§ 01 · EPIDEMIOLOGY AND RISK FACTORS

Prevalence and the Northern European pattern

Lanting's 2014 systematic review and meta-analysis in Plastic and Reconstructive Surgery, drawing on 23 high-quality population studies, remains the most cited European prevalence reference: prevalence ranges from 0.6 to 31.6 per cent across studies, rising sharply with age.1 The wider Salari 2020 meta-analysis pools 85 studies and 6.6 million individuals, reporting a worldwide pooled prevalence of 8.2 per cent (95% CI 5.7–11.7), but the global figure is heavily weighted by referral cohorts and should not be quoted in a European or Australasian context without qualification.2
The conventional clinical teaching — Northern European descent, fifth-to-sixth decade onset, marked male predominance with a Hindocha-cohort male-to-female ratio of 5.9 to 1, bilateral involvement in approximately two-thirds — is supported by the Manchester epidemiological synthesis of Hindocha and colleagues.3 Lifetime risk of operative intervention in a Northern European population approaches several per cent.

Heritability and genetics

The strongest contemporary heritability data come from the Danish twin registry. Larsen and colleagues studied 30,330 same-sex twin pairs and reported male probandwise concordance of 0.37 in monozygotic pairs versus 0.07 in dizygotic pairs, translating to a heritability of approximately 80 per cent.4 The sibling recurrence-risk ratio in the Manchester probands was 2.9 (95% CI 2.6–3.3).5
The foundational is Dolmans and colleagues, New England Journal of Medicine, 2011 — a Dutch–German–British consortium study of 960 cases against 3,117 controls in discovery and 1,365 cases against 8,445 controls in replication.6 Nine susceptibility loci reached genome-wide significance; six harboured Wnt-pathway genes (WNT4, SFRP4, WNT2, RSPO2, SULF1, WNT7B). The strongest signal was SFRP4 (rs16879765) with an odds ratio of 1.98 and p = 5.6 × 10⁻³⁹.
Subsequent meta-GWAS work has expanded the catalogue: Becker 2016 in PLoS One (1,580 cases, 4,480 controls) confirmed all nine Dolmans loci and identified 14 additional suggestive loci, with the Wnt/β-catenin pathway emerging as the dominant deregulated network in transcriptomic analysis.7 Ng and colleagues in American Journal of Human Genetics 2017 (3,871 UK cases, 4,041 replication) identified 17 additional risk variants, bringing the total to 26 loci, and functionally validated the SFRP4 mechanism through reduced secretion in high-risk myofibroblasts.8

Modifiable risk factors

Quantified associations from contemporary meta-analyses and registry data:
  • Alcohol intake. Independent association in the GAZEL cohort of 13,587 French utility workers (Descatha 2014, BMJ Open); odds ratios rise with consumption.9
  • Smoking. Independent association in the same GAZEL cohort and in the Burke 2007 study of 97,537 UK miners.910
  • Diabetes mellitus. Up to 34.1 per cent prevalence among patients with type 1 diabetes in the Salari 2020 meta-analytical subgroup; among the strongest disease associations.2
  • Manual labour and vibration exposure. Modest dose-dependent association in the Descatha 2011 BMC Musculoskeletal Disorders meta-analysis of occupational exposure.11 The British Society for Surgery of the Hand patient material currently states that the disease "does not appear to be associated with manual work" — a position in tension with the occupational-medicine literature that is best characterised, for examination purposes, as an unresolved disagreement between the surgical and occupational-medicine traditions.1112
  • Anticonvulsant use, HIV. Reported associations in case series; mechanism uncertain.

§ 02 · PATHOPHYSIOLOGY

Luck phases

The 1959 Luck classification — proliferative, involutional, residual — remains the histological framework for the disease and is not superseded.13 The proliferative phase is dominated by hypercellular fibroblastic foci and is the substrate of the early nodule. The involutional (contracting) phase is dominated by expressing α-smooth muscle actin and is the substrate of the contracting cord. The residual phase is hypocellular, collagen-dense, and the substrate of the mature cord. The cellular correlates map onto fibroblast, myofibroblast, and fibrocyte populations across the three phases.
Re-analysis in 2010 by Lam and colleagues in the Journal of Hand Surgery (European Volume) quantified the type III to type I collagen ratio shift across phases; the diseased fascia retains a higher proportion of type III collagen than the normal fascia, contributing to the altered biomechanical behaviour.14

Signalling

The pathways relevant to the FEBHS curriculum are TGF-β and the canonical Wnt/β-catenin axis. TGF-β1 is elevated in Dupuytren myofibroblasts compared with control fibroblasts; TGF-β/Smad and ERK1/2 signalling drive the contractile phenotype, and pathway-specific inhibitors (SB-431542, BMP6) suppress the phenotype in vitro.15 The Wnt connection — first identified by the Dolmans GWAS — has been functionally confirmed in expression studies showing upregulated COL1A1 and COL3A1 in cords versus uninvolved fascia.16
The therapeutically actionable finding from the Oxford group — Verjee, Verhoekx, Nanchahal, Proceedings of the National Academy of Sciences USA 2013 — is that TNF acts as an upstream driver of myofibroblast differentiation in Dupuytren tissue, and that adalimumab reduces α-smooth muscle actin expression and collagen contraction in cord-derived cells.17 This is the mechanistic rationale that became the RIDD trial discussed in § 11.

