Needle aponeurotomy (NA)

Needle Aponevrotomy, also called needle aponeurotomy or percutaneous needle fasciotomy (PNF) and in the U.S. usually abbreviated as NA, is a minimal invasive technique that originally became popular in France more than 20 years ago (according to Eliot the first fasciotomy was already performed by Cline in London in the late 18th century, fasciotomy was also suggested by Astley Cooper in 1822 and Guillaume Dupuytren in 1832). The aim of NA is to make bent fingers functional again by straightening them and achieve minimal side effects. The technique uses needles to puncture the contracting (blocking) Dupuytren cord and thus weaken it until it can be broken by mechanical force, typically with a characteristic snap. NA (needle aponeurotomy) is a non-surgical, ambulant, outpatient procedure.

"Before / after" examples of needle aponeurotomy/NA treatment are e.g. shown on the site of the Handcenter in Jupiter, FL, handcenter_NA, Dr. Denkler's NA site, or on the NA web site authored by Dr. Kline. On the latter select Needle Aponevrotomy from the menu there and then e.g. "Left Hand" from the left menu. Another impressive example, including a video, is shown on Dave's Dupuytren's contracture. Below examples include results after 6-8 months and links to several videos showing NA live.

Positive results of NA

NA (needle aponeurotomy or needle fasciotomy) has gained high popularity in France and in the mean time also in the US, the United Kingdom and Germany. The reason is that it usually succeeds in getting bent fingers straight and functional again, takes very little time to apply, requires only local anesthesia, creates no or minimal scarring, provides a fast recovery, is less expensive than surgery, can be repeated, and is typically fairly painless.

 

Example of needle aponeurotomy (NA), also called percutaneous needle fasciotomy (PNF)

Below pictures were provided by A. Meinel, Dupuytren Ambulanz, Germany. The good results documented here should not hide the possibility of recurrence of Dupuytren's contracture after NA. The probability of recurrence after NA (PNF) is suspected to be higher than after thorough surgery but reliable statistics have not been published yet.

Finger with Dupuytren's contracture before needle aponeurotomy (NA)

Finger with Dupuytren's contracture before needle aponeurotomy (NA)

Finger immediately after NA with extension deficit nearly gone

Immediately after NA, extension deficit nearly gone

Palm showing folded skin due to Dupuytren's contracture and needle insertion points.

Palm of above hand immediately after NA, showing the still folded skin

due to Dupuytren's contracture and where needle was applied

Hand 6 months after NA, the contraction is gone, the hand is flat

Above hand 6 months after NA. The finger is now nearly straight, the originally

strong cord became flatter. The patient had worn a night splint for 3 months.

NA (PNF) - 5 year result, The finger is still straight, no recurrence.

After 5 years. The finger is still straight, no recurrence. Skin folds have flattened.

The patient had worn a night splint initially.

Watching treatment of Dupuytren's contracture with NA on video

If you want to watch a NA session you might have a look at below YouTube clips

    NA before and after  (from Ron,a patient who had NA. The video provides comments, and

    shows Ron's hand before and immediately after NA, and two years later)

    NA by Dr. Kline  (20 min film, complete procedure)

    NA by Dr. Belcher  (3.5 min film showing the essentials in a close up)

 

Application of needle aponeurotomy (NA) to advanced stages of Dupuytren's contracture

While NA (PNF) is typically applied in stage 1 of Dupuytren's contracture it can also be a valuable therapy for progressed stages of Dupuytren's contracture. Even stage 4 patients have been treated successfully. In the example below (provided by K. Denkler) the MCP joint (base joint) has been fully released, the more difficult PIP joint (middle joint) remained at 35 deg extension deficit, yet overall a significant improvement for the patient.

Treatment of Dupuytren's contracture in stage 4 with needle aponeurotomy (NA, PNF).

Treatment of Dupuytren's contracture in stage 4 with NA. Upper row: prior to NA. 70 degrees of extension deficit at the base joint and 65 degrees at the middle joint (total = 135 deg = stage 4). Bottom row: 8 months after NA.

See also Keith Denkler "Needle Aponeurotomy for Stage IV Dupuytren’s Contracture: A Wide Awake First Step Approach", presented at the 2009 annual meeting of the American Association of Plastic Surgeons (AAPS) abstract and full presentation (provided by author).

 

Extensive percutaneous aponeurotomy with lipografting

A modified PNF technique, extensive percutaneous aponeurotomy, has been proposed that uses a surgical environment, a regional block (anaesthesia like in surgery) and injection of body fat (lipografting). Using a needle or similar device the cord is punctured with many superficial stitches (nicks) all along its extension. To avoid nerve damage this technique is not penetrating the skin very deeply, less than the classical needle aponeurotomy (NA) and does not attempt to fully cut the cord with the needle. The aim is to loosen the connection between the skin and the Dupuytren nodule and cord. After breaking the damaged cord by pulling on the finger the palm is injected with body fat that has been harvested elsewhere, typically from the stomach area. Pros and cons of this technique are still being evaluated. An overview was given by Roger Khouri at the 2010 Dupuytren's conference in Miami video. Benefits of this technique might be that the injected fat helps healing, restores a better padded finger, releases the connection between nodule and skin and thus might avoid recurrence better than NA. Yet a comparative long-term study is still missing. Initial data have been published by Steven ER Hovius et al. "Extensive Percutaneous Aponeurotomy and Lipografting: A New Treatment for Dupuytren Disease"  Plast Reconstr Surg. 2011;128(1 ):221–8 abstract.


Personal experiences

For personal experience with NA see link_to_personal_story_NA  .


Page last modified: 04/16/2012


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