|Year : 2022 | Volume
| Issue : 1 | Page : 18-22
Role of needle aponeurotomy and buddy taping as a natural continuous passive mobilization machine in Dupuytren’s contracture
Hitesh Lal, Jaswant Kumar, Rakesh Goyal, Nitin Mehta
Sports Injury Centre, VMMC & Safdarjung Hospital, New Delhi, India
|Date of Submission||30-Dec-2021|
|Date of Acceptance||12-Apr-2022|
|Date of Web Publication||13-May-2022|
Sports Injury Centre, VMMC & Safdarjung Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Purpose: Needle aponeurotomy (NA) for Dupuytren’s contracture is gaining popularity and is becoming the standard primary treatment. We present a short series of patients with Dupuytren’s contracture managed by NA and elucidate the augmenting role of buddy taping as a natural anatomic continuous passive motion machine in maintaining the improvement in DASH (Disabilities of the Arm, Shoulder and Hand) scores. Materials and Methods: Four patients (five hands) with Dupuytren’s contracture all of whom were diabetic are included in the short case series. All patients had their contracture released by NA and the operated finger was buddy taped to adjacent finger. Results: The mean age of the patients was 48.75 years. Out of four patients, three had unilateral involvement and one had bilateral involvement of ring finger. The mean flexion contracture at the metacarpophalangeal (MCP) joint was 61°(50°–70°), whereas at PIP joint it was 36° (30°–40°) which improved to mean of 0° and 2° immediately after release and 0° and <5°, respectively, at the final follow-up. The mean DASH score improved from 16.25 to 3.77 at the final follow-up. We did not encounter any neurovascular injury in any of our patients related to the procedure though one patient complained of tingling sensation in all fingers and one patient had 1–2 mm of skin rupture. There was no relapse and no patient required secondary release. Conclusion: Patients with Dupuytren’s contracture released by NA have good clinical results. The mobilization of the taped buddy finger allows early, superior, cost-efficient rehabilitation and prevents relapse. Type of Study/Level of Evidence: Therapeutic IV
Keywords: Buddy taping, Dupuytren’s contracture, flexion contracture, needle aponeurotomy, ring finger
|How to cite this article:|
Lal H, Kumar J, Goyal R, Mehta N. Role of needle aponeurotomy and buddy taping as a natural continuous passive mobilization machine in Dupuytren’s contracture. J Bone Joint Dis 2022;37:18-22
|How to cite this URL:|
Lal H, Kumar J, Goyal R, Mehta N. Role of needle aponeurotomy and buddy taping as a natural continuous passive mobilization machine in Dupuytren’s contracture. J Bone Joint Dis [serial online] 2022 [cited 2022 Nov 27];37:18-22. Available from: http://www.jbjd.in/text.asp?2022/37/1/18/345163
| Introduction|| |
Dupuytren’s contracture (DC) is a myofibroplastic proliferative disease of palmar fascia characterized by presence of nodules or cords.,, As the disease progresses, there is puckering of skin overlying the cord and fixed flexion contracture of metacarpophalangeal (MCP) and proximal inter-phalangeal (PIP) joint leading to inability to extend the involved digits.,, In some cases, it can also cause compression of digital nerves or vascular compromise.,
Numerous treatment methods have been suggested ranging from open fasciectomy or fasciotomy to needle aponeurotomy (NA) to release the DC. The former is associated with many complications and prolonged recovery hence NA is gaining popularity and is becoming the standard primary treatment.,, NA is a technique where fasciotomy is done percutaneously using hypodermic needle beveled tip as a knife. We present a short series of four patients of DC managed with NA and elucidate the augmenting role of buddy taping in maintaining the improvement in DASH (Disabilities of the Arm, Shoulder, and Hand) scores.
| Materials and Methods|| |
Eight patients with DC present to the authors’ outpatient department from 2015 to 2018. Four patients had mild contracture that is less than 20° at MCP joint and were advised physiotherapy regimen of stretching and were buddy taped with the adjacent finger for 3 weeks. Four patients with DC (five hands and five fingers) having MCP flexion deformity >30°, PIP >20°, and functional impairment with no scarring due to previous open release were planned for NA [Figure 1]A. All the patients had complained of difficulty in extending the involved finger and were not able to keep the palm flat on the top of the table (positive Hueston table top test).,,, It was associated with intermittent pain and a mean DASH score of 16.25. None of the patients had a family history of Dupuytren’s disease (DD) and all the patients had diabetes. Informed written consent was taken in all the patients prior to the procedure, explaining about the benefits and risks associated with the procedure. Both the procedures done that is NA is an established method of treatment of DC and buddy taping or strapping adjacent fingers is a traditional form of splinting of fingers in trauma scenario. It is a small case series involving standard methods of treatment, which have been combined in a symbiotic way to achieve good results in a disease like DC. Lignocaine sensitivity testing was done in all patients [Table 1].
