Duputyren’s contracture, a genetically-influenced disease marked by overgrowth of fascia in the palm and fingers, can lead to markedly diminished hand function. Currently there is no cure; even with open surgery, contracture can recur. A nonsurgical approach toward Duputyren’s contracture, needle aponeurotomy, is gaining acceptance as a low-risk, low cost treatment strategy. Michael Darowish, M.D., Penn State Hershey Bone and Joint Institute, trained at the Cleveland Clinic with Avrum Froimson, M.D., a leading expert in aponeurotomy. Darowish explains, “Aponeurotomy is performed in the clinic. I use a fine, 25-gauge needle inserted under the skin. This is swept back and forth to divide the collagen cords that cause finger contracture. I begin distally, injecting a small amount of lidocaine into the skin over the cord, then inserting the needle and dividing the cord. This is repeated at a number of sites, proceeding proximally toward the palm. A small amount of kenalog is injected at the conclusion to soften any remaining nodules.”
Patients are able to straighten the affected finger(s) at the conclusion of the procedure, and can begin to use their hand immediately. After avoiding strenuous gripping or grasping for one week, they may resume full activity. Results with one of Darowish’s patients are illustrated in the figures above. A major benefit of aponeurotomy is its minimal recovery low-risk profile. Darowish notes “The primary risks are nerve and tendon damage, which can be avoided by proper patient selection and careful technique. Optimal candidates are those who present with an isolated, 30 degree to 40 degree metacarpophalangeal (MCP) contracture, show well-defined collagen cords in the palm area, and experience significant functional impairment. I avoid aponeurotomy in patients with only early disease, no functional impairment, or who show diffuse or deeply positioned fascial cords. I’m also very cautious about releasing proximal interphalangeal (PIP) joint contractures, as there’s a relatively greater risk of nerve injury.”
With experience, Darowish has identified certain keys to success. “To ensure efficient, clean cuts of the collagen cords, I use only sharp needles; I may discard a needle after only one or two insertions. I also attach an empty plastic syringe to the needle and use it as a handle, which gives better control over the needle and better proprioception. It is also important to use very limited amounts of lidocaine so that patients retain distal sensation and can let you know if they feel an ‘electric shock’ – this helps to avoid nerve injury.”
Michael Darowish, M.D.
Orthopaedic surgeon, hand and wrist, assistant professor, orthopaedics and rehabilitation
FELLOWSHIP: Orthopaedic hand surgery, Cleveland Clinic Foundation, Cleveland, Ohio
RESIDENCY: Orthopaedic surgery, University of Rochester Medical Center, Rochester, New York
MEDICAL SCHOOL: University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania