|Year : 2020 | Volume
| Issue : 3 | Page : 159-165
Percutaneous needle aponeurotomy and fat injection for the treatment of dupuytren's contracture
Ali Riza Oreroglu1, Tolga Aksan2, Muhammed Besir Ozturk2, Ilker Uscetin3, Suzan Deniz Onol4, Mithat Akan5, Necmettin Kutlu6
1 Dr. Öreroğlu Aesthetic Clinic, Plastic, Reconstructive and Aesthetic Surgery Clinic, Istanbul, Turkey
2 Department of Plastic, Reconstructive and Aesthetic Surgery, T.C. Istanbul Medeniyet University, Istanbul, Turkey
3 Department of Plastic, Reconstructive and Aesthetic Surgery, Okmeydanı Training and Research Hospital, Istanbul, Turkey
4 Department of Radiology, Okmeydanı Training and Research Hospital, Istanbul, Turkey
5 Plastic, Reconstructive and Aesthetic Surgery Clinic, Istanbul, Turkey
6 Department of Plastic, Reconstructive and Aesthetic Surgery, Medicana International Hospital, Istanbul, Turkey
|Date of Submission||27-May-2019|
|Date of Acceptance||04-Aug-2019|
|Date of Web Publication||26-May-2020|
Dr. Ali Riza Oreroglu
Maçka Cd. No. 24/28, Narmanli Apt. Tesvikiye, Nisantasi, 34367 Sisli, Istanbul
Source of Support: None, Conflict of Interest: None
Background: Among the various procedures that have been used to treat Dupuytren's contracture, percutaneous needle aponeurotomy (PNA) is a popular technique with the disadvantage of a high recurrence rate. The purpose of this study is to combine PNA with autologous fat grafting to correct the contracture, return the palmar surface to its normal appearance and feel, and reduce recurrence. Patients and Methods: Thirty-three patients were operated of whom thirty were successfully followed up for 1 year. Forty-two rays were operated on all patients undergoing magnetic resonance (MR) imaging before and after the surgery. All patients had the contracture released by the way of PNA followed by fat grafting. Results: Hand examination revealed a smooth, painless, and soft skin, with an overall improvement rate of 90.1% 1 year postsurgery, presenting a recurrence rate of 18.6% that is significantly lower when compared to other studies performing PNA alone. MR evaluation showed regression in the pathologic cords and stability in the volume of the fat grafts. A minor complication rate of 23.9% and a major complication rate of 6.5% specific for PNA were observed. Conclusion: PNA is a minimally invasive technique that can be used for the treatment of contractures in almost all stages of Dupuytren's disease. Autologous fat grafting can be useful in offering the subcutaneous tissue a soft appearance and feel and preventing recurrence by filling in the potential space by fat instead of fibrosis, preventing expansion of the local mesenchymal progenitor cells responsible for the disease.
Keywords: Dupuytren's contracture, fasciotomy, fat graft, lipofilling, percutaneous needle aponeurotomy
|How to cite this article:|
Oreroglu AR, Aksan T, Ozturk MB, Uscetin I, Onol SD, Akan M, Kutlu N. Percutaneous needle aponeurotomy and fat injection for the treatment of dupuytren's contracture. Turk J Plast Surg 2020;28:159-65
|How to cite this URL:|
Oreroglu AR, Aksan T, Ozturk MB, Uscetin I, Onol SD, Akan M, Kutlu N. Percutaneous needle aponeurotomy and fat injection for the treatment of dupuytren's contracture. Turk J Plast Surg [serial online] 2020 [cited 2020 Sep 26];28:159-65. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/3/159/284958
| Introduction|| |
Dupuytren's disease is characterized by fibroblastic proliferation and fibrosis of the palmar fascia with formation of nodules and cords, resulting in flexion contractures of the fingers at the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and the distal interphalangeal (DIP) joints. Astley Cooper performed the first palmar fasciotomy, and Goyrand performed the first limited fasciectomy, with the technique popularized as the standard operative treatment of the disease for around 150 years. Less-invasive alternatives such as injection of Vitamin E, radiotherapy, physiotherapy, and splinting have been attempted; however, these have proved ineffective or unsuitable for clinical use.
