MMP-1, MMP-8, and MMP-13 Gene Polymorphisms and Haplotype Is a Risk Factor for Dupuytren Contracture: A Case-Control Study

BACKGROUND

There is an increased tissue expression of matrix metalloproteinases (MMPs) on Dupuytren contracture (DC). Genetic polymorphisms (single nucleotide polymorphism [SNPs]) in genes of these enzymes may individually influence these transcriptions. Haplotype analysis, which is the observation of a group of alleles, could be more useful to identify the association between SNPs and DC. The purpose of this study was to evaluate the influence of MMP-1 g.-1607 G>GG (rs1799750), MMP-8 g.-799 C>T (rs11225395), and MMP-13 g.-77 A>G (rs2252070) SNPs individually and in haplotype on DC.

METHODS

A total of 60 patients with a clinical diagnosis of DC were evaluated and matched, according to age and gender, with the control group of 100 patients without this clinical diagnosis. Genomic DNA was extracted from saliva samples, and genotypes were obtained by polymerase chain reaction-restriction fragment length polymorphism. Statistical analysis of the results included Mann-Whitney U test, Chi-squared test, and PHASE and R software, with a significance level of 5%.

RESULTS

The 3 SNPs studied showed significant differences in allele and genotype frequencies between the groups: 2G in MMP-1 (P = .018; odds ratio [OR] 1.80 (95% confidence interval [CI], 1.13-2.88)), T in MMP-8 (P = .015; OR 0.53 (95% CI, 0.33-0.88)), and A in MMP-13 (rs2252070) SNPs (P = .040, OR 0.54 (95% CI, 0.33-0.90)) are risk alleles. The global haplotype analysis indicated a significant difference between both groups.

CONCLUSIONS

In conclusion, MMP-1 g.-1607 G>GG (rs1799750), MMP-8 g.-799 C>T (rs11225395), and MMP-13 g.-77 A>G (rs2252070) SNPs, individually and in haplotype, are a risk factor for DC, indicating that these SNPs may be a potential diagnostic and prognostic factor for DC.

Repeated percutaneous needle fasciotomy for recurrent Dupuytren's disease

Percutaneous needle fasciotomy (PNF) is an attractive option for repeated application for recurrence. We found that extension deficit correction was similar after a first, second and third PNF, though the interval between treatments was longer after a first versus second PNF.

Collagenase Treatment for Dupuytren Contracture of the Metacarpophalangeal Joint After Arthrodesis of the Proximal Interphalangeal Joint

Successful collagenase (Xiaflex) treatment of Dupuytren's contracture in the metacarpophalangeal joint is possible in the presence of previous arthrodesis of the proximal interphalangeal joint.

Surgical Trigger Finger Release Is Associated With New-Onset Dupuytren Contracture in the Short-Term Postoperative Period: A Matched Analysis

BACKGROUND

This article compares the rates and time-to-development of new-onset Dupuytren disease in patients with trigger finger treated by steroid injection, surgical release, or both.

METHODS

PearlDiver's Mariner 30 database was queried to identify patients with trigger finger between January 2010 and June 2019. One-to-one exact matching based on baseline patient demographics allowed us to create 4 identical groups defined by the type of trigger finger intervention received.

RESULTS

The matched population analyzed in this study consisted of 85 944 patients who were equally represented in the steroid injection cohort (n = 21 486, 25.00%), surgical release cohort (n = 21 486, 25.00%), steroids prior to surgery cohort (n = 21 486, 25.00%), and no intervention (control) cohort (n = 21 486, 25.00%). A new Dupuytren diagnosis after trigger finger treatment occurred in 1 in 128 patients overall, 1 in 156 patients treated with steroid injection, and 1 in 126 patients treated with surgical release. Trigger fingers treated by steroid injection only had the lowest rates of Dupuytren disease overall (n = 137, 0.64%, P = .0424) and treatment with fasciectomy (n = 14, 0.07%, P < .0005). In all, 171 patients in the surgery cohort developed Dupuytren disease 1 year after undergoing surgical trigger finger release. Furthermore, this cohort had the highest rates of fasciectomy (n = 55, 0.26%, P < .0005) and the lowest rates of no intervention (n = 103, 0.48%, P = .0471). Trigger fingers managed by surgical release developed Dupuytren disease (mean, 56.11 days; SD, 80.93 days, log-rank P = .02) and underwent fasciectomy (mean, 49.74 days; SD, 62.27 days; log-rank P < .0005) more quickly than all other cohorts.

CONCLUSIONS

Patients solely undergoing surgical release of their trigger finger had significantly higher odds and expedited rate of developing new-onset Dupuytren disease overall and undergoing subsequent treatment by fasciectomy compared with trigger fingers managed by other interventions.

Let's Focus on the Fibrosis in Dupuytren Disease: Cell Communication Network Factor 2 as a Novel Target

Dupuytren disease is a progressive, benign fibroproliferative disorder of the hands that can lead to debilitating hand contractures. Once symptomatic, treatment involves either surgical intervention, specifically fasciectomy or percutaneous needle aponeurotomy, or enzymatic degradation with clostridial collagenase. Currently, collagenase is the only pharmacotherapy that has been approved for the treatment of Dupuytren contracture. There is a need for a pharmacotherapeutic that can be administered to limit disease progression and prevent recurrence after treatment. Targeting the underlying fibrotic pathophysiology is critical. We propose a novel target to be considered in Dupuytren disease-cell communication network factor 2/connective tissue growth factor-an established mediator of musculoskeletal tissue fibrosis.

The Lambda Cord: An Anatomic Configuration of Radial-Sided Dupuytren Disease

The thumb and first webspace are involved in a relatively low proportion of cases of Dupuytren disease of the hand (3%-28%). Given the rarity, there has been a paucity of literature regarding anatomic cord configurations and the surgical technique for the management of such radial-sided diseases. There are unique anatomic considerations in the thumb that warrant understanding prior to safe surgical exploration. A case of an anatomic variant of Dupuytren disease involving the thumb and first webspace treated with a webspace skin-sparing partial fasciectomy is described. The current literature regarding surgical management of Dupuytren disease affecting the thumb and first webspace is also briefly presented.

Perioperative Complications Associated With Limited Surgical Fasciectomy After Collagenase Clostridium Histolyticum for Dupuytren Contracture

BACKGROUND

The purpose of this study was to determine the perioperative complication rate of surgical fasciectomy following previous treatment with collagenase clostridium histolyticum (CCH) treatment in patients with Dupuytren disease.

METHODS

A retrospective review of all patients at a large health system undergoing CCH treatment and subsequent limited surgical fasciectomy for recurrence on the same digit between 2010 and 2020 was performed. Fifty-two patients with 62 affected digits met inclusion criteria, and cases were reviewed for preoperative demographics, treatment characteristics, clinical outcomes, and perioperative complications.

RESULTS

Fifty-five digits in 48 patients were treated with CCH and underwent subsequent limited surgical fasciectomy. Of all digits in the present study, 3 (6.3%) had a documented surgical complication following open surgical fasciectomy. There were zero postoperative infections, vascular injuries, or tendon injuries. The rate of nerve injury was 2.1%. The rate of postoperative skin necrosis was 4.2%. These rates were comparable or lower than those of historical published data.

