Dupuytren’s Disease: Percutaneous Release Charles Eaton MD 2007

Why? Why? …WHY? Conventional Wisdom: Fasciotomy: Is Dangerous Is Ineffective Is Always Followed by Rapid Recurrence Reality: In 2007, Compared to Surgery, Percutaneous Needle Fasciotomy: Is Far Safer in Terms of Flare Reaction, RSD, Stiffness, Nerve Injury Nearly as Effective Does have earlier recurrences 50% recurrence: Fasciectomy:5 yr; NA:3 yr Has Far Less Morbidity Has Far Better Overall Patient Satisfaction

Needle Aponeurotomy (NA) Percutaneous Needle Fasciotomy (PNF) Principles: Needle used as scalpel Multiple levels of release Passive extension separates cords Cords slide relative to skin Minimal skin trauma Minimal deep dissection Surface anesthesia safety net Fascia=sheet; Cord=string

BD PrecisionGlide™ Needle Cutting portion of bevel =0.87mm ≈0.5mm diameter Modified Trochar Design 25 Gauge Needle Needle Geometry 25 Gauge Needle BD PrecisionGlide™ Needle

Cutting edge of 25 Gauge Needle Stab 0.5mm wide { { Maximum Slice depth < 1mm

Wound Geometry and Collateral Damage Zones 25 Gauge 11 Blade 15 Blade

Fasciotomy Geometry Transverse releases Lenticular expansion similar to expanded sheet metal

Needle Technique Initial entry: Define cord Clear septae

Needle Technique: Stab Radial Stab Useful for large cords, fixed skin Linear Stab Useful for small incremental progress

Needle Technique: Slice Tip Slice For thick cords Bevel slice For wide cords

1. Start with Skin Crease Landmarks Portal Diagrams 1. Start with Skin Crease Landmarks

2. Add Common Dupuytren Zones Portal Diagrams 2. Add Common Dupuytren Zones

3. Subdivisions based on Zones and Creases Portal Diagrams 3. Subdivisions based on Zones and Creases

Portal Diagrams Eaton Zones

Office Needle Technique Preop Palpate cords Doppler spiral suspects Diagram cords, nodules, scars, ROM Review Expectations for ROM and recurrence Technique Paresthesias Active finger flexion Postop program Consent

Office Needle Technique Tiny intradermal skin wheal anesthesia 25 gauge 5/8” Needle Bevel perpendicular to cord Release distal to proximal in fingers PIP anesthetic if contracture > 60º Monitor: Nerve: Tip sensibility Tendon: Active flexion with needle inserted Final manipulation +/- block Local anesthetic / steroid injections Diagram portals, events, ROM Bandage

Office Needle Technique Postop Bandages off same day if no skin tears 36 hr Ice / Elevation 1 week no soiling / no strenuous activities Postop pain is uncommon Postop paresthesias are common – few days Expect nodules to soften for 3 weeks Local Histamine type flare common at 6-8 wks Rx Topical Benadryl, Hydrocortisone 3 month static night splint if PROM>>AROM PIP: finger splint MCP: hand based pan splint Combined: intrinsic(+) position

Demonstration

?? Technique Comparison Fasciectomy NA Long Recovery Complications Common Chance for Cure NA Short Recovery Complications Rare Recurrence Common