Excision of the diseased palmar and digital cords while preserving normal fascia · Bruner zigzag for digits, transverse incisions in the palm · advanced
- Indication: progressive Dupuytren's contracture with functional impairment - MCP flexion greater than 30 degrees or any PIP flexion contracture, a positive tabletop test, having failed non-operative management (splinting, collagenase, needle aponeurotomy).
- The spiral cord (pretendinous band, spiral band, lateral digital sheet, Grayson's ligament, natatory ligament) displaces the neurovascular bundle centrally and volarly by up to 1 cm - the highest-risk cord for nerve injury (8-10 percent versus 3-5 percent overall).
- Regional (segmental) fasciectomy removes the diseased cords only while preserving normal fascia - the standard technique, the best balance of recurrence (20-40 percent at 5 years) against morbidity (10-20 percent).
- Find the nerve first: identify and protect the neurovascular bundle under loupe magnification BEFORE dividing any cord, starting on the ulnar side and assuming an abnormal, displaced position.
- Never close skin under tension (use Z-plasty, full-thickness skin graft for defects greater than 2 cm, or the McCash open palm technique for transverse palm wounds) and never forcefully manipulate the PIP joint (proximal phalanx fracture).
When & Why
Indication. Progressive Dupuytren's contracture producing functional impairment, having failed non-operative care, with MCP flexion contracture greater than 30 degrees (Tubiana Stage I or higher), any PIP flexion contracture regardless of degree, a positive tabletop test (cannot lay the palm flat on a table), or progressive disease documented on serial examination. Relative indications include web-space contracture limiting finger abduction, recurrence after collagenase or needle aponeurotomy, and recurrent disease after a previous fasciectomy. Assess the patient and the skin, not just the digit. Before committing, exclude or plan for:
- Dupuytren's diathesis (onset younger than 50, bilateral disease, family history, ectopic disease such as Ledderhose or Peyronie's, Garrod's knuckle pads) - recurrence risk rises to 50-80 percent versus 20-30 percent without diathesis, and may justify dermofasciectomy.
- Skin quality - blanching indicates ischaemic skin (excise and graft), puckering indicates adherence (difficult flap elevation), fixed skin indicates severe disease.
- Severe PIP contracture greater than 90 degrees - poor prognosis (less than 50 percent correction); counsel on alternatives (dermofasciectomy, PIP arthrodesis in 30-40 degrees, or ray amputation of a non-functional small finger).
- Comorbidity - diabetes (infection and CRPS risk, optimise glycaemic control), smoking (flap necrosis - encourage cessation 6 weeks pre-operatively), anticoagulation, previous hand irradiation. Contraindication. Absolute: active hand infection or systemic sepsis, severe peripheral vascular disease with inadequate hand perfusion, comorbidity making anaesthesia unsafe, or a patient unable to comply with post-operative therapy and splinting. Relative: a mild contracture less than 30 degrees at the MCP with preserved function, uncontrolled diabetes, anticoagulation that cannot be paused, or unrealistic expectations. The one decision that matters - which operation. Every fasciectomy begins by excising the diseased cord; the choice is how much fascia to remove and how to manage the skin:
The standard. Removes diseased cords only, preserves normal fascia. Recurrence 20-40 percent at 5 years, morbidity 10-20 percent, recovery 12-16 weeks - the best balance for most patients.
A single cord through a limited incision. Lowest morbidity (5-10 percent) and fastest recovery (6-12 weeks), but highest recurrence (30-50 percent) - for an isolated cord in first-time surgery.
Removes all palmar and digital fascia, including normal tissue. Lowest recurrence (10-20 percent) but highest morbidity (20-30 percent), nerve injury (10-15 percent) and recovery (24-48 weeks) - rarely indicated, for extensive diathesis or multiple recurrences.
Excises fascia and overlying skin with a full-thickness skin graft. Lowest recurrence overall (5-10 percent) but prolonged healing (16-24 weeks) - reserved for severe recurrent disease, severe PIP contracture greater than 90 degrees, or ischaemic/deficient skin.
A closure variant: transverse palm incisions are left open to heal by secondary intention over 3-4 weeks. Near-zero haematoma rate, low infection, accommodates skin deficiency - but only for the palm; digital incisions must be closed.
