Collagenase Treatment Versus Needle Fasciotomy for Single-Digit Dupuytren Contractures: A Meta-Analysis of Randomized Controlled Trials

PURPOSE

The objective of this systematic review and meta-analysis was to synthesize the available randomized controlled trial data comparing needle fasciotomy and collagenase treatment for single-digit Dupuytren contractures with a minimum of 3-year follow-up and determine whether one treatment is superior regarding contracture correction and functional outcomes.

METHODS

A systematic review and meta-analysis was conducted by searching four databases for randomized controlled trials investigating the single-digit treatment outcomes for Dupuytren contracture comparing collagenase treatment and needle fasciotomy with a minimum of 3-year follow-up. The risk of bias of included studies was assessed using the Cochrane risk-of-bias tool. A meta-analysis was performed using a random effects model in anticipation of unobserved heterogeneity. The primary outcome measure was contracture recurrence. Secondary outcome measures included final fixed flexion contracture (FFC), Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) scores, and Unité Rhumatologique des Affections de la Main (URAM) scores.

RESULTS

After screening 264 articles, 4 randomized clinical trials were eligible for final inclusion. One trial had a high risk of bias, and two trials had some concern for bias. The final meta-analysis included 347 patients, 169 who underwent collagenase treatment and 178 who underwent needle fasciotomy. No significant differences were noted between the groups in contracture recurrence, FFC, and URAM scores. The pooled data showed a higher QuickDASH score in the collagenase treatment group compared with the needle fasciotomy group, but the observed difference was less than what would be expected to be clinically relevant.

CONCLUSIONS

Needle fasciotomy and collagenase treatment have similar outcomes with regards to contracture recurrence, final FFC, QuickDASH scores, and URAM scores for the single-digit treatment for Dupuytren contracture at a minimum of 3-year follow-up. Relevant factors that may be considered during the shared decision-making process for treatment selection include surgeon and patient preferences, costs of treatment, and the disparate complication profiles of these two treatments.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Modified dynamic high-frequency ultrasound-guided needle aponeurotomy for Dupuytren's contracture

The aim of this report was to introduce the use of modified dynamic high-frequency ultrasound-guided needle aponeurotomy for Dupuytren's contracture. From January 2014 to February 2019, the technique was used in 42 consecutive patients who suffered from Dupuytren's contracture: 38 male and 4 female; mean age, 57 years (range, 32-80 years). Assessments comprised total active extension deficit and total active flexion of the fingers, active range of motion, Disabilities of the Arm, Shoulder and Hand (DASH) score, and EQ-5D index. Recurrence was defined as ≥20° flexion contracture. Compared to the opposite hand, preoperative total active extension deficit and total active flexion were 105° ± 32° and 221° ±  33°, respectively. The mean active range of motion of the metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints was 42° ± 24°, 37° ± 26° and 62° ± 14°, respectively. Mean follow-up was 27 months (range, 24-35 months). There were no cases of tendon rupture or neurovascular injury. Total active extension deficit and total active flexion at the final follow-up were 17° ± 11° and 225° ± 32°, respectively. The mean active range of motion of metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints was 73° ± 28°, 89° ± 24° and 63° ± 16°, respectively. The pre- and post-operative DASH scores were 18 ± 10 and 5 ± 2, respectively. Health-related quality of life on EQ-5D index improved from 0.72 ± 0.28 pre-operatively to 0.88 ± 0.72 post-operatively (p < 0.05). Recurrence rates in the metacarpophalangeal joint and proximal interphalangeal joint were 7% and 11%, respectively. The modified dynamic high-frequency ultrasound-guided needle aponeurotomy is a safe and effective way to treat Dupuytren's contractures. Ultrasound visualization ensures that the cords can be completely transected. Dynamic ultrasound decreases the risk of iatrogenic injury to the neurovascular bundles and tendons, and decreases the recurrence rate. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Treatment of Recurrent Dupuytren Disease

Treatment of recurrent Dupuytren disease is challenging. Multiple options exist, each having relative benefits and weaknesses. Choice for optimal treatment is made on a case-by-case basis, with shared decision making with the patient. Percutaneous and enzymatic techniques are best reserved for patients with well-defined recurrent disease and offer the benefit of quicker recovery with minimal or no scarring. Surgical treatments have higher risks of neurovascular injury and scarring, but lower recurrence rates. Staged continuous passive elongation followed by dermofasciectomy may lower neurovascular injury and improve outcomes. Salvage procedures may be necessary in patients with poor tissue beds and neurovascular compromise.

Preliminary results with non-centrifuged autologous fat graft and percutaneous aponeurotomy for treating Dupuytren's disease

The aim of this study was to describe our experience with treating Dupuytren's disease using needle aponeurotomy and non-centrifuged autologous fat grafting. The study included 17 patients (18 hands). Patients were treated with needle aponeurotomy and non-centrifuged autologous fat graft under general anesthesia. The fat grafts were injected into the surgical area so as to stay in contact with the operated site. An extension splint was used for 1 week postoperatively and the patients received hand therapy for 3 weeks. Before the treatment, the contracture in the proximal interphalangeal and metacarpophalangeal joints was a mean of 45.06 ± 13.44 degrees and 36.56 ± 13.09 degrees, respectively. It was 1.61 ± 1.65 and -0.56 ± 3.78 degrees at 3 months, respectively. The difference between these measurements was statistically significant. The mean follow-up period was 12 months. The results were satisfactory and no complications were observed during the follow-up period. Based on the results of the study, percutaneous aponeurotomy with non-centrifuged autologous fat grafting was found to have significantly beneficial effects in the treatment of Dupuytren's disease.

[Percutaneous needle aponeurotomy for Dupuytren's disease]

OBJECTIVE

Percutaneous transverse aponeurotomy of the cord by using a hypodermic needle as a scalpel blade in order to improve function of the hand.

INDICATIONS

Symptomatic flexion contracture with positive table top test caused by a single, palpable cord within the palm (primarily Tubiana stages I and II).

CONTRAINDICATIONS

Multiple, infiltrating or broad-based cords within the palm; irritated skin conditions; exclusive digital cord localization; recurrence after aponeurectomy; previous surgical intervention at the site of interest, digital nerve lesions; lack of patient compliance.

SURGICAL TECHNIQUE

Pinpoint surface anesthesia is obtained by injecting each portal area subdermally with 0.1 ml of local anesthetic. These applications start from distally to proximally within the palm while the most distal injection site is located proximal to the distal palm crease. Then the needle tip is introduced perpendicular to the cord. Sawing movements through the cord are performed transversely. While passively extending the contracted finger, the cord is held under tension which guarantees safe cutting. Patients are encouraged to report immediate pain sensation or numbness in order to prevent injuries to neurovascular structures and active finger flexion excludes tendon lesions during the procedure. Introducing the needle tip may be performed at several sites along the cord, if necessary, from distal to proximal at least 5 mm apart with prior pinpoint surface anesthesia. Finally, cautious passive stretching may be done after each release.

POSTOPERATIVE MANAGEMENT

Bandaging allowing immediate motion; application of a hand-based extension splint-glove during the night for 3-6 months.

RESULTS

Recurrence rate was 53% in 15 retrospectively examined patients after a mean interval of 40 months postoperatively.