Collagenase injection as nonsurgical treatment of Dupuytren's disease: 8-year follow-up

Long-term recurrence of Dupuytren's disease treated with clostridium histolitycum collagenase. Surgical treatment and anatomopathological study

OBJECTIVE

To present the functional results obtained and the possible surgical difficulties after the surgical treatment of Dupuytren's disease (DD) recurrence in patients previously treated with Clostridium histolyticum (CCH) collagenase.

MATERIALS AND METHODS

In this prospective study, 178 patients with DD were treated with CCH from 2011 to 2018; During long-term postoperative follow-up, 34 patients (19.1%) had recurrence of DD. In all patients injected in the IFP the disease recurred; In patients injected in the MCP, recurrence was highest in grade III and IV of the Tubiana classification, with involvement of the 5th finger and the two-finger Y-chord. Fourteen patients (7,8%) required surgery by partial selective fasciectomy due to recurrence of cord DD infiltration. The clinical and functional results of the patients, the difficulty of the surgical technique and the anatomopathological analysis of the infiltrated cords were evaluated in comparison with those of cords and patients who had had no previous CCH treatment.

RESULTS

In all patients, cord rupture was achieved after injection, reducing joint contracture. In 14 patients, we observed during the follow-up the existence of DD recurrence that required surgical treatment by selective partial fasciectomy. There were no major difficulties in surgery and good clinical and functional results at 6 months of follow-up. The anatomopathological study of the resected tissue did not present histological alterations with respect to the samples obtained from patients initially treated by selective partial fasciectomy.

CONCLUSIONS

Selective fasciectomy after CCH injection does not lead to important operative difficulties, as long as the CCH injection is performed according to the recommendations. There were no histological changes in the tissue after CCH injection.

LEVEL OF EVIDENCE

III.

Long-term assessment of collagenase treatment for Dupuytren's contracture: A 10-year follow-up study

BACKGROUND

Enzymatic fasciotomy with collagenase clostridium histolyticum (CCH) has revolutionized the treatment for Dupuytren's contracture (DC). Despite its benefits, the long-term outcomes remain unclear. This study presented a comprehensive 10-year follow-up assessment of the enduring effects of CCH on patients with DC.

AIM

To compare the short-term (12 wk) and long-term (10 years) outcomes on CCH treatment in patients with DC.

METHODS

A cohort of 45 patients was treated with CCH at the metacarpophalangeal (MCP) joint and the proximal interphalangeal (PIP) joint and underwent systematic re-evaluation. The study adhered to multicenter trial protocols, and assessments were conducted at 12 wk, 7 years, and 10 years post-surgery.

RESULTS

Thirty-seven patients completed the 10-year follow-up. At 10 years, patients treated at the PIP joint exhibited a 100% recurrence. However, patients treated at the MCP joint only showed a 50% recurrence. Patient satisfaction varied, with a lower satisfaction reported in PIP joint cases. Recurrence exceeding 20 degrees on the total passive extension deficit was observed, indicating a challenge for sustained efficacy. Significant differences were noted between outcomes at the 7-year and 10-year intervals.

CONCLUSION

CCH demonstrated sustained efficacy when applied to the MCP joint. However, caution is warranted for CCH treatment at the PIP joint due to a high level of recurrence and low patient satisfaction. Re-intervention is needed within a decade of treatment.

Long-term clinical outcome of collagenase clostridium histolyticum treatment is independent of Dupuytren Diathesis Score

Collagenase clostridium histolyticum (CCH) is a pharmaceutical, non-surgical treatment option for Dupuytren Disease. However, recurrence is common, and predictors of treatment outcome of CCH treatment are largely unknown. In this retrospective study, we analysed the possible correlation between Abe's Dupuytren Diathesis Score (DDS) and recurrence after treatment with CCH. In a total of 74 patients, with an average follow-up of 5 years, we found an overall recurrence rate of 67% after 5y but no correlation with DDS. Sub-scale analysis indicated that the presence of knuckle pads was associated with a reduced recurrence risk. Patient satisfaction after CCH was high. Deriving from our data, there is no correlation between DDS and recurrence following CCH treatment. Therefore, at this moment, we do not advocate the use of the DDS when informing patients about recurrence rates after CCH treatment. Level of evidence: IV: therapeutic cohort study.

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.

Oral doxycycline prevents skin-associated adverse effects induced by injectable collagenase in a rodent model of capsular contracture around silicone implants

Background

The collagenase of the bacterium Clostridium histolyticum (CCH) is already an established treatment for fibroproliferative diseases like M. Dupuytren and M. Peyronie Although results are comparable to surgical intervention, skin laceration is a severe and relevant side effect. Doxycycline (DOX) recently rose interest as an inhibitor of matrix-metalloproteinases alongside its capabilities of skin accumulation. It therefore might be a potential skin protective agent in the use of CCH.

Methods

For simulation of a fibroproliferative disease adjacent to the skin, we utilized a rodent model of capsular fibrosis involving silicone implants and subsequent fibrotic capsule formation. For in-vitro studies, fibrotic capsules were excised and incubated with 0.9 mg/ml CCH and four different doses of DOX. For in-vivo experiments, animals received 0.0, 0.3 or 0.9 mg/ml CCH injections into the fibrotic capsules with or without prior oral DOX administration. Outcome analysis included histology, immunohistochemistry, gene expression analysis, chemical collagen and DOX concentration measurements as well as μCT imaging.

