Efficacy and safety of concurrent collagenase clostridium histolyticum injections for multiple Dupuytren contractures

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.

Patient Insight With Collagenase Treatment for Dupuytren: A Prospective Study

PURPOSE

There appears to be controversy regarding differing patient and physician perceptions of adverse effects (AEs) in the treatment of Dupuytren disease with collagenase clostridium histolyticum (CCH). The aim of this study was to compare the number, type, and severity of AEs perceived and reported by patients and by their physician METHODS: To assess AEs following CCH injection in a standardized way, patients were given a list of predefined complications and asked to rate their severity on a 4-point Likert scale ranging from 1 (serious) to 4 (insignificant).

RESULTS

Eighty-five patients were included. Patients reported fewer AEs than their physician (mean, 1.48 vs 2.18). There was no agreement between physician- and patient-reported AEs except for skin lacerations, which showed fair agreement (κ = 0.257).

CONCLUSIONS

Patients and physicians differ in their evaluation of AEs due to CCH treatment in Dupuytren disease. A fair level of agreement was observed for skin lacerations.

CLINICAL RELEVANCE

Greater consensus is needed when defining AEs associated with CCH in the treatment of Dupuytren disease.

Dupuytren's Contracture Recurrence and Treatment Following Collagenase Clostridium Histolyticum Injection: A Longitudinal Assessment in a Veteran Population

INTRODUCTION

Dupuytren's contracture is a connective tissue disease characterized by an abnormal proliferation of collagen in the palm and fingers, which leads to a decline in hand function because of progressive joint flexion. In addition to surgical and percutaneous interventions, collagenase clostridium histolyticum (CCH, trade name Xiaflex) is an intralesional enzymatic treatment for adults with palpable cords. The objectives of this study are to evaluate factors predictive of recurrence following treatment with CCH and to review the outcomes of repeat treatments with CCH for recurrent contracture.

MATERIALS AND METHODS

An institutional review board-approved retrospective chart review was conducted for patients between 2010 and 2017 who received CCH injections for Dupuytren's contracture at a Veterans Affairs hospital. Demographics, comorbidities, affected finger and joint, pre/posttreatment contracture, time to recurrence, and treatment of recurrence were recorded. Successful treatment was defined as contracture ≤5° following CCH, and improvement was defined as ≥20° reduction from baseline contracture. Study cohorts were followed after their secondary treatment, and time to recurrence was recorded and plotted using a Kaplan-Meier curve. A Cox proportional hazards model was used to compare treatment group risk factors for recurrence with a P-value less than .05 defined as statistical significance.

RESULTS

Of 174 injections performed for the correction of flexion deformities in 109 patients, 70% (121) were successfully treated with CCH, and an additional 20% (35) had improvement. There was a recurrence of contractures in 43 joints (25%). Of these, 16 contractures were treated with repeat CCH, whereas another 16 underwent limited fasciectomy. In total, 75% (12 of 16) of the repeat CCH group and 75% of the fasciectomy group were successfully treated. Pre-injection contracture of ≥25° was found to be predictive of recurrence (P < .05).

CONCLUSIONS

Initial treatment of contracture with CCH had a 70% success rate with 25% recurrence during the study period. Compared with limited fasciectomy, CCH had decreased efficacy. Based on the findings of this study, we believe that the treatment of primary and/or recurrent Dupuytren's contracture with CCH is a safe and less invasive alternative to fasciectomy in the era of telemedicine. CCH treatment requires no suture removal, which allows the ability to assess motion virtually, and the potential consequences of CCH treatment such as skin tears can be assessed and managed conservatively. In the veteran and active duty population, CCH can facilitate faster recovery and return to service. Strengths of this study include a large series of veteran populations with longitudinal follow-up to determine treatment efficacy for primary Dupuytren's contracture and recurrence. Limitations include a smaller sample size compared to previous trials, a lack of standardized follow-up, and the retrospective nature of our study that prohibits randomization to compare outcomes between CCH treatment and fasciectomy efficacy over time. Directions for future research include stratification of patients by joint and specific digit involvement as well as comparison with percutaneous needle fasciotomy, another minimally invasive technique that could benefit the veteran population at increased risk for developing Dupuytren's disease.

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.

Incidence of Tendon Rupture After Collagenase Clostridium Histolyticum Injection for Treatment of Dupuytren Contracture in Adults: A Postmarketing Safety Analysis

Purpose

Based, in part, on the clinical study reports of tendon rupture events after collagenase clostridium histolyticum (CCH) (Xiaflex, Endo Pharmaceuticals Inc) treatment for Dupuytren contracture (DC), a Risk Evaluation and Mitigation Strategy program was instituted in 2010 by Auxilium Pharmaceuticals (now Endo Pharmaceuticals Inc) to ensure that the benefits of CCH injection outweighed the risks when treating DC. Using the postmarketing surveillance data collected in this program, a retrospective analysis was conducted to evaluate the incidence of flexor tendon rupture after CCH treatment for DC in the clinical practice setting.

Methods

The Endo Pharmaceuticals Inc safety database was searched for cases of tendon rupture reported between February 2, 2010, and October 8, 2015. Total number of CCH treatments for DC and incidence of tendon rupture were estimated using CCH dosing derived from clinical trial experience (1.7 CCH vials/treatment) or clinical practice evidence (1.08 CCH vials/treatment).

Results

Over the 5.8-year surveillance period, 97,609 vials of CCH were distributed for the treatment of DC, equivalent to an estimated total of 57,416 treatments (at 1.7 CCH vials/treatment) or 90,378 treatments (at 1.08 CCH vials/treatment). Although CCH distribution increased during the surveillance period, reports of tendon rupture were infrequent (approximately 13 cases/y; total cases: flexor tendon, n = 57; ligament/pulley, n = 2), corresponding to a 0.10% (1.7 CCH vials/treatment) or 0.06% (1.08 CCH vials/treatment) mean estimated incidence of tendon rupture in patients with DC after CCH treatment.

