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Dupuytren’s Contracture
Needle Aponeurotomy (Fasciotomy) for Dupuytren’s Contracture
Jean-Luc Lermusiaux
1
and Sophie Lahalle
2
1. Associate Practician Consultant, l’Unité Rhumatologique des Affections de la Main, Lariboisière Teaching Hospital;
2. Rheumatologist, Department of Rheumatology and Internal Medicine, La Croix Saint Simon
Abstract
Dupuytren’s contracture is a disease characterised by a hypertrophic and dysplasic fibrosis of the superficial palmar aponeurosis of
the hand, forming nodules and cords and resulting in irreducible flexion of the fingers. It affects several million people in Europe and
North America, leading to hand disability. Several forms are described, as well as an association with knuckle pads, Ledderhose’s
disease and Peyronie’s disease. Familial history of Dupuytren’s contracture and diabetes are the most important risk factors. Needle
aponeurotomy is a non-surgical, ambulatory treatment that relies on the percutanous section of Dupuytren’s cords under local
anaesthesia. This technique allows early treatment with results similar to surgical methods in terms of degree of contracture for
Tubiana stage 1 to 3. The low rate of complications and the rapidity of recovery have made needle aponeurotomy a first-line treatment
in experienced hands.
Keywords
Dupuytren’s contracture, needle aponeurotomy, fasciotomy, Ledderhose’s disease, Peyronie’s disease, knuckle pads, fasciectomy
Disclosure: The authors have no conflicts of interest to declare.
Received: 9 February 2009 Accepted: 20 April 2009
Correspondence: Jean-Luc Lermusiaux, Associate Practician Consultant, l’Unité Rhumatologique des Affections de la Main Assistance Publique-Hopitaux de Paris,
jllermusiaux@club-internet.fr
In 1831 Baron Guillaume Dupuytren, a surgeon at the Hôtel Dieu of multiply, forming nodules and cords and hooking themselves on
Paris, described a condition affecting the hand characterised by a fibrous structures: transverse carpal ligaments, pulleys, scars, skin
fibrous retraction of the middle part of the superficial palmar and bones. The fibroblasts acquire retractile power, transforming into
aponeurosis resulting in progressive irreducible flexion of the myofibroblasts, leading to skin retraction and finger contracture.
4,5
fingers.
1
In fact, the disease has been recognised since the Middle Tension of the cord enhances the retraction. On the molecular level,
Ages. The Okrkneyinga saga tells the story of a Danish baron various authors have reported an increase in immature collagen
whose hooked finger found miraculous cure after he fell during fibrils. Differential expressions of matrix metalloproteinases and
a pilgrimage. Today, Dupuytren’s contracture affects several million excess in oxygen free radicals or tumour growth factor (TGF)-β have
individuals in Europe and North America.
2
The disease usually also been noticed.
6–9
appears between 40 and 50 years of age, with a ratio of eight men
to every one woman. Apart from familial history (its genetic Forms and Staging
transmission dates back to the Vikings)
3
and diabetes, which are Several clinical forms of the disease can be found: palmar,
both major risk factors, alcohol abuse, smoking, medications such palmodigital and strictly digital. These particular forms are more
as phenobarbital or isoniasid and mechanical stress (i.e. rock difficult to treat.
10
In young patients, contracture is particularly quick
climbing or manual labour) are suspected to increase the to evolve.
11
Natatory forms implicate the superficial transverse
occurrence of the contracture. The treatment of Dupuytren’s intermetacarpal ligament, which prevents separation of the fingers.
contracture remained surgical until the middle of last century. In derm-adhesive forms, skin wells and retractions are frequent.
Medical treatments were suggested, including colchicines, Staging of the deformations relies on the Tubiana scale, which
verapamil or intranodular injections of corticosteroids aimed at the counts four stages depending on the global flexion of the finger:
atrophy of the fibrosis, but showed little effect. The spectacular stage 1, from 0 to 45°; stage 2, from 45° to 90°; stage 3, from 90° to
results of needle aponeurotomy (NA) and the spread of the 135°; and stage 4, over 135°.
12
technique from France to the rest of Europe and North America
during the past few decades has markedly improved the treatment Surgical Treatment
of Dupuytren’s contracture worldwide. Selective (or limited) palmar fasciectomy is usually the first-choice
technique for surgical treatment of Dupuytren’s contracture.
13
Physiopathology Diseased tissue is removed under regional anaesthesia with
In Dupuytren’s contracture, the superficial foil of palmar aponeurosis the objective of extending the digit and preventing further
undergoes a hypertrophic and dysplasic transformation. Fibroblasts retraction. Extra- or intra-articular arthrolysis is associated when
© TOUCH BRIEFINGS 2009 15
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