Goyrand introduced the first elaboration by removing short segments of the disease to reduce the chance of the divided ends reattaching, and ‘segmental fasciectomy’ came into being (Goyrand 1833, 1835). Still a quick operation which the author does routinely, instead of fasciotomies, in the elderly, as it is still possible to perform under local anaesthetic and a tourniquet, with, arguably, a lower recurrence rate. Tourniquet time, of course, ceases to be an issue if one uses local anaesthetic with adrenaline.

Fasciotomy (aponeurotomy) or segmental fasciectomy (aponeurectomy) was the state of play in 1839 (Bougery and Jacob 1839). The year 1846 saw a quantum leap in all surgery. Within months of the use of general anaesthesia by Messrs, Clarke, Long and then Morton in Boston, USA, the whole of America and Europe were doing all varieties of surgery never possible previously. First in our field was William Fergusson, of King’s College Hospital, London: with all the time in the world, he did a complete finger fasciectomy, still our commonest operation today.

An incision should be made lengthwise over the whole of the contraction,

and, if the integument [skin] be tolerably soft and thick, it should be turned off on each side, so as to expose the fibrous tissue, which should then be carefully taken away. (Fergusson 1846)

There was an unpredicted twist in the tail of Fergusson’s operation. The previous small operations had been carried out through multiple incisions with skin bridges between them, while this new operation made a cut the full length of the finger, risking healing with a scar contracture. Fergusson solved the problem by making several horizontal skin cuts and allowed these to heal by secondary intention under dressings. Three further ways of avoiding scar contractures were to be created later in the nineteenth century, namely, zigzag incisions, z-plasties and skin grafting with full-thickness and split-thickness skin, and all are still used to avoid this problem after opening the skin on the palmar surface of the digits.

The long Fergusson incisions can be avoided by making transverse incisions and removing the Dupuytren Disease under skin bridges. McIndoe taught this in the 1950s and Burkhalter used the technique more recently. McCash (1964) used the McIndoe approach and then moved the skin bridges distally to close all the skin openings except that of the palmar wound. In the 1970s, these techniques were largely abandoned after strong criticism by Tubiana and others because of the risk of dividing nerves: the first point of nerve danger during fasciectomy being in the distal palm when the neurovascular bundle is pulled centrally by a spiral band, directly under the first of McIndoe’s skin bridges. The Fergusson approach is much safer.

By the end of the nineteenth century, Fergusson fasciectomy in operating theatre conditions more like today was the European ‘norm’, with one exception. William Adams, in London, the doyen of Dupuytren surgery and the most prolific writer on the subject from 1860 to 1900, was still performing Cline-Cooper fasciotomies through very small skin incisions (Adams 1879, 1892) and had worked out how to do this in the fingers without cutting the digital nerves, a technique drawn to our attention again recently by Short and Watson (1982) and then Foucher et al. (2001), but not something for the occasional practitioner! For most of us, percutaneous fasciotomy remains a palm-only technique and only on cases with simple, raised, pretendinous bands, not the ‘sheet’ disease which involves much, or the whole, of the palm, tethering and distorting the palmar skin considerably.

As early as 1831, Dupuytren was advocating postoperative splinting, whether to avoid reattachment of cut ends of the Dupuytren cord after fasciotomy or simply to stretch the scar filling this gap.

le 12 de juin 1831 – Opération 1 : M. L…. Marchand de vins en gros……. . le 14 – au matin, on substitute une machine, plus habilement confectionnée par Lacroix (Bandagiste)

le 5 décembre 1831- Opération 2: On doit employer sur ce malade la machine imaginée par Lacroix. (Dupuytren 1831)

Adams (1892), using more sophisticated splints made of metal covered by leather than our thermoplastic ones, was aware that subcutaneous scar contracture from the surgery could spoil the result. He also knew that surgical scar could be stretched by splints and only contracted for 4–6 months. So night splinting for this period would maintain his operative gain. This is the author’s current reason for night splinting after surgery.

