Needle aponeurotomy (Aponevrotomy) Dupuytren's disease needle fasciotomy Mnimally invasive alternative techniques in Dupuytren contracture Xiaflex Collagenase Enzyme



Keith Denkler, M.D.

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Keith Denkler M.D.  
Plastic and Reconstructive Surgery  
275 Magnolia Ave.  
Larkspur, CA 94939  


 What is Dupuytren's Contracture?

TV Appearance on Xiaflex:

Dupuytren's contracture is a progressive fibrous proliferation of the palmar fascia of the hand. It is a tumor (growth) but not a cancer.  Similar type fibrous growths may also occur in the fascia of the feet and there it is called Ledderhose disease. There is no known cause or etiology for Dupuytren's.  It is considered an inherited condition and not related to work or hand use.  The disease is metabolic and genetic in nature.  Dupuytren's is often observed in persons of Northern European descent, especially Scandinavians. It is sometimes called the "Viking" disease although the "Viking" theory of disease and spread is disputed by some authors [1, 2]  Diet does not seem to have an effect, or change Dupuytren's although diabetics have a higher incidence of the disease[3]. The disease occurs worldwide in all races, but is most concentrated in Scandinavia.  I have personally treated Africans and Chinese with this disease.  Dupuytren's is found more commonly in men[4-6].  There does not seem to be a specific relation to labor or work[7], and it is not covered by workers compensation, although exposure to vibration may increase the risk of developing Dupuytren’s[8].  In a study in Norway, Dupuytren’s was more common in those that labored with their hands rather than those with sedentary work[9].   A French study also confirmed slightly higher Dupuytren's in those that labored with their hands[10].  The cause of the disease is unknown and it usually presents later in life.  It has been reported in children[11-15].   Trauma, such as a fracture has been reported to bring on Dupuytren’s[16]It often starts as nodule in the palm that is composed of fibroblasts. After this, the nodular growth may start connecting and contracting. One will notice pits or grooves in the skin and there may be associated pain or tenderness. Microscopically, myofibroblasts may be found and these are the cells that start the contracture. At this stage, the composition shifts to more type III, and type V collagen. Late stage Dupuytren's is characterized by metacarpophalangeal (MCP or first joint), proximal interphalangeal (PIP or middle joint), and rarely distal interphalangeal (DIP or distal joint) contractures.   The disease most commonly affects the ring finger, and the little finger is second most commonly affected.  Correction of little finger PIP joint contractures (middle joint) are the most difficult to treat even with all the tools available to modern medicine such as needle aponeurotomy, surgery, skin grafting, or XIAFLEX (collagenase) which dissolves the cords. Thumbs, index, and middle fingers may also be affected in some patients.

Associated conditions

Peyronies disease, knuckle pads(Garrod nodes), plantar fibromatosis (Ledderhose disease). Trigger fingers (stenosing tenosynovitis) may also occur in association with Dupuytren's.  Heavy smokers, drinkers, and diabetics have an increased risk of Dupuytren's[17]  However, most patients with Dupuytren's contracture are not smokers or drinkers and do not do manual labor.


A large study in the US Veterans hospitals of 9938 patients found an incidence of 734 per 100,000 population in whites, 237 per 100,000 in Hispanics, 130 per 100,000 in blacks, and 67 per 100,000 in Asians[18].  In the United States the incidence in white populations is about 3%.  In Norway, the incidence is about 30%-40%[6, 19].    The disease is very rare in African Blacks[20]


Dupuytren’s contracture, named after Baron Dupuytren the French Surgeon who detailed the condition in a lecture in 1831.  Dupuytren showed the contracture was from the fascial of the palm of the hands, and not as a result of tendon contracture.  It has been an enigma for centuries. Due to the low incidence in Southern Europeans, no record of Dupuytren’s is found in ancient Greek and Roman medical books.  Dupuytren was not the first to discover this disease but the condition is named after Dupuytren as he clearly showed in anatomical dissections that the contracted fingers were not because of a tendon problem, but rather a build-up, fibrosis, and contracture of the palmar fascia.  The first documented cases in the European literature was the case reported by Plater in 1614.   After Plater, it was Henry Cline (1750-1826) that rediscovered this condition[21].  A French surgeon, Alexis Boyer, described “crispatura tendinum” in 1814.   Boyer felt the contracture problem was a disease of the flexor tendons. Astley Cooper, from England, a contemporary of both Boyer and Dupuytren also described contracted palms in 1822 and correctly proposed its treatment before Dupuytren.  Dupuytren takes the name of the condition as he clearly delineated the contracture is related to the palmar fascia[21].  Dupuytren recognized that it was a contracture of the palmar fascia or palmar aponeurosis and presented his anatomical work in 1831[22]. He proposed the surgery fasciotomy (an incision of the contracted tissues) to correct the contracture.  A few years later Dr. Goyrand, also in Paris proposed longitudinal opening and excision of the diseased tissue[23].  Dupuytren's approach, the release the fascia with small cuts, was the original technique used to treat Dupuytren’s, however it was noted decades before Dupuytren’s description by Dr. Cline in England and later by Dr. Cooper, also in England.   

