Needle Aponeurotomy Versus Collagenase Injections for Dupuytren Disease: A Review of the Literature and Survey of Patient-Reported Satisfaction, Recurrence, and Complications After Needle Aponeurotomy

Abstract

Needle aponeurotomy (NA) and collagenase injections (CI) for treatment of Dupuytren disease are practical and clinically efficient techniques. The purpose of this report is to review the comparative literature and present postprocedure survey data on NA. We reviewed the current literature on treatment of Dupuytren disease with NA and report on direct and indirect comparisons of the 2 treatment options. We also retrospectively identified patients treated with NA for Dupuytren disease, reviewed the demographic details of treatment in the medical records, and solicited patients’ feedback on satisfaction, recurrence, and complications using a phone survey. The results of the survey are discussed in the context of current literature. A total of 250 completed the survey an average of 34 months after treatment. Of those, 178 (71%) were very satisfied or satisfied, 187 (75%) reported some recurrence, and 5% reported a complication. Patients less than 2 years from the procedure were statistically significantly more likely to be satisfied with the procedure and more likely to have it again, and reported less recurrence of disease. Current literature does not clearly suggest a best treatment option for Dupuytren disease. Recent analyses suggest that there is a cost difference, with NA presenting as a more cost-effective option. Survey results demonstrated a low complication rate although the rate of recurrence was high, which was consistent with other studies. Needle aponeurotomy is safe and effective, and results in high patient satisfaction despite a high recurrence rate. Needle aponeurotomy (NA) and collagenase injections (CI) for treatment of Dupuytren disease are practical and clinically efficient techniques. The purpose of this report is to review the comparative literature and present postprocedure survey data on NA. We reviewed the current literature on treatment of Dupuytren disease with NA and report on direct and indirect comparisons of the 2 treatment options. We also retrospectively identified patients treated with NA for Dupuytren disease, reviewed the demographic details of treatment in the medical records, and solicited patients’ feedback on satisfaction, recurrence, and complications using a phone survey. The results of the survey are discussed in the context of current literature. A total of 250 completed the survey an average of 34 months after treatment. Of those, 178 (71%) were very satisfied or satisfied, 187 (75%) reported some recurrence, and 5% reported a complication. Patients less than 2 years from the procedure were statistically significantly more likely to be satisfied with the procedure and more likely to have it again, and reported less recurrence of disease. Current literature does not clearly suggest a best treatment option for Dupuytren disease. Recent analyses suggest that there is a cost difference, with NA presenting as a more cost-effective option. Survey results demonstrated a low complication rate although the rate of recurrence was high, which was consistent with other studies. Needle aponeurotomy is safe and effective, and results in high patient satisfaction despite a high recurrence rate. Numerous treatment options exist for managing Dupuytren disease, including partial or complete fasciectomy or dermofasciectomy, and minimally invasive office-based procedures such as collagenase Clostridium histolyticum injections (CI) and needle aponeurotomy (NA). Recently, several studies1Nydick J.A. Olliff B.W. Garcia M.J. Hess A.V. Stone J.D. A comparison of percutaneous needle fasciotomy and collagenase injection for dupuytren disease.J Hand Surg Am. 2013; 38: 2377-2380Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 2Stromberg J. Ibsen-Sorensen A. Friden J. Comparison of treatment outcome after collagenase and needle fasciotomy for Dupuytren contracture: a randomized, single-blinded, clinical trial with a 1-year follow-up.J Hand Surg Am. 2016; 41: 873-880Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 3Scherman P. Jenmalm P. Dahlin L.B. One-year results of needle fasciotomy and collagenase injection in treatment of Dupuytren’s contracture: a two-centre prospective randomized clinical trial.J Hand Surg Eur Vol. 2016; 41: 577-582Crossref PubMed Scopus (47) Google Scholar, 4Brazzelli M. Cruickshank M. Tassie E. et al.Collagenase clostridium histolyticum for the treatment of Dupuytren’s contracture: systematic review and economic evaluation.Health Technol Assess. 