Symposium 2

Needle Aponeurotomy for the Treatment ofDupuytren’s Contracture

A Prospective Study

• Gary M. Pess, MD• Central Jersey Hand Surgery

• Eatontown, NJ

Nothing of financial value to disclose

Needle AponeurotomyNeedle Aponeurotomy for the for the Treatment ofTreatment of

Dupuytren’s Dupuytren’s ContractureContracture

A Prospective StudyA Prospective Study

Gary M. Pess, MDGary M. Pess, MD

Central Jersey Hand SurgeryCentral Jersey Hand Surgery

Eatontown, NJEatontown, NJ

Why Reconsider Why Reconsider Fasciotomy?Fasciotomy?

Gary M. Pess M.D.Gary M. Pess M.D.

High recurrence rate with open High recurrence rate with open surgerysurgery

Recovery can be prolongedRecovery can be prolonged Some patients never regain full flexionSome patients never regain full flexion Significant surgical complication rateSignificant surgical complication rate

Hand SurgeonsHand SurgeonsAreAre

Perfectionists!Perfectionists!Gary M. Pess M.D.Gary M. Pess M.D.

But can we really cure But can we really cure Dupuytren’s Contracture?Dupuytren’s Contracture?

Needle AponeurotomyNeedle AponeurotomyTechnique Technique Gary M. Gary M.

Pess M.D.Pess M.D. Outpatient procedure – office or surgery centerOutpatient procedure – office or surgery center Local anesthesia (rarely MAC)Local anesthesia (rarely MAC) No tourniquet necessaryNo tourniquet necessary Five cc syringe Five cc syringe 1 cc DepoMedrol + 3 cc Xylocaine 1% plain1 cc DepoMedrol + 3 cc Xylocaine 1% plain Short 25 gauge 5/8” needlesShort 25 gauge 5/8” needles

Needle AponeurotomyNeedle AponeurotomyPost Procedure Post Procedure Gary M. Gary M.

Pess M.D.Pess M.D.

Exercise fingers immediatelyExercise fingers immediately Can wash handCan wash hand No heavy grasping for 2 weeksNo heavy grasping for 2 weeks Night splint for 3 monthsNight splint for 3 months Therapy for stiff fingers and residual Therapy for stiff fingers and residual

contracturecontracture

Needle AponeurotomyNeedle AponeurotomyMaterials and MethodsMaterials and Methods

128 Patients128 Patients 260 Fingers260 Fingers Male : Female - 4 : 1Male : Female - 4 : 1 Average age: 61Average age: 61

Gary M. Pess Gary M. Pess M.D.M.D.

Needle AponeurotomyNeedle AponeurotomyMaterials and MethodsMaterials and Methods

DIGITDIGIT PercentPercent NumberNumber

ThumbThumb 1%1% 22

IndexIndex 5%5% 1212

MiddleMiddle 15%15% 4040

RingRing 37%37% 9696

LittleLittle 42%42% 110110

JOINTJOINT

MPMP 68%68% 225225

PIPPIP 32%32% 136136

Gary M. Pess M.D.

Needle AponeurotomyNeedle AponeurotomyMaterials and MethodsMaterials and Methods

Only one procedure per fingerOnly one procedure per finger Two patients deceasedTwo patients deceased Twelve patients lostTwelve patients lost to follow-upto follow-up Minimum follow-up 2.5 years Minimum follow-up 2.5 years

(Range 2.5 - 3.5 years)(Range 2.5 - 3.5 years)

Gary M. Pess M.D.

ResultsResultsMP Joint MP Joint Gary M. Gary M.

Pess M.D.Pess M.D.

36

1

8

0

5

10

15

20

25

30

35

40

DE

GR

EE

S

PREOP MP POSTOP MP FINAL MP

ResultsResultsPIP Joint PIP Joint Gary M. Gary M.

Pess M.D.Pess M.D.

51

6

31

0

10

20

30

40

50

60

DE

GR

EE

S

PREOP PIP POSTOP PIP FINAL PIP

ResultsResultsPercent Correction Percent Correction Gary M. Gary M.

Pess M.D.Pess M.D.

