A systematic review of outcomes of fasciotomy, aponeurotomy, and collagenase treatments for Dupuytren's contracture

A 10-Year Review of Collagenase Versus Fasciectomy in the Treatment of Dupuytren Contracture

BACKGROUND

Dupuytren disease (DD) is one of the most common disorders of the hand, affecting 5.7% to 11.7% of the global population. This study seeks to evaluate the 10-year efficacy of the 2 most prominent treatment modalities for DD in Veterans Affairs hospitals, injectable collagenase Clostridium histolyticum versus open fasciectomy.

METHODS

A retrospective review was conducted of all electronic medical records of patients who underwent open fasciectomy or collagenase injection to treat their persistent Dupuytren contracture between April 2011 and April 2021. All procedures were performed by 1 of 5 senior surgeons at the same Veterans Affairs Hospital.

RESULTS

A total of 232 patients were treated for DD, with 247 collagenase injections and 44 open fasciectomies performed in this sample. Collagenase patients were, on average, 6.51 years after intervention at the time of review. Open fasciectomy patients were, on average, 4.56 years after operation at the time of review. Collagenase decreased contractures, on average, by 29.40 degrees, whereas open fasciectomy decreased contractures, on average, by 38.59 degrees. Of the contractures that were initially classified as resolved, 50 of 155 (32.2%) treated with collagenase and 6 of 56 (10.7%) treated with open fasciectomy recurred. The use of open fasciectomy compared with collagenase injections to treat contracture was associated with a 74.2% decrease in the likelihood of recurrence.

CONCLUSIONS

This study found that treatment of DD with collagenase injection is associated with a significantly lower degree of deformity correction, lower rate of resolution, and increased rate of recurrence when compared with open fasciectomy.

Safety and Efficacy of In-Office Hand Procedures

Background

The primary concerns with operating on patients in the office setting are insufficient sterility and lack of appropriate resources in case of excessive bleeding or other surgical complications. This study serves to investigate these concerns and determine whether in-office hand surgeries are safe and clinically effective.

Methods

A retrospective review of patients who underwent minor hand operations in the office setting between December 2020 and December 2021 was performed. The surgical procedures included in this analysis are needle aponeurotomy, trigger finger release, foreign body removal, mass removal, and reduction in a finger fracture with or without percutaneous pinning. All fractures, which primarily included metacarpal and phalangeal fractures, were subsequently splinted. Sterility and hemostatic support were achieved via the Wide-Awake Local Anesthesia No Tourniquet (WALANT) method. Major complications were defined as infection, major bleeding, and neurological deficits. Minor complications were defined as prolonged pain, prolonged inflammation, residual symptoms, and recurrence of symptoms within 1 month.

Results

Five patients (3.8%) returned to the office for pain, inflammation, or stiffness of the affected finger, with two of the five returning with symptoms associated with osteoarthritis or pseudogout flare-ups. Five additional patients returned due to residual symptoms or recurrence of the primary complaint within 1 month of surgery. No patients experienced exogenous infection.

Conclusion

The absence of major complications and high success rate for minor hand procedures shows the high degree of safety and efficacy that can be achieved via the in-office setting for select procedures. While proper patient selection is key, our result shows the in-office procedure room setting can offer the necessary elements of sterility and hemostatic support for several common hand surgeries.

Industry Sponsorship Bias in Collagenase Clinical Trials for Dupuytren Disease: A Meta-analysis

BACKGROUND

Collagenase clostridium histolyticum (collagenase) was introduced in 2010 creating a nonoperative treatment option for Dupuytren disease with promising results in sponsored clinical trials. A meta-analysis was performed to investigate industry sponsorship bias.

METHODS

A systematic review of collagenase treatment of Dupuytren contracture was conducted. Articles containing mesh terms including "microbial collagenase" and "Dupuytren's contracture" were searched and limited to only clinical trials with similar protocols for inclusion. Meta-analysis of treatment endpoints of correction of contracture to 0-5 degrees after first and last injection was conducted comparing sponsored versus nonsponsored studies.

RESULTS

Sixteen of the 29 identified articles met criteria for inclusion. Nonsponsored studies reported a significantly higher rate of meeting the primary treatment endpoint compared to sponsored studies after single injection for all joints (69.6% vs 56% P < 0.01), metacarpophalangeal joint (96% vs 64% P < 0.01), and proximal interphalangeal joint (67% vs 36% P = 0.011). The correction in contracture rates was similar between groups with studies evaluating more than one injection.

CONCLUSIONS

Nonsponsored studies published higher success rates in meeting the primary endpoint of full correction after single injection than sponsored studies; however, similar results with multiple injections. This study demonstrated that sponsored studies of collagenase produced highly powered studies that may be reliably depended on for evidence-based clinical application.

Collagenase clostridium histolyticum injection versus limited fasciectomy for the treatment of Dupuytren's disease: a systematic review and meta-analysis of comparative studies

INTRODUCTION

The aim of the present study is to systematically review the literature on well-selected comparative studies for meta-analysis on outcome differences between collagenase clostridium histolyticum (CCH) injection and limited fasciectomy (LF) for Dupuytren's disease.

MATERIALS AND METHODS

PubMed/Medline, Embase, and the Cochrane Library were searched for comparative studies assessing differences in outcomes of CCH and LF. Effect estimates were pooled across studies using random effects models and presented as weighted mean difference (MD) and odds ratio (OR) with corresponding 95% confidence interval (CI).

RESULTS

A total of 11 studies encompassing 1'051 patients was included (619 patients in the CCH and 432 in the LF group). The residual contracture at a minimal average follow-up of three months was higher in the CCH group than in the LF group (27.8 vs. 16.2°, MD 11.6°, 95% CI [8.7, 14.5°], p < 0.001). The recurrence rate was significantly higher in the CCH group (25.8 vs. 9.3%, OR 5.2, 95% CI [1.5, 18.8], p = 0.01) while the rate of severe complications was significantly higher in the LF group (0.3 vs. 7.3%, OR 0.12, 95% CI [0.03, 0.42], p = 0.001).

CONCLUSIONS

Evidence of the present study confirms that CCH injection has a higher rate of disease recurrence whereas LF carries a higher risk for severe complications. It's imperative that the trade-off between these aspects is considered, keeping in mind that CCH injections may be repeated in case of disease recurrence without increasing procedure related risks, especially in complex cases.

Comparing Complications and Patient Satisfaction Following Injectable Collagenase Versus Limited Fasciectomy for Dupuytren's Disease: A Systematic Review and Meta-Analysis

Dupuytren's disease (DD) is a fibroproliferative disorder that manifests as an abnormal growth of myofibroblasts, causing nodule formation and contractures and affecting digit function. If left untreated, these contractures can lead to a loss of mobility and potentially impact hand function. This systematic review critically compares and evaluates the existing literature on the complications and patient satisfaction following injectable collagenase Clostridium histolyticum (CCH) versus limited fasciectomy (LF) for DD. We performed a comprehensive search of the PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), The Cochrane Library, and Excerpta Medica database (EMBASE) databases from 2006 to August 2023. This research targeted all clinical studies involving adults who underwent injectable collagenase and/or limited fasciectomy in the management of DD. Out of the 437 identified studies, only 53 were considered eligible for our analysis, and merely 14 met our inclusion criteria. These selected studies encompassed a total of 967 patients with 1,344 treated joints, with an average follow-up duration of 19.22 (ranging from one to 84.06) months. Within this cohort, 498 joints from 385 patients underwent LF, while 846 joints from 491 patients received CCH injections. Notably, among the 491 patients treated with CCH, 1,060 complications were reported, averaging 2.15 complications per patient, with the most common being contusion/bruising/hematoma/ecchymosis (22.54%), and edema/swelling (18.96%). In contrast, among the 385 patients treated with LF, only 97 complications were reported, translating to 0.25 complications per patient, with the most frequent being paraesthesia or numbness (23.7%), scar sequelae like skin laceration, tear, fissure, or hypertrophic scar (23.7%), and neuropraxia or nerve injury (22.6%). Our meta-analysis indicates that paraesthesia or numbness is more frequently observed in LF than CCH injections, although without statistical significance, with a risk ratio (RR) of 0.39 (95% confidence interval (CI) 0.13-1.18, p-value 0.1). However, scar sequelae (hypertrophic scar, skin laceration, tear, or fissure) show a contrasting pattern, being more commonly associated with CCH injections than LF, with an RR of 1.98 (95% CI 0.26-14.85, p-value 0.51), which, upon eliminating the source of heterogeneity, becomes statistically significant, with an RR of 4.98 (95% CI 1.40-17.72, p-value 0.01). Our data revealed a higher frequency of complications with CCH compared to LF, although more severe adverse effects were observed in the LF group, such as neuropraxia or nerve injury. Scar sequelae were more common with CCH injections. Despite both treatments showing increased patient satisfaction at the final follow-up, CCH injection resulted in earlier improvements in satisfaction.

