Summary of intervention

Dupuytren’s contracture 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. If not treated the finger(s) may bend so far into the palm that they cannot be straightened. All treatments aim to straighten the finger(s) to restore and retain hand function for the rest of the patient’s life. However none cure the condition which can recur after any intervention so that further interventions are required.

 

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

 

Several treatments are available: collagenase injections, needle fasciotomy, fasciectomy and dermofasciectomy. None is entirely satisfactory with some having slower recovery periods, higher complication rates or higher reoperation rates (for recurrence) than others. The need for, and choice of, intervention should be made on an individual basis and should be a shared decision between the patient and a practitioner with expertise in the various treatments of Dupuytren’s contractures.

 

No-one knows which interventions are best for restoring and maintaining hand function throughout the rest of the patient’s life, and which are the cheapest and most cost-effective in the long term. Ongoing and planned National Institute for Health Research studies aim to address these questions.

 

Number of CCG intervention 201718

14,376

 

Recommendation

  • Treatment is not indicated in cases where there is no contracture, and in patients with a mild (less than 20°) contractures, or one which is not progressing and does not impair function.
  • An intervention (collagenase injections, needle fasciotomy, fasciectomy and dermofasciectomy) should be considered for

a.  finger contractures causing loss of finger extension of 30° or more at  the metacarpophalangeal joint or 20° at the proximal interphalangeal

or

b. severe thumb contractures which interfere with function

  •  NICE concluded that collagenase should only be used for:

c. Participants in the ongoing clinical trial (HTA-15/102/04)

or   

d. Adult patients with a palpable cord if:

i. There is evidence of moderate disease (functional problems and metacarpophalangeal joint contracture of 30° to 60° and proximal interphalangeal joint contracture of less than 30° or first web contracture) plus up to two affected joints; and needle fasciotomy is not considered appropriate, but limited fasciectomy is considered appropriate by the treating hand surgeon

 

Rationale for recommendation

Contractures left untreated usually progress and often fail to straighten fully with any treatment if allowed to progress too far. Complications causing loss, rather than improvement, in hand function occur more commonly after larger interventions, but larger interventions carry a lower risk of need for further surgery.

 

Common complications after collagenase injection are normally transient and include skin breaks and localised pain. Tendon injury is possible but very rare. 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.

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