Surgery for Dupuytren Contracture Technique

Updated: Nov 04, 2019
  • Author: Steve Lee, MD; Chief Editor: Harris Gellman, MD  more...
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Closed fasciotomy

In closed fasciotomy for Dupuytren disease, a limiting cord of diseased, superficial fascia is incised via an overlying skin incision. This technique can be successful in metacarpophalangeal (MCP) contractures but is not as useful for proximal interphalangeal (PIP) contracture, in that more than one cord is usually present. Closed fasciotomy presents some risk of neurovascular injury.

One indication described is to facilitate hygiene in a debilitated elderly patient who has contractures that keep the fingernails in contact with the palmar skin or produce secondary wounds. Closed fasciotomy has also been used as an initial stage in very severe contracture to facilitate further release.

In a nonselected series of 160 patients treated with closed fasciotomy, with a 10-year follow-up for the 51% of patients remaining alive, Duthie and Chesney concluded that closed fasciotomy is a useful procedure for patients who may be "unsuitable for local fasciectomy." [17]  Although contracture progressed in most patients, 34% required no further surgery, and the mean time to fasciectomy for the remaining 66% was 5 years. A 4% complication rate was described for this outpatient surgery, performed with local anesthesia or nerve block. [18]

Open fasciotomy

Open fasciotomy allows direct visualization of neurovascular structures. The offending cord is divided at a point not immediately underlying the skin incision. Fasciotomies are usually most successful for MCP flexion contracture. This procedure can be performed with local anesthesia, and recovery is rapid; however, the recurrence rate is high. Open fasciotomy is usually reserved for patients who cannot tolerate a more extensive procedure.

Segmental aponeurectomy of Moermans

Segmental aponeurectomy of Moermans [19, 20]  is a procedure that is intermediate between simple fasciotomy and limited fasciectomy. Segments (1 cm in length) of fascia are excised through C-shaped incisions. Moermans claimed that a Dupuytren cord can resolve once the tension across it is diminished. A prospective study performed by Andrew and Kay demonstrated a recurrence rate comparable to that of other techniques, but with fewer complications. [21]  This is an outpatient procedure.

Percutaneous needle fasciotomy

Percutaneous needle fasciotomy (PNF), adopted by a group of French rheumatologists and repopularized by Foucher and other European surgeons, is a minimally invasive treatment that is usually performed as an office procedure with local anesthesia. [22, 23]  It involves multiple puncture sites and sectioning of the Dupuytren cord using the bevel of a needle.

In study of 211 older patients, (average age, 65 years), one digital nerve injury, no infections, and no tendon injuries were found with needle "aponeurotomy." [24]  However, recurrence (58%) and disease activity (69%) were high at the 3-year follow-up.

Foucher et al believed this technique to be ideal for the elderly patient with a bowing cord and a predominant MCP joint contracture. [24]  Limitations of fasciotomy in treating digital disease and PIP contracture were again noted.

Contraindications for PNF include infiltrating disease, rapid recurrence in a young patient, inaccessible multiple cords, chronic digital disease, and postsurgical recurrence in the digits. [24]

Van Rijssen et al [25]  compared PNF with limited fasciectomy, with short-term follow up, and found less discomfort, quick recovery, and better immediate hand function in the PNF group. PNF demonstrated an improvement of 63% in passive extension deficit and no significant complications. Whereas fasciectomy produced more improvement in contracture, particularly in more advanced cases, the major complication rate was 5%. The authors also noted the need to avoid applying PNF in a zone at the junction of the palm and the base of the finger where the neurovascular bundle may be displaced superficially and toward the midline and be more vulnerable to injury.

Van Rijssen et al concluded from another study that PNF was a good treatment alternative to limited fasciectomy in patients with a total passive extension deficit of 90º or less.


Regional Palmar Fasciectomy

Regional, or limited, palmar fasciectomy is the most commonly performed procedure for Dupuytren disease. In this procedure, only the diseased parts of the superficial fascial aponeurosis are excised—including, for example, pretendinous cords and involved natatory ligaments in the palm, as well as the visibly affected structures in the fingers. Although Dupuytren disease may recur or progress by extension in the nonoperated areas of the hand, good results have been obtained, with acceptable complication rates. [7, 26]

In one study, Hueston concluded that regional fasciectomy does not prevent recurrence but does allow correction of deformity, with more rapid recovery of hand function. Complications were described in 96 operated hands, with hematoma in 7.5%, problematic or persistent edema in 15.5%, digital nerve injury in 2%, skin necrosis in 2%, and wound infection in 1%. [7]  "Functional recovery" was delayed beyond 6 weeks in 15.5%. The rate of hematomas was found to be less than half of that reported in radical fasciectomy. At 2-year follow-up, 27 patients were found to have "extension," and 12 were found to have true recurrence of diseased tissue.

