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Limited Fasciectomy

Open partial excision of the diseased palmar and digital fascia for Dupuytren's contracture, performed under regional anaesthesia and tourniquet through a Bruner-zigzag incision.

Last clinically reviewed

1. Indications

Limited fasciectomy is indicated for adults with whose disease has produced a fixed flexion deformity sufficient to interfere with hand function, where the cord pattern, the joint involvement, or the patient-preference profile favours an open operative approach over .
The clinical picture suited to limited fasciectomy combines:
  • a fixed flexion contracture confirmed on examination, with goniometric measurement of across the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints in each affected ray;
  • a positive or a functional impairment the patient considers worth correcting;1
  • one or more cord patterns that make a percutaneous approach inadvisable — established proximal interphalangeal contracture, disease with bundle displacement, disease, or recurrence in a previously operated field;23
  • intact and well-perfused palmar and digital skin amenable to flap elevation and tension-free closure.
Surgery is offered when:
  • the contracture is producing functional impairment the patient values correcting — typical thresholds are difficulty washing the face, putting the hand in a pocket, or completing occupational tasks that require flat-palm contact;
  • a positive tabletop test is confirmed alongside that functional impairment;1
  • the cord pattern includes a substantive proximal interphalangeal component, such that needle fasciotomy is unlikely to deliver durable correction;4
  • the disease has recurred after a prior modality and the patient values the longer interval to next recurrence that fasciectomy provides;25
  • the disease is unifocal with predominantly metacarpophalangeal involvement but the patient explicitly prefers a more durable correction over a smaller intervention with a higher recurrence rate.
The is recorded routinely.6 Limited fasciectomy performs across the full range of operative disease — Tubiana stages 1 to 4 — although severity of the proximal interphalangeal component governs the difficulty of the operation more than the overall stage. Tubiana stage 3 to 4 disease with a fixed proximal interphalangeal contracture exceeding 60° is operative territory in which the realistic gain at the proximal interphalangeal joint is partial, the operation is technically difficult, and the consent conversation requires explicit communication of expected residual deficit.78
The count — Hindocha-modified, with male sex, onset before age 50, bilateral disease, ectopic disease, and positive family history9 — does not in itself contraindicate fasciectomy, but a strong diathesis (4–5 features) shifts the consent conversation toward consideration of primary with full-thickness skin grafting in selected cases.510 This decision is rarely made on the strength of the diathesis count alone; it is taken in the context of disease pattern, prior surgery, and the patient's expressed priority for delaying recurrence.
Patient-preference factors that align with limited fasciectomy include:
  • explicit acceptance of the longer recovery and more substantive rehabilitation in exchange for greater durability of correction;
  • the cord pattern is one in which percutaneous division has a relative or absolute contraindication;
  • the patient values a single-stage operation with a clear technical correction and a documented operative finding over a series of repeatable percutaneous interventions.
Limited fasciectomy is the contemporary operative workhorse for Dupuytren's disease in European, Polish, and Australasian practice. It is one of three operative options in the contemporary algorithm — alongside percutaneous needle fasciotomy and, where licensed and available, — but it carries the longest interval to recurrence in the contemporary individual-patient-data meta-analysis and remains the default where the disease pattern is unsuited to a percutaneous approach.4

2. Contraindications

There are no specific anatomical contraindications to limited fasciectomy; the contraindications are general operative and patient-factor contraindications, with two patterns of disease in which a more extensive primary procedure is the better choice.
  • Untreated infection at the operative site, active dermatitis, or skin breakdown over the planned operative field.
  • Significant uncorrected coagulopathy or active anticoagulation that cannot be managed within the operative plan. Therapeutic warfarin requires bridging or interruption per local protocol; novel direct oral anticoagulants are managed per the patient's cardiology recommendations.
  • Medical comorbidity precluding regional anaesthesia and tourniquet use in the absence of suitable alternative anaesthetic provision.
  • Strongly diathetic recurrent disease in a heavily scarred field, where the rationale shifts toward primary dermofasciectomy with full-thickness skin graft on the basis that diseased fascia regenerates beneath unaffected skin but is markedly less likely to do so beneath a graft.510
  • Severe established proximal interphalangeal contracture with neurovascular compromise at presentation, where end-stage salvage by proximal interphalangeal arthrodesis or ray amputation may be more reliably functional than fasciectomy with adjunctive joint release.
A relative contraindication that warrants explicit naming: isolated, palpable [g:pretendinous-cord|pretendinous cord] with metacarpophalangeal-predominant contracture in a patient who values low up-front morbidity and rapid recovery and accepts the higher recurrence rate. This is the disease pattern for which percutaneous needle fasciotomy is most clearly indicated; offering fasciectomy as the first operative choice in this setting overestimates the durability advantage and underestimates the morbidity cost.211 The decision belongs with the patient within an honest disclosure of the trade-off.
The ipsilateral diagnosis of from prior surgery is not an absolute contraindication but warrants a specific anaesthetic and rehabilitation plan, and a frank pre-operative discussion of recurrent symptom risk.