Consent specifically for digital nerve injury (3-5 percent overall, higher with a spiral cord), skin-flap necrosis, haematoma, CRPS, recurrence (20-50 percent at 5 years, median 3-5 years), and the realistic expectation that PIP contracture corrects less completely than MCP (50-70 percent versus 80-90 percent). Note that routine post-operative night splinting is NOT supported by randomised evidence for preventing recurrence (Cochrane), though many units still splint selectively. Setup. Supine, arm on a radiolucent hand table abducted 90 degrees at the shoulder, upper-arm tourniquet. General or regional anaesthesia, or WALANT (wide-awake local anaesthesia, no tourniquet) using 1 percent lidocaine with 1:100,000 epinephrine infiltrated 20-30 minutes beforehand. Loupe magnification (2.5-3.5x) is mandatory - identifying and preserving the neurovascular bundle is the whole operation.
The Operation
The goal: expose the diseased fascia through Bruner zigzag incisions in the digits and transverse incisions in the palm, elevate flaps that preserve the subcutaneous blood supply, identify and protect each neurovascular bundle before dividing any cord, excise the diseased cords while sparing normal fascia, release any residual PIP or web contracture, and close without tension (or leave the palm open by the McCash technique). The exposure - finding and protecting the neurovascular bundle - is the heart of the operation.
Operative sequence
- Supine, arm on a hand table abducted 90 degrees at the shoulder, upper-arm tourniquet. Anaesthesia: general, regional (axillary or Bier block), or WALANT (1 percent lidocaine with 1:100,000 epinephrine infiltrated 20-30 minutes beforehand for vasoconstriction).
- Loupe magnification 2.5-3.5x is mandatory - standard of care for identifying the neurovascular structures.
- Exsanguinate with an Esmarch bandage or elevation, inflate the tourniquet to 250 mmHg (about 100 mmHg above systolic); keep tourniquet time under 120 minutes.
- Before incision, document the Tubiana stage and total passive extension deficit per digit, palpate and mark every cord (pretendinous, central, spiral, natatory, retrovascular), and mark the planned Bruner and transverse incisions.
- Digits - Bruner zigzag: transverse limbs at 90-degree angles, offset 5 mm from the midline, each limb 10-15 mm long, with the apex centred over but never crossing a flexion crease at 90 degrees (prevents scar contracture and wound breakdown).
- Palm - transverse incisions parallel to the distal palmar and thenar creases; multiple transverse incisions are preferred over a single longitudinal incision, which would scar-contract.
- Plan Z-plasties over contracted areas: a 60-degree Z-plasty lengthens skin by about 75 percent.
- McCash option: transverse palm incisions may be left open to heal by secondary intention; digital wounds must always be closed.
- Incise skin only with a 15-blade (preserve the subdermal plexus). Never use a straight longitudinal incision in the palm or digit.
- Elevate flaps in the plane just superficial to the diseased fascia, preserving subcutaneous fat and the vascular plexus on the flap undersurface.
- Distinguish diseased from normal fascia throughout: diseased tissue is white, glistening, thickened and cord-like; normal fascia is thin, translucent and wispy.
- Diseased cord is often adherent to skin in severe long-standing disease. If skin blanches (ischaemic) or is thin (less than 2 mm), plan to excise that segment and full-thickness graft it rather than risk necrosis.
- Design flaps with a base wider than the tip (at least 1.5:1) and handle skin gently to protect the longitudinal subcutaneous vessels.
- The most critical principle of Dupuytren's surgery: identify the neurovascular bundle BEFORE dividing any cord.
- Start on the ulnar side (usually easier exposure, less disease burden), beginning in the proximal palm where anatomy is normal, then trace the bundle distally.
- With a spiral cord, assume the bundle is displaced centrally and volarly by up to 1 cm from its normal mid-lateral position.
- Use microsurgical, blunt spreading with fine tenotomy scissors - no sharp dissection near the bundle until it is positively identified. The digital nerve is a pale-yellow cord with longitudinal striations, firm but slightly compressible.
- Once identified, place a vessel loop around the bundle for protection and gentle retraction, then divide the diseased cord away from it. Repeat for the radial side.
- The common digital nerve bifurcation in the web space is particularly vulnerable - a single injury there affects two adjacent digits.
- The flexor sheath lies immediately deep to the diseased fascia and is white, glistening and smooth.