Results

In-vitro, DOX showed a dose-dependent inhibition of CCH activity associated with increasing capsule thickness and collagen density and content. In-vivo, oral DOX administration did neither interfere with capsule formation nor in effectiveness of CCH dissolving fibrotic capsule tissue. However, skin thickness and especially collagen density was significantly higher compared to control groups. This led to a reduced rate of clinical skin lacerations after DOX administration.

Conclusion

DOX inhibits CCH and accumulates in the skin. Thereby, DOX can effectively reduce skin laceration after CCH treatment.

The Effect of Anticoagulation on the Treatment of Dupuytren Contracture with Collagenase

BACKGROUND

There have been no formal studies of the use of collagenase clostridium histolyticum (Xiaflex; Endo Pharmaceuticals, Malvern, Pa.) in the anticoagulated patient. Previous study on its use excluded patients receiving anticoagulation therapy. This study reviewed the effects of anticoagulation use in patients undergoing collagenase clostridium histolyticum injection and cord rupture to determine safety and efficacy.

METHODS

The authors retrospectively reviewed patients receiving collagenase clostridium histolyticum injections for Dupuytren contracture between 2010 and 2017. Outcomes included type of anticoagulation, skin tear, tendon rupture, lymphadenopathy, sensory abnormality, hematoma, and bleeding.

RESULTS

A total of 388 injections were performed in 197 patients. The average clinical follow-up was 311 days. Fifty-two percent of patients (n = 201) were anticoagulated. The vast majority were taking aspirin (acetylsalicylic acid) (n = 182), followed by warfarin (n = 27), clopidogrel (n = 9), apixaban (n = 8), rivaroxaban (n = 4), and dabigatran (n = 2). There were 42 skin tears, 21 in the anticoagulated group. One tendon rupture occurred in the anticoagulated group (acetylsalicylic acid) and none occurred in the nonanticoagulated group (p = 0.34). No patients experienced sensory abnormalities, a hematoma requiring intervention, or uncontrollable bleeding.

CONCLUSIONS

Anticoagulation is commonly encountered by hand surgeons treating Dupuytren contracture. There is no significant difference in complications in the anticoagulated patient versus the nonanticoagulated patient. It is safe to perform collagenase clostridium histolyticum injections for Dupuytren contracture in the anticoagulated patient, regardless of the type of anticoagulation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Collagenase and the Treatment of Dupuytren Contracture: Efficacy of Treatment and Patient Satisfaction

Background: Collagenase clostridium histolyticum has become a widely used treatment in the management of Dupuytren disease. The aims of this study are to assess the immediate success of treatment of Dupuytren contracture with collagenase injection, to measure long-term patient-rated outcomes, to determine whether the risk factors for the disease impacted outcomes and to report complications of collagenase treatment. Methods: A prospective study was performed in a tertiary referral centre. Measurements were recorded pre-treatment, day 1 and day 90. Patient-rated outcome scores were measured using Disability of the Arm, Shoulder and Hand questionnaire (DASH) and the Michigan Hand Questionnaire (MHQ) at minimum 36 months post-injection. Results: The study included 45 patients with 53 hands with a mean age of 65.7 years. The treatment was successful in 62% of patients with the greatest improvement in the metacarpal-phalangeal joint of the little finger. Diabetes, epilepsy, gender, alcohol intake and positive family history had no statistically significant predictive value on successful outcomes. Patient satisfaction at 41 months was high with mean MHQ score of 97.3. Conclusions: Collagenase is effective in the treatment of Dupuytren contracture, with disease involving the little finger showing the greatest benefit. Risk factors for development of Dupuytren disease had no effect on successful outcome and long-term satisfaction rates are high. Level of Evidence: Level III (Therapeutic).

Long-Term Outcomes of Collagenase Clostridium Histolyticum Injection for Palmar Dupuytren’s Deformity Correction

Introduction

The use of collagenase Clostridium histolyticum injection as a minimally invasive procedure for correction of Dupuytren’s deformity is well reported in the literature. We report our experience and long-term outcome of this procedure performed in a single secondary care centre.

Methods

We prospectively evaluated 143 fingers that underwent Dupuytren’s deformity correction using CCH injection. Early side effects, degree of correction, recurrence, and patient-reported outcomes were noted.

Results

Early local complications were resolved in two weeks' duration. No major complications were encountered. More than 80% achieved immediate full correction of deformity and at an average follow-up of five years, 23% of patients had a recurrence. Around 92% were very satisfied with the procedure.

Conclusion

CCH is a safe and effective minimally invasive method to achieve correction of palmar Dupuytren’s deformity and is associated with a high patient satisfaction rate. 

Collagenase Treatment of Dupuytren's Disease with Minimum 5-Year Follow-Up: Recurrence, Reintervention, and Satisfaction

BACKGROUND

The objective of this study was to determine the rates of patient satisfaction, perceived recurrence of flexion deformity, and additional treatment after collagenase clostridium histolyticum treatment for Dupuytren's contracture at a minimum of 5-year follow-up.

METHODS

A retrospective study was performed of 199 digits in 142 patients who underwent collagenase clostridium histolyticum treatments from April of 2010 to December of 2013 with a minimum of 5-year follow-up. Patients were contacted by telephone regarding perceived recurrence, additional treatment, satisfaction, and willingness to undergo this treatment again.