3. Relevant anatomy

The operative anatomy of limited fasciectomy is the laid over the normal palmar and digital fascia described by Rayan in Hand Clinics 1999 and refined by the Groningen group's 2019 description of the .121314 Familiarity with the normal architecture is what makes the diseased architecture safe to dissect. The principal threat across the operation is the , whose position is normally predictable but is displaced by the spiral cord into a position that cannot be assumed without proximal-to-distal identification.

Normal palmar and digital fascia

The palmar fascial complex has five components — radial, ulnar, central, palmodigital, and digital. The structures the surgeon encounters at limited fasciectomy:
  • the , a triangular sheet whose longitudinal fibres condense into the of each digit;
  • the transverse fibres of the palmar aponeurosis (Skoog) — not involved in Dupuytren's disease and to be preserved at fasciectomy on the principle of selective excision;15
  • the , 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.
The palmodigital spiralling sheet described by Malsagova, Zwanenburg, and Werker in 201914 refines the segmental description of the palmodigital fascia into a continuous structure, more accurately capturing why neurovascular bundles can be displaced into the midline at the palmodigital junction.

Pathological cord pattern (operative implications)

McFarlane's 1974 dissection of 69 contracted fingers established the modern cord taxonomy.2 For the open fasciectomist, the operative implications are:
  • [g:pretendinous-cord|Pretendinous cord] — produces metacarpophalangeal joint contracture; does not displace the neurovascular bundle. The proximal half of every fasciectomy operates in this anatomy. McFarlane's principle — the metacarpophalangeal joint is contracted only by the pretendinous cord, and the neurovascular bundle is never displaced by it — is the anatomical anchor for safe proximal dissection.2
  • [g:central-cord|Central cord] — midline distal continuation of the pretendinous cord; produces proximal interphalangeal contracture without bundle displacement.
  • [g:spiral-cord|Spiral cord] — displaces the bundle palmarly, centrally, and proximally — most marked at the proximal phalanx, where the bundle can sit immediately deep to the skin.216 The spiral cord is the principal anatomical reason limited fasciectomy is performed open with proximal-to-distal bundle identification rather than from within the cord plane.
  • [g:lateral-cord|Lateral cord] — derived from the lateral digital sheet; displaces the bundle medially, less dramatically than the spiral cord.
  • [g:retrovascular-cord|Retrovascular cord] — runs deep to the bundle; commonly missed at primary surgery; contributes to proximal interphalangeal contracture and to incomplete correction.2 Identification requires deliberate dorsal exploration of the bundle after spiral and central cords are addressed.
  • [g:abductor-digiti-minimi-cord|Abductor digiti minimi cord] — the most distinctive anatomical exception; lies ulnar to the bundle of the little finger and contributes to small-finger proximal interphalangeal contracture without affecting the radial neurovascular structures.
The — the surface anatomy of the digital neurovascular spiral, described by Mella, Guo, and Hung in Plastic and Reconstructive Surgery — Global Open 2017 — is a useful operative reference for the surface position of the spiral neurovascular bundle in the digit and a surface-marking aid before incision design.17

Surface anatomy of the safe operative field

The cord is palpated in passive extension and marked along its longitudinal axis. Incision design (§ 05) is laid over this marking. The principal surface landmarks the surgeon orientates to:
  • the distal palmar crease, the transition from palmar to digital territory;
  • the proximal palmar crease, a typical proximal extent of the palmar incision when the proximal cord is to be addressed;
  • the base of the digit at the level of the metacarpophalangeal flexion crease;
  • the proximal phalanx volar surface, where the spiral cord places the bundle most superficial — and where the index of suspicion for displaced bundle position is highest at digital incision.