Why this matters clinically

The pathophysiological framework informs three clinical points the examiner expects a candidate to be able to make:
  • The myofibroblast-driven involutional phase is what is amenable to operative correction; the residual hypocellular cord is mechanically resistant but biologically quiet.
  • Recurrence biology is reactivation of myofibroblast populations from residual proliferative foci, not regrowth of the same cord — which is why incomplete resection of nodular tissue at limited fasciectomy correlates with earlier recurrence.
  • The Wnt and TNF mechanistic findings provide the rationale for the only two early-disease pharmacological strategies under serious investigation: anti-TNF (RIDD) and Wnt-pathway modulation (preclinical only at present).

§ 03 · SURGICAL ANATOMY

The fascial nomenclature has two conventions: the normal palmar fascial complex described by Rayan in Hand Clinics 1999, and the McFarlane pathological cord pattern in Plastic and Reconstructive Surgery 1974.1819 The examination expects fluency in both, and especially in the anatomical translation between them — which normal structures contribute to which pathological cord, and where the is at risk.

Normal palmar and digital fascia

The palmar fascial complex comprises five components: the radial fascia, the central palmar aponeurosis, the ulnar fascia, the palmodigital region, and the digital fascia. The principal structures the surgeon encounters are:
  • The palmar aponeurosis, a triangular sheet with longitudinal, transverse, and vertical fibres. The longitudinal fibres condense into the of each finger.
  • The natatory ligament, a transverse fibre arrangement at the level of the distal palmar crease.
  • In the digit, three structures around the neurovascular bundle: volar to the bundle, dorsal to the bundle, and the lateral digital sheet between them.
  • The spiral band running from the pretendinous band, deep to the bundle, to the lateral digital sheet — the connection that, once thickened, produces the surgically critical spiral cord.
  • The Legueu–Juvara septae dividing the palm into vertical compartments.

McFarlane cord pattern

McFarlane's 1974 dissection of 69 contracted fingers in 50 consecutive cases established the modern cord taxonomy, summarised here in the form the FEBHS examination tests:
  • [g:pretendinous-cord|Pretendinous cord] — derived from the pretendinous band; produces MCP joint contracture; does not displace the neurovascular bundle. This is the single most quoted McFarlane principle.
  • [g:central-cord|Central cord] — a midline distal continuation of the pretendinous cord; produces PIP contracture without bundle displacement.
  • [g:spiral-cord|Spiral cord] — the surgically dangerous one; formed from the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament. Displaces the neurovascular bundle palmarly, centrally (toward the midline of the digit), and proximally — most marked at the level of the proximal phalanx, where the bundle can be displaced into a position immediately deep to the skin.
  • Lateral cord — derived from the lateral digital sheet; displaces the bundle medially, less dramatically than the spiral cord but still relevantly.
  • Retrovascular cord — runs deep to the bundle; commonly missed at primary surgery; contributes to PIP contracture and is the typical reason for incomplete correction at fasciectomy.
  • Abductor digiti minimi cord — the most distinctive anatomical exception; lies ulnar to the bundle of the little finger and contributes to small-finger PIP contracture without affecting the radial neurovascular structures.
  • First-web cord — distorts the thumb–index commissure; usually a spiral or natatory equivalent in this region.
McFarlane's stated principle — that the MCP joint is contracted only by the pretendinous cord, and that the neurovascular bundle is never displaced by the pretendinous cord — remains the operative anchor for limited fasciectomy.19 The PIP joint, in contrast, is reached by the spiral, central, lateral, and retrovascular cords, and bundle displacement is common; this is why PIP correction is more difficult, less predictably maintained, and a higher-risk operative target.

The palmodigital spiralling sheet

The Groningen group has refined the conventional segmental description of the palmodigital fascia into a continuous palmodigital spiralling sheet, described by Malsagova, Zwanenburg, and Werker in the Journal of Hand Surgery (European Volume) 2019.20 The spiralling-sheet model more accurately captures why neurovascular bundles can be displaced into the midline at the palmodigital junction, and why the spiral cord is best understood as a localised thickening of a continuous spiralling structure rather than as a discrete pathological neoformation.

Surface anatomy

The Mella Plastic and Reconstructive Surgery Global Open paper of 2017 — "The serpentine zone" — offers the cleanest surface-anatomy reference for the digital neurovascular spiral and is the most useful figure source for trainees learning to anticipate bundle position before incision.21 The principle the examiner reaches for: bundle position cannot be reliably predicted from skin landmarks in the spiral-cord situation, and the surgical discipline is to identify the bundle proximal to the diseased fascia and trace it distally past the cord.

Anatomy of recurrence

The biological substrate of recurrent disease is not regrowth of the same cord. It is reactivation of myofibroblast populations from residual proliferative tissue, typically nodular, that was either left behind at the index operation or that was not present at the index operation but expressed itself subsequently within the diathetic field. This distinction matters at revision: the operative target is residual or new nodular tissue, not the scar of the prior cord.