CONCLUSIONS

The rate of perioperative complications in patients undergoing limited surgical fasciectomy after previous CCH treatment is low. The findings of this study will aid the counseling of Dupuytren patients in deciding whether to pursue treatment with CCH versus open surgical fasciectomy.

Modeling and concepts of the Malingue plasty compared to Z-plasty

Malingue's diamond-shaped skin plasty is a random skin plasty derived from the Z-plasty. Not widely known, this technique is an alternative to fasciectomy in Dupuytren's disease. The main objective of the present study was to analyze the topographical and anatomical differences between Z-plasty and Malingue plasty in cadaveric and experimental models and the geometrical and mathematical differences in modeling, in order to determine the respective gains in length. The study was carried out in two steps. An anatomical step on a cadaveric model studied vascularization. The second step was based on inert models (latex gloves) and cadaveric models, to study the mechanical behavior of the flaps. Differences in gains in length were analyzed by Euclidean and non-Euclidean geometry. The Malingue plasty flaps showed greater vascular richness than in Z-plasty. The experimental cadaver and inert material models showed 50% length gain with a single Malingue plasty, versus 33.3% with Z-plasty. The gain decreased in multiple plasties: respectively, 25% and 17.5% with double plasty and 20% and 16.7% with triple plasty. The analysis of Euclidean plane geometry did not explain these results, whereas 3D analysis on non-Euclidean geometry can explain a superior elongation effect in the Malingue plasty. The Malingue plasty could be an interesting option when significant lengthening is required, especially when Z-plasty would be insufficient.

The Ability of Patients to Provide Standardized, Patient-Taken Photographs for the Remote Assessment of Dupuytren Disease

BACKGROUND

Clinical goniometry for the assessment of contracture in Dupuytren disease is time-consuming and costly, and there is no universal method for evaluating the severity of the disease. This study aims to evaluate the feasibility of patient-taken photography for the remote assessment of Dupuytren disease.

METHODS

Patients at our unit were provided with instructions on how to take standardized photographs of their diseased hand(s), which were subsequently analyzed by computer software to obtain formal measurements of the severity of disease. Compliance with photography instructions and ability to provide a photo of sufficient quality for analysis were measured.

RESULTS

In all, 222 patients supplied photos for analysis; 158 patients (71.2%) were able to take the photographs as instructed. The remaining 28.8% took 1 or more of the images incorrectly or of insufficient quality. There were no statistically significant differences between those able to take the photos as directly versus those who took the photos incorrectly when compared by sex, age, or severity of disease.

CONCLUSIONS

Patient-taken photography used to estimate disease severity in Dupuytren disease is an achievable, efficient, and reliable method of remotely assessing and monitoring patients and may be increasingly useful given the current health care climate and preference for remote consultations.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Routine Pathological Examination of Clinically Presumed Dupuytren Disease: Does It Add Value?

BACKGROUND

In surgery for Dupuytren disease (DD), palmar fascia specimens are routinely submitted for pathological evaluation. The purpose of this study was to determine the rate of discordant diagnosis and the value of, and costs associated with, routine pathological analysis of palmar fascia tissue extracted in surgery for clinically diagnosed DD.

METHODS

All pathology reports for in-house palmar fascia specimens obtained in surgery for clinically diagnosed DD (time period: January 2001 to December 2020) were retrieved from one academic institution. All specimens were classified by a hierarchical free-text string matching algorithm (HFTSMA) and searched for evidence of malignancy. The primary outcome was percentage of concordant, discrepant, and discordant diagnoses. Secondary outcomes included anatomical location and costs. The HFTSMA was used to capture the anatomical location. Costs included professional, laboratory processing, and ancillary fees based on the Ontario Schedule of Benefits.

RESULTS

The search retrieved 1323 pathology reports, with 1480 palmar fascia specimens, from 1078 individual patients. By diagnosis, 96.1% of specimens (1422/1480) were concordant (fibromatosis), 3.9% (58/1480) were discrepant (scarring/fibrosis, benign fascia/connective tissue, or other benign findings), and 0% (0/1480) were discordant. The most common location was ring finger (n = 381, 48.7%). Ancillary testing was minimal. The cost per palmar fascia specimen was estimated to be CAD $34.57. The institutional costs were approximately CAD $2558.18/year.

CONCLUSIONS

Routine pathological examination of specimens in cases of clinically diagnosed DD does not yield additional clinically important findings and may not warrant their costs.

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.

A role for metformin in the treatment of Dupuytren disease?

Dupuytren disease (DD) is a hand-localized fibrotic disorder characterized by a scar-like, collagen-rich cord. Treatment usually comprises surgical removal of the cord, but is associated with a high relapse rate, in some cases requiring finger amputation. There is currently no consensual medical approach for treating DD. Numerous preclinical studies have highlighted antifibrotic properties of metformin, and the aim of this study was to assess a potential antifibrotic role of metformin in DD. Fibroblasts from DD cords (DF) and phenotypically normal palmar fascia (PF) were extracted from surgical specimens and cultured. The fibrotic status of DF and PF was compared at baseline, and under profibrotic (TGF-β stimulation) and antifibrotic (metformin stimulation) conditions, using quantitative RT-PCR, western blot, immunocytochemistry, and a functional fibroblast contraction assay. At baseline, DF showed higher levels of fibrotic markers and contraction capacity compared with PF. Both types of fibroblasts responded to TGF-β stimulation. Treatment of DF and PF with metformin did not affect basal levels of fibrotic markers and contraction but largely prevented their induction by TGF-β. In conclusion, our data show that metformin inhibits TGF-β-induced expression of fibrotic markers and contraction in hand-derived fibroblasts. This supports the case for a clinical trial to assess the repurposing of metformin as an adjuvant to surgery, to prevent, reduce, or delay recurrence in at-risk DD patients.

Patient Preferences for Limited Fasciectomy Versus Collagenase Treatment for Dupuytren Contracture

Background: The primary objective of this study was to assess patient preferences for collagenase Clostridium histolyticum (CCH) treatment versus limited surgical fasciectomy in a cohort that has undergone both treatments for Dupuytren contracture. Methods: We retrospectively identified 68 patients who have undergone both limited surgical fasciectomy and CCH treatment for digital flexion contractures from Dupuytren disease. Patients were contacted by telephone and asked whether they preferred surgery or CCH treatment for their Dupuytren contracture. Multivariable logistic regression was used to determine factors associated with preference for surgery versus CCH treatment. Results: Of the 68 patients who were treated with both CCH and surgery, 37 patients (54.4%) preferred CCH treatment over surgery, 26 (38.2%) preferred surgery over CCH treatment, and 5 (7.4%) were unable to decide. Patients expressed common themes of the perceived ease of recovery following CCH treatment versus the perceived durability of contracture correction with surgery. Preference for surgical fasciectomy over CCH treatment was associated with lower American Society of Anesthesiologists Physical Status Classification (ASA) [odds ratio (OR): 0.32, 95% confidence interval (CI): 0.14-0.75]. The order of treatment was also associated with the treatment preference; treatment with surgery after CCH compared to treatment with CCH after surgery was associated with a preference for surgery (OR: 6.51, 95% CI: 2.15-19.7). Conclusions: In a cohort of patients who have undergone both treatments, patients were divided in their preferences, with a slight majority preferring CCH treatment over surgery. Treatment recommendations should be individualised to each patient's long-term goals and expectations. Level of Evidence: Level III (Therapeutic).