The role of aromatase inhibitors in slim women with breast cancer-related lymphoedema: a reflective case series

BACKGROUND

This case series follows the reflective processes undertaken, when five slim women presented with reactive oedemas of the forearm and hand, that did not respond to usual therapy.

AIM

To raise awareness about Aromatase Inhibitor (AI), Letrozole.

METHODS

Possible causes, including Cyclin-Dependent Kinase 4 and 6 (CDK4/6) inhibitors, Ribociclib and Axillary Web Syndrome, were explored and reviewed, and potential effective treatment options were then sought. New cases presented, which discounted each theory, until Letrozole was suspected.

RESULTS

Inflammatory oedemas were explained by the mechanisms-of-action relating to Aromatase Inhibitor Associated Musculoskeletal Syndrome (AIMSS), the severity of which, especially for slim women with oestrogen deprivation, causes almost 50% of women to cease treatment within 6 months; risking disease reoccurrence.

CONCLUSION

Permissions were gained, a table was collated and sent to referring consultants, requesting risk/benefit analysis of Letrozole with a medication review. If non-responsive, inflammatory oedemas present in clinic, AIs should be considered as a trigger.

Targeting Myofibroblasts as a Treatment Modality for Dupuytren Disease

PURPOSE

Currently, no treatment corrects the contractile nature of Dupuytren myofibroblasts (DMFs) or prevents recurrence following surgery. Antifibrotic and proadipogenic growth factors are released when adipose-derived stem cells (ASCs) are cultured with platelet-rich plasma (PRP), a platelet concentration from whole blood. Reprograming myofibroblasts into adipocytes via growth factors is proposed as a powerful potential tool to target fibrosis. We aimed to assess whether the combination of ASCs and PRP reprograms DMFs into adipocytes in vitro and alters their contractile nature in vivo.

METHODS

Normal human dermal fibroblasts (NHDFs) and DMFs from Dupuytren patients were isolated and cocultured with ASCs and PRP either alone or together. Adipocytes were detected by Oil Red O and perilipin staining. DMFs and NHDFs were transplanted into the forepaws of rats (Rowett Nude [rnu/rnu]) and treated with saline, PRP+ASCs, or collagenase Clostridium histolyticum (clinical comparison) 2 months later. After 2 weeks, the tissue was harvested and subjected to Masson trichrome staining, and collagen I and III and alpha-smooth muscle actin detection by immunohistochemistry.

RESULTS

Myofibroblasts transform into adipocytes upon coculture with PRP+ASCs. DMFs show increased alpha-smooth muscle actin expression in vivo compared with NHDFs, which is significantly decreased after PRP+ASCs and collagenase Clostridium histolyticum treatments. DMFs induce collagen I and III expressions in rat paws compared with NHDFs, with a type III to I ratio increase. Treatment with PRP+ASC reduced the ratio, but collagenase Clostridium histolyticum did not.

CONCLUSIONS

Treating DMFs with PRP+ASCs provides factors that induce myofibroblast to adipocyte transformation. This treatment reduces the contractile phenotype and fibrosis markers in vivo. Future studies should detail the mechanism of this conversion.

CLINICAL RELEVANCE

The combination of PRP and ASCs to induce the differentiation of DMFs into adipocytes may serve to limit surgery to a percutaneous contracture release and biological injection, rather than a moderate or radical fasciectomy, and reduce the recurrence of Dupuytren contracture.

Assessing the Effect of Time from Injection of Collagenase to Manipulation on Success Rates in Dupuytren Disease

PURPOSE

Dupuytren disease can be managed with an injection of collagenase Clostridium histolyticum enzyme followed by manual manipulation. Although the recommended time from injection to manipulation is 24-72 hours, patient and physician schedules may not accommodate this time frame. Therefore, we sought to study the impact of time from injection to manipulation on outcomes and complications of collagenase injection.

METHODS

We performed a review of 309 patients who underwent an injection of collagenase Clostridium histolyticum for Dupuytren disease with manipulation at two, five, or seven days after injection. We compared preinjection and postinjection contracture angles as well as frequency of skin tears and tendon ruptures.

RESULTS

Of the 309 patients, 207 underwent manipulation at two days, 32 at five days, and 70 at seven days. Patients had similar preinjection contracture angles. All patients demonstrated improvement in contracture after manipulation. Rates of skin tears and tendon ruptures were similar in all three groups. Significant predictors of complications included number of cords injected and history of previous collagenase injection, but not history of previous Dupuytren diagnosis.

CONCLUSIONS

Although collagenase injection for Dupuytren disease is typically performed with plans for manipulation at 24-72 hours, postinjection manipulation could be performed as late as seven days without adversely affecting the frequency of skin and tendon complications.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Continuous Passive Elongation Through an External Fixator: A Versatile and Beneficial Adjunct Technique to Treat Severe and Recurrent Cases of Dupuytren Contracture

Dupuytren disease and its associated digit contracture often negatively impact the quality of life for patients. Severe cases of Dupuytren contracture and symptom recurrence are both difficult for hand surgeons to treat. Improved treatment options are therefore needed. One method is continuous passive elongation (CPE). In CPE, a device is affixed to the digit, which applies a continuous extending force to pull the affected finger out of flexion. Multiple external fixators used to induce CPE have been reported. However, a low-profile, hand-specific external fixator, the DigiFix, provides benefits over previously reported devices. We present the technique of CPE using DigiFix as a beneficial and versatile adjunct treatment for severe and recurrent cases of Dupuytren contracture.

Randomized Controlled Trial Comparing the Clinical Effectiveness of Collagenase Injection (Xiaflex®) and Palmar Fasciectomy in the Management of Dupuytren's Contracture

Introduction: Limited palmar fasciectomy (LPF) and collagenase injection (CI) are the most common procedures to manage symptoms of Dupuytren's Disease. This randomized controlled trial (RCT) aimed to directly compare patient outcomes 12 months following CI and LPF. Methods: Twenty-two patients with Dupuytren's Disease were randomized to either LPF or CI. The primary outcome was health state measured by the Michigan Hand Questionnaire. Secondary outcomes were health status (The Health Utility Index-3), function (The Unité Rhumatologique des Affections de la Main and The Southampton Dupuytren's Scoring Scheme), and range of motion (ROM) of treated digits. Measurements were collected at baseline and 1-, 3-, 6-, and 12-months post-procedure. Results: Thirteen patients were randomized to the LPF and eight patients to the CI group. Most patients (85.7%) were male; the average age of the sample was 65.3 years. No statistically significant difference in the MHQ (mean difference [MD]: −12.4 (95% confidence interval [CI]: −30.0, 5.2)), SDSS (.9 (−4.0, 5.8)), URAM (−.9 (−14.4, 12.6)) or HUI-3 (−.04, −.2, .2)) was found between groups 12-months post-operatively. There was no statistically significant difference in 12-month loss of extension between groups at the MCP (−16.9 (−35.4, 1.7) or PIP (−2.9 (−22.9, 17.1) joints. Three CI patients and 1 LPF patient developed a contracture in the same digit requiring surgery. Conclusion: Results should be interpreted with caution given the small sample size. Available data suggests both techniques are reasonable for managing Dupuytren's Disease. Considerations for future RCTs are provided.