4. Patient positioning

The patient is supine with the operative arm abducted onto a hand table, forearm supinated, fingers and thumb gently extended. A pneumatic upper-arm tourniquet is applied over a soft padding wrap; tourniquet pressure is set 100 mmHg above the patient's measured systolic blood pressure with a maximum continuous inflation time of 90 minutes. A second hand table is positioned for the surgeon's instruments and assistant.

Anaesthesia

The standard anaesthetic for limited fasciectomy in this practice is regional block — axillary brachial plexus block under ultrasound guidance, supplemented with intravenous sedation as required for patient comfort during the operative period. Regional block provides reliable surgical anaesthesia, motor relaxation supporting tourniquet tolerance and atraumatic tissue handling, and an adequate post-operative analgesic envelope without the systemic burden of general anaesthesia.
— wide-awake local anaesthesia with adrenaline, no tourniquet — is an alternative anaesthetic approach with established evidence support for primary fasciectomy in unifocal disease, as described by Denkler in Plastic and Reconstructive Surgery 2005 and the Lalonde-led Nelson and colleagues series in Hand 2010.1819 It is offered to patients for whom regional anaesthesia is contraindicated or declined; outside that setting, regional block is the operative standard in this practice.
The hand is prepared with chlorhexidine or povidone-iodine solution and draped to expose the operative hand with the forearm and arm visible to mid-humerus. Loupe magnification (2.5× or 3.5×, surgeon preference) is used throughout. A bipolar diathermy and a low-power monopolar diathermy with a fine-tip handpiece are available; the operative field is illuminated with a head-mounted light supplementing the operating-room lights.
The instrument set is a standard hand-surgery tray supplemented with fine self-retaining retractors (cat's-paw or small Senn retractors), tenotomy and Stevens scissors, and fine-tipped (Adson or Adson-Brown) tissue forceps. A 15 blade is used for incision; a 11 blade and 64 Beaver blade are useful for fine fascial division; sharp-tipped tenotomy scissors are the principal instrument for cord dissection.

5. Approach

The skin incision is designed before tourniquet inflation, with the cord palpated in passive extension and marked. Two principal incision designs are used:
  • Bruner zigzag — alternating volar–dorsal limbs along the digit at angles of approximately 60°, with the apices placed at flexion creases. Preserves digital arterial perfusion to the skin flaps; the most commonly chosen design for digit-only and palmodigital disease.20
  • Longitudinal incision with multiple Z-plasties — straight longitudinal incision over the cord, with secondary Z-plasties at flexion creases to prevent linear scar contracture.
The choice between the two designs is governed by the disease pattern and by the surgeon's preference within that disease pattern. For palmar disease with limited digital extension, a longitudinal palmar incision with proximal and distal Z-plasties is typical. For palmodigital disease extending across the distal palmar crease and into the digit, a Bruner zigzag is the more flexible design — the apex angles can be varied along the incision to follow the cord's path and the palmar limb can be extended proximally as a longitudinal Z-plasty if the disease extends into the proximal palm.
The McCash open palm technique — transverse palmar incision left open to heal by secondary intention, described in 1964 — remains a viable option for severe palmar disease and for the patient at high haematoma risk, with the Schneider 1986 series of 49 patients reporting no haematoma, no infection, and no skin necrosis at mean five-year follow-up.2122 It is not the routine incision in this practice but is a deliberate operative option in selected cases — particularly the elderly patient with thin skin and severe palmar disease where primary closure under tension would compromise flap perfusion.
The tourniquet is inflated after exsanguination with an Esmarch bandage. The marked incision is incised with a 15 blade through skin only; subcutaneous fat is preserved on the flap to maintain the subdermal vascular plexus.

6. Key steps

  1. 1. Skin incision and flap elevation

    The marked incision is incised with a 15 blade through skin only. Skin flaps are elevated on either side of the incision in the plane between subcutaneous fat and the underlying palmar or digital fascia, with the fat preserved on the flap. Bipolar diathermy controls subcutaneous bleeders. Self-retaining retractors expose the underlying diseased fascia and the surrounding normal tissue.
    The flap edges are checked for perfusion; tension on the flap during dissection is minimised by intermittent retractor release. Where the disease has produced dermal involvement (skin pitting and adherence) the flap may be deliberately thinned in that small area; but the principle of preserving subcutaneous fat on the flap applies elsewhere in the field.

