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SCIENTIFIC ARTICLE

Percutaneous Needle Fasciotomy for Recurrent

Dupuytren Disease

Annet L. van Rijssen, MD, PhD, Paul M. N.Werker, MD, PhD

Purpose Increasing options to treat Dupuytren disease include percutaneous needle fas-ciotomy (PNF), a minimally invasive technique that has proven to be effective for thetreatment of primary disease. However, its effect on recurrent disease is not clear.

Methods We studied 30 patients with recurrent Dupuytren disease in 40 fingers, with a meanfollow-up of 4.4 years. Primary outcome measures were total passive extension deficitreduction and interval to a second recurrence, defined as an increase of more than 30°compared with the result at the end of the previous treatment. We noted complications.

Results Total passive extension reduction was 76%. Percutaneous needle fasciotomy wasespecially effective for the metacarpophalangeal joint, with an average reduction of 93%,whereas the average reduction in the proximal interphalangeal joint was 57%. A total of 50%of patients did not develop a secondary recurrence during follow-up. The other 50% did, andwe treated recurrence within an average of 1.4 years after PNF. By means of PNF, wepostponed tertiary treatment an average of 2.9 years starting from the initial treatment forDupuytren disease. We successfully treated all secondary recurrences by limited fasciec-tomy, according to patients’ wishes. We noted no major adverse effects.

Conclusions Percutaneous needle fasciotomy can be applied effectively for recurrent disease;50% of patients remain free of recurrence for a mean of 4.4 years. If a secondary recurrenceoccurs, it does so relatively early after treatment. Patients must therefore be willing to acceptthis uncertainty in the context of the advantages of PNF, such as fast recovery, lowcomplication rate, and minimal invasiveness. (J Hand Surg 2012;37A:1820–1823. Copy-right © 2012 by the American Society for Surgery of the Hand. All rights reserved.)

Type of study/level of evidence Therapeutic IV.

Key words Aponeurotomy, Dupuytren, fasciotomy, recurrence.

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CURRENTLY, DUPUYTREN DISEASE is an incurablechronic condition leading to finger contracturesin many cases. After surgical treatment, fibro-

atosis often recurs or extends and causes recurrencef contracture.1,2 Several risk factors have been sug-ested that adversely influence the interval to, and se-erity of, recurrence.3–6 These include onset of theisease before age 40 years, familial predisposition,

From the Department for Plastic, Reconstructive, and Hand Surgery, Isala Clinics, Zwolle, TheNetherlands.

The authors thank Nicolien Wieringa for help in correcting the English in this article.

Received for publication January 26, 2012; accepted in revised form May 3, 2012.

No benefits in any form have been received or will be received related directly or indirectly to the

subject of this article.

1820 � © ASSH � Published by Elsevier, Inc. All rights reserved.

resence of ectopic lesions, bilateral disease, radial in-olvement, and involvement of the little finger.

Reported recurrence rates vary from 0% to 73% forimited fasciectomy (LF),6–8 to 20% to 100% for col-agenase injections,9,10 50% to 85% for percutaneouseedle fasciotomy (PNF),6,11–13 and 8% to 47% forermofasciectomy.14,15 The reasons these figures vary

so largely are the lack of standard definitions for recur-

Corresponding author: Annet van Rijssen, MD, Department for Plastic, Reconstructive, and HandSurgery, Isala Clinics, Dr van Heesweg 2, 8025 AB Zwolle, The Netherlands; e-mail:annetvanrijssen@hotmail.com.

