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Percutaneous Needle Fasciotomy Versus Collagenase Treatment for Dupuytren Contracture: A Randomized Controlled Trial with a Two-Year Follow-up
Abstract
Background:
Local disruption of the cord that causes contracture of the finger in Dupuytren disease can be achieved either through mechanical division by percutaneous needle fasciotomy (PNF) or through enzymatic digestion by injectable collagenase Clostridium histolyticum (CCH). This study was designed to compare clinical and patient-reported outcomes between patients who had been treated with each method.
Methods:
A prospective, randomized, single-blinded, controlled trial was designed and included 156 patients with a contracture of the metacarpophalangeal (MCP) joint of ≥20°. The patients were allocated to treatment with either PNF or CCH. The primary outcome was a reduction of the MCP contracture to <5°. Secondary outcomes included the reduction of any concomitant contracture of the proximal interphalangeal (PIP) joint, the presence of Dupuytren cords, and changes in patient-reported outcomes as measured with the URAM (Unité Rhumatologique des Affections de Main) and QuickDASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH]) questionnaires and visual analog scales for patient satisfaction. All treatments were performed by a single surgeon and all blinded follow-up measurements were made by a single physiotherapist. The participants were assessed at 1 week, 6 months, and 1 and 2 years after the interventions.
Results:
A total of 152 patients (97%) were examined at 2 years, at which time 58 patients (76%) treated with CCH and 60 (79%) treated with PNF retained a straight MCP joint. No cords were detectable in >50% of the patients at 2 years. There were no significant differences in the reduction of PIP contracture, range of motion, or patient-reported outcomes between the 2 treatments.
Conclusions:
This trial demonstrated no advantage of CCH treatment compared with PNF in terms of clinical outcome at any time during the 2-year follow-up. The significant decrease in the number of pathological cords (p < 0.0001, Wilcoxon signed-rank test) after disruption regardless of the method used may indicate that resorption of pathological collagen occurs when the tension in the Dupuytren cord is diminished.
Level of evidence:
Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
... Our results are in contrast with those of previous studies that reported no difference in clinical outcome or recurrence rates between CCH and PNF treatment after 1, 2, 3, and 5 years [26][27][28][29][30] . The study by Jørgensen and colleagues, which is similar to our study but with a 3-year follow-up, demonstrated a higher rate of MCP joint recurrence and retreatment after PNF compared with CCH (47% versus 19%) 31 . ...
... The study by Jørgensen and colleagues, which is similar to our study but with a 3-year follow-up, demonstrated a higher rate of MCP joint recurrence and retreatment after PNF compared with CCH (47% versus 19%) 31 . Strömberg and colleagues randomized 152 patients to either CCH or PNF treatment 27 . Unlike their primary outcome (clinical success defined as MCP contracture <5°, which was a dichotomous parameter), our primary outcome was a continuous variable assessed in absolute degrees at the MCP joint. ...
... This is likely because of a strict definition of recurrence (20°increase in flexion contracture). Strömberg et al. defined recurrence as an increase in flexion contracture of ‡20°after 2 years, whereas Scherman et al. defined recurrence as an increase in flexion contracture of ‡30°after 3 years (or any retreatment) 27,29 . The CORDLESS study (Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study) defined recurrence as a 30°increase from baseline in their post-hoc analysis, which is similar to our definition 32 . ...
Background
Collagenase Clostridium histolyticum (CCH) and percutaneous needle fasciotomy (PNF) are 2 treatment options for Dupuytren disease. The purpose of this study was to compare these 2 methods in terms of clinical and patient-reported outcomes.
Methods
Eighty patients (median age, 72 years; 83% male) with a single-digit primary metacarpophalangeal (MCP) joint contracture of ≥30° were randomized to either CCH or PNF and followed for 5 years. The primary outcome was the difference in flexion-contracture reduction at the MCP joint from baseline to 2 years, with additional analysis examining the effect of the primary endpoint variable up to 5 years. Secondary outcomes included complications, grip strength, scores on the visual analogue scale (VAS) for pain, the shortened version of the Disabilities of the Arm, Shoulder and Hand, the brief Michigan Hand Questionnaire, Unité Rhumatologique des Affections de la Main, and a VAS for treatment satisfaction as well as recurrence and retreatments.
Results
The mean MCP joint contracture was 48° at baseline and 2° at 5 years in the CCH group, and 50° at baseline and 7° at 5 years in the PNF group. The reduction in MCP contracture at 2 years was larger in the CCH group than in the PNF group, with a mean difference between the groups of 12° (95% confidence interval [CI], 1.5° to 22.3°; p = 0.026). At 5 years, this mean difference was reduced to 6° (−1.5° to 12.8°; p = 0.1). There was no difference between the groups in any patient-reported outcome scores or grip strength beyond 4 weeks, with the exception of the brief Michigan Hand Questionnaire at 5 years. Ten (25%) of the patients in the PNF group compared with no patient in the CCH group had recurrence (contracture of ≥30°) at the MCP joint at 2 years. At 5 years, 17 (42.5%) of 40 patients in the PNF group had been retreated compared with 4 (10%) of 40 in the CCH group (p < 0.001). The CCH group experienced more transient complications (stiffness and hematoma) during the first week and were more satisfied (VAS satisfaction) from 1 year to the 5-year follow-up.
Conclusions
The main finding of this study is that CCH and PNF were equally effective in reducing MCP flexion contracture, but the correction of contracture lasted longer in the CCH group.
Level of Evidence
Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
... PNF is similar to CCH in results. [40][41][42] One study compared PNF with CCH injections in 50 patients with MCPJ disease with a 3-year follow-up and found an initial correction of 100% versus 89%, a recurrence rate of 68% versus 83%, and no difference in the retreatment rate (LOE: 1). 40 Another study compared PNF with CCH in 50 patients with PIPJ disease with a 3-year follow-up finding an initial correction of 67% versus 69% and a recurrence rate of 43% versus 34% (LOE: 1). ...
... 41 A more extensive study compared PNF with CCH injection in 152 patients with MCPJ disease and 2-year follow-up, finding an initial correction of 91% versus 90% and a recurrence rate of 21% versus 24% (LOE: 1). 42 There was no significant difference between CCH and PNF treating MCPJ contractures in range of motion, pain, or QuickDASH score. 42 Regression and disappearance of the cords occurring in more than 50% of patients at two years follow-up may indicate that resorption of the pathological cord occurs when the tension in the DD cords is diminished. ...
... 42 There was no significant difference between CCH and PNF treating MCPJ contractures in range of motion, pain, or QuickDASH score. 42 Regression and disappearance of the cords occurring in more than 50% of patients at two years follow-up may indicate that resorption of the pathological cord occurs when the tension in the DD cords is diminished. 42 A study in 132 matched patients compared CCH with LF with a three-month follow-up in a nonrandomized study (LOE: III). ...
Dupuytren's disease (DD) is a common fibroproliferative condition of the hand.
Methods:
Management of DD includes observation, non-operative management, and operative management. Operative treatments include percutaneous needle fasciotomy (PNF), open fasciotomy (OF), Clostridium collagenase histolyticum (CCH) injections, limited fasciectomy (LF) and dermofasciectomy (DF). The various methods of DD treatment are reviewed.
Results:
We summarize the highlights of each treatment option as well as the strengths and weaknesses. PNF has an immediate improvement, but a higher recurrence rate, potential problematic skin tears, and rare tendon or nerve complications. Limited fasciectomy removes the thickened, diseased tissue but has a more prolonged recovery and has a higher rate of significant complications. Dermofasciectomy has the highest complication rate, and the lowest recurrence. Also, secondary fasciectomy after a previous dermofasciectomy has an unexpected amputation rate as high as 8%. Collagenase injections require two visits, have an increased number of minor side effects such as skin tears, and have rare but significant side effects such as tendon rupture.
Conclusions:
This article gives an overview of different treatment options for DD and each of their strengths and weaknesses and provides procedural tips.
... The shortand intermediate-term results at 1 and 2 years have been previously published, and this study constitutes the follow-up at 5 years. 20,21 ...
