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Abstract
Dupuytren's disease is a heterogenous condition for which a palette of treatment options is required. Randomized control trial evidence is sparse; design challenges, such as validated outcome measures, blinding, equipoise, funding and assessment of recurrence, may limit further data accrual. Recurrence has different significance with different treatments and so rates are not directly comparable. The risk of any treatment is a function of both the chance of a complication and the clinical sequelae of that complication. The patient must be intimately involved in choosing treatment and is often trading rapid recovery for a higher chance of recurrence. Health economies are strained and as custodians of healthcare, surgeons should consider whether many patients even need treatment. To minimize the chance of complex, hazardous and expensive revision surgery, a low threshold for primary skin grafting should be applied, especially for those who are young, have dense disease or vulnerable genes.
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Affiliation(s)
- D Warwick
- University Hospital Southampton, Southampton, UK
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102
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Wozniczka J, Canepa C, Mirarchi A, Solomon JS. Complications Following Collagenase Treatment for Dupuytren Contracture. Hand (N Y) 2017; 12. [PMID: 28635316 PMCID: PMC5684954 DOI: 10.1177/1558944717711461] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Collagenase Clostridium histolyticum (CCH) injection and manipulation is a relatively new method for treating Dupuytren contracture that is growing in popularity. Although side effects such as swelling and ecchymosis are common, they are typically mild and self-limited. Major complications are rare but have included flexor tendon rupture and complex regional pain syndrome. METHODS This study describes a case report of 2 patients seen at our institution. RESULTS Here, we report 2 patients seen at our institution each with different, yet serious complications after CCH injection and manipulation. One patient had extensive skin loss and chose amputation over reconstruction. The other patient had loss of perfusion and required finger amputation. CONCLUSIONS Although it is unclear how directly the administration of CCH is connected to the observed complications, physicians should recognize the potential for serious rare complications in any treatment of Dupuytren contracture.
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Affiliation(s)
| | | | | | - Joel S. Solomon
- Oregon Health & Science University, Portland, USA,Joel S. Solomon, Department of Plastic Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code: L352A, Portland, OR 97239, USA.
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103
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Benefit of Local Anesthesia in Reducing Pain during Collagenase Injection for Dupuytren’s Contracture. Plast Reconstr Surg 2017; 140:565-569. [DOI: 10.1097/prs.0000000000003583] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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104
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Nordenskjöld J, Englund M, Zhou C, Atroshi I. Prevalence and incidence of doctor-diagnosed Dupuytren's disease: a population-based study. J Hand Surg Eur Vol 2017; 42:673-677. [PMID: 28093015 DOI: 10.1177/1753193416687914] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED The prevalence and incidence of doctor-diagnosed Dupuytren's disease in the general population is unknown. From the healthcare register for Skåne region (population 1.3 million) in southern Sweden, we identified all residents aged ⩾20 years (on 31 December 2013), who 1998 to 2013 had consulted a doctor and received the diagnosis Dupuytren's disease (International Classification of Diseases 10th Revision code M720). During the 16 years, 7207 current residents (72% men) had been diagnosed with Dupuytren's disease; the prevalence among men was 1.35% and among women 0.5%. Of all people diagnosed, 56% had received treatment (87% fasciectomy). In 2013, the incidence of first-time doctor-diagnosed Dupuytren's disease among men was 14 and among women five per 10,000. The annual incidence among men aged ⩾50 years was 27 per 10,000. Clinically important Dupuytren's disease is common in the general population. LEVEL OF EVIDENCE III.
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Affiliation(s)
- J Nordenskjöld
- 1 Department of Orthopedics, Hässleholm-Kristianstad-Ystad Hospitals, Hässleholm, Sweden.,2 Department of Clinical Sciences Lund - Orthopedics, Lund University, Lund, Sweden
| | - M Englund
- 3 Clinical Epidemiological Unit, Lund University, Lund, Sweden
| | - C Zhou
- 3 Clinical Epidemiological Unit, Lund University, Lund, Sweden
| | - I Atroshi
- 1 Department of Orthopedics, Hässleholm-Kristianstad-Ystad Hospitals, Hässleholm, Sweden.,2 Department of Clinical Sciences Lund - Orthopedics, Lund University, Lund, Sweden
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105
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Costas B, Coleman S, Kaufman G, James R, Cohen B, Gaston RG. Efficacy and safety of collagenase clostridium histolyticum for Dupuytren disease nodules: a randomized controlled trial. BMC Musculoskelet Disord 2017; 18:374. [PMID: 28854973 PMCID: PMC5577662 DOI: 10.1186/s12891-017-1713-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 08/10/2017] [Indexed: 12/14/2022] Open
Abstract
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
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Affiliation(s)
- Bronier Costas
- The Hand and Upper Extremity Center of Georgia, 980 Johnson Ferry Rd, NE, Suite 1020, Atlanta, GA, 30342, USA.
| | - Stephen Coleman
- Brisbane Hand and Upper Limb Clinic, 259 Wickham Terrace, Spring Hill, Queensland, 4000, Australia
| | - Greg Kaufman
- Auxilium Pharmaceuticals, Inc, 640 Lee Rd, Chesterbrook, PA, 19087, USA
| | - Robert James
- Auxilium Pharmaceuticals, Inc, 640 Lee Rd, Chesterbrook, PA, 19087, USA
| | - Brian Cohen
- Auxilium Pharmaceuticals, Inc, 640 Lee Rd, Chesterbrook, PA, 19087, USA
| | - R Glenn Gaston
- OrthoCarolina, 1915 Randolph Rd, Charlotte, NC, 28207, USA
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106
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Van Beeck A, Van den Broek M, Michielsen M, Didden K, Vuylsteke K, Verstreken F. Efficacy and safety of collagenase treatment for Dupuytren's disease: 2-year follow-up results. HAND SURGERY & REHABILITATION 2017; 36:346-349. [PMID: 28732844 DOI: 10.1016/j.hansur.2017.06.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 06/01/2017] [Accepted: 06/13/2017] [Indexed: 01/24/2023]
Abstract
Dupuytren's contracture is a common hand problem that affects the palmar fascia. Several treatment options exist, but none are curative and recurrence is common. Bacterial collagenase has recently been proven beneficial for treating Dupuytren's disease, cleaving the collagen fibers at different sites, with weakening and eventually rupture of the fibrous cords after manipulation. An independent prospective follow-up study was organized on 87 patients, treated with one or more collagenase injections. Inclusion criteria were a contracture of at least 20° at the metacarpophalangeal (MCP) or the proximal interphalangeal (PIP) joint. The most diseased joint was taken into consideration for follow-up evaluation. The resulting extension deficit was measured at 1 month, 1 year and 2 years and was graded as "clinical success", "clinical improvement" or "clinical failure". The mean contracture improved from 45° (39° for MCP and 54° for PIP joints) before treatment to 5° (2° for MCP and 9° for PIP joints) 4 weeks after treatment. No serious complications occurred. After 2 years, 68 joints were evaluated; 61.5% of the MCP joints and 34.5% of the PIP joints had a contracture of ≤20°. When compared with the 4-week evaluation, 28.2% of MCP joints and 62.1% of PIP joints had a recurrence (20° or greater worsening) or had received additional treatment. Collagenase injection is a safe and effective treatment option for Dupuytren disease, but recurrence is common especially for the PIP joint.