Conclusions

This retrospective analysis showed that flexor tendon rupture occurred infrequently in patients with DC who were treated with CCH in real-world practice settings between 2010 and 2015. On the basis of these findings and other favorable safety evidence, the Risk Evaluation and Mitigation Strategy program requirement for CCH for the treatment of DC was ended by the US Food and Drug Administration in November 2016.

Type of study/level of evidence

Therapeutic IV.

Clostridium Histolyticum Collagenase Underdosed for Multicord Injection in Dupuytren's Disease: A Retrospective Cohort Study

An underdosing of collagenase clostridium histolyticum (0.32 mg) is proposed as a potentially effective option in patients with additional cords in the same hand, after the first cord has been treated with the regular dose of 0.58 mg. The aim of this study was to analyze whether this additional dose is tolerated and effective.

METHODS

Patients with Dupuytren's disease affecting MCP joints with at least two independent pathological cords, causing deformity of two digits, were considered, with their written informed consent, for a simultaneous injection of the two cords with a single vial of collagenase. Digits treated with the standard dose of 0.58 mg were compared with digits injected with the smaller dose of 0.32 mg. Passive extension deficit and range of motion were evaluated after injection. Complications were also compared.

RESULTS

A total of 26 patients (29 hands) were included in the study. Of these, nine patients had two independent cords within one hand, and 17 patients had a single cord (three of these with a cord in each hand). Thirty-five digits were injected, 23 with 0.58 mg and 12 with 0.32 mg. Apart from a smaller mean percentage variation in passive extension deficit within 24 hours in the 0.58-mg dose compared with 0.32 mg (29% versus 40%, P = 0.031), no other differences emerged if a dose of 0.32 mg is used instead of 0.58 mg, in terms of selected outcome measures and rate of complications (P > 0.05).

CONCLUSION

Underdosing collagenase clostridium histolyticum is equally effective in the treatment of Dupuytren's disease.

Dupuytren's disease - what's new: a review

<b><br>Introduction:</b> Dupuytren's disease is a common fibrotic disorder of the palmar aponeurosis characterized by the formation of nodules and cords, as well as development of progressive flexion deformities in the digits, leading to functional impairment. Surgical excision of the affected aponeurosis remains the most common treatment. Quite a few new information appeared about epidemiology, pathogenesis and particularly treatment of the disorder.</br> <b><br>Aim:</b> The aim of this study is an updated review of scientific data in this topic.</br> <b><br>Results:</b> Results of epidemiologic studies showed that Dupuytren's disease is not so uncommon in Asian and African population as it was earlier believed. An important role of genetic factors on development of the disease in a proportion of patients was demonstrated, however, it did not translate neither to the treatment nor to the prognosis. The most changes concerned the management of Dupuytren's disease. A positive effect of steroids injections into the nodules and cords for inhibition of the disease in early stages was shown. In the advanced stages, a standard technique of partial fasciectomy was partly replaced by mini-invasive methods such as needle fasciotomy and collagenase Clostirdium hystolyticum injections. Unexpected withdrawal of collagenase from the market in 2020 resulted in considerable limitation of the availability of this treatment.</br> <b><br>Conclusion:</b> It seems that updated knowledge on Dupuytren's disease may be interested and useful for surgeons involved in management of the disorder.</br>.

Finger Joint Contractures 5 Years After Treatment for Dupuytren Disease: A Comparative Cohort Study of Collagenase Injection Versus Surgical Fasciectomy

PURPOSE

To compare collagenase injection with surgical fasciectomy in Dupuytren disease (DD) for the prevalence of contracture in treated fingers 5 years after treatment.

METHODS

This was a single-center, comparative cohort study comprising 2 cohorts of patients treated for DD in 1 or more of 3 ulnar fingers with collagenase injection (159 patients) or surgical fasciectomy (59 patients). At 5 years after treatment, 13 collagenase-treated and 8 fasciectomy-treated patients had undergone subsequent treatment on the treated fingers and were considered to have current contracture. Of the remaining patients, 112 collagenase-treated patients (128 hands, 180 fingers) and 46 fasciectomy-treated patients (49 hands, 63 fingers) attended follow-up evaluation performed by 2 independent examiners (participation rate 84% and 93%, respectively). We defined current contracture in a treated finger as an active extension deficit of ≥20° in the metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joint or a total (MCP + PIP) active extension deficit (TAED) of ≥30°. We used linear mixed models to analyze differences between the cohorts over time.

RESULTS

In the collagenase cohort, current contracture was present in 45 (25%) MCP and 60 (33%) PIP joints, and in the fasciectomy cohort, current contracture was present in 12 MCP (19%) and 30 PIP (48%) joints; a TAED of ≥30° was present in 79 (44%) of the collagenase-treated and 30 (48%) of the fasciectomy-treated fingers. In MCP and PIP joints with ≥20° pretreatment contracture, complete correction was observed in 82 (56%) MCP and 30 (30%) PIP joints in the collagenase cohort and 23 (70%) MCP and 5 (16%) PIP joints in the fasciectomy cohort. There was no statistically significant difference between the 2 cohorts in the TAED change over time.

