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Downgrading Severe Stages of Dupuytren’s Contracture to Simplify Partial Aponeurectomy Using Percutaneous Needle Fasciotomy

Erne, Holger C. M.D.

Plastic and Reconstructive Surgery: January 2014 - Volume 133 - Issue 1 - p 79e–80e
doi: 10.1097/01.prs.0000436802.12423.3f
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BGU Murnau, Murnau, Germany

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Sir:

In severe cases of Dupuytren’s disease (e.g., Tubiana stage 3 or 4), the classic palmar approach is hindered by heavy flexion contracture. Complicated and time-consuming invasive and noninvasive techniques have been described to reduce flexion contracture and straighten fingers, either as preparation for partial aponeurectomy or to avoid the procedure.1–41–41–41–4 In this article, a new method for reducing flexion contracture is described that has several significant advantages over other methods.

In total, 11 patients with 17 finger rays classified as Tubiana stage 3 or 4 were treated using the established percutaneous needle fasciotomy method.5 First, percutaneous needle fasciotomy was performed immediately before partial aponeurectomy under full surgical conditions (sterile, draped, and under tourniquet).5 A 19-gauge needle was used to perforate the skin and to cut the cord with the bevel. The skin perforation was made at the distal palmar crease level, 1 cm distal or proximal to wherever the cord was most prominent. The bevel was used to cut the cord using sawing movements. When the cord was almost cut, or at least weakened, the finger was extended by applying light pressure; the remaining cord fibers usually ruptured, leading in all cases to a more extended position.

A plan for how to perform the incisions was devised to obtain a much clearer overview of how much skin would be needed to close the wound after the aponeurectomy. The planned incision was drawn onto the skin using a pencil.

Classic partial aponeurectomy was performed, and the cord of the ray was completely resected in all patients. After the tourniquet was opened, hemostasis was achieved, and then the skin was closed in all cases.

In this prospective case series, 11 patients with Dupuytren’s disease at Tubiana stage 3 or 4, and with affected metacarpophalangeal and proximal interphalangeal joints, were followed. The mean contracture was 129 degrees (range, 115 to 150 degrees). After percutaneous needle fasciotomy, the mean contracture was 88 degrees (range, 60 to 120 degrees). The mean reduction in contracture was 41 degrees; the contracture was reduced significantly in all cases.

The t test for paired samples was used to calculate statistical significance. A normal distribution was present with a significance of 0.038 (p < 0.05).

There were no nerve or vessel lesions, but there were two minor skin lesions after the extension maneuver at the distal palmar crease caused by severe adhesion of the skin to the cord. The lesions were easily covered using Z-plasty after the cord resection.

Percutaneous needle fasciotomy is a well-known and established procedure for the treatment of Dupuytren’s disease at stages 1 and 2.5 A new technique is described that facilitates the approach for partial aponeurectomy in difficult cases. In all cases, the contracture can be reduced significantly at the same time as the partial aponeurectomy procedure. Obviously, the duration of surgery can be reduced. Nerve and vessel preparation are easier and safer with more extended finger positions.

The prerequisite for this technique is a well-defined cord in the palm. This technique offers an easy way to reduce flexion contracture effectively and a simplified approach.

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DISCLOSURE

The author has no financial interest to declare in relation to the content of this article.

Holger C. Erne, M.D.

BGU Murnau

Murnau, Germany

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REFERENCES

1. Piza-Katzer H, Herczeg E, Aspek R. Präoperative intermittierende pneumatische Extensionsbehandlung bei Dupuytrenscher Kontraktur im Stadium III und IV. Handchir Mikrochir Plast Chir. 2000;32:33–37
2. Agee JM, Goss BC. The use of skeletal extension torque in reversing Dupuytren contractures of the proximal interphalangeal joint. J Hand Surg. 2012;37:1467–1474
3. Craft RO, Smith AA, Coakley B, Casey WJ 3rd, Rebecca AM, Duncan SF. Preliminary soft-tissue distraction versus checkrein ligament release after fasciectomy in the treatment of Dupuytren proximal interphalangeal joint contractures. Plast Reconstr Surg. 2011;128:1107–1113
4. Messina A, Messina J. The continuous elongation treatment by the TEC device for severe Dupuytren’s contracture of the fingers. Plast Reconstr Surg. 1993;92:84–90
5. Erne H, El Gammal A, Lukas B. Percutaneous needle fasciotomy: A serious alternative? Dupuytren’s Disease and Related Hyperproliferative Disorders. 2012 Berlin, Heidelberg Springer-Verlag In:
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