RESULTS

At an average 7.2-year follow-up, 160 of 199 digits (80 percent) had perceived recurrence, and 105 of 199 digits (53 percent) underwent additional treatment. Average satisfaction was 6.5 on a Likert scale ranging from 1 to 10, and 67 percent would undergo collagenase clostridium histolyticum treatment again. Multivariable logistic regression analysis showed that higher Charlson Comorbidity Index (OR, 0.77; 95 percent CI, 0.63 to 0.93) and isolated metacarpophalangeal joint involvement (OR, 0.53; 95 percent CI, 0.29 to 0.97) were associated with decreased odds of additional treatment, and higher American Society of Anesthesiologists physical status classification (OR, 2.49; 95 percent CI, 1.35 to 4.48) and nonsmoker status (OR, 0.23; 95 percent CI, 0.09 to 0.59) were associated with willingness to undergo the treatment again.

CONCLUSIONS

Patients may be counseled that the long-term perceived recurrence rate of Dupuytren's contractures after collagenase clostridium histolyticum treatment is high, and more than half of patients seek additional treatment. Satisfaction and willingness to undergo collagenase clostridium histolyticum treatment decrease with perceived recurrence.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Risk Factors for Skin Tears Following Collagenase Clostridium histolyticum to Treat Dupuytren Contractures

PURPOSE

Skin tears are an unpleasant complication that may occur after collagenase Clostridium histolyticum (CCH) administration to treat Dupuytren contractures of the fingers. The purpose of this study was to determine risk factors for the development of this complication.

METHODS

Over a 6-year period, patients with a measurable metacarpophalangeal or proximal interphalangeal joint Dupuytren contracture and a palpable cord treated with CCH were prospectively observed. Patients were assessed for the development of skin tears immediately on the day of manipulation as well 30 days or more after manipulation.

RESULTS

A total of 117 patients (174 cords) met inclusion criteria. There was a 25.6% incidence of skin tears (30 of 117 patients; 33 skin tears). Multivariable regression analysis revealed that patients with a combined digital flexion contracture (total combined metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joint contracture) of 75° and greater and those treated with 2 simultaneous doses of CCH in the same hand were more likely to sustain a tear. All skin tears healed with nonsurgical management at short-term follow-up.

CONCLUSIONS

Although a relatively minor complication, skin tears are not well-tolerated by all patients and may change the postinjection course of orthosis use, wound care, and manual activity. Based on these results, patients with digital contractures 75° or greater and those treated with 2 simultaneous doses of CCH in the same hand may be counseled that they have a higher likelihood of developing a skin tear during manipulation. Pretreatment education may reduce anxiety experienced by patients who otherwise unexpectedly develop a skin tear at the time of manipulation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Seven-year clinical outcomes after collagenase injection in patients with Dupuytren's disease: A prospective study

Introduction

This investigation is a prospective cohort study examining the use of Clostridium histolyticum collagenase injection (CCH) for the treatment of Dupuytren's disease (DD) with a 7 years follow-up.

Methods

Forty-five monodigital DD patients were injected with CCH on a single joint. Assessment included measurement of residual passive extension deficit (PED), function (using QuickDASH) and patient satisfaction.

Results

86.7% of PIPJ and 65.6% of MPJ had a worsening of PED. Nevertheless, thirty-nine patients (86.7%) concluded their treatment with only one injection, without any further treatment.

Conclusion

CCH provides a long-term effective solution. Recurrence occurs, especially in PIPJ, with acceptable rates.

Needle Fasciotomy or Collagenase Injection in the Treatment of Dupuytren's Contracture: A Retrospective Study

Dupuytren's contracture is common among older people in Sweden. Previous studies comparing the treatment with an injection of collagenase with percutaneous needle fasciotomy found no differences.

Methods

We retrospectively compared the degree of improvement in the deficit in extension of the joints in 2 groups of patients who had been treated with collagenase (71 fingers) or needle fasciotomy (109 fingers) before and 1 year after treatment. We compared the improvement of the extension deficit among the metacarpophalangeal (MCP) and proximal interphalangeal joints before and after the intervention; additionally, the level of improvement was classified into 3 levels (mild = 0° to 29°; moderate = 30° to 60°; considerable = 61° and more).

Results

The degree of improvement of extension in the MCP joints was 11° greater in the collagenase group (P = 0.001). The number of patients who had an improvement of >60° (considerable) in extension was greater in the collagenase group (P = 0.02).

Conclusion

Collagenase was more effective than needle fasciotomy in treating extension deficits of the MCP joints in Dupuytren's contracture in this retrospective analysis. Further prospective studies are required to confirm the finding.

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.

Advances in Minimally Invasive Treatment of Dupuytren Disease

A comparison is provided between minimally invasive techniques and limited fasciectomy (LF) in the treatment of Dupuytren disease. A technique called percutaneous needle aponeurotomy and lipofilling is described. In a randomized controlled trial, there is no significant difference between this technique and LF after 1 year in contracture correction and recurrent contractures. At 5 years postoperative, however, there is a significant change in recurrence rates in favor of LF. Patients with moderate diathesis should choose between minimally invasive technique with early recurrence, fast recovery, and few complications versus late recurrence, slower recovery, and more complications, as observed with LF or dermofasciectomy.

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.

Use of adipose tissue and stromal vascular fraction in hand surgery

Adipose tissue is an abundant source of various cell types including not only adipocytes, but also progenitor and endothelial cells from thestroma. Interest in adipose tissue has surged since the identification in 2001 of adipose-derived stem cells (ADSCs) and of the stromal vascular fraction (SVF) obtained from adipose tissue by enzymatic digestion and centrifugation. SVF has been proven effective in ensuring tissue regeneration, thus improving tissue trophicityand vascularisation. These effects have generated strong interest among both physicians and surgeons, particularly in the field of hand surgery. Several applications have been developed and used, for instance to treat Dupuytren's contracture, systemic sclerosis-related hand lesions, and skin ageing at the hand. Other uses are being evaluated in clinical or animal studies. The objective of this article is to review the capabilities of adipose tissue and their current and potential applications in hand surgery.

