Skin Laceration in Collagenase Clostridium histolyticum Treatment for Dupuytren's Contracture

Hand therapy or not following collagenase treatment for Dupuytren's contracture? Protocol for a randomised controlled trial

Background

Dupuytren’s contracture (DC) is a fibrotic hand condition in which one or more fingers develop progressive flexion deformities. Quality of life is diminished due to disabling limitations in performing everyday activities. For DC patients treated with collagenase, referral for subsequent hand therapy is inconsistent. It is unknown whether subsequent hand therapy is beneficial compared to no therapy. The purpose of this study is to determine whether hand therapy improves DC patients’ performance of and satisfaction with performing everyday activities one year after collagenase treatment.

Methods

We will conduct a randomised controlled trial with two treatment groups (hand therapy vs. control) of DC patients who have received collagenase treatment. DC patients with contracted metacarpophalangeal joint(s) (MCPJ) (hand therapy, n = 40; control, n = 40) and those with proximal interphalangeal joint(s) (PIPJ) involvement (hand therapy, n = 40; control, n = 40) comprise two subgroups, and we will study if the treatment effect will be different between both groups (n = 160). Patients with a previous injury or treatment for DC in the treatment finger are excluded. Hand therapy includes oedema and scar management, splinting, movement exercises, and practice of everyday activities. The main outcome variable is patients’ performance of and satisfaction with performing everyday activities, as assessed with the Canadian Occupational Performance Measure. Secondary outcomes are DC-specific activity problems, as assessed with the Unité Rhumatologique des Affections de la Main scale, and active/passive flexion/extension of treated joints and grip force using standard measuring tools, and self-reported pain level. Demographic and clinical variables, degree of scarring, cold hypersensitivity, number of occupational sick-leave days are collected. Self-reported global impression of change will be used to assess patient satisfaction with change in hand function. Assessments are done pre-injection and 6 weeks, 4 months, and 1 year later. Standard univariate and multivariate statistical analyses will be used to evaluate group differences.

Discussion

This study aims to assess whether hand therapy is beneficial for activity-related, biomechanical, and clinical outcomes in DC patients after collagenase treatment. The results will provide an objective basis for determining whether hand therapy should be conducted after collagenase treatment.

Trial registration

This study has been registered at ClinicalTrials.gov as NCT03580213 (April 5, 2018).

Short-term efficacy and safety of collagenase injection for Dupuytren's contracture: Therapy protocol for successful outcomes in a clinical setting

PURPOSE

To assess the short-term efficacy and safety of collagenase injection for Dupuytren's contracture and of our post-injection therapy protocol alternative the instruction of phase III studies at clinical setting.

METHODS

The retrospective study included 23 fingers of 21 hands of 18 patients for primary metacarpophalangeal (MP) joints and 11 fingers of 10 hands of 10 patients for primary proximal interphalangeal (PIP) joints with Dupuytren's contracture who were treated with 0.58 mg collagenase Clostridium histolyticum (CCH) injections at our hospital consecutively from September 2015 to October 2017. The mean age of the patients was 73.0 years (range, 57-88) for primary MP joints and 70.7 years (61-81) for primary PIP joints. Following standard CCH injection and manipulation on the next day, certified hand surgeons evaluated and treated each patient based on a defined 4-week therapy protocol that consisted of performing finger exercises during the day and wearing static extension splint at night for all cases, and of wearing Capener dynamic splint intervention to address severely contracted PIP joints. We measured the degree of contracture at baseline, immediately, 4 weeks, and 12 weeks after the last manipulation.

RESULTS

More improvement of contracture was seen in the MP joints than in the PIP joints. For the five fingers severely contracted and treated with Capener splint intervention, the mean passive PIP joint contracture was 62.0° at baseline, 21.0° immediately, further improved to 6.0° by 4 weeks, and maintained 8.0° by 12 weeks after the last manipulation. The adverse events were mild-to-moderate local reactions in the injected hand.

CONCLUSIONS

The clinical efficacy and safety of CCH were confirmed in a clinical setting similar to phase III studies. The improvement of 4-week-intervention was maintained at 12 weeks after the last manipulation. Severely contracted PIP joints could benefit from Capener splint intervention.

Prospective observation of Clostridium histolyticum collagenase for the treatment of Dupuytren's disease in 788 patients: the Austrian register

INTRODUCTION

Since March 2011, the microbial collagenase of Clostridium histolyticum (Xiapex®, Swedish Orphan Biovitrum AB, Stockholm, Sweden) has become available in the European Union for treatment of Dupuytren's disease. The purpose of this study was to evaluate potential safety risks of Xiapex® and to contribute to a better understanding for its use.

METHODS

A prospective, non-interventional, observational study using Xiapex® for Dupuytren's disease named XIANIS was conducted between 1.10.2011 and 01.10.2017. Treatment was conducted in accordance to the manufacturer information. Patients were invited for follow-up after 1 week, 1 month, 3 months and 1 year. Demographic data, treatment data, pain levels, anaesthetic application during passive manipulation, subjective function improvement, subjective satisfaction and adverse events were recorded.

RESULTS

788 patients with 814 treatments were included who suffered from Dupuytren's contracture for a mean of 64 months. The metacarpophalangeal joint was affected in 57% of cases and the PIP joint in 40.8% with a mean contracture of 39° and 56°, respectively. A change in the contracture down to 0°-5° was reported in 66.5% of cases, while 25.5% achieved a partial improvement. The pain during the injection was rated 4.5 and 3.3 during passive manipulation. Adverse events were reported in the majority of treated patients with skin tears being one main common event (26%). Further adverse outcomes were bleeding/hematoma, joint swelling, injection-site swelling, pressure sensitivity, erythema, injection-site pain, peripheral edema, blood blisters, blisters, painless lymphadenopathy, painful lymphadenopathy, axillary pain, arthralgia and sensory abnormality. There were no reported tendon ruptures, anaphylactic reactions or ligament injuries. On 1-year follow-up, 29% showed an increased contracture of a mean of 24° with the need for surgical treatment in 2% of patients. 74% of patients were very satisfied and 72% showed a high functional improvement.

CONCLUSION

The injectable collagenase Clostridium histolyticum (Xiapex®) proved to be effective and safe in patients with Dupuytren's disease. Minor adverse events disappeared within 30 days and the need for surgical treatment within 1 year was very low (2%). No major complications or rare side effects were seen in this prospective observational study.