CONCLUSIONS

In patients with DD, collagenase injection and surgical fasciectomy improved finger joint contracture over the pretreatment status but had a high prevalence of joint contracture in the treated fingers 5 years after treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Enzymatic Dispersion of Biofilms: An Emerging Biocatalytic Avenue to Combat Biofilm-Mediated Microbial Infections

Drug resistance by pathogenic microbes has emerged as a matter of great concern to mankind. Microorganisms such as bacteria and fungi employ multiple defense mechanisms against drugs and the host immune system. A major line of microbial defense is the biofilm, which comprises extracellular polymeric substances that are produced by the population of microorganisms. Around 80% of chronic bacterial infections are associated with biofilms. The presence of biofilms can increase the necessity of doses of certain antibiotics up to 1000-fold to combat infection. Thus, there is an urgent need for strategies to eradicate biofilms. Although a few physicochemical methods have been developed to prevent and treat biofilms, these methods have poor efficacy and biocompatibility. In this review, we discuss the existing strategies to combat biofilms and their challenges. Subsequently, we spotlight the potential of enzymes, in particular, polysaccharide degrading enzymes, for biofilm dispersion, which might lead to facile antimicrobial treatment of biofilm-associated infections.

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).

Treatment Options for Dupuytren’s Disease: Tips and Tricks

Dupuytren's disease (DD) is a common fibroproliferative condition of the hand.

Dupuytren's disease: using needles more across the world

In this article we take an international perspective on the use of needles, either percutaneous needle fasciotomy (PNF) or Clostridial Collagenase Histiolyticum (CCH), in treating Dupuytren's Disease (DD). Worldwide, PNF is now used more frequently. The CCH has been withdrawn from non-USA markets, which lessens its use. Different patients have different preferences, while different surgeons have different skills and opinions. The surgeon should fully consider the patient's preference and should also, in view of the scarcity of surgical resource and the potential hazard of surgery, reconsider and expand the use of a needle rather than an operation. In the future, a cheaper, yet equally safe and effective alternative to CCH, will provide a useful clinical tool for those cords, which, in the surgeon's personal Venn diagram, are too challenging for PNF, but the patient does not want to have surgery.

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. 

Dupuytren Contractures: An Update of Recent Literature

Dupuytren disease is a fibroproliferative disorder that affects the palmar fascia of the hand and results in varying degrees of nodule and cord formation. Over time, patients may develop progressive contractures, impairing their ability to type, to perform with fine instruments, or to participate in social activities such as shaking hands. Treatment options for Dupuytren contractures include needle aponeurotomy (NA), injection of collagenase Clostridium histolyticum (CCH) with manipulation of the digits, and surgical fasciectomy. Over the past decade, the use of CCH has increased. Recent studies have provided additional data regarding the pathophysiology, indications, outcomes, and costs associated with the treatment for Dupuytren contractures, and this review highlights these advances.

Can collagenase effectiveness in Dupuytren's contracture be improved by using ultrasound-guided Injection? A comparative study

The objective of this study was to compare the effectiveness of ultrasound-guided injection of collagenase Clostridium histolyticum (CCH) in patients with Dupuytren's contracture (DC), with the standard injection. We hypothesised that the ultrasound-guided Injection of CCH is more effective than the standard injection. A prospective cohorts study in patients with DC was done. We treated consecutively 47 fingers with the standard injection and 43 with the ultrasound-guided. Patients in both groups had the same inclusion criteria. The degrees of contracture of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints were measured before treatment and after three months. We compared the effectiveness of each type of injection in respect to obtaining a complete finger extension and to the percentage of improvement in each finger and in each joint. With ultrasound-guided injection, complete finger extension was obtained in 54% of cases and an 81% mean percentage of correction of the finger contracture; with standard injection 49% and 77%, respectively. In the MCP joint, the mean percentage of correction was 92.5 % in the ultrasound-guided Injection group and 84% in the standard injection group. In the PIP joint, it was 75.1% in the ultrasound-guided injection group and 65.3% in the standard injection group. These results showed no statistical significance. Hand surgeons must balance the possible benefits of the ultrasound-guided injection with the complexity and resources needed to perform the technique.

The efficacies and limitations of fasciectomy and collagenase clostridium histolyticum in Dupuytren's contracture management: A meta-analysis

BACKGROUND

We intend to assess the efficacies and limitations of collagenase clostridium histolyticum (CCH) and fasciectomy in treating Dupuytren's contracture, and the associated complications and rate of recurrences aiming to present a treatment algorithm.

METHODS

A literature search within the PubMed, Web of Sciences, Cochrane Library, and EMBASE databases was performed using the combined key words 'Dupuytren, palmar aponeurosis contracture, collagenase clostridium histolyticum and fasciectomy', including all possible studies with a set of predefined inclusion and exclusion criteria.

RESULTS

Thirty studies were assessed for eligibility from 215 identified records. Seventeen publications satisfied the inclusion criteria including 2142 joints in 1784 patients. The mean follow-up time was 18.0 months (3-60).

CONCLUSION

Acceptable contractures release was obtained in both techniques. Severe complications associated with fasciectomy outrank those of CCH, whereas the low rate of recurrence favors the fasciectomy technique.

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.

Cost-effectiveness of Recurrent Dupuytren Contracture Treatment

IMPORTANCE

Owing to its tendency to recur, Dupuytren contracture often requires multiple treatments, which places additional economic burden on health care. The likelihood of contracture recurrence varies not only with treatment but also with disease characteristics, such as contracture severity and location, but prior cost-effectiveness analyses of Dupuytren contracture treatments have not considered these patient-specific disease characteristics.

OBJECTIVE

To identify the most cost-effective treatment regimen for patients with recurrent Dupuytren contracture.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation was conducted with state-transition microsimulation modeling using data from published studies and Medicare. A simulated cohort of 10 000 individuals with Dupuytren contracture was created. Patients could transition yearly between the following health states: symptom-free, symptomatic, and death. Available treatments were collagenase clostridium histolyticum injection, percutaneous needle aponeurotomy (PNA), and limited fasciectomy (LF); individuals randomly chose any treatment when symptomatic. Patients were limited to 3 rounds of treatment for a contracture affecting 1 joint, totaling 27 unique combinations. If the contracture recurred after 3 treatments, patients lived with the disease for the remainder of life.

