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

Dupuytren's Disease: A Novel Minimally Invasive Pull-Through Technique

Background  Dupuytren's disease decreases quality of life significantly and often requires surgical treatment, nevertheless there is no actual gold standard. The aim of this study was to introduce the use of minimally invasive pull-through technique. Methods  From 2016 to 2020, 52 patients suffering from Dupuytren's contracture were treated with the minimally invasive pull-through technique. We evaluated the improvement in range of motion, pain, disability, and quality of life in the long term. Total extension deficit, quick disabilities of the arm, shoulder, and hand (QuickDASH), and EuroQol five dimensions-five levels index were systematically scored before each surgical intervention and reevaluated after 24 months. Results  Fourteen patients (26.9%) had already received a previous intervention (percutaneous needle aponeurotomy or collagenase Clostridium histolyticum ). The mean preoperative total active extension deficit was 84.0 ± 23.3 degrees (55-130 degrees). Mean follow-up was 36 months. There were no cases of tendon rupture or neurovascular injury. Total active extension deficit at the final follow-up was 3.4 ± 2.3 degrees (0-12 degrees). The mean active range of motion of the MCP and PIP joints were, respectively, 90.5 ± 3.3 degrees (85-96 degrees) and 82.7 ± 2.5 degrees (80-87 degrees). At 24 months after cord excision, a mean 10.7 points improvement in the QuickDASH questionnaire was registered ( p  < 0.001). Pull-through technique was equally effective both on patients with a primary or a recurrent disease. Eight patients (15.4%) had a recurrence of disease in the metacarpophalangeal joint or proximal interphalangeal joint. Conclusion  The pull-through technique is a simple, accessible, and effective technique for the treatment of Dupuytren's contracture. The use of palmar mini-incisions combined with minimal dissection has a low risk of iatrogenic injury to the neurovascular bundles and tendons, and has a low risk of recurrence rate. This study reflects level of evidence IV.

CLINICAL RESULTS OF COLLAGENASE TREATMENT FOR DUPUYTREN'S DISEASE: A CASE SERIES STUDY WITH 2-YEARS FOLLOW-UP

Objectives

This study aims to report our experience with Clostridium Histolyticum collagenase (CCH) to support the importance of its clinical use and assess its clinical efficacy, complications, and recurrences.

Methods

This prospective observational study of 66 patients with a 2-year follow-up. Patients with an extension lag major of 20° at the metacarpophalangeal joint (MPJ) and/or proximal interphalangeal joint (PIPJ) were included. We collected data on demographic and anamnestic details, MPJ and PIPJ contracture degrees, DASH score, complications, and recurrences.

Results

The mean pre-injection contracture was 34° for MPJ and 31° for PIPJ. At the 2-year follow-up, the mean contracture for the MPJ and PIPJ were respectively 3° and 14.5°. The mean DASH score decreased from 21.8 before injection to 10,4 after 2 years. The disease recurrence occurred in 34.8% of the patients, all with PIPJ contracture. The main complication was skin breakage (25.7%).

Conclusion

The CCH injections remain a consistent option in treating DD; withdrawal from the European market deprives surgeons and patients of low invasiveness and safe tool for treating DD. Level of evidence IV, Therapeutic study investigating treatment results, Case series .

Skin extension with a digito-lateral flap and early active finger extension training for Dupuytren contracture: A retrospective study

In the surgical management of Dupuytren contracture (DC), Y-V plasty (YV) and Z-plasty (ZP) are techniques often used for skin extension. However, achieving sufficient skin extension with these procedures alone is often difficult. Therefore, we addressed this issue with an adjunctive digito-lateral flap (DLF) and report the clinical results of the surgery using a DLF in addition to YV and ZP. Fifteen patients with DC (15 affected fingers) underwent partial fasciectomy using a DLF in addition to YV or ZP, and early active finger extension training was performed immediately after the operation. The flap survival rate, preoperative and postoperative extension angle, Tonkin contracture improvement (TCI) rate, and Tubiana staging grades were evaluated. The contracture sites were at 4 proximal interphalangeal (PIP) and 3 metacarpophalangeal (MP) joints of the little finger and 4 PIP and MP joints each of the ring and little fingers. All the flaps survived, and the extension angle improved at the final observation from a preoperative mean of -45° to -3° and -55° to 5° for the PIP and MP joints, respectively. One patient with PIP joint contracture treated in the early stage of the study experienced a persistent 5° limitation of extension, even though the TCI rate was satisfactory (91.9%) and the outcome was "good." Full extension of the joints was achieved in 15 patients, in whom the TCI rate was 100% and the outcome was "very good." This technique was able to solve 3 important steps to achieve full extension: intraoperatively, wound closure, and rehabilitation. We attained and maintained long-term full extension intraoperatively and immediately after surgery and obtained very good treatment results, as shown in this study. In conclusion, highly favorable clinical outcomes were achieved through the combination of a DLF with YV and ZP. Skin extension with a DLF is a useful surgical technique for DC.