Long-term follow-up of Dupuytren disease after injection of triamcinolone acetonide in Chinese patients in Taiwan

Injection of triamcinolone acetonide is a non-operative treatment for early-stage Dupuytren disease in Caucasians, but its effectiveness in non-Caucasians is unclear. We report averaged 5-year follow-up results of 37 patients (49 affected hands) with early-stage Dupuytren disease for patients in Taiwan (non-Caucasian) who received a single dose of 5 mg triamcinolone acetonide injection into nodules monthly for 3 months. Using ultrasound, we recorded no progression of sizes of the modules following injection after 6 months. After an average 5-year follow-up, two patients with three hands (6%) experienced reactivation of the treated nodules. None required surgical intervention. Ultrasound examination showed that sizes of the treated Dupuytren nodules decreased significantly by 40% 6 months after injection and 56% at the final follow-up. We conclude that in these Chinese patients in Taiwan with early Dupuytren nodules, triamcinolone acetonide injection was effective in reducing the size of the Dupuytren nodules and maintaining long-term durable control of the nodular growth.

LEVEL OF EVIDENCE

III.

Efficacy and safety of collagenase treatment for Dupuytren's disease: 2-year follow-up results

Dupuytren's contracture is a common hand problem that affects the palmar fascia. Several treatment options exist, but none are curative and recurrence is common. Bacterial collagenase has recently been proven beneficial for treating Dupuytren's disease, cleaving the collagen fibers at different sites, with weakening and eventually rupture of the fibrous cords after manipulation. An independent prospective follow-up study was organized on 87 patients, treated with one or more collagenase injections. Inclusion criteria were a contracture of at least 20° at the metacarpophalangeal (MCP) or the proximal interphalangeal (PIP) joint. The most diseased joint was taken into consideration for follow-up evaluation. The resulting extension deficit was measured at 1 month, 1 year and 2 years and was graded as "clinical success", "clinical improvement" or "clinical failure". The mean contracture improved from 45° (39° for MCP and 54° for PIP joints) before treatment to 5° (2° for MCP and 9° for PIP joints) 4 weeks after treatment. No serious complications occurred. After 2 years, 68 joints were evaluated; 61.5% of the MCP joints and 34.5% of the PIP joints had a contracture of ≤20°. When compared with the 4-week evaluation, 28.2% of MCP joints and 62.1% of PIP joints had a recurrence (20° or greater worsening) or had received additional treatment. Collagenase injection is a safe and effective treatment option for Dupuytren disease, but recurrence is common especially for the PIP joint.

Recurrence of Dupuytren's contracture: A consensus-based definition

Purpose

One of the major determinants of Dupyutren disease (DD) treatment efficacy is recurrence of the contracture. Unfortunately, lack of agreement in the literature on what constitutes recurrence makes it nearly impossible to compare the multiple treatments alternatives available today. The aim of this study is to bring an unbiased pool of experts to agree upon what would be considered a recurrence of DD after treatment; and from that consensus establish a much-needed definition for DD recurrence.

Methods

To reach an expert consensus on the definition of recurrence we used the Delphi method and invited 43 Dupuytren’s research and treatment experts from 10 countries to participate by answering a series of questionnaire rounds. After each round the answers were analyzed and the experts received a feedback report with another questionnaire round to further hone in of the definition. We defined consensus when at least 70% of the experts agreed on a topic.

Results

Twenty-one experts agreed to participate in this study. After four consensus rounds, we agreed that DD recurrence should be defined as “more than 20 degrees of contracture recurrence in any treated joint at one year post-treatment compared to six weeks post-treatment”. In addition, “recurrence should be reported individually for every treated joint” and afterwards measurements should be repeated and reported yearly.

Conclusion

This study provides the most comprehensive to date definition of what should be considered recurrence of DD. These standardized criteria should allow us to better evaluate the many treatment alternatives.

"Hills, Plains, and Valleys": A Topographical Concept in the Treatment of Dupuytren's Contracture With Needle Aponeurotomy

Needle aponeurotomy is emerging as a preferred choice of treatment for patients with Dupuytren's contracture keen on a quick, minimally invasive procedure that enables a rapid return of hand function. This article describes a unique topographical concept in the treatment of Dupuytren's contracture with needle aponeurotomy. This concept guides portal placement in a planned manner to achieve better correction and avoid potential complications.

[Treatment of Dupuytren's disease with collagenase Clostridium histolyticum]

BACKGROUND

Dupuytren's disease as a benign fibroproliferative disease leads to hyperplasia of the collagen fibers of the fascia of the palm, which can result in severe impairment of the functionality of the hand.

OBJECTIVES

Examination of the significance of non-operative treatment of Dupuytren's disease with injectable collagenase clostridium histolyticum (CCH) METHODS: Observation of 120 patients treated with injectable collagenase. Documentation of the range of motion before the intervention, 12 months after the intervention, and documentation of any adverse events.