Only much more recently have we realised that Dupuytren cords can also be stretched. In 1831, Dupuytren considered this possibility:

…… on more than one occasion, we have seen that a weight of 100, and even 150, livres

[489.5 g] could be hung from the hook formed by the finger, without its angle of flexion straightening at all. (Dupuytren 1831)

However, it was not until 1968 that this became a reality with a brief report in the Russian literature by Chamraev (Chamraev 1968; Sirotakova and Elliot 1997). Later, the technique was considerably refined by the Messina family (1991, 1993, 2016).

Going back a little in history again, dermofasciectomy, that is removing the overlying skin with the disease and then replacing it with skin graft, was described by Lexer (1931) and popularised in the 1950s and 1960s by Hueston and Iselin, Hueston using full-thickness skin graft and Iselin using split-skin graft. There is no difference in the functional results between the two grafts (Iselin 1986). Even the heaviest manual labourers will only occasionally wear through a graft. Although disease reappears much more rarely after dermofasciectomy (Hueston 1984a), with reappearance in the same digit being less than 10 % at 10 years, this procedure is only done reluctantly by most surgeons as it is perceived as a bit too much surgery, probably for both the patient and the surgeons, and there is a worry about possible graft failure, although this is actually not common. So dermofasciectomy is only performed in the UK when reappearance is particularly likely, in other words in repeatedly reappearing disease or in cases which manifest before the age of 40 years old. This latter indication is tending to be forgotten at present, although John Hueston, in the 1960s, clearly identified a 92 % reappearance rate within 2 years after skin-preserving operations in this age group (Hueston 1963).

Even Hueston was looking for an alternative to this large operation when he described his ‘fire-break’ technique of putting in smaller grafts (Hueston 1984b), so that any disease reappearance cannot travel up the finger, contract and flex the finger, and require reoperation. He later changed the name to ‘fibre-break’ grafting, as he realised that Europeans did not suffer the bush fires of his native Australia. Unfortunately, he died before he could prove the idea. We have operated on over 300 hands with Dupuytren Disease in this way since 1994 and are looking at the 10-year follow-ups. In the first 80 previously operated fingers, collected at 5 years, we had reoperated on only eight fingers for disease causing contracture, although recurrence between the grafts is more common than the need to reoperate.

Recurrence only occurs in the distal palm and in the middle phalanx, never in the proximal palm, making a palmar ‘fibre-break’ graft unnecessary, and we now only graft the proximal 50–75 % of the proximal phalanx. While failure of grafting is unusual, over and above the increased operation time, I think there is one caveat to this procedure. Starting to mobilise the hand after a seven day delay, while the grafts take, worsens the tendency to postop stiffness of the hand. In his classic paper of 1964 on the ‘open-palm’ technique, although not the main point of the paper, this was noted by McCash as a disadvantage of grafting, with the open palm having the benefit of allowing early escape of oedema.

Historically, the open-palm technique has been advocated on three occasions for three different reasons. Dupuytren (1831) was the first to use the open palm, to allow escape of pus, described at that time as ‘inevitable’ and, in an era of surgery without antisepsis or antibiotics, liable to lead to loss of the limb or, even, life if not liberated quickly. McCash subsequently (1964) advocated the technique to avoid palmar haematoma after complete removal of the palmar fascia, which was the routine operation of his time. He believed this created a dead space in the palm and a risk of haematoma collection, certainly a complication to avoid as this almost always leads to a very stiff hand and poor result of surgery. Two outstanding surgeons of our time have commented to the author on McCash’s logic, or the lack of it. Richard Smith in Boston asked the question why leave the wound open when the rest of the surgical world avoided this problem with drains, even in McCash’s time. Dieter Buck Gramcko in Hamburg pointed out that McCash was wrong, there was no dead space after radical palmar fasciectomy and haematoma is rare. He routinely carried out a radical fasciectomy so the undiseased longitudinal palmar fibres cannot develop disease in the future, a logical thought process and a practice the author continues to use in many cases. Both diseased and undiseased longitudinal fibres of the ulnar three digits are removed. The palmar fibres of the index finger are underdeveloped and are rarely involved when disease affects this finger, so these fibres are left intact. This is an addition to any operation in which the palm is opened which may be of value as a prophylaxis and has a zero incidence of haematoma formation in our hands.