Needle aponeurotomy

Because of the increased risk of complications and potential for recurrence associated with invasive surgical techniques, there has been renewed interest in simple fasciotomy to treat flexion contractures. Needle aponeurotomy is a minimally invasive surgical technique indicated for Dupuytren contractures greater than 20˚ at the MCP joint or greater than 30˚ at the PIP joint.8

Performed in the outpatient setting, needle aponeurotomy uses a 23- or 25-gauge needle to release the palmar fascia and cords. The palmar area is infiltrated with 1% lidocaine; using the same puncture site, the needle is inserted with the bevel longitudinally oriented. Rotating the bevel perpendicular to the cord, the needle is stroked to a depth of a few millimeters to cut the collagen fibers.

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The needle is then moved transversely to transect the cord from a right angle. Simultaneously, the digit is passively extended to release the contracture. Optional extension splinting of the digit may be used based on patient needs. One to 20 needle aponeurotomy strokes are typically performed in a single 10- to 20-minute visit. However, successive sessions may be necessary for advanced Dupuytren disease.3

Table 1

  Needle aponeurotomy CCH
Indication Contracture >20° at MCP, >30° at PIP Contracture >30° with palpable cord
Procedure Needle fascia release Injection
Recurrence rate after treatment ~50% <41%
Adverse effects incidence Minimal Common
Considerations Instant fascia release; may require multiple treatments for advanced disease May require multiple visits for a single injection; costly

Needle aponeurotomy is minimally invasive and can be performed in an office setting. Only local anesthesia is required, and there are fewer complications compared with surgical fasciectomy. Patients experience contracture relief almost instantaneously as the fascia begins to release.

Common adverse effects include edema, skin fissures, transient dysesthesia, local infection, and tendon rupture (less than 1%).3 Contraindications for needle aponeurotomy include infiltrating disease with skin involvement, inaccessible multiple cords, rapid recurrence in young patients, and severe and long-standing disease with PIP joint stiffness.

Caution should be directed toward patients with a history of rheumatoid arthritis, diabetes, complex regional pain syndrome, and those on anticoagulation therapy, as these groups have been associated with poor surgical outcomes. Because needle aponeurotomy has a low complication rate, higher-risk patients may be candidates for this procedure.8

Patient selection is important for needle aponeurotomy, as not all patients will experience desired results and recurrence rates are higher than for surgical fasciectomy.8 Recurrence for Dupuytren disease does not have a concrete definition, but a commonly used measure is return of flexion of at least 30˚ from neutral.3 Various  needle aponeurotomy studies demonstrate a recurrence rate of around 50% within a three- to five-year follow-up.3, 8

More than 60% of patients experience some degree of improvement with needle aponeurotomy, and overall patient satisfaction exceeds 80%.3 Even though needle aponeurotomy is associated with higher recurrence rates compared with the more radical surgical fasciectomy, hand specialists are increasingly turning to needle aponeurotomy for Dupuytren disease treatment because of reduction of postoperative complications and its less invasive nature.

This method is appealing to patients because of shortened recovery time, lower cost, and early return of hand function.6,8 Because of the less invasive nature of the procedure and few adverse effects, patients appear more willing to undergo subsequent needle aponeurotomy release if contractures recur rather than a more invasive procedure.