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Affiliation(s)
- A Van Beeck
- Orthopedic department, Monica hospital, 68, Harmoniestraat, 2018 Antwerp, Belgium.
| | - M Van den Broek
- Orthopedic department, Monica hospital, 68, Harmoniestraat, 2018 Antwerp, Belgium
| | - M Michielsen
- Orthopedic department, Monica hospital, 68, Harmoniestraat, 2018 Antwerp, Belgium
| | - K Didden
- Orthopedic department, Monica hospital, 68, Harmoniestraat, 2018 Antwerp, Belgium
| | - K Vuylsteke
- Orthopedic department, Monica hospital, 68, Harmoniestraat, 2018 Antwerp, Belgium
| | - F Verstreken
- Orthopedic department, Monica hospital, 68, Harmoniestraat, 2018 Antwerp, Belgium
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107
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Lewallen LW, Rizzo M. Phalangeal Fracture During Attempted Dupuytrens Release Following Clostridial Collagenase Injection: Case Report. J Orthop Case Rep 2017; 7:21-24. [PMID: 29181346 PMCID: PMC5702696 DOI: 10.13107/jocr.2250-0685.832] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Dupuytren's disease can be a challenging condition for both patients and surgeons. Injectable collagen clostridium histolyticum was approved for clinical use by the Food and Drug Administration in 2010. A number of side effects have been described. In this case report, we present a complication of a proximal phalanx fracture which occurred during attempted release post injection. To the best of our knowledge, this is the first reported case of this particular complication. CASE REPORT The patient is an 80-year-old right-hand dominant retired male with bilateral hand contractures and palmar fibromatosis. His medical history is notable for Type II diabetes mellitus and metastatic thyroid cancer. The patient underwent Xiaflex injection of the left small finger and returned 4 days later for planned release. An appreciable release of the contracture was noted; however, there was a concern for plastic deformation of the proximal phalanx as a result of the manipulation. X-rays confirmed the fracture and apex volar angulation at the base of the proximal phalanx. The fracture appeared amenable to non-operative treatment. The patient has been followed closely and has had no pain or tenderness at the fracture site and minimal swelling. X-rays at 1 week and 1 month showed maintained alignment and signs of consolidation at the fracture site. The patient is currently 4-month post-fracture, and no further intervention has been pursued. CONCLUSIONS This report represents an additional potential complication associated with the use of Xiaflex. We recommend judicious use in elderly patients with severe contractures and/or multiple comorbidities. It is important to appreciate the possibility of this complication at the time of release.
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Affiliation(s)
- Laura W Lewallen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Marco Rizzo
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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108
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Grandizio LC, Akoon A, Heimbach J, Graham J, Klena JC. The Use of Residual Collagenase for Single Digits With Multiple-Joint Dupuytren Contractures. J Hand Surg Am 2017; 42:472.e1-472.e6. [PMID: 28389081 DOI: 10.1016/j.jhsa.2017.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 02/12/2017] [Accepted: 03/01/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE Standard 0.58 mg (0.25 mL) collagenase Clostridium histolyticum (CCH) preparations result in unused CCH that is often discarded. Our purpose was to assess the results on Dupuytren contractures affecting both the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints in the same digit utilizing an injection containing the maximum CCH volume that can be withdrawn from a single vial. METHODS A consecutive series of patients with MCP and PIP cords in the same digit received a single treatment with 2 injections totaling 0.30 mL distributed between the MCP and the PIP cords and underwent manipulation approximately 24 hours later. Reduction in contracture, clinical success, and complications were assessed 30 days after manipulation. RESULTS Thirty-one patients (34 digits) had a mean preinjection flexion contracture of 50° at the MCP joint and 53° at the PIP joint. Clinical success (reduction in joint contracture to 0°-5° of full extension 30-days postmanipulation) was noted in 65% of MCP cords and 38% of PIP joint cords. We had a 24% incidence of skin tears, which correlated with the degree of preinjection contracture. CONCLUSIONS For Dupuytren contractures involving the MCP and PIP joints in the same digit, distributing the maximum amount of CCH that can be withdrawn from a single vial provides efficacy at both joints that is similar to that reported in previously published series, with a comparable complication rate. Utilizing excess CCH typically discarded may provide cost savings. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Louis C Grandizio
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA.
| | - Anil Akoon
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA
| | - Janice Heimbach
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA
| | - Jove Graham
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA
| | - Joel C Klena
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA
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109
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Evidence-Based Medicine: Options for Dupuytren's Contracture: Incise, Excise, and Dissolve. Plast Reconstr Surg 2017; 139:240e-255e. [PMID: 28027258 DOI: 10.1097/prs.0000000000002857] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand updates in the basic science, epidemiology, and treatment of Dupuytren's disease. 2. Understand treatment with needle aponeurotomy, collagenase, and fasciectomy. 3. Understand advanced needle techniques for Dupuytren's contracture. 4. Understand the safety and effectiveness of a new treatment, collagenase. SUMMARY The literature on Dupuytren's disease encompasses many specialties. Its treatment is generally by perforating, excising, or dissolving the affected tissues. This article reviews the changing understanding of this disease and treatment options.