Patients' perspectives of collagenase injection or needle fasciotomy and rehabilitation for Dupuytren disease, including hand function and occupational performance

PURPOSE

To describe patients' perspectives of collagenase injection or needle fasciotomy for Dupuytren disease (DD) including hand therapy, and their view of hand function and occupational performance.

MATERIALS AND METHODS

Interviews were performed with twelve patients who had undergone non-surgical treatment and rehabilitation for DD. Data was analysed using a problem-driven content analysis using the model of Patient Evaluation Process as a theoretical framework.

RESULTS

The participants' previous experiences influenced their expectations of the upcoming treatment and they needed information to be prepared for treatment. Treatment and rehabilitation had a positive impact on daily life and were regarded as effective and simple with quick recovery. However, there could be remaining issues with tenderness or stiffness. The participants expressed their belief in rehabilitation and how their own efforts could contribute to an improved result. Despite concerns about future recurrence participants described increased knowledge and sense of control regarding future needs.

CONCLUSION

Undergoing a non-surgical treatment and rehabilitation process for DD was regarded as quick and easy and can meet the need for improved hand function and occupational performance. Taking responsibility for one's own rehabilitation was considered to influence the outcome positively. The theoretical framework optimally supported the exploration of participants' perspective.Implications for rehabilitationTreatment of Dupuytren Disease (DD) with needle/collagenase combined with hand therapy was experienced as giving fast improvement in hand function and occupational performance.An individualized care process which satisfies the need for knowledge about the disease, prognosis, treatment options and rehabilitation can give individuals suffering from DD a sense of security.The need for active participation in the DD care process can vary and it is crucial to listen to individuals' opinions and needs.Individuals can take considerable responsibility for rehabilitation after non-surgical treatment for DD and regard it as important for the outcome.

Risk Factors for Long-Term Contracture Recurrence after Collagenase Injection for Dupuytren Disease: A Prospective Cohort Study

In Dupuytren disease, little is known about the long-term outcomes of collagenase injection or risk factors for contracture recurrence. In this prospective study, 159 patients (242 fingers) with Dupuytren disease and active extension deficit (AED) ≥20° in a metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joint were treated with collagenase injection during a 14-month period. At 5 years, 18 patients were deceased, 2 could not be contacted, and 13 had undergone fasciectomy. The remaining 126 patients (199 treated fingers) participated in a follow-up evaluation at 52–96 (mean 65) months after injection, with physical examination (114 patients) or telephone interview (12 patients). Recurrence was defined as subsequent treatment (surgery or repeat injection) or ≥20° AED worsening in a treated joint between the 6-week and 5-year measurements. The mean AED at baseline was 42° (SD 24) for MCP joints and 31° (SD 29) for PIP joints and at 5 years 11° (SD 17) and 17° (SD 23), respectively. Recurrence occurred in 17% of MCP joints and 25% of PIP joints. Statistically significant risk factors for PIP joint contracture recurrence were greater baseline AED (odds ratio 1.04, 95% CI 1.02–1.06) and small finger treatment (OR 4.6, 95% CI 1.5–14.3), with no significant risk factors found for MCP contracture recurrence.

Effect of nanoparticle-mediated delivery of SFRP4 siRNA for treating Dupuytren disease

Dupuytren disease (DD) is a progressive fibrous proliferative disease. It invades the palmar aponeurosis and extends to the finger fascia, eventually leading to flexion contracture of the metacarpophalangeal or interphalangeal joint. At present, surgical resection and the local injection of collagenase are the main methods for the treatment of DD, but postoperative complications and high recurrence rates often occur. Bioinformatics analysis showed that the increased expression of SFRP4 protein was closely related to the incidence of DD. Persistent and effective inhibition of SFRP4 expression may be a promising treatment for DD. We prepared SFRP4 siRNA/nanoparticle complexes (si-SFRP4) and negative siRNA/nanoparticle complexes (NC) and applied them in vitro and in vivo. Flow cytometry analysis showed that si-SFRP4 could be successfully transfected into DD cells. MTT and EdU staining assays showed that the OD values and percentage of EdU-positive cells in the si-SFRP4 group were significantly lower than those in the NC group. Scratch tests showed that the wound healing rate of the si-SFRP4 group was lower than that of the NC group, and the difference was statistically significant. The expression of SFRP4 and α-SMA protein in the si-SFRP4 group significantly decreased in both DD cells and xenografts. Compared with the NC group, the xenograft quality of the si-SFRP4 group was significantly reduced. Masson's trichrome staining showed that the collagen and fibrous cells in the si-SFRP4 group were more uniform, slender, parallel and regular. The above experimental results suggest that the proliferation and metabolism of palmar aponeurosis cells and the quality of metacarpal fascia xenografts were both significantly decreased. We speculated that nanoparticle-mediated SFRP4 siRNA can be used as a potential new method for the treatment of DD.

Dupuytren contracture: using qualitative data to inform a conceptual framework for shared decision-making

Multiple treatment options are available to patients with Dupuytren contracture, making shared decision-making complex. Our rigorous qualitative analysis sought to understand patient perceptions of shared decision-making in Dupuytren contracture treatment and create a conceptual framework to optimize patient-physician communication. We interviewed 30 patients with Dupuytren contracture to learn about their experience with treatment selection. The following themes were integral to shared decision-making for Dupuytren contracture treatment: discussing disease progression and treatment initiation, presenting all available treatment options, assessing patients' pre-existing biases towards treatment, patient values and preferences for treatment trade-offs, treatment risks and benefits, physician recommendation and active patient participation. This model can optimize communication about treatment options and expectations for relevant outcomes including, recovery time, contracture recurrence, complications, and treatment-related expenses.Level of evidence: V.

Application of fibrin glue for hematoma prophylaxis in selective aponeurectomy in Dupuytren's disease

INTRODUCTION

Fibrin glue (FG) can be applied in several surgical procedures at wound closure to reduce postoperative complications such as hematoma formation and wound impairment. The purpose of this study is to assess these preventive surgical benefits in Dupuytren's disease of the hand.

PATIENTS AND METHODS

We performed a monocentric retrospective cohort study. All patients who underwent selective aponeurectomy for Dupuytren's disease between 2010 and 2020 were included. Patients were divided into two groups: either receiving or not receiving FG. The primary outcome variables were postoperative bleeding, wound healing impairment, and further pooled postoperative complications.

RESULTS

One hundred and thirty-three patients were included in the analysis of which 108 patients were treated with FG, while 24 did not. There was no statistically significant difference in outcomes regarding postoperative bleeding, infections, or revision surgery. However, in the group receiving FG, there was a tendency toward higher wound healing impairment (13%, p = 0.07). The FG group showed a significantly higher pooled complication rate (18.5%, p < 0.02). Complication in general increased with higher Tubiana classification and number of resected cords. Smoking tripled the risk of impaired wound, while cardiovascular comorbidities increased postoperative bleeding by the factor of 11.

CONCLUSION

FG did not show a preventive outcome regarding bleeding. The FG group had a tendency for a higher wound healing incidence. Smoking and arterial hypertension correlated with a higher postoperative complication rate. The overall incidence of complications was higher in the FG group. The quality of the surgical intervention as well as accurate hemostasis cannot be corrected by the application of FG.

Artrodesis de articulación interfalángica proximal en enfermedad de Dupuytren: Una revisión sistemática cualitativa

Introducción La enfermedad de Dupuytren (ED) se caracteriza por una alta tendencia a la recidiva. Las reintervenciones asocian elevado riesgo de complicaciones, incrementado tras cada cirugía. En contracturas graves y recidivantes, con insuficiencia vascular o mala calidad tisular, nuevas fasciectomías pueden estar contraindicadas por el riesgo de comprometer gravemente la viabilidad cutánea. En estos casos, artrodesar la articulación interfalángica proximal (IFP) es una alternativa a la amputación. La artrodesis también es una alternativa en aquellas contracturas que asocien artrosis o artrofibrosis de la articulación IFP. El limitado conocimiento sobre esta intervención se justifica por su escasa frecuencia. Realizamos una revisión sistemática cualitativa de resultados y complicaciones de artrodesis de la articulación IFP del segundo al quinto dedos en adultos con ED.