§ 04 · CLASSIFICATION, STAGING, AND DIATHESIS

Tubiana staging

The 1968 Tubiana scheme stages an affected ray by total flexion deformity (TFD): stage 0 (no disease), stage N (nodule, no contracture), stage 1 (TFD 0–45°), stage 2 (45–90°), stage 3 (90–135°), stage 4 (>135°).22 The Hindocha 2008 Hand revision incorporates the original Tubiana TFD plus nine additional clinical and diathesis criteria and correlates r² = 0.8 with the original;23 for examination purposes the original Tubiana TFD scheme is what is asked about.
The — the sum of fixed flexion contracture across MCP, PIP, and DIP joints in the affected ray — is the most widely used outcome measure in the operative literature and is the basis of both the Felici and the Kan consensus definitions of recurrence (§ 09). TPED is preferred over single-joint goniometry in trial reporting because it captures the integrated functional loss across the ray.

Hueston tabletop test

The 1982 Hand paper records the test in one sentence: "A simple test is described for the selection of patients with Dupuytren's contracture for operation."24 A positive test — inability to lay the palm and fingers flat against a table top — has historically signalled an indication for surgery. Contemporary practice considers also the patient's functional impairment, the involved joint, and the operative risk-to-benefit calculation; a positive tabletop test alone is no longer regarded as an automatic indication.

Hueston diathesis and the Hindocha modification

The original 1963 Hueston listed four features: ethnic origin (Northern European), bilateral disease, ectopic disease, and positive family history.25 The Hindocha 2006 Journal of Hand Surgery American modification — the contemporary reference — adds male sex and onset before age 50 to the original four, and demonstrates that the cumulative count predicts recurrence.26 A patient with five or six positive diathesis features has substantially higher recurrence risk than a patient with one or two; this prognostic information drives the choice of fasciectomy versus dermofasciectomy in the consent conversation.
The Abe 2004 Journal of Hand Surgery British Japanese cohort independently confirmed the major diathesis features but found that family history was not significantly associated with recurrence in their population, a divergence worth knowing for the exam.27 Population-specific diathesis weightings remain an active area of research.

Ectopic disease

The diathesis-relevant ectopic manifestations are (knuckle pads at the dorsal PIP joints), (plantar fibromatosis), and (penile fibromatosis). All three are histologically related to Dupuytren's and share the myofibroblast-driven mechanism. Their presence increases the diathesis count and worsens prognosis; their management is generally non-operative or, for Peyronie's, urological and beyond the scope of this article.

§ 05 · DIAGNOSIS AND CLINICAL ASSESSMENT

The diagnosis is clinical. History captures family history, ectopic disease, alcohol and tobacco use, diabetes, and the rate of progression. Examination distinguishes nodule from cord, identifies the affected rays, performs the tabletop test, and quantifies joint contracture by goniometry at the MCP, PIP, and DIP joints. The diathesis count is recorded as part of the routine assessment.

Examination

The relevant examination components:
  • Inspection — nodules in the palm or proximal phalanx, cords with characteristic tethering of the overlying skin, pits and dimples in the palmar skin, knuckle pads dorsally.
  • Palpation — distinguishes the firm, ropey cord from the softer, more circumscribed nodule. The natatory cord at the level of the distal palmar crease may be missed if not specifically sought.
  • Goniometry — MCP, PIP, and DIP joint passive extension deficit in each affected ray; sum to obtain TPED.
  • Tabletop test — flat-palm placement on a level surface; positive when not achievable.
  • Vascular and sensory assessment — Allen test if surgery is contemplated; baseline sensation in each digit.

Imaging

Imaging is indicated only in atypical presentations. High-resolution ultrasound can distinguish a pretendinous cord from an anomalous palmaris longus insertion or a stenosing tenosynovitis nodule when the differential is genuinely uncertain. Routine pre-operative imaging is not required for the typical case and adds no operative value.

Differential diagnosis

The differential worth knowing for the FEBHS examination includes:
  • Stenosing tenosynovitis — the A1-pulley nodule is more proximal, more discrete, and is associated with triggering rather than progressive contracture.
  • Ulnar claw posturing — dynamic and reverses with metacarpophalangeal extension; the cord-mediated contracture of Dupuytren's does not.
  • Anomalous palmaris longus insertion — rare; can present as a longitudinal palmar prominence that mimics a pretendinous cord.
  • Camptodactyly — congenital flexion contracture of the PIP joint, typically of the little finger, presenting in childhood or adolescence; not associated with palmar nodules or cords.
  • Post-traumatic scar contracture — history of injury, scar consistent with prior trauma, no nodular pre-cord biology.
The diagnostic discipline is to identify the dominant pattern rather than attempt to exclude every alternative; in the typical Dupuytren's presentation the differential is narrow and clinical examination is decisive.

