By Avrum I. Froimson, MD

Hand surgeons who treat patients with Dupuytren’s contracture should consider doing Needle Aponeurotomy (NA). In selected cases it is clinically and cost effective, providing great patient satisfaction. Recent peer reviewed articles have concluded that NA yields results as good or better than collagenase injection for one fifth the cost.

It can be done in a clinic or office exam or procedure room on a wide awake patient lying comfortably on a treatment table with the hand extended on a board or small table. Only one appointment is necessary for NA. The cord is held under tension and gradually releases as it is cut at as many sites as needed. With enzyme injection therapy, patients need a second office visit for digital manipulation under local or regional nerve block, adding cost and inconvenience.

I was lucky to have seen Dr. Charles Eaton’s instructional course at the 2006 Washington meeting of the Hand Society. His excellent, well illustrated presentation excited my curiosity. I had been doing the Luck percutaneous fasciotomy releases in my office with a number 11 blade under local anesthesia for at least 30 years. But this looked much more elegant and I knew I had to learn how to do it.

So when Dr. Eaton invited anyone in the audience to visit his clinic in Florida to learn the technique, I made the trip. I watched all day as he did the procedure on seven patients with amazing results.

I returned to the Cleveland Clinic and introduced the procedure. In my 46^th year in practice I had no difficulty learning to do Needle Aponeurotomy. That is not surprising, considering that the procedure had been invented by a French rheumatologist who had never operated on a hand. For the first year I did only MP contractures and then progressed to the fingers.

What I most enjoyed was to work with someone wide awake, hear his story, and help him relax. The best part was sharing his excitement. I heard many colorful words and saw only big smiles when the patient realizes that he can once again open his hand and use it. Wow!

My Cleveland Clinic partners and many local hand surgeons were supportive referring patients to me. Who really loves the tedious dissections of fasciectomy with its complications and recurrences?

And by doing presentations at State and Regional meetings, more people called. And as I gradually reduced the number and complexity of my operating room cases, I had more than enough to do in the clinic, continuing practicing nine more years and doing over 1000 NA cases.

I treated patients from across the nation and some from abroad. To avoid patient disappointment, my nurse spoke with everyone and I viewed patient photos before an appointment was scheduled. We did not want somebody to travel to Cleveland from afar if not a suitable candidate. Hands previously operated or injected with xiaflex were not accepted.

In Europe the collagenase option is no longer covered by insurance or government payers. They recognize there that NA is the treatment of choice if surgery in the operating room is neither indicated nor wanted by the patient. Here we also have to remember our obligation to help reduce the cost of medical care.

Any hand surgeon can learn this procedure by reading Dr. Eaton’s articles or by viewing his YouTube presentation. Or visit an office where it is being done. Go for it. You will have many very happy clinic days.