0363-5023/12/37A09-0008$36.00/0http://dx.doi.org/10.1016/j.jhsa.2012.05.022

PNF FOR RECURRENT DUPUYTREN DISEASE 1821

rence and the varying follow-up periods. One of the fewavailable randomized, controlled studies showed PNFand LF to be similarly effective for contracture releasein lower Tubiana stages and showed recovery after PNFto be much faster than after LF. It also showed that therecurrence rate 5 years after PNF was 4 times highercompared with LF.6,16 Despite these differences, manypatients prefer PNF over LF because it is minimallyinvasive and has a short recovery period. In addition,for recurrent disease, many patients choose PNF treat-ment.6

Studies are lacking that have a reasonable follow-upperiod and that look into the efficacy and durability oftreatment for recurrent disease. It has been reported thatsurgery for recurrence is more difficult and is hamperedby more complications than for treating the first diseaseepisode.17 The aims of the present study were to inves-tigate the effectiveness of PNF for the treatment ofrecurrent Dupuytren disease, to search for influences ofknown risk factors on the development of recurrence,and to investigate the amount of time gained byperforming PNF before further treatment becomesadvisable.

MATERIALS AND METHODSWe retrospectively reviewed all patients included in ourprevious randomized, controlled trial on PNF versus LFwho developed recurrence during the 5-year follow-upperiod.6 We did not obtain institutional review boardapproval, because this is not required in our center forthis type of research.

We found an increase of the total passive extensiondeficit (TPED) of at least 30° in 1 or more rays in 45hands treated by PNF. This was our definition of recur-rent disease. A total of 26 patients (26 hands) in thePNF group requested PNF for treatment of recurrentdisease, whereas 7 requested LF. The remaining 12patients declined treatment for recurrence. In the groupinitially treated with LF, 4 of 10 patients (4 hands)wanted treatment for recurrent disease by PNF.

In this study, we specifically focused on the 30patients who underwent PNF for recurrent contractureafter prior successful treatment with PNF (n � 26patients, 26 hands) and LF (n � 4 patients, 4 hands).We treated patients in an outpatient setting under localanesthesia. We sectioned the cord responsible for theflexion contracture of the ray at as many levels aspossible in the palm and finger, depending on the loca-tion and extent of the disease, using a 25-gauge needlemounted on a 10-mL syringe. After we divided thecord, we passively extended the affected finger to pull

the ends of the sectioned cord apart and to obtain

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maximal release of the contracture. We applied a smalldressing for 24 hours. For a more detailed description ofPNF, please refer to our previous study16 and to thearticle on PNF by Eaton.18

Patients received no specific postoperative hand ther-apy regimen or splint therapy.

We looked at the effects of PNF for recurrent diseaseand investigated whether secondary treatment sufficed.If tertiary treatment was necessary, we determined forhow long. We also compared patient groups requiringsecond and third treatment with respect to differences inknown risk factors for developing recurrence. Table 1outlines patient demographics.

We used the chi-square test for categorical data andStudent’s t-test to calculate the recurrence rate. Signif-icance was set at P � .05.

RESULTS

Preoperative TPED was 50° (SD, 21°). We treated 40rays: 4 middle fingers, 15 ring fingers, and 21 smallfingers. These involved 23 fingers in Tubiana stage I(TPED 0° to 45°), 16 in Tubiana stage II (TPED 46° to90°), and 1 stage III (91° to 135°) (Table 2).19

A total of 21 rays were treated for metacarpophalan-geal (MCP) contracture, 13 rays for proximal interpha-langeal (PIP) joint contracture, and 9 for both MCP and

TABLE 1. Patient Characteristics

Patients (n [%])

Male 22 (73%)

Female 8 (17%)

Mean age (y) at time of second PNF 59

Ectopic disease 9 (30%)

Positive family history for Dupuytren disease 12 (40%)

Associated diseases (epilepsy, diabetes) 6 (20%)

Early-onset disease before 50 y 13 (43%)

Abe diathesis (� 4) 6 (20%)

TABLE 2. Tubiana Classification of DupuytrenContracture of the Fingers

Tubiana I TPED of 0°–45°

Tubiana II TPED of 46°–90°

Tubiana III TPED of 91°–135°

Tubiana IV TPED of �135°

PIP joint contractures.

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1822 PNF FOR RECURRENT DUPUYTREN DISEASE

There was no significant preoperative difference inTPED in the initially LF- or PNF-treated groups (P �.406). Postoperative measurements for 6 patients wereunavailable; only data on the necessity of further treat-ment were present in those cases. In the other 24 pa-tients, the mean remaining TPED after treatment was13° (SD, 17°). We treated 32 rays in these 24 patients,14 of which were the MCP joints, 10 the PIP joints, and8 both joints.