§ 06 · TREATMENT LANDSCAPE (MAY 2026)

The contemporary European treatment menu, after the 2020 commercial withdrawal of from the European Economic Area and the 2019 cessation of New Zealand supply, is as follows:
| Modality | Primary indication | Recurrence at 5 years | Pooled complication rate | | --- | --- | --- | --- | | Observation | Asymptomatic nodule | n/a | n/a | | Intralesional steroid | Symptomatic nodule without contracture | n/a | Low | | Percutaneous needle fasciotomy | MCP-predominant disease, isolated palmar cord | ≈85% | 18.9% | | Limited fasciectomy | Established contracture, PIP involvement, recurrent disease | ≈21% | 17.4% | | Dermofasciectomy + FTSG | Recurrent disease, strong diathesis | Markedly reduced beneath grafts | 11.6% | | Salvage (PIP arthrodesis, ray amputation) | End-stage PIP, neurovascular compromise | n/a | n/a |
Pooled complication figures from the Krefter 2017 Hand Surgery and Rehabilitation systematic literature review;28 5-year recurrence figures from the van Rijssen 2012 Zwolle–Groningen randomised trial.29
The Cochrane review by Rodrigues and colleagues, last updated in 2015 and not yet superseded, concluded that the evidence is insufficient to declare relative superiority of one technique over another, and that the choice should be made by patient preference informed by an honest disclosure of the recurrence-versus-morbidity trade-off.30
The 2024 Finnish DETECT randomised trial (Räisänen, Annals of Internal Medicine) compared surgery, needle fasciotomy, and collagenase across six public hospitals (n = 302). At two years, surgery was superior to needle fasciotomy (78 per cent vs 50 per cent success) and superior to collagenase (78 per cent vs 65 per cent success), with three-month outcomes equivalent across all three arms.31 The DETECT 2-year data are the most recent comparative-trial figures examiners will expect a candidate to have read.
The 2025 IPD meta-analysis by van den Berge and colleagues in the Journal of Hand Surgery (European Volume) — the most current Tier 1 synthesis — found clinically relevant contracture correction comparable across limited fasciectomy, needle fasciotomy, and collagenase, with collagenase showing the highest minor-complication rate and limited fasciectomy the longest time to recurrence.32

Observation and intralesional steroid

The asymptomatic nodule does not require treatment. A nodule that is symptomatic but without joint contracture can be managed with intralesional triamcinolone — the original Ketchum series of 2000 reports approximately 50 per cent softening, with frequent need for re-injection over months to years.33 Intralesional steroid does not reverse established contracture and is not a first-line option once a cord with measurable joint deficit is established.

Collagenase clostridium histolyticum — examination context

The exam-relevant facts on collagenase, in five lines:
  • Pivotal RCT — Hurst, Badalamente, New England Journal of Medicine 2009 (CORD I) — established efficacy: 64.0 per cent of treated cords reached the primary endpoint of reduction to 0–5°, versus 6.8 per cent placebo.34
  • 5-year recurrence — Peimer CORDLESS in the Journal of Hand Surgery American 2015 — was 47 per cent overall, 39 per cent for MCP and 66 per cent for PIP joints.35
  • The European Medicines Agency withdrew the marketing authorisation for Xiapex on 1 March 2020 at the request of Swedish Orphan Biovitrum, for commercial reasons, not for safety or efficacy.36
  • New Zealand Medsafe published a Dear Healthcare Professional letter on 28 June 2019 confirming that supply of Xiaflex would cease; Pharmac formally declined the funding application in June 2025.3738
  • The Strömberg 2018 and 2022 Swedish randomised trials showed equivalent outcomes between collagenase and percutaneous needle fasciotomy at 2 and 5 years respectively, with no superiority for collagenase at either time point.3940
For a European or Australasian candidate, collagenase is therefore an examination topic and a comparator in the literature, not a current treatment option. The European examination expects familiarity with the CORD I efficacy figure, the CORDLESS recurrence figure, and the timeline of the European withdrawal.

§ 07 · LIMITED (SELECTIVE) FASCIECTOMY

Hueston's 1961 description of limited fasciectomy — selective removal of diseased fascia with preservation of normal tissue — remains the conceptual basis of the workhorse procedure.41 The technical detail of the operation is documented in the Limited Fasciectomy procedure page on this site, including pitfall callouts on incision design, neurovascular bundle identification, spiral cord handling, and PIP joint release; the present article restricts itself to the comparative-evidence framing.

Incision options

Three incision designs predominate in the contemporary literature:
  • Bruner zigzag — alternating volar–dorsal limbs along the digit; preserves digital arterial perfusion to the skin flaps; most commonly chosen for digit-only disease.
  • Longitudinal with multiple Z-plasties — straight longitudinal incision with secondary Z-plasties at flexion creases to prevent linear scar contracture.
  • McCash open palm (1964) — transverse palmar incision left open to heal by secondary intention; the Schneider 1986 series of 49 patients with mean five-year follow-up reported no haematoma, no infection, and no skin necrosis.4243 The technique remains a viable option for severe palmar disease and for the patient at high haematoma risk.
The Lubahn 1984 comparative series demonstrated that wounds closed primarily had approximately twice the complication rate of wounds left open, although the contemporary literature trends toward primary closure with attention to tension and haematoma drainage.44

Anaesthesia

— wide-awake local anaesthesia with epinephrine, no tourniquet — has accumulated supporting evidence since Denkler's original 60-digit series in Plastic and Reconstructive Surgery 2005 and the Lalonde-led multicentre series (Nelson and colleagues, Hand 2010), with equivalent range of motion, lower systemic risk, and substantial cost savings.4546 It is the contemporary anaesthetic standard for primary fasciectomy in unifocal disease and is increasingly chosen for revision and dermofasciectomy by surgeons familiar with the technique.