Materiales y Métodos Según la declaración de los Ítems Preferidos de Reporte para Revisiones Sistemáticas y Metanálisis (Preferred Reporting Items for Systematic Reviews and Meta-Analyses, PRISMA, en inglés), desarrollamos una búsqueda en las bases de datos PubMed, Embase y Cochrane Library. Evaluamos el riesgo de sesgo mediante la Escala de Newcastle-Ottawa modificada. Junto a variables intra y preoperatorias y complicaciones, se registró las mejorías funcional y del dolor, y el grado de satisfacción.

Resultados Para esta revisión sistemática, se seleccionaron 4 series de casos, con 65 pacientes y 71 artrodesis. No evidenciamos mejorías significativas en términos de dolor o funcionalidad, pero sí un alto grado de satisfacción en todos los estudios. El 11,3% de las complicaciones incluyó una necrosis cutánea, pero ninguna lesión vascular o nerviosa.

Conclusión Pese a no demostrar mejoría en dolor o funcionalidad, este procedimiento asocia alto grado de satisfacción y muy baja tasa de afectación cutánea o de lesiones vasculares o nerviosas. El nivel de evidencia sobre resultados y complicaciones es bajo.

Utilidad de la ecografía en la cirugía de la mano: Parte II

En los últimos años, con los avances técnicos en la ecografía, aumentó la calidad de las imágenes, lo que ha permitido a los cirujanos mejorar su capacidad de evaluar la mano y la muñeca. Las infiltraciones ecoguiadas en cirugía de mano son más precisas y seguras en comparación con las infiltraciones sin el uso de ecografía. El desarrollo de la técnica de ecografía y de transductores de alta resolución nos ayuda a realizar procedimientos ecoguiados, como el tratamiento del dedo en gatillo, la liberación del síndrome del túnel carpiano, y la aponeurotomía en la enfermedad de Dupuytren. El objetivo de este trabajo es describir las técnicas ecográficas en el tratamiento de las patologías de la mano y el estado del arte de las cirugías ecoguiadas de la mano y sus resultados.

Outcomes of Management of Recurrent Dupuytren Contracture: A Systematic Review and Meta-analysis

BACKGROUND

With numerous treatment modalities available, it is unclear whether the treatment of recurrent Dupuytren disease is as effective as its initial treatment. We aimed to investigate the outcomes of management of recurrent Dupuytren contracture.

METHODS

Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, MEDLINE, Embase, PubMed, CINAHL, and Cochrane Central Register of Controlled Trials were searched from their inception to April 2020. Studies of patients aged above 18 years undergoing treatment for recurrent Dupuytren contractures were included. The Risk Of Bias In Non-randomized Studies-of Interventions tool was used for quality assessment. The study was registered with Open Science Foundation.

RESULTS

A systematic review identified 12 studies: 311 patients with 224 affected digits-index (n = 5; 2.2%), long (n = 17; 7.6%), ring (n = 57; 25.4%), small (n = 112; 50%), and unspecified (n = 33; 14.7%); of these, there were 76 metacarpophalangeal joints (MCPJ; 45.5%), 90 proximal phalangeal joints (PIPJ; 53.9%), and 1 distal interphalangeal joint (0.6%). Previous treatment included the following: percutaneous needle aponeurotomy (n = 103 of 311 patients; 33.1%), collagenase clostridium histolyticum-injection (CCH; n = 75 of 311; 24.1%), limited fasciectomy (LF) ± skin graft (n = 83 of 311; 26.7%), fasciotomy (n = 1 of 311; 0.3%), and unspecified (n = 64 of 311; 20.6%). Recurrence was treated by percutaneous needle aponeurotomy (n = 68 of 311 patients; 21.9%); CCH injection (n = 53 of 311; 17.0%); aponeurotomy or dermofasciectomy or LF (n = 176 of 311; 56.6%); ray/digit amputation (n = 8 of 311; 2.6%); and PIPJ arthrodesis (n = 6 of 293; 2.0%). Range of motion was improved by 23.31° (95% confidence interval [CI] = 13.13°-33.50°; I² = 67%; P = .05) and 15.49° (95% CI = 2.67°-28.31°; I² = 76%; P = .01) for MCPJ and PIPJ, respectively.

CONCLUSIONS

There is low level of evidence that both surgical and nonsurgical treatments provide clinically important improvements for recurrent Dupuytren contracture.

Treatment of Dupuytren's Contracture With Collagenase: A Systematic Review

This systematic review investigates complications and recurrence of Dupuytren's contracture in metacarpophalangeal joints (MCPJs) and/or proximal interphalangeal joints (PIPJs) of fingers treated with collagenase clostridium histolyticum (CCH). A review of the literature on Dupuytren's disease was performed using PRISMA guidelines. Included publications described complications and/or recurrences for contractures ≥20° in MCPJs and/or PIPJs treated with CCH. Successful treatments reduced contractures to ≤5° immediately. Treatment-related adverse events (AEs) were classified as minor, major surgical, and major nonsurgical. Contracture recurrence involved return of fixed-flexion contracture ≥20° in a successfully treated finger in patients with ≥12 months of follow-up. Of 2675 patients (3753 joints), 94% experienced ≥1 treatment-related AE, most commonly peripheral edema (64%), pain in extremity (53%), and contusion (51%). Major surgical complications occurred in 9 patients (1.0%). Major nonsurgical complications occurred in 2 patients, specifically nonrupture tendon injury and anaphylaxis. Of 1488 patients (2069 joints), recurrences were reported in 23% of successfully treated joints (n = 466; 20% MCPJs, 28% PIPJs), on average 12 to 24 months after treatment. MCPJs achieved greater success than PIPJs in initial contracture reduction (77% versus 36%). CCH is a safe, effective treatment to improve hand function in Dupuytren's contracture. Most AEs are minor and self-resolving, although the risk of major AEs still exists. Following treatment, 23% of successfully treated joints experience recurrence, typically within 12 to 24 months but sometimes as early as 6 months. Surgeons are encouraged to discuss these risks with patients for shared decision-making regarding optimal treatment modalities.

Ultrasound-guided aponeurotomy and interphalangeal joint capsular release for treatment of Dupuytren's disease

This study describes a new ultrasound-guided surgical technique for aponeurotomy and interphalangeal joint capsular release in patients with Dupuytren's disease and analyses the clinical outcomes. We carried out a retrospective review of 70 digits in 35 patients who underwent ultrasound-guided aponeurotomy and interphalangeal joint capsular release, with a minimum follow-up of 2 years. The primary outcome was the correction of the deformity and the QuickDASH questionnaire score after surgery and at 1 and 2 years. The secondary outcome was the presence of residual contracture immediately after surgery. The mean QuickDASH score fell from 28 before surgery to 14 after surgery. A significant decrease of -63° was observed for the global contracture, -35° the metacarpophalangeal joint contracture and -28° for the proximal interphalangeal joint contracture. Ultrasound-guided aponeurotomy and interphalangeal joint capsular and palmar plate releases are highly accurate and safe.Level of evidence: IV.

The Effect of Shock Wave Therapy on Improving the Symptoms and Function of Patients with Dupuytren's Contracture

INTRODUCTION

We aimed to evaluate the effect of shock wave therapy on the improvement of symptoms and function of patients with Dupuytren's contracture.

MATERIALS AND METHODS

This research is a pre-post intervention study, conducted among patients referred to the physical medicine clinics of Isfahan during 2019-2020. In this study, subjects experienced shock wave therapy for 6 sessions, each in a week, and improvement of symptoms and function were assessed and compared after the period of study and follow-up (before treatment, 6 weeks after treatment, and 14 weeks after treatment). The pain visual analog scale and disabilities of the arm shoulder and hand questionnaire were completed for all patients at the mentioned time, and the finger contraction angle was also measured by a goniometer over these intervals.

