Percutaneous Needle Fasciotomy Research Articles

Dupuytren Disease: Is Collagenase Better Than Needling?: Commentary on an article by Joakim Strömberg, MD, et al.: "Percutaneous Needle Fasciotomy Versus Collagenase Treatment for Dupuytren Contracture. A Randomized Controlled Trial with a Two-Year Follow-up".

Commentary Strömberg et al. have presented the results of a fascinating study designed to determine the outcomes of treating Dupuytren disease with either collagenase or percutaneous needle fasciotomy (PNF). This is an important topic, of special interest to hand surgeons but also to the broader orthopaedic community because these kinds of analyses of 2 different treatment modalities are a crucial element in determining treatment value. Increasingly, proof of that value has become linked to reimbursement for treatment by both government and private payers. The authors made several noteworthy conclusions. First, they found no significant differences in outcomes between the 2 groups. Second, by 2 years after treatment, one-half of the cords crossing the proximal interphalangeal joints had disappeared. Third, using what I believe are flawed calculations, the authors considered the “cost” of using collagenase to be nearly 3 times the “cost” of PNF. Collagenase has been compared with needle aponeurotomy (also termed percutaneous needle fasciotomy [PNF]) before, with prior reports showing 1-year1 and 2-year2 follow-up data. Strömberg et al. presented 2-year follow-up data in more detail. One of the important aspects of this study is that all treatment was rendered by a single surgeon (J.S.). That could be a strength because it ensures consistent treatment, but it is more likely a weakness because it means that one cannot necessarily generalize the findings to a larger population or other centers. Additional study will be needed to resolve this. The finding that the proximal interphalangeal joint contractures improved in both groups even though the treatment was delivered at the level of the metacarpophalangeal (MCP) joint warrants special consideration. It was hypothesized that this might be because once the tension in the Dupuytren cord is removed, the cord tissue resorbs. Skov et al.2 proposed a similar theory. It is intriguing to theorize this treatment effect, but there is no proof; perhaps further study will substantiate or refute that hypothesis. Strömberg et al. calculated that the cost of collagenase was nearly 3-fold higher than that of PNF at their institution. That analysis is flawed. There are a facility fee and costs of other supplies and personnel if PNF is performed in a surgery center. In contrast, collagenase is designed to be used in an office setting so those additional costs are eliminated. The adverse effects of injecting collagenase have been reported on extensively, including in the trials conducted to gain Food and Drug Administration (FDA) approval for use in the U.S. Most of those “adverse” effects are inherent to any procedure for Dupuytren disease. Pain, swelling, and bruising are expected after surgical procedures regardless of whether they are percutaneous or open, but investigators were required to report them as “complications” in the Collagenase Option for the Reduction of Dupuytren’s (CORD) I and II studies3,4, for example. It is unfortunate that Strömberg et al. did not report on adverse effects because it would have been useful to note any important differences between the 2 treatment modalities along these lines. The technique used by Strömberg et al. included injecting methylprednisolone at the same time that the PNF was done. The effect of the steroid is another variable that was not controlled and therefore another open question requiring further study. The best treatment for Dupuytren contractures continues to be fiercely debated. Recently, this was reported by McMillan et al.5 and generated discussion among hand surgeons in an open forum format online (www.assh.org). The addition of the data presented by Strömberg et al. is extremely valuable in helping to clarify the issue. What is known is that Dupuytren disease is progressive. What is unknown is the pace of the progression; that is unique to each patient and even to each extremity of each patient. “Best” treatments remain uncertain. Someday, we may have a better biological solution to the disease, whether through injections or gene therapy. For now, we can continue on our quest to discern the ideal treatment for individual patients, understanding the pros and cons of each modality.

Better patients' treatment experiences are associated with better postoperative results in Dupuytren's disease.

