Efficacy and tolerability of Day 2 manipulation and local anaesthesia after collagenase injection in patients with Dupuytren's contracture

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.

Risk Factors for Long-Term Contracture Recurrence after Collagenase Injection for Dupuytren Disease: A Prospective Cohort Study

In Dupuytren disease, little is known about the long-term outcomes of collagenase injection or risk factors for contracture recurrence. In this prospective study, 159 patients (242 fingers) with Dupuytren disease and active extension deficit (AED) ≥20° in a metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joint were treated with collagenase injection during a 14-month period. At 5 years, 18 patients were deceased, 2 could not be contacted, and 13 had undergone fasciectomy. The remaining 126 patients (199 treated fingers) participated in a follow-up evaluation at 52–96 (mean 65) months after injection, with physical examination (114 patients) or telephone interview (12 patients). Recurrence was defined as subsequent treatment (surgery or repeat injection) or ≥20° AED worsening in a treated joint between the 6-week and 5-year measurements. The mean AED at baseline was 42° (SD 24) for MCP joints and 31° (SD 29) for PIP joints and at 5 years 11° (SD 17) and 17° (SD 23), respectively. Recurrence occurred in 17% of MCP joints and 25% of PIP joints. Statistically significant risk factors for PIP joint contracture recurrence were greater baseline AED (odds ratio 1.04, 95% CI 1.02–1.06) and small finger treatment (OR 4.6, 95% CI 1.5–14.3), with no significant risk factors found for MCP contracture recurrence.

Finger Joint Contractures 5 Years After Treatment for Dupuytren Disease: A Comparative Cohort Study of Collagenase Injection Versus Surgical Fasciectomy

PURPOSE

To compare collagenase injection with surgical fasciectomy in Dupuytren disease (DD) for the prevalence of contracture in treated fingers 5 years after treatment.

METHODS

This was a single-center, comparative cohort study comprising 2 cohorts of patients treated for DD in 1 or more of 3 ulnar fingers with collagenase injection (159 patients) or surgical fasciectomy (59 patients). At 5 years after treatment, 13 collagenase-treated and 8 fasciectomy-treated patients had undergone subsequent treatment on the treated fingers and were considered to have current contracture. Of the remaining patients, 112 collagenase-treated patients (128 hands, 180 fingers) and 46 fasciectomy-treated patients (49 hands, 63 fingers) attended follow-up evaluation performed by 2 independent examiners (participation rate 84% and 93%, respectively). We defined current contracture in a treated finger as an active extension deficit of ≥20° in the metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joint or a total (MCP + PIP) active extension deficit (TAED) of ≥30°. We used linear mixed models to analyze differences between the cohorts over time.

RESULTS

In the collagenase cohort, current contracture was present in 45 (25%) MCP and 60 (33%) PIP joints, and in the fasciectomy cohort, current contracture was present in 12 MCP (19%) and 30 PIP (48%) joints; a TAED of ≥30° was present in 79 (44%) of the collagenase-treated and 30 (48%) of the fasciectomy-treated fingers. In MCP and PIP joints with ≥20° pretreatment contracture, complete correction was observed in 82 (56%) MCP and 30 (30%) PIP joints in the collagenase cohort and 23 (70%) MCP and 5 (16%) PIP joints in the fasciectomy cohort. There was no statistically significant difference between the 2 cohorts in the TAED change over time.

CONCLUSIONS

In patients with DD, collagenase injection and surgical fasciectomy improved finger joint contracture over the pretreatment status but had a high prevalence of joint contracture in the treated fingers 5 years after treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

The effectiveness of manipulation of fingers with Dupuytren's contracture 7 days after collagenase clostridial histolyticum injection

Timing of manipulation of digits after collagenase injection for Dupuytren's disease varies and often takes place within the first few days post-injection. We prospectively investigated the effectiveness of performing manipulation under local anaesthesia 7 days after injection in 100 patients. Demographic data, passive extension deficit, and patient-reported outcome measures were recorded before collagenase injection. Four to 7 weeks after manipulation, passive extension deficit and patient-reported outcome measures improved significantly without the development of any tendon ruptures. Clinical success was achieved in 41% and clinical improvement in 76% of the patients. Adverse events were reported by 85%. The outcomes were comparable with studies with early manipulation, and demonstrate a safe and effective variation to current protocols. We conclude that delaying manipulation to 7 days after collagenase injection is safe and efficient, which allows for flexibility in clinical appointments without negatively affecting outcome. Level of evidence: III.