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110
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Difference in Success Treating Proximal Interphalangeal and Metacarpophalangeal Joints with Collagenase: Results of 208 Treatments. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1275. [PMID: 28507849 PMCID: PMC5426868 DOI: 10.1097/gox.0000000000001275] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 02/01/2017] [Indexed: 12/01/2022]
Abstract
Background: Dupuytren disease (DD) is a fibroproliferative disorder of the palmar fasciae causing extension deficit and impaired hand function. Treatment with injection of collagenase clostridium histolyticum (CCH) is a nonsurgical treatment method. The aim of this study was to evaluate the difference in efficiency and recurrence at 12-month follow-up when treating metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints with CCH. None of the patients had received previous treatments of their condition. Methods: This study is a prospective study of a consecutive series of patients with DD presenting with an extension deficit greater than 20° affecting the MP or PIP joint. Results: We found a mean reduction in extension deficit of 47° (91%) for MP joints and 47° (76%) for PIP joints. Full correction (max 5° deficit) was achieved in 76% of MP and 28% of PIP joints. Skin rupture was seen in 34% of treatments. The 1-year relapse rate was 15% for MP and 67% for PIP joints. The reduction in quickDASH score was only statistically significant for MP joints at 1 year. Eighty-one percent of all patients reported being satisfied or very satisfied. No major adverse events were recorded. Conclusion: Excellent results can be achieved in the treatment of MP-joint contractures, whereas the success rate is significantly lower and recurrence rate is greater for PIP joints.
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111
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Sanjuan-Cerveró R, Carrera-Hueso FJ, Vazquez-Ferreiro P, Gomez-Herrero D. Adverse Effects of Collagenase in the Treatment of Dupuytren Disease: A Systematic Review. BioDrugs 2017; 31:105-115. [PMID: 28181175 DOI: 10.1007/s40259-017-0211-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Collagenase clostridium histolyticum (CCH) has proven to be both safe and effective in the treatment of Dupuytren disease (DD). The medium-term outcomes are similar to those achieved with surgery, and most adverse effects are self-limiting and considered to be mild or moderate. OBJECTIVE Our objective was to conduct a systematic review of the adverse effects of CCH in DD since the release of the drug to evaluate the incidence, severity, classification, and definitions of these effects. METHODS We analyzed the literature in terms of modifications to the original treatment protocol and grouped adverse effects according to their pathophysiological origin. RESULTS We included 28 clinical studies and five case reports or case series analyzing 4456 patients with a mean age of 63.6 years. Mean follow-up was 7.07 months (range 3-24); the mean number of patients per study was 148 (range 5-1082). The studies did not classify the adverse effects they reported into groups. The most common effects were peripheral edema (54.4%), bruising (42.9%), and upper limb pain (28.3%). Significant biases were observed for use of terminology, demarcation of sites of involvement, severity criteria, and assessment methods. CONCLUSION A simpler and clearer consensus-based classification system would enable better evaluation and comparison of the adverse effects of CCH in the treatment of DD. Consideration of inflammatory phenomena as part of the drug's mechanism of action would significantly reduce overall rates of adverse effects.
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Affiliation(s)
- Rafael Sanjuan-Cerveró
- Orthopedics and Traumatology Surgery, Hospital de Denia, Partida Beniadlà, S/N, Denia, 03700, Alicante, Spain. .,University of Granada, Granada, Spain.
| | | | - Pedro Vazquez-Ferreiro
- University of Granada, Granada, Spain.,Ophthalmologic Department, Hospital Virxen da Xunqueira, Cee, A Coruña, Spain
| | - Diego Gomez-Herrero
- University of Granada, Granada, Spain.,Pharmacy Service, Hospital Nisa Rey Don Jaime, Castellón, Spain
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112
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Skov ST, Bisgaard T, Søndergaard P, Lange J. Injectable Collagenase Versus Percutaneous Needle Fasciotomy for Dupuytren Contracture in Proximal Interphalangeal Joints: A Randomized Controlled Trial. J Hand Surg Am 2017; 42:321-328.e3. [PMID: 28473158 DOI: 10.1016/j.jhsa.2017.03.003] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 03/01/2017] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Simon Toftgaard Skov
- Interdisciplinary Research Unit, Center for Planned Surgery, Silkeborg, Denmark; Orthopaedic Research Laboratory, Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark.
| | - Therkel Bisgaard
- Center for Planned Surgery, Regional Hospital Silkeborg, Silkeborg, Denmark
| | - Per Søndergaard
- Center for Planned Surgery, Regional Hospital Silkeborg, Silkeborg, Denmark
| | - Jeppe Lange
- Interdisciplinary Research Unit, Center for Planned Surgery, Silkeborg, Denmark; Orthopaedic Research Unit, Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
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113
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Bear BJ, Peimer CA, Kaplan FTD, Kaufman GJ, Tursi JP, Smith T. Treatment of Recurrent Dupuytren Contracture in Joints Previously Effectively Treated With Collagenase Clostridium histolyticum. J Hand Surg Am 2017; 42:391.e1-391.e8. [PMID: 28341067 DOI: 10.1016/j.jhsa.2017.02.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 01/30/2017] [Accepted: 02/10/2017] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
| | - Clayton A Peimer
- College of Human Medicine, Michigan State University, East Lansing; and the UP Health System-Marquette, Hand Surgery Office, Marquette, MI
| | | | | | | | - Ted Smith
- Endo Pharmaceuticals Inc., Malvern, PA
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114
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Percutaneous Aponeurotomy and Lipofilling (PALF) versus Limited Fasciectomy in Patients with Primary Dupuytren's Contracture: A Prospective, Randomized, Controlled Trial. Plast Reconstr Surg 2017; 140:357e-358e. [PMID: 28418979 DOI: 10.1097/prs.0000000000003536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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115
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Lauritzson A, Atroshi I. Collagenase injections for Dupuytren's disease: prospective cohort study assessing 2-year treatment effect durability. BMJ Open 2017; 7:e012943. [PMID: 28298365 PMCID: PMC5353323 DOI: 10.1136/bmjopen-2016-012943] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To assess 2-year durability of joint contracture correction following collagenase injections for Dupuytren's disease. DESIGN Prospective cohort study. SETTING Orthopaedic Department in Sweden. PARTICIPANTS Patients with palpable Dupuytren's cord and active extension deficit (AED) ≥30° in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint. A surgeon injected 0.80 mg collagenase into multiple cord parts and performed finger manipulation under local anaesthesia after 24-48 hours. A hand therapist measured joint contracture before and 5 weeks after injection in all treated patients. Of 57 consecutive patients (59 hands), 48 patients (50 hands) were examined by a hand therapist 24-35 months (mean 26) after injection. Five of the patients had received a second injection in the same finger within 6 months of the first injection. OUTCOME MEASURES Primary outcome was proportion of treated joints with ≥20° worsening in AED from 5 weeks to 2 years. RESULTS Between the 5-week and the 2-year measurements, AED had worsened by ≥20° in seven MCP and seven PIP joints (28% of the treated hands; all had received a single injection). Mean AED for the MCP joints was 54° before injection, 6° at 5 weeks and 9° at 2 years and for the PIP joints 30°, 13° and 16°, respectively. For joints with ≥10° contracture at baseline, mean (95 % CI) baseline to 2 years AED improvement was for MCP 49° (41-54) and for PIP 25° (17-32). No treatment-related adverse events were observed at the 2-year follow-up evaluation. CONCLUSIONS Two years after collagenase injections for Dupuytren's disease, improvement was maintained in 72% of the treated hands. Complete contracture correction was seen in more than 80% of the MCP but in less than half of the PIP joints.