RESULTS

Twenty patients, 11 (55%) men and 9 (45%) women participated in the study. The mean and standard deviation of their age was 66.6 ± 7.11 years. The trend of pain severity of patients was continuously and significantly decreasing up to 14 weeks, which implies the effectiveness of the intervention (P < 0.05). Moreover, the patients' functional status improved due to the continuation of the intervention, and its trend was decreasing up to 14 weeks (P < 0.05). As for the contraction angle, there was a continuous and significant decreasing trend until week 14, and the intervention was also effective on the contraction angle (P < 0.05).

CONCLUSION

It can be concluded that shock wave therapy can be effective in improving the symptoms and function of patients with Dupuytren's Contracture.

Epineural Methylene Blue Injection May Aid Localization of Digital Nerves in Dupuytren's Surgery

Background

In Dupuytren's surgery, limited fasciectomy is still the gold-standard treatment. A relatively high risk of iatrogenic nerve injury has been observed especially when the spiral cords of the Dupuytren's tissue pull digital nerves away from their normal anatomical location. Intraoperative neural marking could facilitate locating the potentially displaced nerves. Hence, surgery could be undertaken more quickly with a lower risk of iatrogenic nerve injury.

Objectives

We hypothesize that digital nerves may be stained with methylene blue (MB) in vivo providing a visual aid to distinguish them from Dupuytren's tissue. We aim to (a) test an in vivo nerve staining technique using MB in a rat sciatic nerve model and to (b) assess the safety of epineural MB injection.

Methods

Three experiments were performed: first, the effects of (a) sham surgery, (b) epineural needle insertion, and (c) 40 μL epineural saline injection were tested in the rat sciatic nerve. Second, we determined the (a) histoanatomical localization of the epineurally injected 40 µL 1 m/m% MB stock solution and (b) we tested which saline dilution (i.e., 1:40, 1:80, and 1:160) of the stock solution does provide optimal blue color upon 40 µL epineural injection. Third, the functional and morphological effect of 40 µL 1:80 diluted MB injection was compared with that of saline, injected into the contralateral sciatic nerve. The functional effects were tested by assessing the pain threshold by using a dynamic plantar esthesiometer (DPA) and by examination of the animal's gate and paw posture. Sciatic nerves were subjected to histological examination and morphometry to test structural damage.

Results

Neither epineural needle insertion nor saline injection caused any functional or morphological changes. Histological examination revealed that the MB stained the epineural compartment. Epineural injection of 40 μL 1:80 diluted MB into the sciatic nerve stained an 18.18-mm segment of the nerve distal to the puncture point. DPA revealed unchanged pain threshold values on the plantar surface of the limbs. Normal gait and foot posture suggested normal motor functions in all groups. No histological changes were seen in the stained nerves, and the nerve fiber density remained unchanged.

Conclusion

We demonstrated that in vivo nerve staining with MB is a suitable method to mark nerves without causing detectable negative effect to the stained nerve. Human trials are required to prove the efficacy of the technique in Dupuytren's disease.

Dupuytren's Disease: An Outcomes-Focused Update

Dupuytren's disease (DD) remains a common fibroproliferative condition with significant sequelae and impact on patient's lives. The etiology of DD is poorly understood, and genetic predisposition is thought to be a strongly associated factor. Despite remarkable strides in improving our molecular understanding of DD, clinical treatment options have not yet overcome the frequently encountered challenge of recurrence. Recurrence rates continue to shape the prognosis of this fibrotic condition. In this outcomes-focused article, the various treatment modalities are reviewed. This further emphasizes the importance of patient education and providing them with the information to make informed decisions about their treatment.

Feasibility of aponeurectomy in combination with perioperative 192Ir high dose rate brachytherapy for Dupuytren's disease

PURPOSE

Partial aponeurectomy (PA) is a standard procedure for Dupuytren's contracture (DC). Here we report a novel approach using surgery combined with perioperative high dose rate (¹⁹²Ir-HDR) brachytherapy.

METHODS AND PATIENTS

From March 2018 until February 2020, thirteen rays of 6 patients with Dupyutren's contractures underwent PA followed by HDR brachytherapy. After removal of fibrous tissue and mobilization of the tendons, one to three catheters per patient were placed intraoperatively. Immediately after surgery, a planning computer tomography with 3D-planning was performed. Then 10-12 Gy were given to 0-2 mm from the catheters' surface and the catheters were removed 6-12 h after brachytherapy.

RESULTS

No complications were observed. The mean contractures were reduced from 55.4° (standard error SE 19.6) to 15.4° (SE 6.7; p < 0.01). One patient showed progressive fibrosis of a nontreated ray during follow-up.

CONCLUSIONS

HDR brachytherapy in combination with surgery is feasible and harbors the potential for combined modality therapy to reduce relapse rates of advanced or relapsing DC. Controlled studies are warranted to investigate the role of bimodal therapy compared with PA alone.

Experiences of men living with Dupuytren's disease-Consequences of the disease for hand function and daily activities

STUDY DESIGN

Qualitative descriptive.

INTRODUCTION

Dupuytren's disease (DD) is a chronic hand condition causing impairment in hand function. Research describing persons' experiences of living with DD is limited. Understanding the subjective experience of illness is valuable for planning and implementing health-care services.

PURPOSE OF THE STUDY

To explore experiences among men living with an impaired hand function due to DD and the consequences of the disease for daily activities.

METHODS

Interviews were conducted with 21 men before surgery. The model of the patient evaluation process guided data collection. Data were analyzed using problem-driven content analysis.

RESULTS

Participants described DD as a chronic disease caused by heredity, previous injury, hard work, or aging. DD was, according to the participants, an uncomfortable and sometimes painful condition, causing a feeling of constant stiffness in the affected hand. DD could cause participants to have fear of hurting the hand, feelings of shame or embarrassment, and a sense of being old. Participants handled the deteriorating hand function by avoiding or refraining from activities, adapting their performance, or performing activities with less quality. The ideal hand function was seen as being able to use the hands without effort.

DISCUSSION

The diverse experiences of DD and if the hand is experienced as something that causes distress can be understood further using body-self dialectic and Gadow's states of embodiment, as well as the process of adapting and learning to live with the functional limitations.

CONCLUSIONS

A clinical implication for hand therapy is to acknowledge patients' individual experiences and support self-modifications and development of new skills.

External Screw-Threaded Traction Device Helps Optimize Finger Joint Mobility in Severe Stage III and IV Dupuytren Disease

Background

Treating advanced finger joint contractures from Dupuytren disease remains a challenge. We evaluated the effectiveness of a skeletal distraction device versus alternative treatment options.

Material/Methods

We analyzed the surgical treatment of contracted finger joints in stage III and stage IV Dupuytren’s disease over a 10-year period. Data were obtained from inpatient and outpatient medical records, including postoperative clinical examinations and extended Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire scores. Complications of infection, postoperative pain, and wound healing disorders were recorded.

Results

A total of 79 patients (83 hands) were assigned to 2 treatment groups. Patients in group 1 underwent an initial open transection of the main fibrous cord, Z-plasty, distraction with the Erlangen external distraction device, and fasciectomy. The distraction period was 13 to 81 days (mean 31 days). Group 2 underwent a conventional single-stage fasciectomy and arthrolysis. DASH scores and subjective patient satisfaction were lower in group 1 (20.7/33%) than in group 2 (10.3/50%). However, the staged approach of group 1 to treat proximal interphalangeal joint contractures in the long term (improvement >40%) was more effective than the approach of group 2 (>33%). Distraction device pin infections occurred in 20% of hands. Postoperative pain and complex regional pain syndrome type I occurred in 25% of hands in group 1 and 3% in group 2.

Conclusions

A screw thread driven external fixation device is useful in end-stage Dupuytren’s finger joint contractures. It is indicated when joint contractures are advanced and simple arthrolysis is insufficient.