EXPOSURES

PNA, collagenase clostridium histolyticum injection, or LF.

MAIN OUTCOMES AND MEASURES

Quality-adjusted life-years (QALYs), total costs (in US dollars), and incremental cost-effectiveness ratios (ICERs). A willingness-to-pay threshold of $100 000 per quality-adjusted life-year was used to assess cost-effectiveness.

RESULTS

For the base case scenario of a patient aged 60 years with recurrent, low-severity metacarpophalangeal (MCP) joint contracture, repeated PNA treatment was the only cost-effective treatment (2 PNA treatments followed by LF vs 3 PNA treatments, ICER [Monte Carlo SE]: $212 647/QALY [$36 000/QALY]). For recurrent high-severity MCP joint contractures, treatment regimens composed of PNA and LF were cost-effective (ICER [Monte Carlo SE], $93 932/QALY [$16 500/QALY]). LF was cost-effective for high-severity MCP joint contracture (ICER [Monte Carlo SE], $98 624/QALY [$26 233/QALY]). For recurrent proximal interphalangeal (PIP) joint contractures, PNA was the only cost-effective treatment, regardless of severity (eg, 2 PNA treatments followed by LF vs 3 PNA treatments for low-severity PIP joint contracture, ICER [Monte Carlo SE]: $263 726/QALY [$29 000/QALY]). Any combination with collagenase clostridium histolyticum injection compared with 3 PNA treatments had an ICER greater than $100 000 per QALY. Probabilistic sensitivity analysis estimated a 44%, 15%, 41%, and 52% chance of a regimen consisting of only PNA being cost-effective in low-severity MCP, high-severity MCP, low-severity PIP, and high-severity PIP joint contractures, respectively.

CONCLUSIONS AND RELEVANCE

The results of this study suggest that LF is a cost-effective intervention for recurrent high-severity MCP joint contractures. For recurrent low-severity MCP joint contractures and PIP joint contractures of all severity levels, PNA was the only cost-effective intervention. Collagenase clostridium histolyticum injections were not a cost-effective intervention for recurrent Dupuytren contracture and should not be preferred over PNA or LF.

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.

Treatment of Dupuytren's disease using one full dose of Clostridiumhistolyticum collagenase at a lower concentration: Retrospective analysis of clinical outcomes

Clostridiumhistolyticum collagenase (CHC) is rapidly becoming a mainstream treatment option for Dupuytren's disease for hand surgeons. We performed a retrospective study of the efficacy of this substance at a lower concentration, but a higher total dose than recommended by the manufacturer. Thirty-nine patients with 43 affected hands were treated and analyzed at a mean follow-up of 27 months. Subgroup analysis was done for patients who received treatment in one or two joints (group A), and for patients who received treatment in more than two joints (group B). We found that our CHC solution is safe and effective when simultaneously treating as many as four joints affected by Dupuytren's disease. Patients in group B had a lower (but non-significant) treatment failure rate compared to patients in group A. Also, higher satisfaction rates were observed in group B, again non-significant. No major complications were observed in any group. CHC use is associated with only minor complications. The results are consistent even when up to four joints are treated with one dose. LEVEL OF EVIDENCE: III.

contribution of Australian research to Dupuytren’s disease

Introduction: While the history and epidemiology of Dupuytren's disease (DD) is well documented, its aetiology and risk factors, pathogenesis and treatment to this day are still being studied. This paper explores and summarises the significant contributions Australian researchers have made to the understanding of DD and its treatment methodologies.  Methods: We performed a systematic search on EMBASE from 1947 until March 2019 to identify all English literature using keywords: ‘Dupuytren/Dupuytrens/Dupuytren’s disease’ and ‘Australia/Australian/Australasian’. Relevant articles were also identified through bibliographic links. A separate search was conducted using Google Scholar, Research Gate and PubMed using the same keywords. In total, 40 articles were identified. A library search was also conducted, with one book identified with an Australian author. The Royal Australasian College of Surgeons Journal of Surgery was also analysed for published abstracts pertaining to DD from conference presentations between 2014 to 2019. Results and discussion: We present a narrative discussion of Australian research that has contributed to the understanding of DD from its aetiology to treatment methodologies.  Conclusion: Numerous Australians have made significant contributions to the understanding of DD, its pathogenesis, development and multiple treatment modalities, both non-surgical and surgical. Dupuytren’s disease is a progressive disease that reoccurs despite our best efforts and will continue to be a topic of focus for some time to come.

Collagenase injections for Dupuytren disease: 3-year treatment outcomes and predictors of recurrence in 89 hands

Background and purpose - Few prospective studies have reported the long-term effect durability of collagenase injections for Dupuytren disease. We assessed the 3-year treatment outcome of collagenase injections and predictors of recurrence.Patients and methods - We conducted a single-center prospective cohort study. Indication for collagenase injection was palpable Dupuytren's cord and active extension deficit (AED) ≥ 20° in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint. From November 2012 through June 2013, we treated 86 consecutive patients (92 hands, 126 fingers). A hand therapist measured joint contracture before, 5 weeks, and 3 years after injection. The patients rated their treatment satisfaction. Primary outcome was proportion of treated joints with ≥ 20° AED worsening between the 5-week and 3-year measurements. We analyzed predictors of recurrence.Results - 3-year outcomes were available for 83 of the 86 patients (89 hands, 120 treated fingers). Between the 5-week and 3-year measurements, AED worsened by ≥ 20° in 17 MCP (14%) and 28 PIP (23%) joints. At 3 years, complete correction (passive extension deficit 0-5°) was present in 73% of MCP and 35% of PIP joints. Treatment of small finger PIP joint contracture, greater pretreatment contracture severity, and previous fasciectomy on the treated finger were statistically significant predictors of recurrence. Treatment satisfaction was rated as very satisfied or satisfied in 59 of 87 hands. No long-term treatment-related adverse events were observed.Interpretation - 3 years after collagenase injections for Dupuytren disease, improvement was maintained and treatment satisfaction reported in two-thirds of the treated hands, with no adverse events. Complete contracture correction was achieved in 3 of 4 MCP joints, but in only a third of the PIP joints.