Percutaneous aponeurotomy has been described as an potential minimally invasive alternative to limited fasciectomy in this setting. [27]

A three-dimensional fasciectomy (3DF) approach has been described that is intended to unite various forms of limited fasciectomy while excising all potentially diseased tissue and lacking the high complication rates associated with radical fasciectomy. [28]


Radical Fasciectomy

Radical, or total, surgery was thought by McIndoe and Beare to "cure" Dupuytren disease. [6]  They sought to eliminate recurrent Dupuytren disease through complete removal of the palmar aponeurosis and natatory ligaments, working from the idea that Dupuytren nodules cannot form if no remnant of palmar fascia is present. In the digits, all diseased cords and tissue that may be affected are excised.

McIndoe and Beare [6]  reported satisfactory results in over 200 cases with an extended or total palmar fasciectomy utilizing a transverse palmar incision with separate Z-plasty incisions (used, when necessary, in the digits). The authors, who employed hypotensive anesthesia and drains, reported that skin grafting was practically never necessary. Specific data on complications were not provided.

Whereas McIndoe and Beare believed that small hematomas would drain spontaneously, others reported hematoma formation with subsequent swelling and stiffness (as well as infection) to be a formidable problem with this procedure. [7]

Unfortunately, recurrent disease was not eliminated by the more extensive surgery. Hueston found a nearly equal recurrence rate at 5- to 15-year follow-up in a comparison of limited fasciectomy and more radical procedures. [7]  He reserved radical fasciectomy for those few patients with extensive and diffuse involvement of the entire palm in Dupuytren disease. He found this approach to be necessary in roughly 10% of his patients.

McCash reduced the incidence of hematoma by leaving his transverse palmar incision open for closure by secondary intention (open palm technique). [29]  The McCash technique is most often used when diffuse involvement of the entire palm dictates extended or radical fasciectomy. A delayed skin graft can be employed for closure of the palmar wound.



Hueston encountered a 28% overall rate of recurrence following surgical treatment of Dupuytren disease. Early and aggressive (or repeated) recurrence was seen in younger patients. Full-thickness skin grafts appeared to "arrest" this process. Hueston theorized that the skin flaps overlying fasciectomy were the (extrinsic) source of recurrent Dupuytren tissue, rather than unresected elements of palmar fascia left after fasciectomy. [30, 31]

These observations led Hueston to employ dermofasciectomy for recurrent disease, particularly in the digits. In dermofasciectomy, diseased fascia and the overlying skin are excised completely, and full-thickness skin grafting is applied for closure. Later reports of McCann and Logan suggested the dermis as a possible source for myofibroblasts causing recurrent disease. [32]

Tonkin reported that dermofasciectomy with skin grafting prevented recurrent Dupuytren disease without compromising hand function, suggesting it as a prophylactic approach in young patients with Dupuytren diathesis. [33]

Logan recommended dermofasciectomy as the first line of treatment for recurrent digital Dupuytren disease but found that it did not prevent recurrence in all cases. [34]  He also noted that the immobilization required for the associated skin grafts interfered with early postoperative rehabilitation.

McFarlane criticized this approach on the grounds that it may not address the presence of diseased retrovascular tissue and suggested that the exposed flexor tendon sheath is unfavorable as a graft bed. He felt that it was usually possible to separate the diseased fascia from the overlying skin.

Other authors confirmed recurrent Dupuytren disease following this procedure. [35, 36]  Armstrong et al found a recurrence rate of 11.6% in 103 patients undergoing dermofasciectomy, but they still advanced it as the best method for control of "diffuse Dupuytren disease with involvement of the skin." [37]  They raised the possibility that dermofasciectomy was unpopular because of concerns about the success of the skin grafting required.