Non-microsurgical Composite Grafting for Acute Management of Fingertip Amputation

Following a fingertip amputation, if vessels are present and of adequate condition, microsurgical replantation is the preferred technique for management. Composite grafting has a limited role in the management of fingertip amputations due to its unreliable nature but can be an option when an amputated fingertip is not replantable and the patient desires restoration of fingertip length and aesthetics. When composite grafting is selected as the treatment of choice for a particular patient, there are methods of optimizing the chances of graft revascularization and survival, including early grafting, graft cooling, and a moist wound healing environment.

Fasciectomy under local anaesthetic and adrenaline for Dupuytren’s contracture in a community setting in the UK with a cost analysis

Aims

In the UK, fasciectomy for Dupuytren’s contracture is generally performed under general or regional anaesthetic, with an arm tourniquet and in a hospital setting. We have changed our practice to use local anaesthetic with adrenaline, no arm tourniquet, and perform the surgery in a community setting. We present the outcome of a consecutive series of 30 patients.

Methods

Prospective data were collected for 30 patients undergoing open fasciectomy on 36 digits (six having two digits affected), over a one-year period and under the care of two surgeons. In total, 10 ml to 20 ml volume of 1% lidocaine with 1:100,000 adrenaline was used. A standard postoperative rehabilitation regime was used. Preoperative health scores, goniometer measurements of metacarpophalangeal (MCP), proximal interphalangeal (PIP) contractures, and Unité Rheumatologique des Affections de la Main (URAM) scores were measured pre- and postoperatively at six and 12 weeks.

Results

The mean preoperative contractures were 35.3° (0° to 90°) at the metacarpophalangeal joint (MCPJ), 32.5° (0° to 90°) at proximal interphalangeal joint (PIPJ) (a combined deformity of 67.8°). The mean correction was 33.6° (0° to 90°) for the MCPJ and 18.2° (0° to 70°) for the PIPJ leading to a combined correction of 51.8°. There was a complete deformity correction in 21 fingers (59.5%) and partial correction in 14 digits (37.8%) with no correction in one finger. The mean residual deformities for the partial/uncorrected group were MCP 4.2° (0° to 30°), and PIP 26.1° (0° to 85°). For those achieving a full correction the mean preoperative contracture was less particularly at the PIP joint (15.45° (0° to 60°) vs 55.33° (0° to 90°)). Mean preoperative URAM scores were higher in the fully corrected group (17.4 (4 to 31) vs 14.0 (0 to 28)), but lower at three months post-surgery (0.5 (0 to 3) vs 4.40 (0 to 18)), with both groups showing improvements. Infections occurred in two patients (three digits) and both were successfully treated with oral antibiotics. No other complications were noted. The estimated cost of a fasciectomy under local anaesthetic in the community was £184.82 per patient. The estimated hospital theatre costs for a fasciectomy was £1,146.62 under general anaesthetic (GA), and £1,085.30 under an axillary block.

Conclusion

This study suggests that a fasciectomy performed under local anaesthetic with adrenaline and without an arm tourniquet and in a community setting is safe, and results in favourable outcomes regarding the degree of correction of contracture achieved, functional scores, and short-term complications. Local anaesthetic fasciectomy in a community setting achieves a saving of £961.80 for a GA and £900.48 for an axillary block per case. Cite this article: Bone Joint J 2020;102-B(10):1354–1358.

A New Animal Model for Pathological Subcutaneous Fibrosis: Surgical Technique and in vitro Analysis

Fibrosis is a condition that affects the connective tissue in an organ or tissue in the restorative or responsive phase as a result of injury. The consequences of excessive fibrotic tissue growth may lead to various physiological complications of deformity and impairment due to hypertrophic scars, keloids, and tendon adhesion without understating the psychological impact on the patient. However, no method accurately quantifies the rate and pattern of subcutaneous induced hypertrophic fibrosis. We, therefore, devised a rodent excisional model to evaluate the extent of fibrosis with talc. Tissue specimens were set on formalin, and paraffin sections for histological, immunohistochemical, and molecular analysis talc was used to induce the fibroproliferative mechanism typical of hypertrophic scars. This pathway is relevant to the activation of inflammatory and fibrotic agents to stimulate human hypertrophic scarring. This model reproduces morpho-functional features of human hypertrophic scars to investigate scar formation and assess potential anti-scarring therapies.

Office-Based Percutaneous Fasciotomy for Dupuytren Contracture

Percutaneous fasciotomy is a safe, simple, and inexpensive treatment for mild to moderate Dupuytren contracture. The decrease in extension deficit in the metacarpophalangeal and proximal interphalangeal joints after release correlates with improvement in patient-reported outcomes. Complications are rare and primarily include skin tears, which occur in approximately 4% of patients. Most patients are satisfied with the outcomes of the procedure at 1 year.

Comparison of Treatment Outcomes after Collagenase Injection and Percutaneous Needle Fasciotomy for Dupuytren's Contracture: Objective and Subjective Comparisons with a 3-Year Follow-Up

BACKGROUND

This study compared the effectiveness of injectable collagenase clostridium histolyticum and percutaneous needle fasciotomy in the treatment of Dupuytren's contracture.

METHODS

Patients with a total passive extension deficit of 30 degrees or more in a single digital ray were enrolled and assigned randomly to receive either collagenase clostridium histolyticum injections or percutaneous needle fasciotomy. Preoperative severity of proximal interphalangeal joint contracture for Dupuytren's disease was classified according to the British Society for Surgery of the Hand as less than 30 degrees (stage I) or 30 degrees or more (stage II).

RESULTS

Of the 70 patients enrolled, 36 patients with 46 joints received collagenase clostridium histolyticum injections and 34 patients with 48 joints received percutaneous needle fasciotomy. At day 30, successful corrections were obtained in only 50 percent of the injection group and 67 percent of the fasciotomy group for stage II proximal interphalangeal joints. Recurrences were frequent among patients with stage II joint contractures. The mean Quick Disabilities of the Arm, Shoulder and Hand questionnaire score at day 30 was significantly higher in the injection group compared with the fasciotomy group (7.5 versus 4.2, respectively). In the injection group, adverse events were reported for all patients. In the fasciotomy group, complications were reported for 15 percent of patients.

CONCLUSIONS

The collagenase clostridium histolyticum and percutaneous needle fasciotomy groups had similar outcomes for Dupuytren's contracture with 3 years' follow-up. Recurrences were frequent among patients with stage II proximal interphalangeal joint contractures. The Unité Rhumatologique des Affections de la Main scale and Quick Disabilities of the Arm, Shoulder and Hand questionnaire score decreased significantly for both groups at final follow-up.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

The burden of productivity loss of U.S. commercially insured patients diagnosed with Dupuytren's disease undergoing collagenase versus fasciectomy treatment

Background: We conducted a comparative assessment of the productivity loss associated with the two different treatment options for Dupuytren's disease: collagenase and fasciectomy. Methods: The retrospective claims analysis was performed using the data from IBM MarketScan® Commercial (CD) and Health and Productivity Management (HPM) Databases over five years (2012-2016). We identified two cohorts of patients who underwent either collagenase or fasciectomy in the CD. Propensity-score matched patients were linked to their productivity loss claims in the HPM database. Productivity loss measures were assessed over a 12-month follow-up period. Results: Out of 702 collagenase and 999 fasciectomy propensity score-matched patients in the CD, there were 147 collagenase and 273 fasciectomy patients in the HPM database. Over the follow-up period, collagenase-treated patients were significantly less likely to use short-term disability (STD) leave (9.7% vs. 20.2%; P = 0.009), reflecting in the lower average number of absent STD days (mean, 2.8 vs. 8.1; P = 0.002) in comparison to fasciectomy-treated. The mean indirect STD cost was considerably lower in the collagenase vs. fasciectomy group ($375 vs. $1,108; P = 0.002). Conclusion: This study indicates that collagenase vs. fasciectomy treatment may be related to a lower rate of workplace absence and lower indirect cost in a year following the treatment.