... The results of this study at 1 and 2 years have been previously reported, and this study presents the long-term results at 5 years. 20,21 Patients referred to the department of hand surgery at Sahlgrenska University Hospital were enrolled and treated between October 2012 and October 2014. The inclusion criteria were: (1) a palpable Dupuytren cord with (2) an extension deficit of 20 in the metacarpophalangeal (MCP) joint in (3) a single finger, in (4) an adult patient who agreed to participate and signed the written informed consent form. ...
... The results of this trial at 1 week, 6 months, 1 year, and 2 years have previously been reported. 20,21 At 5 years, 45 patients in the CCH group and 57 patients in the NF group were examined (Fig. 1) and the medical records for all remaining patients were reviewed. The mean time for the clinical follow-up was 5.1 years, ranging from 4.8 to 6.3 years. ...
Purpose
Over the past decade, collagenase treatment and needle fasciotomy (NF) have gained widespread popularity in the treatment of Dupuytren contracture. This prospective study was designed to compare the results of these treatments in terms of clinical and patient-reported outcomes.
Methods
A prospective, randomized, controlled trial included patients with a contracture of 20° or more in a single metacarpophalangeal joint. Patients were allocated to treatment with either NF or collagenase Clostridium histolyticum. The primary outcome was a reduction in the metacarpophalangeal joint contracture to less than 5°. Secondary outcomes included recurrence, the presence of Dupuytren cords, and changes in patient-reported outcomes. The participants were examined 5 years after the intervention.
Results
The study cohort comprised 156 patients divided into 2 equally sized groups. After 5 years, data were collected from 143 (92 %) of the initially enrolled participants. The mean time for the clinical follow-up was 5.1 years. In the remaining cohort without a second procedure, 51% (23 patients) in the collagenase Clostridium histolyticum group and 47% (27 patients) in the NF group still had extension deficits of less than 5°. Among the participants with a successful initial procedure, the recurrence rate was 56% (36 patients) in the collagenase Clostridium histolyticum group and 45% (30 patients) in the NF group. There were no differences between the 2 treatments in regard to passive joint extension, reduction of contracture, range of motion, or patient-reported outcomes.
Conclusions
The 5-year outcomes for NF are similar to those for collagenase in terms of sustained correction, recurrence, presence of Dupuytren cords, and patient-reported outcomes for the treatment of metacarpophalangeal joint contractures.
Type of study/level of evidence
Therapeutic I.
... Confirmatory factor analysis was used to test the structural validity of the questionnaire. We included 231 patients (273 cases) with a mean age of 67 (SD, 9) years. Cronbach's alpha was 0.91. ...
... La validité structurelle du questionnaire a é té é valué e à l'aide d'une analyse factorielle confirmatoire. Deux cent trente et un patients (273 cas) ont é té inclus, l'âge moyen é tait de 67 ans (ET,9). L'alpha de Cronbach é tait de 0,91. ...
... The URAM has been translated into German using a structured approach and is comparable to the original English and French version [8]. It has been used in several studies that investigated outcomes after percutaneous needle fasciotomy, collagenase injection or surgical treatment for Dupuytren's disease [9][10][11][12]. Only a few studies have shown the adequate measurement properties of the URAM in patients with Dupuytren's disease, despite its potential suitability for assessing hand function in this population [4,7,13,14]. ...
We sought to investigate the reliability, validity, responsiveness, and interpretability of the German version of the Unité Rhumatologique des Affections de la Main (URAM) scale in patients with Dupuytren’s disease. Patients with Dupuytren’s disease were evaluated before receiving an injection of collagenase Clostridium histolyticum or undergoing surgical treatment and again 1 year later. Patients completed the URAM, the brief Michigan Hand Outcomes Questionnaire (brief MHQ), and the 5-level EuroQol version (EQ-5D-5L). Flexion contracture was measured. Internal consistency (Cronbach’s alpha), construct validity (Spearman’s correlation coefficient, r), responsiveness (effect size), and the minimally important change (MIC) and minimally important difference (MID) were determined. Confirmatory factor analysis was used to test the structural validity of the questionnaire. We included 231 patients (273 cases) with a mean age of 67 (SD, 9) years. Cronbach’s alpha was 0.91. Correlations between the URAM and the brief MHQ, EQ-5D-5L and flexion contracture were r = −0.76, r = −0.46 and r = 0.53, respectively. The URAM effect size was 0.96 and the MIC and MID were 6 and 7 points, respectively. The factor analysis revealed unidimensionality but indicated that one item (pick up small objects) could be removed. The German URAM has high reliability, good construct validity and excellent responsiveness. However, the questionnaire could be shortened by one item to increase its structural validity. We recommend using the URAM as a specific tool for evaluating the treatment effect in patients with Dupuytren’s disease in daily practice and for research purposes.
... Also, according to some data, the recurrence rates are lower following the CHC therapy as compared to NF [30,31]. Nonetheless, many studies demonstrate similar effectiveness of both techniques, with a fundamental difference consisting in the price of the materials used [32]. ...
... Perhaps, the first wave of COVID-19 had an influence on the decision as it dramatically reduced the number of elective procedures; doubts raised by some experts and healthcare managers with regard to the actual cost-effectiveness and efficiency of the method might have also played a role. With no doubt, however, the method used to have numerous advocates; in the US, CHC injection procedures remain to outnumber partial fasciectomies [32]. ...
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Introduction: 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.
Aim: The aim of this study is an updated review of scientific data in this topic.
Results: 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.
Conclusion: It seems that updated knowledge on Dupuytren’s disease may be interested and useful for surgeons involved in management of the disorder.</br
... 3,4 Recent randomized controlled trials have reported no difference in recurrence between CCH injection and PNF in the treatment of Dupuytren disease. [5][6][7] One study found collagenase injection to be associated with more transient complications in the treatment of isolated proximal interphalangeal joint involvement and with no difference in recurrence rates at 2-year follow-up. 6 In this randomized controlled trial, we compared the recurrence of Dupuytren disease at 3 years following needle fasciotomy or collagenase injection treatment for isolated metacarpophalangeal (MCP) joint contractures. ...
... Strömberg et al. found no difference between CCH and PNF treatment of isolated MCP joint extension deficit in a randomized study of 152 patients. 7 After 2 years, 76% of patients in the CCH group, and 79% of patients in the PNF group, had less than 5 degrees of extension deficit. Similarly, Abe found no difference in recurrence between CCH and PNF in a randomized trial of 70 patients with PIP contracture after 3 years. ...
Background:
In this randomized controlled trial, we compared the recurrence of Dupuytren's disease at 3-years following needle fasciotomy or collagenase injection treatment for isolated metacarpophalangeal joint contractures.
Methods:
The study was conducted between 2013 and 2015. The study design was a single centre randomized controlled clinical trial with an independent blinded observer. Patients were randomized between collagenase clostridium histolyticum injections (Xiapex®) and percutaneous needle fasciotomy (CCH vs PNF). A total of 36 patients were followed in the PNF group and 32 in the CCH group.
Results:
Patients who were treated with CCH had a significantly lower recurrence rate than patients treated with PNF during the three-year period (p = 0.007). Of the 36 patients who were followed in the PNF group, 47% (n=17) had recurrence of extension deficit or progression of the disease leading to further treatment. Of the 32 patients who were followed in the CCH group, 19% (n=6) had recurrence or progression. No serious adverse event was reported in any of the patients.
Conclusions:
In this randomized controlled trial, we find less recurrence and progression of Dupuytren's disease using collagenase injection as compared to percutaneous needle fasciotomy three years following treatment for isolated metacarpophalangeal joint contractures.Level of evidence: I.
... The studies included for the calculation of transition parameters were published between 2002 and 2018, with a mean follow-up time of 1.6 years (range: 1 month to 2 years). [9][10][11]14,17,20,[25][26][27][28][29][30][31][32][33][34][35][36][37][38][39] In accordance with previous randomized clinical trials, we included studies that defined treatment success as less than 5°of residual contracture at 30-day follow-up. Recurrence was defined as return of a contracture greater than 20°. ...