Cooper fasciotomy performed via fine needles under local anesthesia was reintroduced in the 1970s and was named percutaneous needle fasciotomy or percutaneous needle aponeurotomy (PNA). The first results of this technique were published in 1980 by Lermusiaux and Debeyre. Badois et al. in 1993, Foucher et al., in 2001, and van Rijssen and Werker in 2006 presented their long-term results with needle fasciotomy, each with different modifications and results.
Fasciectomies seem more of a definite solution in terms of contracture release and less recurrences but are more invasive, with drawbacks such as high complication rates and relatively long periods of recovery. On the other hand, PNA is less invasive with a reported lower rate of complications,,, and a shorter recovery period, but a higher tendency to recur. Other disadvantages include inability to correct skin shortage after contracture release and inability to correct capsular contractures of the PIP joint. Today, PNA can be performed in the office setting, permitting return to normal manual activities 1 week after the procedure, and is recommended for Dupuytren's disease prior to more invasive surgical intervention.
The purpose of this study is to combine PNA with the relatively new era of autologous fat injection. In addition to contracture release with minimal surgery, we aimed to prevent recurrences that we have observed after PNA. Meanwhile, the fat graft can return the normal appearance and feel of palmar surface by filling the subcutaneous pocket with autologous fat. This hypothesis of lipofilling suggests prevention of fibrosis, and therefore, a reduction in the recurrence rate that follows cord release by the needle.
| Patients and Methods|| |
The study prospectively included patients with Dupuytren's contracture operated between June 2008 and August 2010, and was approved by our local institutional review board. Inclusion criteria were flexion contractures in the MCP, PIP, or DIP joints resulting in a positive “tabletop” test, a defined pathologic cord in the palmar fascia causing the contracture with or without pathologic nodules, and willingness for PNA and liposuction. Thirty-three patients with primary disease were included in the study, with exclusion criteria defined as secondary cases operated at other centers, patients unable to stop taking anticoagulants or with general conditions not suitable for surgery, and finally those who were not willing to undergo this procedure and preferred alternative treatment options.
On initial presentation, the involved rays and the amount of passive extension deficit (PED) for the MCP, PIP, and DIP joints were measured. Total PED (TPED) was calculated and quantified in degrees according to the Tubiana staging system. The patients were observed for the presence of knuckle pads, fatty tissue between the cord and the skin distal to the distal palmar crease (which is an indication of possible relocation of the digital bundle by a spiral cord), and the presence of plantar or penile involvement.
All hands were visualized with magnetic resonance (MR) imaging in the axial plane, measuring the thickness of the fibrotic cords and the fat graft in the subcutaneous pocket preoperatively and postsurgery at specified intervals. The participants underwent imaging on a 1.5-T Philips Achieva system Philips 2004 Netherlands and a transmit/receive knee coil. Axial images were obtained using a field of view of 130 cm, reduced FOV of 65 cm, 4-mm slice thickness, NSA (number of signal averages/acquisitions) of 6, 0.5-mm gap, and a 256 × 352 matrix. T1-weighted (TR/TE 485/20 ms) MR images were obtained and interpreted jointly by our coauthor radiologist. The configuration and extent of each cord, involvement of nerves and blood vessels, and the presence and position of nodules were noted. The cross-sectional dimensions of each cord were measured, and the signal characteristics of the lesions were recorded. The thickness of the subcutaneous fat graft was also measured at the same point for every measurement per ray.