Using Evidence for Hand Surgery: How to Practice Evidence-Based Hand Surgery Care

Each step of the evidence-based practice process is critical and requires clear understanding for accurate application. To practice evidence-based care, providers must acquire a specific skillset that facilitates translation of a patient problem into an answerable research question. Additional requirements are understanding of electronic databases, critical appraisal of the available evidence, and integration of the findings to generate a specific, individualized treatment plan. Although this process is demanding, evidence-based practice is essential in the delivery of optimal patient care.

Segmental aponeurectomy with Z-Plasty as a treatment option in Dupuytren's disease: A retrospective cohort study

BACKGROUND

Aponeurectomy remains the reference standard treatment for digit tethering by palmar fascial cords in Dupuytren's disease but is associated with a substantial complication rate. An alternative technique decreases metacarpophalangeal joint (MCPJ) flexion contracture by combining palmar segmental aponeurectomy with Z-plasty skin closure. The primary objective of this study was to assess range of motion of the operated ray after the procedure. The secondary objectives were to assess the complication rate and to determine the recurrence rate after at least 1 year.

HYPOTHESIS

Palmar segmental aponeurectomy with Z-plasty closure may provide the advantages of aponeurectomy while decreasing the surgical risk and recurrence rate.

MATERIAL AND METHODS

A retrospective study was conducted in 16 patients with predominant MCPJ flexion contracture due to a well-defined palmar fascial cord. Anaesthesia was loco-regional. The Z-plasty design involved a longitudinal incision along the palmar cord with an oblique incision at each end at a 60° angle to the longitudinal incision. The length of the aponeurectomy was about 1.5cm, to allow full MCPJ extension.

RESULTS

In all, the 16 patients-13 males and 3 females-had 17 segmental palmar aponeurectomy procedures with Z-plasty closure. Mean operative time was 18minutes. Before surgery, mean loss of extension was 47° at the MCP joint and 15° at the corresponding proximal interphalangeal joint (PIPJ). Immediately after surgery, a 97% improvement in MCPJ extension was noted, leaving a mean extension deficit of 1.25°. Mean follow-up was 18.9 months. No complications occurred. Two patients experienced a recurrence.

DISCUSSION

Segmental palmar aponeurectomy as described by Moermans in 1991 improves extension similarly to extensive aponeurectomy but has a lower complication rate. Z-plasty provides good exposure of the pedicles and takes advantage of the greater pliability of the skin on either side of the cord to lengthen the skin by 75%, thereby limiting the risk of the complications seen with needle aponeurotomy. Segmental palmar aponeurectomy with Z-plasty has a role in the management of Dupuytren's disease with flexion contracture predominantly involving the MCPJ.

Isolated Small Finger Distal Interphalangeal Joint Dupuytren's Contracture

Dupuytren's contracture is a disease involving abnormal myofibroblast proliferation and collagen deposition leading to the formation of pathologic cords in the hand. Given that Dupuytren's contractures rarely extend to the distal interphalangeal joint (DIP), affecting only 5% of patients, there are few cases reported in the literature. Collagenase injection is a frequently used option for minimally invasive treatment of Dupuytren's disease with greater than a 20-degree joint contracture. Unfortunately, there is limited research on the effectiveness of these injections in isolated DIP joint deformities. We present a case of a 61-year-old right hand-dominant male with a 2-year history of isolated right small finger Dupuytren's contracture at the DIP joint who achieved significant improvement after collagenase injection.

Outcomes and Direct Costs of Needle Aponeurotomy, Collagenase Injection, and Fasciectomy in the Treatment of Dupuytren Contracture

PURPOSE

The aims of our study were to evaluate the rates and predictors of reinterventions and direct costs of 3 common treatments of Dupuytren contractures-needle aponeurotomy, collagenase injection, and surgical fasciectomy.

METHODS

A retrospective review identified 848 interventions for Dupuytren contracture in 350 patients treated by a single surgeon from 2005 to 2016. The treatments included needle aponeurotomy (NA) (n = 444), collagenase injection (n = 272), and open fasciectomy (n = 132). We collected information on demographics, contracture details, and comorbidities. Outcomes included reintervention rates, time to reintervention, and direct cost of treatments. Standardized costs were calculated by applying 2017 Medicare reimbursement to professional services and cost-to-charge ratios to hospital charges.

RESULTS

Demographics were similar among the 3 treatment groups. The fifth finger was the most commonly affected digit including 43% of the NA, 60% of the collagenase, and 45% of the fasciectomy groups. The 2-year rates of reintervention following NA, collagenase, and fasciectomy were 24%, 41%, and 4%, respectively, and the 5-year rates were 61%, 55%, and 4%, respectively. Younger age and severity of preintervention proximal interphalangeal (PIP) joint contracture were predictive of reintervention in the NA and collagenase groups. The standardized direct costs for NA, collagenase, and fasciectomy were $624, $4,189, and $5,291, respectively. Including all reinterventions, the cumulative costs per digit following NA, collagenase, and surgery at 5 years were $1,540, $5,952, and $5,507, respectively.

CONCLUSIONS

Treatment with collagenase resulted in the highest rate of reintervention at 2 years, comparable reintervention rates to NA at 5 years, and the highest cumulative costs. The NA was the least expensive and resulted in longer duration before reintervention compared with collagenase. More severe PIP joint contractures and younger age at time of initial intervention were predictive of reintervention after collagenase and NA. Fasciectomy has a high initial cost but the lowest reintervention rate.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Collagenase Clostridium histolyticum for the Treatment of Distal Interphalangeal Joint Contractures in Dupuytren Disease

PURPOSE

To explore the efficacy of injectable collagenase Clostridium histolyticum (CCH) in distal interphalangeal (DIP) joint contractures in Dupuytren disease.

METHODS

A retrospective review was conducted for patients with DIP joint contractures treated with CCH. Baseline contracture and posttreatment residual contracture were recorded. The primary end point was achievement of 0° to 5° of residual contracture 30 days postmanipulation. Recurrence and adverse events are also reported.

RESULTS

Twenty-one patients were treated with collagenase for DIP joint contractures and had a mean follow-up of 2.6 months. Seventeen of 21 patients reached the primary end point of less than 5° residual flexion contracture. Eleven of 21 patients experienced an adverse event, most commonly bruising and edema. No serious complications such as neurovascular injuries or tendon ruptures were recorded. Two patients had recurrence of disease.

CONCLUSIONS

Injection with CCH is an option for the treatment of DIP joint contractures in Dupuytren disease.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Investigating the effects of Pirfenidone on TGF-β1 stimulated non-SMAD signaling pathways in Dupuytren's disease -derived fibroblasts

BACKGROUND

Dupuytren's disease (DD) is a progressive, debilitating condition of the hand that can eventually cause contractures of the affected fingers. Transforming growth factor- β1 (TGF-β1) has been reported to play a key role in DD pathology. Increased expression of TGF-β1 has shown to be the main stimulator of myofibroblast activity and in DD contractures. Pirfenidone (PFD), a small active molecule possess the ability to inhibit TGF-β1-mediated action in various fibrotic disorders. Our recent published findings show that PFD reduced TGF-β1-mediated cellular functions implicated in DD through SMAD signaling pathways. In the present study, the effect of PFD on TGF-β1-mediated non-SMAD signaling pathways were investigated in both carpal tunnel (CT) - and DD-derived fibroblasts.

METHODS

Fibroblasts harvested from Dupuytren's disease (DD) and carpal tunnel (CT) tissues were cultured in the presence or absence of TGF-β1 (10 ng/ml) and/or PFD (800 μg/ml). Cell lysates were analyzed using Western blots. Equal amounts of proteins were loaded to determine the phosphorylation levels of phosphatidylinositol-3 kinase (PI3K/AKT), extracellular regulated kinases (ERK1/2), p38 mitogen-activated protein kinase and Rho family related myosin light chain (MLC).