Surgical treatment of Dupuytren’s

Needle fasciotomy (otomy=opening, fasciotomy is opening of the fascia) also called needle aponeurotomy, NA, or needle aponevrotomy is a technique developed and refined in France by Rheumatologists Lermusiaux, Badois and others since the 1970's[24, 25].  It involves cutting the tight contracted Dupuytren's cord under local anesthesia as on office procedure using hypodermic needles instead of a scalpel. Small needles are used to release the cords in multiple areas, and then the cords are popped as the finger is straightened. This technique has been reported in the British Journal of Hand Surgery[26]  There was a low incidence of nerve injury (0.3%) and no tendon injuries. They also found significant gain in extension at the MCP joint and also good improvement at the PIP joint. The need for reoperation at average follow up of 3.2 years was only 24%.

The most common complication of needle aponeurotomy is skin openings that occur with rupture of the Dupuytren's cord. This occurs about 16% of the time and may require a suture or can be left open to heal[26].  The diseased Dupuytren's tissue is not removed, but is only incised or nicked. Recurrence at 5 years is reported to be 50%[25]. The good news is that needle aponeurotomy may be repeated if recurrence develops, or the new enzyme, XIAFLEX, could be injected into recurrent areas of Dupuytren's. 

A great advantage of this technique is the lack of hospitalization, outpatient surgery centers, or an anesthesiologist. The small needles provide little trauma to the tissues and if done in areas where the skin is pliable, skin tears do not occur. Healing is rapid. The initial bulky dressing may be removed after a day or two and then may only require Band-Aids. Formal physical therapy is not usually necessary unless the middle joint (PIP) is severely bent.  Surgical removal of Dupuytren's frequently requires therapy. However, needle aponeurotomy only separates the bands. Scar tissue may reform and start the contracture again. It is important to do finger stretching frequently to maximize the results. In the beginning, this may be difficult due to the recent procedure. As weeks pass, aggressive hyperextension can prevent the severed cords from re-connecting.   I am in favor of stretching to prevent and slow down the recurrence of Dupuytren's.  Dupuytren's occurs in the feet and is called Ledderhose disease.  Despite severe trauma to the foot over a lifetime and constant overstretching of the toes with each step, the toes do not curl underneath.  Therefore, I believe lack of stretching, or bending back of the fingers is more of a problem in the hand.  I encourage my patients to fight the Dupuytren's from contracting. 

Subcutaneous Fasciotomy the Original Aponeurotomy for Dupuytren's

This technique was first suggested by Dr. Astley Cooper in 1822 for the treatment of fascial contractions of the finger i.e. Dupuytren's. Dr. Cooper stated: but when the aponeurosis is the cause of the contraction and the contracted band is narrow, it may be with advantage divided by a pointed bistoury (scalpel), introduced through a very small wound in the integument. The finger is extended and a splint is applied to preserve it in a straight position." From Cooper, A: Treatise on dislocations and on Fractures of the Joints, Ed. 2 p. 521 Longmans, London 1823. The open fasciotomy of Dupuytren involves cutting straight down through the skin and fascia and avoiding the tendons which are deep. The subcutaneous fasciotomy, like the needle aponeurotomy cuts the contracted tissues under the skin and doesn't usually leave any major skin openings. Articles reporting on the success of blind scalpel aponeurotomy with great success include the works of Kelly in 1959[27] , and Luck[28] Kelly's article from 1959 in the Plastic and Reconstructive Surgery Journal stated very strongly as to why major surgical approaches are undertaken when the results from subcutaneous release can be so good. The quote from Kelly is below"