Five-Year Results of a Randomized, Controlled Trial of Collagenase Treatment Compared With Needle Fasciotomy for Dupuytren Contracture

PURPOSE

Over the past decade, collagenase treatment and needle fasciotomy (NF) have gained widespread popularity in the treatment of Dupuytren contracture. This prospective study was designed to compare the results of these treatments in terms of clinical and patient-reported outcomes.

METHODS

A prospective, randomized, controlled trial included patients with a contracture of 20° or more in a single metacarpophalangeal joint. Patients were allocated to treatment with either NF or collagenase Clostridium histolyticum. The primary outcome was a reduction in the metacarpophalangeal joint contracture to less than 5°. Secondary outcomes included recurrence, the presence of Dupuytren cords, and changes in patient-reported outcomes. The participants were examined 5 years after the intervention.

RESULTS

The study cohort comprised 156 patients divided into 2 equally sized groups. After 5 years, data were collected from 143 (92 %) of the initially enrolled participants. The mean time for the clinical follow-up was 5.1 years. In the remaining cohort without a second procedure, 51% (23 patients) in the collagenase Clostridium histolyticum group and 47% (27 patients) in the NF group still had extension deficits of less than 5°. Among the participants with a successful initial procedure, the recurrence rate was 56% (36 patients) in the collagenase Clostridium histolyticum group and 45% (30 patients) in the NF group. There were no differences between the 2 treatments in regard to passive joint extension, reduction of contracture, range of motion, or patient-reported outcomes.

CONCLUSIONS

The 5-year outcomes for NF are similar to those for collagenase in terms of sustained correction, recurrence, presence of Dupuytren cords, and patient-reported outcomes for the treatment of metacarpophalangeal joint contractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Dupuytren's contracture treated with botulinum toxin A injection

Dupuytren's contracture is a condition in which fibromatosis of the palmar and digital fascia can lead to painful contractures of the hand. Common conservative treatments are of limited efficacy, while invasive options have risk of adverse effects. A 57-year-old female presented with chronic, bilateral hand pain secondary to Dupuytren's contractures. Traditional conservative treatments did not provide relief. She received a series of three botulinum toxin A injections into the palmar fascia of both hands, resulting in four months of improved hand function and pain relief. This case presents a novel treatment for Dupuytren's contracture using botulinum toxin injection. Botulinum toxin has inhibitory effects on the neuromuscular junction and pain signaling pathways to relax muscles and reduce pain. We believe its action on this patient's intrinsic hand muscles resulted in her improved hand function. Botulinum toxin injection can be considered as a treatment option for Dupuytren's contracture.

Long-term Effects of Skin Tearing on Outcomes After Collagenase Treatment of Dupuytren Contractures

Background: The objective of this study was to compare the rates of recurrence, additional treatment, patient satisfaction, and willingness to undergo Clostridium histolyticum (CCH) treatment again for Dupuytren disease in patients with and without skin tearing at minimum 5-year follow-up. Methods: We identified 199 digits in 142 patients who underwent CCH treatments for Dupuytren disease from April 2010 to December 2013 with minimum 5-year follow-up. Patients were contacted by telephone to collect our response variables: perceived recurrence of contracture, additional treatment, satisfaction, and willingness to undergo CCH treatment again. Medical records were reviewed for skin tearing at manipulation and patient-related and disease-specific variables. Results: At the time of manipulation, 16 out of 142 patients (11%) and 22 out of 199 digits (11%) had skin tearing. Older age was associated with skin tearing. At an average 7.2-year follow-up, the mean satisfaction was 7.1 ± 2.6 on a 1 to 10 Likert scale for patients with skin tearing and 6.5 ± 3.4 for patients without skin tearing. Eighty-one percent of patients with skin tearing expressed willingness to undergo CCH treatment again, compared with 68% of patients without skin tearing. Perceived recurrence of contracture occurred in 82% of digits with skin tearing and 80% of digits without skin tearing. Additional treatment was performed in 45% of digits with skin tearing and 54% of digits without skin tearing. No difference was statistically significant. Conclusions: Although skin tearing at CCH manipulation complicates the short-term course following CCH treatment, it does not affect long-term perceived contracture recurrence or patient satisfaction.

Magnetic resonance imaging of diffusion characteristics following collagenase clostridium histolyticum injection in Dupuytren's contracture

PurposeWe aimed to evaluate the extent of collagenase clostridium histolyticum (CCH) diffusion in Dupuytren's contracture (DC) for tissues outside of the contracture cord using Magnetic Resonance Imaging (MRI) immediately after CCH injection. Methods: 10 male patients aged 57-79 with DC of the metacarpophalangeal (MCP) joints were examined. Extension deficits were 10-60°(mean, 34.3) and 0-60°(mean, 26.6) in the MCP and proximal interphalangeal (PIP) joints, respectively. CCH injection was performed according to the standard method. MRI was performed within 15 min of CCH injection. Results: In all 10 cases, the extended area of high-intensity signal change outside of the cord was observed on short-T1 inversion recovery images (STIRs). Continuity from the insertion site was observed in the area of signal change involving the flexor tendon and neurovascular bundle. The signal change area spanned distally and proximally beyond the injection level. The signal change area expanded along the tendon sheath but no signal changes were observed inside the flexor tendon, suggesting the tendon sheath serves as a protective barrier from the CCH solution. After 1 week of injection, the mean decrease in contracture was 32.5°(94.7%) for the MCP joint and 19.8°(74.4%) for the PIP joint. In nine out of 10 cases, the extension deficit was within five degrees of full extension in the affected finger. There was no neurovascular injury or tendon rupture at 3 months of observation. Conclusions: MRI indicated the possible leakage of the drug outside of the cord during the early phase after administration, suggesting that CCH could persistently affect healthy tissues until CCH inactivates its enzyme process.

Limited Fasciectomy Versus Collagenase Clostridium histolyticum for Dupuytren Contracture: A Propensity Score Matched Study of Single Digit Treatment With Minimum 5 Years of Telephone Follow-Up

PURPOSE

The purpose of this study was to compare reintervention and perceived recurrence, with minimum 5 years of telephone follow-up, after limited fasciectomy or collagenase Clostridium histolyticum (CCH) in the treatment of Dupuytren contracture affecting a single digit.

