Complications Following Collagenase Treatment for Dupuytren Contracture

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's disease - what's new: a review

<b><br>Introduction:</b> Dupuytren's disease is a common fibrotic disorder of the palmar aponeurosis characterized by the formation of nodules and cords, as well as development of progressive flexion deformities in the digits, leading to functional impairment. Surgical excision of the affected aponeurosis remains the most common treatment. Quite a few new information appeared about epidemiology, pathogenesis and particularly treatment of the disorder.</br> <b><br>Aim:</b> The aim of this study is an updated review of scientific data in this topic.</br> <b><br>Results:</b> Results of epidemiologic studies showed that Dupuytren's disease is not so uncommon in Asian and African population as it was earlier believed. An important role of genetic factors on development of the disease in a proportion of patients was demonstrated, however, it did not translate neither to the treatment nor to the prognosis. The most changes concerned the management of Dupuytren's disease. A positive effect of steroids injections into the nodules and cords for inhibition of the disease in early stages was shown. In the advanced stages, a standard technique of partial fasciectomy was partly replaced by mini-invasive methods such as needle fasciotomy and collagenase Clostirdium hystolyticum injections. Unexpected withdrawal of collagenase from the market in 2020 resulted in considerable limitation of the availability of this treatment.</br> <b><br>Conclusion:</b> It seems that updated knowledge on Dupuytren's disease may be interested and useful for surgeons involved in management of the disorder.</br>.

Treatment Options for Dupuytren’s Disease: Tips and Tricks

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

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.

Current Concepts in the Management of Dupuytren Disease of the Hand

Dupuytren disease is a fibroproliferative disorder of the palmar fascia of the hand. Little agreement and remarkable variability exists in treatment algorithms between surgeons. Because the cellular and molecular etiology of Dupuytren has been elucidated, ongoing efforts have been made to identify potential chemotherapeutic targets that could modulate the phenotypic expression of the disease. Although these efforts may dramatically alter the approach to treating this disease in the future, these approaches are largely experimental at this point. Over the past decade, the mainstay nonsurgical options have continued to be percutaneous needle aponeurotomy and collagenase Clostridium hystoliticum, and the most common surgical option is limited fasciectomy.

Targeting Cell Contractile Forces: A Novel Minimally Invasive Treatment Strategy for Fibrosis

Fibrosis is a complication of tendon injury where excessive scar tissue accumulates in and around the injured tissue, leading to painful and restricted joint motion. Unfortunately, fibrosis tends to recur after surgery, creating a need for alternative approaches to disrupt scar tissue. We posited a strategy founded on mechanobiological principles that collagen under tension generated by fibroblasts is resistant to degradation by collagenases. In this study, we tested the hypothesis that blebbistatin, a drug that inhibits cellular contractile forces, would increase the susceptibility of scar tissue to collagenase degradation. Decellularized tendon scaffolds (DTS) were treated with bacterial collagenase with or without external or cell-mediated internal tension. External tension producing strains of 2-4% significantly reduced collagen degradation compared with non-tensioned controls. Internal tension exerted by human fibroblasts seeded on DTS significantly reduced the area of the scaffolds compared to acellular controls and inhibited collagen degradation compared to free-floating DTS. Treatment of cell-seeded DTS with 50 mM blebbistatin restored susceptibility to collagenase degradation, which was significantly greater than in untreated controls (p < 0.01). These findings suggest that therapies combining collagenases with drugs that reduce cell force generation should be considered in cases of tendon fibrosis that do not respond to physiotherapy.

Treatment of Dupuytren's disease using one full dose of Clostridiumhistolyticum collagenase at a lower concentration: Retrospective analysis of clinical outcomes

Clostridiumhistolyticum collagenase (CHC) is rapidly becoming a mainstream treatment option for Dupuytren's disease for hand surgeons. We performed a retrospective study of the efficacy of this substance at a lower concentration, but a higher total dose than recommended by the manufacturer. Thirty-nine patients with 43 affected hands were treated and analyzed at a mean follow-up of 27 months. Subgroup analysis was done for patients who received treatment in one or two joints (group A), and for patients who received treatment in more than two joints (group B). We found that our CHC solution is safe and effective when simultaneously treating as many as four joints affected by Dupuytren's disease. Patients in group B had a lower (but non-significant) treatment failure rate compared to patients in group A. Also, higher satisfaction rates were observed in group B, again non-significant. No major complications were observed in any group. CHC use is associated with only minor complications. The results are consistent even when up to four joints are treated with one dose. LEVEL OF EVIDENCE: III.

Current role of the collagenase Clostridium histolyticum in Dupuytren's disease treatment

BACKGROUND

Collagenase Clostridium histolyticum (CCH) is a recent treatment for Dupuytren disease, which is a fibroproliferative disorder that leads to progressive, persistent digital flexion contracture that interferes with basic daily activities. While CCH has changed the treatment of this hand disorder, numerous concerns have to be analyzed.

AIMS

Our purpose is to assess the current status of this medical treatment.

METHODS

Literary review based on a manual search on PubMed, Web of Science, and Google Academic.

RESULTS

Pharmacoeconomic analyses support the use of CCH, but long-term studies showing that it should be favored over conventional surgery or other treatments are lacking. Treatment decisions, therefore, must be guided by current data, which include a 5-year recurrence rate of 47%. Complications following CCH treatment are also a controversial topic, as rates of over 90% have been reported, although most of the complications are mild and self-limiting. A definition and classification of CCH-related complications is sorely needed. If we exclude adverse effects that could be considered inherent to the mechanisms of action of CCH, then the complication rate would be similar to rates reported for other techniques. Although CCH is becoming an increasingly popular treatment for Dupuytren disease, the potential applications of this modality, are much higher than currently believed, for more disorders characterized by excessive fibrosis.

CONCLUSION

Currently, the administration of this treatment is promising although long-term studies are necessary to see the real role that this drug can play in both Dupuytren's disease and other fibrotic disorders.

Adverse effects associated with collagenase clostridium histolyticum in Dupuytren disease: A prospective study

BACKGROUND

Collagenase clostridium histolyticum is now recognized as a viable treatment for Dupuytren disease. The high rate of adverse effects reported in patients continues to spark debate and raise questions about the true frequency of effects and their associated mechanisms of action.

HYPOTHESIS

To investigate whether outcomes of CCH treatment are related to the number of adverse effects experienced. To evaluate short-term clinical outcomes in a series of patients.

MATERIAL AND METHODS

Prospective single-center cohort study. The Primary End Point for effectiveness at 30 days was deficit of 0°-5°. Adverse effects were evaluated during CCH injection, removal of the dressing prior to finger extension, and finger extension. To investigate the relationship between adverse effects and treatment effectiveness, we analyzed the association between number of effects and clinical outcome at 30 days.

RESULTS

A total of 208 injections were evaluated. The mean baseline contracture was 32.11°. Ninety-four patients (45.2%) had a mild contracture. Treatment was effective at 30 days in 194 of the injections (93.3%). The rate of effectiveness per joint was 93.5% for metacarpophalangeal joints (n=129) and 92.9% for proximal-interphalangeal joints (n=65). In total, 734 adverse effects were reported (mean, 3.53). No statistically significant associations were identified between disease severity and secondary effects. Variance analysis showed statistically significant differences in patients with severe contractures (mean, 3.91; 95% CI 3.57-4.25), and in patients with proximal-interphalangeal contractures (mean, 4.17; 95% CI 3.76-4.59).

CONCLUSIONS

We found no relationship between number of adverse effects and treatment effectiveness at one month following CCH injection.

LEVEL OF PROOF

IV, cohort prospective study.