Abstract
The aim of this study was to examine our results of 74 percutaneous needle fasciotomies for Dupuytren’s contracture. Pre-operative and postoperative total passive extension deficit was measured. Patients were seen at the outpatient clinic at 32 months for final follow-up. Extension deficit and sensibility were measured and flexor tendon function assessed. Recurrence, defined as an increase of the passive extension deficit of 30° or more compared to the immediate postoperative measurement, and other complications were also noted. Immediate outcome was excellent with an average improvement of 77%. After 32 months, we reviewed 55 rays. Their recurrence rate was 65%. Two patients experienced a slightly diminished sensibility on one side of the finger. There were no flexor tendon injuries. This procedure has a good short-term effect. It may be suitable for patients who want a minimally invasive treatment and to whom long-term results are less important. It may also have a place in delaying fasciectomy.
The first treatment for Dupuytren’s disease, proposed in the 18th century by Henry Cline (1777), consisted of sectioning the pathological Dupuytren’s cords. This treatment, called fasciotomy or aponeurotomy, remained in use until the end of the 19th century, largely because of William Adams (1892), who used the technique routinely and wrote extensively about it up to the last decade of the 19th century. However, soon after the advent of general anaesthesia in the 1840s, Sir William Fergusson introduced treatment by excision of the diseased fascia (Fergusson, 1842) and this, increasingly, became the standard operation for this condition for the next 150 years, despite being hampered by high complication and recurrence rates. The latter have led to attempts to treat Dupuytren’s disease by less-invasive alternatives, such as injection of vitamin E, splinting, radiation, physical therapy and dimethylsulfphoxide. Unfortunately, these have either proved clinically ineffective or unsuitable for clinical use (Badois et al., 1993).
Baxter et al. (1952) introduced the use of local steroid injections, but, despite initial optimism and success in softening some nodules, this has never achieved regression of actual contractures. Five years later, De Seze and Debeyre (1957) combined the injection of local steroids with splint therapy. Although they had excellent short-term results, the long-term results were not satisfactory. They, then, introduced the use of a needle, as a punch to weaken the cords, after injecting a mixture of predniso-lone and lignocaine. Thus, the new technique of “needle fasciotomy” was born, although, if one compares the size of the bevel of a needle with the size of the blades of the bistoury knives used by Cline and his contemporaries, one realises that this new technique was little more than a revival of Cline’s technique. Because of its shorter recovery period and less invasive character, needle fasciotomy quickly gained favour with patients. The first results of this technique were published in 1980 by Lermusiaux and Debeyre (1980). In the 1990s, Badois et al. (1993) and Foucher et al. (2001) presented their long-term results of needle fasciotomy, the latter only using lignocaine and needle fasciotomy, without steroid injection.
In this article we present our experience since early 2001 with percutaneous needle fasciotomy, or PNF, following a visit in February 2001 by the senior author (PMNW) to the French rheumatologists, Drs. Thysse-dou and Lermusiaux, in Paris.
PATIENTS AND METHODS
From April 2001, percutaneous needle fasciotomy was offered to all patients with primary Dupuytren’s disease who had a clearly defined cord and a contracture of at least 20° at either the metacarpophalangeal (MCP) joint or at the proximal interphalangeal (PIP) joint. Only one patient in this study underwent percutaneous needle fasciotomy for contracture of the distal interphalangeal (DIP) joint. Fifty-two patients were included in this pilot study with disease of 56 hands, in which 74 rays were treated. Forty-four patients were men and 8 were women. The mean age of the patients was 65 years (SD 10). Thirty-one left and 25 right hands, including 9 middle, 29 ring and 36 little finger rays underwent percutaneous needle fasciotomy. Two rays were treated at the same operation in 16 hands and 3 rays were treated synchronously in one hand.
On initial presentation, the flexion contractures of the MCP, PIP and DIP joints of involved rays were measured. These figures were added to achieve the total passive extension deficit (TPED) of each ray and classified according to Tubiana’s staging system (Tubiana, 1999) (Fig 1).