This prospective study investigates the extent to which a better experience with healthcare delivery is associated with better postoperative treatment outcomes after surgery for Dupuytren’s contracture. Patients undergoing limited fasciectomy or percutaneous needle fasciotomy for Dupuytren’s contractures completed the Michigan Hand Outcomes Questionnaire before and 3 months after surgery, together with a patient reported experience measure, while hand therapists assessed the straightness of the finger with a goniometer. Regression analyses were used to examine associations. We found that a better experience with healthcare delivery was associated with better patient-reported outcomes, while association with residual extension deficit was minimal. Strongest associations were seen with communication of the physician, postoperative care and information about the treatment. Experience with the treatment explained up to 12% of the variance in treatment outcome. These findings suggest that patient reported treatment outcomes in Dupuytren’s disease can be improved by improving the treatment context.Level of evidence: II

Preferred treatment options of German hand surgeons in Dupuytren disease

This study was performed to determine whether between 2015 and 2017 there has been a change in the preferred method of treatment of Dupuytren disease by German hand surgeons, especially with respect to percutaneous needle fasciotomy. In 2015 and 2017, 530 members of the German Society for Surgery of the Hand were invited to take part in an online survey, asking for their preferred treatment for Dupuytren disease, including decision criteria and in relation to Tubiana stages. 110 and 101 responders, respectively, took part. In both surveys, 86 surgeons stated that they treated up to 100 patients per year (Group A), while 24 and 15 surgeons, respectively, treated more than 100 Dupuytren patients annually (Group B). In both surveys, limited fasciectomy was found to be the preferred method (82.9 % and 87.7 %). Treatment with clostridial collagenase is performed only sporadically (1.3 % or 1.4 %). Percutaneous needle fasciotomy is of minor relevance in stage I (19.1 % or 10.9 %) and II (16.4 % or 9.9 %) and is performed mainly by surgeons who treat more than 100 patients per year.The most important criterion for the decision on what treatment should be chosen was "best outcome" (54.3 % and 68.6 %). Between 2015 and 2017, there was no great change in the choice of treatment for Dupuytren disease in Germany. In particular, there was no increase in PNF procedures.

Morphological patterns of the pretendinous cord in Dupuytren’s disease: a predictor of clinical outcome?

The morphology of the pretendinous cord in Dupuytren’s disease is poorly described in vivo and especially with respect to recurrence after treatment. This prospective study was designed to describe the morphology of Dupuytren’s cords by ultrasound and to identify possible correlation between the ultrasonographic characteristics of these cords and the clinical outcomes two years after treatment. Thirty-nine patients with a contracture of at least 20° in the metacarpophalangeal (MCP) joint, who were scheduled for local treatment by either injectable collagenase clostridium histolyticum (CCH) or percutaneous needle fasciotomy (PNF), were examined by ultrasound. The echogenicity and position of the pretendinous cords in relation to flexor tendons and neurovascular bundles were categorized. The structure of the cords was described and characterized as predominantly nodular or fibrillar. All 39 patients were assessed clinically after two years. A majority of the patients (84%) had cords with nodular components, and six patients (16%) had fibrillar cords. After two years, the clinical results were compared to the ultrasonographic findings before treatment. Three patients had recurrent contracture, and a retrospective analysis showed that all of these patients had cords with mixed echogenicity and nodules before treatment. Fifteen patients had a palpable pretendinous cord, and all but one of these had cords with mixed echogenicity and nodular structure before treatment. This pilot study indicates that some ultrasonographic features of the Dupuytren’s cord, such as mixed echogenicity and nodular structure, may predict recurrence after minimally invasive treatment for Dupuytren’s contracture. However, a larger study in correlation with histological examination of the excised cords would be necessary to confirm the pathoanatomical significance of these ultrasonographic features.

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

IntroductionDupuytren’s contracture (DC) is a chronic fibroproliferative disorder of the palmar fascia which leads to flexion contracture in one or more fingers. There is no definitive cure for DC, and...

What do we know about managing Dupuytren\u2019s disease cost-effectively?