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Affiliation(s)
- Anna Lauritzson
- Department of Orthopedics, Hässleholm-Kristianstad-Ystad Hospitals, Hässleholm, Sweden
- Department of Rehabilitation, Hässleholm Hospital, Hässleholm, Sweden
| | - Isam Atroshi
- Department of Orthopedics, Hässleholm-Kristianstad-Ystad Hospitals, Hässleholm, Sweden
- Department of Clinical Sciences—Orthopedics, Lund University, Lund, Sweden
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Brauns A, Van Nuffel M, De Smet L, Degreef I. A clinical trial of tension and compression orthoses for Dupuytren contractures. J Hand Ther 2017; 30:253-261. [PMID: 28236563 DOI: 10.1016/j.jht.2016.11.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 11/29/2016] [Accepted: 11/30/2016] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Randomized clinical trial on 2 patient groups with Dupuytren's disease. INTRODUCTION Despite an unpredictable outcome, surgery remains an important treatment for Dupuytren's disease. Orthotic devices are a controversial noninvasive treatment method to influence the myofibroblasts in the nodules. PURPOSE OF THE STUDY To detect how much improvement 2 types of orthotic device (tension and compression) as only treatment intervention can provide on a Dupuytren's contracture. Is a compression orthosis better than a tension orthosis? METHODS Thirty patients with measurable flexion contractures of the fingers were identified. Both primary and recurrence cases were included. Patients were randomized in 2 groups of 15 patients. One group had a standard tension orthosis (Levame), the other group a newly designed silicon compression orthotic device. Patients were instructed to wear the orthotic devices 20 hours a day during 3 months. Data were collected at first visit and after 3 months of orthotic treatment. Primary outcomes were active extension deficit of each joint and total active extension (TAE) of the digit. Secondary outcome was patient satisfaction. Visual Analog Scale (VAS) score of function and esthetics (0-10 points) were recorded at the start and after 3 months. RESULTS Flexion contracture was reduced at least 5 degrees in all patients. After 3 months, TAE was significantly reduced in both groups (both P < .001).The mean change in TAE was 32.36° in the tension group and 46.47° in the compression group. Although reduction of TAE deficit was bigger in the compression group, this difference was not statistically significant (P = .39). VAS scale of esthetics and functionality was significantly increased in both treatment groups. The functional VAS scale after 3 months was 11% higher in the compression group than in the tension group (P = .03). A major complication of a tension orthotic is skin ulcers. DISCUSSION Too much tension may cause myofibroblast stimulation and disease progression, whereas continuous limited tension can improve flexion contractures. The idea of a compression device is based on the treatment concept of hypertrophic burn scars. CONCLUSION Tension and compression orthotic devices can be used as a nonoperative treatment of Dupuytren's disease in both early proliferative untreated hands and aggressive postsurgery recurrence. Although there is no statistically significant difference, compression orthoses appear to be more effective and are better tolerated. Nevertheless, adjustment of orthotic design and research on long-term results are needed. LEVEL OF EVIDENCE I (Randomized controlled trial, Therapeutic study).
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Affiliation(s)
- Annelien Brauns
- Orthopaedic Department, Hand Unit, University Hospitals Leuven, Pellenberg Campus, Pellenberg, Belgium.
| | - Maarten Van Nuffel
- Orthopaedic Department, Hand Unit, University Hospitals Leuven, Pellenberg Campus, Pellenberg, Belgium
| | - Luc De Smet
- Orthopaedic Department, Hand Unit, University Hospitals Leuven, Pellenberg Campus, Pellenberg, Belgium
| | - Ilse Degreef
- Orthopaedic Department, Hand Unit, University Hospitals Leuven, Pellenberg Campus, Pellenberg, Belgium
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Keller M, Arora R, Schmiedle G, Kastenberger T. [Treatment of Dupuytren's disease with collagenase Clostridium histolyticum]. DER ORTHOPADE 2017; 46:321-327. [PMID: 28138723 DOI: 10.1007/s00132-017-3386-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Dupuytren's disease as a benign fibroproliferative disease leads to hyperplasia of the collagen fibers of the fascia of the palm, which can result in severe impairment of the functionality of the hand. OBJECTIVES Examination of the significance of non-operative treatment of Dupuytren's disease with injectable collagenase clostridium histolyticum (CCH) METHODS: Observation of 120 patients treated with injectable collagenase. Documentation of the range of motion before the intervention, 12 months after the intervention, and documentation of any adverse events. RESULTS All in all, 120 patients were treated (107 male, 13 female) (mean age 62 years, range 30-84 years). In 49% the little finger, in 44% the ring finger, in 4% the middle finger, and in 3% the index finger were treated. Full release was accomplished in 71%, partial release in 26%, and no change in 3% of the patients. The median contracture before the treatment was 37° for the metacarpophalangeal (MP) joint (range 25-100°) and 51° for the proximal interphalangeal (PIP) joint (range 30-97°). After 12 months, the mean contracture for the MP joint was 9° (range 0-25°) and 21° (range 10-36°) or the PIP joint. Adverse events occurred in 96% of patients within 3 months after treatment. No tendon ruptures, anaphylactic reactions, nerve, or ligament injuries were observed.