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.

Initial Treatment Choice Affects Cost-Effectiveness and Reintervention Rates for Dupuytren Contracture: A National Census Among Veterans Affairs Patients

BACKGROUND

A multitude of treatments for Dupuytren contracture are available, including both invasive and minimally invasive options. This study compares the reintervention rates and costs associated with various treatment options for Dupuytren disease (DD) within the Veterans Affairs (VA) Health Administration.

METHODS

Using the Corporate Data Warehouse, a national census was performed including all patients treated for DD in years 2014 to 2020 within the VA health care system. Patients treated with collagenase clostridium histolyticum (CCH), percutaneous needle aponeurotomy (PNA), open fasciotomy, palmar fasciectomy, single finger fasciectomy, and multifinger fasciectomy were compared. The total cost of initial treatment was compared between modalities. The 5-year reintervention rates were compared using a Kaplan-Meier analysis.

RESULTS

During the study period, 8530 patients were treated for DD (3501 fasciectomy, 3351 CCH, 880 PNA, 798 fasciotomy). The overall median treatment cost was found to be the least for PNA (P < .0001). The 5-year reintervention rates were significantly lower for single finger fasciectomy (6.5%), operative fasciotomy (8.2%), and palmar fasciectomy (9%) when compared with PNA (12.3%), multifinger fasciectomy (13.1%), and CCH (14.4%) (P < .001). However, reintervention rates were comparable between patients treated with PNA, multifinger fasciectomy, and CCH (P > .05).

CONCLUSIONS

Within the VA population, PNA is the most affordable procedure per treatment episode and is associated with reintervention rates that are comparable to those of CCH. Multifinger fasciectomy, CCH, and PNA had comparable reintervention rates. The differences in reintervention rates may partially be explained by patients' willingness to consider additional treatment to correct any remaining or recurrent deformity.

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 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.

Collagenase Clostridium Histolyticum Injection for Dupuytren Contracture: 2-Year Follow-up

Background

Dupuytren disease is characterized by the development of palmar fibrous tissue that can lead to fixed flexion contracture (FFC) and contribute to functional loss of the involved digits. Our goal was to investigate rates of contracture resolution and recurrence in patients who underwent enzymatic fasciotomy for Dupuytren contracture consisting of collagenase clostridium histolyticum (CCH) injection followed by passive manipulation combined with splinting and home-based therapy.

Methods

We prospectively enrolled 34 patients (44 metacarpophalangeal [MCP] and 33 proximal interphalangeal [PIP] joints) treated by one orthopaedic hand surgeon between November 2010 and November 2014. On day 1, CCH was injected into a palpable fibrous cord of the involved fingers. The next day, the finger was passively extended to its maximal corrective position. FFC was measured for each joint before injection and immediately after manipulation. Patients were instructed to wear an extension splint at night and perform stretching exercises at home and were re-evaluated at 6 weeks, 4 months, 1 year, and 2 years. Resolution was defined as improvement of contracture to ≤ 5° of neutral. Recurrence was defined as an increase in FCC of ≥ 20° after treatment.

Results

Immediate contracture resolution occurred in 42 of 44 MCP joints (p < 0.001), improving from 50° to 1.5°, and in 14 of 33 PIP joints (p = 0.182), improving from 44° to 16°. Four joints had recurrence within 6 weeks. Of the 48 joints with minimum 4-month follow-up (mean, 26 months), 12 had recurrence at 2-year follow-up (MCP, 6; PIP, 6). At 2-year follow-up, MCP and PIP contractures measured 17° and 35.5°, respectively. Older age and multiple digit involvement were associated with higher recurrence rates.

Conclusions

CCH offers a safe, nonoperative option to correct FCC in Dupuytren disease with greater success for MCP joints compared to PIP joints. There is a tendency of reoccurrence within 2 years of treatment. Further investigation is needed to determine optimal timing of repeat CCH injection to improve upon or extend the period of contracture resolution.

Efficacy of collagenase Clostridium histolyticum injection for Dupuytren's contracture in East-Asian population

BACKGROUND

Treatment with injection of collagenase Clostridium histolyticum (CCH) has been recognized as an effective option for the Dupuytren's contracture (DC) in Europe and North America. However, there are no studies describing mid-term efficacy of CCH treatment in East-Asian population. The purpose of this study was to assess 2-year outcomes following CCH treatment in Japanese patients.

