NEEDLE APONEUROTOMY: FREQUENTLY ASKED QUESTIONS

• How do I know that I have Dupuytren's and not some other problem? Dupuytren's is diagnosed by the appearance of the skin of the hand. Before travelling far for treatment, it is a good idea to have the diagnosis confirmed by a local a health care professional. Dupuytren's is a very specific type of problem. It is not arthritis, tendinitis, trigger finger, carpal tunnel syndrome, or other conditions resulting in stiff or bent fingers, so if there is any question about the diagnosis, have it checked out in person by a health care professional. More information on Dupuytren's is available at www.eatonhand.com.
• What actually is Needle Aponeurotomy?
• It is a procedure performed in a doctor's office using local anesthesia to help straighten fingers bent by Dupuytren's contracture. In Dupuytren's disease, a layer of tissue just under the skin of the palm becomes hard and shrinks. Dupuytren's may result in a lengthwise tightness beneath the skin of the palm which keeps the fingers from straightening, called a "cord". With needle aponeurotomy, a physician lengthens a tight cord by cutting it beneath the skin with a small needle, usually at several points along the line of tightness.
• Technically speaking, needle aponeurotomy is a type of procedure referred to as a percutaneous fasciotomy. "Percutaneous" means going through the skin with the smallest hole possible, and "fasciotomy" means cutting fascia, which is the layer under the skin affected by Dupuytren's disease.
• Needles may be used percutaneously to cut the tight fascia, inject nodules with cortisone, or both:
   
• What are the limitations of Needle Aponeurotomy?
• NA is not a cure-all for bent fingers. It is one of several techniques to straighten fingers bent by Dupuytren's disease, applicable when there are string-like cords which can be felt beneath skin which is still somewhat soft.
• NA is not appropriate for contractures due to other problems, such as contractures due to prior injury, chronic tendinitis ("trigger finger"), or medical problems producing generalized stiffness, such as reflex sympathetic dystrophy, scleroderma, or diabetic stiff hand syndrome. This is why it may be important to have a physician confirm that the primary problem producing contractures is Dupuytren's before making plans for NA at the Hand Center.
• NA is usually not appropriate for hands which are persistently painful, tender, or swollen.
• NA may not be technically possible when the skin has lost its stretchiness -  if
• The skin itself has shrunk or hardened too much.
• There are tight lengthwise scars from previous surgery.
• There are skin grafts in the middle of the contracted area.
• The skin over the cord is hard, scarred, or nodular (lumpy).
• Nodules are hard lumps in the palm where the Dupuytren's process is the most active. If a cord is like a string, a nodule is like a bead on that string. Nodules are unfavorable areas for NA, and if nodules involve long areas, it may not be possible to perform NA. However, nodules usually shrink and soften after a cortisone shot, and it may be possible to treat the area with cortisone shots and return in a few months to perform NA.
• PIP contractures are difficult problems for both traditional surgery and NA, and partial rather than complete improvement is to be expected. On the average, PIP contractures over 45 degrees are improved about 50 percent with either NA or traditional surgery.
• Severe contractures or combined contractures of both the MCP and PIP joints may require two sessions, several months apart, in order to gain the maximum benefit. Two sessions are usually required for Stage III and IV contractures. Remember, the goal of NA is improvement without a long recovery period. Severe PIP joint contractures and severe combined MCP and PIP contractures are rarely restored to normal, even with traditional surgery.
• Secondary problems may limit the usefulness of NA. When a finger joint has been too bent too far too long, the joint itself may become stuck, even after the Dupuytren's cord has been released. This is most common with PIP joint contractures. Also, the tendons which run on the back of the finger which straighten the PIP and MCP joints may stretch out or slide over to the side of the knuckle, no longer able to pull the knuckle straight. If this happens, the contracture will likely recur after NA, and traditional tendon reconstruction surgery should be considered.
• When should I consider having NA? When is the earliest it can be done? Needle release should be considered when there is a contracture which prevents the fingers from stretching back. A release can only be done if there is a contracture which limits joint movement: Needle aponeurotomy can't only be done effectively if the PIP and MCP joints can each be straightened fully at the same time. Even if the tightness seems to be progressing, there must be some contracture to try NA.