BackgroundDupuytren’s disease (DD) is a common and progressive, fibroproliferative disorder of the palmar and digital fascia of the hand. Various treatments have been recommended for advanced disease or to retard progression of early disease and to prevent deterioration of the finger contracture and quality of life. Recent studies have tried to evaluate the clinical and cost-effectiveness of therapies for DD, but there is currently no systematic assessment and appraisal of the economic evaluations.MethodsA systematic literature review was conducted, following PRISMA guidelines, to identify studies reporting economic evaluations of interventions for managing DD. Databases searched included the Ovid MEDLINE/Embase (without time restriction), National Health Service (NHS) Economic Evaluation Database (all years) and the National Institute for Health Research (NIHR) Journals Library) Health Technology Assessment (HTA). Cost-effectiveness analyses of treating DD were identified and their quality was assessed using the CHEERS assessment tool for quality of reporting and Phillips checklist for model evaluation.ResultsA total of 103 studies were screened, of which 4 met the study inclusion criteria. Two studies were from the US, one from the UK and one from Canada. They all assessed the same interventions for advanced DD, namely collagenase Clostridium histolyticum injection, percutaneous needle fasciotomy and partial fasciectomy. All studies conducting a cost-utility analysis, two implemented a decision analytic model and two a Markov model approach. None of them were based on a single randomised controlled trial, but rather synthesised evidence from various sources. Studies varied in their time horizon, sources of utility estimates and perspective of analysis. The overall quality of study reporting was good based on the CHEERS checklist. The quality of the model reporting in terms of model structure, data synthesis and model consistency varied across the included studies.ConclusionCost-effectiveness analyses for patients with advanced DD are limited and have applied different approaches with respect to modelling. Future studies should improve the way they are conducted and report their findings according to established guidance for conducting economic modelling of health care technologies.Trial registrationThe protocol was registered (CRD42016032989; date 08/01/2016) with the PROSPERO international prospective register of systematic reviews.

Efficacy and adverse effects of collagenase use in the treatment of Dupuytren's disease: a meta-analysis.

The aim of this meta-analysis was to assess the safety and efficacy of collagenase clostridium histolyticum compared with fasciectomy and percutaneous needle fasciotomy (PNF) for Dupuytren's disease. We systematically searched PubMed, EMBASE, LILACS, Web of Science, Cochrane, Teseo and the ClinicalTrials.gov registry for clinical trials and cohort or case-control studies which compared the clinical outcomes and adverse effects of collagenase with those of fasciectomy or PNF. Of 1345 articles retrieved, ten were selected. They described the outcomes of 425 patients treated with collagenase and 418 treated by fasciectomy or PNF. Complications were assessed using inverse-variance weighted odds ratios (ORs). Clinical efficacy was assessed by differences between the means for movement of the joint before and after treatment. Dose adjustment was applied in all cases. Random-effects modelling showed that patients treated with collagenase had 3.24 increased odds of adverse effects compared with those treated by fasciectomy (OR 4.39) or PNF (OR 1.72,). The effect was lost when only major complications were assessed. Joint movement analysis revealed a difference between means of less than 10%, indicating equivalent clinical efficacy in the short and medium term for collagenase and fasciectomy. We were unable to analyse this for PNF due to a shortage of data. There were no significant differences in effect size between collagenase and fasciectomy. The use of collagenase was associated with a higher overall risk of adverse effects than both fasciectomy and PNF. Cite this article: Bone Joint J 2018;100-B:73-80.

Ultrasound-Guided Percutaneous Needle Fasciotomy after Steroid Injection for Dupuytren's Contracture

Ultrasound-Guided Percutaneous Needle Fasciotomy after Steroid Injection for Dupuytren's Contracture

Complications after treating Dupuytren's disease. A systematic literature review

The objective of this study was to review the incidence of complications associated with different treatment options for patients with Dupuytren's disease. In a systematic literature review, the PubMed, EMBASE, Cochrane and Scopus databases were searched for clinical studies reporting complications after collagenase treatment, percutaneous needle fasciotomy (PNF), fasciectomy and dermofasciectomy. The incidence of complications was extracted from each study and stratified by procedure. From a total of 2251 references, 113 studies were analyzed and included with complication incidences varying from 0% to 100%. The highest number of nerve and vessel lesions were reported after fasciectomy, whereas the highest rate of edema was after collagenase injection. Accidental skin tears were mostly associated with collagenase and PNF treatment. Pooled complication incidences were 17.4% (95% CI: 11.7–23.1) for fasciectomy, 78.0% (95% CI: 59.6–96.4) for collagenase treatment, 18.9% (95% CI: −5.5–43.3) for PNF and 11.6% (95% CI: 0.0–23.2) for dermofasciectomy. Due to inconsistencies in reporting complications as well as the lack of a standardized definition, the literature does not provide evidence in favor of a specific procedure for Dupuytren's disease. A standardized definition of complications is required to improve the comparability of published results.