"Subcutaneous fasciotomy" was first suggested for the treatment of flexion contracture of the fingers by Sir Astley Cooper in 1822. He wrote "... but when the aponeurosis is the cause of the contraction and the contracted band is narrow, it may be with advantage divided by a pointed bistoury, introduced through a very small wound in the integument. The finger is extended and a splint is applied to preserve it in a straight position". This procedure fell into disrepute through the years because it was indiscriminately applied to all cases of contracture; but Luck, 1958, has recently reintroduced it and it has achieved limited popularity. Having perused 20 papers, published since Skoog's monograph in 1948, on the surgical treatment of flexion contracture, we find that fasciotomy is either not mentioned at all or condemned. The radical fasciectomy, on the other hand, is given not merely as the procedure of choice but is considered the only satisfactory surgical treatment. This blind adherence to a single procedure for the treatment of a disease that has many individual variations and several stages of development shows an infatuation with a technical exercise that does not properly answer each patient's need.

The current technique of needle aponeurotomy, developed in France for the flexion contracture of Dupuytren is a type of subcutaneous fasciotomy.

Subcutaneous fasciotomy was the predominant treatment for Dupuytren's till the 1900's.  At that time, with improvements in anesthesia and surgical technique, excision of Dupuytren's, fasciectomy, became the normal treatment.  Radical excision of Dupuytren's, removing all palmar fascia, both diseased and normal tissue as a prevention fell into disfavor in the 1960's due to the complications associated with this surgery.

Segmental Fasciectomy

A scalpel excision (removal or fasciectomy; ectomy=excise) of a short segment or piece of a contracted Dupuytren's cord. This technique was developed by Moermans[29, 30]

He has reported favorable long term results and this is the most non-invasive surgical technique. Patients with previous surgery on Dupuytren contracture may need segmental surgical releases as needle fasciotomies or NA are less effective after previous surgery.

It is very useful on the thumb, as it is difficult to release thick thumb cords which lie over the digital nerves. In many cases, a small incision, under local anesthesia, will break up the contracting cord.A bigger surgery than needle releases, recovery will take weeks or even a month or two. Formal physical therapy is not usually required as it is after a limited fasciectomy.

Limited fasciectomy

The most common surgical procedure performed in the USA and also very common in France[31].  An excisional technique removing diseased areas of Dupuytren’s. It is normally performed under general anesthesia or nerve blocks and a mechanical tourniquet. The McCash technique is a limited fasciectomy that is left partially open in order to prevent postoperative bleeding[32] [33, 34].


A technique that involves cutting out the diseased Dupuytren's with its overlying skin and replacing the defect with a skin-graft taken from somewhere else. It was popularized by Hueston[35].  The new transplanted skin seems to prevent recurrence of Dupuytren’s. This surgery can be very useful in scarred and recurrent Dupuytren’s. Another technique developed by Hueston is the “firebreak” graft which is a skin-graft placed between excised or ruptured bands of Dupuytren’s to prevent the cord from redeveloping.  The success of this procedure is based on the fact that Dupuytren's does not readily recur under a skin graft[36-40].  

Radical Fasciectomy

Radical fasciotomy is a historical technique. It was developed and proposed by McIndoe[41].  It involves cutting out all disease Dupuytren's cords and normal palmar aponeurosis. This is to prevent recurrence of the disease by removing all palmar fascia which could turn into contracted Dupuytren's nodules or fibrosis. The operation has a high complication rate and is rarely performed nowadays.  

Medical (non-surgical) Treatment of Dupuytren's 

Enzymatic dissolution of Dupuytren's via the product XIAFLEX (collagenase) is FDA approved since February 2010.  Treatment requires injections of the the Xiaflex enzyme followed by breaking of the contracting cords of Dupuytren’s after numbing, the next day or some weeks later.  The first use of clinical collagenase was for burns.  Now, it is approved for Dupuytren's, and possibly in 2011 for Peyronies disease.