|Figure 1: (A) Dupuytren’s contracture involving ring finger with prominent cord. (B) After needle aponeurotomy (NA), showing buddy taping with long finger|
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|Table 1: Demographic profile and characteristics of the deformity with follow-up of the patients in the study|
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The procedure was carried out as a daycare procedure. The involved area was cleaned with betadine and spirit solution. The hypodermic needle of 23 G was mounted over a 5-mL syringe and was filled with 1% lignocaine without adrenaline. Syringe increases the lever arm and helps in better handling and manipulation of the needle. The patient was given a small amount of local anesthesia only in the skin of diseased area of the palm and finger. Finger was held in mild extension to make cords more prominent and the cord and the needle puncture sites adjacent to cord (as described later) were marked. Hypodermic needle was inserted into the cord, the patient was asked to move the fingers to ensure that the needle was not in the tendon. Patient was also advised to immediately intimate the surgeon if he felt tingling sensation in the finger tips at any stage of the procedure. The release proceeded from proximal to distal with syringe and needle held in a pencil grip in the following two to three ways: (1) Multiple perforation were done into the pretendinous cord in different directions perpendicular to the long axis of the cord. This weakened the cord and allowed some passive correction in most cases. Another advantage of this (in cases not corrected by perforation alone) is that it made the weakened perforated cord easily amenable to release by the next method involving stroking or swiping the cord; it not only required less effort but also avoided bending of the thin 23-gauge needle. (2) Stroking and swiping: if after multiple perforations the deformity could not be corrected completely then the needle was held closed to tip, its bevel used as knife and the needle was moved in a windshield wiper manner transversely over the cord to percutaneously incise the cord. The deformity was then corrected passively and a popping sensation was often heard heralding the same. The needle punctures were planned in two ways: (1) We proceeded with the DC release from proximal to distal, the puncture location is chosen so as to avoid skin creases, the first usually being proximal to proximal palmar crease and the other between proximal and distal palmar crease. (2) When the skin was fixed and a skin cave had formed with mouth distally: the puncture and swiping of the cord by needle was done proximally over the mobile skin proximal to the cave blind end. (3) Natatory cords were released carefully and preferably only by multiple puncture technique to avoid injury to neurovascular bundle. The finger was extended fully and 5°–10° hyperextension was the endpoint of correction in all cases. The finger was buddy taped to the adjacent long finger and dressed with transparent small adhesive dressing [Figure 1B].
Prophylactic antibiotic was given to all patients, ice packs were applied for one day and dressing was checked at 3 days. Patients were advised active and active assisted finger extension the assist is provided by the movement of uninvolved buddy long finger. The patients were advised to use extension splint in night at home. Buddy taping was used for 3–4 weeks. Heavy work with hand was allowed after 3 weeks of the procedure.
| Results|| |
The mean age of the patients was 48.75 years (range 40–60 years) and all were male patients. All the patients had only one finger (ring finger) involved in the disease process and had unilateral involvement except one patient who had bilateral involvement of ring finger, that is, four patients with five involved rays. In five rays, three were on the right side and two were on the left side. All the patients were managed with NA technique with a mean operating time of 25 min (range 10–40 min). All needle puncture wounds healed by 1 week. The mean follow-up period was 21 months (16–25 months).
The mean flexion contracture at the MCP joint was 61°(50°–70°), whereas at PIP joint it was 36° (30°–40°) which improved to mean of 0° and 2°, respectively, immediately after release. At the final follow-up, the mean flexion contracture at MCP joint level was 0° and at PIP joint level, mean flexion contracture of <5° was present, and a DASH score of 3.77 [Figure 2]A–G.
|Figure 2: (A–D) Full extension movement. (E) Full flexion. (F) Splaying of fingers thus no web contracture. (G) Fist formation|
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We did not encounter any neurovascular injury in any of our patients related to the procedure though one patient complained of tingling sensation in all the fingers which was controlled by conservative treatment. 1–2 mm skin rupture was seen in a case who had skin incaving which healed with dressing. None of the patients required secondary release or had relapse at the last follow-up.
| Discussion|| |
DC is an autosomal dominant genetic disease, resulting in myofibroblastic proliferation of palmar fascia of the hand and is characterized by presence of nodules and cords.,,, In progressive course of the diseases, cords get thickened and shortened and causes flexion contracture of the involved digits at MCP and PIP joint level. In advanced stages, it can also cause compression of nerve and vascular compromise.,
It is usually bilateral and in unilateral cases, it is more common on the right side. In our series also, it was more common on the right side. Predominantly, it involves males and there is a strong family history associated with DC.,, All the patients were male in our series. The disease process usually involves ring and the little finger. In our series, only ring finger was involved in all the cases. Commonly associated factors are alcohol, diabetes mellitus, smoking, epilepsy.,, All the patients in our series were diabetic. None of the patients in our series had systemic involvement of DD such as Peyronie’s disease (involvement of dartos fascia of penis), Ledderhose disease (plantar fascia involvement) and Garrod’s disease (dorsal knuckle pads involvement).,
In our series, patients had pretendinous cords in all cases, natatory cord involvement in one case, had nodules in two cases, skin caving in one. Others features were blanching of the skin on extending the involved finger, flexion contracture, inability to extend the involved finger and not able to keep the palm flat on the top of the table (positive Hueston table top test).,,,
Treatment ranges from conservative method to operative procedures. Conservative method is advised when diseases process is stable and there is no functional impairment and involves stretching of involved diseases and local steroid injections., Conservative treatment was practiced in four patients, we advised patients to do passive stretching at home by pressing on dorsum of hand and buddy taped it to the unaffected finger. Thus, active self-mobilization of the unaffected buddy finger stretched and moved the involved adjacent finger.