RESULTS

All in all, 120 patients were treated (107 male, 13 female) (mean age 62 years, range 30-84 years). In 49% the little finger, in 44% the ring finger, in 4% the middle finger, and in 3% the index finger were treated. Full release was accomplished in 71%, partial release in 26%, and no change in 3% of the patients. The median contracture before the treatment was 37° for the metacarpophalangeal (MP) joint (range 25-100°) and 51° for the proximal interphalangeal (PIP) joint (range 30-97°). After 12 months, the mean contracture for the MP joint was 9° (range 0-25°) and 21° (range 10-36°) or the PIP joint. Adverse events occurred in 96% of patients within 3 months after treatment. No tendon ruptures, anaphylactic reactions, nerve, or ligament injuries were observed.

MRI in flexor tendon rupture after collagenase injection

Flexor tendon rupture is an unusual complication following collagenase injection to relieve contractures. These patients require a close follow-up and in the event of tendon rupture, a decision has to be made whether to repair the tendon or manage the complication conservatively. The authors report the utility of MRI in the prognostication and management of a patient with Dupuytren's contracture, who underwent collagenase injection and subsequently developed flexor digitorum profundus tendon rupture.

Connective Tissue Degeneration: Mechanisms of Palmar Fascia Degeneration (Dupuytren's Disease)

Dupuytren's disease is a connective tissue disorder of the hand causing excessive palmar fascial fibrosis with associated finger contracture and disability. The aetiology of the disease is heterogeneous, with both genetic and environmental components. The connective tissue is abnormally infiltrated by myofibroblasts that deposit collagen and other extracellular matrix proteins. We describe the clinical profile of Dupuytren's disease along with current therapeutic schemes. Recent findings on molecular and cellular parameters that are dysregulated in Dupuytren's disease, which may contribute to the onset of the disease, and the role of resident inflammation promoting fibrosis, are highlighted. We review recent literature focusing on non-myofibroblast cell types (stem cell-like cells), their pro-inflammatory and pro-fibrotic role that may account for abnormal wound healing response.

Collagenase clostridium histolyticum for the treatment of Dupuytren's contracture: systematic review and economic evaluation

BACKGROUND

Dupuytren's disease is a slowly progressive condition of the hand, characterised by the formation of nodules in the palm that gradually develop into fibrotic cords. Contracture of the cords produces deformities of the fingers. Surgery is recommended for moderate and severe contractures, but complications and/or recurrences are frequent. Collagenase clostridium histolyticum (CCH) has been developed as a minimally invasive alternative to surgery for some patients.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of collagenase as an alternative to surgery for adults with Dupuytren's contracture with a palpable cord.

DATA SOURCES

We searched all major electronic databases from 1990 to February 2014.

REVIEW METHODS

Randomised controlled trials (RCTs), non-randomised comparative studies and observational studies involving collagenase and/or surgical interventions were considered. Two reviewers independently extracted data and assessed risk of bias of included studies. A de novo Markov model was developed to assess cost-effectiveness of collagenase, percutaneous needle fasciotomy (PNF) and limited fasciectomy (LF). Results were reported as incremental cost per quality-adjusted life-year (QALY) gained. Deterministic and probabilistic sensitivity analyses were undertaken to investigate model and parameter uncertainty.

RESULTS

Five RCTs comparing collagenase with placebo (493 participants), three RCTs comparing surgical techniques (334 participants), two non-randomised studies comparing collagenase and surgery (105 participants), five non-randomised comparative studies assessing various surgical procedures (3571 participants) and 15 collagenase case series (3154 participants) were included. Meta-analyses of RCTs assessing CCH versus placebo were performed. Joints randomised to collagenase were more likely to achieve clinical success. Collagenase-treated participants experienced significant reduction in contracture and an increased range of motion compared with placebo-treated participants. Participants treated with collagenase also experienced significantly more adverse events, most of which were mild or moderate. Four serious adverse events were observed in the collagenase group: two tendon ruptures, one pulley rupture and one complex regional pain syndrome. Two tendon ruptures were also reported in two collagenase case series. Non-randomised studies comparing collagenase with surgery produced variable results and were at high risk of bias. Serious adverse events across surgery studies were low. Recurrence rates ranged from 0% (at 90 days) to 100% (at 8 years) for collagenase and from 0% (at 2.7 years for fasciectomy) to 85% (at 5 years for PNF) for surgery. The results of the de novo economic analysis show that PNF was the cheapest treatment option, whereas LF generated the greatest QALY gains. Collagenase was more costly and generated fewer QALYs compared with LF. LF was £1199 more costly and generated an additional 0.11 QALYs in comparison with PNF. The incremental cost-effectiveness ratio was £10,871 per QALY gained. Two subgroup analyses were conducted for a population of patients with moderate and severe disease and up to two joints affected. In both subgroup analyses, collagenase remained dominated.

LIMITATIONS

The main limitation of the review was the lack of head-to-head RCTs comparing collagenase with surgery and the limited evidence base for estimating the effects of specific surgical procedures (fasciectomy and PNF). Substantial differences across studies further limited the comparability of available evidence. The economic model was derived from a naive indirect comparison and was hindered by a lack of suitable data. In addition, there was considerable uncertainty about the appropriateness of many assumptions and parameters used in the model.

CONCLUSIONS

Collagenase was significantly better than placebo. There was no evidence that collagenase was clinically better or worse than surgical treatments. LF was the most cost-effective choice to treat moderate to severe contractures, whereas collagenase was not. However, the results of the cost-utility analysis are based on a naive indirect comparison of clinical effectiveness, and a RCT is required to confirm or refute these findings.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013006248.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Collagenase clostridium histolyticum in Dupuytren's contracture: a systematic review

INTRODUCTION

In the last few years, the use of collagenase clostridium histolyticum for management of Dupuytren's contracture has increased. The procedure of enzymatic fasciectomy has become popular because it is non-invasive, safe and fast to perform.