  2. 2. Identification of the digital neurovascular bundle

    The digital neurovascular bundle is identified proximal to the diseased fascia, where its anatomy is undisturbed, and is then traced distally. This proximal-to-distal identification is the central safety architecture of limited fasciectomy. Working from inside the cord, or trying to find the bundle distally where it may have been displaced by a spiral cord, is the technical pattern that generates most digital nerve injuries reported in the published series.216
    The proximal limit of dissection is at the level of the distal palmar crease or, where the disease has a proximal palmar component, in the mid-palm. At this level the bundle lies in its anatomically normal position — radial and ulnar to the flexor sheath, deep to Grayson's ligament. The surgeon identifies the bundle on the side of the diseased fascia in question (or on both sides where the disease is bilateral on the digit), confirms its identity by visualisation of the artery beneath the perineural sheath, and places a vessel loop around it as a real-time identifier through the rest of the dissection.

  3. 3. Tracing the bundle past the spiral cord

    The bundle is traced distally. Where a spiral cord is present, the bundle's path deviates from its anatomically normal position: palmarly (toward the volar skin), centrally (toward the midline of the digit), and proximally (the bundle's effective entry into the digit is more proximal than the surgeon expects).216 The traction of the spiral cord on the bundle most commonly places it immediately deep to the volar skin at the level of the proximal phalanx.
    The surgeon dissects parallel to the bundle's path, not through the spiral cord directly. Stevens-scissor dissection in the plane between cord and bundle, with frequent reorientation as the bundle's path deviates, is the technical sequence that delivers the bundle out of the spiral cord with intact perineural integrity. The bundle is followed at least to the level of the proximal interphalangeal joint, and where the dissection extends into the middle phalanx, to the level of the middle phalanx as required by the cord's distal extent.

  4. 4. Selective excision of the diseased fascia

    With the bundles loop-marked and traced through and past the spiral cord, the diseased fascia is excised. The principle is selective excision: the diseased pretendinous, central, spiral, lateral, retrovascular, and (in the little finger) abductor digiti minimi cords are removed; normal palmar aponeurosis (including the Skoog transverse fibres15) is preserved.
    The dissection proceeds proximal to distal along each cord. The proximal cord is divided sharp at its proximal extent and is then dissected distally as a single specimen, working within the cord plane and lifting the cord off the underlying flexor sheath and the bundle on either side. Where the cord extends into the digit, the dissection follows the cord across the distal palmar crease and into the proximal phalanx, with frequent re-identification of the bundle on either side.
    The retrovascular cord — running dorsal to the bundle — is the cord most commonly missed at primary surgery and the typical cause of incomplete proximal interphalangeal correction.2 It is identified by deliberate dorsal exploration after the volar cords are excised: the bundle is lifted volarly with the vessel loop, the dorsal aspect is inspected for cord presence, and where present the retrovascular cord is divided and excised.

  5. 5. Assessment of joint correction and tourniquet release

    With the diseased fascia excised, passive extension is tested at each affected joint. The metacarpophalangeal joints typically extend fully or near-fully after cord excision alone; this is consistent with McFarlane's principle that the metacarpophalangeal contracture is mediated by the pretendinous cord and resolves once that cord is removed.2
    The proximal interphalangeal joint commonly retains a residual extension deficit even after technically complete fascial excision. The decision faced at this point is whether to proceed with adjunctive proximal interphalangeal joint release — accessory collateral ligament release, checkrein resection (Watson 1979),23 or, in selected severe cases, volar plate release — to address the joint capsular and ligamentous component of the contracture.
    The threshold and operative reasoning for adjunctive proximal interphalangeal release are the subject of a separate procedure page (in preparation). For the present page, the relevant operative threshold is:
    • A residual proximal interphalangeal extension deficit of 30° or less after complete fascial excision is accepted; aggressive capsular release at this level does not reliably improve the outcome and risks added stiffness and joint stiffness.24
    • A residual proximal interphalangeal extension deficit greater than 30° to 45° prompts intra-operative consideration of staged release — accessory collateral ligament first, checkrein second — with the principle that release proceeds only as far as required to achieve the surgically reasonable correction without joint-position over-correction or volar plate injury.23
    • A residual deficit greater than 60° is the operative territory in which the realistic gain is partial, the consent conversation should have anticipated this, and the question of whether ongoing capsular release is operatively justifiable belongs with intra-operative judgement informed by the patient's stated priorities.7
    The tourniquet is released and haemostasis is achieved with bipolar diathermy. The wound is irrigated. Bleeding from the dorsal aspect of the bundle and from the small palmar cutaneous vessels at the proximal palmar incision is the most common source of post-operative haematoma; both are controllable with patience and bipolar diathermy.