• What happens to the cord after it has been cut? The cord is softened and digested by the body's normal enzymes, and heals in a lengthened state. The cord is a normal structural layer which has become wider and shorter from the effects of Dupuytren's. It is not a tumor - it does not have to be removed, and when it is returned to it's proper length, it becomes hard to feel - just like it was before Dupuytren's affected it.
• If the nerve is wrapped around a cord, how can the cord be cut without cutting the nerve? Very carefully. At the Hand Center, the procedure is performed with local anesthetic only in the skin itself. Deep to the skin, nothing has much feeling, except the nerve. If the needle gets close to the nerve, you will feel an electrical tingle, which tells the doctor to reorient and stay away. As long as you can feel in the fingertip, it's safe to keep working. The finger may be temporarily numb at the end of the procedure from additional anesthetic or stretching the nerve, but statistically, permanent nerve damage is less likely than for traditional surgery.
• What happens to the nodules? Nodules soften up from two effects. They soften after the tension has been relieved from cutting cords attached to them. They also soften after being injected with a small dose of a long lasting cortisone. The softening and flattening takes place over month or two two after the procedure.
• What about my knuckle pads? Knuckle pads (on the back of the PIP joints) can be injected with cortisone, which will make them soften and flatten some. However, the skin may become thin from the cortisone, so it's best to hold off injecting unless they are big and hard. Knuckle pads frequently go away after a few years, can come back after removal, and are not routinely operated on at The Hand Center
• Can I have the NA procedure performed the same day as my initial evaluation? Yes - that is the usual schedule.
• I have a severe case - is NA still appropriate? NA is always an option - if...
• If: there is a lengthwise cord which can be felt beneath the skin,
• And If: The skin is not too scarred, shrunk or hardened - the skin has to have some "give" or stretch left.
• Two NA sessions, three months apart, may be needed to achieve the most benefit in severe cases.
• When is NA NOT an option? What are the limitations of NA? See above.
• What if NA is not possible? Surgery is always an option. If the disease is beyond the point of NA, it is usually bad enough to require a skin graft or joint fusion - traditional surgical options.
• I am diabetic - Is NA safe? Yes, as long as your diabetes is under good medical control.
• I am on blood thinners - is NA safe? The risk of bleeding complications following NA is small. NA can be performed even if you are fully anticoagulated, as long as you are able to keep your hand constantly elevated (hand pointing up) the day of and the day following the procedure. However, ideally, you should be off all blood thinners (aspirin, plavix, coumadin, etc.) before any elective procedure, but only do this under the direction of the doctor who has prescribed these medicines. Blood thinners do increase the risk of excessive bruising and complications of bleeding following any procedure, including NA.
• Can I qualify for disability during my recovery from NA? No, not from the NA procedure itself. If you wish to receive disability benefits, all arrangements must be made by your primary doctor, if they believe that you qualify for disability based solely on your current condition. The Hand Center can't process disability requests.
• Is the procedure painful? Not terribly. The shots feel about as bad as a wasp sting, but don't last as long. Anxiety and anticipation are usually bigger problems than pain. Slow deep breathing and other relaxation techniques are very helpful. Narcotic pain medicines are not needed during or after NA.
• Can I have both hands done on the same day? No, this is usually not a good idea - better to stage the hands at least one day apart.
• Why aren't more doctors doing needle aponeurotomy? Many doctors in the US are simply not aware of the benefits of NA. Also, there is a very strong surgical tradition in the US of fasciectomy (removing the abnormal tissue) instead of fasciotomy (cutting the tight cord). It's just a matter of time before this changes - there's no conspiracy, no hidden agendas. Britain's National Health Service has reviewed the procedure and has published favorable policy statements regarding this - see http://www.nice.org.uk/search.aspx?search-mode=simple&ss=dupuytren.
• Is Dr. Eaton training other surgeons in this technique? Yes - although there is no formal certification for this technique. Interested surgeons are invited to visit The Hand Center and observe the technique. Physicians who have visited The Hand Center to observe Needle Aponeurotomy are listed here, along with their contact information.
• What's the difference between needle aponeurotomy and other procedures?
  Here's a comparison:

• I've already had surgery for Dupuytren's. Can I still have a needle procedure? Yes - if you have developed cords beneath fairly normal skin. However, needle aponeurotomy may not be possible after surgery if you have tight or hard skin, tight scars, or if no remaining cord can be felt. In these situations, traditional surgery may be the best solution, possibly with a skin graft.