- Develop the plane between cord and sheath by blunt spreading; release fibrous adhesions from chronic inflammation carefully.
- Preserve the sheath completely - any breach causes peritendinous adhesions, triggering and stiffness.
- Preserve the critical A2 and A4 pulleys (prevent bowstringing). The A1 pulley may be released if it is thickened, triggering, or limiting correction; preserve A3 where possible.
- Excise the diseased cord from its proximal extent (where diseased meets normal fascia - preserve normal fascia) to its distal insertion (which may reach the middle phalanx or DIP), including the lateral digital sheet where it is involved.
- Regional fasciectomy removes all diseased segments while preserving normal fascia - the balance between limited (single cord) and radical (all fascia).
- Divide the cord sharply at each end only after the bundle is protected; remove en bloc where safe, or in segments.
- Send the specimen to pathology if there are any atypical features (exclude a rare sarcoma).
- After fascial excision, if residual PIP contracture is greater than 20 degrees, release sequentially: the check-rein (accessory collateral) ligaments from the volar plate bilaterally, then a proximal release of a contracted volar plate (preserve its distal insertion to the middle phalanx to avoid swan-neck).
- If severe, consider A3 release; test intrinsic tightness with Bunnell's test (PIP flexion easier with the MCP flexed than extended) and release if positive. Capsulotomy is rarely needed.
- Never forcefully manipulate the PIP joint to gain extension - high risk of proximal phalanx fracture, especially in the elderly osteoporotic patient.
- Divide a contracted natatory ligament completely at both attachments and excise the diseased cord, protecting the common digital nerve bifurcation.
- Lengthen tight web skin with a four-flap Z-plasty or V-Y advancement to prevent web creep (progressive narrowing) and restore finger abduction.
- Never close under tension - skin deficiency occurs in 10-20 percent of cases.
- Z-plasty for smaller defects (60 degrees gives 75 percent length gain); full-thickness skin graft for defects greater than 2 cm (hypothenar skin gives the best colour match; groin or medial arm for larger grafts), secured with a tie-over bolster for 5-7 days.
- McCash open palm for transverse palm wounds only (heals by secondary intention over 3-4 weeks) - digital wounds must always be closed.
- Close digits with 4-0 or 5-0 nylon, suturing the Bruner apex first to align the flaps. Secure a skin graft with a tie-over bolster (5-0 chromic long tails tied over cotton and non-adherent gauze).
- For McCash, pack the open palm with a non-adherent dressing (Xeroform or Adaptic) for daily changes.
- Apply a bulky dressing and a static extension splint: wrist 30 degrees extension, MCP 0 degrees, PIP and DIP 0 degrees, volar from fingertips to proximal forearm.
- Release the tourniquet, wait 5 minutes, and check every affected digit: capillary refill less than 2 seconds, colour (pink), warmth, and two-point discrimination on radial and ulnar sides against the preoperative baseline.
- If there is any concern for nerve or vessel injury, re-explore immediately while still in theatre, and document all findings in the operative note (a medicolegal requirement).
Before dividing any cord, identify each neurovascular bundle under loupe magnification, starting on the ulnar side in normal proximal tissue. With a spiral cord, assume the bundle is displaced centrally and volarly by up to 1 cm - assuming normal anatomy here is how nerves are transected. Loop the bundle, retract gently, and divide the cord away from it. Nerve-injury rates run 3-5 percent overall, 8-10 percent with a spiral cord, 15-20 percent with a retrovascular cord, and 10-15 percent in revision surgery. If a nerve is transected and recognised intra-operatively, repair it primarily with 8-0 or 9-0 nylon epineural sutures under the microscope; if recognised later and there is no recovery by 3 months on EMG, explore and graft (sural or medial antebrachial cutaneous nerve).
Two non-negotiable rules: do not forcefully manipulate the PIP joint to gain extension (proximal phalanx fracture in osteoporotic bone - a catastrophic, disabling complication), and never close skin under tension (flap necrosis and recurrent flexion contracture). When correction or skin is inadequate, use soft-tissue releases, Z-plasty, a full-thickness skin graft, or the McCash open palm technique instead.
Loupe magnification (2.5-3.5x) is strongly recommended and considered standard of care for Dupuytren's surgery - it is the single biggest factor in identifying and preserving the neurovascular bundles. WALANT additionally allows intra-operative testing of active digit motion and sensation, and eliminates tourniquet pain; its drawback is reliance on epinephrine (rather than a tourniquet) for haemostasis.
