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Dupuytren’s contracture release in adults

Dupuytren’s contracture release in adults

Statutory Guidance

Guidance under review

This guidance is clinically safe but is being updated to reflect the latest evidence identified during a recent review of all published EBI guidance.

Content will be updated and finalised by the end of September 2024.

Summary

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.

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.

Patient information

Information for Patients

In some cases surgery to treat Dupuytren’s Contracture is not necessary. This is because medical evidence tells us that in most cases, alternative treatments should be tried first and can be more effective.

About the condition

Dupuytren’s contracture is a condition caused by fibrous cords which form in the palm of the hand and fingers. These draw the finger or fingers and sometimes the thumb into the palm and prevent them from straightening fully.  Affected fingers will not straighten again without treatment and may gradually bend further and further into the palm. It is not usually a painful condition, but it does reduce hand function.

Treatment is recommended if the symptoms become troublesome. This is usually when the deformity prevents you from being able to put your hand flat on a table. However, if contractures are left to get too severe then treatment is less likely to be successful. If your fingers do start to contract, you should ask your GP to refer you to a hand surgeon who 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.

What are the BENEFITS of the intervention?

The aim of treatment is to straighten the affected fingers and restore hand function and to prevent the contracted fingers from becoming so bent that they cannot be straightened with any treatment.

What are the RISKS?

Open surgery to release the fibrous cords is done under anaesthetic. Incisions are made in the hand to remove the diseased tissue and straighten the fingers. This carries some risks including infection, numbness and finger stiffness. In about 1:3 cases, the condition recurs within five years.

What are the ALTERNATIVES?

There are two alternatives, the first involves cutting through the fibrous band with a needle to allow the finger to be straightened under a local anaesthetic. The second is to inject a drug into your contracted finger to dissolve part of the fibrous band. The finger is then pulled straight by your surgeon a few days later under local anaesthetic. Neither treatment is as effective in straightening the finger as open surgery and both have higher risks of recurrence. The risk of a major problem is much lower with needle treatment than surgery.

What if you do NOTHING?

Doing nothing is not likely to be harmful to your health, but the more the affected fingers bend into the palm, the less likely that any treatment can straighten them. Advanced hand contractures can significantly and permanently reduce hand function.

Coding

Code script

WHEN LEFT(der.Spell_Dominant_Procedure,4) in ('T521','T522','T525','T526','T541','T543')
AND isnull(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 19 AND 120 
AND LEFT(der.Spell_Primary_Diagnosis,4)='M720’ 
AND APCS.Admission_Method not like ('2%')
THEN 'N_dupuytr'

Code Definitions

Procedure codes (OPCS)

Main
T521 Palmar fasciectomy
T522 Revision of palmar fasciectomy
T525 Digital fasciectomy
T526 Revision of digital fasciectomy
T541 Division of palmar fascia NEC
T543 Needle fasciotomy of palmar fascia
Potential
T528 Other specified excision of other fascia
T529 Unspecified excision of other fascia
T548 Other specified division of fascia
T549 Unspecified division of fascia

Diagnosis codes (ICD)

M720 Palmar fascial fibromatosis [Dupuytren] (there is no way to differentiate between Dupuytren’s disease and contracture in the classification)

Exclusions
apcs.der_diagnosis_all not like '%C[0-9][0-9]%' and 
apcs.der_diagnosis_all not like '%D0%' and 
apcs.der_diagnosis_all not like '%D3[789]%' and
apcs.der_diagnosis_all not like '%D4[012345678]%’

This code captures code in the ranges C00-C99, D00-D09 and D37-D48.
Age range: the codes use the following age ranges 0-18 for children and 19-120
for adults.
— Private Appointment Exclusion
AND apcs.Administrative_Category<>’02’

References

  1. British Society for Surgery of the Hand (2016) Duputren’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.

How up to date is this information?

Last revised December 2023


Changes

December 2023 - Coding updated. August 2022 - Coding updated