Collagenase injections for Dupuytren disease: 3-year treatment outcomes and predictors of recurrence in 89 hands

Background and purpose - Few prospective studies have reported the long-term effect durability of collagenase injections for Dupuytren disease. We assessed the 3-year treatment outcome of collagenase injections and predictors of recurrence.Patients and methods - We conducted a single-center prospective cohort study. Indication for collagenase injection was palpable Dupuytren's cord and active extension deficit (AED) ≥ 20° in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint. From November 2012 through June 2013, we treated 86 consecutive patients (92 hands, 126 fingers). A hand therapist measured joint contracture before, 5 weeks, and 3 years after injection. The patients rated their treatment satisfaction. Primary outcome was proportion of treated joints with ≥ 20° AED worsening between the 5-week and 3-year measurements. We analyzed predictors of recurrence.Results - 3-year outcomes were available for 83 of the 86 patients (89 hands, 120 treated fingers). Between the 5-week and 3-year measurements, AED worsened by ≥ 20° in 17 MCP (14%) and 28 PIP (23%) joints. At 3 years, complete correction (passive extension deficit 0-5°) was present in 73% of MCP and 35% of PIP joints. Treatment of small finger PIP joint contracture, greater pretreatment contracture severity, and previous fasciectomy on the treated finger were statistically significant predictors of recurrence. Treatment satisfaction was rated as very satisfied or satisfied in 59 of 87 hands. No long-term treatment-related adverse events were observed.Interpretation - 3 years after collagenase injections for Dupuytren disease, improvement was maintained and treatment satisfaction reported in two-thirds of the treated hands, with no adverse events. Complete contracture correction was achieved in 3 of 4 MCP joints, but in only a third of the PIP joints.

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).

Surgical fasciectomy versus collagenase injection in treating recurrent Dupuytren disease: study protocol of a randomised controlled trial

INTRODUCTION

There is no definitive cure for Dupuytren disease (DD), and recurrence of finger contractures after treatment is common. Surgical fasciectomy is considered the standard treatment method for recurrence, although associated with a high incidence of complications. Collagenase injection, a non-surgical treatment option, has been shown to be a safe and effective method; however, most studies regarding collagenase have involved first-time treatment. Collagenase efficacy in patients with recurrent DD beyond the immediate effect has not yet been determined. The aim of our study is to compare surgical fasciectomy and collagenase injection in treating recurrent DD.

METHODS AND ANALYSIS

The study is a single-centre randomised controlled trial. Inclusion criteria are recurrence of DD in one or more fingers after previous treatment with fasciectomy or collagenase injection, a passive extension deficit ≥30° in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint, and a palpable cord causing the recurrent contracture. A total of 56 patients will be randomised to either surgical fasciectomy or collagenase injection. A hand therapist blinded to patients' group allocation will measure range of motion at baseline, 3 months, 12 months, 24 months and 60 months. The primary outcomes are the total active extension deficit (MCP plus PIP) at 3 months and the proportion of patients with contracture worsening ≥20° in the treated finger joint at 2 years compared with 3 months. The secondary outcomes include changes in total active motion, active and passive extension deficit from baseline up to 5 years, scores on patient-reported outcome measures, adverse events and costs of treatment.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Regional Ethical Review Board, Lund University, Sweden(2017/623). The trial will be conducted according to the Helsinki Declaration of 1975, revised in 2000. The results of the trial will be disseminated as published articles in peer-reviewed journals.

TRIAL REGISTRATION

NCT03406338; Pre-results.

One year follow-up after treatment with CCH for Dupuytren's disease: A prospective view

Aim Clostridium histolyticum collagenase (CCH) is nowadays an alternative treatment for the contracture of Dupuytren. Our objective is to assess its effectiveness at one year in a series of consecutive patients.

MATERIAL AND METHOD

Prospective study with minimum follow-up of one year. Evaluation of results and adverse effects.