The operation is performed with an arm tourniquet under regional or general anesthesia, according to the anesthesiologist's and patient's preferences. The abdominal area is prepared and draped in addition to the hand before performing the PNA. A solution of 25-ml 2% lidocaine and 1 ml 1:1000 adrenaline/1000 ml of lactated Ringer's solution is prepared, and 250–500 ml of the solution is injected diffusely in the subcutaneous abdominal fat. The fat is then harvested using a 4-mm cannula connected to a 60-ml syringe providing vacuum suction. The lipoaspirate is separated from the tumescent solution by gravity while the PNA is being performed.
No local anesthesia or steroid injections are applied prior to PNA. The pathologic cords are marked on the palm and fingers upon forced extension of the finger involved. Puncture-release sites are chosen on the palm and the proximal phalanx avoiding the flexure crease over the PIP joint. The patient's finger is kept in a slightly forced extension position applying tension to the cord, while superficial cuts are made along the cord through the skin at multiple levels, starting proximally in the palm and progressing distally, using a 21G hypodermic needle. The tip of the needle is placed under the skin perpendicular to the cord and moved up and down across the cord, at different angles to cut the cord. Care is taken to avoid injuring neurovascular bundles, especially where fatty tissue is present between the cord and the skin in the distal part of the palm. The needle crossing the cord is associated with a sensation of resistance. PNA is considered complete with the loss of this sensation or with reduced flexion contracture. The entire thickness of the cord is not transected, with only superficial cuts made on several points along each cord. Under forced extension, this results in disintegration of the cord with a shearing effect tearing the fibrotic band from its weakest points where cut by the needle. Having all the fingers in full extension immediately after release, adhesions of the cord and dermal skin via vertical fibers are also released by either inserting the needle laterally in a horizontal basis or bending the needle tip by 75° and using this technique from the same point used for cord release.
Once all the cords are released and an obvious subcutaneous pocket is created, the fat graft prepared in 1-ml syringes is injected into the subcutaneous pocket with cannula along each cord with an average of 8–10 ml of loose lipoaspirate per cord. The whole procedure takes an average of 45–60 min. A small dressing is applied, and the hand is splinted in the anatomic position for 5 days. The patients are encouraged to start active flexion and extension of the hand thereafter with a 2-week physical therapy started 1 week postoperatively.
The mean, standard deviation, and frequency data were used as statistical information. Distribution of the variables was tested via the Kolmogorov–Smirnov test. Disease stages and nonparametric repetitive values were analyzed using the Wilcoxon sign test. Parametric repetitive values were analyzed using the paired samples test. Statistical evaluation was performed using statistical software SPSS version 19.0 (SPSS Inc., Chicago, IL, USA). Statistical significance was set at P < 0.05.
| Results|| |
Thirty-three patients were operated; none had a family history of Dupuytren's disease. One patient deceased early in the follow-up period, and two patients discarded from the study due to complications. Thirty patients (25 men and 5 women) were then successfully followed up for 1 year, consisting a total of 42 rays (2 index, 2 middle, 26 ring, and 12 rays of the small fingers with multiple ray involvement of 2 rays in 6 hands and 3 rays in 1 hand) [Table 1], classified into Tubiana stages as 23 Stage-I, 12 Stage-II, 6 Stage-III, and 1 ray as Stage-IV disease [Table 2]. The MCP joint was affected in 42 rays, PIP joint in 20 rays, and DIP joint in 1 ray. Contractures of the MCP joint showed an average of 35.36°; the PIP + DIP joint combination showed an average of 36.25°. The mean preoperative TPED was 52.62° per ray [Table 3]. All patients were seen postsurgery on a regular 1-week, 1-month, 6-month, and 1-year basis while contracture measurements were taken by the same surgeon, the flexion capability of each finger was assessed, and MR visualization was performed according to the same standards. Complications were noted, and photographs were obtained in all these visits [Figure 1]. The subcutaneous cord and fat graft consistency were evaluated with MR 1 month and 1 year postsurgery to compare the replacement of the subcutaneous fibrotic tissue with fat and the stability of this fat graft with time, determined as the fat graft thickness measured in the axial MR 1 month and 1 year postsurgery [Figure 2]. The mean follow-up period at the time of statistical evaluation was 20.74 months, with 14 patients in the postoperative 2nd year and 16 patients in the postoperative 1st year.