  6. 6. Closure planning

    With haemostasis confirmed, the closure plan is reviewed against the residual flap geometry. Most cases close primarily with Z-plasties at the flexion creases and direct skin approximation along the longitudinal limbs of the Bruner zigzag. Where the closure would require tension at any point — most commonly across the proximal interphalangeal flexion crease in severely contracted disease — the options are:
    • McCash open palm closure at the palmar transverse limb of the incision, with the palmar wound left open to heal by secondary intention;2122
    • Z-plasty rearrangement at the flexion crease in question, sacrificing length for breadth across the high-tension area;
    • Full-thickness skin graft as a "" at the flexion crease — though the Ullah randomised trial in the Journal of Bone and Joint Surgery (British Volume) 2009 found no significant difference in recurrence between firebreak FTSG and Z-plasty closure at 36 months, so the firebreak is not a default;25
    • Dermofasciectomy with full-thickness skin graft over the cord bed, where the diathesis is strong and recurrence prevention is the primary aim — this is a deliberate change of operative plan from limited fasciectomy to a more extensive procedure, made on the table.510
    The closure plan is finalised before any single suture is placed; reactive Z-plasty or graft addition mid-closure produces the most ill-considered closures.

7. Closure

Skin closure is by interrupted simple sutures of 5-0 or 6-0 nylon, or by interrupted 5-0 absorbable monofilament where the patient prefers to avoid suture removal. Bruner-zigzag apices are closed with care at the corners — the most common site of ischaemic flap-tip necrosis is the unsupported corner of an undermined flap. A small drain is not routinely required; where dead space is significant or post-tourniquet bleeding is brisk, a small Penrose drain through the proximal palm to reduce haematoma risk is placed for 24 hours.
A non-circumferential soft bulky dressing is applied with the hand in a position of moderate metacarpophalangeal flexion and proximal interphalangeal extension — not in full extension at all joints, as this generates flap-edge tension, particularly across the proximal interphalangeal flexion crease. A volar resting splint is applied at the dressing level for the first few days for comfort and dressing protection; it is not the routine post-operative splinting that prior practice mandated, and it is removed at the first dressing change.26
Sutures are removed at 10 to 14 days; a McCash palmar wound is checked weekly until secondary closure is complete, typically at three to four weeks.2122

8. Aftercare

Routine referral to a hand therapist is standard practice for every patient undergoing limited fasciectomy. The first hand-therapy appointment is within the first one to two weeks after surgery; the therapist guides oedema management, scar management once the wound is healed, graduated active and passive range of motion, and occupational re-introduction.
Routine post-operative night-time splinting is not recommended on the contemporary evidence. 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 does not improve outcomes and is not recommended unless extension deficit recurs.26 Selective night-extension splinting may be appropriate for the patient who develops early recontracture during recovery, or who had a severe pre-operative proximal interphalangeal contracture that the surgical correction was barely adequate to address.
Patients are encouraged to begin gentle active finger range of motion from the first day, within the protection of the soft dressing. Passive and active assisted ranges are escalated by the hand therapist over the first two to four weeks. Graded scar massage is started once the wound is fully healed at two to three weeks. Return to light hand use is typical at one to two weeks; return to heavier occupational hand use is typical at six to twelve weeks depending on occupation and on the rehabilitation course.
The first scheduled clinic review is at two weeks for wound check and suture removal. The second is at six weeks, at which point the corrected position is documented as the time-zero reference for recurrence per the Felici 2014 European consensus definition (passive extension deficit of more than 20° at any treated joint, in the presence of a palpable cord, compared with the value measured at six weeks to three months postoperatively).27 Routine clinical review is offered at six months and at one year. After this, follow-up is on demand.
The patient is given a clear instruction to return at any time if a new cord becomes palpable, if the corrected position deteriorates, or if a new joint becomes affected — both because the natural history is one of progression and recurrence, and because a recurrence after fasciectomy may be addressable by repeat fasciectomy, by needle fasciotomy, or by dermofasciectomy depending on the recurrence pattern.25