RESULTS

A total of 75 joints treated in 51 patients were included. The average age was 65.18years (SD: 7.288) and 82.7% were males. The initial mean contraction of the MCP was 34.0 degrees (SD: 27.37), PIP 41.5 degrees (SD: 31.33) and combined impairment (MCF+IFP) of 75.5 degrees (SD: 35.2). Efficacy was achieved in 68 patients (90.7%). Adverse effects were mild and self-limiting. The mean correction for the MCP joint was 28.96 degrees (SD: 26.90) and for PIP it was 28.72 degrees (SD: 24.30). The recurrence rate was 18 (24.0%) joints in 14 patients, being more frequent in severe cases. QuickDASH score showed minimal differences measured before the intervention and once a year.

DISCUSSION

Our results show a better outcome in mild cases; the outcome was more favourable and with a higher success rate in the MCP joint. QuickDASH score is not a useful tool for the assessment of Dupuytren's contracture.

CONCLUSIONS

Treatment with CCH for Dupuytren's contracture is an effective treatment in the medium term. It has a poorer outcome in combined joint disorders, 5th finger, PIP and severe cases.

Resultado precoz del tratamiento de la enfermedad de Dupuytren mediante inyección de colagenasa

Objetivo: Presentar nuestro protocolo de tratamiento y el resultado precoz obtenido en una serie inicial de pacientes tratados con colagenasa.

Material y método: Estudio prospectivo sobre 40 pacientes afectos de enfermedad de Dupuytren, tratados mediante colagenasa en 47 dedos. Los criterios de inclusión han sido cuerdas palpables con una flexión metacarpo-falángica y/o interfalángica proximal superior a 20°. Se han recogido los grados de contractura de las articulaciones metacarpo-falángica, interfalángica proximal e interfalángica proximal con metacarpo-falángica en máxima flexión, antes y después del tratamiento al mes y a los tres meses de la inyección.

Resultados: Se ha obtenido extensión completa (contractura igual o menor de 5°) en el 53% de los dedos tratados, con una media de 1,19 inyecciones por dedo. El 91% de los pacientes ha considerado satisfactorio el resultado. La corrección en las metacarpo-falángicas ha sido completa en el 71% y en las interfalángicas proximales en el 43%. Cuando la interfalángica proximal se corregía previamente con la metacarpo-falángica en flexión, su extensión completa se ha obtenido en el 77%. Se detallan las características de las roturas cutáneas observadas.

Conclusión: La inyección de colagenasa es un método efectivo de tratamiento, con una tasa elevada de satisfacción en los pacientes.

Complications Following Collagenase Treatment for Dupuytren Contracture

BACKGROUND

Collagenase Clostridium histolyticum (CCH) injection and manipulation is a relatively new method for treating Dupuytren contracture that is growing in popularity. Although side effects such as swelling and ecchymosis are common, they are typically mild and self-limited. Major complications are rare but have included flexor tendon rupture and complex regional pain syndrome.

METHODS

This study describes a case report of 2 patients seen at our institution.

RESULTS

Here, we report 2 patients seen at our institution each with different, yet serious complications after CCH injection and manipulation. One patient had extensive skin loss and chose amputation over reconstruction. The other patient had loss of perfusion and required finger amputation.

CONCLUSIONS

Although it is unclear how directly the administration of CCH is connected to the observed complications, physicians should recognize the potential for serious rare complications in any treatment of Dupuytren contracture.

Difference in Success Treating Proximal Interphalangeal and Metacarpophalangeal Joints with Collagenase: Results of 208 Treatments

Background:

Dupuytren disease (DD) is a fibroproliferative disorder of the palmar fasciae causing extension deficit and impaired hand function. Treatment with injection of collagenase clostridium histolyticum (CCH) is a nonsurgical treatment method. The aim of this study was to evaluate the difference in efficiency and recurrence at 12-month follow-up when treating metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints with CCH. None of the patients had received previous treatments of their condition.

Methods:

This study is a prospective study of a consecutive series of patients with DD presenting with an extension deficit greater than 20° affecting the MP or PIP joint.

