The National Institute for Clinical Excellence is examining needle fasciotomy for Dupuytren's contracture and will publish guidance on its safety and efficacy to the NHS in England and Wales. The Institute's Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisors, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about needle fasciotomy for Dupuytren's contracture.

This document has been prepared for public consultation. It summarises the procedure and sets out the provisional recommendations made by the Advisory Committee.

Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation.

The process that the Institute will follow after the consultation period ends is as follows.

• The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.
• The Advisory Committee will then prepare the Final Interventional Procedure Document (FIPD) and submit it to the Institute.
• The FIPD may be used as the basis for the Institute's guidance on the use of the procedure in the NHS in England and Wales.

For further details, see the Interim Guide to the Interventional Procedures Programme, which is available from the Institute's website (www.nice.org.uk/ip).

Closing date for comments: 25 November 2003

Target date for publication of guidance: March 2004

Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation.

Current evidence on the safety and efficacy of needle fasciotomy for Dupuytren's contracture appears adequate to support the use of the procedure, provided that normal arrangements are in place for consent, audit and clinical governance.

Dupuytren's contracture is a benign, slowly progressive condition of unknown origin. The disease is characterised by a thickening of the connective tissue in the palm of the hand, leading to difficulties in extending the fingers.

Most individuals with Dupuytren's contracture are affected in both hands. The most commonly involved digit is the ring finger, followed by the little finger and then the middle finger.

Treatment seeks to restore hand function and prevent progression, because the underlying disease will remain. Both surgical and non-surgical options exist. Data are lacking on the effectiveness of most non-surgical treatments for Dupuytren's contracture, such as vitamin E cream and ultrasonic therapy.

Needle fasciotomy is an outpatient procedure in which one or more fibrous bands (contractures) are sectioned using a blade or the bevel of a needle. The procedure can be performed in either the palm or the fingers.

On the basis of the evidence, the main benefit offered by this procedure is a short-term reduction in the degree of contracture. Recurrence rate is approximately 50% at 3-5 years and seems to depend on the severity of the disease. Some data also suggest that individuals with less severe disease and/or with metacarpophalangeal joint contracture benefited most from this procedure. For more details, refer to the Overview (see Appendix).

One Specialist Advisor commented that although the procedure was not as efficacious in the long term as open surgery, patients experienced less morbidity and had faster recovery. A second Advisor stated that efficacy of the procedure was greater in patients with predominantly palmar disease or with metacarpophalangeal joint contracture.

Common complications reported in the studies included splitting of the skin, localised pain and nerve injuries. For more details, refer to the Overview (see Appendix).

The Specialist Advisors listed nerve injury, tendon injury and infection as the main complications of the procedure, with one Advisor citing a complication rate of 1% or less.

The Interventional Procedures Advisory Committee noted the importance of patient selection and considered it particularly suitable in older patients who are unsuitable for more major surgery.

They also noted that Dupuytren's contracture tends to recur after all types of treatment, but needle fasciotomy can be repeated.

The following document, which summarises the evidence, was considered by the Interventional Procedures Advisory Committee when making it's provisional recommendations.

• Interventional Procedure Overview of Needle fasciotomy for Dupuytren's contracture, April 2003

Available from: www.nice.org.uk/ip177overview