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

Surgical Management of Dupuytren Disease: A Systematic Review and Network Meta-analyses

BACKGROUND

Dupuytren disease is a common fibroproliferative disease that affects the palmar fascia of the hands. Currently, there is limited consensus regarding the optimal therapy for this condition, with treatment decisions based largely on surgeon preference. Therefore, the aim of this study was to determine which treatments are the most effective for Dupuytren disease.

METHOD

A systematic review and network meta-analyses were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. Medline, EMBASE, and Web of Science were searched for randomized trials comparing treatments for Dupuytren disease in adults. Eligible treatments included open limited fasciectomy, collagenase injection, and percutaneous needle fasciotomy. Study selection, data extraction, and quality appraisal were performed in duplicate. The methodological quality was evaluated with the Cochrane risk-of-bias critical appraisal tool.

RESULTS

Eleven randomized clinical trials were included in this study. At short-term (1-12 weeks) and long-term (2-5 years) time points, fasciectomy improved contracture release more than collagenase and needle fasciotomy as inferred by a lower total passive extension deficit. However, there was no difference between the groups regarding the best possible outcome at any time point. Fasciectomy was also superior in terms of recurrence and patient satisfaction compared with collagenase and needle fasciotomy, but only at later time points. There was no difference in skin damage-related and nerve damage-related complications following fasciectomy compared with other modalities. Risk of bias was generally moderate.

CONCLUSIONS

Fasciectomy provides superior long-term advantages in terms of patient outcomes when compared with collagenase and needle fasciotomy. Larger trials with better blinding of outcome assessors are needed in the future.

Randomized Controlled Trial Comparing the Clinical Effectiveness of Collagenase Injection (Xiaflex®) and Palmar Fasciectomy in the Management of Dupuytren's Contracture

Introduction: Limited palmar fasciectomy (LPF) and collagenase injection (CI) are the most common procedures to manage symptoms of Dupuytren's Disease. This randomized controlled trial (RCT) aimed to directly compare patient outcomes 12 months following CI and LPF. Methods: Twenty-two patients with Dupuytren's Disease were randomized to either LPF or CI. The primary outcome was health state measured by the Michigan Hand Questionnaire. Secondary outcomes were health status (The Health Utility Index-3), function (The Unité Rhumatologique des Affections de la Main and The Southampton Dupuytren's Scoring Scheme), and range of motion (ROM) of treated digits. Measurements were collected at baseline and 1-, 3-, 6-, and 12-months post-procedure. Results: Thirteen patients were randomized to the LPF and eight patients to the CI group. Most patients (85.7%) were male; the average age of the sample was 65.3 years. No statistically significant difference in the MHQ (mean difference [MD]: -12.4 (95% confidence interval [CI]: -30.0, 5.2)), SDSS (.9 (-4.0, 5.8)), URAM (-.9 (-14.4, 12.6)) or HUI-3 (-.04, -.2, .2)) was found between groups 12-months post-operatively. There was no statistically significant difference in 12-month loss of extension between groups at the MCP (-16.9 (-35.4, 1.7) or PIP (-2.9 (-22.9, 17.1) joints. Three CI patients and 1 LPF patient developed a contracture in the same digit requiring surgery. Conclusion: Results should be interpreted with caution given the small sample size. Available data suggests both techniques are reasonable for managing Dupuytren's Disease. Considerations for future RCTs are provided.

Dupuytren's Contracture: Approach to Treatment and Counseling Patients in 2024

Dupuytren disease is a progressive disease process that causes debilitating flexion contractures of the metacarpophalangeal and proximal interphalangeal joints. There are multiple interventions to choose from, ranging from minimally invasive techniques with little downtime to open surgical excision with a lengthy postoperative rehabilitation. Our understanding of the disease process continues to evolve. Depending on the extent of flexion contracture, needle aponeurotomy and collagenase injection have satisfactory results with moderate long-term efficacy. Surgical palmar fasciectomy continues to be the mainstay treatment of extensive contractures, with durable results.

Clinical Outcomes of Collagenase Injections in Management of Dupuytren Contracture of the Proximal Interphalangeal Joint

Purpose

Dupuytren contracture is characterized by the formation of cords and nodules in the palm. Surgical release has historically been the definitive treatment. Collagenase clostridium histolyticum (CCH) has been used successfully as an alternative to surgery. The treatment of proximal interphalangeal (PIP) contractures is the most challenging. The purpose of this study was to evaluate CCH treatment for Dupuytren contracture of the PIP joint.

Methods

A retrospective chart review was performed for CCH treatment of Dupuytren contracture at a single institution from January 2010 to April 2023. Data collected included pretreatment/posttreatment total flexion contracture and adverse events. Contractures were analyzed both by severity (high >40° and low <40°) and type (isolated PIP; combined metacarpophalangeal and PIP).

Results

A total of 304 patients with 470 PIP joints treated were included. Digits with isolated and combined contractures each had an average pre-CCH treatment contracture of 51 (±23) degrees. Postmanipulations the contractures were 6 (±13) and 7 (±16) degrees, respectively. Clinical success (<5° residual contracture) and improvement (>50% correction of contracture) were associated with low severity contractures at postmanipulation. There were 256 adverse events recorded (54.5%), including 187 skin tears (39.8%), 68 cases of lymphadenopathy (14.5%), and one injection site infection (0.2%). High severity and combined contractures were independently associated with an increased incidence of skin tears upon manipulation.