METHODS

We performed a retrospective cohort study of 48 patients with single digit treatment who underwent limited surgical fasciectomy at one hospital and 111 patients who underwent CCH treatment at a second hospital from 2010 to 2013. Patients were contacted by telephone about reintervention and perceived recurrence. Average length of telephone follow-up was 7.3 years in the CCH group and 7.4 years in the surgery group. The 2 groups were compared using 2 methods to control for potential confounding bias: (1) propensity score matching and (2) multivariable analysis accounting for potential confounders.

RESULTS

After propensity score matching, there were 44 patients in each group with similar disease and demographic characteristics. Rates of reintervention and perceived recurrence were significantly higher in the CCH group than the surgery group at a minimum of 5 years following treatment.

CONCLUSIONS

Long-term overall reintervention and perceived recurrence following treatment of Dupuytren contracture affecting a single digit were higher with CCH treatment than surgical fasciectomy when comparing groups with similar baseline characteristics. Our findings may be used to counsel patients on the durability of the outcomes of treatment when considering treatment options for Dupuytren contractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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

STUDY DESIGN

Qualitative descriptive.

INTRODUCTION

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

PURPOSE OF THE STUDY

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

METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSIONS

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

Minimally Invasive Treatments of Dupuytren Disease: An Overview

Dupuytren disease (DD) is a fibroproliferative disorder that originates at the palmar fascia and results in flexion contracture of the digits. The gold standard treatment for DD has been surgery. Surgical treatment of DD can be done with various methods, from percutaneous needle fasciotomy to dermatofasciectomy. The most commonly used surgical treatment is limited fasciectomy (LF). The potential complications of limited fasciectomy include long recovery time, scarring, neurovascular injury, and tendon injury. Minimally invasive treatment for DD, which is simple and allows for rapid return of function, has gained popularity amongst both patients and surgeons. Currently, minimally invasive treatments for DD include percutaneous needle fasciotomy (PNF) and collagenase clostridium histolyticum (CCH). In this review, we provide an overview of the minimally invasive treatments for Dupuytren disease and summarize the current evidence regarding these minimally invasive treatments.

Limited progression of subclinical Dupuytren's disease

AIMS

With novel promising therapies potentially limiting progression of Dupuytren's disease (DD), better patient stratification is needed. We aimed to quantify DD development and progression after seven years in a population-based cohort, and to identify factors predictive of disease development or progression.

METHODS

All surviving participants from our previous prevalence study were invited to participate in the current prospective cohort study. Participants were examined for presence of DD and Iselin's classification was applied. They were asked to complete comprehensive questionnaires. Disease progression was defined as advancement to a further Iselin stage or surgery. Potential predictive factors were assessed using multivariable regression analyses. Of 763 participants in our original study, 398 were available for further investigation seven years later.

RESULTS

We identified 143/398 (35.9%) participants with DD, of whom 56 (39.2%) were newly diagnosed. Overall, 20/93 (21.5%) previously affected participants had disease progression, while 6/93 (6.5%) patients showed disease regression. Disease progression occurred more often in patients who initially had advanced disease. Multivariable regression analyses revealed that both ectopic lesions and a positive family history of DD are independent predictors of disease progression. Previous hand injury predicts development of DD.

CONCLUSION

Disease progression occurred in 21.5% of DD patients in our study. The higher the initial disease stage, the greater the proportion of participants who had disease progression at follow-up. Both ectopic lesions and a positive family history of DD predict disease progression. These patient-specific factors may be used to identify patients who might benefit from treatment that prevents progression. Cite this article: Bone Joint J 2021;103-B(4):704-710.

A Rare Finding in Dupuytren's Disease - Heterotopic Ossification

We present the case of a severe and long-standing Dupuytren's contracture where intraoperatively an ossified nodule was encountered within the diseased tissue. Histologically palmar fibromatosis in contact with cartilaginous tissue with central ossification could be confirmed, compatible with metaplasia. Our finding suggests that metaplastic activity inherent to longstanding, severely diseased Dupuytren's tissue can lead to heterotopic ossification.

Vibrotactile perception in Dupuytren disease

PURPOSE

Dupuytren disease (DD) has been associated with enlarged Pacinian corpuscles (PCs) and with PCs having a greater number of lamellae. Based on these associations, we hypothesized that subjects with DD would have altered sensitivity to high-frequency vibrations and that the changes would be more prominent at 250 Hz, where healthy subjects demonstrate the highest sensitivity.

METHODS

A novel device was created to deliver vibrations of specific frequencies and amplitudes to the fingers and palm. Using a Psi-marginal adaptive algorithm, vibrotactile perception thresholds (VPTs) were determined in 36 subjects with DD and 74 subjects without DD. Experiments were performed at 250 Hz and 500 Hz at the fingertip and palm. The VPTs were statistically analyzed with respect to disease status, age, gender, location tested, and frequency tested.

RESULTS

We found that VPT increases with age, which agrees with findings by others. Women showed greater sensitivity (i.e. lower VPT) than men. Men exhibited lower sensitivity in DD versus healthy subjects, but the results were not statistically significant. In subjects with DD presenting unilaterally, the unaffected hand was more sensitive than the affected hand, in particular for a 250 Hz stimulus applied to the finger.

CONCLUSIONS

The data on vibration sensitivity obtained from a large group of subjects with and without DD present interesting trends that may serve as a useful reference to future DD researchers. Understanding additional symptoms of DD may facilitate development of novel diagnostic or prognostic protocols.

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.

Office-Based Percutaneous Fasciotomy for Dupuytren Contracture

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

Reliability and Interpretability of Sonographic Measurements of Palmar Dupuytren Nodules

PURPOSE

In the future, it is expected that treatment of Dupuytren disease (DD) may shift toward control of early disease. Ultrasound might be an accurate method to measure the outcome of such treatment. The aim of this study was to assess the reliability of sonographic measurement of palmar nodules.

METHODS

Fifty patients with nodules characteristic for early disease were assessed with ultrasound by 2 observers. Four different aspects of DD nodules were measured in the transversal and sagittal planes, width, depth, circumference, and area. The intra- and interobserver reliabilities were calculated using the intraclass correlation coefficient (ICC). The standard error of measurement (SEM) and the smallest detectable change (SDC) were also calculated for each aspect.

RESULTS

The intraobserver reliability was good (ICC, 0.724 [0.562-0.833] to 0.886 [0.808-0.934]), except for width in the sagittal direction (ICC, 0.671 [0.484-0.799]). The interobserver reliability was moderate (ICC, 0.385 [0.126-0.596] to 0.757 [0.538-0.869]). The intraobserver ICCs of area were highest (transverse, 0.847 [0.744-0.893]; sagittal, 0.886 [0.808-0.934]). The SEM and SDC of area were 6.1 and 16.9 mm² in the transverse and 8.0 and 22.2 mm² in the sagittal plane.

CONCLUSIONS

The intraobserver reliability of sonographic assessment of DD nodules is good. The measurement of area is the most reliable and is, therefore, recommended for future studies. However, even single-observer measurements have a clear dispersion, and a change beyond 16.9 (61%) and 22.2 mm² (79%) has to be observed in the transverse and sagittal planes, respectively, before it can be considered as regression or progression.