Operative sequence

The conceptual operative sequence of limited fasciectomy:
  1. Incision design appropriate to the cord pattern and the planned PIP release.
  2. Identification of the digital neurovascular bundle proximal to the diseased fascia, where its anatomy is undisturbed, and tracing distally.
  3. Careful dissection of the cord off the bundle and the flexor sheath, with awareness of the spiral cord's three displacement vectors.
  4. Removal of diseased fascia with preservation of normal tissue.
  5. Adjunctive PIP joint release if required — volar plate release, accessory collateral ligament release, or checkrein release (Watson 1979) as the contracture demands.47
  6. Tension-free skin closure, with consideration of a full-thickness graft in the recurrent or strongly diathetic case.
  7. Compressive dressing and early mobilisation.

Postoperative management

The Jerosch-Herold pragmatic multi-centre randomised trial of 154 patients in BMC Musculoskeletal Disorders 2011 demonstrated that routine night-time splinting after primary fasciectomy or dermofasciectomy is not recommended unless extension deficit recurs.48 This is a useful negative result to know — it represents a moderate-evidence shift away from the prior practice default of routine post-operative splinting.

Outcomes

  • MCP joint correction is well-maintained; PIP joint correction is less reliably maintained at five years and beyond.
  • The Dias and Braybrooke 2006 BSSH audit — 1,177 patients, mean follow-up 27 months — remains the largest patient-reported audit of fasciectomy outcomes: 75 per cent of patients achieved full or near-full correction, 46 per cent reported at least one complication, and recurrence or persistence was 15 per cent (158 of 1,037).49
  • 5-year recurrence in the van Rijssen Zwolle–Groningen RCT was 20.9 per cent, defined as ≥30° increase in TPED.29

§ 08 · PERCUTANEOUS NEEDLE FASCIOTOMY

The original modern series is Foucher, Medina, and Navarro from Strasbourg — 211 patients, 261 hands, 311 fingers, mean 3.2-year follow-up — published in the Journal of Hand Surgery British in 2003.50 Postoperative gain was greater at MCP than at IP joint level (79 per cent versus 65 per cent), there was a single digital nerve injury during a re-procedure, and there were no infections or tendon ruptures across the entire series. This is the citation that anchors the procedure historically and the figures the examiner expects.
The technical detail — needle gauge, insertion levels, sequence, and the "scalpel-as-needle" mechanics — is documented in the Percutaneous Needle Fasciotomy procedure page on this site, including pitfall callouts on the spiral cord and the PIP joint; the present article restricts itself to the comparative-evidence framing.

Patient selection

The principal patient-selection consideration is the MCP-versus-PIP question and the pretendinous-versus-spiral cord distinction:
  • Best indication. Pretendinous cord with predominantly MCP contracture, palpable in the palm, no spiral component apparent on examination.
  • Acceptable indication. Mixed MCP–PIP disease where the patient values a low-morbidity, repeatable intervention and accepts the higher recurrence rate.
  • Relative contraindication. Spiral cord with substantial PIP contracture, where bundle displacement makes blind needle placement higher-risk.
  • Absolute contraindication. Recurrent disease in a heavily scarred field where the bundle position cannot be reliably predicted.

Comparative evidence

The central comparative randomised trial is van Rijssen and Werker, Plastic and Reconstructive Surgery 2012 — 111 patients with minimum 30° passive extension deficit randomised to needle fasciotomy or limited fasciectomy with 5-year follow-up.29 Recurrence, defined as ≥30° increase in TPED, was 84.9 per cent in the needle fasciotomy arm and 20.9 per cent in the fasciectomy arm (p < 0.001). The clinically informative finding alongside this recurrence differential is that 53 per cent of patients preferred needle fasciotomy in the event of a recurrence — a fact that grounds the patient-preference framing of the choice.
The largest single-surgeon series is Pess, Pess, and Pess in the Journal of Hand Surgery American 2012 — 474 patients, 1,013 fingers, minimum three-year follow-up (range 3.0 to 6.2 years).51 Immediate postoperative correction averaged 99 per cent at the MCP and 89 per cent at the PIP joint; skin tears were the dominant complication. The Pess data are the figures most often cited for the immediate operative result of needle fasciotomy.
The Strömberg 2-year and 5-year randomised trials comparing needle fasciotomy with collagenase showed equivalent outcomes on most measures, with no superiority for collagenase at either time point.3940 This finding — predating the European withdrawal — has additional retrospective relevance: the modality lost was not demonstrably superior to the modality retained.

Repeatability

The repeatability of needle fasciotomy is the key pragmatic argument and is supported by van Rijssen and Werker's separate paper on recurrent disease in the Journal of Hand Surgery American 2012 — 50 per cent of patients remained free of recurrence at a mean 4.4 years after a repeat percutaneous procedure.52 The framing the examiner expects: a higher 5-year recurrence rate is not a weakness of needle fasciotomy in an appropriately selected patient who values low morbidity and accepts the trade-off, because the procedure can be repeated with comparable safety.

§ 09 · DERMOFASCIECTOMY AND THE FIREBREAK CONTROVERSY

with full-thickness skin grafting — the McIndoe and Beare salvage procedure for recurrent disease and strong diathesis — replaces both the diseased fascia and the overlying skin with a graft, on the rationale that diseased fascia regenerates beneath unaffected skin but is markedly less likely to do so beneath a graft.
The robust supporting evidence is the Brotherston 1994 British Journal of Plastic Surgery long-term series of 34 hands with mean 100-month follow-up: contracture beneath the grafts did not exceed 15° at any joint, and there was no clinically detectable recurrence.53 The Tonkin 1984 comparative series of 100 patients reached the same qualitative conclusion: recurrence beneath full-thickness grafts is very low.