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Affiliation(s)
- M Keller
- Department für Unfallchirurgie, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - R Arora
- Department für Unfallchirurgie, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
| | - G Schmiedle
- Department für Unfallchirurgie, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - T Kastenberger
- Department für Unfallchirurgie, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
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Zhao JZ, Hadley S, Floyd E, Earp BE, Blazar PE. The Impact of Collagenase Clostridium histolyticum Introduction on Dupuytren Treatment Patterns in the United States. J Hand Surg Am 2016; 41:963-968. [PMID: 27546441 DOI: 10.1016/j.jhsa.2016.07.090] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 07/06/2016] [Accepted: 07/08/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE The U.S. Food and Drug Administration approved the use of collagenase Clostridium histolyticum (CCH) in the United States in February 2010. This study addresses the impact of that approval on the number of Dupuytren contracture (DC) encounters and treatment patterns in the United States. METHODS Using the Intercontinental Marketing Services Health Office-Based Medical Claims database, we identified the monthly number of DC encounters and DC procedures between January 2007 and December 2013. Collagenase Clostridium histolyticum usage data from March 2010 to December 2013 was derived from the U.S. CCH manufacturer's data warehouse. Using the combined data, the yearly increasing trends in DC encounters and treatment volume were compared before and after the introduction of CCH. Time trends in the relative procedure frequencies were then examined. Finally, the presence of seasonal variation was tested for in each treatment type. RESULTS Dupuytren contracture encounters increased on average by 19,015 per year between 2007 and 2009, whereas between 2011 and 2013, DC encounters increased on average by 34,940 per year. In terms of absolute procedure counts, the surgery trend line began decreasing in 2010 with the release of CCH. Meanwhile, CCH continuously increased between 2010 and 2013, and needle aponeurotomy (NA) remained relatively stable. By the year 2013, minimally invasive techniques (NA and CCH) comprised 39% of all treatment, compared with only 14% in 2007. Lastly, there was a statistically significant seasonal increase in the number of surgical procedures during the wintertime but no seasonal variation in NA or CCH. CONCLUSIONS After the introduction of CCH, the number of Dupuytren encounters increased at a greater annual rate. The introduction and growth of CCH coincided with a decrease in surgery. The number of NA procedures remained steady throughout the study period. The number of open surgery cases followed a predictable seasonal variation with more procedures during the winter months, but this seasonal variation was not seen with less invasive techniques. TYPE OF STUDY/LEVEL OF EVIDENCE Economic/Decision Analysis II.
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Affiliation(s)
- John Z Zhao
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Scott Hadley
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Emerson Floyd
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Brandon E Earp
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Philip E Blazar
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA.
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Warwick D, Arandes-Renú JM, Pajardi G, Witthaut J, Hurst LC. Collagenase Clostridium histolyticum: emerging practice patterns and treatment advances. J Plast Surg Hand Surg 2016; 50:251-61. [PMID: 27050718 PMCID: PMC5044771 DOI: 10.3109/2000656x.2016.1159568] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 12/13/2015] [Accepted: 01/24/2016] [Indexed: 01/28/2023]
Abstract
OBJECTIVE This study aims to provide a comprehensive review of the role of Collagenase Clostridium histolyticum (CCH). METHODS This review is based on a literature review and practical experience. RESULTS This review provides practical management strategies for using collagenase by sharing clinical experiences over the past few years; logistical aspects of in-clinic treatment, lessons learned, and novel approaches to correct traditionally hard-to-treat contractures are discussed. In addition a brief, yet comprehensive overview is provided on the pathophysiology of the disease, the mechanism of collagenase action and results of clinical studies. CONCLUSION CCH has an evolving role as one of the tools available for treating Dupuytren's disease.
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Affiliation(s)
- David Warwick
- The Hand Clinic, University Hospital Southampton,
Hampshire,
UK
| | - José M. Arandes-Renú
- Servicio de Cirugía Ortopédica y Traumatología, Unidad de Mano, Hospital Clínic,
Barcelona,
SpainUniversidad de Barcelona
| | - Giorgio Pajardi
- Department of Hand Surgery, San Giuseppe MultiMedica University Hospital, Milan and Università degli Studi di,
Milano,
Italy
| | - Jörg Witthaut
- Hand Surgery, Schön Klinik Vogtareuth,
Vogtareuth,
Germany
| | - Lawrence C. Hurst
- Department of Orthopaedics, Stony Brook School of Medicine,
Stony Brook,
NY,
USA
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Strömberg J, Ibsen-Sörensen A, Fridén J. Comparison of Treatment Outcome After Collagenase and Needle Fasciotomy for Dupuytren Contracture: A Randomized, Single-Blinded, Clinical Trial With a 1-Year Follow-Up. J Hand Surg Am 2016; 41:873-80. [PMID: 27473921 DOI: 10.1016/j.jhsa.2016.06.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 04/27/2016] [Accepted: 06/26/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE This study compared the efficacy of collagenase treatment and needle fasciotomy for contracture of the metacarpophalangeal (MCP) joint in Dupuytren disease. METHODS This is a prospective, single-blinded, randomized study with follow-up 1 week and 1 year after treatment. One hundred and forty patients with an MCP contracture of 20° or more in a single finger were enrolled, of whom 69 patients were randomized to collagenase treatment and 71 patients to needle fasciotomy. The patients were followed at 1 week and were examined by a physiotherapist after 1 year. Measurements of joint movement and grip strength were recorded as well as patient-perceived outcomes measured by the Unité Rhumatologique des Affections de la Main (URAM) questionnaire and a visual analog scale (VAS) for the estimation of procedural pain and subjective treatment efficacy. RESULTS Eighty-eight percent of the patients in the collagenase group and 90% of the patients in the needle fasciotomy group had a reduction in their MCP contracture to less than 5° 1 week after treatment, and the median gains in passive MCP movement were 48° and 46°, respectively. The median VAS score for procedural pain was 4.9 of 10 in the collagenase group and 2.7 of 10 in the needle fasciotomy group. After 1 year, 90% of the patients in both groups had full extension of the treated MCP joint. One patient in each group had a recurrence of the contracture. The median improvement in URAM score was 8 units in both groups and the VAS estimation of treatment efficacy by the patients was 8.7 of 10 in both groups. CONCLUSIONS There was no significant difference between the treatment outcomes after collagenase and needle fasciotomy treatment after 1 year. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.
