NEEDLE APONEUROTOMY (NA) : FREQUENTLY ASKED QUESTIONS

Transcription

1 NEEDLE APONEUROTOMY (NA) : FREQUENTLY ASKED QUESTIONS Hw d I knw that I have Dupuytren's and nt sme ther prblem? Dupuytren's is diagnsed by the appearance f the skin f the hand. Befre travelling far fr treatment, it is a gd idea t have the diagnsis cnfirmed by a lcal a health care prfessinal. Dupuytren's is a very specific type f prblem. It is nt arthritis, tendinitis, trigger finger, carpal tunnel syndrme, r ther cnditins resulting in stiff r bent fingers, s if there is any questin abut the diagnsis, have it checked ut in persn by a health care prfessinal. Yu can find infrmatin abut cmmn hand cnditins such as Dupuytren s cntracture at the American Sciety fr Surgery f the Hand. What is Needle Apneurtmy? It is a prcedure perfrmed in a dctr's ffice using lcal anesthesia t help straighten fingers bent by Dupuytren's cntracture. In Dupuytren's disease, a layer f tissue just under the skin f the palm becmes hard and shrinks. Dupuytren's may result in a lengthwise tightness beneath the skin f the palm which keeps the fingers frm straightening, called a "crd". With needle apneurtmy, a physician lengthens a tight crd by cutting it beneath the skin with a small needle, usually at several pints alng the line f tightness. Technically speaking, needle apneurtmy is a type f prcedure referred t as a percutaneus fascitmy. "Percutaneus" means ging thrugh the skin with the smallest hle pssible, and "fascitmy" means cutting fascia, which is the layer under the skin affected by Dupuytren's disease. Needles may be used percutaneusly t cut the tight fascia, inject ndules with crtisne, r bth: Charles Eatn (2007) What causes Dupuytren's? It is inherited, but desn't shw up in every generatin. With Dupuytren's, a tissue layer just under the skin f the palm shrinks and keeps n shrinking, which bends the fingers. They say it's hereditary but n ne in my family has Dupuytren's. Why d I have it? It can skip many generatins. Abut half f peple with Dupuytren's knw f a clse relative with it, but half dn't knw anyne in their family with it. Des an injury cause Dupuytren's? Smetimes an injury f the hand r wrist, like a cut r a brken bne can activate Dupuytren's earlier than it therwise wuld have, but the main reasn that peple get Dupuytren's is due t genetics. My dctr says it isn't painful, s why d I have pain? Sme peple have tenderness, burning r itching in the lumpy areas when the Dupuytren's is actively prgressing. Mst dn't. There are als ther painful hand prblems which are mre cmmn than Dupuytren's, like arthritis and tendinitis.

2 Will my fingers be straight/perfect after the NA? This depends n the severity f yur Dupuytren s cntracture. Dr Gates makes an estimatin when he lks at yur hands r pictures f yur hands, but it's impssible t predict with cmplete accuracy. The gal f the NA prcedure is t get yur fingers nticeably straighter withut the risks and the rdeal f traditinal pen surgery. Why d yu say yu can't get the PIP jint straight? Why is there nly abut a 50% imprvement? Can they get it straighter if I have the regular surgery? The PIP jint is ne f the unslved prblems in hand surgery. The way the jint is shaped n the inside makes it prne t getting stuck with a bend in it when anything happens t it. Yu can wind up with a permanent bend in this jint frm a sprain, frm finger tendinitis, r frm having surgery n the jint itself. When the jint is bent clse t ninety degrees, surgery may give a better imprvement than NA, but it is pretty unpredictable. Will the Dupuytren's cme back after I have this prcedure? Recurrence is ne f the big prblems with Dupuytren's. I can nly give yu a statistical answer. By three years after NA abut half f peple will have a return f a bend enugh t think abut having anther release. After pen surgery, half will recur by five years, s n the average pen surgery lasts lnger, but the recvery time and the risk f cmplicatins are abut ten times wrse with pen surgery. Why des it cme back? Dupuytren's is a prblem with the verall bdy chemistry which then affects the hands. Surgery wrks n the changes that result frm Dupuytren's but desn't take away