The firebreak controversy

The contested question is whether a smaller "firebreak" graft — used prophylactically at primary surgery rather than as part of a dermofasciectomy in the recurrent or strongly diathetic case — also reduces recurrence. The Ullah randomised trial in the Journal of Bone and Joint Surgery British 2009 found no significant difference between firebreak FTSG and Z-plasty closure at the studied follow-up.54
The 2023 De Ketele systematic review in Hand Surgery and Rehabilitation concluded that FTSG is associated with lower recurrence but that high risk of bias and definitional heterogeneity prevent definitive conclusions.55
For examination purposes:
  • The dermofasciectomy result is robust — full skin replacement does reduce recurrence in the patient with established recurrent disease and a strongly positive diathesis.
  • The firebreak result is not robust — a small prophylactic graft at primary surgery is not clearly supported and is not the contemporary default.
  • The candidate's defensible position — dermofasciectomy is reserved for recurrent disease or strong diathesis at primary surgery; firebreak grafting is a surgeon-preference adjunct without consistent randomised support.

§ 10 · OUTCOMES AND RECURRENCE

The Werker definitional problem

Werker, Pess, van Rijssen, and Denkler reviewed 21 studies in the Journal of Hand Surgery American 2012 and demonstrated that recurrence definitions in the Dupuytren literature were so heterogeneous — varying in joint(s) measured, threshold of contracture, baseline reference point, and follow-up window — that direct cross-study comparison was impossible.56 This is the foundational paper for understanding why historical recurrence rates are non-comparable across studies. It identified the problem; it did not solve it.

Felici 2014 and Kan 2017 — the two parallel consensus definitions

Two parallel Delphi-consensus definitions were subsequently produced. The European Delphi (Felici and colleagues, Handchirurgie · Mikrochirurgie · Plastische Chirurgie 2014) defines recurrence as a passive extension deficit of more than 20° in at least one treated joint, in the presence of a palpable cord, compared to the result obtained at time 0.57 The international Delphi (Kan, Hovius, and colleagues, PLoS One 2017) defines recurrence as more than 20° of contracture recurrence in any treated joint at one year post-treatment compared to six weeks post-treatment, and explicitly does not require a palpable cord.5859
Both definitions agree on the 20° threshold and on individual-joint reporting. They disagree on:
  • Baseline timing — time of operation (Felici) versus six weeks post-operative (Kan).
  • Palpable cord requirement — required (Felici) versus not required (Kan).
  • Endpoint timing — unspecified (Felici) versus one year (Kan).
The 2019 Kan correction in PLoS One explicitly acknowledges the parallel Felici consensus.59 The Kan 2013 Journal of Plastic, Reconstructive and Aesthetic Surgery paper is the cleanest single source for putting numbers on the heterogeneity problem: across the literature, reported recurrence rates after Dupuytren treatment range from 0 to 100 per cent depending on the definition used; applied to a single dataset, the chosen definition shifted the resulting recurrence rate from 2 to 86 per cent.60
For the FEBHS examination, the candidate should be able to:
  • Name both consensus definitions and their lead authors.
  • State the points of agreement (20° threshold, individual-joint reporting).
  • State the points of disagreement (baseline timing, palpable cord, endpoint).
  • Characterise any cited recurrence figure as definition-dependent rather than as a free-standing fact.

Patient-reported outcome measures

The only Dupuytren-specific patient-reported outcome measure is the — 9 items, 0–45 score — validated in Arthritis Care and Research in 2011.61 The minimal clinically important difference is 2.9 points. URAM has been validated against Tubiana, the Cochin Hand Functional Scale, and DASH, and shown to have the highest convergent validity for Dupuytren-specific disability.62
Hensler's 2020 German validation demonstrated comparable measurement properties in a German-speaking cohort with effect size 0.96, supporting URAM use across European linguistic settings.63 The Karpinski 2020 systematic review documents the heterogeneity of outcome measures across the published Dupuytren literature and supports the development of a core outcome set.64
The Michigan Hand Outcomes Questionnaire and the QuickDASH remain useful generic upper-limb measures but are not Dupuytren-specific; the FESSH-preferred disease-specific instrument is URAM.

§ 11 · COMPLICATIONS

The pooled complication rates from the Krefter 2017 systematic literature review across 113 studies provide the contemporary headline figures:28
  • Limited fasciectomy: 17.4 per cent (95% CI 11.7–23.1). Highest rates of digital nerve and digital artery injury.
  • Percutaneous needle fasciotomy: 18.9 per cent. Skin tears the dominant complication; digital nerve injury rare but described in the spiral-cord/PIP setting.
  • Dermofasciectomy: 11.6 per cent. Lower than fasciectomy.
  • Collagenase: 78.0 per cent (95% CI 59.6–96.4). Driven by minor adverse events — skin tear, peripheral oedema, contusion — rather than serious complications.