Results:

We found a mean reduction in extension deficit of 47° (91%) for MP joints and 47° (76%) for PIP joints. Full correction (max 5° deficit) was achieved in 76% of MP and 28% of PIP joints. Skin rupture was seen in 34% of treatments. The 1-year relapse rate was 15% for MP and 67% for PIP joints. The reduction in quickDASH score was only statistically significant for MP joints at 1 year. Eighty-one percent of all patients reported being satisfied or very satisfied. No major adverse events were recorded.

Conclusion:

Excellent results can be achieved in the treatment of MP-joint contractures, whereas the success rate is significantly lower and recurrence rate is greater for PIP joints.

Adverse Effects of Collagenase in the Treatment of Dupuytren Disease: A Systematic Review

BACKGROUND

Collagenase clostridium histolyticum (CCH) has proven to be both safe and effective in the treatment of Dupuytren disease (DD). The medium-term outcomes are similar to those achieved with surgery, and most adverse effects are self-limiting and considered to be mild or moderate.

OBJECTIVE

Our objective was to conduct a systematic review of the adverse effects of CCH in DD since the release of the drug to evaluate the incidence, severity, classification, and definitions of these effects.

METHODS

We analyzed the literature in terms of modifications to the original treatment protocol and grouped adverse effects according to their pathophysiological origin.

RESULTS

We included 28 clinical studies and five case reports or case series analyzing 4456 patients with a mean age of 63.6 years. Mean follow-up was 7.07 months (range 3-24); the mean number of patients per study was 148 (range 5-1082). The studies did not classify the adverse effects they reported into groups. The most common effects were peripheral edema (54.4%), bruising (42.9%), and upper limb pain (28.3%). Significant biases were observed for use of terminology, demarcation of sites of involvement, severity criteria, and assessment methods.

CONCLUSION

A simpler and clearer consensus-based classification system would enable better evaluation and comparison of the adverse effects of CCH in the treatment of DD. Consideration of inflammatory phenomena as part of the drug's mechanism of action would significantly reduce overall rates of adverse effects.

New insights into the immediate outcome of collagenase injections for Dupuytren's contracture

Collagenase clostridium histolyticum is now established as an effective and safe option to treat patients with a single joint affected with Dupuytren's contracture. We have extended its use to natatory and combined cords. In a prospective consecutive series of 298 cords in 237 patients, the mean total extension loss improved in cords crossing the metacarpophalangeal joint from 46° to 1°, in cords crossing the proximal interphalangeal joint from 56° to 7°, in natatory cords from 130° to 25° and in combined cords from 102° to 16°. The immediate correction of combined cords and natatory cords was less reliable than that obtained in cords crossing the metacarpophalangeal joint or proximal interphalangeal joint. Less severe pre-intervention contractures tended to correct better. We found a high complication rate, which may cause alarm. A total of 21% developed skin splits, with the risk of skin splits generally increasing with more severe pre-injection deformity. Blood blisters were only encountered after manipulation of the more severe contractures. A total of 23 patients (8%) had a spontaneous rupture and 57 patients (19%) had a partial spontaneous rupture. Only 4.9% needed a second injection. We noticed a learning curve, with seven of the first 20 cords (35%) needing a second injection to achieve a satisfactory correction and then only seven (2.5%) in the rest.

LEVEL OF EVIDENCE

IV.

Collagenase clostridium histolyticum in Dupuytren's contracture: a systematic review

INTRODUCTION

In the last few years, the use of collagenase clostridium histolyticum for management of Dupuytren's contracture has increased. The procedure of enzymatic fasciectomy has become popular because it is non-invasive, safe and fast to perform.

SOURCES OF DATA

A systematic search was performed on Medline (PubMed), Web of Science and Scopus databases using the combined keywords 'Dupuytren collagenase' and 'Dupuytren clostridium histolyticum'. Forty-three studies were identified. The quality of the studies was assessed using the Coleman Methodological Score.

AREAS OF AGREEMENT

The use of collagenase clostridium histolyticum provides better outcomes in patients with mild-moderate joint contracture, with lower complications and side effects than open fasciectomy. Manipulation can be performed 2-7 days after the injection. The use of collagenase is cost-effective.

AREAS OF CONTROVERSY

Most of the studies did not report patient-related outcomes. The role of dynamic splint has to be investigated with randomized clinical trials.