OPERATIVE TECHNIQUE
Percutaneous needle fasciotomy was performed as described by Lermusiaux and Debeyre (1980). Patients were treated in an outpatient setting under local anaesthesia using 1 ml or less of lidocaine 1% and epinephrine 1:100,000 per treatment site. After disinfection and draping, the cord responsible for the flexion contracture of the ray was sectioned at as many levels as possible in the palm and fingers, depending on the location and extent of the disease, using a 25 Gauge needle mounted on an 10 ml syringe. In those cases where a soft tissue mass was present overlying the cord, in between the distal palm crease and the base of the finger, the fasciotomy in the distal part of the palm was performed with extra care to avoid nerve damage because a soft tissue mass at this site can indicate the presence of a spiral nerve (Short and Watson, 1982; Umlas et al., 1994). After division of the cord, the affected finger was passively extended to pull the ends of the sectioned cord apart and to obtain maximal release of the contracture. A small dressing was applied for 24 hours. Patients were encouraged to start flexing and extending their fingers immediately after treatment and to start using their hands normally after 24 hours. No splint was used or physiotherapy given.
All patients were seen after 1 week and the same measurements as pre-operatively were taken. Special attention was paid to identify possible complications, such as rupture of a flexor tendon, nerve damage or skin lacerations.
Patients were reviewed after 8 to 9 months postoperatively and finally, in June 2005, at a mean of 33 (SD 13) months. At this final review, 38 of the 52 patients were available for follow up. One patient had died, two patients did not want to participate further in the study, two had severe health problems and nine could not be traced. At 8 to 9 months and at final review, the same measurements were taken as pre-operatively. In addition, light touch sensitivity, tested by light stroking of each side of the fingertip, and the flexion deficit of the finger, as indicated by the distance between the pulp of the finger and the distal palmar crease during maximal active flexion, were measured. Light touch sensitivity was compared to this sensation on the other fingers of the same hand.
The diseased tissue, which is still present in the palm following percutaneous needle fasciotomy sometimes softens after the procedure and is hardly palpable. However, nodules usually remain unchanged. Because of this, the usual definition of recurrence, viz. the appearance of a new nodule or cord, cannot be used. Therefore, a recurrence was defined as a TPED increase during follow-up of 30° or more compared to the immediate postoperative measurements. This value was chosen because we recommend patients to undergo treatment in our centre when a contracture reaches 30° or more.
STATISTICS
We used the paired samples t-test for comparison of pre-operative, postoperative and follow-up measurements. The χ2 test was used for comparing of categorical data, such as recurrence rates. For comparing the recurrence rates, we included Tubiana Stage III and Tubiana Stage IV rays in one group, because the latter contained only one digit. Significance was set at P < 0.05 (Table 1).
RESULTS
The mean pre-operative TPED was 62° (SD 31°).
One week review
Mean TPED immediately after surgery was 18° (SD 26°), which was a mean reduction of TPED of 77%. The best results were obtained at the MCP joints, at which percutaneous needle fasciotomy achieved a mean reduction of TPED of 88%. The mean reduction was only 46% at the PIP joint. At the single DIP joint released in this study, percutaneous needle fasciotomy achieved a reduction of TPED of 75%. In respect of the Tubiana stages before percutaneous needle fasciotomy, there was a trend towards better results with the lower stages, but there was no significant difference between the results for different stages (Table 2).
Nine month review
After 9 months, 58 rays were available for review. Of these, the mean TPED now measured 21° (SD 25°). As the mean immediate postoperative result of these 58 rays was 19°, this deterioration was not statistically different (P = 0.349).
Final review
Fifty-five rays (74% of the original 74 rays) in 41 hands in 38 patients were available for final follow-up. Of these, 23 rays (42%) in 16 hands in 15 patients had already been treated for recurrence, 12 by percutaneous needle fasciotomy and four by selective fasciectomy after a mean of 23 (SD 14) months.
The remaining 32 treated rays in 25 hands in 23 patients were seen after a mean of 33 (SD 13) months (Table 3). The mean TPED at follow up of these 32 rays was 26° (SD 21°), which was a mean reduction of TPED of 44% from the TPED 1 week after surgery. This was a statistically significant change (P = 0.000).
