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Document type
Clinical policy
Place
Hertfordshire and West Essex ICB
Output type
Clinical Policies & Evidence-based Interventions
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Dupuytren’s contracture release in adults (Surgery and Injections)

v1.0 January 2025

Policy:

This is a national Evidence Based Intervention policy formally adopted by Hertfordshire and West Essex Integrated Care Board. Please see https://ebi.aomrc.org.uk/

Dupuytren’s is a progressive and lifelong genetic contracture of the fibrous elements related to the palmar fascia. The condition is caused by fibrous bands in the palm of the hand which draw the finger(s) (and sometimes the thumb) into the palm and prevent them from straightening fully. While the condition is not painful, the condition may lead to function limitation due to inability to open up the fingers completely. All treatments aim to straighten the finger to improve hand function. Despite treatment, deformities may likely recur following intervention and multiple procedures may be required, progressively increasing the risk of additional complication.

Splinting and radiotherapy have not been shown to be effective treatments of established Dupuytren’s contractures.

Several treatments are available: needle fasciotomy, fasciectomy and dermofasciectomy. None of these interventions are curative. Some have slower recovery periods, higher complication rates or higher re-operation rates (for recurrence) than others.

The disease process affects the hand to varying degrees and patients may present at different stages in the disease process. It is hence important that the timing and choice of intervention is tailored to the individual patient and based on shared decision making between the patient and a practitioner with clinical expertise in the various treatment options. It is recommended that as part of the consultation process of patients undergoing intervention, a validated decision aid tool should be used during the consenting process to ensure that the patients’ desired outcomes have been considered. An example of decision aid tool is on the NHS website.

Currently there is a lack of consensus and high-quality evidence on the best and most cost-effective long-term treatment option, however, this may change in the future.

Recommendation:

 

  • This intervention should not be undertaken for purely cosmetic purposes – which is in accordance with NHS policy more widely.

  • Treatment is not indicated in cases where there is no contracture, or the contracture is not progressing and does not impair function.

  • An intervention (Needle fasciotomy, fasciectomy and dermofasciectomy) should be considered for contractures with significant interference with function e.g. it significantly impacts an individual’s ability to use their fingers.

  • A validated decision support tool could be used when consenting patients for possible intervention taking into account factors such as severity of deformity, patient choice and patient health status. An example of decision aid tool is on the NHS website. 

As aligns with the NICE guidance, there is inadequate evidence to recommend the use of radiation therapy in the management of Dupuytren’s disease. It should only be used with special arrangement for clinical governance, audit or research.
 

Rationale for Recommendation

Contractures usually progress and often fail to straighten fully with any treatment if allowed to progress too far. Larger interventions tend to carry a lower risk for recurrence, however, are associated with complications that can lead to loss of function rather than overall improvement.

Significant complications with lasting impact after needle fasciotomy are very unusual (about 1%) and include nerve injury. Such complications after fasciectomy are more common (about 4%) and include infection, numbness and stiffness.

Patient Information

Information for Patients
Early Dupuytren’s contracture does not always require surgery. Surgery should only be offered if the contracture is severe enough to affect how your hand works.

About the condition
Dupuytren’s contracture is a condition caused by fibrous cords that form in the palm of the hand and fingers. These cords pull the fingers and sometimes the thumb into the palm. This stops them from straightening fully.  Affected fingers will not straighten again without treatment and may gradually bend further into the palm. It is not usually a painful condition, but it may affect how your hand works. 

Surgery is recommended if the symptoms begin to significantly affect the use of fingers or the hand overall. This is usually when the condition prevents you from being able to put your hand flat on a table. If it is interfering with your day-to-day life, you should ask your GP to refer you to a hand surgeon. A hand surgeon will be able to explain the benefits and risks of the possible treatments and what is likely to happen if you do nothing. This will allow the two of you to come to a shared decision as to which treatment, if any, is best for you. 

Dupuytren’s contracture will always come back even with surgery. For about one in three people this will be within five years. The risk of repeated surgery must be balanced with how the hand is affecting day to day life.

What are the BENEFITS of the intervention?
Surgery aims to straighten the affected fingers, restore hand function and/or prevent fingers from becoming so bent that they can no longer be straightened with any treatment. Surgery involves either cutting or removing the tight parts of the fibrous cords to straighten the fingers.
 