 Needle and XIAFLEX are an excellent combination.  XIAFLEX (collagenase) injections don't seem to injure nerves, but there is a remote risk of tendon rupture from Xiaflex (the actual risk in FDA clinical trials was 00.3% for tendon rupture).  The limitations of Xiaflex are that it only treats the segments that are injected, and it takes two visits at a minimum.  I have been able to treat one to three digits at a time by using the whole vial and spreading the drug around.  Patients with more severe disease in one finger may have the whole vial (0.9mg) or about a 1/2 cc of drug used for that finger from the proximal palm to near the end of the finger.  Small doses, 0.1 mg may be used to treat the last joint near the fingernail (DIP joint) if there is disease at that location.Use of the drug 30 days later is performed to touch up and re-treat residual areas of Dupuytren's.  One vial can usually treat one to two fingers.The drug is very powerful, but highly useful. After the injection there is a lot of swelling and bruising. There can be redness, itching, pain, and bruising up the arm into the armpit days after the injection.  All the Dupuytren's that is dissolved is metabolized out through the body via the lymphatic system.  Needle aponeurotomy does not remove any Dupuytren's and so recurrence rate would be more rapid.  Xiaflex, like surgery removes the disease albiet surgery removes more.  The advantage of Xiaflex is that it may be repeated and is an office treatment under local anesthesia with a fairly rapid recovery.  I believe the recovery rate is fastest with needl aponeurotomy, longer with Xiaflex, and very long with surgery.  I believe the complicaiton rate is lowest with Xiaflex, low with needle aponeurotomy, and highest with surgical fasciectomy.  Xiaflex spares nerves.  Nerves are a different collagen than Dupuytrens.  Nerve damage (sensory or feelig nerves only) is the highest with surgery about 3%, low with needle 0.5% to 1%, and lowest with Xiaflex which was  0.1%.  One patient in the trials, out of over 2400 injections developed intermittent sensory changes. 

I have performed over 400 injections of Xiaflex.  My impression is that the drug is an excellent addition to treatment of Dupuytren’s contracture.  The drug has excellent local effects on Dupuytren's and scar tissue, plus it spares nerve injury, the most common severe complication after open surgery or needle aponeurtomy.  Xiaflex has a high rate of improvement in contracture although repeat injections may be necessary as the disease is genetic and progressive.  To treat a finger it may take more than one injection, although most paitients only need one or two injections per finger.  I try to treat more than one finger at a time.  I use all the Xiaflex per patient 0.9 mg, rather than the recommended 0.58 mg an waste the rest.  I dilute the Xiaflex by about 10% to lesson the risk of deeper penetration, and I use it more widely than recommended to lesson the risk of deeper penetration to the tendons.  Complications are few.  On September 6th, 2011 Auxilium Pharmaceutical reported on 11,000 Xiaflex injections since release.  The tendon rupture rate was 5 out of 11,000 injections or 0.045%.  The rate of tendon rupture with needle is 0.1% and the rate of tendon rupture with surgery is about 0.2% (Denkler Complications of Dupuytren's surgery 2010).  There was no nerve damage and no infections.  Infection rate with surgery for Dupuytren's is about 34% and with needle is about 1%.  To compare, one would expect about 400 infections out of 11,000 surgeries and about 400 cases of nerve damage from open surgery for Dupuytren's.  

In my experience, about 10% of people did have very severe pain from the injection although most patients (90%) do not.  My most common complication after Xiaflex use is a skin tear which occurs at straightening aobut 10-15% of the time.  These skin tears will heal on there own.  I have not needed to do any skin grafting.  About 10% of patients receiving Xiaflex have a lot of pain during the first day or so, but 90% do not.  Most patients take Advil, although some require Vicodin.  I almost always use local anesthesia for the injection in order to be more precise in my injection technique.  I always use local anesthesia blocks of the fingers for the straightening, so that this is not painful for the paitient and I can do a better job.  I preferentially delay the straightening for a week or two, except in those that are flying in and out.  This allows the swelling to more optimally resolve before straightening.  About 10 percent of patients have prolonged swelling and edema sometimes for several weeks to a month.  In my practice skin tears occur about 10 percent of the time and these can take a month to heal and must be kept clean.  The patients that have had surgery before do remarkable well with Xiaflex and it is definitely a huge part of their solution as an alternative to surgery.  The enzyme dissolves both the surgery scar and the Dupuytren’s tissue.  Surgical skin scars can limit the results and may need to be corrected.  Overall, my experience has been very positive.  I do not prefer concentrating Xiaflex heavily, and I think it is better to spread the enyzme out in order to prevent too concentrated an injection area from going deep.  The enzyme does not dissolve or injure nerve tissue.  The biggest risk of surgery or needle for Dupuytren’s is nerve damage.Xiaflex spares nerve tissue.

