Editor's choice| Volume 42, ISSUE 12, P963-970.e6, December 2017

Variation in Treatment Recommendations for Dupuytren Disease

Published:September 23, 2017DOI:


      To examine agreement on Dupuytren disease (DD) treatment recommendations in an international sample of hand surgeons.


      A survey was developed to determine expertise in needle aponeurotomy, surgery, and collagenase injection to treat DD and to examine treatment recommendations for 16 case scenarios. Case scenarios were predeveloped using expert input. Each case represented a unique combination of 4 dichotomous variables including cord thickness, contracture severity, patient age, and joint involvement. Interrater reliability statistics were calculated and multinomial logistic regression modeling and analysis of variance were used to examine the impact of surgeon- and case-related variables on treatment recommendations.


      A total of 36 hand surgeons from 9 countries (mean experience, 17 years) participated. Average pairwise percent agreement and Krippendorff’s alpha were 26% and .012, respectively. Predictors of a recommendation for surgery over multiple options were a total contracture of greater than 70°, a thick precentral cord, involvement of the metacarpophalangeal and proximal interphalangeal joints, and greater years in practice. A greater number of years in practice predicted recommendation for collagenase injection and the presence of a thick precentral cord predicted a recommendation for needle aponeurotomy.


      Little agreement exists on treatment recommendations for common presentations of DD in this sample.

      Clinical relevance

      Further investigation into the sources of potential widespread discrepancies in the management of DD may improve the capacity to make evidence-based recommendations.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Lanting R.
        • van den Heuvel E.R.
        • Werker P.M.N.
        Clusters in short-term disease course in participants with primary Dupuytren disease.
        J Hand Surg Am. 2016; 41: 354-361
        • Becker K.
        • Tinschert S.
        • Lienert A.
        • et al.
        The importance of genetic susceptibility in Dupuytren’s disease.
        Clin Genet. 2015; 87: 483-487
        • Broekstra D.C.
        • Lanting R.
        • Werker P.M.N.
        • van den Heuvel E.R.
        Intra- and inter-observer agreement on diagnosis of Dupuytren disease, measurements of severity of contracture, and disease extent.
        Man Ther. 2015; 20: 580-586
        • Crean S.M.
        • Gerber R.A.
        • Hellio Le Graverand M.P.
        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 Vol. 2011; 36: 396-407
        • Hurst L.C.
        • Badalamente M.A.
        • Hentz V.R.
        • et al.
        Injectable collagenase clostridium histolyticum for Dupuytren’s contracture.
        N Engl J Med. 2009; 361: 968-979
        • Hovius S.E.
        • Kan H.J.
        • Smit X.
        • Selles R.W.
        • Cadoso E.
        • Khouri R.K.
        Extensive percutaneous aponeurotomy and lipografting: a new treatment for Dupuytren disease.
        Plast Reconstr Surg. 2011; 128: 221-228
        • Lukas B.
        • Lukas M.
        Flap plasty in advanced Dupuytren’s disease.
        Oper Orthop Traumatol. 2016; 28: 20-29
        • Betz N.
        • Ott O.J.
        • Adamietz B.
        • Sauer R.
        • Fietkau R.
        • Keilholz L.
        Radiotherapy in early-stage Dupuytren’s contracture: long-term results after 13 years.
        Strahlenther Onkol. 2010; 186: 82-90
        • Keilholz L.
        • Seegenschmiedt M.H.
        • Sauer R.
        Radiotherapy for prevention of disease progression in early-stage Dupuytren’s contracture: initial and long-term results.
        Int J Radiat Oncol Biol Phys. 1996; 36: 891-897
        • Eaton C.
        Evidence-based medicine: Dupuytren contracture.
        Plast Reconstr Surg. 2014; 133: 1241-1251
        • Becker G.W.
        • Davis T.R.
        The outcome of surgical treatments for primary Dupuytren's disease—a systematic review.
        J Hand Surg Eur Vol. 2010; 35: 623-626
        • Dahlin L.B.
        • Bainbridge C.
        • Szczypa P.P.
        • Cappelleri J.C.
        • Guerin D.
        • Gerber R.A.
        Current trends in the surgical management of Dupuytren’s disease in Europe: the surgeon’s perspective.
        Eur Orthop Traumatol. 2012; 3: 25-30
        • Dias J.
        • Bainbridge C.
        • Leclercq C.
        • et al.
        Surgical management of Dupuytren’s contracture in Europe: regional analysis of a surgeon survey and patient chart review.
        Int J Clin Pract. 2013; 67: 271-281
        • Dibenedetti D.B.
        • Nguyen D.
        • Zografos L.
        • Ziemiecki R.
        • Zhou X.
        Prevalence, incidence, and treatments of Dupuytren’s disease in the United States: results from a population-based study.
        Hand (N Y). 2011; 6: 149-158
        • Dahlin L.B.
        • Bainbridge C.
        • Leclercq C.
        • et al.
        Dupuytren’s disease presentation, referral pathways and resource utilization in Europe: regional analysis of a surgeon survey and patient chart review.
        Int J Clin Pract. 2013; 67: 261-270
        • Kan H.J.
        • Verrijp F.W.
        • Huisstede B.M.A.
        • Hovius S.E.R.
        • van Nieuwenhoven C.A.
        • Selles R.W.
        The consequences of different definitions for recurrence of Dupuytren’s disease.
        J Plast Reconstr Aesthet Surg. 2013; 66: 95-103
        • Baltzer H.
        • Binhammer P.A.
        Cost-effectiveness in the management of Dupuytren’s contracture: a Canadian cost-utility analysis of current and future management strategies.
        Bone Joint J. 2013; 95-B: 1094-1100
        • Huisstede B.
        • Hoogvliet P.
        • Coert J.H.
        • Friden J.
        Dupuytren disease: European hand surgeons, hand therapists, and physical medicine and rehabilitation physicians agree on a multidisciplinary treatment guideline: results from the HANDGUIDE study.
        Plast Reconstr Surg. 2013; 132: 964e-976e
        • van Dijk D.
        • Finigan P.
        • Gerber R.A.
        • et al.
        Recognition, diagnosis and referral of patients with Dupuytren’s disease: a review of current concepts for general practitioners in Europe.
        Curr Med Res Opin. 2013; 29: 269-277
        • Akhavani M.A.
        • McMurtrie A.
        • Webb M.
        • Muir L.
        A review of the classification of Dupuytren’s disease.
        J Hand Surg Eur Vol. 2015; 40: 155-165
        • Neuendorf K.A.
        The Content Analysis Guidebook.
        Sage, Thousand Oaks, CA2002
        • Hayes A.F.
        • Krippendorff K.
        Answering the call for a standard reliability measure for coding data.
        Commun Methods Meas. 2007; 1: 77-89
      1. Krippendorff K. Computing Krippendorff’s alpha-reliability. Accessed February 24, 2016.

