Clinical UM Guideline



Subject: Surgical Treatment for Dupuytren's Contracture
Guideline #:  CG-SURG-11 Current Effective Date:    09/27/2017
Status: Reviewed Last Review Date:    08/03/2017

Description

This document addresses surgical treatments for Dupuytren's contracture. Dupuytren's contracture is a painless thickening and fixed tightening (contracture) of the tissue beneath the skin on the palm of the hand and fingers. Progressive contracture may result in deformity and loss of function of the hand.

Note: Please see the following related document(s) for additional information:

Clinical Indications

Medically Necessary:

Surgical treatment for Dupuytren's contracture is considered medically necessary when a palpable palmar cord has been documented to impair the individual's functional activities and any of the following:

Not Medically Necessary:

Surgical treatment for Dupuytren's contracture is considered not medically necessary when the criteria above are not met.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT    
26040 Fasciotomy, palmar (eg, Dupuytren's contracture); percutaneous
26045 Fasciotomy, palmar (eg, Dupuytren's contracture); open, partial
     
ICD-10 Procedure    
0MN70ZZ Release right hand bursa and ligament, open approach  
0MN73ZZ Release right hand bursa and ligament, percutaneous approach  
0MN74ZZ Release right hand bursa and ligament, percutaneous endoscopic approach  
0MN80ZZ Release left hand bursa and ligament, open approach  
0MN83ZZ Release left hand bursa and ligament, percutaneous approach  
0MN84ZZ Release left hand bursa and ligament, percutaneous endoscopic approach  
     
ICD-10 Diagnosis    
M72.0 Contracture of palmar fascia  
     
Discussion/General Information

Dupuytren's contracture is a multifactorial disease, meaning that several causes have been associated with the development of the disease, but a single cause is not known. The disease is most common in Caucasian males over 50 years of age. It has also been shown to be more common in those with diabetes, seizure disorders, HIV positive status, hypothyroidism, those who smoke and those who consume alcohol. Minor trauma and genetic predisposition may play a role. One or both hands may be affected. The ring finger is affected most often, followed by the little, middle, and index fingers. The MP and PIP joints are the most commonly affected joints.

Initially, a small, painless nodule develops in the connective tissue and eventually develops into a cord-like band. The cord tightens over time, pulling the affected finger towards the palm in an abnormal position. Extension of the finger becomes difficult to impossible with advanced cases. The goal of surgery (palmar fasciectomy) is to release or excise the fibrous attachments between the palmar fascia and the tissues around it, thereby releasing the contracture. Once released, finger movement should improve; although this is largely dependent upon the joint(s) being treated. Surgery is more effective if the contracture occurs in the metacarpophalangeal (MP) joint of only one finger and is less effective when two or more fingers and MP joints are involved. When the contracture occurs at the proximal interphalangeal (PIP) joint, the improvement rate decreases (Bird, 2007). 

In 2012, van Rijssen and colleagues reported 5 year results of a clinical trial comparing percutaneous needle fasciotomy versus limited fasciectomy for the treatment of Dupuytren's contracture. A total of 111 subjects with a minimal passive extension deficit of 30 degrees were randomized into one of two groups. The primary endpoint was recurrence. Ninety-three subjects reached the endpoint. The recurrence after 5 years was greater in the needle fasciotomy group than in the limited fasciectomy group (84.9% vs. 20.9% respectively) and occurred sooner in the needle fasciotomy group (p=0.0001). Individual satisfaction was higher in the limited fasciectomy group; however, 53% of the subjects preferred percutaneous needle fasciotomy in case of recurrence.

A 2015 Cochrane review noted that patient satisfaction was better after fasciotomy at six weeks, but the magnitude of effect was not specified. Fasciectomy improved contractures more effectively in severe disease: Mean percentage reduction in total passive extension deficit at six weeks for Tubiana grades I and II was 11% lower after needle fasciotomy than after fasciectomy, whereas for grades III and IV disease, it was 29% and 32% lower. By 5 years, satisfaction (on a scale from 0 to 10, with higher scores showing greater satisfaction) was 2.1/10 points higher in the fasciectomy group than in the fasciotomy group, and recurrence was greater after fasciotomy (849/1000 vs 209/1000). The authors concluded that the evidence is insufficient to show the relative superiority of different surgical procedures for treating Dupuytren's contracture and that well designed studies are needed.

References

Peer Reviewed Publications:

  1. Crean SM, Gerber RA, Le Graverand MP, et al. The efficacy and safety of fasciectomy and fasciotomy for Dupuytren's contracture in European patients: a structured review of published studies. J Hand Surg Eur. 2011; 36(5):396-407.
  2. Dias JJ, Braybrooke J. Dupuytren's contracture: an audit of the outcomes of surgery. J Hand Surg Br. 2006; 31(5):514-521.
  3. Foucher G, Medina J, Navarro R. Percutaneous needle aponeurotomy: complications and results. J Hand Surg Br. 2003; 28(5):427-431.
  4. Hovius SE, Kan HJ, Smit X, et al. Extensive percutaneous aponeurotomy and lipografting: a new treatment for Dupuytren disease. Plast Reconstr Surg. 2011;128(1):221-228.
  5. Lee LC, Zhang AY, Chong AK, et al. Expression of a novel gene, MafB, in Dupuytren's disease. J Hand Surg Am. 2006; 31(2):211-218.
  6. van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren's disease: percutaneous needle fasciotomy versus limited fasciectomy. Plast Reconstr Surg. 2012; 129(2):469-477.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Bird B, Ball C, Balasuntharam P. Rehabilitation after surgery for Dupuytren's contracture. Cochrane Database Syst Rev. 2007;(2):CD006508.
  2. Rodrigues JN, Becker GW, Ball C, et al. Surgery for Dupuytren's contracture of the fingers. Cochrane Database Syst Rev. 2015;(12):CD010143.
Websites for Additional Information
  1. American Academy Orthopedic Surgeons (AAOS). Dupuytren's Contracture. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=a00008. Accessed on June 29, 2017.
  2. Dupuytrens Foundation. Available at: http://www.dupuytrenfoundation.org/. Accessed on June 29, 2017.
Index

Aponeurotomy, Percutaneous Needle
Dupuytren's Contracture Release
Fasciectomy, Fasciotomy

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History
Status Date Action
Reviewed 08/03/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section.  
Reviewed 08/04/2016 MPTAC review. Discussion, References and Websites were updated. Updated formatting in Clinical Indications section. Removed ICD-9 codes from Coding section.  
Reviewed 08/06/2015 MPTAC review. References were updated.  
Reviewed 08/14/2014 MPTAC review. References were updated.  
Reviewed 08/08/2013 MPTAC review. References were updated.  
Reviewed 08/09/2012 MPTAC review. Discussion/General Information and References updated.  
Revised 08/18/2011 MPTAC review. Medically necessary contracture criteria for the metacarpophalangeal (MP) joint changed to 20 degrees. Discussion/General Information and References updated.  
Revised 11/18/2010 MPTAC review. Criteria revised to include contracture measurements. Title changed. Discussion/General Information and References were updated.  
Reviewed 11/19/2009 MPTAC review. Place of service removed. Discussion and references were updated.  
Reviewed 11/20/2008 MPTAC review. References were updated.  
Reviewed 11/29/2007 MPTAC review. References were updated.  
Reviewed 12/07/2006 MPTAC review. References updated.  
Revised 12/01/2005 MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.  
     

Pre-Merger Organizations

Last Review Date Document Number Title

Anthem, Inc.

 

    None
WellPoint Health Networks, Inc. 12/02/2004 Guideline Dupuytren's Contracture Release