Grayson's ligament lies volar to the neurovascular bundle and is involved in the disease (it is a component of the spiral cord); Cleland's ligament lies dorsal to the bundle and is spared. The bundle runs between the two - a reliable way to locate it. As the spiral cord contracts through Grayson's ligament, it pulls the bundle centrally and volarward.
Early active motion (day 3-5) is the cornerstone of rehabilitation. A static extension splint maintains correction in the early phase, but the Cochrane review (Rodrigues 2015) found NO proven benefit from routine post-operative night splinting and a possible reduction in final active flexion - so splinting is now used selectively (for example, for a residual extension lag) rather than mandated as recurrence prophylaxis.
Normally at the mid-lateral line, but displaced centrally and volarly up to 1 cm by a spiral cord. The common digital nerve bifurcation in the web is most vulnerable. Protect it by finding it first under loupes and looping it.
Immediately deep to the diseased fascia. Preserve the glistening sheath to avoid adhesions and triggering; protect A2 and A4 (bowstringing); release A1 only if it contributes to the contracture.
Within the neurovascular bundle and displaced with it; may be atherosclerotic in diabetics and the elderly. Gentle dissection, low bipolar settings, and a perfusion check after tourniquet release.
Diseased fascia may be adherent to skin, which has a longitudinal blood supply. Elevate just above the fascia, design a base wider than the tip, and excise ischaemic skin rather than risk necrosis.
Osteoporotic in the elderly beneath a severe PIP contracture. Never forcefully manipulate the PIP for extension - progressive correction with therapy and splintage after soft-tissue release only.
Aftercare & Complications
Rehabilitation | Phase | Timing | Management | |-------|--------|------------| | Immediate | Day 0-2 | Bulky dressing with extension splint; elevate above the heart; ice 20 minutes on / 20 minutes off; regional block then oral analgesia; neurovascular checks every 2 hours for 24 hours | | Early motion | Day 3-5 | First dressing change; begin active ROM with a hand therapist; splint off 3-4 times daily for tendon-gliding and composite flexion/extension; oedema control; McCash daily dressing changes | | Suture removal | Day 10-14 | Remove nylon sutures (skin-graft bolster off day 5-7); active ROM 6-8 times daily; begin scar massage with silicone or vitamin E; splint between sessions and at night | | Progressive motion | Week 2-6 | Progressive ROM; oedema control (compression glove, Coban, retrograde massage); scar management; assess for CRPS, infection and stiffness; McCash wounds 75-90 percent healed by week 4 | | Strengthening | Week 6-12 | Therapy putty and graded grippers, work simulation; continue night splinting (3-6 months total); 80-90 percent of final motion achieved by 12 weeks | | Maturation | Month 3-6 | Continue strengthening; night splinting selective; scar matures over 12-18 months; full recovery around 6 months | Expected outcomes. MCP contracture corrects 80-90 percent (excellent, regardless of severity); PIP contracture corrects only 50-70 percent and worse with severity - less than 45 degrees pre-operatively 80-90 percent, 45-90 degrees 60-70 percent, greater than 90 degrees 40-50 percent. Grip strength recovers to 80-90 percent of the contralateral hand by 6 months, DASH scores improve 30-40 points, and overall satisfaction is 75-85 percent (higher for MCP-predominant, lower for PIP-predominant disease). Return to work: light duty 6-12 weeks, manual labour 12-16 weeks, full strength 4-6 months. Recurrence counselling. Recurrence is defined as a palpable cord with contracture greater than 20 degrees in a treated digit; the median time to recurrence is 3-5 years (early recurrence under 1 year suggests residual disease; late recurrence beyond 5 years suggests new disease). Recurrence runs 20-50 percent at 5 years depending on technique and diathesis, and revision surgery carries a 10-15 percent nerve-injury risk. Complications
- Recognition
- Numbness or altered two-point discrimination; may be delayed; EMG/NCS at 3 months
- Prevention
- Find the bundle first under loupes; assume displacement with a spiral cord; vessel loops; start ulnar
- Management
- Intra-op: primary 8-0/9-0 nylon epineural repair under microscope. Post-op: observe (may be neuropraxia), explore and graft (sural or MABCN) if no recovery at 3 months
- Recognition
- Darkening flap tip, no needle-stick bleed, demarcation by day 3-5