... Then, these probabilities were adjusted by the relative risk of success and recurrence contingent on the affected joint type and contracture severity ( Table 1). 2,4,8,9,[11][12][13][14]17,20,21,24,25,[28][29][30][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49] ...
Importance:
Owing to its tendency to recur, Dupuytren contracture often requires multiple treatments, which places additional economic burden on health care. The likelihood of contracture recurrence varies not only with treatment but also with disease characteristics, such as contracture severity and location, but prior cost-effectiveness analyses of Dupuytren contracture treatments have not considered these patient-specific disease characteristics.
Objective:
To identify the most cost-effective treatment regimen for patients with recurrent Dupuytren contracture.
Design, setting, and participants:
This economic evaluation was conducted with state-transition microsimulation modeling using data from published studies and Medicare. A simulated cohort of 10 000 individuals with Dupuytren contracture was created. Patients could transition yearly between the following health states: symptom-free, symptomatic, and death. Available treatments were collagenase clostridium histolyticum injection, percutaneous needle aponeurotomy (PNA), and limited fasciectomy (LF); individuals randomly chose any treatment when symptomatic. Patients were limited to 3 rounds of treatment for a contracture affecting 1 joint, totaling 27 unique combinations. If the contracture recurred after 3 treatments, patients lived with the disease for the remainder of life.
Exposures:
PNA, collagenase clostridium histolyticum injection, or LF.
Main outcomes and measures:
Quality-adjusted life-years (QALYs), total costs (in US dollars), and incremental cost-effectiveness ratios (ICERs). A willingness-to-pay threshold of 212 647/QALY [93 932/QALY [98 624/QALY [263 726/QALY [100 000 per QALY. Probabilistic sensitivity analysis estimated a 44%, 15%, 41%, and 52% chance of a regimen consisting of only PNA being cost-effective in low-severity MCP, high-severity MCP, low-severity PIP, and high-severity PIP joint contractures, respectively.
Conclusions and relevance:
The results of this study suggest that LF is a cost-effective intervention for recurrent high-severity MCP joint contractures. For recurrent low-severity MCP joint contractures and PIP joint contractures of all severity levels, PNA was the only cost-effective intervention. Collagenase clostridium histolyticum injections were not a cost-effective intervention for recurrent Dupuytren contracture and should not be preferred over PNA or LF.
... 5,6 To date, few randomized clinical trials have compared percutaneous needle fasciotomy with collagenase clostridium histolyticum. [7][8][9][10] This study compared the effectiveness of percutaneous needle fasciotomy with collagenase clostridium histolyticum using prospectively gathered data from single hand surgery practice sites in Japan. ...
... Most articles on the treatment of Dupuytren's contracture focus on biometric assessments, such as the measurement of contractures, and patient-reported outcome measures, such as the URAM scale or QuickDASH questionnaire, are more uncommon. [7][8][9][10][17][18][19] In the present study, although the recurrence rate was not satisfactory, the URAM scale and the QuickDASH score statistically significantly decreased by 28 percent and 33 percent, respectively, from the baseline, even in patients with stage II proximal interphalangeal joint contractures. No significant differences in patient-reported outcome measures were revealed between the collagenase clostridium histolyticum and percutaneous needle fasciotomy procedures at 3 years, although the QuickDASH score was significantly higher in the collagenase clostridium histolyticum group than in the percutaneous needle fasciotomy group at day 30. ...
Background:
This study compared the effectiveness of injectable collagenase clostridium histolyticum and percutaneous needle fasciotomy in the treatment of Dupuytren's contracture.
Methods:
Patients with a total passive extension deficit of 30 degrees or more in a single digital ray were enrolled and assigned randomly to receive either collagenase clostridium histolyticum injections or percutaneous needle fasciotomy. Preoperative severity of proximal interphalangeal joint contracture for Dupuytren's disease was classified according to the British Society for Surgery of the Hand as less than 30 degrees (stage I) or 30 degrees or more (stage II).
Results:
Of the 70 patients enrolled, 36 patients with 46 joints received collagenase clostridium histolyticum injections and 34 patients with 48 joints received percutaneous needle fasciotomy. At day 30, successful corrections were obtained in only 50 percent of the injection group and 67 percent of the fasciotomy group for stage II proximal interphalangeal joints. Recurrences were frequent among patients with stage II joint contractures. The mean Quick Disabilities of the Arm, Shoulder and Hand questionnaire score at day 30 was significantly higher in the injection group compared with the fasciotomy group (7.5 versus 4.2, respectively). In the injection group, adverse events were reported for all patients. In the fasciotomy group, complications were reported for 15 percent of patients.
Conclusions:
The collagenase clostridium histolyticum and percutaneous needle fasciotomy groups had similar outcomes for Dupuytren's contracture with 3 years' follow-up. Recurrences were frequent among patients with stage II proximal interphalangeal joint contractures. The Unité Rhumatologique des Affections de la Main scale and Quick Disabilities of the Arm, Shoulder and Hand questionnaire score decreased significantly for both groups at final follow-up.
Clinical question/level of evidence:
Therapeutic, II.
... The procedure is painless and short. Outcome is excellent: 80% of patients retain joint extension after two years 22,23 . ...
Ultrasound (US) has gained importance in musculoskeletal imaging. One of the reasons is that it is the best technique to guide interventional procedures. These procedures have grown unstoppably. A recent review found more than 80 different procedures, the vast majority with US guidance. Shoulder pain treatments were the first introduced. They include treatment of calcific tendinitis, infiltrations of bursa and rotator cuff, joint injections, and nerve blocks. Tendons and fasciae are also targets of these procedures, including infiltrations, several treatments for tendinosis and fasciitis, trigger finger and palmar fibromatosis treatment. Musculoskeletal cysts (ganglions and Baker´s) and fluid collections can also be treated with ultrasound-guided techniques, as well as conditions at joints and nerves. Finally, foreign bodies can be removed also using US. This article reviews these applications. The list of procedures cannot be exhaustive, given the large number of procedures and their complexity, but it will serve to give a glimpse of how these techniques can solve specific musculoskeletal problems.
... However, the substantially lower recurrence rates in the present study highlight the need for more research. Based on the similar results between collagenase and needle fasciotomy that were reported previously, it has been suggested that needle fasciotomy should be favored due to lower costs [23,25]. Our previous work as well as that of Zhao et al. have shown trends of fewer surgical fasciectomies after the introduction of collagenase, possibly suggesting that collagenase injections may be used as an alternative to surgical fasciectomy [13,26]. ...
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.
... The procedure is painless and short. Outcome is excellent: 80% of patients retain joint extension after two years 22,23 . ...
Ultrasound has important advantages to guide procedures on the skin: it is non-expensive and highly available and does not use ionizing radiation. As it is a superficial organ, the resolution of ultrasound on the skin is superior to that of any other technique.Performing ultrasound-guided procedures requires careful planning and adequate aseptic and anesthetic measures. A hands-free technique (holding the needle in one hand and the probe in the other) is preferred. The needle is introduced with real-time control following the ultrasound exam plane. High-resolution linear transducers are ideal for performing skin interventions.Procedures performed include biopsies, treatment of cystic lesions, arteriovenous malformations, palmar fasciitis, removal of cosmetic fillers, or removal of foreign bodies. Biopsies can be performed using fine needle techniques to obtain cytological samples or core biopsies to obtain histological samples. The latter have higher sensitivity and specificity with a low complication rate.KeywordsUltrasound imagingInterventional ultrasoundFine needle aspiration biopsyCore needle biopsiesGanglion cystBursitisDupuytren’s contracture FillerArteriovenous malformationForeign body
... 16 We have no explanation for the much higher recurrence rates reported by Skov et al compared with 22% in the collagenase group and 21% in the PNF group in our study. A research group headed by Strömberg et al 21 reported in a prospective, randomized study that 58 patients (76%) treated with CCH and 60 (79%) treated with PNF retained a straight MCP joint throughout the trial after 2 years. The same research group recently described that the recurrence rate in the MCP joint contracture was not different between the two treatment groups 5 years after the intervention. ...