Specific complications

  • Digital nerve injury. Highest rates reported after fasciectomy — particularly in the recurrent setting or in a heavily scarred field. The principal preventive discipline is to identify the bundle proximal to the diseased fascia, where its anatomy is undisturbed, and trace it distally past the spiral cord. The Foucher 2003 needle-fasciotomy series of 311 fingers reported a single nerve injury, occurring during a re-procedure.50
  • Digital artery injury. Rare but described in the PIP-cord setting; bundle displacement by the spiral cord is the typical reason. Direct repair under loupe magnification is the management.
  • Haematoma. A significant cause of poor wound healing and skin necrosis after fasciectomy; the open-palm McCash technique was developed specifically to address this.42
  • Skin tear. The dominant complication of percutaneous needle fasciotomy, particularly in the elderly patient with thin skin and severe MCP contracture; managed conservatively and rarely consequential.
  • Wound complications and skin necrosis. Reduced by tension-free closure, attention to flap blood supply, and primary use of full-thickness graft when closure under tension is unavoidable.
  • Complex regional pain syndrome. Reported after all modalities; incidence below 5 per cent in most series. Female sex and previous CRPS in another limb are recognised predisposing factors.
  • PIP joint stiffness. A particular concern after PIP joint release; reflects the difficulty of the PIP correction itself rather than a true new complication.
  • Recurrence. Treated as the primary outcome rather than a complication; § 10.

§ 12 · EMERGING AND ADJUNCT THERAPIES

Anti-TNF (RIDD)

The Nanchahal RIDD trial in Lancet Rheumatology 2022 — phase 2b, randomised, double-blind, placebo-controlled — randomised 140 participants with early-stage Dupuytren's nodules to four 3-monthly intranodular injections of 40 mg adalimumab or placebo over 12 months.65 The trial reported softening and reduction in nodule size at 12 months without correction of established contracture. The phase 2b finding is that anti-TNF blockade modifies early-stage disease biology; the unanswered question, as of May 2026, is whether the effect translates to long-term prevention of contracture and whether a phase 3 trial will progress to licensing. The earlier Nanchahal phase 2a dose-finding trial in EBioMedicine 2018 established the active dose used in RIDD.66
Anti-TNF for Dupuytren's is currently off-label, restricted to research settings, and not a routine treatment option. It is, however, the strongest evidence-based candidate for early-disease modification and is an examination topic in any current FEBHS curriculum.

Radiotherapy

The German radiation-oncology tradition treats early-stage Dupuytren's with orthovoltage radiotherapy — typically 30 Gy delivered as 2 × (5 × 3 Gy). The Keilholz 1996 series of 96 patients (142 hands) is the foundational reference;67 the Betz 2010 long-term Erlangen follow-up of 135 patients (208 hands) at a median 13 years reports stable disease in 59 per cent and progression in 31 per cent, with the best results in Tubiana stage N (87 per cent stable) and N–I (70 per cent stable).68
The DEGRO 2022 S2e guideline on radiotherapy of benign disorders supports radiotherapy for early Dupuytren's disease at Tubiana stage N or N–I, with no or minimal contracture and recently demonstrated progression.69 Routine availability is concentrated in Germany and selected European centres; the examination expects the candidate to know the indication, the dose, and the German-tradition geographical distribution.

Adjuncts and investigational

  • Intralesional triamcinolone for nodules. Ketchum 2000; ~50 per cent softening; frequent re-injection.33
  • Percutaneous Aponeurotomy and Lipofilling (PALF). Hovius and Khouri 2015; Kan RCT 2016 demonstrated non-inferiority at one year compared with limited fasciectomy, but the Selles 2018 five-year follow-up showed substantially higher recurrence after PALF.707172
  • External fixation for severe PIP contracture. Small case series; useful adjunct in selected end-stage cases as an alternative to PIP arthrodesis.
  • Intraoperative steroid. Limited supporting evidence; not a contemporary default.
The 2020 Sambuy RCT of limited fasciotomy with adjunctive adipose graft injection demonstrated no advantage over limited fasciotomy alone on TPED outcomes, and indeed reported worse functional scores and higher complication rates in the fat-graft group; the contemporary position is that fat-graft adjuncts are not yet supported by randomised evidence.73

Treatments not supported by contemporary evidence

  • Extracorporeal shockwave therapy. Trial evidence inconclusive.
  • Topical or oral collagenase analogues. No clinical evidence.
  • Verapamil and other calcium channel blockers. No clinical evidence in Dupuytren's.

§ 13 · GUIDELINES AND CONSENSUS

The Cochrane review by Rodrigues and colleagues remains the current systematic review of surgery for Dupuytren's contracture; no superseding Cochrane update has been published as of May 2026.30
The British Society for Surgery of the Hand patient information page is current and accessible. The substantive BSSH surgical guideline is under revision. The HAND-2 randomised trial — 406 patients comparing percutaneous needle fasciotomy with limited fasciectomy across UK centres — closed to recruitment on 31 January 2024 with two-year follow-up to 2027 and is expected to be the largest UK comparative dataset when published.
A formal AAOS or ASSH practice guideline of comparable graded methodology to the BSSH does not currently exist for Dupuytren's disease; Eaton 2011 and Rayan 2007 remain the leading US synthesis articles.7475 A formal Deutsche Gesellschaft für Handchirurgie S3-level surgical guideline is not currently registered with the AWMF; the DEGRO 2022 S2e radiotherapy guideline is the most authoritative German society document directly applicable to Dupuytren's disease.69
The de facto European consensus statements on Dupuytren's are the Felici 2014 and Kan 2017 recurrence-definition Delphi papers (§ 10).5758 These two papers, with their disagreements, are the European-consensus material the examination tests.