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Affiliation(s)
- Joakim Strömberg
- Department of Hand Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Centre for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | | | - Jan Fridén
- Department of Hand Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Centre for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital, Gothenburg, Sweden
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121
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Warwick DJ, Graham D, Worsley P. New insights into the immediate outcome of collagenase injections for Dupuytren's contracture. J Hand Surg Eur Vol 2016; 41:583-8. [PMID: 26307140 DOI: 10.1177/1753193415600670] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 05/27/2015] [Indexed: 02/03/2023]
Abstract
UNLABELLED Collagenase clostridium histolyticum is now established as an effective and safe option to treat patients with a single joint affected with Dupuytren's contracture. We have extended its use to natatory and combined cords. In a prospective consecutive series of 298 cords in 237 patients, the mean total extension loss improved in cords crossing the metacarpophalangeal joint from 46° to 1°, in cords crossing the proximal interphalangeal joint from 56° to 7°, in natatory cords from 130° to 25° and in combined cords from 102° to 16°. The immediate correction of combined cords and natatory cords was less reliable than that obtained in cords crossing the metacarpophalangeal joint or proximal interphalangeal joint. Less severe pre-intervention contractures tended to correct better. We found a high complication rate, which may cause alarm. A total of 21% developed skin splits, with the risk of skin splits generally increasing with more severe pre-injection deformity. Blood blisters were only encountered after manipulation of the more severe contractures. A total of 23 patients (8%) had a spontaneous rupture and 57 patients (19%) had a partial spontaneous rupture. Only 4.9% needed a second injection. We noticed a learning curve, with seven of the first 20 cords (35%) needing a second injection to achieve a satisfactory correction and then only seven (2.5%) in the rest. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- D J Warwick
- Hand Unit, University Hospital Southampton, Southampton, UK Musculoskeletal Research Unit, University Hospital Southampton and University of Southampton, Southampton, UK
| | - D Graham
- Hand Unit, University Hospital Southampton, Southampton, UK
| | - P Worsley
- Musculoskeletal Research Unit, University Hospital Southampton and University of Southampton, Southampton, UK
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Smeraglia F, Del Buono A, Maffulli N. Collagenase clostridium histolyticum in Dupuytren's contracture: a systematic review. Br Med Bull 2016; 118:149-58. [PMID: 27151958 PMCID: PMC5127428 DOI: 10.1093/bmb/ldw020] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2016] [Indexed: 11/14/2022]
Abstract
INTRODUCTION In the last few years, the use of collagenase clostridium histolyticum for management of Dupuytren's contracture has increased. The procedure of enzymatic fasciectomy has become popular because it is non-invasive, safe and fast to perform. SOURCES OF DATA A systematic search was performed on Medline (PubMed), Web of Science and Scopus databases using the combined keywords 'Dupuytren collagenase' and 'Dupuytren clostridium histolyticum'. Forty-three studies were identified. The quality of the studies was assessed using the Coleman Methodological Score. AREAS OF AGREEMENT The use of collagenase clostridium histolyticum provides better outcomes in patients with mild-moderate joint contracture, with lower complications and side effects than open fasciectomy. Manipulation can be performed 2-7 days after the injection. The use of collagenase is cost-effective. AREAS OF CONTROVERSY Most of the studies did not report patient-related outcomes. The role of dynamic splint has to be investigated with randomized clinical trials. GROWING POINTS The shorter recovery time and the low incidence of serious or major adverse effects are the main advantages of this new technology. AREAS TIMELY FOR DEVELOPING RESEARCH There is a need to perform studies with longer follow-up because the recurrence rate seems to increase with time. Further investigations are necessary to assess whether it is safe and effective to inject two or more cords at the same time.
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Affiliation(s)
- Francesco Smeraglia
- Department of Orthopaedic Surgery, 'Federico II' University of Naples, Naples, Italy
| | - Angelo Del Buono
- Department of Orthopaedic and Trauma Surgery, Ospedale Vaio Fidenza(PR), Fidenza, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84081 Baronissi, Salerno, Italy Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentirstry, Mile End Hospital, 275 Bancroft Road, London E1 4 DG, UK
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123
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Bradley J, Warwick D. Patient Satisfaction With Collagenase. J Hand Surg Am 2016; 41:689-97. [PMID: 27132016 DOI: 10.1016/j.jhsa.2016.03.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/10/2016] [Accepted: 03/07/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To establish patient satisfaction after collagenase clostridium histolyticum (CCH) injection. METHODS In a cross-sectional study, 213 patients who had been treated for Dupuytren disease with CCH were reviewed between 37 and 1421 days after injection. RESULTS A total of 73% of the patients were very satisfied or satisfied, and 21% were dissatisfied; 75% would probably or definitely have CCH again, whereas 17% probably or definitely would not. We found that satisfaction and willingness to undergo a second treatment decreased over time and had a negative relationship with recurrence. Dissatisfaction was greater in those with a poor initial outcome but not in those with an initial complication. Of 212 patients, 78 had previously experienced surgery for Dupuytren disease of whom 71% would prefer CCH to surgery and 15% the converse. Satisfaction shows a relationship with function as measured by both QuickDASH and the Southampton Dupuytren Scoring Scheme. CONCLUSIONS Patient satisfaction with CCH is generally high but deteriorates over time as the disease recurs. To manage patient expectation, this issue should be made explicit to patients in the consent process. CLINICAL RELEVANCE Overall satisfaction with CCH is high, with initial satisfaction rates especially good. Forewarning of complications and recurrence can help maintain satisfaction levels.
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Affiliation(s)
- Jack Bradley
- University Hospital Southampton and University of Southampton, Southampton, United Kingdom
| | - David Warwick
- University Hospital Southampton and University of Southampton, Southampton, United Kingdom.