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.
... Most studies about Dupuytren's disease report passive extension measures (Hurst et al., 2009;Kaplan and Crosby, 2018;Strömberg et al., 2018;van Rijssen et al., 2012), while it is unclear in others if active or passive extension was measured (Gaston et al., 2015;Peimer et al., 2015a), which may affect the result (Pratt and Ball, 2016;Rodrigues et al., 2015). In the present study, active extension Table 3. Patients rating of hand function problems, sensibility testing and QuickDASH at the follow-up assessments (total, 79). ...
The aim of this study was to report hand function, disability and satisfaction and patients’ perception of functionally troublesome contractures 5 years after injection with collagenase Clostridium histolyticum and hand therapy for Dupuytren's disease. Data from 79 patients were collected before and at 3, 12 and 60 months after treatment. Hand function was significantly improved, and 70% achieved a functional range of motion in the treated hand. QuickDASH scores and range of motion were best at 3 months follow-up. At 60 months, mean total extension deficit was 48°, which was 57% of the deficit before treatment. Thirty-seven patients (47%) had developed recurrent contractures in treated finger(s) meeting the criteria for new treatment. The threshold for functionally troublesome contractures was found to be 30°–60° in the finger joints. Treatment was experienced as painful, but few hand function problems occurred. Most patients would choose this treatment method again.
Level of evidence: IV
... In contrast to open surgery, both methods disrupt the cord while leaving the bulk of the pathologic collagen intact. [8][9][10][11] Disclosure: The authors have no financial interest to declare in relation to the content of this article. ...
Dupuytren's contracture is common among older people in Sweden. Previous studies comparing the treatment with an injection of collagenase with percutaneous needle fasciotomy found no differences.
Methods:
We retrospectively compared the degree of improvement in the deficit in extension of the joints in 2 groups of patients who had been treated with collagenase (71 fingers) or needle fasciotomy (109 fingers) before and 1 year after treatment. We compared the improvement of the extension deficit among the metacarpophalangeal (MCP) and proximal interphalangeal joints before and after the intervention; additionally, the level of improvement was classified into 3 levels (mild = 0° to 29°; moderate = 30° to 60°; considerable = 61° and more).
Results:
The degree of improvement of extension in the MCP joints was 11° greater in the collagenase group (P = 0.001). The number of patients who had an improvement of >60° (considerable) in extension was greater in the collagenase group (P = 0.02).
Conclusion:
Collagenase was more effective than needle fasciotomy in treating extension deficits of the MCP joints in Dupuytren's contracture in this retrospective analysis. Further prospective studies are required to confirm the finding.
... Needle fasciotomy disrupts the Dupuytren cord, but a recent study has suggested that this division may lead to resorption of the residual collagen [15] and half of the fingers in this study had no residual cord at final follow-up ( Figure 1) which lends support to this thesis. ...
Needle fasciotomy (NF) is a minimally invasive treatment option for Dupuytren contractures, but long-term results have indicated a high recurrence rate. This prospective study was initiated to monitor the introduction of NF in a context where limited fasciectomy had been the only treatment option, and to investigate the long-term results. The inclusion criterion was a palpable cord with a Metacarpophalangeal (MCP) and/or Proximal interphalangeal (PIP) contracture in one or more fingers. Fifty-eight fingers in 42 patients (40 male and 2 female with a median age of 68 years) were treated by needle fasciotomy between November 2010 and March 2012, and were followed for a median of 6.5 years. The median total passive extension deficit (TPED) was 52° at baseline, but decreased significantly to 20° postoperatively. No severe adverse events such as nerve or tendon injuries were reported. At final-follow up of 48 fingers the median TPED was still significantly reduced to 23° for all fingers (p < 0.0001). Twenty-nine fingers retained full correction of the contracture, and in patients with recurrent contractures NF was preferred in 13 out of 17 patients. This study showed that needle fasciotomy is a safe procedure for Dupuytren’s contracture, with excellent immediate reduction of the joint contracture and with a recurrence rate comparable to treatment by collagenase clostridium histolyticum (CCH).
... Randomized controlled trials comparing collagenase injection with percutaneous needle fasciotomy for isolated MCP joint contractures have been reported with up to 3-year followup. These studies show no statistically significant difference in treatment outcome, and the authors suggest an advantage for percutaneous needle fasciotomy, foremost based on presumed difference in initial treatment cost (Scherman et al. 2018, Strömberg et al. 2018. Our data show that during the study period 34 hands were treated with surgical fasciectomy at the study center, constituting 27% of all treatments for Dupuytren disease (see Supplementary data). ...
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.
... The patients were allocated to treatment with either PNF or by CCH. There was no advantage of CCH treatment compared with PNF in terms of clinical outcome at any time during a 2-year follow-up [37]. ...
Introduction
The partial aponeurectomy for treatment of Dupuytren’s contracture represents the gold standard for treatment of Dupuytren’s contracture. In selected cases, the alternative is the percutaneous needle fasciotomy (PNF).
Materials and methods
Between 2008 and 2018, 80 rays in 64 patients were treated using PNF. 53 patients (68 rays) were reviewed with a mean follow-up of 31 months.
Results
The recurrence rate was 18.9%. 49 patients with 62 rays had a totally free extension intra-operatively (92.4%). There were no complications. Only one patient reported a transient dysesthesia (1.8%) in the zone of operation. 86% of all patients would undergo the treatment again, if necessary. Patients were able to return to their job in an average of 5.5 days.
Conclusions
PNF is reliable and relatively simple to perform compared to partial aponeurectomy. Therefore, the PNF could be seen as a serious alternative for selected cases.
Background:
Surgery, needle fasciotomy, and collagenase injection are used to treat Dupuytren contracture. The treatment decision requires balancing initial morbidity and costs of surgery against its potential long-term benefits over needle fasciotomy and collagenase.
Objective:
To compare the effectiveness of surgery, needle fasciotomy, and collagenase injection at 3 months and 2 years (secondary time points of the trial).
Design:
A multicenter, randomized, outcome assessor-blinded, superiority trial. (ClinicalTrials.gov: NCT03192020).
Setting:
6 public hospitals in Finland.
Participants:
302 persons with treatment-naive Dupuytren contracture (contracture angle <135°).
Intervention:
Surgery (n = 101), needle fasciotomy (n = 101), or collagenase (n = 100).
Measurements:
The primary outcome was the success rate, defined as greater than 50% contracture release and patients reaching the patient acceptable symptom state. Secondary outcomes included hand function, pain, quality of life, patient satisfaction, residual contracture angle, finger flexion, risk for retreatment, and serious adverse events.
Results:
A total of 292 (97%) and 284 (94%) participants completed the 3-month and 2-year follow-ups. Success rates were similar at 3 months: 71% (95% CI, 62% to 80%) for surgery, 73% (CI, 64% to 82%) for needle fasciotomy, and 73% (CI, 64% to 82%) for collagenase. At 2 years, surgery had superior success rates compared with both needle fasciotomy (78% vs. 50%; adjusted risk difference [aRD], 0.30 [CI, 0.17 to 0.43]) and collagenase (78% vs. 65%; aRD, 0.13 [CI, 0.01 to 0.26]). Secondary analyses paralleled with the primary analysis.
Limitation:
Participants were not blinded.
Conclusion:
Initial outcomes are similar between the treatments, but at 2 years success rates were maintained in the surgery group but were lower with both needle fasciotomy and collagenase despite retreatments.
Primary funding source:
Research Council of Finland.