RESULTS

We show that the TGF-β1-induced phosphorylation of AKT was significantly decreased by the addition of PFD (800 μg/mL) in both CT- and DD-derived fibroblasts. Interestingly, there was no significant difference in the phosphorylation levels of both ERK and p38 on TGF-β1- induced cells in both CT-and DD-derived fibroblasts. But, PFD significantly decreased the TGF- β1-induced phosphorylation levels of ERK1/2 in both CT- and DD- cells. In contrast, PFD significantly decreased the basal and TGF- β1-induced phosphorylation levels of p38 in DD-derived fibroblasts. TGF- β1-induced phosphorylation levels of MLC was decreased by PFD in DD-derived fibroblasts.

CONCLUSIONS

These in-vitro results indicate for the first time that PFD has the potential to inhibit TGF-β1-induced non-SMAD signaling pathways in both CT- and DD-derived fibroblasts but pronounced statistically significant inhibition on all molecules was observed only in DD-derived fibroblasts. Our previous studies show that PFD can inhibit TGF-β1- induced SMAD signaling pathway proteins, namely p- SMAD2/SMAD3. These broad and complementary actions suggest PFD as a promising candidate to inhibit the TGF-β1- mediated molecular mechanisms leading to DD fibrosis.

Phalangeal fracture leading to digital amputation, sustained during manipulation for Dupuytren's disease as part of clostridial collagenase treatment

Collagenase injection was approved in Europe for use in the treatment of Dupuytren's disease in 2011. Reported adverse effects include skin tears, swelling, pain and complex regional pain syndrome. Here, we present a case of a rare complication of phalangeal fracture following treatment with collagenase clostridium and the resultant digital amputation. An 81-year-old man was treated for a 25-year history of progressively disabling Dupuytren's disease of his left middle and ring fingers. Nine days post-manipulation he presented with persistent pain and swelling and was diagnosed with a displaced fracture of the proximal phalanx of his ring finger. Following discussion of surgical options and potential outcome, he elected to undergo amputation of the digit. He has experienced good treatment results in his middle finger and has no significant functional impairment as a result of this complication. Those offering collagenase injection in the management of Dupuytren's disease should be aware of this potential complication and it should be included in the consent process.

Prospective observation of Clostridium histolyticum collagenase for the treatment of Dupuytren's disease in 788 patients: the Austrian register

INTRODUCTION

Since March 2011, the microbial collagenase of Clostridium histolyticum (Xiapex®, Swedish Orphan Biovitrum AB, Stockholm, Sweden) has become available in the European Union for treatment of Dupuytren's disease. The purpose of this study was to evaluate potential safety risks of Xiapex® and to contribute to a better understanding for its use.

METHODS

A prospective, non-interventional, observational study using Xiapex® for Dupuytren's disease named XIANIS was conducted between 1.10.2011 and 01.10.2017. Treatment was conducted in accordance to the manufacturer information. Patients were invited for follow-up after 1 week, 1 month, 3 months and 1 year. Demographic data, treatment data, pain levels, anaesthetic application during passive manipulation, subjective function improvement, subjective satisfaction and adverse events were recorded.

RESULTS

788 patients with 814 treatments were included who suffered from Dupuytren's contracture for a mean of 64 months. The metacarpophalangeal joint was affected in 57% of cases and the PIP joint in 40.8% with a mean contracture of 39° and 56°, respectively. A change in the contracture down to 0°-5° was reported in 66.5% of cases, while 25.5% achieved a partial improvement. The pain during the injection was rated 4.5 and 3.3 during passive manipulation. Adverse events were reported in the majority of treated patients with skin tears being one main common event (26%). Further adverse outcomes were bleeding/hematoma, joint swelling, injection-site swelling, pressure sensitivity, erythema, injection-site pain, peripheral edema, blood blisters, blisters, painless lymphadenopathy, painful lymphadenopathy, axillary pain, arthralgia and sensory abnormality. There were no reported tendon ruptures, anaphylactic reactions or ligament injuries. On 1-year follow-up, 29% showed an increased contracture of a mean of 24° with the need for surgical treatment in 2% of patients. 74% of patients were very satisfied and 72% showed a high functional improvement.

CONCLUSION

The injectable collagenase Clostridium histolyticum (Xiapex®) proved to be effective and safe in patients with Dupuytren's disease. Minor adverse events disappeared within 30 days and the need for surgical treatment within 1 year was very low (2%). No major complications or rare side effects were seen in this prospective observational study.

Treatment of Dupuytren's contracture: a systematic review

Aims

Dupuytren's contracture is a benign, myoproliferative condition affecting the palmar fascia that results in progressive contractures of the fingers. Despite increased knowledge of the cellular and connective tissue changes involved, neither a cure nor an optimum form of treatment exists. The aim of this systematic review was to summarize the best available evidence on the management of this condition.

Materials and Methods

A comprehensive database search for randomized controlled trials (RCTs) was performed until August 2017. We studied RCTs comparing open fasciectomy with percutaneous needle aponeurotomy (PNA), collagenase clostridium histolyticum (CCH) with placebo, and CCH with PNA, in addition to adjuvant treatments aiming to improve the outcome of open fasciectomy. A total of 20 studies, involving 1584 patients, were included.

Results

PNA tended to provide higher patient satisfaction with fewer adverse events, but had a higher rate of recurrence compared with limited fasciectomy. Although efficacious, treatment with CCH had notable recurrence rates and a high rate of transient adverse events. Recent comparative studies have shown no difference in clinical outcome between patients treated with PNA and those treated with CCH.

Conclusion

Currently there remains limited evidence to guide the management of patients with Dupuytren's contracture. Cite this article: Bone Joint J 2018;100-B:1138-45.

Needle Aponeurotomy for Dupuytren Disease

Needle aponeurotomy is an effective, minimally invasive treatment for metacarpophalangeal and interphalangeal joint contractures caused by Dupuytren disease. Multiple joints and digits can be safely treated in 1 session. Needle aponeurotomy is more cost-effective and has a significantly lower complication rate compared with open fasciectomy and collagenase injections. Recurrence rates are higher compared with open fasciectomy and collagenase injections. Patient satisfaction rates are high following needle aponeurotomy; the single clinic visit required and the minimal downtime after treatment are advantages unique to this procedure compared with other treatment modalities, including open fasciectomy, dermatofasciectomy, collagenase injections, and lipofilling.

Treatment of Recurrent Dupuytren Disease

Treatment of recurrent Dupuytren disease is challenging. Multiple options exist, each having relative benefits and weaknesses. Choice for optimal treatment is made on a case-by-case basis, with shared decision making with the patient. Percutaneous and enzymatic techniques are best reserved for patients with well-defined recurrent disease and offer the benefit of quicker recovery with minimal or no scarring. Surgical treatments have higher risks of neurovascular injury and scarring, but lower recurrence rates. Staged continuous passive elongation followed by dermofasciectomy may lower neurovascular injury and improve outcomes. Salvage procedures may be necessary in patients with poor tissue beds and neurovascular compromise.

Extracorporeal Shock Wave Therapy in Dupuytren's Disease

Objectives:

We investigated the use of extracorporeal shock wave therapy (ESWT) in patients with Dupuytren’s Disease (DD) palmar nodules in an attempt to reduce the contracture, alleviate the pain (if any), increase the range of motion and quality of life, and delay a probable surgery in the long term.

Methods:

Patients with DD who presented to our hand surgery clinic and fulfilled the inclusion criteria were enrolled. The treatment was performed by the same physician using the ESWT device once a week for six weeks. The patients were evaluated with the VAS score, Quick-DASH questionnaire, and MAYO wrist score, and their grip strength was measured using a Jamar dynamometer.

Results:

The mean age of the 23 patients included in the study was 51 years. There was a significant improvement in the second measurement of VAS and DASH scores compared with the preoperative values. The increase in the second and final follow-up measurements of the MAYO score and grip strength results compared with the preoperative values was found significant. The table-top test results turned negative in 16 patients.

Conclusion:

We can suggest that ESWT in the early term can be preferred over costly injections and surgical intervention options as it increases the quality of life and delays the recurrence of contractures.