the underlying reasn. Hw much time d I have befre it cmes back? It depends n yur bdy chemistry. Dupuytren's cmes back mre quickly in patients wh have related cnditins like Ledderhse disease r knuckle pads and in peple wh have clse family members with Dupuytren's. Beynd that, I can nly give yu a statistical answer. On the average, abut half f peple will have a return f a bend enugh t think abut having anther release three years after NA. Hw many NA prcedures can I have? There's nt an abslute maximum. Dr. Gates uses these guidelines: If the last release was successful fr the patient, if it lasted at least a year, if the skin is still sft r has sme give left and if there is a well defined crd which can be felt with the fingertip, it's prbably wrth anther try. If nt, it might be time t start thinking abut traditinal pen surgery. Hw lng is the recvery time? One day f icing and elevating the hand, ne full week befre glf, tennis, weight training r strenuus use f the hand. Hw lng d I have t stay in twn? Why dn't yu have fllw-up pst NA ffice visits? Yu dn't have t stay in twn. The Paris grup demnstrated that traditinal aftercare checkups are nt necessary, and that has been Dr. Gates experience. Hw lng d I have t be disabled r ff wrk? Usually tw days fr sedentary r keybard wrk, ne week fr mre strenuus wrk. Will yu sign a disability frm fr me t be ff wrk? Yes, but fr mst cases this will be fr a week after the prcedure. If yu are cnsidering lng term disability frm the Dupuytren's itself, a lcal physician shuld take care f yur frms. After I have the NA prcedure, will I be able t drive? Mst patients are able t drive immediately after NA. If yu are cncerned that yu wn't be able t manage driving, yu shuld make alternate arrangements fr the tw days fllwing the prcedure. Can I fly after having the NA prcedure? Yu can fly the same day as NA as a passenger in a plane, but shuld wait fr a week if yu are the pilt. After the prcedure, can I use my hands? Yu will need t try t keep yur hand pinting up as much as yu can the day f the prcedure. Yu shuld be able t eat, get dressed and g t the bathrm withut assistance the day f the prcedure. It's best t avid mre strenuus activities fr ne week after NA. After the prcedure, can I lift things? Fr ne week, yu have t avid gripping things against the skin where the needles were used. This means that yu shuld nly grip r lift lighter bjects with yur fingertips fr the first week after NA. Hw sn can I play glf / tennis / swim? Yu can get yur hand wet in the shwer and wash yur hands the day after, but yu shuldn't g swimming r submerge yur hand underwater fr at least tw days after the prcedure. Yu can play glf and tennis ne week after the prcedure.

3 Hw can I use my hands? Right after the prcedure, yu will have little rund bandaids n the areas where the needles were used. Usually, the bandaids can be taken ff and left ff the same day. Right after the prcedure, yu'll have sme numbness in yur fingers, which usually wears ff by the next mrning. Yu shuld be able t eat, get dressed and g t the bathrm withut assistance the day f the prcedure. It's best t avid mre strenuus activities such as glf, tennis, and weightlifting fr 1 week after NA. D I have t keep the hand bandaged? Usually, all bandaids are taken ff and left ff the day f the prcedure. Wet bandaids shuld be remved. Smetimes the skin will crack like a paper cut in the palm and will weep fr a few days like a scraped knee. If yur skin cracks, yu shuld keep bandaids n the areas until the areas dry up and heal.. Hw lng will my hand be sre? Mild sreness may last a day r tw. Sreness may last lnger if there is much wrk dne n the PIP jints. Hw lng will my hand be numb? Usually fr several hurs and smetimes until the next mrning. Hw lng shuld my hand be swllen? If yu fllw instructins with ice and elevatin, yu shuld have very little swelling. If swelling des ccur, it usually lasts less than a week. Wn't I need pain pills? If yu fllw instructins with ice and elevatin, yu shuld have very little pain, if yu have any at all. Tylenl, Advil r Aleve shuld be strng enugh fr this. Narctic pain medicines are rarely prescribed fr this, and nly fllwing the