“The hand is the visible part of the brain”—Immanuel Kant
The hand is a remarkable and special part of our body. Not only is it critical to function, allowing us to grip, grasp, pinch, and finely manipulate objects and instruments, it allows us to communicate and perceive the world. Operating as an independent sensory organ, the fingers can replace the eyes, allowing us to feel and “see” the details of many things around us. The hand works alongside, and sometime in place of, speech to communicate and convey what we feel and yearn. It is integral to our everyday life and existence as human beings. This chapter focuses on the principal anatomy of the hand along with a comprehensive approach to assess its function and integrity. In addition, the non-surgical and post-surgical management of common injuries and conditions that affect the hand is also reviewed here.KeywordsHand anatomyHand fractureCarpalMetacarpalPha lanx
Background:
Dupuytren disease is a common fibroproliferative disease that affects the palmar fascia of the hands. Currently, there is limited consensus regarding the optimal therapy for this condition, with treatment decisions based largely on surgeon preference. Therefore, the aim of this study was to determine which treatments are the most effective for Dupuytren disease.
Method:
A systematic review and network meta-analyses were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. Medline, EMBASE, and Web of Science were searched for randomized trials comparing treatments for Dupuytren disease in adults. Eligible treatments included open limited fasciectomy, collagenase injection, and percutaneous needle fasciotomy. Study selection, data extraction, and quality appraisal were performed in duplicate. The methodological quality was evaluated with the Cochrane risk-of-bias critical appraisal tool.
Results:
Eleven randomized clinical trials were included in this study. At short-term (1-12 weeks) and long-term (2-5 years) time points, fasciectomy improved contracture release more than collagenase and needle fasciotomy as inferred by a lower total passive extension deficit. However, there was no difference between the groups regarding the best possible outcome at any time point. Fasciectomy was also superior in terms of recurrence and patient satisfaction compared with collagenase and needle fasciotomy, but only at later time points. There was no difference in skin damage-related and nerve damage-related complications following fasciectomy compared with other modalities. Risk of bias was generally moderate.
Conclusions:
Fasciectomy provides superior long-term advantages in terms of patient outcomes when compared with collagenase and needle fasciotomy. Larger trials with better blinding of outcome assessors are needed in the future.
Dupuytren disease is a common pathologic condition that can be especially challenging to hand surgeons in recurrent or severe contractures. Recurrence risk may be reduced with a variety of techniques, including skin grafting, external fixator application, radiation, and many others described in this article. Management of recurrence requires special attention to anatomy at risk. Adjuvant therapy may help to prevent the progression or recurrence of severe disease.
Purpose
To provide a comprehensive, evidence-based overview of the treatment for Dupuytren disease, specifically needle techniques, radiotherapy, primary conservative therapy, surgery, lipofilling, operative arthrolysis, salvage techniques, and the postoperative protocol and to make clinical recommendations for health care practitioners and patients.
Methods
Comprehensive multidisciplinary guideline process funded by the Quality Foundation of the Dutch Federation of Medical Specialists. This process included a development, commentary, and authorization phase. Patients participated in every phase. Multiple databases and existing guidelines up to August 2020 were searched. Studies on Dupuytren disease were considered eligible. Specific eligibility criteria were described per module. To appraise the certainty of the evidence, reviewers extracted data, assessed the risk of bias, and used the Grading of Recommendations Assessment, Development and Evaluation method, where applicable. Important considerations were as follows: patient values and preferences, costs, acceptability of other stakeholders, and feasibility of implementation. Recommendations were made based on the evidence from the literature and the considerations. The primary and secondary outcome measures were defined per module based on the input of patients obtained in collaboration with the Netherlands Patient Federation and health care providers from different professions.
Results
The following 8 specific modules were completed for Dupuytren disease: (1) needle techniques, (2) radiotherapy, (3) primary conservative therapy, (4) surgery, (5) lipofilling, (6) operative arthrolysis, (7) salvage techniques, and (8) the postoperative protocol.
Conclusions
Our Dutch multidisciplinary guideline on Dupuytren disease provides 8 modules developed according to the standards of the Dutch Federation of Medical Specialists. Evidence-based recommendations for clinical practice are provided for needle techniques, radiotherapy, primary conservative therapy, surgery, lipofilling, operative arthrolysis, salvage techniques, and the postoperative protocol. This guideline can assist health care providers and patients in clinical practice.
Type of study/level of evidence
Systematic review/I-II.
Purpose: The aim of this study was to assess the sex differences in enrollment into clinical trials for Dupuytren's disease (DD), treatment efficacy, and complications. Methods: Three databases were searched; Ovid MEDLINE, Ovid EMBASE, and EBSCO CINAHL. Included studies were clinical trials on adult patients with DD. Exclusion criteria were non-English studies and other study designs. Two independent reviewers completed abstract screening, full-text review, and data extraction. The number and percentage of studies that reported ad hoc analyses for sex differences in treatment efficacy, tolerability, and complications were reported. A meta-analysis was performed on the proportion of female participants enrolled in clinical trials for DD. Results: A total of 3172 references were screened, and 59 studies were identified for full-text review. We identified 28 clinical trials for DD of which none reported secondary analyses for sex differences. Only 2 trials discussed sex differences in complications, and one trial reported sex differences in tolerability. The proportion of female participants in the meta-analysis was 19.5% [95% CI: 16.1-23.0%]. Conclusion: Sex differences in the clinical trials for DD are not widely considered in clinical trials despite their critical role. Males and females do not have equal representation in clinical trials for DD. Future studies should account for sex differences in the design and the analysis of clinical trials.
Severe forms of Dupuytren disease are difficult to treat. Surgical fasciectomy is often the first choice, despite its high complication rate. At times, amputation is recommended. The authors evaluated the efficacy of minimally invasive needle fasciotomy (needle aponeurotomy) as the first and only treatment for severe (stage IV) Dupuytren contracture using a retrospective chart review of a single surgeon's consecutive experience over 8 years. A total of 204 rays from 165 patients with severe Dupuytren disease with total passive extension digit contracture of 135 degrees or greater were included in the study. Mean follow-up was 22.3 months. Standard goniometric measurements of finger joint contractures were taken before needle aponeurotomy and at follow-up visits. Total passive extension digit and flexion contracture improved significantly at each finger joint. Before the procedure, median flexion contractures were as follows: at the metacarpophalangeal joint, -70 degrees (interquartile range, -80 to -55); at the proximal interphalangeal joint, -75 degrees (interquartile range, -85 to -65); and at the distal interphalangeal joint, -5 degrees (interquartile range, -20 to 0); median total passive extension of digit was -145 degrees (interquartile range, -160 to -135). Flexion contractures after the procedure improved with 74 percent gain at the metacarpophalangeal joint, 32 percent gain at the proximal interphalangeal joint, and 46 percent gain at the distal interphalangeal joint, with 55 percent gain of total passive digit extension overall ( p < 0.001). The study shows that needle aponeurotomy led to significant improvements in joint contractures at all finger joints with minimal adverse effects. Needle aponeurotomy is an effective and safe first-line treatment for severe Dupuytren disease as the sole treatment or as a preliminary step for more invasive procedures if needed.
Clinical question/level of evidence:
Therapeutic, IV.
Tissue banking programs fail to meet the demand for human organs and tissues for transplantation into patients with congenital defects, injuries, chronic diseases, and end-stage organ failure. Tendons and ligaments are among the most frequently ruptured and/or worn-out body tissues owing to their frequent use, especially in athletes and the elderly population. Surgical repair has remained the mainstay management approach, regardless of scarring and adhesion formation during healing, which then compromises the gliding motion of the joint and reduces the quality of life for patients. Tissue engineering and regenerative medicine approaches, such as tendon augmentation, are promising as they may provide superior outcomes by inducing host-tissue ingrowth and tendon regeneration during degradation, thereby decreasing failure rates and morbidity. However, to date, tendon tissue engineering and regeneration research has been limited and lacks the much-needed human clinical evidence to translate most laboratory augmentation approaches to therapeutics. This narrative review summarizes the current treatment options for various tendon pathologies, future of tendon augmentation, cell therapy, gene therapy, 3D/4D bioprinting, scaffolding, and cell signals.
