Dupuytren’s contracture is a progressive condition in which connective cords form, thicken, and shorten (typically in the connective tissue of the palmar fascia), causing permanent flexion contractures of joints and of one or more fingers. The metacarpophalangeal joint (MCP) and the proximal interphalangeal joint (PIP) are most often affected. Eventually, the contractures lead to hand deformity and impaired hand function, and potentially reduced quality of life for the affected individual. Dupuytren’s contracture may present as an unilateral or bilateral disease. The primary cause of Dupuytren’s contracture has yet to be determined, although there is a strong hereditary component.

There is no cure for Dupuytren’s contracture and only a handful of treatment options exist. The most commonly used treatments are surgery (partial or total fasciectomy), fasciotomy, collagenase clostridium histolyticum injections, or corticosteroid injections. Surgery (especially open, partial fasciectomy [OPF]) is the mainstay treatment option, which is recommended for functionally impaired patients with contractures more than 30 degrees of the MCP joint. There is some disagreement as to when surgery is recommended when PIP joints are affected.

There are two types of fasciotomy: open fasciotomy where the surgeon uses a scalpel to section the cords, and closed fasciotomy or percutaneous needle fasciotomy (also called aponeurotomy [PNF]), which involves a minimally invasive technique whereby a small needle is used to weaken and manipulate the cords. With percutaneous needle fasciotomy, the cords eventually break after being weakened by means of passive finger extension.

Collagenase clostridium histolyticum (CCH) has recently been approved by Health Canada as treatment for Dupuytren’s contracture in adults with a palpable cord. The monthly injection of CCH (up to three injections per Dupuytren’s cord) hydrolyzes the collagen in the Dupuytren’s cord, thereby resulting in enzymatic disruption of the cord and release of the contracture.

The objective of this report is to conduct a review of the clinical evidence regarding open and closed fasciotomy for treating Dupuytren’s contracture compared with fasciectomy and collagenase clostridium histolyticum. The cost-effectiveness of the fasciotomy techniques will also be reviewed. This is an update to a previous Rapid Response report.

Contents

• CONTEXT AND POLICY ISSUES
• RESEARCH QUESTIONS
• KEY FINDINGS
• METHODS
  • Literature Search Strategy
  • Selection Criteria and Methods
  • Exclusion Criteria
  • Critical Appraisal of Individual Studies
• SUMMARY OF EVIDENCE
  • Quantity of Research Available
  • Summary of Study Characteristics
  • Summary of Critical Appraisal
  • Summary of Findings
• LIMITATIONS
• CONCLUSIONS AND IMPLICATIONS FOR DECISION OR POLICY MAKING
• REFERENCES
• APPENDIX 1 Selection of Included Studies
• APPENDIX 2 Summary of Study Characteristics
• APPENDIX 3 Summary of Critical Appraisal
• APPENDIX 4 Summary of Findings