthetic Surgery (2016), http://dx.doi.org/10.1016/j.bjps.2016.04.023
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MODEL
Correspondence and communication them to heal by secondary intention. All of the exposed tendons and NVBs will be covered with granulation tissue by 9e10 days after release and fully re-epithelialised by 4 weeks, with satisfactory scar outcomes at 3e6 months (Figure 2). However, it is important to keep the digit in a (volar) extension splint continuously for the first 9e10 days after release to prevent a rapid recurrence of the flexion deformity while healing occurs. Thereafter, the senior author advocates lifelong splinting of the treated digits in maximum extension e at night. He has found that this also reduces the risk of a recurrence of a significant flexion deformity. Van Rijssen and colleagues found high levels of patient satisfaction in PNF patients and almost 53% of his patients preferred the percutaneous approach in cases of recurrence.2 Many surgeons feel that PNF cannot be applied in cases of recurrence or after previous fasciectomy. However, the senior author routinely treats recurrences of his own fasciectomy cases e and those of his colleagues e with PNF (Figure 2). Moreover, PNF can easily be repeated5 and, unlike Van Rijssen who deemed it only suitable to treat patients with mild flexion deformities (Tubiana type 1 and 2), the senior author now uses PNF as his primary treatment for Dupuytren’s regardless of the degree of flexion deformity.
Conflict of interest
3
References 1. van Rijssen AL, Gerbrandy FS, Ter Linden H, Klip H, Werker PM. 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):717e25. 2. van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: percutaneous needle fasciotomy versus limited fasciectomy. Plast Reconstr Surg 2012;129(2):469e77. 3. McCash CR. The open palm technique in Dupuytren’s contracture. Br J Plast Surg 1964;17:271e80. 4. Chick LR, Lister GD. Surgical alternatives in Dupuytren’s contracture. Hand Clin 1991;7(4):715e9. discussion 21e2. 5. van Rijssen AL, Werker PM. Percutaneous needle fasciotomy for recurrent Dupuytren disease. J Hand Surg Am 2012;37(9): 1820e3.
Dariush Nikkhah Norbert Kang Royal Free Hospital, Hampstead, UK E-mail addresses: [email protected], [email protected] 6 April 2016
None. Consent for publication was taken from patients.
Please cite this article in press as: Nikkhah D, Kang N, Percutaneous needle fasciotomy for Dupuytren’s: Further insights, Journal of Plastic, Reconstructive & Aesthetic Surgery (2016), http://dx.doi.org/10.1016/j.bjps.2016.04.023
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2016) xx, 1e3
CORRESPONDENCE AND COMMUNICATION Percutaneous needle fasciotomy for Dupuytren’s: Further insights Dear Sir, Percutaneous needle fasciotomy (PNF) is a simple technique to release Dupuytren’s cords and achieves the same functional outcome as more invasive fasciectomy procedures for Dupuytren’s contracture.1,2 It also has a similar or lower complication rate compared to fasciectomy procedures.2 In a randomised trial Van Rijssen et al. found needle fasciotomy to be the preferred treatment amongst the elderly who were willing to accept a possible early recurrence.1 The senior author has made a number of clinical observations in a consecutive series of 150 cases of PNF. In this letter, we discuss and illustrate a few pearls that he has learnt which may be useful to surgeons thinking of introducing PNF into their practices. The procedure is performed under wrist block supplemented with digital anaesthesia. The cord is released in a skin crease and the digit is held under tension to make the cord easier to palpate and to facilitate division of the cord.
