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:
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Aponeurotomy
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Fasciectomy
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Collagenase
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Setting
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Office - one day
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Outpatient Surgery
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Office - two days
|
|
Recovery (one hand)
|
2 - 7 days
|
2 - 3 months
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?
|
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Recovery (both hands)
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4 - 7 days
|
4 - 6 months
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?
|
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Fees
|
Physician
|
Physician, Facility, Anesthesia
|
Physician, Medication (not covered by Medicare)
|
|
Therapy
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Uncommon
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Usual, 3 X/week, 4-12 weeks
|
?
|
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Splinting
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For PIP or multiple releases, nightly for 3 months.
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For most releases, nightly for 3 months.
|
?
|
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Repeatability / touch up
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Any time, straightforward
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Wait at least 3 months, difficult.
|
?
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- 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?
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