release f very severe cntractures invlving three r mre fingers. Yu cannt drive while taking narctic pain medicatin. When can I shwer? The next mrning. Hw lng will I need physical therapy n my hand? Mst peple dn't need any frmal hand therapy after needle release. Smetimes, depending n yur particular situatin, it may be helpful fr yu t wear a splint r brace at night fr a few mnths after release. Usually, this type f splint needs t be custm made by a hand therapist after the prcedure. Dr. Gates has a Certified Hand Therapist n staff. Why wn't yu d NA n bth hands the same day? It's like the difference between having a patch ver ne eye and a patch ver bth eyes. Experience has shwn that ding releases n bth hands n the same day greatly increases the chances f flaring up a lt f inflammatin r even infectin. NA has a lw cmplicatin rate if everything is care is taken t prevent unnecessary cmplicatins. Hw des the splint help? Splints are wrn at night t keep yu frm sleeping with yur fingers bent int a fist. They gently pen the fingers during the healing prcess. Splints need t be wrn lsely and cmfrtably, r they may actually aggravate the Dupuytren's. Shuld I take / nt take chndritin/glucsaminethere is n real data n this s far, but because f individual reprts pssibly linking chndritin/glucsamine with Dupytren's, a practical recmmendatins is that if yu have Dupuytren's and feel thrugh yur wn experience that this suppliment is helping jint pain, then keep taking it. If yu can't tell whether r nt chndritin is helping yu, dn't take it r dn't start taking it. Hw can I keep it frm prgressing r recurring? That's the hly grail f Dupuytren's, and peple have been trying t find a medical treatment fr Dupuytren's since the time f Dupuytren, 200 years ag. The is n medicine, salve, exercise, therapy, nutritinal supplement r dietary change which has been shwn t help Dupuytren's. One thing t avid is frcing the fingers back, stretching them straight: that may actually prvke mre cntracture. What are the limitatins f Needle Apneurtmy? NA is nt a cure-all fr bent fingers. It is ne f several techniques t straighten fingers bent by Dupuytren's disease, applicable when there are string-like crds which can be felt beneath skin which is still smewhat sft. NA is nt apprpriate fr cntractures due t ther prblems, such as cntractures due t prir injury, chrnic tendinitis ("trigger finger"), r medical prblems prducing generalized stiffness, such as reflex sympathetic dystrphy, sclerderma, r diabetic stiff hand syndrme. This is why it may be imprtant t have a physician cnfirm that the primary prblem prducing cntractures is Dupuytren's befre making plans fr NA with Dr. Gates. NA is usually nt apprpriate fr hands which are persistently painful, tender, r swllen. NA may nt be technically pssible when the skin has lst its stretchiness r if:

4 The skin itself has shrunk r hardened t much. There are tight lengthwise scars frm previus surgery. There are skin grafts in the middle f the cntracted area. The skin ver the crd is hard, scarred, r ndular (lumpy). Ndules are hard lumps in the palm where the Dupuytren's prcess is the mst active. If a crd is like a string, a ndule is like a bead n that string. Ndules are unfavrable areas fr NA, and if ndules invlve lng areas, it may nt be pssible t perfrm NA. Hwever, ndules usually shrink and sften after a crtisne sht, and it may be pssible t treat the area with crtisne shts and return in a few mnths t perfrm NA. PIP cntractures are difficult prblems fr bth traditinal surgery and NA, and partial rather than cmplete imprvement is t be expected. On the average, PIP cntractures ver 45 degrees are imprved abut 50 percent with either NA r traditinal surgery. Severe cntractures r cmbined cntractures f bth the MCP and PIP jints may require tw sessins, several mnths apart, in rder t gain the maximum benefit. Tw sessins are usually required fr Stage III and IV cntractures. Remember, the gal f NA is imprvement withut a lng recvery perid. Severe PIP jint cntractures and severe cmbined MCP and PIP cntractures are rarely restred t nrmal, even with traditinal surgery. Secndary prblems may limit the usefulness f NA. When a finger