2015; 19: 1-202Crossref Scopus (48) Google Scholar, 5Skov S.T. Bisgaard T. Sondergaard P. Lange J. Injectable collagenase versus percutaneous needle fasciotomy for Dupuytren contracture in proximal interphalangeal joints: a randomized controlled trial.J Hand Surg Am. 2017; 42: 321-328.e323Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 6Chen N.C. Srinivasan R.C. Shauver M.J. Chung K.C. A systematic review of outcomes of fasciotomy, aponeurotomy, and collagenase treatments for Dupuytren’s contracture.Hand (N Y). 2011; 6: 250-255Crossref PubMed Scopus (88) Google Scholar, 7Molenkamp S. Schouten T.A.M. Broekstra D.C. Werker P.M.N. Moolenburgh J.D. Early postoperative results of percutaneous needle fasciotomy in 451 patients with Dupuytren disease.Plast Reconstr Surg. 2017; 139: 1415-1421Crossref PubMed Scopus (18) Google Scholar, 8Stromberg J. Ibsen Sorensen A. Friden J. Percutaneous needle fasciotomy versus collagenase treatment for Dupuytren contracture: a randomized controlled trial with a two-year follow-up.J Bone Joint Surg Am. 2018; 100: 1079-1086Crossref PubMed Scopus (43) Google Scholar sought to identify whether collagenase injections or NA provide improved outcomes. Results of these investigations suggested that there is no clinical benefit of collagenase injection compared with NA, despite potentially higher complication rates5Skov S.T. Bisgaard T. Sondergaard P. Lange J. Injectable collagenase versus percutaneous needle fasciotomy for Dupuytren contracture in proximal interphalangeal joints: a randomized controlled trial.J Hand Surg Am. 2017; 42: 321-328.e323Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar and notably higher cost.9Chen N.C. Shauver M.J. Chung K.C. Cost-effectiveness of open partial fasciectomy, needle aponeurotomy, and collagenase injection for dupuytren contracture.J Hand Surg Am. 2011; 36: 1826-1834.e1832Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar, 10Baltzer H. Binhammer P.A. Cost-effectiveness in the management of Dupuytren’s contracture: a Canadian cost-utility analysis of current and future management strategies.Bone Joint J. 2013; 95-B: 1094-1100Crossref PubMed Scopus (44) Google Scholar, 11Sharma P. Scotland G. Cruickshank M. et al.Is self-monitoring an effective option for people receiving long-term vitamin K antagonist therapy? A systematic review and economic evaluation.BMJ Open. 2015; 5e007758Crossref PubMed Scopus (25) Google Scholar, 12Raisanen M.P. Karjalainen T. Goransson H. et al.DupuytrEn Treatment EffeCtiveness Trial (DETECT): a protocol for prospective, randomised, controlled, outcome assessor-blinded, three-armed parallel 1:1:1, multicentre trial comparing the effectiveness and cost of collagenase clostridium histolyticum, percutaneous needle fasciotomy and limited fasciectomy as short-term and long-term treatment strategies in Dupuytren’s contracture.BMJ Open. 2018; 8e019054PubMed Google Scholar Several studies1Nydick J.A. Olliff B.W. Garcia M.J. Hess A.V. Stone J.D. A comparison of percutaneous needle fasciotomy and collagenase injection for dupuytren disease.J Hand Surg Am. 2013; 38: 2377-2380Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 13Bradley J. Warwick D. Patient satisfaction with collagenase.J Hand Surg Am. 2016; 41: 689-697Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 14Witthaut J. Jones G. Skrepnik N. Kushner H. Houston A. Lindau T.R. Efficacy and safety of collagenase clostridium histolyticum injection for Dupuytren contracture: short-term results from 2 open-label studies.J Hand Surg Am. 2013; 38: 2-11Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar, 15Warwick D. Arner M. Pajardi G. et al.Collagenase clostridium histolyticum in patients with Dupuytren’s contracture: results from POINT X, an open-label study of clinical and patient-reported outcomes.J Hand Surg Eur. 2015; 40: 124-132Crossref Scopus (42) Google Scholar, 16van Rijssen A.L. ter Linden H. Werker P.M. Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: percutaneous needle fasciotomy versus limited fasciectomy.Plast Reconstr Surg. 2012; 129: 469-477Crossref PubMed Scopus (201) Google Scholar evaluating patient satisfaction after limited fasciectomy, CI, and NA treatments identified recurrence of disease and complications such as pain and skin tearing as the main reasons for dissatisfaction with Dupuytren treatment. The purposes of this review were to summarize the recent literature comparing NA with CI and to present a survey study designed to evaluate whether patients treated with NA would have rates of satisfaction, recurrence, and complications similar to those reported in other published studies. After obtaining institutional review board approval, we identified subjects treated with NA over a 6-year period from November 1, 2011 through November 11, 2017. We collected basic demographic and disease-specific information. Eligible subjects were then contacted by telephone and informed consent was obtained verbally. Consented subjects completed a brief survey using a standardized script that focused on patient satisfaction, initial correction achieved, complications, recurrence, and subsequent and/or previous treatments. We recorded the following patient-determined complications: bruising, skin tearing, allergic reaction, and nerve or tendon irritation. We identified 331 eligible participants, 250 of whom completed the survey (Table 1). For patients with multiple procedures, we asked each to respond based on the most recent NA. A total of 235 procedures were unilateral (94%) and 15 were bilateral (6%), performed on separate occasions. Eighty-eight procedures were performed in the palm only (35%), 41 were digital only (16%), and 121 were both (48%). All procedures were performed as previously described by van Rijssen and Werker17van Rijssen A.L. Werker P.M. Percutaneous needle fasciotomy in dupuytren’s disease.J Hand Surg Br. 2006; 31: 498-501Crossref PubMed Scopus (130) Google Scholar in the clinical office setting.Table 1Demographic Survey DataParameterMeasurement%Gender Male19076 Female6024Age, y65Time since NA, mo33.5Location of NA Right12048 Left11546 Bilateral156 Palmar8835.2 Digital4116.4 Palmodigital12148.4Ethnicity Caucasian30190.9 African American30.9 Unknown278.2 Open table in a new tab Statistical analyses were conducted post hoc on the survey results. For a cohort analysis of time since the procedure, the 2-year cutoff for analysis was selected based on previous studies indicating maintenance of clinical improvement by the 2-year point.5Skov S.T. Bisgaard T. Sondergaard P. Lange J. Injectable collagenase versus percutaneous needle fasciotomy for Dupuytren contracture in proximal interphalangeal joints: a randomized controlled trial.J Hand Surg Am. 2017; 42: 321-328.e323Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar We used chi-square test for categorical data. t test was used for continuous data such as age. Significance was set at P < .05. A total of 250 patients completed the survey an average of 34 months (range, 6–75 months) after treatment with NA (Table 2). We were unable to obtain survey data for 81 subjects (we were unable to contact 79 patients, one patient was unable to complete the survey, and one had died). Of the 250 patients, 190 were male (76%), average age 64.5 years (range, 34–87 years). Ninety-seven patients (39%) reported a family history of Dupuytren disease (Fig. 1).Table 2Survey ResultsSurvey QuestionMeasurement%Satisfaction Very satisfied11746.8 Satisfied6124.4 Neither208 Dissatisfied2911.6 Very dissatisfied239.2Have again Definitely13453.6 Likely3815.2 Unsure2610.4 Likely not228.8 Definitely not3012Initial correction Complete6024 Nearly complete11646.4 Partial6325.2 Failed to correct114.4Complications Bruising20.8 Skin tearing10.4 Allergic reaction00 No complications23895.2 Nerve irritation93.6Recurrence Original deformity7931.6 Partial recurrence6224.8 Minimal recurrence4819.2 No recurrence6124.4 Open table in a new tab A total of 178 patients (71%) were satisfied or very satisfied; 52 patients (21%) reported dissatisfaction and 172 patients (69%) would definitely or likely have the procedure again (Table 2). Moreover, 176 patients (70%) reported complete or nearly complete initial correction, and 187 (75%) reported either no or minimal recurrence of the disease in the treated digits at the time of survey. Patients were divided into 2 groups based on time from procedure to survey completion: group 1 (n = 86) was assessed less than 2 years from NA, and group 2 (n = 164) at 2 to 65 years from NA (Table 3). Patients less than 2 years from surgery were significantly more satisfied with procedure (P < .01) and were more likely to have the procedure again (P < .01). They reported less recurrence of disease (P < .01).Table 3Time Since NA Cohort AnalysisData<2 Y (n = 86)>2 Y (n = 164)P ValueDemographics Age, y65.264.2.44 Gender (male)6323.46Survey results, n (%) Satisfied patients72 (84)106 (65)< .01 Would have NA again70 (81)102 (62)< .01 Initially corrected62 (71)114 (70).67 Reported complications4 (5)6 (4).70 Presence of recurrence34 (40)107 (65)< .01 Family history of disease29 (34)68 (42).23 Open table in a new tab Patients were grouped into 2 cohorts based on their reported satisfaction (Table 4). Group 1 (n = 178) was either very satisfied or satisfied, and group 2 (n = 72) was very dissatisfied, dissatisfied, or neither satisfied nor dissatisfied. There were no significant differences in age, gender, time since NA, or family history of disease, and satisfied patients were more likely to have the procedure again (P < .01), report initial correction of deformity (P < .01), not have recurrence (P < .01), and not report complications (P < .01).Table 4Patient Satisfaction Cohort AnalysisDataSatisfied (n = 178)Not Satisfied (n = 72)P ValueDemographics Age, y64.863.9.56 Gender (male)13654.81Survey results Time since NA, wk32.635.8.17 Would have NA again, n (%)157 (88)15 (21)< .01 Initially corrected, n (%)147 (83)29 (40)< .01 Reported complications, n (%)4 (1)9 (13)< .01 Presence of recurrence, n (%)77 (43)66 (92)< .01 Family history of disease, n (%)71 (40)26 (36).58 Open table in a new tab There is controversy regarding the best minimally invasive treatment for Dupuytren disease. Despite many well-designed studies aimed at determining the most effective, safest, and satisfactory treatment for Dupuytren disease, the literature does not clearly suggest that one treatment option is better than another. Many studies have identified both NA and CI as safe and effective treatment options for Dupuytren disease.14Witthaut J. Jones G. Skrepnik N. Kushner H. Houston A. Lindau T.R. Efficacy and safety of collagenase clostridium histolyticum injection for Dupuytren contracture: short-term results from 2 open-label studies.J Hand Surg Am. 2013; 38: 2-11Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar, 18Gaston R.G. Larsen S.E. Pess G.M. et al.The efficacy and safety of concurrent collagenase Clostridium histolyticum injections for 2 Dupuytren contractures in the same hand: a prospective, multicenter study.J Hand Surg Am. 2015; 40: 1963-1971Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 19Pess G.M. Pess R.M. Pess R.A. Results of needle aponeurotomy for Dupuytren contracture in over 1,000 fingers.J Hand Surg Am. 2012; 37: 651-656Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 20Pess GM, Sundbom M, Wilson K, Lindqvist D, Dahlin LB. A post hoc analysis of Dupuytren contracture treated with collagenase Clostridium histolyticum across disease stages [published online ahead of print July 24, 2018]. J Plast Surg Hand Surg.Google Scholar, 21Zhou C. Selles R.W. Slijper H.P. et al.Comparative effectiveness of percutaneous needle aponeurotomy and limited fasciectomy for Dupuytren’s contracture: a multicenter observational study.Plast Reconstr Surg. 2016; 138: 837-846Crossref PubMed Scopus (21) Google Scholar Both methods have been shown to be safe with limited major complications and lower complication rates compared with open procedures. However, there is controversy regarding which results are more important to patients and surgeons, specifically, whether a successful procedure is defined by obtaining complete correction at the time of intervention and/or a lack of recurrence at short-term or long-term follow-up. The 5-year data from the Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study indicates that CI is both effective and safe with a reduction in disease and low complication rates.22Peimer C.A. Blazar P. Coleman S. Kaplan F.T. Smith T. Lindau T. Dupuytren contracture recurrence following treatment with collagenase Clostridium histolyticum (CORDLESS [Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study]): 5-year data.J Hand Surg Am. 2015; 40: 1597-1605Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar Moreover, Pess et al20Pess GM, Sundbom M, Wilson K, Lindqvist D, Dahlin LB. A post hoc analysis of Dupuytren contracture treated with collagenase Clostridium histolyticum across disease stages [published online ahead of print July 24, 2018]. J Plast Surg Hand Surg.Google Scholar demonstrated that collagenase injections were effective in improving contracture at both the metacarpophalangeal and proximal interphalangeal joints at all stages of disease, and Gaston et al18Gaston R.G. Larsen S.E. Pess G.M. et al.The efficacy and safety of concurrent collagenase Clostridium histolyticum injections for 2 Dupuytren contractures in the same hand: a prospective, multicenter study.J Hand Surg Am. 