Procedure that requires prior approval
Application form: - Dupuytren’s contracture

Name of Referring Clinician
GP Name and Surgery
Patients NHS Number
Is the patient/guardian aware of the proposed treatment and have they consented to you raising this request on their behalf? / Yes ☐No ☐
Has the patient/guardian consented for their personal and clinical information to be provided to the IFR service via all means, including electronic and automated approvals, to enable full consideration of this funding request? / Yes ☐No ☐
Is this a patient/guardian led application? / Yes ☐No ☐
Most Urgent: Decision needed within a week as the patient’s life may be in danger. / ☐ /
Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate. / ☐ /
Routine: Decision needed in 4 to 6 weeks. / ☐ /
Most patients with Dupuytren’s contracture do not need treatment and can be managed expectantly. However, indications for surgical intervention as per British Society for Surgery of the Hand (BSSH) classification are moderate or severe disease. Surgery for mild Dupuytren’s contracture is not normally funded.
In the first instance the GP should refer to the local MKS service for assessment and treatment.
Collagenase clostridium histolyticum (CCH)
People who meet the inclusion criteria for the ongoing clinical trial (HTA-15/102/04), comparing collagenase clostridium histolyticum (CCH) with limited fasciectomy, are encouraged to participate in the study. Consideration for the trial is not through the IFR/Prior Approval Process.
Radiation therapy for early Dupuytren's disease is not normally funded due to limited evidence.
Prior approval is required prior to treatment in secondary care. All patients should have access to high quality conservative management before surgery is considered.
Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR serviceat or consideration.
The policy statements are available at:
Clinical Criteria required for consideration of treatment / Please Tick
  1. Has the patient mild symptoms as classified by British Society for Surgery of the Hand (BSSH)?
Mild: No functional problems, no contracture or metacarpophalangeal joint contracture of less than 30°. / YES☐NO☐
  1. Has the patient moderate to severe symptoms as classified by BSSH?
Moderate symptoms: functional problems; metacarpophalangeal joint contracture 30° to 60°; proximal interphalangeal joint contracture of less than 30°; or first web contracture
ORSevere symptoms: Severe contracture of both metacarpophalangeal joint (greater than 60°) and severe contracture of proximal interphalangeal joint (greater than 30°)
Clinical evidence must be attached to confirm severity. / YES☐NO☐
  1. Please confirm that the patient has been advised that approximately 40% of people will have a recurrence following surgery.
/ YES☐NO☐
  1. Patient’s Body Mass Index (BMI):
BMI / kg/m2
Height / cm
Weight / kg
  1. Is the patient a non-smoker?
/ YES☐NO☐

South, Central and West Commissioning Support Unit April 2018 TVPC18 BW