CLINICAL RELEVANCE

Repeated ultrasonographic measurements in DD should ideally be done by a single observer, using area of the nodule in the sagittal plane. Change beyond 16.9 (transverse) and 22.2 (sagittal) mm2 can be considered as a real change in nodule size.

Risk Factors for Skin Tearing in Collagenase Treatment of Dupuytren Contractures

PURPOSE

To determine factors associated with skin tearing at the time of manipulation in patients undergoing collagenase Clostridium histolyticum (CCH) treatment for Dupuytren contractures.

METHODS

We identified 368 digits in 261 patients who underwent a total of 469 CCH treatments at a tertiary care referral center from April, 2010 to December, 2013. Medical records were reviewed for the primary outcome, skin tearing at manipulation. Patient-related and disease-specific explanatory variables were collected. We used bivariate analysis to screen for risk factors and multivariable logistic regression to determine associated risk factors for skin tearing.

RESULTS

The overall rate of skin tearing with CCH treatment was 12%. Multivariable logistic regression analysis showed older age (odds ratio = 1.04; 95% confidence interval, 1.00-1.07) and amount of contracture correction (odds ratio = 1.02; 95% confidence interval, 1.01-1.04) to be associated with skin tearing at manipulation.

CONCLUSIONS

A 10-year increase in age results in a 1.5 times increase in the odds of skin tearing. A 30° increase in contracture correction results in a 1.8 times increase in the odds of skin tearing. Patients can be counseled before CCH treatment that older age and increased contracture correction are risk factors for this common complication.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

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.

Imaging for Dupuytren disease: a systematic review of the literature

BACKGROUND

As treatment of Dupuytren disease (DD) is expected to shift towards prevention of progression, the use of imaging in patients with DD becomes more important. In this systematic review an overview is given of the different methods for and applications of imaging for DD that have been described.

METHODS

The MEDLINE and EMBASE databases were searched for articles reporting the use of imaging in patients with DD, published before May 17, 2018. Studies were systematically examined in two rounds by two observers according to the PRISMA systematic. All studies containing original data on imaging for DD were considered for inclusion.

RESULTS

Three hundred and seven unique studies were identified, of which 23 were included in the study. Only studies on the use of ultrasound (US) and magnetic resonance imaging (MRI) were identified. Broadly, articles could be divided into 5 categories. Seven studies were found on diagnosis, two on measurement of disease extent, four on measurement of disease activity, seven on guidance of minimally invasive procedures and five studies on evaluation of treatment. According to the Oxford CEBM, the levels of evidence were low, ranging from level 3 to 5.

CONCLUSIONS

A variety of applications for US and MRI for patients with DD has been described. Based on the results of this review, the largest value for imaging lies in the measurement of disease activity and the follow-up of treatment of patients with early stage disease. Unfortunately, the overall level of evidence of the available literature was low. Future research is necessary to define the exact value of US and MRI in the management of patients with DD.

Grayson Ligament: A Revised Description of its Anatomy and Function

PURPOSE

Grayson ligament has been described as a common pathway for digital contracture in Dupuytren disease. Its anatomical descriptions in the literature are, however, inconsistent.

METHODS

We have performed a microsurgical dissection study in 20 fresh-frozen and thawed digits to revisit the anatomy of Grayson ligaments. We also performed dissections in Thiel-preserved hands to be able to study the changes in tension of the ligaments during flexion and extension of the finger.

RESULTS

We found the ligaments originally described by Grayson to be the best developed part of a trabecular network of fibers, originating in continuity with the outer adventitial layer of the flexor tendon sheath and running toward their insertions into the skin in multiple planes, all volar to the neurovascular bundle. The most dorsal fibers, which cover the neurovascular bundles, form a chevron shape with its midline apex pointing distally in an extended finger. During flexion, the fibers become more transversely oriented.

CONCLUSIONS

We found Grayson ligament comprises a trabecular network of fibers, instead of a ligament, with a dynamic fiber orientation on the volar side of the finger. The main function of this network of fibers seems to be the stabilization of the skin and fat pad in digit extension while the relaxation in flexion allows the skin and volar fat pad to adapt optimally to the form of the object that is held.

CLINICAL RELEVANCE

The new insights in the anatomy of Grayson trabecular network of fibers may be of importance in the understanding of the pathological anatomy of Dupuytren disease.

Ultrasound Features of Palmar Fibromatosis or Dupuytren Contracture

OBJECTIVES

To retrospectively characterize the ultrasound appearance of palmar fibromatosis in patients with a surgical or clinical diagnosis of palmar fibromatosis.

METHODS

A search of ultrasound reports from 2005 to 2015 and a subsequent search of medical records were performed to identify patients with a surgical or clinical diagnosis of palmar fibromatosis. The ultrasound images were retrospectively reviewed to record the lesion location, size, echogenicity, compressibility, hyperemia, and calcification.

RESULTS

A total of 36 patients were identified (average age, 60 years; 61% male), yielding a total of 55 palmar fibromatosis lesions, of which 2%, 7%, 29%, 36%, 20%, and 5% were located at the first, second, third, fourth, and fifth digits and between the fourth and fifth digits, respectively. The lesions were located directly superficial to the flexor tendons in 93% with their epicenters at the distal metacarpal in 89%. Average lesion dimensions were 13.1 mm in length, 6.8 mm in width, and 2.5 mm in depth. On ultrasound images, the lesions were characteristically hypoechoic (98%) and noncompressible (95%). Atypical features included calcification (2%), compressibility (5%), hyperemia on color Doppler images (6%), epicenters at the metacarpophalangeal joint (7%) or proximal phalanx (4%), and location superficial but lateral to the flexor tendons (7%).

CONCLUSIONS

Palmar fibromatosis most commonly appears hypoechoic and is located directly superficial to the flexor tendons with an epicenter at the distal metacarpal, most commonly the fourth digit. However, the epicenter location may be at the distal metacarpal and proximal phalanx of other digits, adjacent to the flexor tendons, with possible hyperemia and calcification.

3-Dimensional fasciectomy: A highly efficacious common ground approach to Dupuytren's surgery

BACKGROUND

Numerous Dupuytren's fasciectomy techniques have been described, each associated with unique surgical challenges, complications and recurrence rates. We describe a common ground surgical approach to Dupuytren's disease; 3-dimensional fasciectomy (3DF). 3DF aims to address the potential contributors to the high recurrence rate of Dupuytren's disease and unite current limited fasciectomy practice that varies considerably between surgeons.

METHODS

We describe the 3DF principles; raising thin skin flaps (addressing dermal involvement), excising diseased palmar fascia with a 3-5 mm clearance margin (treating highly locally recurrent conditions) and excising the vertical septae of Legueu and Juvara (providing deep clearance, hence addressing all potentially involved pathological tissue). The surgical outcomes between traditional limited fasciectomy (LF) and 3DF are compared.

RESULTS

From the 786 operations included (n=585), postoperative recurrence rates were significantly lower for the 3DF group (2/145, 1.4%) than the LF group (72/641, 11.2%) (P=0.001), and the time to recurrence was significantly longer (5.0±0 years vs. 4.0±0.2 years; P<0.0001). With recurrence excluded, there were no differences between the postoperative complication rates for 3DF (5/145, 3.5%) and LF (41/641, 6.4%) (P=0.4).