Distraction and Passive Extension Techniques

Successful use of bone distraction and tissue expansion techniques has led to the use of distraction devices in conjunction with fasciectomies. According to Messina, this technique of gradual passive extension allowed salvage of severely contracted digits. [38, 39, 40, 41]

The application of continuous passive extension was used to elongate the contracted palmar fascia. Authors described reorganization of the once densely packed collagen fibers in the cords of Dupuytren disease into a parallel, ribbonlike appearance. [39]

In 1994, another device for PIP extension, referred to as the Proximal Interphalangeal Skeletal Traction Extender, was introduced by Hodgkinson for preoperative outpatient use. [42]  The rationale was that this device should make adjacent tissues more available and decrease PIP flexion contracture, thereby facilitating successful surgery.


Correction of Proximal Interphalangeal Joint Contracture

Correction of the PIP joint is a more difficult technical problem in Dupuytren disease. If complete extension is not obtained by careful digital fasciectomy, the options are either to rely on postoperative therapy and splinting or to perform some form of volar PIP joint release. PIP joint release is usually employed when the flexion contracture is greater than 30º. The flexor sheath can be incised and the lateral proximal attachment of the volar plate (so-called checkrein ligaments) released, as necessary.

However, if these maneuvers do not achieve full PIP extension, some have recommended further joint capsulotomy, as described by Curtis. [43]  His stepwise approach involved sequential release of accessory collateral ligaments followed by release of the proper collateral ligaments on one side of the joint at a time until full joint extension was achieved or all structures had been released.

Others have cautioned that the correction achieved at surgery would not be maintained and that aggressive capsulotomy of the PIP joint is likely to result in permanent loss of flexion range, which is more limiting than a mild flexion contracture. [44]

In 1979, Watson et al examined 115 checkrein releases and found full intraoperative extension in 110 joints, with additional release necessary in only five joints. [45]  They concluded that releasing the accessory collateral or proper collateral ligaments is almost never required with successful checkrein excision.

McFarlane and Botz discouraged the use of capsulotomy in patients with chronic PIP contracture if correction to 40º of flexion or less could be obtained. [44]

A study by Weinzweig et al of 42 involved PIP joints in 28 patients demonstrated no advantage to capsuloligamentous release in comparison with fasciectomy alone. [46]  The authors also felt that stretching or adherence of the extensor mechanism with prolonged flexion contracture could render it ineffective, contributing to late return of flexion deformity.

Alternative procedures

Alternatives for severe PIP joint contracture include arthroplasty (including implant arthroplasty) and arthrodesis. The shortening concomitant with arthroplasty (or arthrodesis) results in improvement of the contracture. Whereas PIP arthrodesis establishes a desired functional angle at the joint, it further limits function.

Amputation is rarely necessary in digital disease. It is usually performed in elderly patients with a severely contracted fifth digit following thorough surgeon-patient discussion and realistic analysis of attainable function.

Distal interphalangeal joint hyperextension

Hyperextension of the distal interphalangeal (DIP) joint usually occurs secondary to long-standing PIP joint contracture, with foreshortening of the Landsmeer ligament (oblique retinacular ligament); the DIP joint itself remains normal. If DIP joint deformity is passively correctable, it usually resolves with correction of PIP contracture. If it is not passively correctable, division of Landsmeer ligaments usually corrects the deformity. Severe fibrosis of dorsal skin related to knuckle pads can also limit DIP joint flexion.


Wound Closure

Skin grafting

Excision of skin (and fascia) leaves a wound that requires additional coverage. Although McIndoe and Beare believed that grafts were practically unnecessary, [6, 47]  they reported a lower recurrence rate of Dupuytren disease when grafts or flaps were placed in flexion creases. It has generally been believed that skin replacement should be reserved for young patients who have an active diathesis, postfasciectomy recurrence, or a rapid progression of skin fixation and deformity. [48]  Skin grafting has also been used in conjunction with the open-palm technique of McCash.

Good results with a technique of limited palmar fasciectomy with skin grafting have been reported. [49]

Reports have not confirmed either a lower rate of recurrence or better functional results when skin grafting is combined with other procedures. [50]

Generally, authors recommending digital dermofasciectomy prefer full-thickness skin grafting to split-thickness skin grafting, because of increased wound contraction beneath the latter. Ipsilateral inner-arm donor sites can be used for skin grafting; distant donor sites, including the distal lower extremity, have been suggested for improved cosmesis. [37]

The successful use of skin grafts requires a protective dressing and precludes early or vigorous interphalangeal (IP) joint movement. [51]


Local flap wound closure (beyond Z-plasty) has rarely been used. An L-shaped skin flap, called the Jacobsen flap, was developed as a modification of the McCash technique by Tripoli and Merle. [52]  Upon flap transposition, a more limited 15mm palmar skin defect is left to heal by secondary intention. The authors reported satisfactory correction of contracture and a low complication rate in 98 cases using this technique.