GROWING POINTS

The shorter recovery time and the low incidence of serious or major adverse effects are the main advantages of this new technology.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is a need to perform studies with longer follow-up because the recurrence rate seems to increase with time. Further investigations are necessary to assess whether it is safe and effective to inject two or more cords at the same time.

The Efficacy and Safety of Concurrent Collagenase Clostridium Histolyticum Injections for 2 Dupuytren Contractures in the Same Hand: A Prospective, Multicenter Study

PURPOSE

To evaluate efficacy and safety of concurrent administration of 2 collagenase clostridium histolyticum (CCH) injections to treat 2 joints in the same hand with Dupuytren fixed flexion contractures (FFCs).

METHODS

Patients with 2 or more contractures in the same hand caused by palpable cords participated in a 60-day, multicenter, open-label, phase 3b study. Two 0.58 mg CCH doses were injected into 1 or 2 cords in the same hand (1 injection per affected joint) during the same visit. Finger extension was performed approximately 24, 48, or 72 or more hours later. Changes in FFC and range of motion, incidence of clinical success (FFC ≤ 5°), and adverse events (AEs) were summarized.

RESULTS

The study enrolled 715 patients (725 treated joint pairs), and 714 patients (724 joint pairs) were analyzed for efficacy. At day 31, mean total FFC (sum of 2 treated joints) decreased 74%, from 98° to 27°. Mean total range of motion increased from 90° to 156°. The incidence of clinical success was 65% in metacarpophalangeal joints and 29% in proximal interphalangeal joints. Most treatment-related AEs were mild to moderate, resolving without intervention; the most common were swelling of treated extremity, contusion, and pain in extremity. The incidence of skin lacerations was 22% (160 of 715). Efficacy and safety were similar regardless of time to finger extension.

CONCLUSIONS

Collagenase clostridium histolyticum can be used to effectively treat 2 affected joints concurrently without a greater risk of AEs than treatment of a single joint, with the exception of skin laceration. The incidence of clinical success in this study after 1 injection per joint was comparable to phase 3 study results after 3 or more injections per joint. Two concurrent CCH injections may allow more rapid overall treatment of multiple affected joints, and the ability to vary the time between CCH injection and finger extension may allow physicians and patients greater flexibility with scheduling treatment.

Delayed manipulation after collagenase clostridium histolyticum injection for Dupuytren contracture

BACKGROUND

Collagenase clostridium histolyticum (CCH) injection for Dupuytren contracture was approved in the USA in 2010. Current FDA guidelines stipulate that finger manipulation occurs the day following injection. To investigate the safety and efficacy of delaying manipulation to 2 or 4 days following CCH injection, we conducted a prospective, randomized trial at two sites.

METHODS

Patients with Dupuytren contracture involving the metacarpophalangeal (MCP) joint ≥20° caused by a palpable cord participated. All patients received one dose of CCH (0.58 mg/0.25 ml) and were followed for 90 days. The primary end point was the percent of patients maintaining clinical success (reduction of contracture to 0°-5°) at 90 days post-injection. Adverse events and change in Michigan Hand Questionnaire (MHQ) score were recorded as secondary end points.

RESULTS

Thirty-seven patients enrolled; 13 were manipulated on day 1, 11 on day 2, and 13 on day 4. At 30 days after injection, the percentage of patients obtaining reduction of contracture to <0°-5° extension was 92, 82, and 85 % in groups 1, 2, and 3, respectively, with no significant difference. At 90 days follow-up, the percentage of patients maintaining 0°-5° extension was 91, 82, and 83 % in groups 1, 2, and 3, respectively, with no significant difference. Adverse events were comparable to rates in prior studies. There were no serious adverse events. There was no statistical difference in MHQ scores between groups at any time point.

CONCLUSIONS

Delaying manipulation to day 2 or 4 following CCH injection for MCP joint contractures does not increase adverse events or result in loss of efficacy.

LEVEL OF EVIDENCE

Therapeutic, Level II.

