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Needle Aponeurotomy (Fasciotomy) for Dupuytren’s Contracture
appropriate tools. Using a blade or troncular anaesthesia increases Figure 3: Decision Tree
the risk of tendon damage, skin scar and nerve lesion.
23
Table test
Needle Multiaponeurotomy
Multiaponeurotomy consists of the treatment of an entire hand in
one session of five to 15 needle aponeutomies. Recently, Beaudreuil
and Coll reported results after 18 months of follow-up of a series of
Needle aponeurotomy Surveillance
42 patients with severe and complex forms (55 hands, 157 digits)
who received an average of 8±3 aponeurotomies in one session.
24
Results in terms of degree of contracture reduction, disability
Recurrence Failure
Clobetasole,
measure by visual analogue scale and patient satisfaction were
if painful or pruritic
nodules
similar to those seen with classic aponeurotomy, with a minor
adverse effects rate of 2%. Progress was maintained after 18
Faciectomy, skin grafts
months, with a satisfaction score of 80%. Social and economic (surgery)
costs are still attractively low: no surgery room, no sick-leave (with
the exception of dirty work) and no post-operative care.
25
Figure 4: Knuckle Pads
Current Decision Tree
Indication for NA of a patient with Dupuytren’s contracture is easily
determined by the ‘table test’. The patient is asked to apply his or
her hand to a table palm-down. When the patient is no longer able
to fully extend his or her hand on the table, the table test is positive
and NA is indicated (see Figure 3).
Reoccurrences
Whatever the technique used, NA or surgical aponeurotomy, the
reoccurrence rate reaches about 50% after five years. NA can
Green: Digital fascia and nodule; Blue: Extensor tendon.
Source: JP Teyssedou.
always be repeated even after post -surgical relapse, with the
exception of retractile scars. form Dupuytren’s diathesis.
28
Described by Garrod, knuckle pads
are the dorsal form of Dupuytren’s disease (see Figure 5). They are
Comparison of Needle Aponeurotomy and particularly common in Northern Europe. They are well tolerated
Limited Fasciectomy – Surgical Indications but, when voluminous, can limit the flexion of PIP joints or become
In a randomised controlled trial, Van Rijssen and Coll compared NA an aesthetic issue. Intra-nodular injection of a corticosteroid brings
with limited fasciectomy (LF) as a first-line treatment for Dupuytren’s a dramatic reduction.
27
Disinfection is followed by subcutaneous
contracture.
26
In total, 125 hands (121 patients) were randomised to injection inside the nodule with a 25G 0.5x16mm needle adapted on
LF or NA as described by Lermusiaux. Outcome was evaluated one a 2ml syringe. The corticosteroid should not be fluorinated because
and six weeks later. After six weeks, the improvement of global of the risks of cutaneous atrophy. We use prednisolone acetate
contracture was higher after LF than after NA (79 versus 63%), but 2.5%. The injection is rarely painful and can be performed without
with no statistical difference between the two treatment strategies anaesthesia. Complications are exceptional, and septic risks the
for Tubiana stage 1 and 2. For higher stages, results were better same as with usual corticosteroid injections. One or two injections
after LF then NA, and showed a 75 versus 46% improvement in at two-week intervals reduces the size of the nodule in two weeks
passive extension deficit for stage 3 disease and a 79 versus 47% after a dyschromic phase, of which the patient should be
improvement for stage 4. This could be explained by the fact that in forewarned. However, these inconveniences are negligible
this study, only one session of NA was performed for all Tubiana of compared with the poor results of surgery for knuckle pads, which
Dupuytren’s contracture. The rate of complications was clearly in frequently leads to cheloid scars.
favour of NA, with a 5% major complication rate (haematoma, nerve
injury and infection) after LF versus a 0% rate after NA. At six weeks, Ledderhose’s disease presents as a unique fibrous nodule or cord
there were no patients in the NA group with flexion deficit compared located on the sole of the feet, very similar in aspect to Dupuytren
with 19 patients out of 56 in the LF group. Patients treated with NA nodules. Not as frequent as Dupuytren’s contracture (2–3%
were more satisfied with the function of their hand at six weeks than association), it occurs at an earlier age, often between 20 and 40
those treated by LF (p=0.002), and experienced a lesser degree of years of age. Contraction of the toes never complicates the
discomfort. Today, one can admit the superiority of surgery only in evolution, but a conflict can arise with the shoe, with the patient
cases of frequent reoccurrence by use of skin graft, failure of NA, complaining of a feeling of ‘pebble in the shoe’ when walking or
buttonhole deformity and irreducible stiffness of the PIP joint by running. Surgical treatment should be avoided because of a major
arthrolysis or arthrodesis. risk of painful scars as well as reoccurence on the scar. An injection
of 2.5ml of prednisolone acetate with 2.5ml of lidocaine followed by
Associated Lesions – Knuckle Pads and aponeurotomy with the same needle (25G 0.5x16mm) is a good
Dupuytren’s Diasthesis
27
alternative. In our experience, night-time application of local
Dupuytren’s contracture can be associated with knuckle pads of imiquimod (Aldara
®
cream) for five weeks shows a 30% rate of
the hand, Ledderhose’s disease in the foot and Peyronie’s disease satisfactory results due to softening of the cord.
EUROPEAN DERMATOLOGY 17
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