Percutaneous needle fasciotomy for Dupuytren's disease: A one-stop approach incidentally suited to the era of COVID-19.

Dear Sir,

The era of COVID-19 has and continues to present a unique challenge to the provision of healthcare across the National Health Service. The redeployment of many theatre personnel and anaesthetists to areas of high Covid-burden has seen surgical practice drastically condensed. Here we describe an example whereby percutaneous needle fasciotomy (PNF), delivered as the treatment of choice for Dupuytren's, facilitated continued service provision at an unaffected standard for patients presenting to our unit.

Upon the announcement of ‘lockdown’ and with the redeployment of many anaesthetists and theatre personnel to ‘Covid-red areas’, plastic surgery staff at our unit were reorganised into three main teams providing service in cancer, urgent electives and trauma. All elective lists were subsequently deferred, effective on March 17th in line with national guidelines. The majority of theatres across the Trust were stripped of ventilators and other equipment. Such restrictions to service, though undoubtedly needed, have compounded excess morbidity and mortality as an indirect consequence of the pandemic, estimates of which are difficult to evaluate and may inevitably have an enduring impact.

As the expected load of Covid patients was mercifully not seen in our region, limited resourcing for outpatient procedures was maintained such that less resource intensive procedures including PNF for Dupuytren's contracture could be carried out in a one-stop approach. In this method, patients are COVID-tested and those patients proven COVID-negative are offered to attend for PNF, which is carried out in procedure rooms by a surgeon and a single assistant, without the requirement for an anaesthetist or ventilator. Following fasciotomy, patients directly see hand physiotherapy for fitting of a thermoplastic splint which they are able to remove for short periods as required. Patients are not required to have nurse follow-up at seven days post-operatively (as per usual protocol) but are given details of the plastic surgery ward to contact if required, limiting avoidable exposure to both staff and patients. Additionally, patients are followed up via telemedicine at three months to evaluate the outcome of the procedure. Though this precludes physical examination, patients are typically asked questions such as ‘How are you finding the use of your hand today?’, ‘How straight is your finger now?’, ‘Is the sensation to your finger as before the procedure?’ and ‘Would you have the procedure again if necessary?’ in order to assess outcomes and patient satisfaction.

Though an established technique with documented safety in several large series studies including that by Therkelsen et al., there is a relative paucity in the literature regarding the provision of ‘office-based’ PNF which has also shown to be effective without compromise to patient safety. The increased uptake of such practices may be vital in conserving theatre space, a resource which is likely to remain limited for the foreseeable future, enabling greater capacity for more demanding procedures and cases with greater need and/or complexity. As the demand for elective hand surgery continues to rise against the expected backdrop of economic recession and rationed healthcare, it may be essential to increase the provision of more sustainable and cost-effective approaches to treating surgical hand disease. In the era of COVID-19, when anaesthetists, ventilators and other resources are a scarcity, we found that PNF facilitated a one-stop treatment approach to treatment of Dupuytren's disease and as such is ideally suited to continue service provision in this time of extreme resource limitation.

Declaration of Competing Interest

The authors would like to confirm that there are no conflicts of interest.