METHODS

Twenty hands (28 joints) from 18 DC patients underwent CCH injection with manipulation according to the product specifications with 2-year follow-up. Patients were assessed for extension deficit on treated metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joints before treatment, at 4 weeks and 2 years after the treatment.

RESULTS

At 4 weeks after CCH treatment, contracture of treated joints significantly improved from the mean extension deficit of 45° before treatment to 3° for MCP joints, and from 41° to 14° for PIP joints (P < 0.001, <0.001, respectively). Improved contracture was maintained with 4° and 23° at 2 years after CCH treatment (P < 0.001, <0.05, respectively). Successful correction defined as ≤ 5° extension deficit was obtained in 14/16 MCP and 5/12 PIP joints at 4 weeks; of these, 11 MCP and 1 PIP joints maintained the corrected range of motion at 2-year follow-up.

CONCLUSION

CCH treatment could be a useful option to improve contracture in Japanese patients. During 2-year follow-up, this treatment could provide comparable effect durability to previous studies from Western countries. Moreover, our results support the evidence that better correction of the contracture can be obtained in the MCP joints than PIP joints after CCH treatment.

Factors predicting the 1-year outcome of collagenase treatment for Dupuytren's disease

INTRODUCTION

Several studies have investigated the clinical outcome after collagenase treatment for Dupuytren's disease in terms of range of motion of the affected finger. However, good objective clinical outcome defined by a small remaining flexion contracture does not necessarily translate into satisfactory patient-subjective hand function. The aim of the present study was to identify predictors of patient-reported as well as objective clinical outcome in patients 1 year after collagenase treatment for Dupuytren's disease.

MATERIALS AND METHODS

Socio-demographic and disease-related data of 92 Dupuytren patients were collected prior to the intervention. Flexion contracture of the most affected finger was measured at baseline and 1 year after treatment. Patients also completed the brief Michigan Hand Outcomes Questionnaire (brief MHQ) before the intervention and at 1-year follow-up. First, univariate correlations using Pearson's correlation coefficient of the baseline variables with the two target variables were investigated. All variables with r > 0.35 were selected for a multivariate linear stepwise backwards regression model.

RESULTS

The mean brief MHQ score increased between baseline (72 ± 14) and the 1-year follow-up (85 ± 15) (p ≤ 0.001) and baseline flexion contracture decreased from 76° (± 26) to 33° (± 31) (p ≤ 0.001). Higher hand function at baseline (R² = 0.31) and less flexion contracture (R² = 0.46) were identified as positive predictors for the outcome 1 year after collagenase treatment for Dupuytren's disease. Other variables such as age, gender, manual work and if the MCP or PIP joint was affected did not determine outcome in our patient series.

CONCLUSIONS

Collagenase treatment resulted in considerable improvement in flexion contracture as well as patient-reported hand function at the 1-year follow-up. Clinicians can expect better outcome after collagenase infiltration in patients with less flexion contracture and in patients showing good initial self-reported hand function.

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.

One year follow-up after treatment with CCH for Dupuytren's disease: A prospective view

Aim Clostridium histolyticum collagenase (CCH) is nowadays an alternative treatment for the contracture of Dupuytren. Our objective is to assess its effectiveness at one year in a series of consecutive patients.

MATERIAL AND METHOD

Prospective study with minimum follow-up of one year. Evaluation of results and adverse effects.

RESULTS

A total of 75 joints treated in 51 patients were included. The average age was 65.18years (SD: 7.288) and 82.7% were males. The initial mean contraction of the MCP was 34.0 degrees (SD: 27.37), PIP 41.5 degrees (SD: 31.33) and combined impairment (MCF+IFP) of 75.5 degrees (SD: 35.2). Efficacy was achieved in 68 patients (90.7%). Adverse effects were mild and self-limiting. The mean correction for the MCP joint was 28.96 degrees (SD: 26.90) and for PIP it was 28.72 degrees (SD: 24.30). The recurrence rate was 18 (24.0%) joints in 14 patients, being more frequent in severe cases. QuickDASH score showed minimal differences measured before the intervention and once a year.

DISCUSSION

Our results show a better outcome in mild cases; the outcome was more favourable and with a higher success rate in the MCP joint. QuickDASH score is not a useful tool for the assessment of Dupuytren's contracture.

CONCLUSIONS

Treatment with CCH for Dupuytren's contracture is an effective treatment in the medium term. It has a poorer outcome in combined joint disorders, 5th finger, PIP and severe cases.