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Percutaneous needle fasciotomy for Dupuytren's disease: Minimizing morbidity
Accepted Manuscript Percutaneous needle fasciotomy for Dupuytren’s disease: minimizing morbidity Luca Lancerotto, Dominique M. Davidson PII:
S1748-6815(17)30088-8
DOI:
10.1016/j.bjps.2017.02.010
Reference:
PRAS 5248
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 12 February 2017 Accepted Date: 17 February 2017
Please cite this article as: Lancerotto L, Davidson DM, Percutaneous needle fasciotomy for Dupuytren’s disease: minimizing morbidity, British Journal of Plastic Surgery (2017), doi: 10.1016/j.bjps.2017.02.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Percutaneous needle fasciotomy for Dupuytren’s disease: minimizing morbidity
Luca Lancerotto and Dominique M Davidson
RI PT
Edinburgh Department of Plastic Surgery, St. John’s Hospital at Howden, West Lothian, UK
Corresponding author
SC
Luca Lancerotto
Edinburgh Department of Plastic Surgery
M AN U
St. John’s Hospital at Howden
Livingston, West Lothian
EH54 6PP
AC C
EP
[email protected]
TE D
United Kingdom
Keywords
Dupuytren; PNF; percutaneous needle fasciotomy; cordotomy; hand
ACCEPTED MANUSCRIPT Dear Sirs,
We read with interest the letter by Nikkhah and Kang in the January issue of the journal (1), describing anecdotal observations derived from a series of 150 patients treated with percutaneous needle fasciotomy (PNF). Nikkhah and Kang perform PNF along the lines described by Foucher et al. (2). Our own PNF practice
RI PT
differs in several significant respects. In particular, we question the requirement for wrist block, and we highlight differences in the positioning of the PNF sites, the gauge of needle and the post-operative splinting regime.
SC
As per other authors (3), we use a 25G needle to introduce a very small amount of local anaesthetic subcutaneously at the proposed site of cordotomies. We find that this is easily tolerated by the patient and
M AN U
provides adequate analgesia for the cordotomy and the post-cordotomy passive extension of the digit. It also provides a hydro-dissection effect that separates the cord from the dermis, which may be of help in reducing the incidence of the sizeable skin tears described by Nikkhah and Kang. As an integral part of the procedure, the patient is required to inform the surgeon if he experiences dysaesthesia in the distribution of the digital nerve. This provides warning of proximity to the digital nerves and allows modification of the site of attempted
TE D
cordotomy. The use of regional anaesthesia is associated with a small but recognised risk of nerve damage. It converts a minor procedure, whether in the outpatient or theatre setting, into a more lengthy and expensive procedure than necessary. Most importantly, in PNF it removes the potential for intra-operative protection of
EP
the digital nerve.
We note that Nikkhah and Kang use a relatively large gauge needle for their procedure. In our practice, as with
AC C
others (3), we prefer the use of a 23G (blue) needle, mounted on a syringe to increase balance and control on the oscillation of the tip. We believe that a thinner gauge and shorter cutting bevel minimise the risk to neurovascular and tendon structures. As described by others, we initially perforate the cord with penetrating volar to dorsal movements of the needle in order to weaken the structure of the cord, and then convert to transverse cutting oscillations of gradually increasing penetration. The needle is held in a tripod grip similar to that described by Nikkhah and Kang, but we highlight the importance of extending the index finger along the needle to within 1 cm of the tip, to guard against inadvertent deepening of the cordotomy and damage to underlying structures.
ACCEPTED MANUSCRIPT In contrast to Nikkhah and Kang, we position our cordotomies, where possible, at inter-crease sites, in between rather than at the points of maximal adherence of the cords to the dermis, in order to minimise the occurrence of skin tears (5). Our experience with skin crease incisions left open following open fasciotomy procedures (4) leads us to agree with Nikkah and Kang that healing from such skin crease incisions/tears is
RI PT
usually uncomplicated. However, one of the primary patient aims in selecting a PNF procedure is the minimal morbidiy and early return to full manual activity, without requirement for dressing changes. By contrast, the open fasciotomy is a more significant surgical intervention than PNF, necessitating regional anaesthesia and post-operative dressings, but with the advantage of direct visualisation and protection of the neurovascular
SC
bundles.
M AN U
Post-PNF splinting is currently the subject of debate. We mobilise freely in the immediate post-operative period, but use a nocturnal extension splint for six weeks post-operatively in cases of moderate or severe preoperative contractures. We question the cost/benefit ratio, comfort of the patient, and likelihood of
Nothing to disclose
None
AC C
Funding sources
EP
Conflicts of interest
TE D
compliance associated with the regime of lifelong nocturnal splinting advocated by Nikkhah and Kang.
ACCEPTED MANUSCRIPT References
1.
Nikkhah D, Kang N. Percutaneous needle fasciotomy for Dupuytren's: Further insights. J Plast
2.
RI PT
Reconstr Aesthet Surg 2017; 70:144-6. Foucher G, Medina J, Navarro R. Percutaneous needle aponeurotomy: complications and
results. J Hand Surg Br 2003; 28:427-31. 3.
van Rijssen AL, Werker PM. Percutaneous needle fasciotomy in dupuytren's disease. J Hand
Stewart CJ, Davidson DM, Hooper G. Re-operation after open fasciotomy for Dupuytren's
M AN U
4.
SC
Surg Br 2006; 31:498-501.
disease in a series of 1,077 consecutive operations. J Hand Surg Eur Vol 2014; 39:553-4. 5.