Conclusions

Collagenase clostridium histolyticum treatment is effective for isolated or combined PIP joint contractures. Adverse events were associated with more severe contractures. Given the degree of improvement based on contracture severity, earlier intervention may provide better correction of contracture.

Type of study/level of evidence

Therapeutic III.

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.

Sex Difference in the Treatment of Dupuytren's Disease: A Systematic Review and Meta-Analysis of Clinical Trials

Purpose: The aim of this study was to assess the sex differences in enrollment into clinical trials for Dupuytren's disease (DD), treatment efficacy, and complications. Methods: Three databases were searched; Ovid MEDLINE, Ovid EMBASE, and EBSCO CINAHL. Included studies were clinical trials on adult patients with DD. Exclusion criteria were non-English studies and other study designs. Two independent reviewers completed abstract screening, full-text review, and data extraction. The number and percentage of studies that reported ad hoc analyses for sex differences in treatment efficacy, tolerability, and complications were reported. A meta-analysis was performed on the proportion of female participants enrolled in clinical trials for DD. Results: A total of 3172 references were screened, and 59 studies were identified for full-text review. We identified 28 clinical trials for DD of which none reported secondary analyses for sex differences. Only 2 trials discussed sex differences in complications, and one trial reported sex differences in tolerability. The proportion of female participants in the meta-analysis was 19.5% [95% CI: 16.1-23.0%]. Conclusion: Sex differences in the clinical trials for DD are not widely considered in clinical trials despite their critical role. Males and females do not have equal representation in clinical trials for DD. Future studies should account for sex differences in the design and the analysis of clinical trials.

Uterine fibroids: current research on novel drug targets and innovative therapeutic strategies

INTRODUCTION

Uterine fibroids, the most common nonmalignant tumors affecting the female genital tract, are a significant medical challenge. This article focuses on the most recent studies that attempted to identify novel non-hormonal therapeutic targets and strategies in UF therapy.

AREAS COVERED

This review covers the analysis of the pharmacological and biological mechanisms of the action of natural substances and the role of the microbiome in reference to UFs. This study aimed to determine the potential role of these compounds in UF prevention and therapy.

EXPERT OPINION

While there are numerous approaches for treating UFs, available drug therapies for disease control have not been optimized yet. This review highlights the biological potential of vitamin D, EGCG and other natural compounds, as well as the microbiome, as promising alternatives in UF management and prevention. Although these substances have been quite well analyzed in this area, we still recommend conducting further studies, particularly randomized ones, in the field of therapy with these compounds or probiotics. Alternatively, as the quality of data continues to improve, we propose the consideration of their integration into clinical practice, in alignment with the patient's preferences and consent.

Challenges and innovations in the surgical treatment of advanced Dupuytren disease by percutaneous needle fasciotomy: indications, limitations, and medico-legal implications

BACKGROUND

Dupuytren disease, a chronic thickening and retraction of the palmar aponeurosis of the hands, may result in permanent and progressive flexion of one or more fingers. Percutaneous needle fasciotomy is a simple method that uses a hypodermic needle usually performed under local anaesthesia. The study aim was to report the postoperative results and complications using a percutaneous approach to treat Dupuytren contracture in a consecutive series of patients with advanced Dupuytren disease, also considering the relevant medico-legal implications.

METHODS

Retrospective multicentre study of all patients with Tubiana stage 3-4 Dupuytren contracture treated with percutaneous needle aponeurotomy, with no ultrasound assistance, from 2012 to 2022. Patient demographics, disease severity, treatment-related complications, and the incidence of recurrence were identified. An overview of therapeutic treatment options has accounted for 52 relevant sources spanning the 2007-2023 time period.

RESULTS

Overall, 41.7% (N = 200) of patients were females, the mean age was 72 years (60-89), the right hand was treated in 54.2% (N = 260) of patients. The little finger was involved in 50% of the patients. The 12 months mean PED was 9°, the mean quickDASH was 8, the mean URAM 6. Minor complications were reported in 18.7% (N = 90) of patients, typically skin lacerations (83.3%) with no clinical sequelae, and no major complications were reported. Recurrence occurred in 30% (N = 144) of patients.

CONCLUSIONS

Percutaneous needle fasciotomy is safe and reliable even in patients with advanced Dupuytren disease, resulting in predictably acceptable outcome with low risk of complications.

A 10-Year Review of Collagenase Versus Fasciectomy in the Treatment of Dupuytren Contracture

BACKGROUND

Dupuytren disease (DD) is one of the most common disorders of the hand, affecting 5.7% to 11.7% of the global population. This study seeks to evaluate the 10-year efficacy of the 2 most prominent treatment modalities for DD in Veterans Affairs hospitals, injectable collagenase Clostridium histolyticum versus open fasciectomy.

METHODS

A retrospective review was conducted of all electronic medical records of patients who underwent open fasciectomy or collagenase injection to treat their persistent Dupuytren contracture between April 2011 and April 2021. All procedures were performed by 1 of 5 senior surgeons at the same Veterans Affairs Hospital.

RESULTS

A total of 232 patients were treated for DD, with 247 collagenase injections and 44 open fasciectomies performed in this sample. Collagenase patients were, on average, 6.51 years after intervention at the time of review. Open fasciectomy patients were, on average, 4.56 years after operation at the time of review. Collagenase decreased contractures, on average, by 29.40 degrees, whereas open fasciectomy decreased contractures, on average, by 38.59 degrees. Of the contractures that were initially classified as resolved, 50 of 155 (32.2%) treated with collagenase and 6 of 56 (10.7%) treated with open fasciectomy recurred. The use of open fasciectomy compared with collagenase injections to treat contracture was associated with a 74.2% decrease in the likelihood of recurrence.