Fibrillin microfibrils and proteases, key integrators of fibrotic pathways

Supramolecular networks composed of multi-domain ECM proteins represent intricate cellular microenvironments which are required to balance tissue homeostasis and direct remodeling. Structural deficiency in ECM proteins results in imbalances in ECM-cell communication resulting often times in fibrotic reactions. To understand how individual components of the ECM integrate communication with the cell surface by presenting growth factors or providing fine-tuned biomechanical properties is mandatory for gaining a better understanding of disease mechanisms in the quest for new therapeutic approaches. Here we provide an overview about what we can learn from inherited connective tissue disorders caused primarily by mutations in fibrillin-1 and binding partners as well as by altered ECM processing leading to defined structural changes and similar functional knock-in mouse models. We will utilize this knowledge to propose new molecular hypotheses which should be tested in future studies.

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.

Range of motion, postoperative rehabilitation and patient satisfaction in MCP and PIP joints affected by Dupuytren Tubiana stage 1-3: collagenase enzymatic fasciotomy or limited fasciectomy? A clinical study in 52 patients

INTRODUCTION

In Switzerland, collagenase Clostridium histolyticum therapy (CCH) for Dupuytren's disease was introduced in 2011. This study analyzes possible differences between CCH and limited fasciectomy (LF) in terms of range of motion, patient satisfaction and postoperative rehabilitation.

MATERIALS AND METHODS

This retrospective study included 52 patients with Dupuytren's disease stage 1-3 according to Tubiana, treated with CCH or LF between January 2012 and December 2013. Complications were analyzed for each patient. The contracture of each treated joint measured on average at the 3 months and up to 2 years follow-up was compared with the preoperative values. The Michigan Hand score was evaluated at 2 years and the patients were asked to subjectively evaluate the outcome of the treatment and whether they would repeat it if necessary. Postoperative rehabilitation was also precisely quantified.

RESULTS

11 minor complications were reported for a complication rate of 29% in the CCH group. No major complications were reported in both groups. In the CCH group, mean MCP joint contracture was, respectively, 44° ± 20°, 9° ± 2° (gain of mobility compared to the preoperative situation 35°, P < 0.001), and 10° ± 3° (gain 34°, P < 0.001), respectively, before, at the 3 months' control and at the 2-year clinical control. In the LF group, mean MCP joint contracture was, respectively, 30° ± 21°, 2° ± 0.5° (gain 28°, P < 0.001), and 1° ± 0.5° (gain 29°, P < 0.001) for the same control periods. In the CCH group, mean PIP joint contracture was, respectively, 51° ± 21°, 18° ± 3° (gain of mobility compared to the preoperative situation 33°, P < 0.001), and 32° ± 4° (gain 19°, P < 0.001), respectively, before, at the 3 months' control and at the 2-year clinical control. In the LF group, mean PIP joint contracture was, respectively, 30° ± 20°, 2° ± 0.5° (gain of mobility compared to the preoperative situation 28°, P < 0.001), and 11° ± 4° (gain 19°, P < 0.001) for the same control periods. Outcomes were compared across the LF and CCH groups: surgery performed better than collagenase for PIP joint treatment at early (P < 0.001) and 2-year follow-up (P = 0.004) controls. However, patient satisfaction was higher in the CCH group: 92% were satisfied or very satisfied of the treatment compared to 71% in the LF group. All patients would reiterate the treatment in the CCH group if necessary compared to only 71% in the LF group. Rehabilitation was highly reduced in the CCH group compared to the LF group.

CONCLUSION

In this study, surgery performed better than collagenase at early and 2-year follow-up in PIP joints and similar in MCP joints. While surgery seems to achieve better results, collagenase is considered in Switzerland as an off-the-shelf therapy that provides consistent results without scars, with shorter rehabilitation time, minor hand therapy, shorter splinting time, and applicability.

LEVEL OF EVIDENCE AND STUDY TYPE

Level III.

Five-year results after collagenase treatment of Dupuytren disease

This study assesses the joint-specific sustained effect of collagenase clostridium histolyticum treatment of Dupuytren disease over a 5-year follow-up period. The study includes 107 consecutive treatments in patients with extension deficits greater than 20° affecting the metacarpophalangeal or proximal interphalangeal joints. Success was defined as no follow-up treatment due to relapse or maintained extension deficit less than 20°. The 5-year estimate of no follow-up treatment was 79% (95% CI: 64-88) for metacarpophalangeal and 49% (95% CI: 26-69) for proximal interphalangeal joints, which was a significant difference (log-rank test, p = 0.0044). For those who did not undergo re-treatment, a non-significant relapse was found for metacarpophalangeal joints and a 65% (34°, 95% CI: 24-46) relapse for proximal interphalangeal joints. We conclude that treating metacarpophalangeal joints with collagenase clostridium histolyticum is effective with acceptable recurrence rates. However, when treating proximal interphalangeal joints with collagenase clostridium histolyticum, patients should be informed of the high risk of recurrence and the greater chance of need for further treatment.