9. Complications

The contemporary headline complication rate for limited fasciectomy is the Krefter 2017 systematic review pooled estimate across 113 studies: 17.4 per cent (95 per cent CI 11.7–23.1), with the highest rates of digital nerve and digital artery injury of any operative modality for Dupuytren's disease.28 The Dias and Braybrooke 2006 BSSH audit of 1,177 patients with mean 27-month follow-up reported a patient-reported complication rate of 46 per cent, with full or near-full correction in 75 per cent and recurrence or persistence in 15 per cent (158 of 1,037).29 The contrast between the 17 per cent figure and the 46 per cent figure reflects the difference between surgeon-reported and patient-reported outcomes; both are real, and both belong in the consent conversation.
The complications discussed at consent:
  • Persistent or recurrent contracture. The dominant long-term concern. Five-year recurrence in the van Rijssen 2012 randomised trial — defined as ≥30° increase in total passive extension deficit relative to the postoperative value — was 20.9 per cent.2 The Dias and Braybrooke audit recurrence-or-persistence rate at mean 27 months was 15 per cent.29 Recurrence patterns fall along the lines of disease pattern: proximal interphalangeal disease recurs more readily than metacarpophalangeal disease, and strongly diathetic disease recurs more readily than non-diathetic disease.29
  • Digital nerve injury. The highest-rate complication of limited fasciectomy across modalities. Reported rates vary across series; the Foucher 2003 needle-fasciotomy series had a single nerve injury in 311 fingers,11 but published fasciectomy series in the recurrent or scarred field report higher rates, driven by the difficulty of bundle identification in distorted anatomy.28 Prevention rests on proximal-to-distal bundle identification before any cord dissection, on tracing the bundle past the spiral cord, and on dissection in the bundle plane rather than within the cord (§ 06 Steps 2 and 3).
  • Digital artery injury. Less commonly reported separately from nerve injury; same anatomical setting (spiral cord, recurrent disease). Direct repair under loupe magnification or, in selected cases, ligation when collateral perfusion is intact, is the management.
  • Haematoma. A significant cause of poor wound healing and skin necrosis. The McCash open-palm technique was developed specifically to address haematoma in severe palmar disease.21 Prevention rests on patient release of the tourniquet before closure, on systematic bipolar haemostasis at the dorsal aspect of the bundle and at the palmar cutaneous vessels, and on selective use of a Penrose drain in cases of brisk bleeding.
  • Wound complications and skin necrosis. Reduced by tension-free closure, by attention to flap thickness (subcutaneous fat preserved on the flap, § 06 Step 1), by Z-plasty rearrangement at flexion creases, and by primary use of full-thickness skin graft when closure under tension is unavoidable.
  • Joint stiffness — particularly proximal interphalangeal joint. Reflects the difficulty of the proximal interphalangeal correction itself rather than a true new complication. The contemporary framing is that the proximal interphalangeal correction is partial in established disease and that the post-operative course contains a stiffness phase that hand therapy is intended to mitigate, not eliminate.
  • [g:complex-regional-pain-syndrome|Complex regional pain syndrome]. Reported in less than 5 per cent of cases across most series. Female sex and a history of complex regional pain syndrome in another limb are recognised risk factors, regardless of operative modality.
  • Wound infection. Less than 1 per cent in contemporary series.
  • Flare reaction. The classical "Dupuytren flare" — a localised inflammatory response with erythema, pain, and stiffness in the early post-operative period — is recognised in older literature; its incidence in contemporary practice is poorly characterised but is generally treated symptomatically with continued hand therapy and time.
Major nerve injury at primary fasciectomy in non-recurrent disease is rare. The Bulstrode 2005 review of fasciectomy complications gives the contemporary single-source synthesis of the operative complication profile and is the standard reference for the consent conversation.30