Operative treatment is indicated when there is MCP contracture is >30° and when there is involvement of PIP joint >20° with impairment of functions., Surgical fasciectomy is associated with complications such as wound dehiscence, hematoma, neurovascular injury, swelling, infection, recurrence and long recovery period., NA is relatively a minimal invasive technique where percutaneous fasciotomy is performed using hypodermic needle beveled tip as knife and resulting in release of the cords., NA involves three steps, that is, clear, perforate and sweep as described by Eaton. NA can be performed in all the flexion contracture which are due to DD. It is contraindicated in contractures due to post open fasciectomy recalcitrant scarring of hand, treatment resistant DD, contracture due to any reason other than DD, joint contracture and in cases of lack of patient compliance.,,, Various advantages include percutaneous procedure, no visible scar, faster recovery, less complication rate, can be done in office settings, limited requirement of resources.,,
Cheng et al. in their series of 8 patients operated with NA showed the mean follow-up period of 22 months and mean flexion contracture at MCP and PIP joint of 50° and 46°, respectively. This improved to 0° and 11° immediately after release and at final follow-up, residual contracture was of 12° and 27° at MCP and PIP joint, respectively.
Foucher et al. in 311 fingers showed post-procedure improvement of 79% at MCP level and 65% at PIP level. Yoshihiro Abe et al. reported at mean contracture of 43° and 42° at MCP and PIP joint which improved to 2° and 8°, respectively, at 6 weeks post-procedure and at final follow-up of 12 months, the residual contracture at MCP joint was 11° and 17° at PIP joint level.
Gelman et al. in their series of minimal invasive partial fasciectomy showed improvement from 34° to 19° at MCP joint level and however, they reported an increase in flexion contracture from 39° to 45° at PIP joint level in 2 years of follow-up.
In a study by Pess et al., 1013 cords were released by NA method. Study showed correction to 1° from 35° at MCP joint level and 6° from 50° at PIP joint level immediately after the release. After 3 years, the residual contracture was 11° and 35° at MCP and PIP joint, respectively. Their study showed that patient >55 years had better outcome as compared to patients <55 years age.
A systemic review conducted by Ball et al. showed that pre-operative DASH score ranges from 12.1 to 24 which improved to 3.44–8 in postoperative period. In our series, DASH score improved from 16.25 to 3.77. The better results that were maintained even at the last follow-up in our small number of cases was probably because of the use of buddy taping (BT). The taping of operated finger to unaffected long finger has dual advantages: (1) It splints the operated finger in the immediate postoperative period thus providing pain relief and avoiding the need of any postoperative splintage. (2) The active relatively painless flexion and extension of unaffected taped buddy finger allowed assisted mobilization of operated finger in the immediate postoperative period. This helped in maintaining range of motion and active hyperextension of operated finger in postoperative period. The use of buddy taping was extended in one case who reported mild loss of movement at 12 months, he recovered after a short period of physiotherapy in form of stretching and short period of active assisted mobilization by buddy taping.
Thus, it is not wrong to address BT as a cost-efficient natural anatomic continuous passive mobilization (CPM) machine whereby the mechanical movement of the taped normal finger actively assists in mobilizing the adjacent operated finger. It acts as a dynamic splint which the patient can move voluntarily at any time, and doesn’t need special training or care. The buddy taping mobilization use can be extrapolated to other single-/two-finger hand surgery be it tendon repair or transfer with above advantages (senior author has used it in tendon surgery with good effect).
In our case series, we observed that correction is better achieved at MCP joint level as compared to PIP joint level. Other studies also support this.,,
The complications associated with NA are skin rupture (most common), nerve injury mostly at PIP joint level and flexor tendon injury., But as compared to other surgical procedures, it has a less complication rate and due to several advantages over other surgical interventions, it has become a preferred choice.,, In one patient who had a skin in caving just distal to proximal palmar crease there was a 1–2 mm skin rupture which healed with dressing in 5 days. One patient reported with tingling sensation in all fingers with no signs of complex regional pain syndrome probably because of diabetic neuropathy. He was managed with neurotropic medication and strict diabetic control.
NA has a good outcome in DC release and buddy taping maintains the gains achieved by it and is a useful cost-efficient biological aid in early rehabilitation. Its use in future as a short-term aid can prevent relapse.
Limitation of the study
The limitation of this study is that this is a relatively short series to show the synergistic effect of NA and buddy taping in DC.
The authors are grateful to Dr. Vinod Kumar Sabharwal (DNB Ortho) for the continuous support while preparing this manuscript.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflict of interest
There are no conflicts of interest.
Ethical standard statement
Institutional ethical clearance was taken.
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