LEVEL OF EVIDENCE

II.

Adverse effects associated with collagenase clostridium histolyticum in Dupuytren disease: A prospective study

BACKGROUND

Collagenase clostridium histolyticum is now recognized as a viable treatment for Dupuytren disease. The high rate of adverse effects reported in patients continues to spark debate and raise questions about the true frequency of effects and their associated mechanisms of action.

HYPOTHESIS

To investigate whether outcomes of CCH treatment are related to the number of adverse effects experienced. To evaluate short-term clinical outcomes in a series of patients.

MATERIAL AND METHODS

Prospective single-center cohort study. The Primary End Point for effectiveness at 30 days was deficit of 0°-5°. Adverse effects were evaluated during CCH injection, removal of the dressing prior to finger extension, and finger extension. To investigate the relationship between adverse effects and treatment effectiveness, we analyzed the association between number of effects and clinical outcome at 30 days.

RESULTS

A total of 208 injections were evaluated. The mean baseline contracture was 32.11°. Ninety-four patients (45.2%) had a mild contracture. Treatment was effective at 30 days in 194 of the injections (93.3%). The rate of effectiveness per joint was 93.5% for metacarpophalangeal joints (n=129) and 92.9% for proximal-interphalangeal joints (n=65). In total, 734 adverse effects were reported (mean, 3.53). No statistically significant associations were identified between disease severity and secondary effects. Variance analysis showed statistically significant differences in patients with severe contractures (mean, 3.91; 95% CI 3.57-4.25), and in patients with proximal-interphalangeal contractures (mean, 4.17; 95% CI 3.76-4.59).

CONCLUSIONS

We found no relationship between number of adverse effects and treatment effectiveness at one month following CCH injection.

LEVEL OF PROOF

IV, cohort prospective study.

The Role of Hand Therapy in Dupuytren Disease

The role of hand therapy in the treatment of Dupuytren disease varies depending on the patient and the procedure. There is limited evidence for hand therapy as a preventive treatment of Dupuytren disease. Before corrective treatment, the hand therapist can contribute with assessments to promote evaluation of outcome. After corrective treatment, hand therapy is tailored to each patient's needs and consists of orthoses, exercise, edema control, and pain or scar management. Orthoses are usually part of the hand therapy protocol after corrective procedures despite lack of strong supporting evidence and should be provided based on individual patient needs.

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.

Skin Laceration in Collagenase Clostridium histolyticum Treatment for Dupuytren's Contracture

BACKGROUND

Dupuytren's contracture produces a progressive flexion contracture of the affected fingers. Collagenase Clostridium histolyticum produces breakdown of the cord in the hand and/or finger(s) that tightens as a result of the disease creating a contracture, allowing manual traction and cord rupture. One of the side effects is spontaneous skin laceration when the finger is extended.

OBJECTIVES

To evaluate the development of skin lacerations in Dupuytren's contracture treated with collagenase Clostridium histolyticum, to determine predisposing factors, and evaluate the effectiveness of 2 different treatments (antiseptic and non-antiseptic dressings).

PARTICIPANTS

Included 157 patients diagnosed with Dupuytren's contracture and treated with collagenase Clostridium histolyticum.

METHODS

Analysis of variables and logistic regression model were applied to determine their possible relationship with skin lacerations. The effectiveness of the type of treatment used was evaluated by comparing the amount of time required for healing.

RESULTS

Skin lacerations were present in 33.1% (n = 52) of patients, with an average laceration length of 1.12 (SD: 0.70) cm. Characteristics that were significant predisposing factors for lacerations were disease bilateralism (p = .002), previous surgical intervention (p = .003), and initial matacarpophalangeal joint contracture (p < .001). Worse initial contracture (Z = 5.94; p < .001) had a greater risk of laceration as did those who had prior hand surgery, or whose little finger was affected. Average treatment length of healing was 11.24 days (SD: 8.13). All wounds healed successfully. There were no significant differences (p = .511) in healing between different dressings evaluated.

CONCLUSIONS

Skin lacerations as a consequence of treating Dupuytren's contracture with collagenase Clostridium histolyticum occur often and are moderately serious. For all cases, evolution is satisfactory in less than 2 weeks, and the type of treatment does not appear to make any difference in healing time.

Complications after treating Dupuytren's disease. A systematic literature review

The objective of this study was to review the incidence of complications associated with different treatment options for patients with Dupuytren's disease. In a systematic literature review, the PubMed, EMBASE, Cochrane and Scopus databases were searched for clinical studies reporting complications after collagenase treatment, percutaneous needle fasciotomy (PNF), fasciectomy and dermofasciectomy. The incidence of complications was extracted from each study and stratified by procedure. From a total of 2251 references, 113 studies were analyzed and included with complication incidences varying from 0% to 100%. The highest number of nerve and vessel lesions were reported after fasciectomy, whereas the highest rate of edema was after collagenase injection. Accidental skin tears were mostly associated with collagenase and PNF treatment. Pooled complication incidences were 17.4% (95% CI: 11.7-23.1) for fasciectomy, 78.0% (95% CI: 59.6-96.4) for collagenase treatment, 18.9% (95% CI: -5.5-43.3) for PNF and 11.6% (95% CI: 0.0-23.2) for dermofasciectomy. Due to inconsistencies in reporting complications as well as the lack of a standardized definition, the literature does not provide evidence in favor of a specific procedure for Dupuytren's disease. A standardized definition of complications is required to improve the comparability of published results.

Resultado precoz del tratamiento de la enfermedad de Dupuytren mediante inyección de colagenasa

Objetivo: Presentar nuestro protocolo de tratamiento y el resultado precoz obtenido en una serie inicial de pacientes tratados con colagenasa.