10. Evidence

The evidence base for limited fasciectomy spans Hueston 1961 (the original conceptual description), McCash 1964 and Schneider 1986 (the open-palm technique and its long-term evaluation), the van Rijssen 2012 randomised comparison with percutaneous needle fasciotomy at five years, the Dias and Braybrooke 2006 BSSH multicentre audit, the Krefter 2017 systematic review of complications, the Jerosch-Herold 2011 randomised trial against routine post-operative splinting, and the van den Berge 2025 individual-patient-data meta-analysis as the most current Tier 1 synthesis.
The Hueston Plastic and Reconstructive Surgery, Transplantation Bulletin 1961 description of limited fasciectomy — selective removal of diseased fascia with preservation of normal tissue — established the conceptual basis of the workhorse procedure and remains the conceptual anchor of the contemporary operation.31 The technique has been refined incrementally since 1961, but the principle of selective excision over radical excision is unchanged.
The McCash British Journal of Plastic Surgery 1964 description of the open-palm technique introduced the four operative principles that remain valid: transverse incisions at skin creases; division of the cords; splinting in extension for four weeks (a recommendation since superseded for primary fasciectomy by the Jerosch-Herold trial26); and palmar wounds left open.21 The Schneider, Hankin, and Eisenberg Journal of Hand Surgery (American Volume) 1986 series of 49 patients with mean five-year follow-up reported no haematoma, no infection, and no skin necrosis, with 32 per cent recurrence and 48 per cent extension — a counterweight to claims of long-term superiority of any incision approach.22 The Lubahn Journal of Hand Surgery (American Volume) 1984 comparative series demonstrated that primarily closed wounds had approximately twice the complication rate of open-palm wounds.32
The Hueston Australian and New Zealand Journal of Surgery 1984 description of the firebreak full-thickness skin graft, and the Brotherston British Journal of Plastic Surgery 1994 long-term dermofasciectomy series of 34 hands with mean 100-month follow-up, established the rationale for selective use of full-thickness skin graft in recurrent and strongly diathetic disease — recurrence beneath full-thickness grafts is very low, and contracture beneath grafts did not exceed 15° at any joint in the Brotherston series.510 The Ullah, Dias, and Bhowal Journal of Bone and Joint Surgery (British Volume) 2009 randomised trial of 79 patients found no significant difference in recurrence between prophylactic firebreak FTSG and Z-plasty closure at 36 months — a negative result that means the firebreak is not the default at primary fasciectomy.25
The van Rijssen Plastic and Reconstructive Surgery 2012 randomised trial of 111 patients (115 hands) with a minimum 30° passive extension deficit, comparing percutaneous needle fasciotomy with limited fasciectomy at five-year follow-up, is the central comparative document for the operative choice between modalities.2 Recurrence at five years was 20.9 per cent in the fasciectomy arm versus 84.9 per cent in the needle-fasciotomy arm (p < 0.001). The fasciectomy recurrence figure is the contemporary anchor for the recurrence-versus-morbidity trade-off discussion at consent.
The Dias and Braybrooke Journal of Hand Surgery (British Volume) 2006 BSSH audit of 1,177 patients with mean 27-month follow-up 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).29 The patient-reported complication rate is a useful counterweight to surgeon-reported figures and grounds the consent conversation in patient-centred outcomes.
The Krefter Hand Surgery and Rehabilitation 2017 systematic review across 113 studies pooled complication rates across modalities: limited fasciectomy 17.4 per cent (95 per cent CI 11.7–23.1), with the highest rates of digital nerve and digital artery injury.28 This is the contemporary headline figure for the surgeon-reported fasciectomy complication rate.
The Jerosch-Herold BMC Musculoskeletal Disorders 2011 pragmatic multi-centre randomised trial of 154 patients demonstrated that routine night-time splinting after primary fasciectomy or dermofasciectomy does not improve outcomes and is not recommended unless extension deficit recurs.26 This is the moderate-evidence basis for the contemporary practice of selective rather than routine post-operative splinting.
The WALANT–Dupuytren evidence — Denkler in Plastic and Reconstructive Surgery 2005 (60 consecutive digits) and Nelson, Higgins, Conrad, Bell, and Lalonde in Hand 2010 (multicentre 102 fingers under WALANT versus 46 under general anaesthesia across 111 patients) — supports wide-awake local anaesthesia with adrenaline and no tourniquet as a legitimate alternative to regional anaesthesia for primary fasciectomy in unifocal disease, with equivalent range of motion, lower systemic risk, and substantial cost savings.1819 Adoption is surgeon-preference within the available evidence.
The van den Berge Journal of Hand Surgery (European Volume) 2025 individual-patient-data meta-analysis is the most current comparative synthesis: clinically relevant contracture correction is comparable across limited fasciectomy, percutaneous needle fasciotomy, and collagenase; collagenase carries the highest minor-complication burden; limited fasciectomy delivers the longest time to recurrence.4 This is the contemporary anchor for the position that fasciectomy is the most durable of the three modalities at the cost of the highest up-front morbidity.
The Räisänen DETECT trial in Annals of Internal Medicine 2024 — multicentre randomised trial across six Finnish public hospitals, 302 patients, two-year follow-up — found surgery (limited fasciectomy) superior to needle fasciotomy (78 versus 50 per cent success) and to collagenase (78 versus 65 per cent success) at two years, with three-month outcomes equivalent.33 The trial reinforces the same direction of difference established by van Rijssen 2012 in a contemporary public-system setting.
The Cochrane review of Rodrigues et al. 2015 remains the current Cochrane synthesis as of May 2026 and characterises much of the comparative literature as insufficient evidence;34 the BSSH HAND-2 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.35
Recurrence figures are sensitive to definition; the Werker, Pess, van Rijssen, and Denkler 2012 review documented heterogeneity from 0 to 100 per cent across 21 published studies depending on the definition applied.36 The contemporary consensus definitions are the Felici 2014 European Delphi (passive extension deficit of more than 20° at any treated joint, in the presence of a palpable cord, compared with the postoperative value at six weeks to three months)27 and the Kan 2017 international Delphi (no palpable cord required; baseline at six weeks; endpoint at one year).37 Either definition is acceptable for trial reporting.
A formal AAOS or ASSH practice guideline of comparable graded methodology to the BSSH guideline does not currently exist for Dupuytren's disease; Eaton 2011 and Rayan 2007 remain the leading US synthesis articles.38 A specific German handchirurgische S3 Leitlinie zum Morbus Dupuytren is not currently registered with the AWMF as of search date in May 2026.
For patients — plain-language summary