SOURCES OF DATA

A systematic search was performed on Medline (PubMed), Web of Science and Scopus databases using the combined keywords 'Dupuytren collagenase' and 'Dupuytren clostridium histolyticum'. Forty-three studies were identified. The quality of the studies was assessed using the Coleman Methodological Score.

AREAS OF AGREEMENT

The use of collagenase clostridium histolyticum provides better outcomes in patients with mild-moderate joint contracture, with lower complications and side effects than open fasciectomy. Manipulation can be performed 2-7 days after the injection. The use of collagenase is cost-effective.

AREAS OF CONTROVERSY

Most of the studies did not report patient-related outcomes. The role of dynamic splint has to be investigated with randomized clinical trials.

GROWING POINTS

The shorter recovery time and the low incidence of serious or major adverse effects are the main advantages of this new technology.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is a need to perform studies with longer follow-up because the recurrence rate seems to increase with time. Further investigations are necessary to assess whether it is safe and effective to inject two or more cords at the same time.

What are we measuring? A critique of range of motion methods currently in use for Dupuytren's disease and recommendations for practice

BACKGROUND

Range of motion is the most frequently reported measure used in practice to evaluate outcomes. A goniometer is the most reliable tool to assess range of motion yet, the lack of consistency in reporting prevents comparison between studies. The aim of this study is to identify how range of motion is currently assessed and reported in Dupuytren's disease literature. Following analysis recommendations for practice will be made to enable consistency in future studies for comparability. This paper highlights the variation in range of motion reporting in Dupuytren's disease.

METHODS

A Participants, Intervention, Comparison, Outcomes and Study design format was used for the search strategy and search terms. Surgery, needle fasciotomy or collagenase injection for primary or recurrent Dupuytren's disease in adults were included if outcomes were monitored using range of motion to record change. A literature search was performed in May 2013 using subject heading and free-text terms to also capture electronic publications ahead of print. In total 638 publications were identified and following screening 90 articles met the inclusion criteria. Data was extracted and entered onto a spreadsheet for analysis. A thematic analysis was carried out to establish any duplication, resulting in the final range of motion measures identified.

RESULTS

Range of motion measurement lacked clarity, with goniometry reportedly used in only 43 of the 90 studies, 16 stated the use of a range of motion protocol. A total of 24 different descriptors were identified describing range of motion in the 90 studies. While some studies reported active range of motion, others reported passive or were unclear. Eight of the 24 categories were identified through thematic analysis as possibly describing the same measure, 'lack of joint extension' and accounted for the most frequently used.

CONCLUSIONS

Published studies lacked clarity in reporting range of motion, preventing data comparison and meta-analysis. Percentage change lacks context and without access to raw data, does not allow direct comparison of baseline characteristics. A clear description of what is being measured within each study was required. It is recommended that range of motion measuring and reporting for Dupuytren's disease requires consistency to address issues that fall into 3 main categories: Definition of terms, Protocol statement, Outcome reporting.

Injectable collagenase Clostridium histolyticum as a nonsurgical treatment for Dupuytren's disease

OBJECTIVE

Nonsurgical treatment of Dupuytren's disease using collagenase Clostridium histolyticum (CCH).

INDICATIONS

Metacarpophalangeal (MP) joint (20-100°) and proximal interphalangeal (PIP) joint (20-80°) contractures.

CONTRAINDICATIONS

Pregnancy, previous hypersensitivity to collagenase or excipients, anticoagulant use within 7 days prior to treatment.

INJECTION TECHNIQUE

CCH injected directly into the Dupuytren's cord weakening the contracted cord. After injection, the patient returns the following day to allow CCH to lyse the collagen within the cord. An extension force is then applied to the involved finger to disrupt the weakened cord.

POSTMANIPULATION MANAGEMENT

Use of extension splint at night, movement instructions during the day.

RESULTS

A total of 120 patients (107 men; 13 women; mean age 62 years, range 30-84 years) were treated. In 49% the little finger, in 44% the ring finger, in 4% the middle finger, and in 3% the index finger was treated. Full release was achieved in 71%, partial release in 26%, and no change in 3% of patients. The median pretreatment contracture for the MP joint was 37° (range 25-100°) and PIP joint 51° (range 30-97°). At 12 months, the mean contracture for the MP joint was 9° (range 0-25°) and for the PIP joint 21° (range 10-36°). Adverse events observed in 96% of patients for 3 months . No tendon ruptures, anaphylactic reactions, or nerve or ligament injuries observed.

Dupuytren's Contracture: A Bibliometric Study of the Most Cited Papers

The literature on Dupuytren's contracture is vast yet little information is known as to which papers have been the most influential. The purpose of this study was to identify the 50 most cited papers on Dupuytren's contracture and perform a citation analysis. Utilizing the Web of Science, 23 surgical, medical, plastic and hand surgery journals were searched for papers on Dupuytren's contracture. Resulting articles were ranked in order of times cited and each paper was analyzed for article-type, year of publication, country of origin, institution and level of evidence. The 50 most cited articles represent many important landmarks in Dupuytren's treatment and contain several seminal works by experts in the field. Whilst the top 50 list highlights the important papers on the condition, they certainly do not provide information about the quality of the evidence of the research, as most papers presented level 4 or 5 evidence.

Comparison between Collagenase Injection and Partial Fasciectomy in the Treatment of Dupuytren’s Contracture

Background: A comparative study between two treatment methods (collagenase injection and open partial fasciectomy) for Dupuytren’s contracture. This study will determine differences in clinical outcome, complication rate and patient satisfaction.