        • Krippendorff K.
        Reliability in content analysis: some common misconceptions and recommendations.
        Human Communication Research. 2004; 30: 411-433
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Werker P.M.N.
        • Pess G.M.
        • van Rijssen A.L.
        • Denkler K.
        Correction of contracture and recurrence rates of Dupuytren contracture following invasive treatment: the importance of clear definitions.
        J Hand Surg Am. 2012; 37 (2095–2015)
        • Kan H.J.
        • de Bekker-Grob E.W.
        • van Marion E.S.
        • et al.
        Patients’ preferences for treatment for Dupuytren’s disease: a discrete choice experiment.
        Plast Reconstr Surg. 2016; 137: 165-173
        • Engstrand C.
        • Kvist J.
        • Krevers B.
        Patients’ perspective on surgical intervention for Dupuytren’s disease—experiences, expectations and appraisal of results.
        Disabil Rehabil. 2016; 38: 2538-2539
        • Zhou C.
        • Hovius S.E.R.
        • Slijper H.P.
        • et al.
        Predictors of patient satisfaction with hand function after fasciectomy for Dupuytren’s contracture.
        Plast Reconstr Surg. 2016; 138: 649-655
        • Wach W.
        • Manley G.
        International patient survey (part 1: Dupuytren disease).
        in: Werker P. Dias J. Eaton C. Reichert B. Wach W. Dupuytren Disease and Related Diseases—The Cutting Edge. Cham, Switzerland: Springer International Publishing, 2017: 29-40
        • Aliu O.
        • Davis M.M.
        • DeMonner S.
        • Chung K.C.
        The influence of evidence in the surgical treatment of thumb basilar joint arthritis.
        Plast Reconstr Surg. 2013; 131: 816-828
        • Birkmeyer J.D.
        • Reames B.N.
        • McCulloch P.
        • Carr A.J.
        • Campbell W.B.
        • Wennberg J.E.
        Understanding of regional variation in the use of surgery.
        Lancet. 2013; 382: 1121-1129
        • Hageman M.G.J.S.
        • Guitton T.G.
        • Ring D.
        How surgeons make decisions when the evidence is inconclusive.
        J Hand Surg Am. 2013; 38: 1202-1208
        • Davis T.R.C.
        Surgical treatment of primary Dupuytren’s contractures of the fingers in the UK: surgeons’ preferences and research priorities.
        J Hand Surg Eur Vol. 2012; 38: 83-85
        • Skov S.T.
        • Bisgaard T.
        • Sondergaard P.
        • Lange J.
        Injectable collagenase versus percutaneous needle fasciotomy for Dupuytren contracture in proximal interphalangeal joints: a randomized controlled trial.
        J Hand Surg Am. 2017; 42: 321-328
        • Stromberg J.
        • Ibsen-Sorensen A.
        • Friden J.
        Comparison of treatment outcome after collagenase and needle fasciotomy for Dupuytren contracture: a randomized, single-blinded, clinical trial with a 1-year follow-up.
        J Hand Surg. 2016; 41: 873-880
        • Pannucci C.J.
        • Wilkins E.G.
        Identifying and avoiding bias in research.
        Plast Reconstr Surg. 2010; 126: 619-625
        • Feinstein A.R.
        • Cicchetti D.V.
        High agreement but low Kappa: I. The problems of two paradoxes.
        J Clin Epidemiol. 1990; 43: 543-549
        • Ball C.
        • Pratt A.L.
        • Nanchahal J.
        Optimal functional outcome measures for assessing treatment for Dupuytren’s disease: a systematic review and recommendations for future practice.
        BMC Musculoskelet Disord. 2013; 14: 131
        • Felici N.
        • Marcoccio I.
        • Glunta R.
        • et al.
        Dupuytren contracture recurrence project: reaching consensus on a definition of recurrence.
        Handchir Mikrochir Plast Chir. 2014; 46: 350-354