Needle Fasciotomy or Collagenase Injection in the Treatment of Dupuytren's Contracture: A Retrospective Study

Comparison of Rheological Properties of Healthy versus Dupuytren Fibroblasts When Treated with a Cell Contraction Inhibitor by Atomic Force Microscope

Mechanical properties of healthy and Dupuytren fibroblasts were investigated by atomic force microscopy (AFM). In addition to standard force curves, rheological properties were assessed using an oscillatory testing methodology, in which the frequency was swept from 1 Hz to 1 kHz, and data were analyzed using the structural damping model. Dupuytren fibroblasts showed larger apparent Young's modulus values than healthy ones, which is in agreement with previous results. Moreover, cell mechanics were compared before and after ML-7 treatment, which is a myosin light chain kinase inhibitor (MLCK) that reduces myosin activity and hence cell contraction. We employed two different concentrations of ML-7 inhibitor and could observe distinct cell reactions. At 1 µM, healthy and scar fibroblasts did not show measurable changes in stiffness, but Dupuytren fibroblasts displayed a softening and recovery after some time. When increasing ML-7 concentration (3 µM), the majority of cells reacted, Dupuytren fibroblasts were the most susceptible, not being able to recover from the drug and dying. These results suggested that ML-7 is a potent inhibitor for MLCK and that myosin II is essential for cytoskeleton stabilization and cell survival.

Robot and ultrasound assisted needle insertion to the transverse carpal ligament

BACKGROUND

A potential alternative treatment to surgery for carpal tunnel syndrome is to inject enzymes into the transverse carpal ligament to decrease its stiffness and alleviate pressure off the median nerve. An accurate injection is needed for delivery to achieve the effects of tissue degradation. The purposes of this study were to 1) determine injection sites using 3D reconstructed anatomy, and 2) insert the needle to the middle of the transverse carpal ligament thickness in situ.

METHODS

Six fresh-frozen cadaveric hands were used in this study. Five injection sites were determined in the sagittal plane along the center of the transverse carpal ligament thickness ulnar to the thenar muscle attachment using 3D ultrasonographic reconstruction. Each injection was delivered by rigidly fixing a 27-gauge needle to a six degrees of freedom robot arm programmed to insert the needle tip to the intended target. Ultrasound images were taken of the needle after insertion to measure accuracy and precision of the needle placement.

FINDINGS

The needle tip was successfully delivered to the middle region of the transverse carpal ligament thickness and visualized using ultrasound imaging. The accuracy and precision of the needle insertion were 0.83 and 0.31 mm, respectively.

INTERPRETATION

Methodology was established for robot-assisted needle insertion to the transverse carpal ligament using 3D ultrasonographic reconstructed anatomy. This methodology can be used in the future to deliver enzymatic injections to the transverse carpal ligament as a potential treatment for carpal tunnel syndrome.

Dupuytren Disease: A Retrospective Cohort Study Comparing Collagenase Injection and Percutaneous Needle Fasciotomy

Collagenase Clostridium histolyticum (CCH) injection and percutaneous needle fasciotomy (PNF) are minimally invasive procedures aiming to relieve Dupuytren disease (DD) by disrupting the cord and restoring the normal functionality of the hand. The purpose of this study is to compare the outcomes and recurrence rates for treatment of DD in the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints with either collagenase or percutaneous needle at 3-year follow-up. Moreover, we aim to determine the role of these therapeutic modalities and their impact on hand functionality and quality of life.

Methods

In this retrospective analysis, we compare treatment outcomes in 35 patients, of whom 22 were treated with PNF and 13 with CCH injection.

Results

The mean outcome in contracture degrees at 3-year follow-up was 9 degrees for MCP joints for both treatment groups, 34 degrees for PNF, and 28 degrees for CCH for PIP joints. There was no statistical significance between the treatment groups in MCP joints (P = 0.786) or in PIP joints (P = 0.474). Contracture recurrences were similar in PIP joints of both groups and greater in MCP joints in the CCH group compared to PNF. The Disabilities of the Arm, Shoulder, and Hand and the Unité Rhumatologique des Affections de la Main scores showed a reduction in impairment in both groups without significant differences between the two groups.

Conclusions

The results of this study show that PNF appears to be as effective and minimally invasive as CCH injection, but at significantly lower cost. Considering these factors, the authors prefer and recommend the use of PNF over CCH.

Cost Analysis and National Trends in the Treatment of Dupuytren Contracture Comparing Collagenase Injection, Needle Fasciotomy, and Open Fasciectomy Procedures

BACKGROUND

Dupuytren contracture (DC) is a common disorder characterized by progressive fibrosis of palmar fascia. This study analyzed cost trends of 3 common treatments for DC: fasciotomy, fasciectomy, and collagenase injection (CI)/cord manipulation.

METHODS

The Vizient Clinical Data/Resource Manager electronic database was reviewed for all procedures for the treatment of DC at participating hospitals in the United States (US) from October 1, 2015, to September 1, 2019. Cases were placed into 1 of 3 categories: (1) CI, (2) needle fasciotomy (NF), and (3) open fasciectomy (OF). Total and direct costs were averaged for each procedure and compared nationally and regionally. Temporal trends and specific market share were analyzed. One-tailed t test and Pearson correlation analysis was performed (P < 0.05 and r > 0.9 or r < -0.9 was considered significant).

RESULTS

A total of 22,974 total cases were identified. A total of 16,966 OF, 3962 NF, and 2046 CI were performed. There was a nearly a 4-fold increase in number of procedures to treat DC from 2015 to 2018. Market share percentage of each procedure stayed relatively similar over time. However, market share percentage differed between procedures. Needle fasciotomy had the lowest market share percentage approximately 7%. Collagenase injection had the highest average cost at US $4453.66 and was significantly higher than OF at US $3394.90 and NF at US $2010.75. Cost and distribution of procedures were further analyzed by geographic regions. In 2018, 32% of procedures performed were in the Northeastern US, 29% in the Midwestern US, 23% in the Southern US, and 16% in the Western US. Total number of Dupuytren procedures increased more than 300% in all regions across the US from 2015 to 2018. In every region, NF was the lowest cost intervention. Cost of OF and CI varied between regions and was often the most expensive intervention.

CONCLUSIONS

Treatment of DCs with NF seems to be the least costly treatment option. Needle fasciotomy seems to be the least commonly performed procedure. Regional data show variations in the cost of OF and CI. However, OF has the majority market share nationally and regionally. Although the cost of these procedures seems to vary regionally, the type of procedures being performed seem to be similar across regions.