Methods: 37 patients with 62 metacarpophalangeal joints (MCP) and 44 proximal interphalangeal joints (PIP) treated. There were 21 MCP joints (34%) and 8 PIP joints (18%) treated with injection. The remaining 66% of MCP joints and 82% of PIP joints were treated by open partial fasciectomy.

Results: Overall, both treatment methods were successful in correcting the passive extension deficit in the MCP and PIP joints. Minor complications were reported in 45% of patients in the injection group versus 42% in the surgery group. Patient satisfaction was nearly equal for both groups.

Conclusions: Both treatment options have proven their effectiveness in treating Dupuytren’s contracture. Open surgery is able to address additional joint contracture problems commonly associated with Dupuytren’s disease. Collagenase injection has the advantage of early return of hand function and avoidance of surgical complications.

WT1 expression is increased in primary fibroblasts derived from Dupuytren's disease tissues

Dupuytren's disease (DD) is a fibroproliferative and contractile fibrosis of the palmar fascia that, like all other heritable fibroses, is currently incurable. While DD is invariably benign, it exhibits some molecular similarities to malignant tumours, including increased levels of ß-catenin, onco-fetal fibronectin, periostin and insulin-like growth factor (IGF)-II. To gain additional insights into the pathogenesis of DD, we have assessed the expression of WT1, encoding Wilm's tumour 1, an established tumour biomarker that is syntenic with IGF2, the gene encoding IGF-II in humans. We found that WT1 expression is robustly and consistently up regulated in primary fibroblasts derived from the fibrotic palmar fascia of patients with DD (DD cells), whereas syngeneic fibroblasts derived from the macroscopically unaffected palmar fascia in these patients and allogeneic fibroblasts derived from normal palmar fascia exhibited very low or undetectable WT1 transcript levels. WT1 immunoreactivity was evident in a subset of cells in the fibrotic palmar fascia of patients with DD, but not in macroscopically unaffected palmar fascia. These findings identify WT1 expression as a novel biomarker of fibrotic palmar fascia and are consistent with the hypothesis that the pathogeneses of DD and malignant tumours have molecular similarities.

Clinical Results of Percutaneous Needle Fasciotomy for Dupuytren's Disease in Japanese Patients

BACKGROUND

Clinical results of percutaneous needle fasciotomy (PNF) in Japanese patients with Dupuytren's disease are reported.

METHODS

In this prospective study, 51 patients (103 fingers: 1 index, 9 middle, 47 ring, and 46 small) underwent PNF at 99 metacarpophalangeal (MCP) and 68 proximal interphalangeal (PIP) joints. Patients were assessed postoperatively after 1 day, at 1, 2, 4, 6, and 8 weeks, and at 3, 6, 9, and 12 months. Correction of contracture was measured in degrees, and an improvement index (% improvement) was described previously by Tonkin et al. A correction of the contracture to 5° or less at each joint and at each digital ray represented a successful correction. The recurrence rates in MCP and PIP joints were also evaluated. Correlations between the Tubiana classification stage and successful correction, % improvement, and recurrence rate were evaluated. The relationships between recurrence rate and the diathesis score (more/less than 5 points) and between recurrence rate and age at surgery (<50/≥50 years) were also examined.

RESULTS

In MCP and PIP joints, the improvement maintained at final follow-up was 89% and 57%, respectively, with successful corrections in 89% and 76%, respectively. PNF corrected digital rays at various Tubiana stages: stage 1 = 100%, stage 2 = 82%, stage 3 = 46%, and stage 4 = 0%. Improvements were preserved in stage 1 = 83%; stage 2 = 62%; stage 3 = 58%, and stage 4 = 60%. Recurrence of Dupuytren's disease was significant for the PIP joint, severe Tubiana stage, and younger patients.

CONCLUSIONS

Clinical results of PNF in Japanese patients with Dupuytren's contractures were similar to those of whites.

Myofibroblast expression in skin wounds is enhanced by collagen III suppression

Generally speaking, the excessive expression of myofibroblasts is associated with excessive collagen production. One exception is seen in patients and animal models of Ehlers-Danlos syndrome type IV in which the COL3A1 gene mutation results in reduced collagen III but with concurrent increased myofibroblast expression. This paradox has not been examined with the use of external drugs/modalities to prevent hypertrophic scars. In this paper, we injected the rabbit ear wound model of hypertrophic scarring with two doses of a protein called nAG, which is known to reduce collagen expression and to suppress hypertrophic scarring in that animal model. The higher nAG dose was associated with significantly less collagen III expression and concurrent higher degree of myofibroblast expression. We concluded that collagen III content of the extracellular matrix may have a direct or an indirect effect on myofibroblast differentiation. However, further research is required to investigate the pathogenesis of this paradoxical phenomenon.

A bioactive film based on cashew gum polysaccharide for wound dressing applications

This work presents the development of a new bioactive material for wound therapeutics which may play a dual role of modulate metallo proteinases activity while prevents infection blocking out pathogenic microorganisms and foreign materials. A CGP/PVA film was activated by covalent immobilization of trypsin. Results from biocompatibility test revealed that PDL fibroblasts grown on the surface of CGP/PVA and the high amount of viable cells proved absence of cytotoxicity. Trypsin immobilized onto CGP/PVA film remained 100% active after 28 days stored dried at room temperature. In addition, CGP/PVA-trypsin film could be used for 9 cycles of storage/use without loss of activity. After immobilization, trypsin retained its collagenolytic activity, indicating this material as a promising material for wound dressing applications.