Dupuytren’s disease (DD) is a chronic progressive hand disease characterized by the formation of nodules and cords in the palmar and digital fascia. This fibrous tissue results in fingers contractures and functional disability of the hand.In general, the literature suggests that, in the therapy of DD, the method of choice is limited fasciectomy (LF), which has the lowest risk of recurrence despite the high risk of complications. Therefore, over recent years, mini-invasive approaches have been favored because they have minimum complications and an early return to normal life but greater recurrence rates and residual contracture.In 2012, van Rijssen published the results of a comparison of LF with needle aponeurotomy (NA) after 5 years, recurrence was 21% in LF, and 85% in NA. In 2018, Hovius published results of a comparison of PALF with LF. After the first year, there was no significant difference between LF and PALF. After 5 years there were already different results. Recurrence was 39% for LF and 74% for PALF. The results of the CORDLESS study demonstrated that the 5-year disease recurrence in successfully treated contractures with collagenase clostridium histolyticum is 48% (39% MP joints, 66% PIP joints).KeywordsPALFDupuytren’s diseaseRegenerativeFat graftingNeedle aponeurotomyStem cell
Background:
There have been no formal studies of the use of collagenase clostridium histolyticum (Xiaflex; Endo Pharmaceuticals, Malvern, Pa.) in the anticoagulated patient. Previous study on its use excluded patients receiving anticoagulation therapy. This study reviewed the effects of anticoagulation use in patients undergoing collagenase clostridium histolyticum injection and cord rupture to determine safety and efficacy.
Methods:
The authors retrospectively reviewed patients receiving collagenase clostridium histolyticum injections for Dupuytren contracture between 2010 and 2017. Outcomes included type of anticoagulation, skin tear, tendon rupture, lymphadenopathy, sensory abnormality, hematoma, and bleeding.
Results:
A total of 388 injections were performed in 197 patients. The average clinical follow-up was 311 days. Fifty-two percent of patients (n = 201) were anticoagulated. The vast majority were taking aspirin (acetylsalicylic acid) (n = 182), followed by warfarin (n = 27), clopidogrel (n = 9), apixaban (n = 8), rivaroxaban (n = 4), and dabigatran (n = 2). There were 42 skin tears, 21 in the anticoagulated group. One tendon rupture occurred in the anticoagulated group (acetylsalicylic acid) and none occurred in the nonanticoagulated group (p = 0.34). No patients experienced sensory abnormalities, a hematoma requiring intervention, or uncontrollable bleeding.
Conclusions:
Anticoagulation is commonly encountered by hand surgeons treating Dupuytren contracture. There is no significant difference in complications in the anticoagulated patient versus the nonanticoagulated patient. It is safe to perform collagenase clostridium histolyticum injections for Dupuytren contracture in the anticoagulated patient, regardless of the type of anticoagulation.
Clinical question/level of evidence:
Therapeutic, III.
Background: Unité Rhumatologique des Affections de la Main (URAM) is a novel and disease-specific questionnaire for Dupuytren contracture, a fibroproliferative disease that affects hands causing progressive contracture in flexion of the fingers.
Objectives: To evaluate the sensitivity and specificity of the URAM scale in Dupuytren contracture.
Materials and Methods: We performed meta-analyses of 10 articles published in PubMed, Embase, Cochrane, Google Scholar, Latin American and Caribbean Health Sciences Literature (LILACS), and in various grey literature databases that describe the use of the URAM and Tubiana scales to assess treatment outcomes in Dupuytren contracture. We built three models: a hierarchical summary receiver operating characteristic (HSROC) model to determine the optimal threshold for defining Dupuytren contracture, a difference in means model to assess the magnitude of the effect of different treatment modalities, and a meta-regression model to determine the effect on patient quality of life questionnaires such as the URAM, according to variations in Tubiana scores after treatment.
Results: The HSROC and bivariate models showed a sensitivity of 80.23% (95% CI: 75.66 to 84.14) and an overall specificity of 2.61% (95% CI: 1.11 to 6.05). The second model showed an overall difference in means of 1.95 (95% CI: -2.86 to -1.04) for partial fasciectomy and collagenase Clostridium histolyticum (CCH) injections, and -1.30 (95% CI: -1.77 to -0.83) for partial fasciectomy, and -2.75 (95% CI: -4.73 to -0.78) for CCH. The coefficient obtained in the meta-regression model was -1.666 (95% CI: -4.183 to 0.851).
Conclusion: The URAM scale is highly sensitive to changes in Dupuytren contracture but has low specificity. It also showed a strong correlation with worsening of finger contracture as measured by the Tubiana scale.
Background: Percutaneous needle fasciotomy (PNF) has been successfully used for the treatment of contracture bands in the hand in patients with Dupuytren disease. The aim of this study is to determine aesthetic and functional outcomes at 2 weeks following PNF in patients with Dupuytren contracture.
Methods: Seventy-five patients undergoing PNF for Dupuytren disease during a 4-month period were included. Patients completed the Visual Analogue Appearance Score (VAAS), Derriford Appearance Score (DAS), and the quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH) preoperatively and at 2 weeks after surgery. In addition, VAAS was done in the immediate postoperative period as well.
Results: Seventy-four (99%) patients completed the immediate postoperative VAAS scores and 51 (68%) completed the VAAS, DAS, and QuickDASH at 2 weeks. Preoperative VAAS fell from 6.01 to 1.53 (p < 0.0001) immediately post operation. Two weeks later, VAAS increased to 2.91 but was still significantly lower than preoperatively (p < 0.0001). DAS was unchanged. QuickDASH decreased from 22.4 preoperatively to 12.1 2 weeks later (p = 0.001).
Conclusion: PNF for Dupuytren contracture resulted in improvement in both aesthetic and functional outcomes at 2 weeks. Longer term follow-up is required to determine whether these improvements are sustained.
Level of Evidence: Level IV (Therapeutic)
Background
Revision procedures for recurrent Dupuytren disease (DD) can be difficult and carry a high risk of complications. Our goal was to describe surgical strategies used for cases of recurrence and report on their outcomes.
Methods
We reviewed 1 surgeon’s operative cases for recurrent DD performed at 1 institution. Prior procedures included collagenase injection, percutaneous needle fasciotomy, or open surgical fasciectomy in the same digit or area of the hand.
Results
From January 1981 to December 2020, 54 procedures were performed on 33 patients for recurrent DD. Most patients were men (82%), had bilateral involvement (64%) and family history (52%), and some had ectopic disease in their feet (24%). The small finger was involved in 76% of the cases, and the proximal interphalangeal (PIP) joint was involved in 83% of these digits. The procedures included 38 partial fasciectomies (72%), 12 dermofasciectomies (23%), 3 radical fasciectomies (6%), 1 of each needle fasciotomy, ray amputation, and PIP joint arthrodesis (2%). Twenty-three patients (43%) required full thickness skin grafts with an average area of 7.1 cm ² (range: 1-20 cm ² ).
Conclusions
This study highlights the complexity of recurrent DD case management and found the treatment required for 95% of patients in this series was open partial fasciectomy with or without demofasciectomy. Full thickness skin grafting was necessary in nearly half of the cases.
Background:
The worldwide prevalence of Dupuytren's disease (DD) is 8%. DD is a chronic disease for which there is no cure. Various treatments are available.
Methods:
This review is based on pertinent publications retrieved by a selective search in PubMed and Embase.
Results:
Genetic factors account for 80% of the factors involved in causing this disease. Diabetes mellitus, hepatic diseases, epilepsy, and chronic occupational use of vibrating tools are also associated with it. Limited fasciectomy is the most common treatment and is considered the reference standard. Possible complications include persistent numbness in areas where the skin has been elevated, cold sensitivity, and stiffness, with a cumulative risk of 3.6 -39.1% for all complications taken together. The recurrence rate at 5 years is 12-73%. Percutaneous needle fasciotomy is the least invasive method, with more rapid recovery and a lower complication rate than with limited fasciectomy. 85% of patients have a recurrence after an average of 2.3 years. Radiotherapy can be given before contractures arise in patients with high familial risk, or postoperatively in selected patients with a very high individual risk of recurrence.
Conclusion:
Although DD is not curable, good treatments are available. Recurrences reflect the pathophysiology of the disease and should not be considered complications of treatment. When counseling patients about the available treatment options, particularly the modalities and timing of surgery, the physician must take the patient's degree of suffering into account. Nowadays, fast recovery from surgery and less postoperative pain are a priority for many patients. Different surgical methods can be used in combination. It remains difficult to predict the natural course and the time to postoperative recurrence in individual patients; these matters should be addressed in future studies.