Material y método: Estudio prospectivo sobre 40 pacientes afectos de enfermedad de Dupuytren, tratados mediante colagenasa en 47 dedos. Los criterios de inclusión han sido cuerdas palpables con una flexión metacarpo-falángica y/o interfalángica proximal superior a 20°. Se han recogido los grados de contractura de las articulaciones metacarpo-falángica, interfalángica proximal e interfalángica proximal con metacarpo-falángica en máxima flexión, antes y después del tratamiento al mes y a los tres meses de la inyección.

Resultados: Se ha obtenido extensión completa (contractura igual o menor de 5°) en el 53% de los dedos tratados, con una media de 1,19 inyecciones por dedo. El 91% de los pacientes ha considerado satisfactorio el resultado. La corrección en las metacarpo-falángicas ha sido completa en el 71% y en las interfalángicas proximales en el 43%. Cuando la interfalángica proximal se corregía previamente con la metacarpo-falángica en flexión, su extensión completa se ha obtenido en el 77%. Se detallan las características de las roturas cutáneas observadas.

Conclusión: La inyección de colagenasa es un método efectivo de tratamiento, con una tasa elevada de satisfacción en los pacientes.

The Use of Residual Collagenase for Single Digits With Multiple-Joint Dupuytren Contractures

PURPOSE

Standard 0.58 mg (0.25 mL) collagenase Clostridium histolyticum (CCH) preparations result in unused CCH that is often discarded. Our purpose was to assess the results on Dupuytren contractures affecting both the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints in the same digit utilizing an injection containing the maximum CCH volume that can be withdrawn from a single vial.

METHODS

A consecutive series of patients with MCP and PIP cords in the same digit received a single treatment with 2 injections totaling 0.30 mL distributed between the MCP and the PIP cords and underwent manipulation approximately 24 hours later. Reduction in contracture, clinical success, and complications were assessed 30 days after manipulation.

RESULTS

Thirty-one patients (34 digits) had a mean preinjection flexion contracture of 50° at the MCP joint and 53° at the PIP joint. Clinical success (reduction in joint contracture to 0°-5° of full extension 30-days postmanipulation) was noted in 65% of MCP cords and 38% of PIP joint cords. We had a 24% incidence of skin tears, which correlated with the degree of preinjection contracture.

CONCLUSIONS

For Dupuytren contractures involving the MCP and PIP joints in the same digit, distributing the maximum amount of CCH that can be withdrawn from a single vial provides efficacy at both joints that is similar to that reported in previously published series, with a comparable complication rate. Utilizing excess CCH typically discarded may provide cost savings.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Evidence-Based Medicine: Options for Dupuytren's Contracture: Incise, Excise, and Dissolve

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand updates in the basic science, epidemiology, and treatment of Dupuytren's disease. 2. Understand treatment with needle aponeurotomy, collagenase, and fasciectomy. 3. Understand advanced needle techniques for Dupuytren's contracture. 4. Understand the safety and effectiveness of a new treatment, collagenase.

SUMMARY

The literature on Dupuytren's disease encompasses many specialties. Its treatment is generally by perforating, excising, or dissolving the affected tissues. This article reviews the changing understanding of this disease and treatment options.

Difference in Success Treating Proximal Interphalangeal and Metacarpophalangeal Joints with Collagenase: Results of 208 Treatments

Background:

Dupuytren disease (DD) is a fibroproliferative disorder of the palmar fasciae causing extension deficit and impaired hand function. Treatment with injection of collagenase clostridium histolyticum (CCH) is a nonsurgical treatment method. The aim of this study was to evaluate the difference in efficiency and recurrence at 12-month follow-up when treating metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints with CCH. None of the patients had received previous treatments of their condition.

Methods:

This study is a prospective study of a consecutive series of patients with DD presenting with an extension deficit greater than 20° affecting the MP or PIP joint.

Results:

We found a mean reduction in extension deficit of 47° (91%) for MP joints and 47° (76%) for PIP joints. Full correction (max 5° deficit) was achieved in 76% of MP and 28% of PIP joints. Skin rupture was seen in 34% of treatments. The 1-year relapse rate was 15% for MP and 67% for PIP joints. The reduction in quickDASH score was only statistically significant for MP joints at 1 year. Eighty-one percent of all patients reported being satisfied or very satisfied. No major adverse events were recorded.

Conclusion:

Excellent results can be achieved in the treatment of MP-joint contractures, whereas the success rate is significantly lower and recurrence rate is greater for PIP joints.

Adverse Effects of Collagenase in the Treatment of Dupuytren Disease: A Systematic Review

BACKGROUND

Collagenase clostridium histolyticum (CCH) has proven to be both safe and effective in the treatment of Dupuytren disease (DD). The medium-term outcomes are similar to those achieved with surgery, and most adverse effects are self-limiting and considered to be mild or moderate.

OBJECTIVE

Our objective was to conduct a systematic review of the adverse effects of CCH in DD since the release of the drug to evaluate the incidence, severity, classification, and definitions of these effects.

METHODS

We analyzed the literature in terms of modifications to the original treatment protocol and grouped adverse effects according to their pathophysiological origin.

RESULTS

We included 28 clinical studies and five case reports or case series analyzing 4456 patients with a mean age of 63.6 years. Mean follow-up was 7.07 months (range 3-24); the mean number of patients per study was 148 (range 5-1082). The studies did not classify the adverse effects they reported into groups. The most common effects were peripheral edema (54.4%), bruising (42.9%), and upper limb pain (28.3%). Significant biases were observed for use of terminology, demarcation of sites of involvement, severity criteria, and assessment methods.

