Surgery will not cure disease

General indications

• Loss of function or difficulty with hygiene​

• MCPJ contracture >30° or PIPJ contracture of any degree

• Rapidly progressive disease

General cnontraindications​

• Mild MCPJ joint contracture <30°​

• Nodules or cords without contracture

• Unrealistic patient expectations

Collagenase Clostridium histolyticum injections​

• 45%-65% achieve near-full extension

• Only 1 cord can be treated at a time

• Indications​

  • Contracture due to a palpable, tensionable cord with adequate skin reserve​

• Contraindications

  • Severe allergic reaction​

  • Tight skin or scars preventing extension

  • Recurrence in young patient

  • Infection or healing wounds

  • Safety unknown in pregnancy, breastfeeding, <18 years 

• Technique​

  • Performed over 2 consecutive days per hand​

  • Under sterile conditions, the central substance of the chosen cord segment is injected at 3 closely spaced points and hand is wrapped in a soft immobilising bandage

  • Manipulation is performed by surgon on postinjection days 1-4

  • Static extension night time splint for 1 month, and active range-of-movement exercises during the day

Needle fasciotomy

• Indications​

  • Contracture due to a palpable, tensionable cord with adequate skin reserve​

• Contraindications​

  • Unable to tolerate awake procedures

  • Tight skin or scars preventing extension

  • Recurrence in young patient

  • Infection or healing wounds

• Technique​

  • Local prep and field sterility​, local anaesthetic infiltration

  • Small gauge hypodermic needle inserted, and while cord is maintained under tension, the needle tip is used to progressively sever fibres

  • Procedure repeated for all chosen cords

  • Light bandage, avoid strenous gripping for 1 week

Fasciectomy

• Indications

  • Failed minimally invasive treatment​

  • Diffuse disease

  • Concurrent treatment of secondary pathology

  • Surgeon/patient preference

• Contraindications​

  • Patients in whom a long operation, long recovery, postoperative therapy is not possible

  • Skin tightness beyond what local flaps could be expected to correct

• Technique​​

  • Segmental fasciectomy​

    • Multiple short transverse or longitudinal C-shaped incisions​

    • Nodules and cord segments excised

    • Skin closed and soft bandage applied

  • Regional fasciectomy​

    • Longitudinal, longitudinal zigzag or transverse incisions​

    • All visibly diseased tissue is removed​

Dermofasciectomy

• Indications​

  • Longitudinal skin shortage beyond capacity for local flaps to correct​

  • Recurrect contracture with diffuse skin involvement or extensive scarring

  • Devascularised skin during surgery

  • Strong diathesis profile

• Contraindications​

  • ​Patients in whom a long operation, long recovery, postoperative therapy is not possible

  • Patients in whom skin grafting is not advisable

• Technique​

  • Wide extensile exposure in primary procedure, or limited exposure to planned areas for excision in recurrent cases​

  • All zones of skin replacement excised

  • Skin left to heal secondarily or closed with full thickness skin graft