Purpose
The Evidence-Based Practice Committee of the American Society for Surgery of the Hand (ASSH) set out to assess the membership’s practice patterns (PPs) and knowledge of evidence-based principles for Dupuytren disease (DD).
Methods
A 21-item multiple-choice survey was distributed to all ASSH members via email in June 2020. Questions were divided into 2 types: evidence-based practice (EBP) and PPs. The survey addressed the following subtopics: nonsurgical, percutaneous, and open surgical management of DD.
Results
The response rate was 18% (n = 419). Of 13 EBP questions, 5 were answered with the preferred response by >75% of surgeons. The remaining 8 EBP questions had greater frequencies of less preferred responses, which concerned the current evidence for percutaneous management, as well as nonsurgical and postoperative management of DD. Of the PP questions, there were differences in opinion on how to manage a painful nodule, the percutaneous technique (eg, collagenase injection vs percutaneous needle aponeurotomy), and the choice of surgical incision for open fasciectomy (eg, Bruner incision with Z-plasties, partial closure with an open transverse palmar component, or longitudinal incision with Z-plasties).
Conclusions
Hand surgeons continue to be well informed about current evidence-based practices for treating DD and can improve their knowledge by familiarizing themselves with current data on percutaneous and nonsurgical methods. There exist differences in PPs for DD in the ASSH membership, specifically with less invasive management; and knowledge of peer practices can help navigate differences, critically interpret the evidence, and optimize patient care.
Type of study/level of evidence
Economic/Decision Analyses V.
In this article we take an international perspective on the use of needles, either percutaneous needle fasciotomy (PNF) or Clostridial Collagenase Histiolyticum (CCH), in treating Dupuytren’s Disease (DD). Worldwide, PNF is now used more frequently. The CCH has been withdrawn from non-USA markets, which lessens its use. Different patients have different preferences, while different surgeons have different skills and opinions. The surgeon should fully consider the patient’s preference and should also, in view of the scarcity of surgical resource and the potential hazard of surgery, reconsider and expand the use of a needle rather than an operation. In the future, a cheaper, yet equally safe and effective alternative to CCH, will provide a useful clinical tool for those cords, which, in the surgeon’s personal Venn diagram, are too challenging for PNF, but the patient does not want to have surgery.
Introduction
Several general hand functional assessment tools for Dupuytren’s disease have been reported, but none of the patient-reported-outcome measures specific to Dupuytren’s disease-associated disabilities are available in the Italian language. The purpose of this study was to culturally adapt the Unité Rhumatologique des Affections de la Main (URAM) into Italian (URAM-I) and determine its measurement properties.
Methods
Cross-cultural adaptation was performed according to the current guidelines. Construct validity (convergent and divergent validity) was measured by comparing the URAM-I with the Pain-Rated Wrist/Hand Evaluation (PRWHE-I), Short-Form 36 (SF-36-I) scale and finger range of motion, respectively. Factor analysis was used to investigate the URAM-I’s internal structure. Reliability was assessed by internal consistency (Cronbach’s alpha) and test-retest reliability by Intra-Class Correlation Coefficient (ICC).
Results
This study included 96 patients (males = 85%, age = 66.8 ± 9.3). Due to the cultural adaptation, we divided the original item #1 into two separate items, thus generating the URAM-I(10). Convergent validity analysis showed a strong positive (r = 0.67), significant (p < 0.01) Pearson’s correlation with the PRWHE-I. Divergent validity analysis showed a weak, negative (r < 0.3) and not significant correlation with the SF-36-I subscales, except for the physical pain subscale (r = −0.21, p < 0.05). Factor analysis revealed a 2-factor, 4-item solution that explained 76% of the total variance. The URAM-I(10) demonstrated high internal consistency (α = 0.94) and high test-retest reliability (ICC = 0.97).
Conclusion
The URAM-I(10) demonstrates moderate construct validity, high internal consistency and test-retest reliability, and showed a 2-factor internal structure. Its evaluative use can be suggested for the Italian Dupuytren’s population.
Dupuytren disease is an incurable fibromatosis of the palmar fascias of the hand with variable phenotype and disease course. Abnormal myofibroblast activity leads to the formation of nodules, skin pits, and cords that once contracting often cause flexion and adduction contractions, hampering normal hand use. It affects predominantly males of North-Western European descent of over 50 years of age. It is a polygenetic disease, which expression is probably also influenced by environment factors. Treatment is mostly symptomatic and primarily indicated for the correction of progressive finger flexion deformities, and can be operative or nonoperative.
Surgical options are percutaneous or open fasciotomy, segmental or limited fasciectomy, or dermofasciectomy, and each has its indications, which may overlap. Skin defects can be closed by skin grafts or flaps, or – especially when in the palm – can be left to heal secondarily. The ability to correct deformities is quite similar amongst the surgical options. The invasiveness of surgical treatment shows a direct relation with the reconvalescence time and an inverse relation to the durability of the result.
Nonsurgical methods include injection of steroids for nodules or collagenase for cords, and radiotherapy for nodules. The efficacy and durability of collagenase resembles that of percutaneous fasciotomy.
This chapter gives an overview of the current knowledge on this subject.
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.
This systematic review investigates complications and recurrence of Dupuytren’s contracture in metacarpophalangeal joints (MCPJs) and/or proximal interphalangeal joints (PIPJs) of fingers treated with collagenase clostridium histolyticum (CCH). A review of the literature on Dupuytren’s disease was performed using PRISMA guidelines. Included publications described complications and/or recurrences for contractures ≥20° in MCPJs and/or PIPJs treated with CCH. Successful treatments reduced contractures to ≤5° immediately. Treatment-related adverse events (AEs) were classified as minor, major surgical, and major nonsurgical. Contracture recurrence involved return of fixed-flexion contracture ≥20° in a successfully treated finger in patients with ≥12 months of follow-up. Of 2675 patients (3753 joints), 94% experienced ≥1 treatment-related AE, most commonly peripheral edema (64%), pain in extremity (53%), and contusion (51%). Major surgical complications occurred in 9 patients (1.0%). Major nonsurgical complications occurred in 2 patients, specifically nonrupture tendon injury and anaphylaxis. Of 1488 patients (2069 joints), recurrences were reported in 23% of successfully treated joints (n = 466; 20% MCPJs, 28% PIPJs), on average 12 to 24 months after treatment. MCPJs achieved greater success than PIPJs in initial contracture reduction (77% versus 36%). CCH is a safe, effective treatment to improve hand function in Dupuytren’s contracture. Most AEs are minor and self-resolving, although the risk of major AEs still exists. Following treatment, 23% of successfully treated joints experience recurrence, typically within 12 to 24 months but sometimes as early as 6 months. Surgeons are encouraged to discuss these risks with patients for shared decision-making regarding optimal treatment modalities.
Introduction: The purpose of this study was to review and compare clinical outcomes between percutaneous needle fasciotomy (PNF) and collagenase Clostridium histolyticum (CCH) injection for the treatment of Dupuytren’s contracture.
Materials and Methods: A systematic review was performed including all level I-III evidence studies investigating the clinical outcomes of PNF and CCH injection in the treatment of Dupuytren’s contracture.
Results: Five studies (278 CCH patients, 225 PNF patients; 285 CCH fingers, 246 PNF fingers, 405 males, and 98 females) were analyzed. Two randomized studies were level I evidence, one randomized study was level II, and two nonrandomized studies were level III. Two studies analyzed a total of 205 patients, each demonstrating statistically superior outcomes in one outcome measure (contracture improvement and Michigan Hand Questionnaire (MHQ) satisfaction subscore) with PNF, while the remaining three studies demonstrated no significant differences in outcomes between the two techniques. Three studies reported a statistically higher rate of minor complications (local pain, edema, ecchymosis, lymphadenopathy, pruritis) with CCH, while the remaining two studies demonstrated no significant difference in complication rates.
