There is still a lot of debate about the best surgical procedure for finger contractures in DD, and most techniques have both enthusiastic supporters and opponents. The same is true for less invasive treatment methods such as percutaneous needle aponeurotomy and collagenase injections.

For example, our group published the results of 3 different operations for DD with contracture of the proximal interphalangeal (PIP) joint. Sixteen patients underwent an open fasciectomy, 13 patients underwent a segmental fasciectomy as described by Moermans (Moermans 1991) and 9 underwent a dermofasciectomy with full-thickness graft. At a mean follow-up of 54 months (range 27–75), the type of operation was not related to the recurrence rate. However, the preoperative extension deficit in the PIP joint was significantly correlated with recurrence (van Giffen et al. 2006). Misra et al. published their results in 2007 and demonstrated that the need for joint release was not correlated with recurrence in 49 PIP joints in 37 patients. Again, the severity of the preoperative contracture (more than 60°) and incomplete correction of the PIP joint contracture were associated with the recurrence at 18 months (Misra et al. 2007). Degreef et al. reported in 2009 on the self-reported recurrence rates in 216 surgically treated patients with a minimal follow-up of 2 years. Surprisingly, the recurrence rate in the four different operative techniques (Z-plasty, Bruner incision, segmental fasciectomy or dermofasciectomy with full-thickness graft) was not significantly different. Moreover, the recurrence rate in the dermofasciectomy with full-thickness graft as a revision procedure was higher than when this was done as a primary procedure (Degreef et al. 2009c). Roush and Stern published similar findings in 2000; they demonstrated that the total active motion (TAM) after dermofasciectomy with full-thickness graft for recurrent DD was no longer different from the preoperative TAM at a 4-year follow-up examination. However, fasciectomy with local flap coverage seemed to be the only technique that still had an improved TAM at the 4-year follow-up (Roush and Stern 2000).

As mentioned before, the self-reported recurrence rate, although a very subjective parameter, cannot be ignored in the evaluation of treatment of DD. Dias and Braybrooke also reported on the self-reported recurrence in an audit in 1177 patients in 2006. A multi-centre postal questionnaire study was conducted by the Audit Committee of the British Society for Surgery of the Hand. With a mean follow-up of 27 months, they found that recurrence was more common in patients with greater initial deformity and less common if adequate correction was achieved at the time of surgery (Dias and Braybrooke 2006). It appears that the immediate postoperative result is more important in preventing recurrence than the surgical technique used to achieve the correction.

The potential benefit of a full-thickness graft remains a subject of debate. In the 1984 study by Tonkin et al., they found an overall recurrence rate of 46.5 % in 229 operations with a mean follow-up of 37.7 months (range 9–90). The recurrence rate was the highest in men who were treated with fasciectomy alone (54 %), although the combination with full-thickness grafting still showed significant recurrence rates, both as a primary procedure (33 %) and as a revision procedure (42 %) (Tonkin et al. 1984). Ullah et al. reported their results in 2009; in 90 fingers, 44 underwent a dermofasciectomy with a so-called “firebreak” skin graft and 46 underwent a fasciectomy. With a mean follow-up of 36 months, they found an overall recurrence rate of 12.2 %, but there was no difference in recurrence rate between the two groups (Ullah et al. 2009). Interestingly, the same patient cohort was reviewed 2 years later, 63 of these patients could be included and there appeared to be 4 types of evolution after the operation, independent of the initial surgery. They differentiated between minimal re-contracture, mild early recurrence, severe early recurrence and progressive re-contracture. Worsening of the contracture more than 6° between 3 and 6 months after surgery seemed to predict a progressive re-contracture at 5 years (Dias et al. 2013).

It appears that there are inherent, patient-related factors that influence the outcome after surgery. It is well known that DD can have a strong familial predisposition, and a lot of research has been done to identify the genes involved (Bayat et al. 2002; Bayat et al. 2003; Hindocha et al. 2006a; Hu et al. 2005). For example, Dolmans et al. reported in 2012 that there were 9 single nucleotide polymorphisms (SNPs) associated with DD in a genome-wide association study. DD patients with clinical diathesis features (predominantly knuckle pads) are more likely to carry more risk alleles for the discovered DD SNPs than patients without these diathesis features (Dolmans et al. 2012).

A detailed description of the genetic factors in DD falls outside of the scope of this chapter. However, the knowledge of these genetic factors might give us more insight in predicting recurrence, especially since the expression patterns of these genes can be evaluated on histological examination.

The idea of using histopathology to identify patients at risk for recurrence is not new, but it is still unclear if the underlying process is an inflammatory process or a neoplasm (Wang and Zhu 2006). This makes the development of histological classification more troublesome. Already in 1959, Luck described different histological stages of DD, namely, “cell-rich” proliferation and involution stages versus residual “cell-poor” stages. The latter is supposed to be correlated with a less-active disease (Luck 1959). Rombouts et al. also examined a correlation between histological classification and recurrence. They described 3 types of histology obtained during fasciectomy in 77 hands of 63 patients. The proliferative type had a high cellularity and mitosis rate, and the fibrocellular type showed a prominent reticulin network, whereas the third or fibrous type contained only few cells. The recurrence rate in patients with type 1 was 70 % versus 18 % in type 3 patients at a mean follow-up of 5 years (range 2–10) (Rombouts et al. 1989).