Collagenase treatment of Dupuytren's contracture using a modified injection method: a prospective cohort study of skin tears in 164 hands, including short-term outcome

BACKGROUND AND PURPOSE

Treatment of Dupuytren's contracture (DC) with collagenase Clostridium histolyticum (CCH) consists of injection followed by finger manipulation. We used a modified method, injecting a higher dose than recommended on the label into several parts of the cord, which allows treatment of multiple joint contractures in 1 session and may increase efficacy. We studied the occurrence of skin tears and short-term outcome with this procedure.

PATIENTS AND METHODS

We studied 164 consecutive hands with DC, palpable cord, and extension deficit of ≥ 20º in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint (mean patient age 70 years, 82% men). A hand surgeon injected all the content of 1 CCH vial (approximately 0.80 mg) into multiple spots in the cord and performed finger extension under local anesthesia after 1 or 2 days. A nurse recorded skin tears on a diagram and conducted a standard telephone follow-up within 4 weeks. A hand therapist measured joint contracture before injection and at a median of 23 (IQR: 7-34) days after finger extension.

RESULTS

A skin tear occurred in 66 hands (40%). The largest diameter of the tear was ≤ 5 mm in 30 hands and > 10 mm in 14 hands. Hands with skin tear had greater mean pretreatment MCP extension deficit than those without tear: 59º (SD 26) as opposed to 32º (SD 23). Skin tear occurred in 21 of 24 hands with MCP contracture of ≥ 75º. All tears healed with open-wound treatment. No infections occurred. Mean improvement in total (MCP + PIP) extension deficit was 55º (SD 28).

INTERPRETATION

Skin tears occurred in 40% of hands treated with collagenase injections, but only a fifth of them were larger than 1 cm. Tears were more likely in hands with severe MCP joint contracture. All tears healed without complications. Short-term contracture reduction was good.

Clinical outcomes following collagenase injections compared to fasciectomy in the treatment of Dupuytren's contracture

INTRODUCTION

The aim of this study is to compare the efficacy of collagenase injections with that of fasciectomy in the treatment of Dupuytren's contracture.

METHODS

This is a case-control retrospective study. We reviewed the electronic medical records from January 2009 through January 2013, identifying 142 consecutive patients who underwent either fasciectomy or collagenase injection. Exclusion criteria for both groups were age <18 years, pregnant women, and arthroplasty or arthrodesis of the treated joint. Follow-up data beyond 1-year duration was available for 117 of the patients: 44 patients who had undergone fasciectomy, and 73 patients who had received collagenase injection. The primary outcome measure in this study was resolution of joint contracture to 0-5° deficit of full extension. Data was analyzed using two-sample t tests for continuous data and chi-square test for categorical data. A significant P value was set at <0.05.

RESULTS

At the latest follow-up, significantly more joints treated with fasciectomy met the primary outcome measure. Metacarpophalangeal (MP) joints responded better than the proximal interphalangeal (PIP) joints for both treatments. At the latest follow-up (14.2 months for collagenase, 16.3 months for fasciectomy), 46 % of MP joints treated with collagenase and 68 % of MP joints treated with fasciectomy maintained resolution of joint contracture. Sub-analysis of the affected joints based on the severity of initial contracture demonstrated that MP and PIP joints with contractures <45° responded better than more severely contracted joints (>45°).

CONCLUSIONS

Fasciectomy yields a greater mean magnitude of correction for digital contractures at the latest follow-up when compared to collagenase. Both treatments were more effective for treatment of MP joint contracture compared to PIP joint contracture.

LEVEL OF EVIDENCE

Level III, therapeutic.

Collagenase clostridium histolyticum in patients with Dupuytren's contracture: results from POINT X, an open-label study of clinical and patient-reported outcomes

In POINT X, a study designed to reflect clinical practice and patient treatment choices, 254 European patients received open-label collagenase for Dupuytren's contracture. The most severely affected joint was treated first in 74% of patients. In total, 52%, 41%, 7%, and 1% of patients selected the little, ring, middle, and index finger, respectively; 79% had one or two joints treated. Only 9% of patients (n = 24) received 4 or 5 injections. The mean improvement in total passive extension deficit (TPED) was 34° on day 1, improving further by day 7 to 42°. This secondary improvement was maintained by day 90 and month 6. The mean number of injections/joint was 1.2 for the metacarpophalangeal joint and 1.25 for the proximal interphalangeal joint. Median time to recovery was 4 days; the mean improvement in hand function was clinically relevant as measured by the Unité Rhumatologique des Affections de la Main (URAM) score. In total, 87% and 86% of patients and physicians, respectively, were very satisfied or satisfied with treatment at month 6, although correlation between TPED and patient satisfaction was weak (Spearman -0.18, 95% CI -0.32 to -0.06). Collagenase was well tolerated, with 10 (3.9%) patients experiencing severe adverse events. As a real-world study, the POINT X findings can be generalized to the at-large population.