jint has been t bent t far t lng, the jint itself may becme stuck, even after the Dupuytren's crd has been released. This is mst cmmn with PIP jint cntractures. Als, the tendns which run n the back f the finger which straighten the PIP and MCP jints may stretch ut r slide ver t the side f the knuckle, n lnger able t pull the knuckle straight. If this happens, the cntracture will likely recur after NA, and traditinal tendn recnstructin surgery shuld be cnsidered. When shuld I cnsider having NA? When is the earliest it can be dne? Needle release shuld be cnsidered when there is a cntracture which prevents the fingers frm stretching back. A release can nly be dne if there is a cntracture which limits jint mvement: Needle apneurtmy can't nly be dne effectively if the PIP and MCP jints can each be straightened fully at the same time. Even if the tightness seems t be prgressing, there must be sme cntracture t try NA. What happens t the crd after it has been cut? The crd is sftened and digested by the bdy's nrmal enzymes, and heals in a lengthened state. The crd is a nrmal structural layer which has becme wider and shrter frm the effects f Dupuytren's. It is nt a tumr - it des nt have t be remved, and when it is returned t it's prper length, it becmes hard t feel - just like it was befre Dupuytren's affected it. If the nerve is wrapped arund a crd, hw can the crd be cut withut cutting the nerve? Very carefully. At Dr. Gates ffice, the prcedure is perfrmed with lcal anesthetic nly in the skin itself. Deep t the skin, nthing has much feeling, except the nerve. If the needle gets clse t the nerve, yu will feel an electrical tingle, which tells the dctr t rerient and stay away. As lng as yu can feel in the fingertip, it's safe t keep wrking. The finger may be temprarily numb at the end f the prcedure frm additinal anesthetic r stretching the nerve, but statistically, permanent nerve damage is less likely than fr traditinal surgery. What happens t the ndules? Ndules sften up frm tw effects. They sften after the tensin has been relieved frm cutting crds attached t them. They als sften after being injected with a small dse f a lng lasting crtisne. The sftening and flattening takes place ver mnth r tw after the prcedure. What abut my knuckle pads? Knuckle pads (n the back f the PIP jints) can be injected with crtisne, which will make them sften and flatten sme. Hwever, the skin may becme thin frm the crtisne, s it's best t hld ff injecting unless they are big and hard. Knuckle pads frequently g away after a few years, can cme back after remval, and are nt rutinely perated n by Dr. Gates. Can I have the NA prcedure perfrmed the same day as my initial evaluatin? Yes this is smetimes dne. I have a severe case - is NA still apprpriate? NA is always an ptin - if... If: there is a lengthwise crd which can be felt beneath the skin,

5 And If: The skin is nt t scarred, shrunk r hardened - the skin has t have sme "give" r stretch left. Tw NA sessins, three mnths apart, may be needed t achieve the mst benefit in severe cases. When is NA NOT an ptin? What are the limitatins f NA? See abve. What if NA is nt pssible? Surgery is always an ptin. If the disease is beynd the pint f NA, it is usually bad enugh t require a skin graft r jint fusin - traditinal surgical ptins. I am diabetic - Is NA safe? Yes, as lng as yur diabetes is under gd medical cntrl. I am n bld thinners - is NA safe? The risk f bleeding cmplicatins fllwing NA is small. NA can be perfrmed even if yu are fully anticagulated, as lng as yu are able t keep yur hand cnstantly elevated (hand pinting up) the day f and the day fllwing the prcedure. Hwever, ideally, yu shuld be ff bld thinners (aspirin, plavix, etc.) befre any elective prcedure, but nly d this under the directin f the dctr wh has prescribed these medicines. Bld thinners d increase the risk f excessive bruising and cmplicatins f bleeding fllwing any prcedure, including NA. Can I qualify fr disability during my recvery frm NA? N, nt frm the NA prcedure itself. If yu wish t receive disability benefits, all arrangements must be made by yur primary dctr, if they believe that yu qualify fr disability based