CONCLUSIONS

This study found that treatment of DD with collagenase injection is associated with a significantly lower degree of deformity correction, lower rate of resolution, and increased rate of recurrence when compared with open fasciectomy.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

III.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Industry Sponsorship Bias in Collagenase Clinical Trials for Dupuytren Disease: A Meta-analysis

BACKGROUND

Collagenase clostridium histolyticum (collagenase) was introduced in 2010 creating a nonoperative treatment option for Dupuytren disease with promising results in sponsored clinical trials. A meta-analysis was performed to investigate industry sponsorship bias.

METHODS

A systematic review of collagenase treatment of Dupuytren contracture was conducted. Articles containing mesh terms including "microbial collagenase" and "Dupuytren's contracture" were searched and limited to only clinical trials with similar protocols for inclusion. Meta-analysis of treatment endpoints of correction of contracture to 0-5 degrees after first and last injection was conducted comparing sponsored versus nonsponsored studies.

RESULTS

Sixteen of the 29 identified articles met criteria for inclusion. Nonsponsored studies reported a significantly higher rate of meeting the primary treatment endpoint compared to sponsored studies after single injection for all joints (69.6% vs 56% P < 0.01), metacarpophalangeal joint (96% vs 64% P < 0.01), and proximal interphalangeal joint (67% vs 36% P = 0.011). The correction in contracture rates was similar between groups with studies evaluating more than one injection.

CONCLUSIONS

Nonsponsored studies published higher success rates in meeting the primary endpoint of full correction after single injection than sponsored studies; however, similar results with multiple injections. This study demonstrated that sponsored studies of collagenase produced highly powered studies that may be reliably depended on for evidence-based clinical application.

Scarring and Skin Fibrosis Reversal with Regenerative Surgery and Stem Cell Therapy

Skin scarring and fibrosis affect millions of people worldwide, representing a serious clinical problem causing physical and psychological challenges for patients. Stem cell therapy and regenerative surgery represent a new area of treatment focused on promoting the body's natural ability to repair damaged tissue. Adipose-derived stem cells (ASCs) represent an optimal choice for practical regenerative medicine due to their abundance, autologous tissue origin, non-immunogenicity, and ease of access with minimal morbidity for patients. This review of the literature explores the current body of evidence around the use of ASCs-based regenerative strategies for the treatment of scarring and skin fibrosis, exploring the different surgical approaches and their application in multiple fibrotic skin conditions. Human, animal, and in vitro studies demonstrate that ASCs present potentialities in modifying scar tissue and fibrosis by suppressing extracellular matrix (ECM) synthesis and promoting the degradation of their constituents. Through softening skin fibrosis, function and overall quality of life may be considerably enhanced in different patient cohorts presenting with scar-related symptoms. The use of stem cell therapies for skin scar repair and regeneration represents a paradigm shift, offering potential alternative therapeutic avenues for fibrosis, a condition that currently lacks a cure.

Collagenase Clostridium Histolyticum for the Treatment of Dupuytren Disease: A Delphi-Based Consensus Study

Purpose

The aim of this study was to establish the consensus recommendations among hand surgeons who were experts in the use of collagenase clostridium histolyticum (CCH) on the appropriate treatment of Dupuytren disease in well-defined patient populations with varying degrees of disease severity and functional impairment.

Methods

A three-round, blinded, modified Delphi process examined panelists' approaches to CCH treatment of metacarpophalangeal (MP) or proximal interphalangeal (PIP) joint contractures involving one or two fingers with varying degrees of severity. Clinical scenarios related to poor-quality skin, postfasciectomy scarring, boutonnière deformity, closed capsulotomy, and blood thinner use were also presented for panelist consideration. Panelists provided responses to clinical scenarios using a 5-point Likert scale or a yes/no response. Consensus was defined as ≥66.7% panelist agreement or disagreement.

Results

Twenty panelists completed round 1; 19 of the 20 panelists completed rounds 2 and 3. Panelists achieved a high level of consensus for using CCH for the treatment of patients with palpable cords and varying severity contractures representing one- or two-finger MP joint contractures, most one- or two-finger PIP joint contractures, and most combined MP and PIP joint contractures. Consensus for the treatment of PIP joint contractures was mostly achieved, but clinical scenarios related to recurrent PIP contracture with poor-quality skin and/or significant postfasciectomy scarring, boutonnière deformity, PIP contractures >70°, closed capsulotomy, and blood thinner use were modified, and then most (95.3%) statements reached consensus for agreement in round 2. In round 3, open-ended responses indicated that panelists considered CCH appropriate for most patients with Dupuytren disease.

Conclusions

Consensus-based findings among expert hand surgeons with substantial CCH experience indicated that CCH has a wide-ranging application for the treatment of Dupuytren disease in patients with varying degrees of disease severity and functional impairment.

Type of study/level of evidence

Therapeutic V.

The Fragility of Landmark Randomized Controlled Trials in the Plastic Surgery Literature

Background

Randomized controlled trials (RCTs) are integral to the progress of evidenced-based medicine and help guide changes in the standards of care. Although results are traditionally evaluated according to their corresponding P value, the universal utility of this statistical metric has been called into question. The fragility index (FI) has been developed as an adjunct method to provide additional statistical perspective. In this study, we aimed to determine the fragility of 25 highly cited RCTs in the plastic surgery literature.