- Prevention
- Base wider than tip (1.5:1); preserve the subdermal plexus; excise ischaemic skin; never close under tension; stop smoking 6 weeks pre-op
- Management
- Local wound care and debridement; full-thickness skin graft if greater than 1 cm squared
- Recognition
- Expanding firm mass, increasing pain, tense dressing, loss of correction; within 24 hours
- Prevention
- Meticulous haemostasis with the tourniquet down; consider McCash; compressive dressing
- Management
- Small and stable: observe and elevate. Expanding or compartment syndrome: urgent evacuation. Under a graft: evacuate immediately
- Recognition
- Increasing pain, erythema, warmth, purulent drainage, day 3-7; cellulitis to deep abscess or flexor tenosynovitis
- Prevention
- Single-dose cephalosporin; sterile technique; haemostasis; diabetic control (HbA1c less than 8 percent)
- Management
- Cellulitis: oral cephalexin or clindamycin. Deep infection: IV antibiotics and drainage; urgent irrigation for Kanavel tenosynovitis
- Recognition
- Disproportionate pain, swelling, stiffness, temperature, colour and sudomotor changes; Budapest criteria
- Prevention
- Gentle technique; early motion day 3-5; vitamin C 500 mg daily peri-operatively
- Management
- Hand therapy and desensitisation; gabapentin or pregabalin; stellate ganglion block; multidisciplinary pain management
- Recognition
- Palpable cord with contracture greater than 20 degrees; median 3-5 years
- Prevention
- Complete excision; regional or radical lower than limited; dermofasciectomy for diseased skin or recurrence; routine splinting not evidence-supported
- Management
- Early: splint, collagenase, needle aponeurotomy. Progressive: revision (10-15 percent nerve risk) or dermofasciectomy; arthrodesis or amputation for severe PIP
- Recognition
- Limited active versus passive ROM (adhesions); global stiffness
- Prevention
- Early active motion day 3-5; preserve the flexor sheath; oedema control; avoid haematoma and infection
- Management
- Tendon-gliding and dynamic splinting; tenolysis if motion plateaus after 4-6 months of therapy
Viva & Exam Focus
SPIRALSPIRAL - the high-risk cord
DEFECTSDEFECTS - managing skin deficiency
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 58-year-old man has a progressive ring-finger contracture from Dupuytren's disease, with a 45-degree MCP and 60-degree PIP flexion contracture and a cord that spirals around the radial side of the digit. What is your concern and how will you manage it intra-operatively?”
“After complete fasciectomy you cannot approximate the skin edges without tension; there is a 3 cm skin deficiency over the proximal phalanx of the ring finger. How do you manage this?”
“You are operating on a 72-year-old manual labourer with a 110-degree PIP flexion contracture (Tubiana Stage IV). After complete fasciectomy there is 70 degrees of residual PIP contracture and he wants maximal correction. How do you proceed, and what would you counsel him?”
Indication
- MCP flexion contracture greater than 30 degrees, or any PIP contracture
- Positive tabletop test with functional impairment
- Failed non-operative care (splint, collagenase, needle aponeurotomy)
Critical anatomy
- Spiral cord (highest risk, 8-10 percent nerve injury) displaces the bundle centrally and volarly up to 1 cm
- Grayson's ligament volar to the bundle and involved; Cleland's dorsal and spared
- Cord types: pretendinous, central, spiral, natatory, retrovascular (very high risk)
- Preserve A2 and A4 pulleys; A1 may be released
The operation
- Find the nerve first under loupes; start ulnar; assume displacement
- Bruner zigzag digits (90 degrees, 5 mm offset, never cross a crease), transverse palm
- Regional fasciectomy: diseased cords only, preserve normal fascia
- Never close under tension; never forcefully manipulate the PIP
Skin deficiency
- Z-plasty for small defects (60 degrees gives 75 percent gain)
- Full-thickness graft for defects greater than 2 cm; tie-over bolster 5-7 days
- McCash open palm for transverse palm wounds only
Complications
- Nerve injury 3-5 percent (spiral 8-10 percent, retrovascular 15-20 percent)
- Skin-flap necrosis 2-5 percent; haematoma 5-10 percent (near-zero McCash)
- CRPS 5-10 percent; stiffness 10-20 percent
- Recurrence 20-50 percent at 5 years; dermofasciectomy lowest (5-10 percent)
Outcomes
- MCP corrects 80-90 percent; PIP corrects only 50-70 percent
- Full recovery around 6 months; manual return to work 12-16 weeks
- Routine post-operative splinting is not evidence-supported (Cochrane)