What the operation involves

Limited fasciectomy is the standard operation for Dupuytren's contracture of the hand. The diseased tissue under the skin of your palm and finger — the cord that is pulling your finger down — is opened up through a zigzag or longitudinal cut, dissected away from the nerves and blood vessels around it, and removed. The skin is then closed with stitches. The operation typically takes one to two hours per finger.
You are awake but the arm is numb. The standard anaesthetic for this operation in this practice is a regional block — local anaesthetic placed around the nerves at the armpit, which numbs the whole arm for several hours. You are sedated for comfort during the operation if you wish. A tourniquet on the upper arm prevents bleeding so the surgeon can see the small nerves and vessels clearly during the dissection.

What to expect immediately afterwards

You go home with a soft padded dressing on the hand and arm, with the fingers held in a comfortable position. The arm-block wears off over six to twelve hours; simple painkillers — paracetamol with anti-inflammatories if you can take them — are usually sufficient once the block has worn off.
You will be referred to a hand therapist before or at the time of your operation, and your first appointment with the therapist is within the first one to two weeks. The therapist will guide your exercises, help with swelling, work on the scar once it is healed, and help plan your return to work.

The first weeks

The dressing stays on and stays dry until your wound check at 10 to 14 days, when the stitches are removed. You can use the hand for light tasks during this time — eating, dressing, light kitchen work — within the protection of the dressing. Most patients return to office or light work at one to two weeks. Heavier work and full hand use typically takes six to twelve weeks depending on the type of work and how the rehabilitation goes.
A night splint to hold the finger straight overnight is not routinely used after this operation. It is sometimes prescribed if early signs of the contracture coming back are seen during the recovery, but it is not the default.

What to expect long term

Limited fasciectomy is the most durable of the operations available for Dupuytren's contracture, but the disease can return over time. Around one in five patients have a recurrence within five years; some people develop disease in a different finger or in the other hand. If the cord does come back, the options at that point depend on where the disease has returned and how severe it is, and they include needle fasciotomy, repeat fasciectomy, or — in selected cases — a more extensive operation called dermofasciectomy with a skin graft.
The realistic gain from this operation depends on which joints are affected. The metacarpophalangeal joint (the joint at the base of the finger) typically straightens fully or near-fully. The proximal interphalangeal joint (the middle joint of the finger) often retains some residual bend even after a technically successful operation, particularly when the contracture there was severe before surgery. The expected residual position will be discussed with you before the operation.

When to seek attention afterwards

Contact the practice if the hand becomes swollen, red, or hot in the days after the operation; if a finger becomes numb or starts to feel cold; if the dressing becomes wet or comes loose; or if pain is not controlled by simple painkillers. A clinic review can be arranged at any time.

References

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