Lermusiaux_newsubbed.qxp 19/5/09 3:14 pm Page 16
Dupuytren’s Contracture
Figure 1: Old Needle (A) and One-use Needle with a bevel of a needle (16-5/10th in Europe, 25G x 5/8 in the US). The
Double Sharp Bevel (B)
same needle is used for the injection of local anaesthetic: 1–3cc of
lidocain 2% is used inside and around the cord after a thorough
AB
disinfection of the skin with 1% iodised alcohol. A small amount of
prednisolone acetate 2.5% can be added to the solution in the
syringe (1ml per 5ml of lidocain) to prevent painful reactions
after the treatment. In contrast to the other non-surgical
techniques to treat Dupuytren’s contracture still in development,
16,17
no enzyme is injected into the cord. Section of the cord is obtained
by to-and-fro movements of the needle perpendicular to the palm,
completed by a firm extension of the treated finger. A dry bandage
protected by an elastic tape (Tensoplast
®
) should be kept in place
for two days.
One to four aponeurotomies can be performed in a single session
and the procedure can be repeated after seven days. One or two
sessions are needed to treat Tubiana stage 1 and 2 diseases
18
(see
Figure 2). Treatment is always initiated from palmar to distal cords
and from P1 to P2 in the finger. A thermoplastic splint worn at night
is sometimes necessary in long-standing proximal interphalangial
forms with capsular retraction. Apart from dirty work, full use of the
Figure 2: Dupuytren’s Contracture (Palmar and Digital
hand is allowed immediately. Two-week sick-leave is necessary only
Forms) Before (A) and After (B) Needle Aponeurotomy
for those employed in manual labour.
A B
Complications of Needle Aponeurotomy
Serious adverse effects are uncommon after NA. However, in fewer
than one in 1,000 cases, rupture of one of the flexor tendons may
occur within a few days of the procedure , which requires prompt
surgical repair. Section of collateral nerve occurs in fewer than one
in 1,000 cases. No complex regional pain syndrome involving the
entire hand has occurred in our centre, and only three focal forms
have been reported over 35 years of experience. Phlegmon is
exceptional. Minor incidents occur in 1% of procedures, including
skin breaks, temporary hypoesthesia, superficial infections and
haematoma. This should be balanced with the high rate of
complications following surgical management of Dupuytren’s
contracture:
19–21
section of nerve 5.2%, section of tendon 2%,
section of artery 1.8%, complex regional pain syndrome (CRPS)
the flexion of the proximal interphalangeal (PIP) joint remains after 1.8%, infections 1–2%, amputations 0.1% and scars 100%.
removal of the cord; intra-articular arthrolysis exposes the patient
to a higher risk of post-operative stiffness. Skin grafts are used in Results
cases of adhesive forms or where there is a high risk of recurrence. Immediate and five-year follow-up results are similar to surgical
Open palm techniques (pioneered by McCash) can also be used to results.
15,21
The immediate results are excellent with Tubiana stage 1
attain complete skin cicatrisation in case of skin shortage. and 2 (89–92% reduction of the degree of contracture), good with
Buttonhole deformations of the finger are treated by tenotomy and stage 3 (83%) and intermediate with stage 4 (48%) disease, with no
elongation of the extensors. In the most advanced cases, where aggravation or failure, unlike in surgical series. After five years,
there are irreducible hooked fingers or multioperated patients, results are sustained in stage 1, 2 and 3 (92, 74 and 57%,
arthrodesis or amputation is performed. Drawbacks of the surgical respectively), but in only 38% in stage 4. The recurrence rate
techniques are the high rate of complications inherant in such reaches 50% in all series, but the safety, ambulatory mode and low
procedures, including nerve and artery transection, complex cost of the technique make re-treatment easy in case of
regional pain syndrome and a long recovery period of three recurrence. Stage 4 treatment still shows insufficient results, which
to six weeks. suggests that treating at earlier stages is preferable, and NA should
be offered as first-line treatment in stages 1, 2 and 3. Technical
Needle Aponeurotomy improvements have allowed treatment of digital forms.
10
NA can be
NA
14,15
was invented in 1972 by JL Lermusiaux. This technique was used to treat post-operative reoccurrences of Dupuytren’s
made possible by the technological progress in single-use medical contracture, with the exception of retractile scars and capsular
needles, with their double sharp bevels being used as retractions of the PIP joint.
22
microscalpels (see Figure 1). The technique is ambulatory and can
be performed in an ordinary medical clinic. The principle consists of We must emphasise that NA is a delicate medical technique that
one or several percutaneous sections of aponeurotic cords with the should be performed by trained practitioners only using the
16 EUROPEAN DERMATOLOGY
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