Methods

A PubMed search was used to identify the 25 highest cited RCTs with statistically significant dichotomous outcomes across 24 plastic surgery journals. Article characteristics were extracted, and the FI of each article was calculated. Additionally, Altmetric scores were determined for each study to determine article attention across internet platforms.

Results

The median FI score across included studies was 4 (2-7.5, interquartile range). The two highest FI scores were 208 and 58, respectively. Four studies (16%) had scores of 0 or 1. Three studies (12%) had scores of 2. All other studies (72%) had FI scores of 3 or higher. The median Altmetric score was 0 (0-3).

Conclusion

The FI can provide additional perspective on the robustness of study results, but like the P value, it should be interpreted in the greater context of other study elements.

Patient Insight With Collagenase Treatment for Dupuytren: A Prospective Study

PURPOSE

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

Dupuytren Cords Do Not Undergo Significant Histopathological Change After Collagenase Clostridium Histolyticum Injection

Background: Dupuytren disease creates thickened cords of the palmar fascia, leading to progressive flexion contractures that severely hinder hand function. Collagenase clostridium histolyticum (CCH) injection is a common, minimally invasive alternative to surgical excision of these cords. The impact of CCH injection on the histological architecture of Dupuytren cords has not been studied extensively. Methods: A series of 10 CCH-injected cords were evaluated histologically. Cellularity, architecture, and connective tissue organization were compared against uninjected Dupuytren cords and normal palmar fascia. Results: No significant histopathological differences between CCH-injected and CCH-uninjected cords were identified. Conclusions: Dupuytren cords do not demonstrate histological changes with prior exposure to CCH.

Assessing the Effect of Time from Injection of Collagenase to Manipulation on Success Rates in Dupuytren Disease

PURPOSE

Dupuytren disease can be managed with an injection of collagenase Clostridium histolyticum enzyme followed by manual manipulation. Although the recommended time from injection to manipulation is 24-72 hours, patient and physician schedules may not accommodate this time frame. Therefore, we sought to study the impact of time from injection to manipulation on outcomes and complications of collagenase injection.

METHODS

We performed a review of 309 patients who underwent an injection of collagenase Clostridium histolyticum for Dupuytren disease with manipulation at two, five, or seven days after injection. We compared preinjection and postinjection contracture angles as well as frequency of skin tears and tendon ruptures.

RESULTS

Of the 309 patients, 207 underwent manipulation at two days, 32 at five days, and 70 at seven days. Patients had similar preinjection contracture angles. All patients demonstrated improvement in contracture after manipulation. Rates of skin tears and tendon ruptures were similar in all three groups. Significant predictors of complications included number of cords injected and history of previous collagenase injection, but not history of previous Dupuytren diagnosis.

CONCLUSIONS

Although collagenase injection for Dupuytren disease is typically performed with plans for manipulation at 24-72 hours, postinjection manipulation could be performed as late as seven days without adversely affecting the frequency of skin and tendon complications.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

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

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

Validation of a Handprint for Clinical Evaluation of Dupuytren's Contracture

Objective  We have developed a handprint-based method for visualizing and quantifying the palmar contact of patients with Dupuytren's contracture. The purpose of this study was to examine whether the generated handprint was useful for assessing the severity of flexion contracture of the fingers and for evaluating the therapeutic effects of collagenase clostridium histolyticum (CCH) injection for Dupuytren's contracture. Methods  The handprint was created by applying medical-grade ethanol-containing hand sanitizer over the entire palmar surface of the affected hand and then pressing it on thermal paper for word processors. The reliability of the handprint was evaluated through test-retest of 10 healthy volunteers at an interval of 10 days, and the validity of the handprint was assessed using a flexion contracture model in which the little finger was fixed in an Alfence splint. In addition, we obtained handprints of the affected hand in 33 patients with unilateral Dupuytren's contracture both before CCH injection and at the final observation after injection to investigate the contact area of the hand (CAH) and the length of the hand (LH). The relationships between CAH, LH, total extension deficit angle (TEDA), and patient-reported outcome measures (Japanese Society for Surgery of the Hand Version of the Quick Disability of Arm, Shoulder, and Hand Questionnaire [Quick DASH-JSSH] and Hand20) were examined. Results  The test-retest correlation coefficient was 0.9187 ( p  < 0.001) for CAH and 0.9052 ( p  < 0.001) for LH, indicating high reliability of the handprint. The ratios of CAH and LH decreased gradually as the contracture angle of the splinted finger increased. The handprint revealed a marked improvement of palmar contact after CCH injection for Dupuytren's contracture. Furthermore, the ratios of CAH and LH were strongly correlated with TEDA, Quick DASH-JSSH, and Hand20 before treatment. Conclusion  Our handprint-based assessment method was extremely useful for clinical evaluation of CCH treatment for Dupuytren's contracture. Type of Study/Level of Evidence  Therapeutic.

Outcomes Following Repeat Collagenase Treatment of Dupuytren Contracture

PURPOSE

Injectable collagenase Clostridium histolyticum has been an effective and well-tolerated nonsurgical treatment option for the management of Dupuytren contracture of the hand. The purpose of this study was to determine the efficacy of collagenase injection and adverse event rate in patients who had undergone previous collagenase treatment.

