PRESENTATION AT THE AMERICAN SOCIETY OF SURGERY OF THE HAND ON NA(Subcutaneous or Needle Fasciotomy)

 Sept. 8, 2006 Washington, DC

1 A New Look At An Old Solution: Closed (Needle) Fasciotomy

  By Keith Denkler, M.D.

Associate Clinical Professor of Plastic Surgery, UCSF

2 Dogma

Limited fasciectomy with, or without grafting, or open techniques (McCash) remains the treatment of choice for Dupuytren’s contracture since the 1960’s

3 What is the Reconstructive Ladder of Treatment for Dupuytren’s?

4 Dupuytren’s Solutions

Medications or creams: Not yet

Injections Kenalog, collagenase (pending)

Skeletal traction before, or after surgery can help, but invasive

Surgical Release via perforations-Fasciotomy

Open or closed types

Small knives or needles may be used

Surgical Removal via excision-Fasciectomy

Localized, limited, or radical fasciectomies

With full-thickness skin graft (dermofasciectomy)

5 NEEDLE FASCIOTOMY: History and Complications

Subcutaneous fasciotomy was advocated/performed? by Cline 1777 and Cooper in 1822 (first fasciotomies)

Dupuytren 1832 Preferred transverse fasciotomy leaving the skin open

Goyrand 1833 proposed longitudinal subcutaneous fasciectomies with suturing to prevent infection (first limited fasciectomy)

6 "Late 19th surgeons liked the reduced chance of infection and results with closed fasciotomy

Adams 1878 and 1890 published two books on this subcutaneous release

7 Radical Fasciectomy

Technical improvements in surgery and anesthesia allowed in the early 20th century surgeons more extensive removal of diseased Dupuytren’s fascia to prevent recurrence

Radical Fasciectomy

Keen (1906) and Iversen (1909)

Lexer (1931) and McIndoe 1948, McIndoe and Beare 1958

8 Limited Fasciectomy

Extensive post-operative complications led to development of the current limited fasciectomy as recurrence rates are reported to be similar

Hueston 1962 and others

First limited fasciectomy by Goyrand 1833

9 Surgery for Dupuytren’s: Fasciectomies; How are we doing?

Personal fifty-year review on Dupuytren’s surgery

Significant and major injuries may occur after surgery

Are we helping our patients with fasciectomies: yes

Are we hurting our patients with fasciectomies: yes

10 Overall Risk of Digital Nerve Injury

Surgical fasciectomy operations carry a 3% risk of digital nerve injury despite a bloodless field, skilled surgeons, loupe magnification, and an open approach

Tubiana 7.7% of 195 surgeries in 1967 to Coert 7.7% of 558 surgeries in 2006

Major number of cases in the review

Geldmacher 2.8% of 2160 in 1994

McFarlane 1.5% of 1339 in 1990

Overall numbers over 50 years 3.2% out of 6,038 reported in the personal series (Range 0.4% to 7.8%)

Incidence in recurrent cases usually much higher Sennwald 27% of 26 repeat operations in 1990 sustained nerve damage

11 Risk of Digital Artery Injury

If two are injured, may require revascularization or lead to secondary necrosis or gangrene

Major problem before surgery for recurrent disease

Overall rate counting unreported as zero is 0.8% out of 6,038 surgeries in 50 year review

12 Risk of Infection

Most small to moderate, but may be severe despite aseptic technique and antibiotics

Range of infections is 0 to 9.6%

Major number of cases in the review

Geldmacher 2.6% of 2160 in 1994

McFarlane 1.3% of 1339

Overall rate 2.4% of 6038

13 Risk of Hematoma

Formerly a major complication due to more undermining of flaps 15.8% of Tubiana’s series in 1967!

Major studies

Geldmacher 1994 1.16 of 2160

McFarlane 2.2% of 1339

Overall risk 2.1% of 6038 surgeries in 50 year review

14 Reflex Sympathetic Dystrophy and Dupuytren’s Surgery

Highly morbid disease requiring difficult, prolonged, and usually disappointing treatment

Major studies

Geldmacher 2.2% of 2160

McFarlane 4.2% of 1339

Overall incidence 3.5% of 6038 surgeries in 50 year review

15 Reflex Sympathetic Dystrophy and Dupuytren’s Surgery

Very rare in NA Probably because of use of local anesthetic

Use of general anesthetic increases risk of RSD!

Incidence may be reduced in with more use of axillary block anesthesia in study published this year

Reuben, S.S., et al., The incidence of complex regional pain syndrome after fasciectomy for Dupuytren's contracture: a prospective observational study of four anesthetic techniques. Anesth Analg, 2006. 102(2): p. 499-503.

16 Skin Slough or Separation

Complication of cutting and undermining

Major studies

Geldmacher 1994 4.7% of 2160

McFarlane 1990 4.7% of 1339

Overall incidence is 5.4% of 6038

Dupuytren’s limited fasciectomy under local anesthesia with epinephrine, my own paper, had a 5% incidence:

Denkler 2005

17 Unusual and or Bad Complications of Dupuytren’s Surgery

Hospital re-admission up to 15% incidence

Mandol in UK 2005 Ann RCS

Medical perioperative complications

Tendon injury 0.23% Geldmacher 1994

Digital gangrene 0.1% McFarlane 1990

Prolonged edema and stiffness may occur

Scar sequelae (incisions too straight) Too frequent?

18 Complications of NA

Usually minor complications

Skin tears Could need sutures

Localized infection

More significant complications

Digital nerve injury approx 1%

Tendon 0.1%

Reflex Sympathetic Dystrophy Rate?

