Dupuytren's contracture – Criteria Led Commissioning Statement

Scope

This commissioning statement refers to:

  • Dupuytren's contracture (Dupuytren's disease) which is a condition that affects the hands and fingers. It causes one or more fingers to bend into the palm of the hand. It can affect one or both hands, and sometimes affect the thumb

Status

​Eligibility Criteria ​

Management of Dupuytren's Contracture depends on the stage of the disease.

Dupuytren's can still be classified as mild, moderate and severe to guide treatment options:

Table 1: Staging of Dupuytren's disease

TFD (total flexion deformity) is the total of the degrees of flexion across all joints in a single finger.

Stage

Deformity

Equivalence to grading used in original GM policy for multiple joint disease

0

No lesion

No disease

N

Palmar nodule without presence of contracture

Minimal early disease

1

TFD between 0° and 45

Mild disease in a single join

2

TFD between 45° and 90°

Moderate

3

TFD between 90° and 135°

Severe

4

TFD greater than 135°

Severe

Surgery of Dupuytren's contracture will only be funded in accordance with the criteria specified below:

  • Flexion deformity >30° at the MCPJoint or PIPJoint OR
  • Rapidly progressive disease OR
  • Contracture interferes with lifestyle and/or occupation

Lifestyle Factors - Best Practice

Obesity

  • Patients with a BMI >30 should be encouraged by their Clinician to lose weight prior to surgery and signposted to appropriate support to address lifestyle factors that would improve their fitness for surgery and recovery afterwards.
  • There is a clinical balance between risk of surgical complications with obesity and the risk to delaying any surgery.
  • See Weight Management Care Pathways

Smoking

  • In line with 'Healthy Lives, Healthy People; a tobacco control plan for England', local authorities and health professionals are committed to encourage more smokers to quit.
  • Smoking remains the leading cause of preventable morbidity and premature death in England.
  • There is sufficient evidence to suggest that people who smoke have a considerably increased risk of intra- and post-operative complications such as chest infections, lung disorders, wound complications and impaired healing.
  • See Smoking Cessation Care Pathways
Please Note: The life style factors above are not a restriction to the commissioning statements unless otherwise stated

Evidence/Rationale

Dupuytren's Contracture is a challenging condition for which there is no satisfactory treatment. All the treatments have high re-occurrence rates and carry the risk of complications.

Dupuytren's disease is a benign, slowly progressive condition of unknown origin, characterised by connective tissue thickening in the palm of the hand, forming nodules and cords, which leads to difficulty in extending the fingers. Symptoms are often mild and painless and do not require treatment but can include reduced range of motion, reduced hand function and pain. Most patients are affected in both hands. Most patients do not need treatment, but regular follow-up is needed to detect early joint contracture - this can pull the joints into a permanently flexed position, making it difficult to perform activities of daily living. The condition often occurs in later life, and is most common in men who are aged over 40. Around one in six men over the age of 65 are affected in the UK.

Intervention is almost exclusively surgical but surgery is not curative and recurrence rates can be high. To justify the risks of surgery a flexion deformity must be present.

Although there is great variation in the rate of progress, it is usually possible to distinguish the more aggressive form of the disease early on. Recurrence is more likely in younger patients if the original contracture was severe or if there is a strong family history of the condition.

References

  1. W A Townley, R Baker, N Sheppard, A O Grobbelaar. Clinical Review. Dupuytren's contracture unfolded. BMJ 2006;332:397–400
  2. NHS Choices http://www.nhs.uk/conditions/Dupuytrens-contracture/Pages/Introduction.aspx
  3. Patient information/Surgery Guidance http://www.bapras.org.uk/public/patient-information/surgery- guides/dupuytren's-contracture
  4. British Society for surgery of the hand (2010) Evidence for surgical treatment – Dupuytren's disease Lee S and Baytion M. Dupuytren contracture. E-Medicine. December 2006
  5. National Institute for Health and Clinical Excellence (NICE). Needle fasciotomy for Dupuytren's contracture. Interventional procedure guidance 43. London: NICE; 2004
  6. Map of Medicine Dupuytren's contracture – management http://healthguides.mapofmedicine.com/choices/map/dupuytren_s_contracture2.html#anchor

Assurance & Governance

  • This policy was developed on: 05.2017
  • This policy was approved by: Clinical Strategy Group (NK) and Clinical Cabinet (WK)
  • Date approved: 05.2017
  • Publication Date: 05.2017
  • Review Date: 04.2018
  • Ref No: PA10 - 05.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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