|Table 2: Tubiana staging system, regression in stages of the disease throughout the 1-year follow-up period, and the recurrence number in 1 year per stage|
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|Table 3: Comparison of the passive extension deficit per joint and the total passive extension deficit values throughout the 1-year follow-up perioda|
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|Figure 1: 65♂ D4 Stage III contracture; left: preoperative view; middle: postoperative 1-month result showing regression to stage 0; right: postoperative 1-year result considered as a recurrence with an increase in total passive extension deficit of 10° and considered Stage I|
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|Figure 2: Axial slice magnetic resonance imaging of the hand shown in Figure 1; top: the 4 mm × 3 mm fibrotic cord (arrow); bottom: 1-year postoperative magnetic resonance image, showing regression of the fibrotic cord to 2 mm × 2 mm and stability of the subcutaneous fat graft measuring 10 mm|
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The mean TPED measured immediately postsurgery was 4.05°, showing a reduction of 92.4% for all joints (mean reduction of MCP: 96.4% and PIP + DIP: 84.2%), all statistically significant (P < 0.001) [Table 3] and [Figure 3]. Compared to the same measurements in the 1st, 6th, and 12th months, the postoperative 1-year results showed a mean TPED of 5.24°, with a mean reduction of 90.1% for all joints (mean reduction of MCP: 93% and PIP + DIP: 85.6%), all statistically significant (P < 0.001) in the 6-month and the 1-year periods [Table 3] and [Figure 3]. Comparison of the Tubiana stages revealed stage regression in 42 operations with statistical significance (P < 0.001) in the immediate postoperative period. This regression was stable in the 6-month measurements, showing stage regression in forty operations in the 1-year control [Table 2] and [Figure 4].
|Figure 3: Distribution of the contractures per joint in the preoperative and different postoperative periods. Wilcoxon-signed test: *P < 0.001 when compared to the preoperative group/†P > 0.05 when compared to the postoperative group|
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|Figure 4: Distribution of the contractures per Tubiana stage in the preoperative and different postoperative periods. Wilcoxon-signed test: *P < 0.001 when compared to the preoperative group/†P > 0.05 when compared to the postoperative group|
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The fibrotic cord thickness showed regression in 18 cords (P < 0.001), increase of area in 5 cords, and no change in 19 cords, 1 year postsurgery [Table 4]. The mean fat graft thickness measured 9.76 mm 1 month postsurgery and 7.43 mm in the 1-year measurements. Evaluation revealed reduction of the graft volume in 35 rays and no change in 7 rays, without any total absorption of the grafts [Table 4].
Recurrence was defined as any increase in the contracture degree measured in the follow-up period. Accordingly, recurrence was seen in eight rays of seven patients (four in the PIP + DIP and four in the MCP joints), resulting in a total recurrence rate of 18.6% in the postsurgery 1-year period [Table 2]. Complications were classified into minor (skin tears early postsurgery at the site of needle penetration and paresthesias evaluated by light touch sensitivity), or major complications (hematoma, infection, nerve injury, or tendon transection). Skin tears were observed in the immediate postoperative period in four patients (six rays), which were managed by routine dressing and antibiotic ointments. Four patients (five rays) complained of transient paresthesia. One patient (two rays) developed reflex sympathetic dystrophy postsurgery, managed by physical rehabilitation. We did not note any case of hematoma requiring drainage or nerve injury. One patient (one ray) had tendon injury that was repaired, and the patient was discarded from the study. These results showed an overall minor complication rate of 23.9% and a major complication rate of 6.5% in our practice of PNA [Table 5].