2015; 40: 1963-1971Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar determined that collagenase injections were safe and effective treating contractures in multiple joints in the same hand. Similar studies looked at the effectiveness and safety of an NA. Zhou et al21Zhou C. Selles R.W. Slijper H.P. et al.Comparative effectiveness of percutaneous needle aponeurotomy and limited fasciectomy for Dupuytren’s contracture: a multicenter observational study.Plast Reconstr Surg. 2016; 138: 837-846Crossref PubMed Scopus (21) Google Scholar evaluated the effectiveness of NA compared with limited fasciectomy. They identified NA to be as effective as partial fasciectomy in reducing contractures in mild to moderately affected digits and to allow for quicker recovery times with lower rates of complication. Similarly, Molenkamp et al7Molenkamp S. Schouten T.A.M. Broekstra D.C. Werker P.M.N. Moolenburgh J.D. Early postoperative results of percutaneous needle fasciotomy in 451 patients with Dupuytren disease.Plast Reconstr Surg. 2017; 139: 1415-1421Crossref PubMed Scopus (18) Google Scholar and Stromberg et al2Stromberg J. Ibsen-Sorensen A. Friden J. Comparison of treatment outcome after collagenase and needle fasciotomy for Dupuytren contracture: a randomized, single-blinded, clinical trial with a 1-year follow-up.J Hand Surg Am. 2016; 41: 873-880Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 8Stromberg J. Ibsen Sorensen A. Friden J. Percutaneous needle fasciotomy versus collagenase treatment for Dupuytren contracture: a randomized controlled trial with a two-year follow-up.J Bone Joint Surg Am. 2018; 100: 1079-1086Crossref PubMed Scopus (43) Google Scholar demonstrated efficacy and safety with NA in the short term with effective postprocedure correction and low complications. Tam and Chung23Tam L. Chung Y.Y. Needle aponeurotomy for Dupuytren contracture: effectiveness of postoperative night extension splinting.Plastic Surg (Oakv). 2016; 24: 23-26Crossref PubMed Scopus (7) Google Scholar retrospectively reviewed patients who underwent NA with postoperative extension orthoses and compared them with patients who had undergone NA without extension orthoses. They noted that despite an overall increase in active range of motion, there appeared to be no difference in active range of motion when extension orthoses were applied after surgery. Based on these series of studies, no clear treatment option is better from a safety or efficacy standpoint, because both CI and NA appear to be safe and effective, and postprocedure orthoses may not change the overall effectiveness. The results of the current survey also demonstrate that NA is safe with a low complication rate and effective at initial correction of disease. Witthaut et al14Witthaut J. Jones G. Skrepnik N. Kushner H. Houston A. Lindau T.R. Efficacy and safety of collagenase clostridium histolyticum injection for Dupuytren contracture: short-term results from 2 open-label studies.J Hand Surg Am. 2013; 38: 2-11Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar evaluated patient satisfaction 9 months after collagenase treatment in a prospective cohort series of 587 patients and found 71% were very satisfied and 21% were quite satisfied with treatment. Similarly, Warwick et al15Warwick D. Arner M. Pajardi G. et al.Collagenase clostridium histolyticum in patients with Dupuytren’s contracture: results from POINT X, an open-label study of clinical and patient-reported outcomes.J Hand Surg Eur. 2015; 40: 124-132Crossref Scopus (42) Google Scholar demonstrated that 87% of 249 patients were satisfied or very satisfied with collagenase treatment at 6 months. At a mean of 2.1 months after collagenase treatment, Bradley and Warwick13Bradley J. Warwick D. Patient satisfaction with collagenase.J Hand Surg Am. 2016; 41: 689-697Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar reviewed 213 patients and reported that 73% patients were satisfied and 71% suggested that they would have the procedure again. In a study of 111 patients, van Rijssen et al16van Rijssen A.L. ter Linden H. Werker P.M. Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: percutaneous needle fasciotomy versus limited fasciectomy.Plast Reconstr Surg. 2012; 129: 469-477Crossref PubMed Scopus (201) Google Scholar rated patient satisfaction after NA compared with limited fasciectomy on a scale of 0 to10, in which 10 was the most satisfied. They demonstrated higher satisfaction for limited fasciectomy (8.1) compared with NA (6.2); these data were strongly correlated with the rate of recurrence. In a nonrandomized retrospective case series, Nydick et al24Nydick J.A. Watt J.F. Garcia M.J. Williams B.D. Hess A.V. Clinical outcomes of arthrodesis and arthroplasty for the treatment of posttraumatic wrist arthritis.J Hand Surg Am. 2013; 38: 899-903Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar compared patient satisfaction between 30 NA-treated and 29 collagenase-treated patients. Both groups demonstrated similar satisfaction rates: 75 ± 34 for collagenase and 81 ± 25 for NA at 6 months. The current survey also assessed patient satisfaction after NA, correlating it with recurrence rate, complication rate, and time since the procedure. A total of 71% of patients had high levels of satisfaction after NA and 68% reported that they would have the procedure again. Our results were similar to satisfaction rates reported for treatment with collagenase alone.13Bradley J. Warwick D. Patient satisfaction with collagenase.J Hand Surg Am. 2016; 41: 689-697Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 18Gaston R.G. Larsen S.E. Pess G.M. et al.The efficacy and safety of concurrent collagenase Clostridium histolyticum injections for 2 Dupuytren contractures in the same hand: a prospective, multicenter study.J Hand Surg Am. 2015; 40: 1963-1971Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 22Peimer C.A. Blazar P. Coleman S. Kaplan F.T. Smith T. Lindau T. Dupuytren contracture recurrence following treatment with collagenase Clostridium histolyticum (CORDLESS [Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study]): 5-year data.J Hand Surg Am. 2015; 40: 1597-1605Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar, 25Peimer C.A. Blazar P. Coleman S. et al.Dupuytren contracture recurrence following treatment with collagenase clostridium histolyticum (CORDLESS study): 3-year data.J Hand Surg Am. 2013; 38: 12-22Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar Together, the studies indicate that patients were satisfied with both CI and NA, and that neither procedure provides a distinct advantage from a patient-reported perspective. Reported complications from both CI and NA are minor and occur at a low rate. The most commonly reported complications with both procedures are skin tearing and bruising; most complications are transient. Major complications are reported, including tendon rupture26Zhang A.Y. Curtin C.M. Hentz V.R. Flexor tendon rupture after collagenase injection for Dupuytren contracture: case report.J Hand Surg Am. 2011; 36: 1323-1325Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar and nerve laceration, but these are rare. Molenkamp et al7Molenkamp S. Schouten T.A.M. Broekstra D.C. Werker P.M.N. Moolenburgh J.D. Early postoperative results of percutaneous needle fasciotomy in 451 patients with Dupuytren disease.Plast Reconstr Surg. 2017; 139: 1415-1421Crossref PubMed Scopus (18) Google Scholar reported a low complication rate (12%); the most common complication was skin tears, which occurred in 9% of subjects. Nydick et al1Nydick J.A. Olliff B.W. Garcia M.J. Hess A.V. Stone J.D. A comparison of percutaneous needle fasciotomy and collagenase injection for dupuytren disease.J Hand Surg Am. 2013; 38: 2377-2380Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar and Pess et al19Pess G.M. Pess R.M. Pess R.A. Results of needle aponeurotomy for Dupuytren contracture in over 1,000 fingers.J Hand Surg Am. 2012; 37: 651-656Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar also reported only minor complications after NA, and skin tearing was the most prevalent. Two prospective studies compared complication rates between NA and CI. Stromberg et al2Stromberg J. Ibsen-Sorensen A. Friden J. Comparison of treatment outcome after collagenase and needle fasciotomy for Dupuytren contracture: a randomized, single-blinded, clinical trial with a 1-year follow-up.J Hand Surg Am. 2016; 41: 873-880Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar reported high rates of skin tears in both groups: a 38% rate of skin tear in 71 patients with NA and a 49% skin tear rate in 69 patients with collagenase. These data were not statistically different. In comparison, Skov et al5Skov S.T. Bisgaard T. Sondergaard P. Lange J. Injectable collagenase versus percutaneous needle fasciotomy for Dupuytren contracture in proximal interphalangeal joints: a randomized controlled trial.J Hand Surg Am. 2017; 42: 321-328.e323Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar found significantly fewer complications in 21 patients treated with NA (24%) when the researchers compared them directly with 29 patients treated with collagenase (93%); there were significantly higher pain and edema values in the collagenase group. Our survey demonstrated an overall complication rate of 5% with NA. The most frequently reported complication was transient nerve irritation. Major complications such as tendon rupture, nerve laceration, vessel injury, and infection were not seen. These findings are consistent with other studies that identified low complications after NA. Overall, although there was some suggestion that the complication rate was lower with NA, both CI and NA had low complication rates compared with more invasive surgical procedures and there limited studies have directly compared the 2 procedures. The definition of recurrence and its relation to satisfaction and efficacy make the interpretation of many prior studies on Dupuytren disease difficult. Werker et al27Werker P.M. Pess G.M. van Rijssen A.L. Denkler K. Correction of contracture and recurrence rates of Dupuytren contracture following invasive treatment: the importance of clear definitions.J Hand Surg Am. 2012; 37: 2095-2105.e2097Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar identified that it is difficult for patients and surgeons to quantify recurrence, especially in retrospective-type studies. van Rijssen et al16van Rijssen A.L. ter Linden H. Werker P.M. Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: percutaneous needle fasciotomy versus limited fasciectomy.Plast Reconstr Surg. 2012; 129: 469-477Crossref PubMed Scopus (201) Google Scholar reported an 85% recurrence rate after NA, which was significantly higher than limited fasciectomy (24%) at 5 years, and Nydick et al1Nydick J.A. Olliff B.W. Garcia M.J. Hess A.V. Stone J.D. A comparison of percutaneous needle fasciotomy and collagenase injection for dupuytren disease.J Hand Surg Am. 2013; 38: 2377-2380Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar reported a recurrence rate of 33% at 6 months after the procedure, which was better than the recurrence rate for collagenase (44%) at 6 months. Skov et al5Skov S.T. Bisgaard T. Sondergaard P. Lange J. Injectable collagenase versus percutaneous needle fasciotomy for Dupuytren contracture in proximal interphalangeal joints: a randomized controlled trial.J Hand Surg Am. 2017; 42: 321-328.e323Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar directly compared 29 patients with collagenase with 21 patients with NA and found that maintenance of correction was less with collagenase (7%) compared with NA (29%) at 2 years after the procedure. Molenkamp et al7Molenkamp S. Schouten T.A.M. Broekstra D.C. Werker P.M.N. Moolenburgh J.D. Early postoperative results of percutaneous needle fasciotomy in 451 patients with Dupuytren disease.Plast Reconstr Surg. 2017; 139: 1415-1421Crossref PubMed Scopus (18) Google Scholar reported on a subset of 21 patients with recurrent disease after NA who did well after repeat NA, which indicated that NA is an effective option for recurrent disease. The current survey demonstrated an overall recurrence rate of 76%, which included subjects reporting only minimal recurrence (19%). Twenty-four percent of subjects reported no recurrence. Study limitations were the lack of physical examination and that a sizable percentage of the treated cohort was not included in the collected data. Our study concludes that NA is a safe and effective option for patients who are willing to accept the possibility of recurrence and who understand that a second procedure may be needed. Similarly, Mansha et al28Mansha M. Flynn D. Stothard J. Safety and effectiveness of percutaneous needle fasciotomy for Dupuytren’s disease in the palm.J Hand Microsurg. 2017; 9: 115-119Crossref PubMed Google Scholar recently published a retrospective questionnaire survey of 46 patients treated with percutaneous NA. At an average of 15 months after surgery, recurrence late was very low and was related to cases that were partially corrected initially. The patients had no observed complications at follow-up. This review suggests that early on, the recurrence rate is higher in incompletely corrected digits. Multiple cost analysis strategies have been applied to determine the cost-effectiveness of NA versus CI. Notably, most studies identified that minimally invasive office-based procedures such as NA and CI are more cost-effective than operating room–based procedures such as partial fasciectomy.9Chen N.C. Shauver M.J. Chung K.C. Cost-effectiveness of open partial