Safety and Effectiveness of Percutaneous Needle Fasciotomy for Dupuytren's Disease in the Palm.

Purpose Percutaneous needle fasciotomy is performed in the authors' department to treat Dupuytren's contracture at metacarpophalangeal joints. This study aimed to establish its safety and efficacy, compared with standard fasciectomy. Materials and Methods All patients who had this procedure performed over the study period were sent the validated British Society for Surgery of the Hand (BSSH) postal questionnaire assessing surgical outcome. Hand function and disability were assessed using the Patient Evaluation Measure (PEM). Results Statistically significant improvement was achieved in Dupuytren's contracture at the mean follow-up of 15 months (SD +/- 10). Approximately 97% of the fingers fully corrected at surgery remain straight. Recurrence rate was 2.2% among fully corrected fingers. However, 2 (40%) out of 5 partially corrected fingers had recurrence. No complication of any kind was noted and no antibiotics used. Hand function was measured using PEM score correlated well with the residual contracture. Conclusion Percutaneous needle fasciotomy is safe, effective, has very low complication rates, and yields comparable results to standard fasciectomy.

Early Postoperative Results of Percutaneous Needle Fasciotomy in 451 Patients with Dupuytren Disease.

Percutaneous needle fasciotomy is a minimally invasive treatment modality for Dupuytren disease. In this study, the authors analyzed the efficacy and complication rate of percutaneous needle fasciotomy using a statistical method that takes the multilevel structure of data, regarding multiple measurements from the same patient, into account. The data of 470 treated rays from 451 patients with Dupuytren disease that underwent percutaneous needle fasciotomy were analyzed retrospectively. The authors described the early postoperative results of percutaneous needle fasciotomy and applied linear mixed models to compare mean correction of passive extension deficit between joints and efficacy of primary versus secondary percutaneous needle fasciotomy. Mean preoperative passive extension deficits at the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints were 37, 40, and 31 degrees, respectively. Mean preoperative total passive extension deficit was 54 degrees. Results were excellent, with a mean total passive extension deficit correction of 85 percent. Percutaneous needle fasciotomy was most effective for metacarpophalangeal joints and less effective for proximal interphalangeal and distal interphalangeal joints. Secondary percutaneous needle fasciotomy was as effective as primary percutaneous needle fasciotomy. Complications were rare and mostly minor. The results of this study confirm that percutaneous needle fasciotomy is an effective and safe treatment modality for patients with mild to moderate disease who prefer a minimally invasive procedure. Therapeutic, IV.

Injectable Collagenase Versus Percutaneous Needle Fasciotomy for Dupuytren Contracture in Proximal Interphalangeal Joints: A Randomized Controlled Trial

Collagenase Clostridium histolyticum (CCH) injection was introduced commercially as a treatment for Dupuytren contracture following initial phase-3 investigations in 2009 with promising results. However, the efficacy of CCH has not been prospectively investigated in a direct comparison to other active treatments of Dupuytren contracture with more than 1-year follow-up, despite a wide and increasing clinical use. In this prospective, independent, open-label, randomized controlled trial, (Clinicaltrials.gov; NCT 01538017), percutaneous needle fasciotomy (PNF) was directly compared with CCH.Fifty patients with primary isolated proximal interphalangeal joint Dupuytren contractures were enrolled and followed for 2 years. The primary outcome was clinical improvement defined as a reduction in contracture by 50% or more relative to baseline. Secondary outcomes included change in contracture, recurrence, adverse events, complications, and Disabilities of the Arm, Shoulder, and Hand questionnaire score. Clinical improvement at 2 years was maintained in 7% of CCH patients (2 of 29) and 29% of PNF patients (6 of 21). Collagenase Clostridium histolyticum led to more, mainly transient, complications, in 93% of patients versus 24% of the patients treated with PNF. No other differences were observed. This study provides evidence that CCH is not superior to PNF in the treatment of isolated proximal interphalangeal joint Dupuytren contracture regarding clinical outcome, and it led to more complications than PNF. Therapeutic I.