Background & Evidence
Epidemiology and diathesis. Dupuytren's disease is most common in men of Northern European descent (so-called "Viking disease"), peaking in the fifth to seventh decades, and is frequently bilateral. Dupuytren's diathesis (onset younger than 50, bilateral disease, family history, ectopic disease such as Ledderhose plantar fibromatosis or Peyronie's disease, and Garrod's knuckle pads) marks an aggressive course with 50-80 percent recurrence versus 20-30 percent without diathesis, and is an indication to consider dermofasciectomy. Pathophysiology. A fibroproliferative process: myofibroblast proliferation with excessive type III collagen deposition in an abnormal extracellular matrix, driven by cytokines (TGF-beta, PDGF, bFGF). Macroscopically the fascia thickens into cords that adhere to skin and produce secondary contracture of the check-rein ligaments, volar plate and joint capsule, with articular cartilage change from chronic flexion. Normal palmar fascia. Three fibre groups: longitudinal (from the palmaris longus at the flexor retinaculum, dividing distally into four pretendinous bands to each digit that insert at the proximal phalanx base and flexor sheath); transverse (the superficial transverse ligament at the MCP level, the natatory ligament in the web, and three commissural ligaments); and vertical (connecting skin to deeper structures and forming the septa of the palmar compartments). Diseased cord types. Disease transforms these normal bands into contractile cords, each with a characteristic course and nerve-injury risk:
- Course and contracture
- Most common; midline palm extending into the digit; causes MCP flexion
- Nerve-injury risk
- Low - bundle in normal position
- Course and contracture
- Distal continuation from the A1 pulley to the middle phalanx; PIP and DIP flexion
- Nerve-injury risk
- Moderate
- Course and contracture
- Pretendinous band plus spiral band, lateral digital sheet and Grayson's ligament; displaces the bundle centrally and volarly up to 1 cm; ring and small fingers
- Nerve-injury risk
- High - 8-10 percent
- Course and contracture
- Diseased natatory ligament in the web; limits finger abduction; common digital nerve bifurcation at risk
- Nerve-injury risk
- Moderate to high
- Course and contracture
- Passes distal to the bundle, past the bifurcation; needs microsurgical dissection
- Nerve-injury risk
- Very high - 15-20 percent
- Course and contracture
- Along the ulnar border of the small finger from abductor digiti minimi to the proximal phalanx; abducts the small finger
- Nerve-injury risk
- Low to moderate
- Total passive extension deficit
- 0-45 degrees; usually isolated MCP
- Correction and prognosis
- Excellent; 80-90 percent correction
- Total passive extension deficit
- 45-90 degrees; MCP and early PIP
- Correction and prognosis
- Good; 70-80 percent correction
- Total passive extension deficit
- 90-135 degrees; significant PIP
- Correction and prognosis
- Guarded; 50-70 percent; may need skin grafting
- Total passive extension deficit
- Greater than 135 degrees; severe MCP and PIP
- Correction and prognosis
- Poor; less than 50 percent PIP; consider dermofasciectomy, arthrodesis or amputation
Other classifications. Luck (grade 1 nodule, 2 nodule and cord, 3 established contracture) and Iselin (type 1 palmar, 2 palmar-digital, 3 digital, 4 commissural) describe disease extent; the Meyerding-Black classification grades the web space (I normal, II narrowed, III severely narrowed and requiring release). The Tubiana stage is the one that correlates with outcome and recurrence and is the exam favourite. Key evidence. van Rijssen's five-year randomised data showed 84.9 percent recurrence after needle fasciotomy versus 20.9 percent after limited fasciectomy, establishing open fasciectomy as the durable standard. The CORD I trial (Hurst) showed collagenase achieves 0-5 degrees correction in 64 percent versus 6.8 percent placebo - the non-surgical option for an isolated cord, with higher recurrence over time. Ullah's randomised trial found a "firebreak" full-thickness graft did NOT reduce recurrence (12.2 percent overall, no difference), so dermofasciectomy is reserved for diseased or deficient skin and recurrent disease rather than routine prophylaxis. The Cochrane review (Rodrigues) confirmed fasciectomy corrects severe contracture better than needle fasciotomy with lower recurrence, found no single procedure clearly superior, and showed no benefit from routine post-operative splinting.