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The efficacy of open partial aponeurectomy for recurrent Dupuytren's contracture. Arch Orthop Trauma Surg 2016; 136:881-9. [PMID: 27038313 DOI: 10.1007/s00402-016-2448-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Indexed: 12/31/2022]
Abstract
INTRODUCTION To evaluate the efficacy of open partial aponeurectomy for recurrent Dupuytren's contracture. METHODS Eighteen patients with recurrent Dupuytren's contracture of 22 fingers were retrospectively assessed with a mean follow-up time of 94 months (range: 70-114 months). Examination parameters included the determination of range of motion (ROM), grip strength, pain and subjective outcome (disabilities of the arm, shoulder and hand (DASH) questionnaire). SURGICAL TECHNIQUE Dissection with special regard to former skin incision and expected wound defect. Modified incisions after Bruner (Mini-Bruner incisions) were facilitated. Dissection started at the palm. Fibrous tissue was resected proximally within the palm including vertical fibrotic septae. Direct preparation of the neurovascular bundles (NVB) was facilitated from proximal to distal. If the anatomy of the neurovascular structures became unclear around the natatory ligament preparation of the NVB at the distal end of the fibrous cord was performed. After complete preparation of a NVB, dissection was continued from medial to lateral until the other bundle was completely released. Transposition flaps and skin transplants were often used for sufficient wound closure. RESULTS Recurrence rate was 36 % applying the definition of van Rijssen et al. Fifteen patients had a grip strength of 90 % or higher in comparison to the contralateral side. Ten patients had a pinch strength of 90 % or higher in comparison to the contralateral side. All patients except for one had pain reduction or none postoperatively. Fifteen patients had a DASH score of 15 or lower (range: 0-47). An unrelated ray amputation was suffered due to wound healing complications. CONCLUSIONS Open partial aponeurectomy performed by a board certified hand surgeon proved to be safe. The postoperative functional outcome seemed to be related to the individual course of the disease.
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Fischer S, Hirche C, Diehm Y, Nuutila K, Kiefer J, Gazyakan E, Bueno EM, Kremer T, Kneser U, Pomahac B. Efficacy and Safety of the Collagenase of the Bacterium Clostridium Histolyticum for the Treatment of Capsular Contracture after Silicone Implants: Ex-Vivo Study on Human Tissue. PLoS One 2016; 11:e0156428. [PMID: 27232716 PMCID: PMC4883774 DOI: 10.1371/journal.pone.0156428] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 05/14/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The fibrotic capsule that surrounds silicone implants consists mainly of collagen. The FDA-approved collagenase of the bacterium clostridium histolyticum provides a reasonable treatment option. Safety and efficacy at the female breast site must be evaluated before clinical utilization. MATERIALS AND METHODS We incubated 20 samples of fibrotic capsule as well as 12 full thickness skin grafts harvested from the female breast site for 24 hours with different doses of collagenase. Outcome measures involved histological assessment of thickness and density of the capsule tissue as well as the skin grafts. Furthermore, we performed a collagen assay and immunohistochemistry staining for collagen subtypes. RESULTS Collagenase treatment was able to degrade human capsule contracture tissue ex-vivo. The remaining collagen subtype after degradation was type 4 only. 0.3 mg/ml of collagenase was most effective in reducing capsule thickness when compared with higher concentrations. Of note, effectiveness was inversely related to capsule density, such that there was less reduction in thickness with higher capsule densities and vice versa. Furthermore, the application of 0.3mg/ml collagenase did not lead to thinning or perforation of full thickness skin grafts. CONCLUSION Adjustment of collagenase dose will depend on thickness and density of the contracted capsule. A concentration of 0.3mg/ml seems to be safe and effective in an ex-vivo setting. The remaining collagen subtype 4 is suitable to serve as a neo-capsule/acellular tissue matrix. Collagenase treatment for capsular contracture may soon become a clinical reality.
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Affiliation(s)
- Sebastian Fischer
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
- * E-mail:
| | - Christoph Hirche
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Yannick Diehm
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Kristo Nuutila
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Jurij Kiefer
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Emre Gazyakan
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Ericka M. Bueno
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Thomas Kremer
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
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Rubin G, Rinott M, Wolovelsky A, Rosenberg L, Shoham Y, Rozen N. A new bromelain-based enzyme for the release of Dupuytren's contracture: Dupuytren's enzymatic bromelain-based release. Bone Joint Res 2016; 5:175-7. [PMID: 27174554 PMCID: PMC4921045 DOI: 10.1302/2046-3758.55.bjr-2016-0072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 03/14/2016] [Indexed: 01/26/2023] Open
Abstract
Objectives Injectable Bromelain Solution (IBS) is a modified investigational derivate of the medical grade bromelain-debriding pharmaceutical agent (NexoBrid) studied and approved for a rapid (four-hour single application), eschar-specific, deep burn debridement. We conducted an ex vivo study to determine the ability of IBS to dissolve-disrupt (enzymatic fasciotomy) Dupuytren’s cords. Materials and Methods Specially prepared medical grade IBS was injected into fresh Dupuytren’s cords excised from patients undergoing surgical fasciectomy. These cords were tested by tension-loading them to failure with the Zwick 1445 (Zwick GmbH & Co. KG, Ulm, Germany) tension testing system. Results We completed a pilot concept-validation study that proved the efficacy of IBS to induce enzymatic fasciotomy in ten cords compared with control in ten cords. We then completed a dosing study with an additional 71 cords injected with IBS in descending doses from 150 mg/cc to 0.8 mg/cc. The dosing study demonstrated that the minimal effective dose of 0.5 cc of 6.25 mg/cc to 5 mg/cc could achieve cord rupture in more than 80% of cases. Conclusions These preliminary results indicate that IBS may be effective in enzymatic fasciotomy in Dupuytren’s contracture. Cite this article: Dr G. Rubin. A new bromelain-based enzyme for the release of Dupuytren’s contracture: Dupuytren’s enzymatic bromelain-based release. Bone Joint Res 2016;5:175–177. DOI: 10.1302/2046-3758.55.BJR-2016-0072.