The Extended Percutaneous Needle Fasciotomy Technique (PNF+) For Dupuytren's Contracture

The extended percutaneous needle fasciotomy (PNF+) is a minimal invasive technique especially suitable for treating severe Dupuytren's contractures and recurrences. The familiar needle fasciotomy is complemented by a spontaneous tearing of the skin and a full-thickness graft to cover the defect. Skin tears in fingers and palm are not a complication, but an integral part of the PNF+. The neurovascular bundles remain intact. This surgical procedure may be repeated as often as required.

Minimally Invasive Treatment of Dupuytren

Objective / Hypothesis: At our clinic of plastic, reconstructive and aesthetic surgery we are looking for the results after two minimally invasive treatments for Dupuytren disease. With the upcoming possible treatment with collagenase the l”old fashioned” therapy with percutaneous needle fasciotomy (PNF) becomes a big revival. The purpose of the non-randomized prospective study was to Iook for differences after 12, 18 and 24 months regarding the two possible treatments. Methods: ln our clinic we propose and perform both treatments, the decision is taken together with the patient. Since more than 2 years we follow-up the patients regarding the results after 3 weeks, 3, 6, 12, 18, 24 months; regarding function, scars, and recurrence (worsening of contracture in comparison to 3 weeks postop at least for 20°). Patients treated with Xiapex: 12 months postop. - 25 patients; 18 months postop. - 16 patients; 24 months postop. -13 patients. PNF: 12 months postop. - 30 patients; 18 months postop. - 19 patients; 24 months postop. - 18 patients. Post I { operative” treatment is night-splinting for 6 weeks at least. Results: We report our results of both groups. We cannot find a real difference between both groups. But the follow-up is only 24 months for the moment. We report also the pros and cons of the two different treatment options. Conclusions: Both minimal invasive treatment options are very similar in results and complications with a slight advantage for the percutaneous needle fasciotomy. But a longer follow up and a bigger study is required.

Surgeon Volume Influences Treatment Outcome in the Dupuytren Disease Surgery

Objective: High surgeon procedural volume has been linked to better outcomes for a variety of surgical procedures, but the impact of surgeon volume on outcomes of Dupuytren surgery remains uncertain. Materials and Methods: We used data from a quality-of-care registry from 6 hand surgery practice sites between 2011 and 2014. We included 561 patients with the Dupuytren disease who underwent fasciectomy (71%) or percutaneous needle fasciotomy (29%) by 16 hand surgeons. Outcomes were the degree of residual contracture and adverse events assessed at 6 to 12 weeks after treatment. Relations between volume and outcomes were examined using linear and logistic regression models, with adjustment for patient characteristics and the type of procedure. Nonlinearity was assessed with restricted cubic splines. Results: Overall, mean residual contracture (total active extension deficit) at follow-up was 24°, which corresponded to a postprocedure improvement of 65%. Forty-seven percent of patients experienced at least 1 adverse event, with neuropraxia (12%), scar sequelae (12%), and wound healing problems (8%) being the three most common events. Surgeon volume was inversely related to the degree of residual contracture: Every 58 additional procedures performed annually were associated with 5° less residual contracture at follow-up ( P, .03). Moreover, surgeon volume had an inverse effect on overall events (odds ratio per 50 additional procedures, 0.86, P, .01). Conclusions: Even among experienced hand surgeons, patients treated by surgeons performing high volumes of Dupuytren surgery had better outcomes in terms of residual contracture and adverse events. The findings of this study suggest that surgeons may improve outcomes by increasing their annual procedural volume for these specific interventions.

Trends in the Treatment of Dupuytren Disease in the United States Between 2007 and 2014.