In 13 rays in 11 hands in 10 patients, the reduction of TPED was more than 30°, which we defined as recurrence. Therefore, the total recurrence rate in this series at a mean of 33 months after PNF was 36 rays. When we compared the recurrence rates for the different Tubiana stages at presentation using the χ2 test, assuming a linear relationship between grade and recurrence, the op value was 0.18. This indicates that there was no statistical difference between the groups. The recurrence rates of the different stages are shown in Table 4.
At first follow-up, 1 week after the operation, we noticed partial loss of sensation in one patient. The ray in which this occurred had a Stage II Tubiana contracture. At the patient’s request, this finger was not explored. At final review, two patients had a reduction of flexion of 1 cm between the pulp of the treated finger and the distal palmar crease, which has not recovered up to now. However, there were no signs of flexor tendon injury. Two further patients were found to have slightly diminished light touch sensation on one side of one treated finger each at final follow-up. This had not been noted at the initial postoperative review.
DISCUSSION
Badois et al. (1993) performed percutaneous needle fasciotomy on 138 patients and found that 81% of the treated hands had good or excellent primary results, defined as a Tubiana classification ≤1 or a residual TPED of less than 45°. In the group of patients with Tubiana Stage IV disease pre-operatively, 48% had good results. Bleton et al. (1997) performed a prospective study of percutaneous needle fasciotomy on 110 digits in 59 patients. Sixty-one per cent showed good results, by which these authors meant an improvement of more than 50%. Foucher and his colleagues reported an immediate improvement of 72% in their 1998 study and 76% in their 2001 study, which included some of the patients of the first study (Foucher et al., 1998, 2001).
Immediate outcome was also very promising in our study as we achieved a reduction of 77% of the contracture in a total of 74 rays treated by percutaneous needle fasciotomy. The results were particularly good at the MCP joint, where a reduction of TPED of 88% was achieved. Results at the PIP joint were less good, with a reduction of TPED of only 46%.
Badois et al. (1993) reviewed an unknown number of rays in 123 hands which he had treated by percutaneous needle fasciotomy and steroid injection after 5 years. Sixty-nine per cent of his patients still had good or excellent results after 5 years, defined as a Tubiana Stage I TPED, or less. Nevertheless, in his series there were 43% who had recurrences among those who originally had had Stage I disease before percutaneous needle fasciotomy and 61% who had recurrence among those who were originally in Tubiana Stage IV. The overall recurrence rate in his series was 50% although his definition of recurrence is not stated clearly in the article. Foucher et al. (2001) reviewed 100 rays treated by percutaneous needle fasciotomy after a mean of 3.2 years. Fifty-eight per cent showed signs of recurrence.
Although our immediate outcome was very promising, the extension deficit was already starting to recur after 9 months. After 33 months, 23 (42%) of the treated rays had already undergone a second treatment for recurrence of the Dupuytren’s disease while an additional 13 (23%) showed signs of recurrence. The cumulative recurrence rate of our study was 36 of 55 rays (65%) at 33 months.
Other authors have described long-term results of percutaneous fasciotomy using a scalpel, albeit defining “recurrence” a little differently in each study, which makes direct comparisons difficult. Duthie and Chesney (1997) reviewed 82 patients with 109 digits after 10 years. Only 28 (34%) had had no further surgery. In the remainder, the mean time to further surgery was 60 months. Bryan and Ghorbal (1988) treated 44 rays and showed similar results, with a recurrence rate of 45% at 5.3 years.
From this study, we conclude that percutaneous needle fasciotomy has excellent results in the short term but recurrence occurs frequently and at a relatively early stage. Recurrence rates after other treatments of Dupuytren’s disease are lower and occur later than after percutaneous needle fasciotomy. After selective fasciectomy, Foucher et al. (1992) reported a recurrence rate of 41% at 5 years and Norotte et al. (1988) reported a 71% recurrence rate at 10 years.
This leads us to the conclusion that percutaneous needle fasciotomy is suitable only for patients, such as the elderly, who want simple treatment without extensive wounds and/or functional disturbances and to achieve a good result quickly following a minimally invasive surgical insult, but for whom long-term results are less important. For others, this procedure may have a use in postponing selective fasciectomy.