METHODS

A retrospective chart review was performed on 332 patients treated with collagenase injection for Dupuytren contracture by three fellowship-trained hand surgeons at a single institution from 2009 to 2019. Fifty-nine joints in 45 patients underwent repeat collagenase therapy for recurrent contracture in the same digit. Pretreatment and posttreatment total metacarpophalangeal and proximal interphalangeal joint flexion contractures were recorded, with complete correction defined as <5° residual digital flexion contracture. Postmanipulation skin tears and adverse events were recorded. A comparison was made between average contracture improvement after initial collagenase injection and that after repeat injection.

RESULTS

Forty-five patients with an average duration of 30 months (range, 6-73 months) between initial and repeat collagenase therapies were identified. The mean improvement after first collagenase injection was 45° ± 24° (39° for metacarpophalangeal joint and 50° for proximal interphalangeal joint) compared with a mean improvement of 43° ± 23° (41° for metacarpophalangeal joint and 44° for proximal interphalangeal joint) after second injection. Although similar complete correction rates and skin tear rates (32.2 % for initial and 30.5% for repeat) were observed between initial (80%) and repeat injections (73%), the occurrence of adverse events was 3 times higher (3.4% for initial and 10.2% for repeat) in the latter group.

CONCLUSIONS

Collagenase treatment of Dupuytren contracture yields effective total flexion contracture correction. Repeat collagenase treatment of previously treated digits yields similar deformity correction and complete correction rates but a higher incidence of adverse events.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Dose- and time-dependent effects of collagenase clostridium histolyticum injection on transverse carpal ligament elastic modulus and thickness in vitro

A potential treatment for carpal tunnel syndrome is to biochemically alter the mechanical properties of the transverse carpal ligament (TCL) through Collagenase Clostridium Histolyticum (CCH) injection. The purpose of this study was to determine the time- and dose-dependent effects of CCH injection on TCL elastic modulus and thickness. Nine TCLs were dissected from cadaveric hands for this study. CCH doses of 50U, 100U, 150U, 200U, and 250U were injected into five points on the TCL, respectively. B-mode and shear wave elastography images were taken of each injection point using robot-assisted ultrasound imaging immediately after injection, as well as 2, 4, 6, 8, and 24 hours after injection. TCL thickness and mean shear wave speed were measured for each CCH dose at each time point. CCH doses of 200U and 250U decreased shear wave speed by 18.70% and 30.01% (p<0.05), respectively, after 24 hours. CCH doses of 150U, 200U, and 250U decreased TCL thickness by 7.28%, 10.97%, and 14.92%, respectively, after 24 hours (p<0.05). Our findings suggest that CCH injection may be effective in degrading TCL tissue, with higher doses of CCH resulting in greater tissue degradation up to 24 hours after injection.

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.

Short-term efficacy and adverse effects of collagenase clostridium histolyticum injections, percutaneous needle fasciotomy and limited fasciectomy in the treatment of Dupuytren’s contracture: a network meta-analysis of randomized controlled trials

Aims

Dupuytren’s contracture (DC) is a chronic debilitating fibroproliferative disorder.

Common treatment options include collagenase clostridium histolyticum injections (CI), percutaneous needle fasciotomy (NF) and limited fasciectomy (LF). Superiority of one specific treatment remains controversial. This study aims to assess the short-term efficacy and safety of CI, NF, and LF for the treatment of DC.

Methods

We included randomized controlled trials of CI compared with placebo, NF and LF for patients with DC. PubMed, Embase and the Cochrane Library were searched from inception to August 2021. Contracture reduction rates in treated joints (within 0–5° of full extension within 30 days), relative reduction in total passive extension deficit (TPED), occurrence of one or more adverse events and number of treatment-related adverse events per patient were the outcomes of interest. The Cochrane risk-of-bias tool was employed for quality assessment of the studies. A network meta-analysis was performed using MetaXL.

Results

Nine studies met our inclusion criteria (n = 903). Overall, risk bias was mixed and mostly low. Short term TPED reduction achieved with LF was superior compared to CI and NF. Although CI achieved greater TPED reduction compared to NF, it was associated with the highest risk of overall adverse effects. The analyzed data was limited to a maximum three-year follow-up period and therefore insufficient for long-term outcome evaluation.

Conclusions

In DC, LF may be able to provide patients with severe disease, superior flexion contracture release postoperatively. CI is a valid treatment alternative to NF, however the higher risk of overall adverse effects must be considered. The quality-of-evidence is limited due to short-term follow-up periods and a lack of standardized definitions of complications and adverse events.

Treatment of Dupuytren's Contracture With Collagenase: A Systematic Review

This systematic review investigates complications and recurrence of Dupuytren's contracture in metacarpophalangeal joints (MCPJs) and/or proximal interphalangeal joints (PIPJs) of fingers treated with collagenase clostridium histolyticum (CCH). A review of the literature on Dupuytren's disease was performed using PRISMA guidelines. Included publications described complications and/or recurrences for contractures ≥20° in MCPJs and/or PIPJs treated with CCH. Successful treatments reduced contractures to ≤5° immediately. Treatment-related adverse events (AEs) were classified as minor, major surgical, and major nonsurgical. Contracture recurrence involved return of fixed-flexion contracture ≥20° in a successfully treated finger in patients with ≥12 months of follow-up. Of 2675 patients (3753 joints), 94% experienced ≥1 treatment-related AE, most commonly peripheral edema (64%), pain in extremity (53%), and contusion (51%). Major surgical complications occurred in 9 patients (1.0%). Major nonsurgical complications occurred in 2 patients, specifically nonrupture tendon injury and anaphylaxis. Of 1488 patients (2069 joints), recurrences were reported in 23% of successfully treated joints (n = 466; 20% MCPJs, 28% PIPJs), on average 12 to 24 months after treatment. MCPJs achieved greater success than PIPJs in initial contracture reduction (77% versus 36%). CCH is a safe, effective treatment to improve hand function in Dupuytren's contracture. Most AEs are minor and self-resolving, although the risk of major AEs still exists. Following treatment, 23% of successfully treated joints experience recurrence, typically within 12 to 24 months but sometimes as early as 6 months. Surgeons are encouraged to discuss these risks with patients for shared decision-making regarding optimal treatment modalities.