Background: Dupuytren disease is a common fibroproliferative disorder. Multiple procedural treatment options are available, with Collagenase Clostridium Histolyticum (CCH) injection being introduced in 2010. The purpose of this study was to investigate trends in the treatment of Dupuytren disease in the United States between 2007 and 2014. Methods: The PearlDiver Humana database was queried using International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) codes for patients with Dupuytren disease that received percutaneous needle aponeurotomy (PNA), fasciotomy, fasciectomy, and CCH injection. Patients were filtered by age, number of comorbidities, and gender. Change in composition of treatments over time was analyzed for each demographic group between 2007 and 2014. Results: Patients presenting to clinic for Dupuytren disease increased from 1118 to 3280, with unchanging treatment percentage of 41. Percent fasciotomies and fasciectomies decreased from 5% to 3% and 33% to 21%, while CCH injection increased to 11% by 2012 to 2014. Percent fasciotomies decreased (P < .05) in younger healthier (age <65, 0-1 comorbidities) and older less healthy (age 65-74, 4+ comorbidities) populations. Percent fasciectomies decreased significantly in nearly all age and comorbidity groups, but by greater amounts in patients with 2+ comorbidities with increasing age. Percent CCH injections increased in all groups, at rates similar to the losses seen in open procedures. Conclusions: CCH injections have risen to substantial levels, with corresponding decreases in the percentage of patients receiving fasciotomies and fasciectomies. Patient age, comorbidities, and gender appear to have influence on the treatment chosen, likely due to their effects on surgical risk and the importance of timely return to activity.

Collagenase clostridium histolyticum for the treatment of Dupuytren's contracture: systematic review and economic evaluation.

Dupuytren's disease is a slowly progressive condition of the hand, characterised by the formation of nodules in the palm that gradually develop into fibrotic cords. Contracture of the cords produces deformities of the fingers. Surgery is recommended for moderate and severe contractures, but complications and/or recurrences are frequent. Collagenase clostridium histolyticum (CCH) has been developed as a minimally invasive alternative to surgery for some patients. To assess the clinical effectiveness and cost-effectiveness of collagenase as an alternative to surgery for adults with Dupuytren's contracture with a palpable cord. We searched all major electronic databases from 1990 to February 2014. Randomised controlled trials (RCTs), non-randomised comparative studies and observational studies involving collagenase and/or surgical interventions were considered. Two reviewers independently extracted data and assessed risk of bias of included studies. A de novo Markov model was developed to assess cost-effectiveness of collagenase, percutaneous needle fasciotomy (PNF) and limited fasciectomy (LF). Results were reported as incremental cost per quality-adjusted life-year (QALY) gained. Deterministic and probabilistic sensitivity analyses were undertaken to investigate model and parameter uncertainty. Five RCTs comparing collagenase with placebo (493 participants), three RCTs comparing surgical techniques (334 participants), two non-randomised studies comparing collagenase and surgery (105 participants), five non-randomised comparative studies assessing various surgical procedures (3571 participants) and 15 collagenase case series (3154 participants) were included. Meta-analyses of RCTs assessing CCH versus placebo were performed. Joints randomised to collagenase were more likely to achieve clinical success. Collagenase-treated participants experienced significant reduction in contracture and an increased range of motion compared with placebo-treated participants. Participants treated with collagenase also experienced significantly more adverse events, most of which were mild or moderate. Four serious adverse events were observed in the collagenase group: two tendon ruptures, one pulley rupture and one complex regional pain syndrome. Two tendon ruptures were also reported in two collagenase case series. Non-randomised studies comparing collagenase with surgery produced variable results and were at high risk of bias. Serious adverse events across surgery studies were low. Recurrence rates ranged from 0% (at 90 days) to 100% (at 8 years) for collagenase and from 0% (at 2.7 years for fasciectomy) to 85% (at 5 years for PNF) for surgery. The results of the de novo economic analysis show that PNF was the cheapest treatment option, whereas LF generated the greatest QALY gains. Collagenase was more costly and generated fewer QALYs compared with LF. LF was £1199 more costly and generated an additional 0.11 QALYs in comparison with PNF. The incremental cost-effectiveness ratio was £10,871 per QALY gained. Two subgroup analyses were conducted for a population of patients with moderate and severe disease and up to two joints affected. In both subgroup analyses, collagenase remained dominated. The main limitation of the review was the lack of head-to-head RCTs comparing collagenase with surgery and the limited evidence base for estimating the effects of specific surgical procedures (fasciectomy and PNF). Substantial differences across studies further limited the comparability of available evidence. The economic model was derived from a naive indirect comparison and was hindered by a lack of suitable data. In addition, there was considerable uncertainty about the appropriateness of many assumptions and parameters used in the model. Collagenase was significantly better than placebo. There was no evidence that collagenase was clinically better or worse than surgical treatments. LF was the most cost-effective choice to treat moderate to severe contractures, whereas collagenase was not. However, the results of the cost-utility analysis are based on a naive indirect comparison of clinical effectiveness, and a RCT is required to confirm or refute these findings. This study is registered as PROSPERO CRD42013006248. The National Institute for Health Research Health Technology Assessment programme.

