Clinical UM Guideline

 

Subject: Surgical Treatment for Dupuytren's Contracture
Guideline #:  CG-SURG-11 Publish Date:    08/29/2018
Status: Reviewed Last Review Date:    07/26/2018

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 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. Chen NC, Srinivasan RC, Shauver MJ, et al. A systematic review of outcomes of fasciotomy, aponeurotomy, and collagenase treatments for Dupuytren's contracture. Hand (N Y). 2011; 6(3):250-255.
  2. 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.
  3. Dias JJ, Braybrooke J. Dupuytren's contracture: an audit of the outcomes of surgery. J Hand Surg Br. 2006; 31(5):514-521.
  4. Foucher G, Medina J, Navarro R. Percutaneous needle aponeurotomy: complications and results. J Hand Surg Br. 2003; 28(5):427-431.
  5. 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.
  6. 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.
  7. Naam NH. Functional outcome of collagenase injections compared with fasciectomy in treatment of Dupuytren's contracture. Hand (N Y). 2013; 8(4):410-416.
  8. 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.
  9. Zhou C, Hovius SE, Slijper HP, et al. Collagenase Clostridium histolyticum versus limited fasciectomy for dupuytren's contracture: outcomes from a multicenter propensity score matched study. Plast Reconstr Surg. 2015; 136(1):87-97.

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 of Orthopedic Surgeons (AAOS). Dupuytren's Contracture. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=a00008. Accessed on June 17, 2018.
  2. Dupuytrens Foundation. Available at: http://www.dupuytrenfoundation.org/. Accessed on June 17, 2018.
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

07/26/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section.

 

 

05/03/2018

The document header wording updated from “Current Effective Date” to “Publish Date.”

 

Reviewed

08/03/2017

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