Free microvascular transfer of a circumflex scapular artery perforator flap was reported for coverage of a very large palmar defect after radical dermofasciectomy for disabling recurrent Dupuytren disease. [53]  After multiple revisions and extensive hand rehabilitation, flexion deformities were significantly improved and satisfactory function was obtained.


Postoperative Care

Proper postoperative care is essential for a successful surgical outcome. The protocol includes splinting in extension and an exercise regimen with a therapist for the institution of range-of-motion (ROM) exercises within the first week after surgery. Patients who undergo PIP joint surgery commonly undergo 6 weeks of continual splinting, including splinting at night, and may require bracing for as long as 3 months overall to minimize secondary scar contractures. [54, 55]  A 2017 systematic review cast doubt on the utility of static night orthosis after surgical correction of Dupuytren contracture. [56]

Given that surgery for Dupuytren disease is most often performed on an outpatient basis, close follow-up in the early postoperative period is recommended. Early motion is encouraged. Some surgeons feel that routine, formal, supervised hand therapy at an early stage of healing is important for functional rehabilitation. Many use intermittent static extension splinting for more resistant contractures. As wound healing progresses, the patient can be encouraged to use the hand in activities of daily living, and more vigorous passive ROM exercises can be employed.



Early complications


Tourniquet release and meticulous hemostasis prior to wound closure are recommended. Adequate drainage, such as an open area in a palmar surgical site, has been beneficial.

Skin loss

Skin flaps can fail for many reasons, but underlying hematoma is a frequent problem. The skin may be very thin after dissection from the underlying fascia. In this situation, if skin viability is in doubt, a preemptive skin graft may be a better option. Potential donor sites can be identified preoperatively.


Infection usually follows hematoma, skin loss, or both. If contracture prevents adequate skin preparation, a fasciotomy can be performed as a preliminary measure before definitive fasciectomy.

Division of digital nerve or artery

Dissection in a fasciectomy is similar to neurolysis; that is, the involved neurovascular bundles must be dissected free along the entire course of the surgical wound. The area of greatest risk is adjacent to the web space over the base of the proximal phalanx. Awareness of the displacement of the neurovascular bundle to the midline by a spiral cord is important. Surgeons should be prepared for appropriate repair of divided nerves and arteries.

Late complications

Loss of flexion range

This is a common late complication. Active and passive preoperative ROM should be recorded. Active flexion exercises should be part of early postoperative care. Maintenance of flexion range is often neglected in the effort to regain full extension. Schneider reported a 41% loss of flexion range after surgery for palmar disease. [2]

Reflex sympathetic dystrophy (complex regional pain syndrome type 1)

Several authors have warned that reflex sympathetic dystrophy (RSD; now commonly known as complex regional pain syndrome [CPRS] type 1) is a significant problem after surgery for Dupuytren disease. [57, 58, 59]  Luck reported that features of RSD were observed with increased frequency after surgery for Dupuytren disease. [60]  This complication is at least five times more common in women than in men with Dupuytren disease.

Other postoperative pain

Local hyperalgesia, possibly due to digital nerve injury and neuroma formation, can be problematic. [60]


Recurrence (ie, Dupuytren tissue forming in the area of resection) and recurrence of flexion deformity with disease extension (ie, Dupuytren tissue appearing outside the area of resection) are believed to be separate entities. [61]  Recurrence is much more likely in a young patient with a strong family history and knuckle pads. [7]  A recurrence rate ranging between 26% and 80% has been reported.

In his evaluation of 224 patients who underwent fasciectomy, Hueston concluded that recurrence is rare after 2 years postoperatively. He also concluded that recurrence is less frequent in older patients but is an early postoperative event in younger patients with Dupuytren diathesis, with some patients requiring multiple reoperations. [30, 31]  The incidence of recurrence has been decreased, but not completely eliminated, with skin replacement techniques.

Definitions of what constitutes recurrence of Dupuytren disease have varied in the literature. A group of 21 experts arrived at a consensus definition, proposing that recurrence be defined as more than 20º of contracture recurrence in any treated joint at 1 year after treatment as compared with 6 weeks after treatment. [62]  In addition, the group recommended that recurrence should be reported individually for every treated joint and that afterward, measurements should be repeated and reported yearly.