Real-world Medicare Healthcare Costs of Patients with Dupuytren's Contracture Treated with Collagenase or Fasciectomy

Background

Our study aimed to compare real-world healthcare resource utilization (HRU) and healthcare cost (HC) of Medicare-insured patients (≥65 years old) with Dupuytren's contracture (DC) treated with Clostridium histolyticum (collagenase) or fasciectomy.

Methods

DC patients treated with collagenase or fasciectomy between July 2011 and June 2017 were identified using the IBM MarketScan Medicare Supplemental Database. The index date was the date of the first procedure. Demographic characteristics were captured on the index date, and comorbidities were assessed during the 24-month preindex period. HRU and HC were analyzed throughout the 12-month postindex period. Patients were matched using propensity score weights. Gamma log-linked generalized linear models were used to evaluate HC drivers.

Results

Out of 37,374 DC patients, 2911 received collagenase, while 6258 underwent fasciectomy. Postmatching, the total average annual HC was similar between collagenase and fasciectomy ($7271 versus $6220, P = 0.357). When HCs were stratified by the service provider, outpatient facility and physician office costs were lower in the collagenase cohort ($850 versus $1284, P = 0.047 and $546 versus $1001, P < 0.001). The costs of professional services were significantly higher than in the fasciectomy cohort due to the cost of collagenase injection ($1682 versus $629, P < 0.001). The HRU was similar between cohorts, except for more frequent outpatient facility visits in fasciectomy patients (12.3 versus 22.9, P < 0.001). Generalized linear model revealed Charlson comorbidity index, plan type, patients' residence region, sleep disorder, and hyperlipidemia as significant predictors of total HC.

Conclusion

This study found comparable total annual HC and HRU between collagenase- and fasciectomy-treated Medicare patients.

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

Background

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

Methods

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

Results

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

Conclusion

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

A 12-Year Review of Clinical Practice Patterns in Dupuytren Contracture Based on Continuous Certification by the American Board of Plastic Surgery

BACKGROUND

The American Board of Plastic Surgery collects data on 20 common plastic surgery operations as part of the Continuous Certification process. The goal of this study was to describe clinical trends in Dupuytren contracture repair since 2008 as they relate to evidence-based medicine articles published in this timeframe.

METHODS

Cumulative tracer data for Dupuytren contracture were reviewed for the period from February of 2008 to March of 2020 and compared with evidence-based medicine articles published in Plastic and Reconstructive Surgery . Topics were categorized as (1) pearls, addressed in both the tracer data and evidence-based medicine articles, (2) topics only addressed in tracer data, and (3) topics only addressed in evidence-based medicine articles.

RESULTS

As of March of 2020, 230 cases of Dupuytren contracture had been entered. The median age at time of surgery was 65 years (range, 38 to 91 years). Practice patterns from 2008 through 2014 were compared with those between 2015 and 2020. The most common surgical technique was limited fasciectomy (62 percent of cases). Differences in practice between these time periods included decrease in the use of radical fasciectomy (34 percent versus 16 percent, p = 0.002), increase in percutaneous cordotomy (0 percent versus 13 percent), and increase in the use of collagenase injections (0 percent versus 9 percent, p = 0.001). Use of Bier blocks increased (1 percent versus 7 percent), and tourniquet use decreased (97 percent versus 80 percent). Significant changes were also noted in postoperative management.

CONCLUSION

By examining American Board of Plastic Surgery tracer data, the authors have described national trends in presentation and surgical techniques for Dupuytren contracture repair over a 14-year period.

Treatment practice for Dupuytren disease in Belgium before 2020: results from an online survey

The treatment of Dupuytren disease (DD) continues to evolve. New insights in risk factors for recurrence and new treatment modalities have changed the management strategies for DD over the past decades. However, several differences may remain between these insights and their clinical application. The current tendencies in management of Dupuytren disease, were investigated in a web-based survey. The survey was sent to all members of the Belgian Hand Group, the professional organisation of hand surgeons in Belgium. The participants indicated their preferred treatment for clinical cases and answered questions on the use and timing of splinting, physiotherapy, medication and adapting the management depending on fibrosis diathesis. These findings were compared to recommendations found in the literature. Forty out of 135 surveyed members of the Belgian Hand Group completed the survey and 7 responded incompletely, yielding a response rate of 35% for most questions. This is comparable to similar studies. There appeared to be still room for debate on surgical techniques for difficult cases. CCH use increased since reimbursement became available in Belgium, mainly due to satisfying clinical results for patient and surgeon. The survey demonstrated a wide variety in pre- and postoperative splinting protocols, but consensus existed with the literature on postoperative night-time application of orthoses for 7 to 12 weeks.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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).