CONCLUSIONS

Our results suggest that 3DF leads to lower recurrence rates and a longer disease-free period for patients, without increasing complications. 3DF provides a safe, efficacious, common ground surgical approach in the treatment of Dupuytren's flexion deformity.

Collagenase Clostridium Histolyticum Injection with Precise Needle Length Adjusted by Silicone Tube Interposition for Dupuytren Contracture

We describe our injection method for Collagenase Clostridium Histolyticum using a medical silicone tube after determining the optimal depth by ultrasonography. This procedure adjusts the exposed needle length to the planned injection depth by placing a sterilized silicone tube over the needle. The restricted depth provides not only precise injection into the middle of the cords but also avoids needle tip migration through the cord and into the vital structures, which prevents possible complications. This method is safe and simple.

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.

A post hoc analysis of Dupuytren contracture treated with collagenase Clostridium histolyticum across disease stages

This post hoc analysis from a multicenter study (NCT01674634) was designed to evaluate the efficacy of collagenase Clostridium histolyticum (CCH) treatment in patients with different stages of Dupuytren contracture. Previously untreated patients who received two concurrent injections of CCH in two affected joints in the same finger were assessed by disease severity (Tubiana stage). The mean (SD) improvement in total fixed flexion contraction (FFC) 31 days post-CCH treatment in 181 patients was: 71.1 (36.5)% for Tubiana I, 77.0 (21.0)% for Tubiana II, 72.0 (20.4)% for Tubiana III and 66.4 (22.2)% for Tubiana IV. Treatment of metacarpophalangeal and proximal interphalangeal joints in the same finger resulted in a mean (SD) improvement of 82.5 (24.8)% and 66.4 (27.9)%, respectively. In conclusion, CCH is an effective treatment alternative for all stages of Dupuytren contracture and it provides a less invasive treatment alternative to surgery with similar short-term efficacy in patients with more severe disease.

The Incidence of Complex Regional Pain Syndrome in Simultaneous Surgical Treatment of Carpal Tunnel Syndrome and Dupuytren Contracture

BACKGROUND

To determine the incidence of complex regional pain syndrome (CRPS) in the concurrent surgical treatment of Dupuytren contracture (DC) and carpal tunnel syndrome (CTS) through a thorough review of evidence available in the literature.

METHODS

The indices of 260 hand surgery books and PubMed were searched for concomitant references to DC and CTS. Studies were eligible for inclusion if they evaluated the outcome of patients treated with simultaneous fasciectomy or fasciotomy for DC and carpal tunnel release using CRPS as a complication of treatment. Of the literature reviewed, only 4 studies met the defined criteria for use in the study. Data from the 4 studies were pooled, and the incidence of recurrence and complications, specifically CRPS, was noted.

RESULTS

The rate of CRPS was found to be 10.4% in the simultaneous treatment group versus 4.1% in the fasciectomy-only group. This rate is nearly half the 8.3% rate of CRPS found in a randomized trial of patients undergoing carpal tunnel release.

CONCLUSIONS

Our analysis demonstrates a marginal increase in the occurrence of CRPS by adding the carpal tunnel release to patients in need of fasciectomy, contradicting the original reports demonstrating a much higher rate of CRPS. This indicates that no clear clinical risk is associated with simultaneous surgical treatment of DC and CTS. In some patients, simultaneous surgical management of DC and CTS can be accomplished safely with minimal increased risk of CRPS type 1.

[Minimally invasive treatment of Dupuytren's contracture by Pi needle percutaneous multi-segmental fasciotomy]

OBJECTIVE

To investigate the clinical efficacy of Pi needle percutaneous multi-segmental fasciotomy as a minimally invasive treatment for Dupuytren's contracture.

METHODS

Sixteen patients(25 fingers: 4 middle fingers, 12 ring fingers, 9 little fingers) were involved in the study, including 11 males and 5 females. There were 2 cases on both hands and 14 cases of single hand disease, including 8 cases of left hand and 6 cases of right hand. The age ranged from 48 to 79 years old, with a mean age of 58.5 years old. The duration of the disease ranged from 1 to 15 years, with a mean time of 5.5 years. There were 12 cases of physical labor, 4 cases of non physical labor, with no family history of palmar fascial contracture. There were 9 cases of tobacco and alcohol addicts, 6 cases with hypertension history, and 3 cases of diabetes mellitus. According to Meyerding classification, 1 case was stage 0, 1 case was stage I, 10 cases were stage II, 4 cases were stage III and 0 case was stage IV. The postoperative function of Dupuytren's contracture patients was evaluated according to Adam efficacy evaluation criteria.

RESULTS

The time of incision healing time ranged from 7 to 14 days, 10 days on average. The 3 fingers incision skin cracked 3 to 4 mm during the loosening process, and 14 days after dressing changed, no skin necrosis and wound infection complication occurred. After treatment, fascia contracture of 24 fingers completely or almost disappeared. Limited extension of metacarpophalangeal joint and interphalangeal joint ranged from 0 to 10 degrees, 22 fingers showed normal function of finger extension, 2 fingers had more than 75% elongation function, and 1 finger recurred. According to the evaluation of Adam evaluable standard of curative effect on the postoperative function of Dupuytrens's contracture: 22 fingers got an excellent result, 2 fingers good and 1 finger recurred. The patients were satisfied with the results of the treatment.

CONCLUSIONS

Pi needle percutaneous multi-segmental fasciotomy for the treatment of Dupuytren's contracture is a simple, minimally invasive and effective method.

Night Orthosis After Surgical Correction of Dupuytren Contractures: A Systematic Review

PURPOSE

To determine the role of night orthosis use after surgical correction of Dupuytren contracture.

METHODS

We searched MEDLINE, EMBASE, CINAHL, AMED, OTSeeker, and CENTRAL for articles published from inception of the databases to August 2015. Assessment was undertaken by 2 independent reviewers (O.A.S. and S.A.). Methodological quality of randomized controlled trials was assessed using the Cochrane risk of bias tool and the Newcastle-Ottawa instrument.

RESULTS

Seven studies met the standard for inclusion in this review. A total of 659 patients across these 7 studies were included in the analysis, with follow-up ranging from 3 to 72 months. None of the included studies assessed recurrence. The analysis revealed no significant improvement in range of motion of hand joints for patients who received a static night orthosis after Dupuytren surgery compared with patients without an orthosis. Similarly, no differences were found in patient-reported functional status across the 2 groups.

CONCLUSIONS

The current literature does not appear to support the use of static night orthosis in addition to hand therapy after surgical correction of Dupuytren contracture.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Efficacy and safety of collagenase clostridium histolyticum for Dupuytren disease nodules: a randomized controlled trial

Background

To determine the safety and efficacy of collagenase clostridium histolyticum (CCH) injection for the treatment of palmar Dupuytren disease nodules.