Recurrence risk reported with Xiaflex is good.  Recurrence with Xaiflex will be better than needle aponeurotomy since the Dupuytren’s tissue is dissolved.  Needle aponeurotomy does not remove any diseased Dupuytren's fascia.  After needle all Dupuytren’s tissue remains.  I compare the treatments like a taut rope inside the hand.  Surgery would excise the rope.  Needle aponeurotomy is like taking an ice pick and chopping up the rope and breaking it.  However, all the rope remains.  Xiaflex actually dissolves some of the rope so I believe it will be harder for the Dupuytren’s to recur.  Xiaflex does require metabolism of the dissolved Dupuytren's and bruising up and out the arm and axilla.


Recurrence Data at Three Years as published by Auxilium:




Data from the XIAFLEX Three Year Follow-up

At three years, 34.8% of joints that had achieved clinical success had experienced recurrence. Of those patients with affected MP joints, 26.6% of joints that had achieved clinical success had recurrence through three years, while 56.4% of PIP joints that had achieved clinical success had recurrence through three years.

Recurrence per protocol definition of >20 degrees or medical intervention

Joints with recurrence at 1 year (n/%) 
All Joints  19/623 (3.0%) 
MP Joints  8/451 (1.8%) 
PIP Joints11/172 (6.4%) 

Joints with recurrence at 2 years (n/%) 
All Joints  122/623(19.6%) 
MP Joints  64/451(14.2%) 
PIP Joints  58/172(33.7%) 

Joints with recurrence at 3 years (n/%) 
All Joints 217/623 (34.8%) 
MP Joints  120/451 (26.6%) 
PIP Joints 97/172 (56.4%) 


Using at 30 degree defintion of recurrence the results are much better and are 22% recurrence at three years (see below).


The study also tracks whether a joint successfully treated with XIAFLEX received any further medical intervention. Through year three of follow-up 93.1% of joints that were successfully treated with XIAFLEX did not receive any medical or surgical intervention. Of the 43 (6.9 %) successfully treated joints that received medical or surgical intervention through three years, 30 had surgery, seven received needle aponeurotomy (of which 2 subsequently received a third intervention), and six received XIAFLEX. XIAFLEX has been commercially available in the U.S. only since March 2010.


Other Top-Line Findings through Three Years:

High severity PIP joints (those with baseline contractures > 40 degrees) had a statistically significant higher recurrence rate than low severity PIP joints (71% versus 50%, respectively). Combined with data from the CORD I study this suggests that treatment of PIP joints, before they reach high severity, may be beneficial(1).
Recurrence rates in successfully treated MP joints with low severity (those with baseline contractures less than or equal to 50 degrees) and high severity were not statistically different.
Sixteen patients in this study have been retreated with XIAFLEX (6 in a previously successfully treated joint and the remainder in previously untreated joints) through three years follow-up, with a local adverse event profile similar to previous first-line clinical studies. One retreated patient had a serious adverse event of a motor vehicle accident, which was considered unrelated to drug.
The adverse event profile of XIAFLEX treated joints through three years follow-up revealed no new long-term adverse events.
Of the 74 serious adverse events reported through three years of follow-up, none were considered related to XIAFLEX and none occurred in the treated finger.

"While I am very impressed with the three year recurrence rate of 35% using a 20 degree change to define recurrence, the surgical literature has often defined recurrence as a 30 degree change. Using this definition, XIAFLEX demonstrates an even lower 22% recurrence rate at three years," said Dr. Vincent Hentz, Professor Emeritus, Plastic and Reconstructive Surgery, Stanford Medical School. "With this longer term data, I believe that treatment with XIAFLEX of Dupuytren's patients' palpable cords can provide durable outcomes with a very acceptable rate of recurrence in the majority of patients."




I recommend patients interested in Xiaflex to call 1-877-XIAFLEX to explore how their insurance will cover the cost of the medicine and physician treatments.





To see how your insurance covers Xiaflex treatments, please call for pre-approval: 

1-877-XIAFLEX (1-877-942-3539)


TV Appearance on Xiaflex: 




Nerve Damage

(Sensation loss)

Tendon Injury

(Occurs with all techniques


Severe Pain Syndrome


Bleeding or Hematoma


Healing Complications

Or Skin Tears/Lacerations

Needle Aponeurotomy



2.7% [42]


0.2%[43](ref. 6 by Badois)






Bruising usually minor














100% get

bruising of the hand and sometimes into the wrist




XIAFLEX (collagenase enzyme)

Temporary minor Itching or lymph node enlargement in 10% of Xiaflex treatments[48]


Questionable relationship to Xiaflex.  Occured six months later.