Eaton C. Percutaneous fasciotomy for Dupuytren's contracture. J Hand Surg Am 2011;
AC C
EP
TE D
36:910-15.
S1748-6815(17)30088-8
DOI:
10.1016/j.bjps.2017.02.010
Reference:
PRAS 5248
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 12 February 2017 Accepted Date: 17 February 2017
Please cite this article as: Lancerotto L, Davidson DM, Percutaneous needle fasciotomy for Dupuytren’s disease: minimizing morbidity, British Journal of Plastic Surgery (2017), doi: 10.1016/j.bjps.2017.02.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Percutaneous needle fasciotomy for Dupuytren’s disease: minimizing morbidity
Luca Lancerotto and Dominique M Davidson
RI PT
Edinburgh Department of Plastic Surgery, St. John’s Hospital at Howden, West Lothian, UK
Corresponding author
SC
Luca Lancerotto
Edinburgh Department of Plastic Surgery
M AN U
St. John’s Hospital at Howden
Livingston, West Lothian
EH54 6PP
AC C
EP
[email protected]
TE D
United Kingdom
Keywords
Dupuytren; PNF; percutaneous needle fasciotomy; cordotomy; hand
ACCEPTED MANUSCRIPT Dear Sirs,
We read with interest the letter by Nikkhah and Kang in the January issue of the journal (1), describing anecdotal observations derived from a series of 150 patients treated with percutaneous needle fasciotomy (PNF). Nikkhah and Kang perform PNF along the lines described by Foucher et al. (2). Our own PNF practice
RI PT
differs in several significant respects. In particular, we question the requirement for wrist block, and we highlight differences in the positioning of the PNF sites, the gauge of needle and the post-operative splinting regime.
SC
As per other authors (3), we use a 25G needle to introduce a very small amount of local anaesthetic subcutaneously at the proposed site of cordotomies. We find that this is easily tolerated by the patient and
M AN U
provides adequate analgesia for the cordotomy and the post-cordotomy passive extension of the digit. It also provides a hydro-dissection effect that separates the cord from the dermis, which may be of help in reducing the incidence of the sizeable skin tears described by Nikkhah and Kang. As an integral part of the procedure, the patient is required to inform the surgeon if he experiences dysaesthesia in the distribution of the digital nerve. This provides warning of proximity to the digital nerves and allows modification of the site of attempted
TE D
cordotomy. The use of regional anaesthesia is associated with a small but recognised risk of nerve damage. It converts a minor procedure, whether in the outpatient or theatre setting, into a more lengthy and expensive procedure than necessary. Most importantly, in PNF it removes the potential for intra-operative protection of
EP
the digital nerve.
We note that Nikkhah and Kang use a relatively large gauge needle for their procedure. In our practice, as with
AC C
others (3), we prefer the use of a 23G (blue) needle, mounted on a syringe to increase balance and control on the oscillation of the tip. We believe that a thinner gauge and shorter cutting bevel minimise the risk to neurovascular and tendon structures. As described by others, we initially perforate the cord with penetrating volar to dorsal movements of the needle in order to weaken the structure of the cord, and then convert to transverse cutting oscillations of gradually increasing penetration. The needle is held in a tripod grip similar to that described by Nikkhah and Kang, but we highlight the importance of extending the index finger along the needle to within 1 cm of the tip, to guard against inadvertent deepening of the cordotomy and damage to underlying structures.
ACCEPTED MANUSCRIPT In contrast to Nikkhah and Kang, we position our cordotomies, where possible, at inter-crease sites, in between rather than at the points of maximal adherence of the cords to the dermis, in order to minimise the occurrence of skin tears (5). Our experience with skin crease incisions left open following open fasciotomy procedures (4) leads us to agree with Nikkah and Kang that healing from such skin crease incisions/tears is
RI PT
usually uncomplicated. However, one of the primary patient aims in selecting a PNF procedure is the minimal morbidiy and early return to full manual activity, without requirement for dressing changes. By contrast, the open fasciotomy is a more significant surgical intervention than PNF, necessitating regional anaesthesia and post-operative dressings, but with the advantage of direct visualisation and protection of the neurovascular
SC
bundles.
M AN U
Post-PNF splinting is currently the subject of debate. We mobilise freely in the immediate post-operative period, but use a nocturnal extension splint for six weeks post-operatively in cases of moderate or severe preoperative contractures. We question the cost/benefit ratio, comfort of the patient, and likelihood of
Nothing to disclose
None
AC C
Funding sources
EP
Conflicts of interest
TE D
compliance associated with the regime of lifelong nocturnal splinting advocated by Nikkhah and Kang.
ACCEPTED MANUSCRIPT References
1.
Nikkhah D, Kang N. Percutaneous needle fasciotomy for Dupuytren's: Further insights. J Plast
2.
RI PT
Reconstr Aesthet Surg 2017; 70:144-6. Foucher G, Medina J, Navarro R. Percutaneous needle aponeurotomy: complications and
results. J Hand Surg Br 2003; 28:427-31. 3.
van Rijssen AL, Werker PM. Percutaneous needle fasciotomy in dupuytren's disease. J Hand
Stewart CJ, Davidson DM, Hooper G. Re-operation after open fasciotomy for Dupuytren's
M AN U
4.
SC
Surg Br 2006; 31:498-501.
disease in a series of 1,077 consecutive operations. J Hand Surg Eur Vol 2014; 39:553-4. 5.
Eaton C. Percutaneous fasciotomy for Dupuytren's contracture. J Hand Surg Am 2011;
AC C
EP
TE D
36:910-15.