Patient satisfaction was evaluated by a questionnaire inquiring whether the patient would recommend this technique to his/her relatives and friends and whether the patient would choose the technique again and prefer fat injection. All responding patients chose PNA as the preferred treatment option and none were disappointed with the liposuction procedure. In fact, it was surprising that even patients with a recurrence asked for PNA treatment again.
| Discussion|| |
Dupuytren's contracture has a history of treatment modalities from radical fascia excisions to less-invasive fasciotomies and other nonsurgical treatments., Surgical options include total fasciectomy, segmental and selective aponeurectomies, “open-palm,” dermofasciectomy with skin grafting, and open or closed palmar fasciotomy (PNA).,,,,,,,,,,,,,, Other nonsurgical modalities proposed include radiotherapy, magnetic field, enzymatic fasciotomy, ultrasonic therapy, 5-fluorouracil, hyperbaric oxygen treatment, steroid injection, and traumatic release. Evolved in the 1970s, PNA is being re-popularized today with studies comparing it with fasciectomies and investigating the effectivity and recurrence rates associated with this technique.,,,,,,,,,
PNA is not a technique for all cords, requiring careful patient selection mandatory. The best indication is for Stage-I disease with isolated and moderate flexion at the MCP level. PNA facilitates avoidance of further postponement of surgical management, which carries the risk of negligence and re-examination of the patient at a very advanced stage of the disease. Presence of a spiral cord is not a contraindication for PNA, as it could be anticipated by examination and fasciotomy performed at a distance from the crossing pedicle. A long-standing PIP contracture is also not an absolute contraindication for PNA; however, it carries a higher risk for neurovascular injury and skin tears.
Multiple authors have reported considerable reduction in flexion contracture via PNA. Excellent results have been shown by the studies of Badois et al., Bleton, Foucher et al.,, and van Rijssen and Werker., MCP joints have been shown the greatest improvement (79%–100%), whereas PIP joints improve to a lesser extent (46%–76%).,,,,,,, The recurrence rates were, however, as high as 65%, [3,,,,, making PNA a technique with excellent results in the short term but frequent recurrences at a relatively early stage. Foucher et al., reported an immediate improvement of 72% in 1998 and 76% in 2001, with a recurrence rate of 41% after 5 years. In 2001, they reviewed 65 hands with a mean follow-up of 2.5 years, reporting a “disease activity” rate of 54%. In 2003, they presented another prospective series of 211 patients treated with PNA, showing a mean extension gain of 76% with only one nerve injury and no other complications. Their recurrence rate was, however, as high as 58% after 3 years, whereas the recurrence rate of limited fasciectomy had been reported to be 41% after 5 years.
van Rijssen and Werker reported a 65% recurrence rate 32 months after PNA in their study in 2006. Another study by van Rijssen et al. comparing PNA with limited fasciectomy showed TPED improvement of 63% through PNA, compared with 79% in fasciectomy. There was a 38% minor complication rate for PNA compared to 17% for fasciectomy. The fasciectomy group, however, experienced a 5% major complication rate, whereas no major complications were observed in PNA. They concluded that PNA is only an alternative to fasciectomy in cases with a TPED of 90° or less in the short term. Their study also showed a higher rate of recurrence in the fasciotomy group, hence the major disadvantage of this technique.
Cheng et al. reported their results with PNA as correction of the MCP contracture by 50° with a 100% improvement and correction of PIP by 35° with a 76% improvement. Their 22-month follow-up revealed a 12° mean residual flexion contracture of the MCP with a 70% long-term improvement and 27° contracture of the PIP with a 41% long-term improvement. Rahr et al. showed a significant change in TPED in 92 patients with any Tubiana stage after 2 years, with a better correction of the MCP and more modest results in the PIP and DIP joints. Their overall change in TPED was 42%, with 42% of their cases having recurrent contracture requiring treatment after 33 months. Hovius et al. published their similar technique of extensive PNA and lipografting just before our attempt to send our paper for publication, making inclusion of this study in our discussion mandatory. They reported their two-center experience with 99 hands, of which goniometric evaluation has been performed on fifty patients, with an average follow-up period of 44 weeks. MCP contracture has been improved from 37° to −5°, whereas PIP has been corrected from 61° to 27°, with digital nerve injury in one patient, wound infection in one patient, and regional pain syndrome in four patients. They, however, do not evaluate the fat graft objectively via any imaging technique nor do they provide any data regarding their recurrence rate.