I consider Xiaflex nerve friendly, a major advantage







70-80% get bruising as the dissolved Dupuytren's travels up the arm to be metabolized and excreted




Concepts of Treatment

   Easiest for the patient.

      Needle, then XIAFLEX, and surgery.

            Needle recovery can be very fast.   XIAFLEX involves passage of the dissolved

                  tissue out of the body via the lympatics in the armpit.  XIAFLEX takes some

               days or a week or two to recover.   Rarely a month or longer


Longest lasting (slowest to recurrence in the treated area).

      Surgery, then XIAFLEX, and then needle. 

            Surgery removes the most tissue, but heals with the most scar tissue.  XIAFLEX 

            is good at removing scar, and Dupuytren's as both are type III collagen.  XIAFLEX is an excellent choice for recurrent Dupuytren's contracture after previous open surgery.

Safest for the patient

      XIAFLEX, and then needle.  Open surgery has the most complications.  XIAFLEX spares nerves and blood vessels so it is quited safe.  Infections (.5-1% after needle and 3% after surgery).  Infections are extremely remote after XIAFLEX.

Best for recurrence after previous surgery (fasciectomy)

      XIAFLEX is the number one choice for recurrent disease.  Possibly needle.  Another open surgery, after a previous open surgey has a higher risk of complications.

Use in thick lateral or medial cords over the nerve

      XIAFLEX is nerve sparing.  Needle is difficult in thick tissue. 




Alternative Medications


Some medications that have been tried are allopurinol[49-51] , colchicine[52, 53], vitamin E[49, 54-59], calcium channel blockers[60], interferon[49, 61, 62], DMSO[49, 63, 64], and NAC (N-acetyl-L-cystein)[65, 66]. None of these alternatives have been shown to be consistently effective.

Radiation Therapy

Radiation therapy is helpful in preventing progression of the disease and may have some use in preventing contractures or keeping fingers straight after treatment[67-69].  Radiotherapy should be done when the fingers are straight and therefore preliminary needle aponeurotomy or enzyme treatments would be necessary to straighten the fingers.  Radiotherapy would then be performed to prevent recurrence although 31% of patients with Dupuytren’s continued to progress despite radiation[67].

 Betz et al in 2010 reported on long term followup of radiation for Dupuytren's contracture.  Sixty percent did very well long term if the disease was early.  More advanced disease, such as stage II (over 45 degree contracture)usually continued to progress despite radiation.  However, it is possible to convert stage II disease to stage I with needle, XIAFLEX, or both and then do radiation to help prevent progression of the disease. 


 Ledderhose Disease 

A condition related to Dupuytren's of the hand but it occurs on the fibrous fascia of the feet. It also may be treated with needle release. Since there are usually no contracted toes the results are not as dramatic as one finds in the NA of Dupuytren's of the fingers. Ledderhose disease needle aponeurotomy requires optimally two visits separated 2-3 weeks apart to perform NA and settle down the painful nodules.


For more information visit the Dupuytren contracture forum:

Dr. Eaton's Dupuytren's Foundation BlogSpot

Or Auxilium's website, the Xiaflex company:



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24.         Lermusiaux, J.L., et al., How should Dupuytren's contracture be managed in 1997? Rev Rhum Engl Ed, 1997. 64(12): p. 775-6.

25.         Badois, F.J., et al., [Non-surgical treatment of Dupuytren disease using needle fasciotomy]. Rev Rhum Ed Fr, 1993. 60(11): p. 808-13.

26.         Foucher, G., J. Medina, and R. Navarro, Percutaneous needle aponeurotomy: complications and results. J Hand Surg Br, 2003. 28(5): p. 427-31.

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30.         Moermans, J.P., Segmental aponeurectomy in Dupuytren's disease. J Hand Surg Br, 1991. 16(3): p. 243-54.

31.         Maravic, M. and P. Landais, Dupuytren's disease in France--1831 to 2001--from description to economic burden. J Hand Surg Br, 2005. 30(5): p. 484-7.

