What is fine needle aponeurotomy (FNA) for Dupuytren's contracture?

Fine Needle Aponeurotomy for Dupuytren's Contracture

Fine needle aponeurotomy (also called percutaneous needle fasciotomy or needle aponeurotomy) is a minimally invasive office-based procedure that uses a small-gauge needle to percutaneously cut the pathologic Dupuytren's cord and restore finger extension, offering significant functional improvement with minimal complications and rapid recovery.

What the Procedure Involves

Needle aponeurotomy uses the beveled edge of a 25-gauge, 16mm needle to mechanically divide the contracted palmar fascia (Dupuytren's cord) through multiple percutaneous punctures under local anesthesia. 1 The procedure is performed in an outpatient or office setting without requiring an operating room. 1, 2

Standard Technique (Lermusiaux's Method)

• Local anesthesia consists of a mixture of lidocaine and prednisolone acetate injected directly into the cord. 1
• The needle bevel is used to cut through the pathologic tissue by making multiple perforations along the cord until the contracture releases. 1
• The procedure aims to restore full extension at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. 1

Clinical Efficacy

Needle aponeurotomy demonstrates excellent short-term structural efficacy with approximately 80% good results immediately post-procedure and 69% at 5-year follow-up. 1 More recent large series show even better outcomes:

• In 204 consecutive rays with severe stage IV disease (≥135° total passive extension deficit), needle aponeurotomy achieved 74% improvement at MCP joints, 32% at PIP joints, and 55% overall total passive digit extension gain. 3
• Immediate good results occur in 84% of patients, with superior outcomes in earlier disease stages. 4
• Complete intraoperative extension is achieved in 92.4% of treated rays. 5

Disease Stage Matters

Early-stage Dupuytren's disease responds significantly better to needle aponeurotomy than advanced disease. 1, 4 Palmar involvement shows better results than digital involvement with modified techniques, though Lermusiaux's standard technique performs consistently across locations. 1

Recurrence Rates

Recurrence rates for needle aponeurotomy range from 10-20% per year, which is approximately double the 5-10% annual recurrence rate of open fasciectomy. 2 However, specific studies report:

• 18.9% recurrence rate at mean 31-month follow-up 5
• 12% recurrence rate in a 10-year experience series 4

The higher recurrence rate is offset by the ability to easily repeat the procedure, minimal complications, and rapid recovery. 2

Complications and Safety Profile

Needle aponeurotomy has a dramatically lower complication rate compared to open fasciectomy, making it exceptionally safe. 2 Reported complications include:

• Skin fissures/tears: 3-8% (most common complication) 1, 2
• Transient dysesthesia: 1.8-3% 5, 1
• Local infection: 0.7% 1
• Flexor tendon rupture: 0.2% 1
• No major neurovascular injuries or complex regional pain syndrome reported in large series 5, 3

Lermusiaux's standard technique appears to provide fewer recurrences and adverse events compared to modified techniques. 1

Recovery and Return to Function

Patients return to work in an average of 5.5 days following needle aponeurotomy. 5 This represents a dramatic advantage over open fasciectomy, which typically requires weeks of recovery. Patient satisfaction is high, with 86% stating they would undergo the treatment again if necessary. 5

Clinical Positioning

Needle aponeurotomy should be offered as first-line treatment for Dupuytren's contracture, particularly in early-stage disease. 2 The procedure is especially valuable for:

• Patients with early-stage disease (better outcomes) 1, 4
• Elderly or medically complex patients who cannot tolerate surgery 2
• Patients requiring rapid return to work or activities 5
• Even severe stage IV disease as initial treatment or bridge to more invasive procedures 3

Important Caveats

PIP joint contractures remain more challenging to correct than MCP joint contractures, with lower correction rates (32% vs 74% improvement). 3 However, even in severe disease, meaningful functional improvement occurs. 3

The procedure can be repeated if recurrence occurs, as the minimally invasive nature allows multiple treatments over time without the cumulative morbidity of repeated open surgeries. 2

Needle aponeurotomy is cost-effective compared to open fasciectomy when considering direct costs, recovery time, and complication management. 2