Clinical Results of Percutaneous Needle Fasciotomy for Dupuytren's Disease in Japanese Patients.

Background:Clinical results of percutaneous needle fasciotomy (PNF) in Japanese patients with Dupuytren’s disease are reported.Methods:In this prospective study, 51 patients (103 fingers: 1 index, 9 middle, 47 ring, and 46 small) underwent PNF at 99 metacarpophalangeal (MCP) and 68 proximal interphalangeal (PIP) joints. Patients were assessed postoperatively after 1 day, at 1, 2, 4, 6, and 8 weeks, and at 3, 6, 9, and 12 months. Correction of contracture was measured in degrees, and an improvement index (% improvement) was described previously by Tonkin et al. A correction of the contracture to 5° or less at each joint and at each digital ray represented a successful correction. The recurrence rates in MCP and PIP joints were also evaluated. Correlations between the Tubiana classification stage and successful correction, % improvement, and recurrence rate were evaluated. The relationships between recurrence rate and the diathesis score (more/less than 5 points) and between recurrence rate and age at surgery (<50/≥50 years) were also examined.Results:In MCP and PIP joints, the improvement maintained at final follow-up was 89% and 57%, respectively, with successful corrections in 89% and 76%, respectively. PNF corrected digital rays at various Tubiana stages: stage 1 = 100%, stage 2 = 82%, stage 3 = 46%, and stage 4 = 0%. Improvements were preserved in stage 1 = 83%; stage 2 = 62%; stage 3 = 58%, and stage 4 = 60%. Recurrence of Dupuytren’s disease was significant for the PIP joint, severe Tubiana stage, and younger patients.Conclusions:Clinical results of PNF in Japanese patients with Dupuytren’s contractures were similar to those of whites.

Ultrasound-Assisted Percutaneous Needle Fasciotomy for Dupuytren's Contracture.

Although percutaneous needle fasciotomy for Dupuytren's contracture is a simple, inexpensive procedure, it is a blind procedure with risks including injury to nerves, arteries, and tendons. The authors describe a novel technique using ultrasound as an adjunct to percutaneous fasciotomy for Dupuytren's contracture. Generally, patients have no postoperative restrictions other than to avoid submerging their hands for 48 hours. To date, the authors have noted, in 66 cases, no permanent complete nerve dysfunction following needle aponeurotomy using ultrasound assistance. Recurrence of the disease is the most common complication, occurring at a higher rate than with open procedures. Ultrasound mapping of the digital neurovascular structures can be successfully used as an adjunct to help prevent these neurovascular complications.

BD Nokor™ admix needle for percutaneous needle fasciotomy: a novel use of a universal pharmacy needle.

The authors declare they have no conflicts of interest. Percutaneous needle fasciotomy is one of the less invasive surgical options for treating Dupuytren's contracture.1 We describe the use of a ubiquitous pharmacy needle, the BD Nokor™ admix needle (Beckton, Dickinson and Company, Franklin Lakes, NJ, US), as an alternative for performing percutaneous fasciotomy. The needle has a blade at its tip that can be used as a small scalpel for division of fibrous bands (Fig 1). The technique is similar to performing a fasciotomy with a scalpel blade or a conventional needle. In our experience, the BD Nokor™ admix needle can be used effectively for percutaneous fasciotomy in palmar lesions. We would not advocate its use in the digits. Figure 1 Illustration of target tissue (abnormal cords in palmar fascia) in needle fasciotomy and the scalpel tip of the BD Nokor™ admix needle