Keith Felcyn, a retired senior editor of BusinessWeek magazine who lives in Greenwich, Conn., had not been able to fully extend the little and ring fingers of his left hand for 20 years. But last month, it took 20 minutes for a doctor in Ontario, Ore., to reverse his Dupuytren’s disease, a benign but ultimately disabling disorder in which the fascia of the hand thickens and draws the fingers permanently into the palm. “When he finished and I could lay my hand flat,” Mr. Felcyn recalled, “I said, ‘My God, this is a miracle.’ ” The procedure, called needle aponeurotomy or percutaneous fasciotomy, involves using the bevel of a hypodermic needle to essentially shred the ropes of constricting fascia characteristic of Dupuytren’s disease. The disorder, named for Baron Guillaume Dupuytren, a 19th-century French surgeon who wrote about it, afflicts up to 25 percent of people over 40 in Western countries and is most common in men of northern European descent. Ronald Reagan had it; so does Margaret Thatcher. Risk factors for the disease include hand or wrist trauma, repetitive strain, alcoholism, smoking and diabetes. Needle aponeurotomy, which leaves only superficial puncture wounds, was developed 30 years ago by a group of French rheumatologists and is now being practiced in the United States by fewer than a dozen physicians. Thousands of patients like Mr. Felcyn are flocking to these doctors every year, many against the advice of hand surgeons who say open hand surgery is more effective. “Surgery has a lower recurrence rate,” said Dr. Richard Gelberman, chairman of the department of orthopedics at Washington University in St. Louis, and president of the American Society for Surgery of the Hand. The recurrence rate for needle aponeurotomy is around 50 percent after three years, according to several studies published in French medical journals. Studies in the British and American medical literature indicate that the recurrence rate for fasciectomy, or surgical removal of the diseased fascia, is 40 percent after five years. But surgery carries a significantly higher risk of complications like nerve and vascular injury, infection, inflammation and something called a flare reaction in which the hand gets very swollen, red and stiff. “Fasciectomy is a delicate procedure that requires meticulous technique,” said Dr. Steven Z. Glickel, director of the C.V. Starr Hand Surgery Center at St. Luke’s-Roosevelt Hospital Center in New York. Moreover, he added, “Patients have to be committed to physical therapy” for six weeks to four months before they can expect to regain full function of the hand. The disabling disorder causes patients’ fingers to become fixed in a bent position.Credit...Photo Researchers
Mr. Felcyn played tennis the day after his needle aponeurotomy, which, unlike surgery, can be easily repeated should he have a recurrence.
Dr. David Kline, who performed the procedure using a mild local anesthetic, had the same thing done to both his hands five years earlier in France.
“I cried the day I had it done,” Dr. Kline said. “I was so happy to be able to use my hands.” As an emergency room doctor, he had thought his career was over until an Internet search turned up a group of rheumatologists at the Hôpital Lariboisière in Paris offering an alternative to surgery.
Dr. Kline paid 40 euros, about $55, to undergo the procedure. He returned to Paris in 2005 to receive training in the technique. Dr. Kline said he had since performed more than 600 needle aponeurotomies, in addition to continuing to practice emergency medicine, at Holy Rosary Medical Center, in Ontario, Ore.
There is little competition because so few doctors offer it in the United States; a list can be found at //www.dupuytren-online.info/needle-aponeurotomy.html.
The cost is $500 to $650 per affected finger and is covered by Medicare.
Dr. Charles Eaton, a hand surgeon in Jupiter, Fla., said the technique had been slow to gain acceptance by other American surgeons because “it sounds crazy to work on the delicate structures of the hand without cutting it open to see what you are doing,” especially when Dupuytren’s disease often distorts the anatomy of the hand.
But because patients are awake for the procedure, he said they can report a tingling sensation if the one-half millimeter needle gets too close to a nerve, and they can move their fingers to reveal the location of tendons.
“It took a long time for arthroscopy to take hold, too,” Dr. Eaton said.
Overview
A child born with clinodactyly has an abnormally curved finger. The finger may be curved so much that it overlaps with other fingers. The bent finger usually functions fine and doesn’t hurt, but its appearance can make some children self-conscious.
Clinodactyly is uncommon, affecting about 3 percent of babies born in the general population. Any finger on either hand can be curved due to clinodactyly. It’s unusual, though, for fingers on both hands to be affected.
Approximately 25 percent of children with Down syndrome have this condition. In babies with Down syndrome, it’s sometimes the thumb that’s bent away from the other fingers. In most people, however, the little finger is usually affected, with the joint closest to the fingernail bent toward the ring finger.
Clinodactyly is a congenital condition. That means a child’s born with it, as opposed to developing it later on. The unusual shape may be caused by the growth of an abnormally shaped finger bone or by a problem with a growth plate in one of the finger’s bones.
It’s not clear why some children have this problem and others don’t. However, it’s associated with certain disorders, such as:
- Down syndrome
- Klinefelter syndrome
- Turner syndrome
- Fanconi anemia
Clinodactyly is also more common in boys than in girls. There may also be a genetic component, though many babies born with clinodactyly are the first in their families to have this condition.
You’re not likely to have a second child with clinodactyly just because your first child had the condition. If, though, your first child also has Down syndrome and clinodactyly, your chances of having a second child with Down syndrome are higher.
In mild cases, clinodactyly may not be noticeable until a child is a few years old. Often, though, clinodactyly can be preliminarily diagnosed shortly after birth.
A thorough physical examination of the hand will include range-of-motion tests to determine whether hand motion and coordination are affected. X-rays are usually taken to help confirm a diagnosis. They will show a C-shaped bone in the curved finger.
A prenatal ultrasound may detect clinodactyly, but there’s no treatment that can be done while a baby is in the womb.
Because clinodactyly usually causes no symptoms and doesn’t severely restrict the use of the affected finger, your child’s doctor may not recommend any treatment.
Splinting the finger with a neighboring finger to help straighten it isn’t recommended. It could worsen the health and growth of the affected finger.
In mild cases, your child’s doctor may choose to monitor the growth of the fingers and hand to watch for signs that the condition in worsening or affection function.
When the curve is more than 30 degrees, hand function may be compromised, and surgical treatment may be necessary. Surgery usually has the best results when your child is young and the bones are still growing.
Surgery to treat clinodactyly usually involves:
- taking out a wedge-shaped section of curved bone
- stabilizing the finger
- making sure the bones and tissue in the affected finger are lined up properly within the finger
- lining up the finger that was operated on with the other fingers
A cast or splint will be placed on the finger while it heals after surgery. The hand and forearm may be placed in a sling for further protection. The operation usually involves an orthopedic surgeon and a plastic surgeon. The two doctors check that the function of the finger is retained or improved, while also helping to make sure the finger’s appearance is as normal as possible.
Treatment may also involve some physical therapy and occupational therapy after the bones heal.
The long-term outlook is very good for someone born with clinodactyly. If the condition is treated successfully with surgery, there’s a chance that clinodactyly may recur in that finger. However, your child can live a long life with no further signs or complications from clinodactyly.
Because clinodactyly may be caused by a growth plate problem in a finger, you should pay attention for other growth-related concerns with your child. Talk with your child’s pediatrician about any other signs of bone or growth abnormalities. And if you’re considering surgery to treat the finger, seek out a specialist with experience treating children with clinodactyly.
Your child’s doctor should also outline when it’s fine to resume normal activities with the affected hand.