99%

88%

79%

43%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% MP JOINT

PIP JOINT

FINAL CORRECTION %POSTOP CORRECTION %

P<.001

Results by DigitResults by DigitMP Joint Final Correction MP Joint Final Correction Gary M. Gary M. Pess M.D.Pess M.D.

84%

78%

90%

80%

75%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

THUMB INDEX MIDDLE RING LITTLE

Results by DigitResults by DigitPIP Joint Final CorrectionPIP Joint Final Correction Gary M. Gary M. Pess M.D.Pess M.D.

73%

41%

50%

39%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

INDEX MIDDLE RING LITTLE

Results by AgeResults by AgeFinal Correction Final Correction Gary M. Gary M.

Pess M.D.Pess M.D.

67%

81%

26%

48%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% FINAL CORRECTION MP % FINAL CORRECTION PIP

AGE <=50

AGE >50p<.001

p<.001

P<.001

P<.001

Results by GenderResults by GenderFinal Correction Final Correction Gary M. Gary M.

Pess M.D.Pess M.D.

79% 80%

44%41%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% FINAL CORRECTION MP % FINAL CORRECTION PIP

MALE

FEMALE

ResultsResultsSuccess in Correcting <= Success in Correcting <= 5º5º Gary M. Gary M. Pess M.D.Pess M.D.

MP Joint: 97% fingersMP Joint: 97% fingersPIP Joint: 70% PIP Joint: 70% fingersfingers

ResultsResultsJoint Recurrence > 20ºJoint Recurrence > 20º Gary M. Gary M. Pess M.D.Pess M.D.

MP Joint: 14% fingersMP Joint: 14% fingers PIP Joint: 54% fingersPIP Joint: 54% fingers

ResultsResultsFinal Improvement >=50%Final Improvement >=50% Gary M. Gary M. Pess M.D.Pess M.D.

MP Joint: 81%MP Joint: 81%PIP Joint: 50%PIP Joint: 50%

ResultsResultsComplications Complications Gary M. Gary M.

Pess M.D.Pess M.D.

Skin tear: 1.9% (5) – All healedSkin tear: 1.9% (5) – All healed Temporary Neurapraxia: 1.2% (3)Temporary Neurapraxia: 1.2% (3) Tendon or Pulley Rupture: 0%Tendon or Pulley Rupture: 0% Nerve Laceration: 0%Nerve Laceration: 0% Arterial Laceration: 0%Arterial Laceration: 0% Hematoma: 0%Hematoma: 0% Infection: 0%Infection: 0% RSD: 0%RSD: 0% Hospitalization: 0%Hospitalization: 0%

ConclusionsConclusionsNeedle AponeurotomyNeedle Aponeurotomy Gary M. Gary M. Pess M.D.Pess M.D.

Statistically significance difference: MP v. PIP (p<.001) Statistically significance difference: MP v. PIP (p<.001) Statistically significance difference: <= 50 v. > 50 Statistically significance difference: <= 50 v. > 50

(p<.001)(p<.001) No difference based on gender or digit affectedNo difference based on gender or digit affected Correction of contracture <=5ºCorrection of contracture <=5º

– MP Joint: MP Joint: 97%97%– PIP Joint: PIP Joint: 70%70%

ConclusionsConclusionsNeedle AponeurotomyNeedle Aponeurotomy Gary M. Gary M. Pess M.D.Pess M.D.

Final Final ResultResult

MP JointMP Joint PIP JointPIP Joint

Recurrence Recurrence

> 20º> 20º14%14% 54%54%

ImprovemeImprovement >= 50%nt >= 50%

81%81% 50%50%

ConclusionsConclusionsNeedle AponeurotomyNeedle Aponeurotomy Gary M. Gary M. Pess M.D.Pess M.D.

Needle Aponeurotomy is a safe procedure Needle Aponeurotomy is a safe procedure Complication rate Complication rate lowerlower than fasciectomy than fasciectomy Can be performed in an office settingCan be performed in an office setting High patient satisfactionHigh patient satisfaction Excellent procedure for Dupuytren’s Excellent procedure for Dupuytren’s

ContractureContracture

Surgical GoalSurgical Goal Gary M. Gary M.

Pess M.D.Pess M.D.

Thank You!Thank You! Gary M. Gary M.

Pess M.D.Pess M.D.