Contracture reduction after PNF was 76% (SD,34%). Again, there was no difference in TPED reduc-tion, regardless of whether patients were previouslytreated with PNF or LF (P � .331). Average passiveextension deficit reduction in the MCP joint was 93%,whereas in the PIP joint it was 57%. The differencebetween PIP and MCP joints was statistically signifi-cant (P � .001).

No serious adverse effects such as nerve injuries orflexor tendon injuries occurred. We found skin fissures,none of which needed intervention.

The average follow-up of our patients was 4.4 yearsafter PNF (SD, 1.5 y; range, 2–7 y). Of the 30 patientswho underwent secondary PNF, 15 developed a con-tracture again and requested tertiary treatment (50%recurrence rate). Of the 24 patients from whom we hada complete data set, 11 developed recurrence of con-tracture (46%). All were treated by LF. This modalitywas the patient’s choice after having been informedabout the longer disease-free interval of LF.15 We per-formed LF between 0.3 and 4.0 years after the secondPNF procedure, with an average of 1.4 years (SD,1.9 y). Because the average time to the first recurrencehad been 1.5 years, the secondary PNF treatment post-poned LF 2.9 years on average.

We found no statistical differences in the distributionof known risk factors between the patient group requir-ing secondary treatment and the groups that also re-ceived tertiary treatment. Age, ectopic disease and as-sociated conditions, involvement of the little finger, andage at onset of disease did not seem to influence thedevelopment of recurrences.5 Moreover, we could notdemonstrate that the severity of PIP joint disease influ-enced the recurrence rate (P � .204). We were unableto find differences in the outcomes between patientswho previously received PNF or LF, most likely be-cause the LF group was too small to allow statisticalcomparison.

DISCUSSIONOur reduction of TPED as a result of the second PNFwas larger than we reported in our previous study on

primary disease.12,16 We suggest this is partly because

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preoperative measurements showed that contractureswere slightly less severe than in the previous study and,more important, that we observed increased experiencewith our application and execution of the surgical tech-nique and dared to work more distally in the finger,which enabled us to gain better results.

The same arguments may apply to the lower recur-rence rate. In one of our previous studies, we found85% recurrences after 5.0-year follow-up, comparedwith the current rate of 50% after 4.4 years.6 In addi-tion, our direct results in both MCP joints and PIP jointswere better than those we previously reported.

We were unable to prove any influences of knownrisk factors on the occurrence of secondary recurrence,likely because the sample size is relatively small.

We were unable to find any reports on PNF forrecurrent disease, and therefore we cannot compareresults with those of other researchers.

In a previous study, we proved that advanced agehad an inhibitory effect on the appearance of recurrentdisease.6 In the current study, we could not reconfirmthis, probably because our study group was muchsmaller this time.

Our findings do not correlate with the findings ofmany authors, which support the view that Dupuytrendiathesis is a risk factor for recurrence or extension. Wewere unable to find a statistically significant influenceon recurrences of involvement of the little finger, earlyonset, radial disease, familial predisposition, ectopiclesions, sex, or comorbidities such as diabetes and ep-ilepsy. In our study on the long-term effects of PNF andLF, we could not prove the influence of these riskfactors, either.6 McFarlane et al20 reported 5-year re-sults on LF with the open-palm technique and was alsounable to prove the effect of Hueston diathesis. Theirfindings are consistent with ours.

From the current study, we conclude that for bothpost-PNF and post-LF recurrence, PNF leads to goodimmediate results. A second recurrence occurred in50% of cases after 4.4 years on average. We treated allof these patients with LF. By using PNF to treat the firstrecurrence, we postponed the LF procedure by 2.9years. We found that LF as a tertiary procedure was notmore complicated than in a case of primary disease.However, the cords seem to be broader and more dif-fuse than in primary disease. These findings suggestthat PNF is a valuable treatment method for patientswith recurrent Dupuytren disease.

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