slely n yur current cnditin. Is the prcedure painful? Nt terribly. The shts feel abut as bad as a wasp sting, but dn't last as lng. Anxiety and anticipatin are usually bigger prblems than pain. Slw deep breathing and ther relaxatin techniques are very helpful. Narctic pain medicines are nt needed during r after NA. Can I have bth hands dne n the same day? N, this is usually nt a gd idea - better t stage the hands at least ne day apart. Why aren't mre dctrs ding needle apneurtmy? Many dctrs in the US are simply nt aware f the benefits f NA. Als, there is a very strng surgical traditin in the US f fasciectmy (remving the abnrmal tissue) instead f fascitmy (cutting the tight crd). It's just a matter f time befre this changes - there's n cnspiracy, n hidden agendas. Britain's Natinal Health Service has reviewed the prcedure and has published favrable plicy statements regarding this - see What's the difference between needle apneurtmy and ther prcedures? Here's a cmparisn: Apneurtmy Fasciectmy (NA) (Traditinal Dupuytren s Surgery) Setting Office - ne day Outpatient Surgery Recvery (ne hand) 2-7 days 2-3 mnths Recvery (bth hands) 4-7 days 4-6 mnths Physician, Fees Physician Facility, Anesthesia Therapy Uncmmn Usual, 3 times a week, 4-12 weeks Splinting Repeatability / tuch up Fr PIP r multiple releases, nightly fr 3 mnths. Any time, straightfrward Fr mst releases, nightly fr 3 mnths. Wait at least 3 mnths, difficult.

6 I've already had surgery fr Dupuytren's. Can I still have a needle prcedure? Yes - if yu have develped crds beneath fairly nrmal skin. Hwever, needle apneurtmy may nt be pssible after surgery if yu have tight r hard skin, tight scars, r if n remaining crd can be felt. In these situatins, traditinal surgery may be the best slutin, pssibly with a skin graft. What can I expect after the prcedure? Bandage? If yur skin is in gd cnditin and yu have n "skin tear" frm the prcedure, yu may simply need dt band aids n yur palm fr a day at the needle sites. Otherwise, yu may be wrapped in a gauze bandage fr 2 r 3 days. If yu have a large skin tear, which is uncmmn, yu may need t change a light bandage n yur palm fr 2 weeks. Splint? If yu have PIP cntractures r have multiple fingers released, yu may benefit frm wearing a splint while sleeping fr 3 mnths. Usually, a custm splint can be made by a hand therapist n site n the day f the prcedure. Otherwise, yu may be given a prescriptin fr a splint t be fabricated within the next few days. Therapy? Unlike pen surgery, scheduled sessins f hand therapy are nt rutinely needed after needle apneurtmy. Activity? Fr the day f the prcedure, it's best t try t keep yur hand elevated (pinting up abve the level f yur heart) as much as pssible and t apply a cld pack t yur hand fr 10 minutes an hur (ice, gel pack, hlding a cld beverage, etc.). Yur fingers may be numb fr a few hurs, but even with this, yu shuld be able t eat, change clthing, g t the restrm and drive a car withut assistance immediately after the prcedure. Yu may be sre and bruised fr a week, s plan t take it easy fr cmfrt's sake - hld ff n sprts and strenuus activities at least 1 week after the prcedure. Medicatins? Yu may be given a single dse f antiinflammatry medicine n the day f the prcedure, r yu may bring yur wn t take. N narctic pain medicines are needed. If yu are quite anxius abut the prcedure, yu may wish t speak with yur lcal physician abut prescribing an anti-anxiety medicatin t take n the day f the prcedure. Hw sn can I use my hand after a needle apneurtmy? See "Activity", just abve. Can my feet be treated as well? Nt currently. Hw d I schedule an appintment? Call Dr. Gates ffice at Hw far in advance d I need t make an appintment? At least ne mnth. Is this prcedure cvered by insurance? Mst plans cver NA, but yu shuld cntact yur insurance cmpany t check yur plan cverage. What d I need t tell my insurance cmpany? Yur insurance cmpany will want t knw these insurance cdes ICD Cde CPT Cde (Percutaneus Fascitmy - ne finger) ICD Cde CPT Cde (Sterid injectin Dupuytren's ndule) and ccasinally ICD Cde CPT (Sterid injectin f finger jint) and even less cmmnly ICD Cde CPT (Tendn release fr butnniere defrmity).