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33.         Chick, L.R. and G.D. Lister, Surgical alternatives in Dupuytren's contracture. Hand Clin, 1991. 7(4): p. 715-9; discussion 721-2.

34.         Lubahn, J.D., G.D. Lister, and T. Wolfe, Fasciectomy and Dupuytren's disease: a comparison between the open-palm technique and wound closure. J Hand Surg Am, 1984. 9A(1): p. 53-8.

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36.         Ullah, A.S., J.J. Dias, and B. Bhowal, Does a 'firebreak' full-thickness skin graft prevent recurrence after surgery for Dupuytren's contracture?: a prospective, randomised trial. J Bone Joint Surg Br, 2009. 91(3): p. 374-8.

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43.         Cheng, H.S., et al., Needle aponeurotomy for Dupuytren's contracture. J Orthop Surg (Hong Kong), 2008. 16(1): p. 88-90.

44.         Denkler, K., Surgical complications associated with fasciectomy for dupuytren's disease: a 20-year review of the English literature. Eplasty, 2010. 10: p. e15.

45.         Loos, B., V. Puschkin, and R.E. Horch, 50 years experience with Dupuytren's contracture in the Erlangen University Hospital--a retrospective analysis of 2919 operated hands from 1956 to 2006. BMC Musculoskelet Disord, 2007. 8: p. 60.

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48.         Hurst, L.C., et al., Injectable collagenase clostridium histolyticum for Dupuytren's contracture. N Engl J Med, 2009. 361(10): p. 968-79.

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51.         Murrell, G.A., M.J. Francis, and L. Bromley, Free radicals and Dupuytren's contracture. Br Med J (Clin Res Ed), 1987. 295(6610): p. 1373-5.

52.         Akkus, E., et al., Is colchicine effective in Peyronie's disease? A pilot study. Urology, 1994. 44(2): p. 291-5.

53.         Dominguez-Malagon, H.R., et al., Clinical and cellular effects of colchicine in fibromatosis. Cancer, 1992. 69(10): p. 2478-83.

54.         Parsons, A.R., Dupuytren's contracture; treatment by massive doses of vitamin E. Ir J Med Sci, 1948. 19(270): p. 272-4.

55.         King, R.A., Vitamin E therapy in Dupuytren's contracture; examination of the claim that vitamin therapy is successful. J Bone Joint Surg Am, 1949. 31B(3): p. 443.

56.         Thomson, G.R., Treatment of Dupuytren's contracture with vitamin E. Br Med J, 1949. 2(4641): p. 1382, illust.

57.         Thomson, G.R., The treatment of Dupuytren's contracture with vitamin E; report of a case. Glasgow Med J, 1949. 30(9): p. 329-32.

58.         Steinberg, C.L., Tocopherols in treatment of primary fibrositis; including Dupuytren's contracture, periarthritis of the shoulders, and Peyronie's disease. AMA Arch Surg, 1951. 63(6): p. 824-33.

59.         Kirk, J.E. and M. Chieffi, Tocopherol administration to patients with Dupuytren's contracture; effect on plasma tocopherol levels and degree of contracture. Proc Soc Exp Biol Med, 1952. 80(4): p. 565-8.

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62.         Pittet, B., et al., Effect of gamma-interferon on the clinical and biologic evolution of hypertrophic scars and Dupuytren's disease: an open pilot study. Plast Reconstr Surg, 1994. 93(6): p. 1224-35.

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65.         Knobloch, K., J. Redeker, and P.M. Vogt, Antifibrotic medication using a combination of N-acetyl-L-cystein (NAC) and ACE inhibitors can prevent the recurrence of Dupuytren's disease. Med Hypotheses, 2009. 73(5): p. 659-61.

66.         Kopp, J., et al., N-acetyl-L-cysteine abrogates fibrogenic properties of fibroblasts isolated from Dupuytren's disease by blunting TGF-beta signalling. J Cell Mol Med, 2006. 10(1): p. 157-65.

67.         Betz, N., et al., Radiotherapy in early-stage Dupuytren's contracture. Long-term results after 13 years. Strahlenther Onkol, 2010. 186(2): p. 82-90.

68.         Seegenschmiedt, M.H., T. Olschewski, and F. Guntrum, Radiotherapy optimization in early-stage Dupuytren's contracture: first results of a randomized clinical study. Int J Radiat Oncol Biol Phys, 2001. 49(3): p. 785-98.

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