Prospective randomized controlled trial comparing 1- versus 7-day manipulation following collagenase injection for dupuytren contracture

PURPOSE

To compare the efficacy, tolerance, and safety of manual manipulation at day 7 to day 1 following collagenase Clostridium histolyticum (CCH) injection for Dupuytren contracture.

METHODS

Eligible patients were randomized to manipulation at day 1 versus day 7 following CCH injection. Preinjection, premanipulation, postmanipulation, and 30-day follow-up metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint contractures were measured. Pain scores were recorded at each time point. Data were stratified per cohort based on primary joint treated (MCP vs PIP). Means were compared using paired and unpaired t-tests.

RESULTS

Forty-three patients with 46 digits were eligible and were randomized to 1-day (22 digits) and 7-day (24 digits) manipulation. For MCP joints, there were no significant differences in flexion contractures between 1- and 7-day cohorts for initial (47° vs 46°), postmanipulation (0° vs 2°), or 30-day follow-up (1° vs 2°) measurements. Premanipulation, the residual contracture was significantly lower in the 7-day group (23° vs 40°). For PIP joints, there were no significant differences between 1- and 7-day cohorts for initial (63° vs 62°), premanipulation (56° vs 52°), postmanipulation (13° vs 15°), or 30-day (14° vs 16°) measurements. There were no significant differences in pain or skin tears between the 2 groups. No flexor tendon ruptures were observed.

CONCLUSIONS

The effectiveness of CCH in achieving correction of Dupuytren contractures was preserved when manipulation was performed on day 7, with no differences in correction, pain, or skin tears. These data suggest that manipulation can be scheduled at the convenience of the patient and surgeon within the first 7 days after injection.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Costs for collagenase injections compared with fasciectomy in the treatment of Dupuytren's contracture: a retrospective cohort study

OBJECTIVES

To compare collagenase injections and surgery (fasciectomy) for Dupuytren's contracture (DC) regarding actual total direct treatment costs and short-term outcomes.

DESIGN

Retrospective cohort study.

SETTING

Orthopaedic department of a regional hospital in Sweden.

PARTICIPANTS

Patients aged 65 years or older with previously untreated DC of 30° or greater in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joints of the small, ring or middle finger. The collagenase group comprised 16 consecutive patients treated during the first 6 months following the introduction of collagenase as treatment for DC at the study centre. The controls were 16 patients randomly selected among those operated on with fasciectomy at the same centre during the preceding 3 years.

INTERVENTIONS

Treatment with collagenase was given during two standard outpatient clinic visits (injection of 0.9 mg, distributed at multiple sites in a palpable cord, and next-day finger extension under local anaesthesia) followed by night-time splinting. Fasciectomy was carried out in the operating room (day surgery) under general or regional anaesthesia using standard technique, followed by therapy and splinting.

PRIMARY AND SECONDARY OUTCOME MEASURES

Actual total direct costs (salaries of all medical personnel involved in care, medications, materials and other relevant costs), and total MCP and PIP extension deficit (degrees) measured by hand therapists at 6-12 weeks after the treatment.

RESULTS

Collagenase injection required fewer hospital outpatient visits to a therapist and nurse than fasciectomy. Total treatment cost for collagenase injection was US$1418.04 and for fasciectomy US$2102.56. The post-treatment median (IQR) total extension deficit was 10 (0-30) for the collagenase group and 10 (0-34) for the fasciectomy group.

CONCLUSIONS

Treatment of DC with one collagenase injection costs 33% less than fasciectomy with equivalent efficacy at 6 weeks regarding reduction in contracture.