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Physicians Update

 
Spring 2009

Minimally Invasive Procedure Can Free Frozen Fingers

Needle aponeurotomy offers quicker procedure with fewer complications, less pain and faster recovery.

Frozen Fingers ProcedureA minimally invasive alternative to conventional open surgery can help people who suffer from Dupuytren’s contracture, a debilitating condition that results in one or more fingers becoming permanently bent.

Dupuytren’s contracture is usually an inherited progressive condition that primarily affects people of Northern European ancestry in which cords of the palmar fascia thicken and shorten, pulling fingers into a curled position that cannot be straightened. The bending usually occurs in the knuckle or middle joints of the ring finger and pinkie, but other fingers and joints may also be involved.

“While the condition is rarely painful, bent fingers complicate a patient’s life,” says Prosper Benhaim, M.D., associate professor in the UCLA Department of Orthopaedic Surgery and Division of Plastic & Reconstructive Surgery. “Everyday activities such as shaking hands, putting on gloves and using a computer keyboard are very difficult. It is easy to poke yourself in the eye while just combing your hair.”

Conventional open surgery to correct the condition involves a large zig-zag incision in the palm and fingers to remove the scar bands. Recovery can take several months, with physical therapy, and some patients experience complications such as nerve damage, infection, stiffness or a chronic-pain syndrome called reflex sympathetic dystrophy.

The alternative procedure is called needle aponeurotomy; it is has been performed in Europe since the 1970s, but only recently has been introduced to the United States. Dr. Benhaim is among the few surgeons in the U.S. to do the procedure. Rather than cutting into the hand, the surgeon repeatedly inserts a standard needle, under local anesthesia, into the palm and, using a back-and-forth motion, punctures and scores the toughened tissue. Then, the weakened cords are mechanically ruptured by hyperextending the affected fingers, often with a characteristic snap, allowing the fingers to again lie flat.

Compared to conventional surgery for Dupuytren’s contracture, needle aponeurotomy is fast (as little as 10 minutes to complete in some cases), has a shorter recovery period (seven to 10 days, with no rehabilitation necessary and little or no need for pain medication), has fewer complications (up to 10 times less compared with traditional open surgery, according to some estimates, with minimal chance of a painful flare reaction and limited scarring), and it is much less expensive.

Frozen HandNot all patients with Dupuytren’s contracture are good candidates for needle aponeurotomy. The best candidates are those in which the contracture is isolated to the knuckle joint, close to the palm, Dr. Benhaim says. Patients with scarring from previous surgery or with contracture in the middle joint of the finger are sometimes poor candidates.
And needle aponeurotomy is not without risk, Dr. Benhaim cautions. It is a “blind” procedure, meaning that the surgeon works under closed skin and is not able to visualize the tissue; he must rely on his experience, knowledge of anatomy and expertise to ensure that he does not damage tendons or nerves. “Much of the procedure is based on feedback, both touch and auditory,” Dr. Benhaim says. “When we are in the toughened tissue it sounds like gristle; when I hear that sound I know we’re OK.”

Fortunately, the risk of a significant complication is less than one percent overall, Dr. Benhaim says. In addition, as with conventional open surgery, the condition may recur and the procedure may need to be repeated. Unlike conventional surgery, however, repeat aponeurotomy can be performed much more easily several times over the course of a patient’s lifetime, Dr. Benhaim says.

To hear Dr. Benhaim discuss needle aponeurotomy and to see him perform the procedure, go to: http://streaming.uclahealth.org/frozenfingers





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