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

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

Treatment Options for Dupuytren’s Disease: Tips and Tricks

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

Dupuytren's disease: using needles more across the world

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

The past, present, and future of enzyme-based therapies

Enzyme-based therapeutics (EBTs) have the potential to tap into an almost unmeasurable amount of enzyme biodiversity and treat myriad conditions. Although EBTs were some of the first biologics used clinically, the rate of development of newer EBTs has lagged behind that of other biologics. Here, we review the history of EBTs, and discuss the state of each class of EBT, their potential clinical advantages, and the unique challenges to their development. Additionally, we discuss key remaining technical barriers that, if addressed, could increase the diversity and rate of the development of EBTs.

Cost-Effectiveness and Patient Outcomes of Injectable Collagenase to Treat Dupuytren’s Contracture

Introduction

Dupuytren’s contracture is a disabling and progressive flexion contracture of the hand that is often treated by a surgical release. Collagenase clostridium histolyticum injection (CCH-I) was introduced to the UK in 2011 as an alternative and less invasive treatment for contracture. The purpose of this study was to evaluate the cost-effectiveness and patient-reported outcome measures (PROMs) of treating Dupuytren’s contracture with collagenase compared to surgery.

Methods

A retrospective review identified 151 patients who underwent CCH-I (n=94), limited fasciectomy (LF; n=38) and percutaneous needle fasciotomy (PNF; n=19). Outcomes included PROMs (satisfaction, QuickDASH), complication rates (recurrence, reintervention) and direct costs.

Results

Standardised treatment costs for CCH-I, LF and PNF were £1,125.82, £3,438.28 and £1,143.32 respectively. Collagenase presented a cost-benefit of £88,205 had the LF/PNF group undergone CCH-I. At a mean six-year follow-up, there were no significant differences in complication rates (=0.621) or QuickDASH scores (p=0.157). Collagenase-treated patients reported the highest satisfaction and lowest recurrence rates.

Discussion

Collagenase presents a significant cost reduction with superior PROMs relative to surgery for treating single-digit contracture.

Conclusion

Outpatient CCH-I is a cost-effective treatment with fewer clinical encounters, a similar risk profile to LF/PNF and high levels of patient satisfaction, which warrants serious consideration in light of overburdened waiting lists due to COVID-19.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

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.

Dupuytren Contractures: An Update of Recent Literature

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

Dupuytren's Disease: An Outcomes-Focused Update

Dupuytren's disease (DD) remains a common fibroproliferative condition with significant sequelae and impact on patient's lives. The etiology of DD is poorly understood, and genetic predisposition is thought to be a strongly associated factor. Despite remarkable strides in improving our molecular understanding of DD, clinical treatment options have not yet overcome the frequently encountered challenge of recurrence. Recurrence rates continue to shape the prognosis of this fibrotic condition. In this outcomes-focused article, the various treatment modalities are reviewed. This further emphasizes the importance of patient education and providing them with the information to make informed decisions about their treatment.

Does Use of a Night Extension Orthosis Improve Outcomes in Patients With Dupuytren Contracture Treated With Injectable Collagenase?

Purpose

Current prescribing information for the treatment of patients with Dupuytren contracture with injectable collagenase Clostridium histolyticum (CCH) recommends use of a night extension orthosis for 4 months after treatment. The present study examines whether this treatment improves the outcomes.

Methods

Adult patients with Dupuytren contracture treated with CCH during the study period were eligible for inclusion. The patients were randomized to orthosis or no orthosis groups and were stratified based on the severity of contracture prior to randomization. The orthosis group was fitted postmanipulation with a hand-based custom orthosis that held the treated finger in maximal comfortable extension, and the patients were instructed to wear the orthosis at night for 3 months. The patients were assessed at 7–10 days, 30 days, and 90 days postmanipulation. Orthosis compliance was measured with a survey. The primary outcome measure was improvement in total active extension (TAE), defined as the sum of active metacarpophalangeal (MCP), proximal interphalangeal, and distal interphalangeal joint extension in the treated finger at 90 days after treatment. Secondary outcomes included total active flexion (TAF), Michigan Hand Questionnaire scores, patient satisfaction, and clinical success.

Results

Twenty-six patients completed the study, 12 in the orthosis group and 14 in the no orthosis group. The majority of contractures (90%) were primarily through the MCP joint. The patients in both the groups demonstrated significant improvements in TAE at 90-day follow-up (orthosis P = .002, no orthosis P = .001) . The difference in improvement in the median TAE between the 2 groups was not significant (P = .40). There were no significant differences between groups for TAE, TAF, Michigan Hand Questionnaire scores, patient satisfaction, or clinical success at any of the time points assessed (P > .05).

Conclusions

In patients with Dupuytren contracture with primarily MCP joint involvement, providing an orthosis after treatment with CCH may not offer a short-term benefit compared with CCH treatment alone in terms of TAE, TAF, or patient-reported outcome measures.

Type of study/level of evidence

Therapeutic I.