Prospective randomized controlled trial comparing 1- versus 7-day manipulation following collagenase injection for dupuytren contracture

PURPOSE

To compare the efficacy, tolerance, and safety of manual manipulation at day 7 to day 1 following collagenase Clostridium histolyticum (CCH) injection for Dupuytren contracture.

METHODS

Eligible patients were randomized to manipulation at day 1 versus day 7 following CCH injection. Preinjection, premanipulation, postmanipulation, and 30-day follow-up metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint contractures were measured. Pain scores were recorded at each time point. Data were stratified per cohort based on primary joint treated (MCP vs PIP). Means were compared using paired and unpaired t-tests.

RESULTS

Forty-three patients with 46 digits were eligible and were randomized to 1-day (22 digits) and 7-day (24 digits) manipulation. For MCP joints, there were no significant differences in flexion contractures between 1- and 7-day cohorts for initial (47° vs 46°), postmanipulation (0° vs 2°), or 30-day follow-up (1° vs 2°) measurements. Premanipulation, the residual contracture was significantly lower in the 7-day group (23° vs 40°). For PIP joints, there were no significant differences between 1- and 7-day cohorts for initial (63° vs 62°), premanipulation (56° vs 52°), postmanipulation (13° vs 15°), or 30-day (14° vs 16°) measurements. There were no significant differences in pain or skin tears between the 2 groups. No flexor tendon ruptures were observed.

CONCLUSIONS

The effectiveness of CCH in achieving correction of Dupuytren contractures was preserved when manipulation was performed on day 7, with no differences in correction, pain, or skin tears. These data suggest that manipulation can be scheduled at the convenience of the patient and surgeon within the first 7 days after injection.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Multiple collagenase injections are safe for treatment of Dupuytren's contractures

The authors report the case of a 65-year-old, right-hand-dominant man who had severe Dupuytren's disease with multiple cords and flexion contractures of the metacarpophalangeal and proximal interphalangeal joints of both hands and underwent repeated collagenase injections for treatment. Collagenase has been shown to be safe and effective in the treatment of Dupuytren's contractures when administered as a single dose, but the results of multiple injections over a prolonged period are unknown. Antibodies to collagenase develop in all patients after several treatments, raising concerns about safety and efficacy as a result of sensitization from repeated exposures. The antibodies generated as a result of repeated exposure to collagenase could theoretically render it less effective with time and could also lead to immune reactions as severe as anaphylaxis. The authors present the case of a single patient who experienced continued correction of his contractures with only minor and self-limited adverse reactions after administration of 12 collagenase doses through 15 injections during a 4-year period. Over time, the injections continued to be effective at correcting metacarpophalangeal joint contractures, but less effective at correcting proximal interphalangeal joint contractures. The patient did eventually require a fasciectomy, but the safety and modest success of the repeated collagenase injections shows promise for a less invasive treatment with a better risk profile than open fasciectomy. Although further studies are needed, repeated administration of collagenase appears to be safe and modestly effective for severe Dupuytren's contractures, although a fasciectomy may ultimately be required in the most severe cases.

Surgical findings in the treatment of Dupuytren's disease after initial treatment with clostridial collagenase (Xiaflex)

We investigated the difficulty of surgical fasciectomy after previous treatment with clostridial collagenase injection. The 35 clinicians who had participated in the initial trials of this injection were contacted via email. Twenty-eight responded, nine of whom reported on 15 patients. Most (seven of nine) felt there was no significant distortion of anatomy and rated the level of technical difficulty as equivalent to a primary Dupuytren's fasciectomy at the observed degree of contracture (nine of 15 cases). One respondent (four of 15 cases) reported significantly more difficulty and grossly distorted anatomy. One surgical complication, a wound dehiscence, was reported.

Dupuytren's disease: current state of the art

BACKGROUND

This review article critically examines the current literature for Dupuytren's disease.

METHODS

Five procedures are considered: dermofasciectomy, limited fasciectomy, segmental aponeurectomy, needle aponeurotomy, and collagenase injection. Studies regarding the efficacy of these treatments focus primarily on the initial degree of correction, rate of recurrence, and complications.

RESULTS

No one treatment has been declared superior and substantial controversy exists. Comparison between studies has been hampered by the absence of uniform definitions for clinical success and measurable disease progression. Traditional post-operative care includes formal therapy and night splinting, but recent studies have questioned the value of these adjuncts.

CONCLUSION

The extent of involvement at which the surgeon should intervene was previously well accepted by convention, but as the paradigm shifts towards less invasive procedures, treatment may be offered at an earlier stage. Future research should be structured to recognize the value-based decision making used by patients when selecting treatment.

Collagenase injections for treatment of Dupuytren disease

Palmodigital fasciectomy remains the gold standard. The initial outcome is, in my experience, far more predictable than either NA or enzyme fasciotomy (EF). It is also a more durable treatment. NA and EF can be conceptualized as similar procedures--one uses a needle and the other an enzyme to weaken a cord sufficient to be able to rupture it and thus straighten a contracted joint. Both are less invasive and the hand is quick to recover. Both procedures are equally initially effective. CHH seems to offer greater durability. Today’s patients are often better educated and seek a specific type of treatment, in particular, effective nonoperative treatment. Pharmaceutical companies now market directly and effectively to patients, and this strategy and Internet use have already resulted in an increase in the number of patients searching for practitioners willing to administer and capable of administering collagenase treatment.