19 Complications of NA

Digital nerve injury

1% of 473 overall cases in published series by hand surgeons

JHS (Am) Rijssen 2006

JHS (Br) Foucher 2001

French data Lermusiaux 1997 and 2001

Large numbers (50,000) are anecdotal and not part of series States “nerve as rare as tendon” and “five tendons out of 50,000”

20 Complications of NA

Summarized by Foucher 2001

May be a large number of unreported complications We do not really know the denominator

Foucher 2001 references

Badois data from 1993 3736 aponeurotomies

Two tendon injuries or 0.05% Two nerve injuries or 0.05%

21 My Own Complications 443 Digits

Digital nerve injury 4/443 or 0.9% (one case was after previous surgery for recurrent disease)

A few patients developed temporary neuropraxia from nerve “stretching”

Flexor tendon injury 1/443 or 0.2% (case #20 -60 degrees PIP)

Infection 5/443 or 1.1% (two severe in/around PIP joint 2 severe were recurrent PIP disease needing needle capsulotomies of the PIP joint

22 My Own Complications 443 Digits: RSD

1/443 or 0.2% incidence of Reflex Sympathetic Dystrophy

(patient had previous surgery and RSD after previous surgery)

A second RSD from previous surgery did not develop RSD after my NA procedure!

Skin tears Sutured 10/443 or 2%

Minor, from stretching skin approx 10% and not sutured

FTSG in 1/443 or 0.2% stage 4 finger -145 MCP+PIP total loss of extendion

23 Can We Do Better?

There is no one operation for Dupuytren’s!

Can we take the old, add the new, and help our patients by doing less?

Why not start small?

Repeat as necessary!

TABLE OF LITERATURE ON DUPUYTREN'S SURGERY

Reference	Number	Nerve Injury%	Infection%	Hematoma%	Sympathetic Dystrophy%
Coert[7]	558	7.7	3.6	?	4.5
Rijssen[8] 2006	78	1.2	1.2	1.2	0
Denkler[9] 2005	102	2.9	7	1	0
Bulstrode[10] 2005	253	2.0	9.6	2.0 McCash technique	2.4
Leclercq[11] 2003	245	2	?	0.4	0
Leclercq[12] 2000	183	2	0.5	1	3
Foucher[13] 1995	54	1.9	?	0	9.3
Geldmacher 1994[14]	2160	2.82	2.68	1.16	2.18
Foucher 1992	140	3.2		0.7	7
Sennwald[15] 1990	98	7.8	1	3	19
McFarlane[16, 17] 1990	1339	1.5	1.3	2.2	4.2
Hout[18] 1988	326	5.2	3.4	5.8	1.8
Allieu and Tessier 1986	77	3.6			11.6
Rodrigo 1976	230	0.4	1.3	4	10
Tubiana[19] 1967	195	7.7	2.6	15.8	?
Total with weighted average	6038	3.2	2.4	2.1	3.5

Historical Comments on Subcutaneous Release (Fasciotomy) of Dupuytren's Contracture

Binnie[1] in 1917:   “subcutaneous section is usually followed by recurrence, but the recurrence may be so delayed and the operation is so trivial that many patients prefer repeated section to a more formidable radical operation”

Luck[2] from 1959:  "Subcutaneous fasciotomy was first suggested for the treatment of flexion contracture of the fingers by Sri Astley Cooper in 1822.  He wrote "... but when the aponeurosis is the cause of the contraction and the contracted band is narrow, it may be with advantage divided by a pointed bistoury, introduced through a very small wound in the integument. The finger is extended and a splint is applied to preserve it in a straight position".  This procedure fell into disrepute through the years because it was indiscriminately applied to all cases of contracture; but Luck has recently reintroduced it and it has achieved limited popularity.  Having perused 20 papers, published since Skoog's monograph in 1948, on the surgical treatment of flexion contracture, we find that fasciotomy is either not mentioned at all or condemned.  The radical fasciectomy, on the other hand, is given not merely as the procedure of choice but is considered the only satisfactory surgical treatment.  This blind adherence to a single procedure for the treatment of a disease that has many individual variations and several stages of development shows an infatuation with a technical exercise that does not properly answer each patient's need.

Howard[3] outlined indications for fasciotomy:

          1) as a preliminary to fasciectomy in severe cases, since it allows the palmar skin to stretch out before the fascia is excised

          2) for older, retired, or non-working patients with limited palmar involvement and cords limited to one or two fingers

          3) for skilled workers with palmar cords who cannot afford the loss of working time associated with fasciectomy, provided they understand that later fasciectomy or repeat fasciotomy will be necessary

          4) for patients who have arthritis or who for other reasons are prone to joint stiffness

          5) for patients who, because of other physical impairment, can only tolerate minor procedures.

McFarlane 1988[4]  “no one method to treat Dupuytren’s contracture has been established.  All methods are equally defensible.  One’s choice of treatment becomes a decision based on training, technical skill, and one’s concept of the disease process.” 

Neuropraxia has been reported even when the fasciotomy has been limited to the palm and has been attributed to overstretching of the finger after a severe contracture[5]

 Bryan[6] confirms the findings of Colville (1983) and Rowley (1984) et al. who suggested that fasciotomy has a role to offer as a corrective procedure in those patients whose contracture is restricted to the MP joints and as a preliminary procedure in those with deformity affecting the PIP joint as well.”…  It may also be stated that 57% of patients with deformity affecting mainly the MP joint will have maintained their correction at five years.

Other complications of Open Surgery for Dupuytren's

          Digital gangrene 0.1%[17]

          Myocardial infarction, left ventricular failure, urinary retention[10]

          Arterial injury, gangrene, and amputation[21]

          Emergency revascularization[22, 23]

Secondary amputation 1.30% as a result of malperfusion from divided arteries [14]

          Tendon injury 0.23%[14]

          Inclusion cyst 1.3%[24]

Scar sequelae 1.2% [10]