Our series reveals a complication rate in concordance with other studies, which have shown the most common complications to be skin fissures and transient nerve paresthesias, with less common nerve injury and flexor tendon ruptures.,,,,,, Under local anesthesia, nerve and tendon monitoring can be accomplished, reducing the risk of damage. Unfortunately, due to patient willingness, most patients in our study were operated under general anesthesia, reducing our chance of nerve and tendon monitoring.
van Rijssen and Werker defined recurrence as an increase of 30° or more in TPED with values less than that not classified as recurrence. This is an important limitation when comparing recurrence rates. Most studies do not include a definition of recurrence at all. Almost half of the patients have been followed for 2 years; however, we have included the 1-year results of all cases for statistical equality. Our report shows a postsurgery overall improvement rate of 90.1% that is comparative to other PNA studies.,,,,,, In addition, we present a total recurrence rate of 18.6%, with our definition of recurrence being any increase of the corrected TPED in the postoperative follow-up period. Even with this definition of recurrence, our rate is lower when compared to most studies performing PNA alone.,,,,, The pathologic cords are just released and cut at various points in PNA in contrast to fasciectomy where the cords are excised. This is one reason why PNA enhances a higher recurrence rate because the diseased tissues are not removed. Our study showed reduction in the thickness of the released cords in almost half of the cases. This may simply be the result of cord disintegration by PNA or may be a more complex cord regression caused by lipofilling. A more extensive research is, however, required for proof.
Dermofasciectomy that involves excision of the skin and fascia along with subdermal fat and replacement with a full-thickness skin graft has shown reduced recurrence rates, below 12% even in the most severe cases. Palmar fat has been implicated in the pathogenesis of Dupuytren's disease although the exact roles of adipocytes and fat stromal cells remain unclear., In a study by Hindocha et al., hematopoietic and mesenchymal stem cells in different tissue components of the diseased hand were screened for the expression of selected stem cell markers. They concluded that each structural component of the Dupuytren hand (cord, nodule, perinodular fat, and skin) had distinct stem cell populations, supporting the hypothesis that Dupuytren's disease may result from mesenchymal progenitor cell expansion. The concept of fat grafting combined with PNA aims at filling in the empty space left over after the fasciotomy, which may be the potential for fibrosis and therefore the high recurrence rates seen in the aforementioned studies. In addition, filling the potential empty space with abdominal fat may prevent the expansion of the local mesenchymal progenitor cells responsible for the disease.
| Conclusion|| |
Although the fat graft showed a reduction of volume in time, enough fat was present in all the cases, giving the palmar surface a natural look and feel. Taking into mind the safe, minimally invasive aspect and the higher patient satisfaction numbers seen in this technique, the addition of fat graft may be a preventive cause of recurrence, hence an aid in re-popularizing the technique disinhibiting the high recurrence rate disadvantage of the needle fasciotomy technique alone. The fat graft in addition to performing a cushion effect over the newly released fibrotic cords may have a curing effect on the disease area, decreasing the fibrosis. This biomolecular behavior of the fat graft also leaves an area of further study.
Publication of a similar technique just prior to our manuscript preparation required revision of our discussion, in order to evaluate their results in addition to the reminding report of our first 12 cases treated with PNA and fat grafting with a follow-up of 1 year presented at the 6th BAPRAS congress at Ohrid, Macedonia, in June 2009.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]