fasciectomy, needle aponeurotomy, and collagenase injection for dupuytren contracture.J Hand Surg Am. 2011; 36: 1826-1834.e1832Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar, 10Baltzer H. Binhammer P.A. Cost-effectiveness in the management of Dupuytren’s contracture: a Canadian cost-utility analysis of current and future management strategies.Bone Joint J. 2013; 95-B: 1094-1100Crossref PubMed Scopus (44) Google Scholar, 11Sharma P. Scotland G. Cruickshank M. et al.Is self-monitoring an effective option for people receiving long-term vitamin K antagonist therapy? A systematic review and economic evaluation.BMJ Open. 2015; 5e007758Crossref PubMed Scopus (25) Google Scholar Chen et al9Chen N.C. Shauver M.J. Chung K.C. Cost-effectiveness of open partial fasciectomy, needle aponeurotomy, and collagenase injection for dupuytren contracture.J Hand Surg Am. 2011; 36: 1826-1834.e1832Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar performed a cost utility analysis comparing NA and CI. Using an expected value decision analysis model, they determined that NA was a cost-effective treatment option for Dupuytren disease. Similarly, Baltzer and Binhammer determined that NA was the preferred treatment option for Dupuytren disease of a single finger, and was more cost-effective if employed to treat recurrence. Herrera et al29Herrera F.A. Benhaim P. Suliman A. Roostaeian J. Azari K. Mitchell S. Cost comparison of open fasciectomy versus percutaneous needle aponeurotomy for treatment of Dupuytren contracture.Ann Plast Surg. 2013; 70: 454-456Crossref PubMed Scopus (15) Google Scholar analyzed the direct cost associated with NA compared with limited fasciectomy. They determined that NA was associated with decreased direct costs in the short term compared with partial fasciectomy. Brazeelli et al4Brazzelli M. Cruickshank M. Tassie E. et al.Collagenase clostridium histolyticum for the treatment of Dupuytren’s contracture: systematic review and economic evaluation.Health Technol Assess. 2015; 19: 1-202Crossref Scopus (48) Google Scholar performed a systematic review of the cost-effectiveness of CI. Although they did not directly compare this with NA, the results indicated that partial fasciectomy compared with collagenase was more cost-effective in treating moderate to severe contractures. The Dupuytren Treatment Effectiveness Trial study is a prospective, randomized, controlled, multicenter study aimed at comparing the cost-effectiveness of collagenase injections, percutaneous NA, and partial fasciectomy in the short and long term.12Raisanen M.P. Karjalainen T. Goransson H. et al.DupuytrEn Treatment EffeCtiveness Trial (DETECT): a protocol for prospective, randomised, controlled, outcome assessor-blinded, three-armed parallel 1:1:1, multicentre trial comparing the effectiveness and cost of collagenase clostridium histolyticum, percutaneous needle fasciotomy and limited fasciectomy as short-term and long-term treatment strategies in Dupuytren’s contracture.BMJ Open. 2018; 8e019054PubMed Google Scholar It is hoped that this study will answer the questions of cost-effectiveness among 3 different treatment options, because this appears to be the one differing factor with relation to office-based treatment options. A major critique of these cost analysis studies is that they do not factor in indirect costs such as loss of work and/or complications, physician time required for the procedure, or other indirect costs not easily identifiable.30Wiwanitkit V. Cost of open partial fasciectomy, needle aponeurotomy, and collagenase injection for dupuytren contracture.J Hand Surg Am. 2012; 37 (author reply 394–395): 394Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Also, facility fees may differ among institutions and are difficult to incorporate directly into cost analysis models. However, based on several studies, it appears that NA is a more cost-effective treatment option than CI for Dupuytren disease. Both NA and CI were demonstrated to be safe and effective and to result in high patient satisfaction with relatively low rates of complications compared with open surgical procedures. Some studies suggested that recurrence may occur sooner and more frequently with NA compared with CI and that this may be related to the degree of initial correction achieved. Current cost analyses, in contrast, suggest that NA is more cost-effective than CI. Ultimately, all procedural factors, including efficacy, safety, recurrence, and cost, should be considered and discussed with patients before beginning treatment.