Methods

In this 8-week, double-blind trial, palpable palmar nodules on one hand of adults with Dupuytren disease were selected for treatment. Patients were randomly assigned using an interactive web response system to receive a dose of 0.25 mg, 0.40 mg, or 0.60 mg (1:1:1 ratio) and then allocated to active treatment (CCH) or placebo (4:1 ratio). All patients and investigators were blinded to treatment. One injection was made in the selected nodule on Day 1. Caliper measurements of nodule length and width were performed at screening and at Weeks 4 and 8. Investigator-reported nodular consistency and hardness were evaluated at baseline and Weeks 1, 4, and 8. Investigator-rated patient improvement (1 [very much improved] to 7 [very much worse]) and patient satisfaction were assessed at study end.

Results

In the efficacy population (n = 74), percentage changes in area were significantly greater with CCH 0.40 mg (−80.1%, P = 0.0002) and CCH 0.60 mg (−78.2%, P = 0.0003), but not CCH 0.25 mg (−58.3%, P = 0.079), versus placebo (−42.2%) at post-treatment Week 8. Mean change in nodular consistency and hardness were significantly improved with CCH versus placebo at Weeks 4 and 8 (P ≤ 0.0139 for all). At Week 8, investigator global assessment of improvement was significantly greater with CCH 0.40 mg and 0.60 mg (P ≤ 0.0014) but not statistically significant with CCH 0.25 mg versus placebo (P = 0.13). Most patients were “very satisfied” or “quite satisfied” with CCH 0.40 mg and 0.60 mg. Contusion/bruising (50.0% to 59.1%) was the most common adverse event with CCH treatment.

Conclusion

In patients with Dupuytren disease, a single CCH injection significantly improved palmar nodule size and hardness. The safety of CCH was similar to that observed previously in patients with Dupuytren contracture.

Trial registration

ClinicalTrials.gov identifier: NCT02193828. Date of trial registration: July 2, 2014 to December 5, 2014

Injectable Collagenase Versus Percutaneous Needle Fasciotomy for Dupuytren Contracture in Proximal Interphalangeal Joints: A Randomized Controlled Trial

PURPOSE

Collagenase Clostridium histolyticum (CCH) injection was introduced commercially as a treatment for Dupuytren contracture following initial phase-3 investigations in 2009 with promising results. However, the efficacy of CCH has not been prospectively investigated in a direct comparison to other active treatments of Dupuytren contracture with more than 1-year follow-up, despite a wide and increasing clinical use.

METHOD

In this prospective, independent, open-label, randomized controlled trial, (Clinicaltrials.gov; NCT 01538017), percutaneous needle fasciotomy (PNF) was directly compared with CCH. Fifty patients with primary isolated proximal interphalangeal joint Dupuytren contractures were enrolled and followed for 2 years. The primary outcome was clinical improvement defined as a reduction in contracture by 50% or more relative to baseline. Secondary outcomes included change in contracture, recurrence, adverse events, complications, and Disabilities of the Arm, Shoulder, and Hand questionnaire score.

RESULTS

Clinical improvement at 2 years was maintained in 7% of CCH patients (2 of 29) and 29% of PNF patients (6 of 21). Collagenase Clostridium histolyticum led to more, mainly transient, complications, in 93% of patients versus 24% of the patients treated with PNF. No other differences were observed.

CONCLUSIONS

This study provides evidence that CCH is not superior to PNF in the treatment of isolated proximal interphalangeal joint Dupuytren contracture regarding clinical outcome, and it led to more complications than PNF.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Treatment of Recurrent Dupuytren Contracture in Joints Previously Effectively Treated With Collagenase Clostridium histolyticum

PURPOSE

Collagenase Clostridium histolyticum (CCH) is approved for the treatment of adults with Dupuytren contracture with a palpable cord. This open-label, phase 4 study evaluated the safety and efficacy of CCH for the retreatment of recurrent contractures in joints that were previously effectively treated with CCH.

METHODS

Patients participating in a long-term follow-up study who had contracture recurrence (increased ≥ 20° with a palpable cord) after successful treatment in the previous study were eligible. Recurrent joint contractures were treated with up to 3 CCH injections (∼ 1 month apart). Patients were followed for 1 year to evaluate safety. Assessments included change in joint contracture, range of motion, and the percentage of joints that achieved contracture of 5° or less at day 30 after the last injection.

RESULTS

The efficacy analysis included 51 patients with 1 treated joint per patient (31 metacarpophalangeal, 20 proximal interphalangeal). A total of 35 joints (69%) received 1 injection, 12 (24%) received 2 injections, and 4 (8%) received 3 injections. Fifty-seven percent of joints achieved contracture of 5° or less (29 of 51). Overall, 86% (43 of 50) patients had a 20° or greater increase in range of motion. The adverse event profile was consistent with previous studies. One ligament injury was reported.

CONCLUSIONS

At a short-term follow-up of 1 year, recurrent contracture in joints previously successfully treated with CCH may be effectively retreated with up to 3 injections of CCH.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Measurement Properties of the Brief Michigan Hand Outcomes Questionnaire in Patients With Dupuytren Contracture

PURPOSE

The brief Michigan Hand Outcomes Questionnaire (briefMHQ) was developed as a shorter version of the Michigan Hand Outcomes Questionnaire (MHQ), but its measurement properties have not been investigated in patients with Dupuytren contracture. The objective of the study was to investigate the reliability, validity, responsiveness, and interpretability of the briefMHQ.

METHODS

Fifty-seven patients diagnosed with Dupuytren contracture completed the briefMHQ as well as the full-length MHQ and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire at baseline. Two to 14 days after baseline and 1 year after collagenase injection or surgery, patients again filled out the briefMHQ. Reliability was determined using the intraclass correlation coefficient and by calculating internal consistency (Cronbach alpha). Validity was tested by quantifying correlations with the full-length MHQ and QuickDASH. Responsiveness, based on the standardized response mean and the minimally clinically important change, was also determined.

RESULTS

The briefMHQ had an intraclass correlation coefficient of 0.87, Cronbach alpha of 0.88, and correlations of r = 0.88 and -0.82 with the original MHQ and QuickDASH, respectively. The standardized response mean was 0.9 and the minimally clinically important change was 7 points.

CONCLUSIONS

Overall, the briefMHQ demonstrates excellent reliability, good validity, and high responsiveness in patients with Dupuytren contracture.

CLINICAL RELEVANCE

The briefMHQ is an accurate and time-saving tool to evaluate patients with Dupuytren contracture and the effect of a corresponding treatment.

Needle aponeurotomy for Dupuytren contracture: Effectiveness of postoperative night extension splinting

BACKGROUND

Night extension splinting has been used to treat patients with Dupuytren contracture to improve active range of motion (AROM) of the hand. A published case study demonstrated the benefit of splinting following needle aponeurotomy; however, no larger studies have evaluated the impact of postoperative splinting.

OBJECTIVES

To compare the impact of night extension splinting on AROM, specifically extension, following needle aponeurotomy for Dupuytren contracture.