References
Patterns of the diseased fascia in the fingers in Dupuytren's contracture. Displacement of the neurovascular bundle
- Defined the surgical fascial anatomy of Dupuytren's disease and the cord types affecting each digit
- Described the spiral cord and the mechanism by which it draws the neurovascular bundle proximally, centrally and superficially (volarly) toward the midline
- Established that the displaced digital nerve can lie directly beneath the cord at the proximal phalanx - the basis of the find-the-nerve-first principle
Five-year results of a randomized clinical trial on treatment in Dupuytren's disease: percutaneous needle fasciotomy versus limited fasciectomy
- 111 patients (115 hands) randomised to percutaneous needle fasciotomy versus limited fasciectomy, followed for 5 years
- Recurrence (increase in total passive extension deficit greater than 30 degrees) at 5 years was 84.9 percent after needle fasciotomy versus 20.9 percent after limited fasciectomy (p less than 0.001)
- Recurrence occurred significantly sooner after needle fasciotomy; satisfaction was higher after fasciectomy but most patients would still choose the minimally invasive option for any recurrence
Injectable collagenase clostridium histolyticum for Dupuytren's contracture (CORD I)
- 308 patients in a randomised, double-blind, placebo-controlled multicentre trial of collagenase versus placebo
- Reduction of contracture to 0-5 degrees was achieved in 64.0 percent of collagenase-injected cords versus 6.8 percent of placebo (p less than 0.001)
- Serious adverse events were two tendon ruptures and one CRPS; no digital nerve injuries and no systemic allergic reactions in this trial
Does a 'firebreak' full-thickness skin graft prevent recurrence after surgery for Dupuytren's contracture? A prospective, randomised trial
- 79 patients randomised to firebreak full-thickness skin graft over the proximal phalanx versus standard fasciectomy with Z-plasty closure
- Overall recurrence was 12.2 percent with no difference in correction or recurrence between groups up to 3 years
- Firebreak grafting did not improve outcomes over fasciectomy alone and took longer to perform
Surgery for Dupuytren's contracture of the fingers
- 13 trials, 944 hands; fasciectomy corrected severe contracture (Tubiana III-IV) more effectively than needle fasciotomy and had lower 5-year recurrence
- Found insufficient evidence to declare any single surgical procedure clearly superior overall, with most trials at high or unclear risk of bias
- Meta-analysis showed no benefit from postoperative night splinting and a possible reduction in final active flexion
Classic and supporting references 1. Becker GW, Davis TR. The outcome of surgical treatments for primary Dupuytren's disease - a systematic review. J Hand Surg Eur Vol. 2010;35(8):623-626. 2. Dias JJ, Braybrooke J. Dupuytren's contracture: an audit of the outcomes of surgery. J Hand Surg Br. 2006;31(5):514-521. (MCP correction 80-90 percent versus PIP 50-70 percent.) 3. Townley WA, Baker R, Sheppard N, Grobbelaar AO. Dupuytren's contracture unfolded. BMJ. 2006;332(7538):397-400. 4. McCash CR. The open palm technique in Dupuytren's contracture. Br J Plast Surg. 1964;17:271-280. (Original description of leaving transverse palm wounds open.) 5. Tonkin MA, Burke FD, Varian JP. Dupuytren's contracture: a comparative study of fasciectomy and dermofasciectomy in one hundred patients. J Hand Surg Br. 1984;9(2):156-162. (Dermofasciectomy recurrence 5 percent versus regional 20 percent at 5 years.) 6. Citron N, Messina JC. The use of skeletal traction in the treatment of severe primary Dupuytren's disease. J Bone Joint Surg Br. 1998;80(1):126-129. 7. Bulstrode NW, Jemec B, Smith PJ. The complications of Dupuytren's contracture surgery. J Hand Surg Am. 2005;30(5):1021-1025. (Nerve injury 3-5 percent, skin-flap necrosis 2-5 percent, haematoma 5-10 percent, CRPS 5-10 percent, recurrence 20-50 percent at 5 years.)