What are the RISKS?
Surgery to release the fibrous cords is done under general anaesthetic. Incisions are made in the hand to remove the fibrous tissue and straighten the fingers. Surgery on the affected area can also include removal of the skin around the affected area and may involve a skin graft. In addition, surgery also carries some risks including infection, numbness and finger stiffness.
 

What are the ALTERNATIVES?
An alternative treatment involves cutting through the fibrous band with a needle to allow the finger to be straightened under a local anaesthetic. This works best on thin cords in the palm and cannot be used for thick cords in the finger. The fingers will straighten immediately but the tight parts of the cords are not removed. This may mean that the condition could return quicker than if you had surgery. 

In rare cases some patients who have had multiple operations on the same finger may choose to have the finger amputated. This requires very little rehab and gives good function.

What if you do NOTHING?
Doing nothing is not harmful to your health, but the more the fingers bend into the palm, the less likely it is that any treatment will straighten them. Severe contractures can significantly and permanently reduce how your hand works.

Further information can be found at https://ebi.aomrc.org.uk/interventions/dupuytrens-contracture-release-in-adults/This weblink was correct as of 27/11/2024.


Coding

WHEN Primary_Spell_Procedure IN ('T521','T522','T525','T526','T541','T543','X654','X658','X659')
AND Primary_Spell_Diagnosis='M720'
-- Age Between 19 and 120
AND (ISNULL(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 19 AND 120)
-- Only Elective Activity
AND APCS.Admission_Method not like ('2%')
THEN 'N_dupuytr'

Exclusions

WHERE 1=1
-- Cancer Diagnosis Exclusion
AND (Any_Spell_Diagnosis not like '%C[0-9][0-9]%'
AND Any_Spell_Diagnosis not like '%D0%'
AND Any_Spell_Diagnosis not like '%D3[789]%'
AND Any_Spell_Diagnosis not like '%D4[012345678]%'
OR Any_Spell_Diagnosis IS NULL)

-- Private Appointment Exclusion
AND apcs.Administrative_Category<>'02'


References

  1. British Society for Surgery of the Hand (2016) Dupuytren’s disease patient leaflet.
  2. CKS Dupuytren’s disease. https://cks.nice.org.uk/dupuytrens-disease
  3. Crean SM, Gerber RA, Le Graverand MP, Boyd DM, Cappelleri JC. The efficacy and safety of fasciectomy and fasciotomy for Dupuytren’s contracture in European patients: a structured review of published studies. J Hand Surg Eur 2011;36(5):396-407.
  4. Krefter C, Marks M, Hensler S, Herren DB, Calcagni M. Complications after treating dupuytren’s A systematic literature review. Hand surgery & rehabilitation. 2017, 36: 322-9.
  5. NICE Interventional procedures guidance (2004). Needle fasciotomy for Dupuytren’s contracture. [IPG43]
  6. Rodrigues JN, Becker GW, Ball C, Zhang W, Giele H, Hobby J, et al. Surgery for Dupuytren’s contracture of the fingers. Cochrane Database Syst 2015(12):CD010143.
  7. Scherman P, Jenmalm P, Dahlin LB. Three-year recurrence of Dupuytren’s contracture after needle fasciotomy and collagenase injection: a two-centre randomized controlled J Hand Surg Eur Vol. 2018;43(8):836-40.
  8. Skov ST, Bisgaard T, Sondergaard P, Lange J. Injectable Collagenase Versus Percutaneous Needle Fasciotomy for Dupuytren Contracture in Proximal Interphalangeal Joints: A Randomized Controlled Trial. J Hand Surg 2017;42(5):321-8 e3.
  9. Stromberg J, Ibsen Sorensen A, Friden J. Percutaneous Needle Fasciotomy Versus Collagenase Treatment for Dupuytren Contracture: A Randomized Controlled Trial with a Two-Year Follow-up. J Bone Joint Surg 2018;100(13):1079-86.
  10. van Rijssen AL, Gerbrandy FS, Ter Linden H, Klip H, Werker PM. A comparison of the direct outcomes of percutaneous needle fasciotomy and limited fasciectomy for Dupuytren’s disease: A 6-week follow-up study. J Hand Surg 2006, 31: 717-25.
  11. van Rijssen AL, ter Linden H, Werker Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: Percutaneous needle fasciotomy versus limited fasciectomy. Plast Reconstr Surg. 2012, 129: 469-77.



 

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