METHODS

A retrospective chart review was conducted in which the charts of 53 patients who underwent needle aponeurotomy for Dupuytren contracture between 2009 and 2013 were reviewed. The control group consisted of patients who underwent needle aponeurotomy only, whereas the treatment group was also referred for fabrication of custom night extension splints after surgery. Comparisons in pre- and postoperative AROM measurements for the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints were made between both groups of patients. The degrees of change in AROM for each joint were categorized in terms of levels of change: mild (0° to 29°); moderate (30° to 60°); and significant (≥61°).

RESULTS

All patients exhibited increased AROM after surgery for both MCP and PIP joints. Both groups had a greater increase in AROM in the MCP joint. Twelve joints from the control group had moderate changes and two from the treatment group had significant changes. When both groups were compared, the levels of change of AROM between both groups did not vary significantly.

CONCLUSION

Night extension splinting following needle aponeurotomy may not improve AROM of the MCP or PIP joints.

Clusters in Short-term Disease Course in Participants With Primary Dupuytren Disease

PURPOSE

The course of Dupuytren disease (DD) is thought to be progressive; however, the course differs for each patient. The purpose of this study was to study the rate and pattern of progression of DD.

METHODS

We prospectively analyzed the course of DD at intervals of 3 to 6 months in 247 Dutch participants with primary DD by measuring the surface area of nodules and cords and the total passive extension deficit. The association between surface area and Tubiana stage was tested with generalized estimating equations. Latent class models were used to study different clusters in changes regarding the course of the disease.

RESULTS

The variance in disease course between participants was large. Regarding the change in surface area (in all fingers) and total passive extension deficit (in the ring and little finger), different clusters were observed. Progression of disease was seen but there were also signs of stability and even regression. Patients with a smaller surface area at baseline were more likely to exhibit regression.

CONCLUSIONS

This study showed that DD is not always progressive and that up to 75% of patients have a different short-term disease course, such as stability or even regression of disease. This should be taken into account when evaluating the effects of treatment for early-phase DD and in the design of future studies. Furthermore, this information may be useful when counseling patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

GLYCOSAMINOGLYCANS AND PROTEOGLYCANS IN PALMAR FASCIA OF PATIENTS WITH DUPUYTREN

Objective

: To evaluate and compare the behavior of glycosaminoglycans (GAGs) in Dupuytren disease (DD).

Methods

: This is an experimental study with 23 patients diagnosed with DD. Tissue collected through fasciectomy with incision type Brunner or McCash were evaluated by electrophoresis for identification of GAGs. The quantification was carried out by immunofluorescence and dosage of proteins for different types of glycosaminoglycans. The results were expressed in percentage and statistically evaluated.

Results

: A significant increase was observed through eletrophoresis in GAGs, as compared to the control (p<0.05). Immunofluorescence of hyaluronic acid was reduced (23 times) when compared to the control (p<0.0001).

Conclusion

: An increase of sulfated GAGs in Dupuytren's disease, mainly dermatan sulfate, was evident from our results, as well as a pronounced decrease of hyaluronic acid in the palmar aponeurosis from the same patients. Level of Evidence III, Case-Control Study.

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

OBJECTIVE

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

INDICATIONS

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

CONTRAINDICATIONS

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

INJECTION TECHNIQUE

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

POSTMANIPULATION MANAGEMENT

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

RESULTS

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

Delayed manipulation after collagenase clostridium histolyticum injection for Dupuytren contracture

BACKGROUND

Collagenase clostridium histolyticum (CCH) injection for Dupuytren contracture was approved in the USA in 2010. Current FDA guidelines stipulate that finger manipulation occurs the day following injection. To investigate the safety and efficacy of delaying manipulation to 2 or 4 days following CCH injection, we conducted a prospective, randomized trial at two sites.

METHODS

Patients with Dupuytren contracture involving the metacarpophalangeal (MCP) joint ≥20° caused by a palpable cord participated. All patients received one dose of CCH (0.58 mg/0.25 ml) and were followed for 90 days. The primary end point was the percent of patients maintaining clinical success (reduction of contracture to 0°-5°) at 90 days post-injection. Adverse events and change in Michigan Hand Questionnaire (MHQ) score were recorded as secondary end points.

RESULTS

Thirty-seven patients enrolled; 13 were manipulated on day 1, 11 on day 2, and 13 on day 4. At 30 days after injection, the percentage of patients obtaining reduction of contracture to <0°-5° extension was 92, 82, and 85 % in groups 1, 2, and 3, respectively, with no significant difference. At 90 days follow-up, the percentage of patients maintaining 0°-5° extension was 91, 82, and 83 % in groups 1, 2, and 3, respectively, with no significant difference. Adverse events were comparable to rates in prior studies. There were no serious adverse events. There was no statistical difference in MHQ scores between groups at any time point.

CONCLUSIONS

Delaying manipulation to day 2 or 4 following CCH injection for MCP joint contractures does not increase adverse events or result in loss of efficacy.

LEVEL OF EVIDENCE

Therapeutic, Level II.

Dupuytren Contracture Recurrence Following Treatment With Collagenase Clostridium histolyticum (CORDLESS [Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study]): 5-Year Data

PURPOSE

Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study was a 5-year noninterventional follow-up study to determine long-term efficacy and safety of collagenase clostridium histolyticum (CCH) treatment for Dupuytren contracture.

METHODS

Patients from previous CCH clinical studies were eligible. Enrolled patients were evaluated annually for contracture and safety at 2, 3, 4, and 5 years after their first injection (0.58 mg) of CCH. In successfully treated joints (≤ 5° contracture following CCH treatment), recurrence was defined as 20° or greater worsening (relative to day 30 after the last injection) with a palpable cord or any medical/surgical intervention to correct new/worsening contracture. A post hoc analysis was also conducted using a less stringent threshold (≥ 30° worsening) for comparison with criteria historically used to assess surgical treatment.

RESULTS

Of 950 eligible patients, 644 enrolled (1,081 treated joints). At year 5, 47% (291 of 623) of successfully treated joints had recurrence (≥ 20° worsening)-39% (178 of 451) of metacarpophalangeal and 66% (113 of 172) of proximal interphalangeal joints. At year 5, 32% (198 of 623) of successfully treated joints had 30° or greater worsening (metacarpophalangeal 26% [119 of 451] and proximal interphalangeal 46% [79 of 172] joints). Of 105 secondary interventions performed in the successfully treated joints, 47% (49 of 105) received fasciectomy, 30% (32 of 105) received additional CCH, and 23% (24 of 105) received other interventions. One mild adverse event was attributed to CCH treatment (skin atrophy [decreased ring finger circumference from thinning of Dupuytren tissue]). Antibodies to clostridial type I and/or II collagenase were found in 93% of patients, but over the 5 years of follow-up, this did not correspond to any reported clinical adverse events.

CONCLUSIONS

Five years after successful CCH treatment, the overall recurrence rate of 47% was comparable with published recurrence rates after surgical treatments, with one reported long-term treatment-related adverse event. Collagenase clostridium histolyticum injection proved to be an effective and safe treatment for Dupuytren contracture. For those receiving treatment during follow-up, both CCH and fasciectomy were elected options.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.