Percutaneous Needle Fasciotomy versus Collagenase Injection for Dupuytren's Contracture: A Systematic Review of Comparative Studies

Introduction  The purpose of this study was to review and compare clinical outcomes between percutaneous needle fasciotomy (PNF) and collagenase Clostridium histolyticum (CCH) injection for the treatment of Dupuytren's contracture. Materials and Methods  A systematic review was performed including all level I-III evidence studies investigating the clinical outcomes of PNF and CCH injection in the treatment of Dupuytren's contracture. Results  Five studies (278 CCH patients, 225 PNF patients; 285 CCH fingers, 246 PNF fingers, 405 males, and 98 females) were analyzed. Two randomized studies were level I evidence, one randomized study was level II, and two nonrandomized studies were level III. Two studies analyzed a total of 205 patients, each demonstrating statistically superior outcomes in one outcome measure (contracture improvement and Michigan Hand Questionnaire (MHQ) satisfaction subscore) with PNF, while the remaining three studies demonstrated no significant differences in outcomes between the two techniques. Three studies reported a statistically higher rate of minor complications (local pain, edema, ecchymosis, lymphadenopathy, pruritis) with CCH, while the remaining two studies demonstrated no significant difference in complication rates. Conclusion  For the treatment of Dupuytren's contracture, there is some evidence that suggests superior clinical outcomes of PNF compared with CCH and a higher minor complication rate with CCH.

Collagenase-loaded pH-sensitive nanocarriers efficiently remodeled tumor stroma matrixes and improved the enrichment of nanomedicines

The dense extracellular matrix (ECM) in tumor tissue severely hinders the penetration and enrichment of antitumor nanomedicines, which could significantly affect their efficiency. In this study, we used pH-sensitive nanocarriers loaded with collagenase (Col) to remold the tumor microenvironment (TME). Furthermore, we combined the collagenase delivery system with a nanomedicine to improve its penetration and enrichment in the tumor, thereby improving efficacy. We synthesized acetalated dextran (Ace-DEX) with an ideal pH-sensitivity as the carrier material of collagenase. Under mild preparation conditions, collagenase was loaded into Ace-DEX nanoparticles (NPs) with a high loading capacity (>4%) and remained highly active (>90%). Col-carrying NPs (Col-NPs) significantly reduced the tumor collagen content by 15.1%. Pretreatment with Col-NPs increased the accumulation of doxorubicin (DOX)-loaded liposome (DOX-Lipo) in the tumor by 2.8-fold. There were no safety concerns as the Col-NP showed no significant toxicity and reduced Col-induced damage to healthy tissues. Additionally, the number of circulating tumor cells remained unchanged after Col-NP treatment, suggesting no increased risk of tumor metastasis. Because the Col-NP acts essentially independent of the subsequent treatment, it has considerable potential for enhancing many existing delivery systems and drugs for cancer treatment. It may also be used for treating other collagen-related diseases.

Tissue adaptation rate in the treatment of Dupuytren contracture

STUDY DESIGN

Basic research (cross-sectional).

INTRODUCTION

Dupuytren disease can cause disabling contractures of the finger joints. After partial fasciectomy, postoperative hand splinting helps to maintain extension range of motion.

PURPOSE OF THE STUDY

To measure how the contraction forces of the finger on the splint change over time.

METHODS

Subjects who were treated for Dupuytren contracture with partial fasciectomy were invited to participate in this study. Force sensors were placed in their dorsal extension splint, and the applied force was measured continually for several weeks.

RESULTS

Eleven subjects (aged 59-75 years) with the metacarpophalangeal (8) or proximal interphalangeal (3) as their most severely affected finger joint participated. Each night, the measured force consistently decreased to reach a plateau after about 3 hour (adaptation time, 2.55; 95% confidence interval, 0.2-31.8 hours). The time to reach this plateau decreased with time after surgery (≈5%/day, P = .0005, R² = 0.08).

DISCUSSION AND CONCLUSIONS

The observed rate of decrease in the measured force indicates a tissue adaptation time of approximately 3 hours.

The influence of skin tears following collagenase treatment of Dupuytren's disease on treatment outcomes

This study investigated influence of skin tears on patient-reported outcomes of injection of collagenase clostridium histolyticum for Dupuytren's disease and association between extension deficit of digits before injection and skin tear after the injection. From 2016 to 2018, 391 Dupuytren's cords were treated in 184 patients in a prospective cohort study and the patients were evaluated before injection and six months after injection. Skin tears occurred in 50% of these patients. We found no significant differences in the patient-reported outcomes between patients with or without skin tears. A higher extension deficit before treatment was associated with significantly increased frequency of skin tears. We conclude that the incidence of skin tears after injection does not affect patient reported outcomes six months after collagenase injection, but the incidence of skin tears is significantly associated with the severity of pre-treatment finger extension deficits.Level of evidence: II.

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

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

UVA-Degradable Collagenase Nanocapsules as a Potential Treatment for Fibrotic Diseases

Peyronie and Dupuytren are pathologies characterized by the appearance of localized fibrotic lesions in an organ. These disorders originate from an excessive production of collagen in the tissue provoking dysfunction and functional limitations to the patients. Local administration of collagenase is the most used treatment for these fibrotic-type diseases, but a high lability of the enzyme limits its therapeutic efficacy. Herein, we present a novel methodology for the preparation of collagenase nanocapsules without affecting its enzymatic activity and capable of releasing the enzyme in response to an ultraviolet A (UVA) light stimulus. Polymeric coating around collagenase was formed by free-radical polymerization of acrylamide-type monomers. Their degradation capacity under UVA irradiation was provided by incorporating a novel photocleavable acrylamide-type crosslinker within the polymeric framework. This property allowed collagenase release to be triggered in a controlled manner by employing an easily focused stimulus. Additionally, UVA irradiation presents considerable benefits by itself due to its capacity to induce collagenase production in situ. An expected synergistic effect of collagenase nanocapsules in conjunction with UVA effect may present a promising treatment for these fibrotic diseases.