§ 14 · SPECIAL POPULATIONS

  • Recurrent disease. The diathesis count is the principal recurrence predictor (§ 04). Operative options include repeat needle fasciotomy (50 per cent recurrence-free at 4.4 years; van Rijssen 2012)52 and revision dermofasciectomy with full-thickness graft (Brotherston 1994).53 The decision is patient-preference-driven within an honest discussion of the recurrence-versus-morbidity trade-off.
  • Severe PIP contracture (>60°). Limited fasciectomy with adjunctive PIP joint release; alternative options include external fixation as adjunct, or salvage by PIP arthrodesis or ray amputation in end-stage disease with neurovascular compromise. The single most useful framing for the patient is that severe PIP contracture is the joint-position least reliably corrected by any procedure.
  • Diabetic patient. Higher disease prevalence; outcome data sparse but suggest comparable correction with marginally higher complication risk; no specific operative modification required.
  • Female patient. Disease less common but, when present, often more severe and progressive; the Hindocha 2006 diathesis includes male sex as a risk factor for recurrence, but female disease is not benign.26
  • Bilateral disease. A diathesis criterion. Bilateral simultaneous surgery is feasible but rarely chosen in contemporary practice; the conventional approach is to operate one hand at a time with several months between operations.
  • Ectopic disease in the same patient. Garrod's pads, Ledderhose disease, Peyronie's disease — all increase the diathesis count and worsen prognosis, but their presence is not in itself an indication for an altered operative approach beyond consideration of dermofasciectomy in strongly diathetic cases.

§ 15 · CONTEMPORARY DEBATES

The unresolved or partially resolved questions:
  • Limited fasciectomy versus percutaneous needle fasciotomy. The 5-year recurrence differential (≈85% vs ≈21%) is large; the immediate-morbidity differential favours needle fasciotomy. The choice is patient-preference-driven within an honest disclosure, and the Cochrane review supports neither as superior. The HAND-2 trial 2-year data, when reported in 2027, will be the next major comparative evidence drop.
  • Recurrence definition. Felici versus Kan. Likely to remain unresolved without a unified Delphi process; current best practice is to report under both definitions when the dataset permits.
  • WALANT versus traditional anaesthesia. Strong evidence for local-only as the contemporary default; adoption barriers are theatre culture and reimbursement structure rather than evidence.
  • Firebreak grafting at primary surgery. Negative randomised evidence (Ullah 2009) against the practice; positive narrative-review evidence; not a contemporary default but defensible in selected diathetic cases.
  • Anti-TNF for early disease. RIDD-supported but unlicensed; the question is whether phase 3 will progress and whether early-disease pharmacological prevention will become a clinical reality.
  • Radiotherapy for early disease. German-tradition standard; not in routine UK or NZ practice. The DEGRO 2022 guideline endorses it; the BSSH does not address it. The geographical inconsistency is the contemporary debate, not the evidence base.
  • Manual work as a causative factor. Occupational-medicine literature supports a modest dose-dependent association; the BSSH patient page does not. The unresolved question is how the surgical and occupational-medicine traditions reconcile.

§ 16 · SUMMARY POSITIONS

The contemporary defensible positions:
  1. Diagnose Dupuytren's disease clinically; reserve imaging for atypical cases. Record the Hindocha-modified diathesis count routinely. The Hueston tabletop test is a functional indication-for-surgery test, not a diagnostic test.
  2. The McFarlane cord pattern, with its three displacement vectors of the spiral cord and its principle that the pretendinous cord does not displace the bundle, remains the operative anatomical anchor.
  3. Offer observation or intralesional triamcinolone for the symptomatic nodule without contracture; do not offer the patient a treatment intended to prevent contracture, with the partial exception of radiotherapy in the German-practice setting and adalimumab in the research setting.
  4. Choose between limited fasciectomy and percutaneous needle fasciotomy as the patient prefers, within an honest disclosure of the recurrence-versus-morbidity trade-off. Default to limited fasciectomy where PIP involvement, established contracture, or recurrent disease predominate; default to needle fasciotomy where MCP-predominant, isolated palmar-cord disease and patient preference for low morbidity coincide.
  5. Use WALANT as the default anaesthetic for primary fasciectomy; do not splint routinely after primary fasciectomy or dermofasciectomy. Use NSAIDs with paracetamol for post-operative analgesia.
  6. Reserve dermofasciectomy with full-thickness skin graft for recurrent disease and strongly diathetic primary cases. Do not offer routine firebreak grafting in primary surgery on the current evidence.
  7. Recognise collagenase as an examination topic and a literature comparator, not a current European or Australasian treatment option. Be familiar with the CORD I and CORDLESS figures and the 2020 European withdrawal timeline.
  8. Report recurrence under a named consensus definition (Felici 2014 or Kan 2017); characterise any cited recurrence figure as definition-dependent rather than as a free-standing fact.
  9. Maintain awareness that the HAND-2 trial (2027 readout) and any RIDD phase 3 progression will materially shift the contemporary evidence base and that the present synthesis will require revision when those data arrive.
Last clinically reviewed 5 May 2026.