• What can I expect after the procedure?
• Bandage? If your skin is in good condition and you have no "skin tear" from the procedure, you may simply need dot band aids on your palm for a day at the needle sites. Otherwise, you may be wrapped in a gauze bandage for 2 or 3 days. If you have a large skin tear, which is uncommon, you may need to change a light bandage on your palm for 2 weeks.
• Splint? If you have PIP contractures or have multiple fingers released, you may benefit from wearing a splint while sleeping for 3 months. Usually, a custom splint can be made by a hand therapist on site on the day of the procedure. Otherwise, you may be given a prescription for a splint to be fabricated within the next few days.
• Therapy? Unlike open surgery, scheduled sessions of hand therapy are not routinely needed after needle aponeurotomy.
• Activity? For the day of and the day after the procedure, it's best to try to keep your hand elevated (pointing up) as much as possible and to chill the needle sites 10 minutes an hour (ice, gel pack, holding a cold beverage, etc.). Your fingers may be numb for a few hours, but even with this, you should be able to eat, change clothing, go to the restroom and drive a car without assistance immediately after the procedure. You may be sore and bruised for a week, so plan to take it easy for comfort's sake - hold off on sports and strenuous activities at least 2 days after the procedure.
• Medications? You may be given a single dose of antiinflammatory medicine on the day of the procedure, or you may bring your own to take. If you are young and have aggressive disease in both hands, you may be given a prescription for colchicine, a medication which may reduce the risk of recurrence. No narcotic pain medicines are needed. If you are quite anxious about the procedure, you may wish to speak with your local physician about prescribing an anti-anxiety medication to take on the day of the procedure.
• How soon can I use my hand after a needle aponeurotomy? See "Activity", just above.
• Can my feet be treated as well? Not currently at The Hand Center.
• Can I run a question or two by the doctor before scheduling an appointment? Not usually. This FAQ and web site have been created to provide clear answers to many common questions. Legally,  one-on one detailed answers to specific questions about an individual's medical condition by a physician is considered to be medical advice, which our lawyers tell us can only be given to a patient who has already been seen in person as a patient at The Hand Center. This is one of the unsolved difficulties in long-distance medical relationships.
• How do I schedule an appointment? Call The Hand Center 561-746-7686, and give your address or FAX to receive a medical questionnaire.
• How far in advance do I need to make an appointment? At least one month.
• Is this covered by insurance? Yes.
• What do I need to tell my insurance company? Your insurance company will want to know the insurance codes for your
       Diagnosis: ICD Code 728.6 (Dupuytren's)
  and your
       Procedure: CPT Code 26040 (Percutaneous Fasciotomy - one finger)
  Under very unusual circumstances, the procedure may possibly also include CPT 26060 Tenotomy (for boutonniere deformity) or 26525 Capsulotomy (for severe PIP joint contracture).
• My insurance company tells me that they won't cover this because...
• The Hand Center physicians are not providers. The Hand Center physicians are Medicare providers, and are on many, but not all insurance plans. If our physician is not contracted with your plan, The Hand Center will file your insurance for your later reimbursement - but you will be responsible for payment in full on the day of your office visit (cash, cashier's check, MC, Visa).
• Other surgeons do Dupuytren's surgery. That's true, but if you want a needle aponeurotomy rather than open surgery, ask your plan representative for a list of other providers who perform this procedure, and mention that the total cost of traditional outpatient Dupuytren's surgery, including facility, anesthesia, and therapy will be ten to twenty times that of an office needle aponeurotomy. Mention that twice.
• This is cosmetic surgery, and so is not covered. Absolutely not true. Don't accept this explanation. Correction of contracture has been reported to improve hand function and dexterity lost to the disease (see the publication by Inha R, Cresswell TR, Mason R, Chakrabarti I: Functional benefit of Dupuytren's surgery. J Hand Surg [Br]. 2002 Aug;27(4):378-81). Advanced untreated Dupuytren's contracture has led to finger amputation for some patients, and Dupuytren's alone has qualified some sufferers for permanent complete medical disability. That's not cosmetic, period. Speak with your plan representative's supervisor, get their name, and let them know that you will be naming them personally when you write your insurance commissioner to complain that your plan is using a fraudulent explanation to deny a medically necessary treatment which is covered by Medicare. Contact your state insurance commissioner.