CONCLUSION

A simpler and clearer consensus-based classification system would enable better evaluation and comparison of the adverse effects of CCH in the treatment of DD. Consideration of inflammatory phenomena as part of the drug's mechanism of action would significantly reduce overall rates of adverse effects.

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.

Collagenase Clostridium histolyticum: emerging practice patterns and treatment advances

OBJECTIVE

This study aims to provide a comprehensive review of the role of Collagenase Clostridium histolyticum (CCH).

METHODS

This review is based on a literature review and practical experience.

RESULTS

This review provides practical management strategies for using collagenase by sharing clinical experiences over the past few years; logistical aspects of in-clinic treatment, lessons learned, and novel approaches to correct traditionally hard-to-treat contractures are discussed. In addition a brief, yet comprehensive overview is provided on the pathophysiology of the disease, the mechanism of collagenase action and results of clinical studies.

CONCLUSION

CCH has an evolving role as one of the tools available for treating Dupuytren's disease.

New insights into the immediate outcome of collagenase injections for Dupuytren's contracture

Collagenase clostridium histolyticum is now established as an effective and safe option to treat patients with a single joint affected with Dupuytren's contracture. We have extended its use to natatory and combined cords. In a prospective consecutive series of 298 cords in 237 patients, the mean total extension loss improved in cords crossing the metacarpophalangeal joint from 46° to 1°, in cords crossing the proximal interphalangeal joint from 56° to 7°, in natatory cords from 130° to 25° and in combined cords from 102° to 16°. The immediate correction of combined cords and natatory cords was less reliable than that obtained in cords crossing the metacarpophalangeal joint or proximal interphalangeal joint. Less severe pre-intervention contractures tended to correct better. We found a high complication rate, which may cause alarm. A total of 21% developed skin splits, with the risk of skin splits generally increasing with more severe pre-injection deformity. Blood blisters were only encountered after manipulation of the more severe contractures. A total of 23 patients (8%) had a spontaneous rupture and 57 patients (19%) had a partial spontaneous rupture. Only 4.9% needed a second injection. We noticed a learning curve, with seven of the first 20 cords (35%) needing a second injection to achieve a satisfactory correction and then only seven (2.5%) in the rest.

LEVEL OF EVIDENCE

IV.

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.

Collagenase Treatment in Dupuytren Contractures: A Review of the Current State Versus Future Needs

Dupuytren disease is highly prevalent and the finger contractures can be very extensile, compromising the patients' hand function. To restore full function, contractures have been addressed by cutting the causative strands for nearly 200 years, ever since Baron Guillaume Dupuytren demonstrated his technique at the beginning of the nineteenth century. Surgery can be minimal (fasciotomy) or quite invasive (fasciectomy and even skin replacement). However, in the last decade translational research has introduced the non-surgical technique of enzymatic fasciotomy with collagenase injections. Now, finger contractures can be released with single injections on monthly intervals, to address one joint contracture at a time. However, in hands affected with Dupuytren contractures to the extent that the patient calls for treatment, most often more than one joint is involved. In surgical treatment options all contracted joints are addressed in a single procedure. Nevertheless, extensile surgery withholds inherent risks of complications and intense rehabilitation. Today, the minimally-invasive method with enzymatic fasciotomy by collagenase injection has demonstrated reliable outcomes with few morbidities and early recovery. However, single-site injection is todays' standard procedure and multiple joints are addressed in several sessions with monthly intervals. This triggers a longer recovery and treatment burden in severely affected hands even though surgery is avoided. Therefore, further treatment modalities of collagenase use are explored. Adjustments in the treatment regimes' flexibility and collagenase injections addressing more than one joint contracture simultaneously will improve the burden of multiple sessions and, therefore, enzymatic fasciotomy may become the preferred method in more extensile Dupuytren contractures. In this independent review, the challenge of Dupuytren disease affecting a single versus multiple joints is presented. The pros and cons of collagenase use are weighed, founded by the available scientific background. The demands and options for collagenase in future treatment regimens for extensile Dupuytren contractures are discussed.

Collagenase@magnetite: proteolytic composite for magnetically targeted minimally invasive surgery

Fully biocompatible proteolytic magnetic nanocolloid providing high stability and prolonged activity has been developed.

Enzymes approved for human therapy: indications, mechanisms and adverse effects

Research and drug developments fostered under orphan drug product development programs have greatly assisted the introduction of efficient and safe enzyme-based therapies for a range of rare disorders. The introduction and regulatory approval of 20 different recombinant enzymes has enabled, often for the first time, effective enzyme-replacement therapy for some lysosomal storage disorders, including Gaucher (imiglucerase, taliglucerase, and velaglucerase), Fabry (agalsidase alfa and beta), and Pompe (alglucosidase alfa) diseases and mucopolysaccharidoses I (laronidase), II (idursulfase), IVA (elosulfase), and VI (galsulfase). Approved recombinant enzymes are also now used as therapy for myocardial infarction (alteplase, reteplase, and tenecteplase), cystic fibrosis (dornase alfa), chronic gout (pegloticase), tumor lysis syndrome (rasburicase), leukemia (L-asparaginase), some collagen-based disorders such as Dupuytren's contracture (collagenase), severe combined immunodeficiency disease (pegademase bovine), detoxification of methotrexate (glucarpidase), and vitreomacular adhesion (ocriplasmin). The development of these efficacious and safe enzyme-based therapies has occurred hand in hand with some remarkable advances in the preparation of the often specifically designed recombinant enzymes; the manufacturing expertise necessary for commercial production; our understanding of underlying mechanisms operative in the different diseases; and the mechanisms of action of the relevant recombinant enzymes. Together with information on these mechanisms, safety findings recorded so far on the various adverse events and problems of immunogenicity of the recombinant enzymes used for therapy are presented.