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Affiliation(s)
- G Rubin
- Orthopaedic Department, Central Emek Hospital, Afula, Israel
| | - M Rinott
- Orthopaedic Department, Central Emek Hospital, Afula, Israel
| | - A Wolovelsky
- Orthopaedic Department, Central Emek Hospital, Afula, Israel
| | - L Rosenberg
- Orthopaedic Department, Central Emek Hospital, Afula, Israel
| | - Y Shoham
- Plastic and Reconstructive Surgery Department and Hand Unit, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - N Rozen
- Plastic and Reconstructive Surgery Department and Hand Unit, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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127
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Collagenase Clostridium histolyticum in Dupuytren’s contracture: a guide to its use in the EU. DRUGS & THERAPY PERSPECTIVES 2016. [DOI: 10.1007/s40267-016-0291-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Degreef I. Collagenase Treatment in Dupuytren Contractures: A Review of the Current State Versus Future Needs. Rheumatol Ther 2016; 3:43-51. [PMID: 27747514 DOI: 10.1007/s40744-016-0027-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Indexed: 11/26/2022] Open
Abstract
Dupuytren disease is highly prevalent and the finger contractures can be very extensile, compromising the patients' hand function. To restore full function, contractures have been addressed by cutting the causative strands for nearly 200 years, ever since Baron Guillaume Dupuytren demonstrated his technique at the beginning of the nineteenth century. Surgery can be minimal (fasciotomy) or quite invasive (fasciectomy and even skin replacement). However, in the last decade translational research has introduced the non-surgical technique of enzymatic fasciotomy with collagenase injections. Now, finger contractures can be released with single injections on monthly intervals, to address one joint contracture at a time. However, in hands affected with Dupuytren contractures to the extent that the patient calls for treatment, most often more than one joint is involved. In surgical treatment options all contracted joints are addressed in a single procedure. Nevertheless, extensile surgery withholds inherent risks of complications and intense rehabilitation. Today, the minimally-invasive method with enzymatic fasciotomy by collagenase injection has demonstrated reliable outcomes with few morbidities and early recovery. However, single-site injection is todays' standard procedure and multiple joints are addressed in several sessions with monthly intervals. This triggers a longer recovery and treatment burden in severely affected hands even though surgery is avoided. Therefore, further treatment modalities of collagenase use are explored. Adjustments in the treatment regimes' flexibility and collagenase injections addressing more than one joint contracture simultaneously will improve the burden of multiple sessions and, therefore, enzymatic fasciotomy may become the preferred method in more extensile Dupuytren contractures. In this independent review, the challenge of Dupuytren disease affecting a single versus multiple joints is presented. The pros and cons of collagenase use are weighed, founded by the available scientific background. The demands and options for collagenase in future treatment regimens for extensile Dupuytren contractures are discussed.
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Affiliation(s)
- Ilse Degreef
- Orthopedic Department, Hand Surgery, University Hospitals Leuven, Louvain, Belgium.
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Reply: Salvage Palmar Fasciectomy following Initial Treatment with Collagenase Clostridium Histolyticum. Plast Reconstr Surg 2016; 137:761e-762e. [PMID: 26741890 DOI: 10.1097/prs.0000000000001997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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130
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Peimer CA. In Reply. J Hand Surg Am 2015; 40:2317-8. [PMID: 26518324 DOI: 10.1016/j.jhsa.2015.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 08/07/2015] [Indexed: 02/02/2023]
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Holzer LA. Letter Regarding "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". J Hand Surg Am 2015; 40:2317. [PMID: 26518325 DOI: 10.1016/j.jhsa.2015.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 07/06/2015] [Indexed: 02/02/2023]
Affiliation(s)
- Lukas A Holzer
- Department of Orthopaedic Surgery, Medical University of Graz, Graz, Austria
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Gaston RG, Larsen SE, Pess GM, Coleman S, Dean B, Cohen BM, Kaufman GJ, Tursi JP, Hurst LC. The Efficacy and Safety of Concurrent Collagenase Clostridium Histolyticum Injections for 2 Dupuytren Contractures in the Same Hand: A Prospective, Multicenter Study. J Hand Surg Am 2015. [PMID: 26216077 DOI: 10.1016/j.jhsa.2015.06.099] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate efficacy and safety of concurrent administration of 2 collagenase clostridium histolyticum (CCH) injections to treat 2 joints in the same hand with Dupuytren fixed flexion contractures (FFCs). METHODS Patients with 2 or more contractures in the same hand caused by palpable cords participated in a 60-day, multicenter, open-label, phase 3b study. Two 0.58 mg CCH doses were injected into 1 or 2 cords in the same hand (1 injection per affected joint) during the same visit. Finger extension was performed approximately 24, 48, or 72 or more hours later. Changes in FFC and range of motion, incidence of clinical success (FFC ≤ 5°), and adverse events (AEs) were summarized. RESULTS The study enrolled 715 patients (725 treated joint pairs), and 714 patients (724 joint pairs) were analyzed for efficacy. At day 31, mean total FFC (sum of 2 treated joints) decreased 74%, from 98° to 27°. Mean total range of motion increased from 90° to 156°. The incidence of clinical success was 65% in metacarpophalangeal joints and 29% in proximal interphalangeal joints. Most treatment-related AEs were mild to moderate, resolving without intervention; the most common were swelling of treated extremity, contusion, and pain in extremity. The incidence of skin lacerations was 22% (160 of 715). Efficacy and safety were similar regardless of time to finger extension. CONCLUSIONS Collagenase clostridium histolyticum can be used to effectively treat 2 affected joints concurrently without a greater risk of AEs than treatment of a single joint, with the exception of skin laceration. The incidence of clinical success in this study after 1 injection per joint was comparable to phase 3 study results after 3 or more injections per joint. Two concurrent CCH injections may allow more rapid overall treatment of multiple affected joints, and the ability to vary the time between CCH injection and finger extension may allow physicians and patients greater flexibility with scheduling treatment.
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Affiliation(s)
| | - Søren Erik Larsen
- Unit for Hand Surgery, Department of Orthopaedics, Odense University Hospital, Odense, Denmark
| | | | - Stephen Coleman
- Brisbane Hand and Upper Limb Clinic, Brisbane, Queensland, Australia
| | - Brian Dean
- Auxilium Pharmaceuticals, Inc., Chesterbrook, PA
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