• What is the history of Needle Aponeurotomy?
• Needle Aponeurotomy is a new twist on the old procedure of percutaneous fasciotomy. In fact, percutaneous fasciotomy was probably the first surgical procedure ever reported for the treatment of Dupuytren's contracture - before it was even called Dupuytren's. In 1822, prior to Dupuytren's 1831 presentation of open fasciotomy, the renowned British surgeon, Sir Astley Cooper wrote "The fingers are sometimes contracted ... when the aponeurosis is the cause of the contraction, and the contracted band is narrow, it may be with advantage be divided by a pointed bistoury, introduced through a very small wound in the integument. The finger is then extended, and a splint is applied...". Translating aponeurosis=fascia, bistoury=knife, integument=skin, this is clearly a description of percutaneous fasciotomy for what later came to be called Dupuytren's contracture.
• In the 1800's, percutaneous procedures were were common, referred to as "subcutaneous surgery". Percutaneous release of Dupuytren's contracture was reported by many surgeons of the era, including Guérin, Fergusson, Little, Erichsen, Gant, Druitt, and others. In1879, Dr. William Adams in London published  a 63 page monograph "Observations on Contraction of the Fingers (Dupuytren's Contraction) and its Successful Treatment by Subcutaneous Divisions of the Palmar Fascia, and Immediate Extension".In this, Dr. Adams clearly and elegantly describes the concept and practice of percutaneous release of Dupuytren's contracture using long, narrow scalpels, performing "multiple subcutaneous divisions of the fascia...by as many punctures as may be necessary". His descriptions of fascial releases in the palm and digits are remarkably similar to current experience with needle aponeurotomy.
• In the nineteen hundreds, percutaneous fasciotomy fell out of favor as a surgical procedure, and is mentioned only briefly in current surgical texts. The reasons for this are unclear, but probably reflects the strong trend toward fasciectomy over fasciotomy in the last century. Available literature does not strongly document a clear superiority of fasciectomy over fasciotomy, and surgical practice may simply reflect convention rather than consideration, as is the case for many surgical procedures.
• About thirty years ago, the French rheumatologist, Dr. Jean-Luc Lermusiaux , first performed a percutaneous fasciotomy for Dupuytren's using a 25 gauge needle, with such dramatic success that he recalls that "...the patient was so happy, she jumped up and kissed me". He is currently part of a group of Paris rheumatologists who perform many thousands of needle aponeurotomy procedures each year. The use of a small needle instead of a scalpel was a small but critical modification of the percutaneous fasciotomy technique which reduces both inflammation and recovery time compared to traditional surgery.
• In 2003, the American hand surgeon Dr. Charles Eaton visited the Paris group and brought the procedure back to the United States. Already skilled in traditional Dupuytren's surgery, Dr. Eaton applied his knowledge and experience as a hand surgeon to refine and standardize this technique, referred to as the Eaton Method of Needle Aponeurotomy. In 2004, Dr. Eaton and Dr. Paul Zidel visited the Paris group to formally introduce Dr. Zidel to the originators of the technique and to compare thoughts and experiences with the procedure. Both physicians offer Needle Aponeurotomy at The Hand Center.
• What is the closest airport? Palm Beach International airport (PBI) is the closest, about 15 miles south of The Hand Center, but Fort Lauderdale (30 miles further south) flights may be less expensive.
• How do I find out more information about the Jupiter/Palm Beach/South Florida area? Check with the Jupiter Chamber of Commerce 561-746-7111 (http://www.jupiterfl.org), expedia.com, travelocity.com, hotels.com - hey, this the Internet - check it out!
• How do I find out more about Needle Aponeurotomy?
• An online television news report of the procedure at The Hand Center is archived at this Channel 6 web page
• The Web Page of the Paris Group is http://assoc.wanadoo.fr/f.badois-dupuytren/html/gbsommaire.html
• The Biospecifics Dupuytren's discussion forum is http://www.biospecifics.com/forum/
• Run a live Google Search for "Needle Aponeurotomy" with this link.

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