A 16G (white-hub) needle is held in a tripod grip using the thumb, index and middle fingers to provide optimal control of the needle point (Figure 1). The bevel of the needle should be oriented so that it acts like a small blade. The Dupuytren’s cord is progressively divided by stroking the tip of the needle transversely across the cord (Figure 1). The aim should be to cause a partial division of the cord with the needle-tip. The digit is then passively extended with more force to tear the remainder of the cord (Figure 1). If this cannot be done easily at the first attempt, then more of the cord should be divided before trying to passively extend the finger again. Otherwise, there is a risk of more serious damage to the digit (e.g. fracture of the phalanges). In the senior author’s practice, skin tears are frequent after passive manipulation, especially when the proximal interphalangeal joint (PIPJ) flexion deformity is significant (>60 ). In many cases, 1 cm2 or more of the flexor tendon may then become exposed. Similarly, the neurovascular bundles (NVBs) will become exposed. In such a scenario, many hand surgeons might feel compelled to cover the defects with a full thickness skin graft or a flag flap from the adjacent digit to expedite healing and/or avoid a rapid recurrence of the flexion deformity. Instead, the senior author uses an approach similar to the McCash technique for the palm,3,4 leaving any digital wounds open and allowing
Figure 1 Demonstration of the important steps in PNF (A e palpation of cord under tension, B e tripod grip to control needle tip, C e passive manipulation to break the cord, D e full correction on table e with skin tearing. http://dx.doi.org/10.1016/j.bjps.2016.04.023 1748-6815/ª 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Nikkhah D, Kang N, Percutaneous needle fasciotomy for Dupuytren’s: Further insights, Journal of Plastic, Reconstructive & Aesthetic Surgery (2016), http://dx.doi.org/10.1016/j.bjps.2016.04.023
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MODEL
Correspondence and communication
Figure 2 Demonstration of PNF. A and B e recurrent flexion deformity after five previous fasciectomy procedures (plan to release little, ring and index fingers). C e Intra-operative view showing release of little and ring fingers with exposed NVBs and flexor tendons, D e 10 days after release showing granulation tissue covering tendons and NVB of little and ring fingers. E and F e good correction of flexion deformity (little, ring and index fingers) and satisfactory scar at 6 months.
Please cite this article in press as: Nikkhah D, Kang N, Percutaneous needle fasciotomy for Dupuytren’s: Further insights, Journal of Plastic, Reconstructive & Aesthetic Surgery (2016), http://dx.doi.org/10.1016/j.bjps.2016.04.023
+
MODEL
Correspondence and communication them to heal by secondary intention. All of the exposed tendons and NVBs will be covered with granulation tissue by 9e10 days after release and fully re-epithelialised by 4 weeks, with satisfactory scar outcomes at 3e6 months (Figure 2). However, it is important to keep the digit in a (volar) extension splint continuously for the first 9e10 days after release to prevent a rapid recurrence of the flexion deformity while healing occurs. Thereafter, the senior author advocates lifelong splinting of the treated digits in maximum extension e at night. He has found that this also reduces the risk of a recurrence of a significant flexion deformity. Van Rijssen and colleagues found high levels of patient satisfaction in PNF patients and almost 53% of his patients preferred the percutaneous approach in cases of recurrence.2 Many surgeons feel that PNF cannot be applied in cases of recurrence or after previous fasciectomy. However, the senior author routinely treats recurrences of his own fasciectomy cases e and those of his colleagues e with PNF (Figure 2). Moreover, PNF can easily be repeated5 and, unlike Van Rijssen who deemed it only suitable to treat patients with mild flexion deformities (Tubiana type 1 and 2), the senior author now uses PNF as his primary treatment for Dupuytren’s regardless of the degree of flexion deformity.
Conflict of interest
3
References 1. van Rijssen AL, Gerbrandy FS, Ter Linden H, Klip H, Werker PM. 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):717e25. 2. van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: percutaneous needle fasciotomy versus limited fasciectomy. Plast Reconstr Surg 2012;129(2):469e77. 3. McCash CR. The open palm technique in Dupuytren’s contracture. Br J Plast Surg 1964;17:271e80. 4. Chick LR, Lister GD. Surgical alternatives in Dupuytren’s contracture. Hand Clin 1991;7(4):715e9. discussion 21e2. 5. van Rijssen AL, Werker PM. Percutaneous needle fasciotomy for recurrent Dupuytren disease. J Hand Surg Am 2012;37(9): 1820e3.
Dariush Nikkhah Norbert Kang Royal Free Hospital, Hampstead, UK E-mail addresses: [email protected], [email protected] 6 April 2016
None. Consent for publication was taken from patients.
Please cite this article in press as: Nikkhah D, Kang N, Percutaneous needle fasciotomy for Dupuytren’s: Further insights, Journal of Plastic, Reconstructive & Aesthetic Surgery (2016), http://dx.doi.org/10.1016/j.bjps.2016.04.023