Conclusion: For the treatment of Dupuytren’s contracture, there is some evidence that suggests superior clinical outcomes of PNF compared with CCH and a higher minor complication rate with CCH.
Background:
In health care, quality-of-life surveys and questionnaires related to care are becoming increasingly important as a measure of its quality. There is currently no Spanish version of the URAM scale, which makes it suitable for hand pathology.The purposes of this study were to develop a Spanish version of the URAM and perform a transcultural adaptation of it, analyzing the result for reliability, validity and sensitivity to changes.
Methods:
The questionnaire was evaluated for patients with Dupuytren's disease and Carpal Tunnel Syndrome. The cohort study subjects were interviewed at three points in time (baseline, three days after intervention, and one month after), administering the QuickDASH, URAM, and SF12 (CF12= physical component, CM12= mental component) questionnaires at baseline and after intervention; and only the URAM at 3 days. Content validity was evaluated using Cronbach α. The distribution of the factorial loads of the items and the pattern of the answers were checked. Responsiveness was evaluated by the size of the effect and the reliable rate of change. Convergent and divergent validity was performed using Spearman's r between the different questionnaires.
Results:
The study was conducted with 106 patients. The mean baseline scores were: URAM= 14.8, QuickDash= 41.6, CF12= 39.3 and CM12= 49.4. Ceiling or floor effects were not observed in the Spanish URAM. The Cronbach α= 0.853 explains 49.6% of the variance. The study had a high reproducibility (ICC= 0.939). Size effect, measured as differences in scores, was moderate for URAM (-0.69) and QuickDash (-0.51); and low for CF12 and CM12. The correlation of URAM with QuickDash was high (r= 0.716), and moderate with DD and CTS.
Conclusion:
The Spanish version of the URAM is a valid and reliable tool for use in assessing hand pathology
Background
The URAM (Unité Rhumatologique des Affections de la Main) scale is a patient-reported functional outcome measurement tool validated for exclusive use in Dupuytren contracture (DC) a condition in which one or more fingers become permanently bent in a flexed position. The current study´s purposes were to evaluate: How sensitive and specific is the URAM scale for defining quality of life in patients with in DC and how sensitive to change is the URAM scale after treatment.
Methods
We performed a meta-analysis of all relevant articles published in PubMed, Embase, Cochrane, Google Scholar, LILACS and in various gray literature databases that describe the use of the URAM. We built three models: a hierarchical summary receiver operating characteristic (HSROC) model to determine the optimal threshold for defining DC, a difference in means models to assess the magnitude of the effect of different treatment modalities, and a meta-regression model to determine the effect on patient quality of life questionnaires according to variations in Tubiana scores after treatment (URAM).
Results
The HSROC and bivariate models showed a sensitivity of 80.23% (95%CI: 75.66 to 84.14) and an overall specificity of 2.61% (95%CI: 1.11–6.05). The second model showed an overall difference in means of 1.95 (95%CI: -2.86 to -1.04). The coefficient obtained in the meta-regression model was − 1.666 (95%CI: -4.183 to 0.851).
Conclusion
The URAM scale is highly sensitive to changes in DC but has low specificity. It also showed a strong correlation with worsening of finger contracture.
Update
This article was updated on June 12, 2020, because of a previous error.
An erratum (JBJS JOPA. 2020;8[2]: e0024ER) has been published for this article.
Dupuytren's disease is a benign fibromatosis that affects the palmar and digital fascia. The pathology associated with the development of Dupuytren's disease is the cause of some debate. Patients usually present with firm dense nodules or cords that cause flexion contractures of the metacarpal phalangeal (MCP) joints or proximal interphalangeal (PIP) joints. The severity of contracture, amount of functional impairment, and patient desired treatment will have an effect on the overall recovery following treatment. Historically, the standard of care for Dupuytren's disease was open surgical fasciectomy, percutaneous/open fasciotomy, and needle fasciotomy. Indications for surgical intervention include patients with functional impairment and metacarpophalangeal joint contractures of 30° or more. Collagenase Clostridium histolyticum (CCH), (enzymatic fasciotomy), which lyses collagen and leads to disruption of contracted cords, is an office-based, minimally invasive, nonsurgical option for the treatment of advanced Dupuytren's disease. Many of the studies looking at treatment with collagenase/manual manipulation have reported favorable 5-year outcomes. These studies have shown near-normal return of range of motion at the MCP and, to a lesser extent, PIP joints. The side effect/adverse effect profile has been promising. Injection sight pain and skin tears are the more commonly reported events associated with CCH therapy. Surgical fasciotomy has reported the most severe adverse effects consisting of sensory, motor, and vascular injuries. Physicians have used extension orthoses postoperatively to maintain finger extension following fasciotomy vs. fasciectomy. Some research studies have questioned the value of extension splinting indicating that the tension placed on the contracted tissue can lead to local tissue hypoxia. This has been reported to trigger a flare reaction and thus lead to more increased scar tissue formation. The treatment of Dupuytren's disease requires a comprehensive assessment of the patients' physical limitations; most consider cost-effective therapies that have limited adverse effects and provide long-term improvement in their daily functional activities.
Percutaneous fasciotomy is a safe, simple, and inexpensive treatment for mild to moderate Dupuytren contracture. The decrease in extension deficit in the metacarpophalangeal and proximal interphalangeal joints after release correlates with improvement in patient-reported outcomes. Complications are rare and primarily include skin tears, which occur in approximately 4% of patients. Most patients are satisfied with the outcomes of the procedure at 1 year.
Each step of the evidence-based practice process is critical and requires clear understanding for accurate application. To practice evidence-based care, providers must acquire a specific skillset that facilitates translation of a patient problem into an answerable research question. Additional requirements are understanding of electronic databases, critical appraisal of the available evidence, and integration of the findings to generate a specific, individualized treatment plan. Although this process is demanding, evidence-based practice is essential in the delivery of optimal patient care.
Background and purpose — Percutaneous needle fasciotomy (PNF) is a minimally invasive treatment option for Dupuytren contracture, which has gained momentum worldwide in recent years. However, evidence regarding safety and severe complications associated with PNF is sparse. Thus, we evaluated safety of a specific PNF method in the largest cohort reported in literature.
Patients and methods — This is a single-center, register-based, observational study on PNF treatments between 2007 and 2015. The study cohort was identified by the Danish National Patient Registry, and diagnosis codes and procedure codes were used to identify potential severe postoperative complications such as: tendon rupture, nerve damage, infection, amputation, and reflex dystrophy for all index treatments. The Danish National Prescription Registry was used to identify non-hospital-treated infections. All index treatments and postoperative complications were verified by review of medical records.
Results — 2,257 patients received PNF treatment of 3,331 treated finger rays. Median follow-up was 7.2 years (interquartile range: 4.9–9.5 years, range 1–12 years). 4 patients sustained flexor tendon rupture. 1 patient had digital nerve damage. 2 patients had an infection treated in hospital, while 31 patients received antibiotics in the primary sector for an infection or based on suspicion of an infection after PNF. None of the infections required surgical intervention. No finger amputations or ipsilateral upper limb reflex dystrophy cases were registered in relation to the procedure.
Interpretation — Percutaneous needle fasciotomy for Dupuytren contracture is a safe procedure with a low rate of severe postoperative complications when a specific PNF method is applied.
Background: The objective of this study was to compare the rates of recurrence, additional treatment, patient satisfaction, and willingness to undergo Clostridium histolyticum (CCH) treatment again for Dupuytren disease in patients with and without skin tearing at minimum 5-year follow-up. Methods: We identified 199 digits in 142 patients who underwent CCH treatments for Dupuytren disease from April 2010 to December 2013 with minimum 5-year follow-up. Patients were contacted by telephone to collect our response variables: perceived recurrence of contracture, additional treatment, satisfaction, and willingness to undergo CCH treatment again. Medical records were reviewed for skin tearing at manipulation and patient-related and disease-specific variables. Results: At the time of manipulation, 16 out of 142 patients (11%) and 22 out of 199 digits (11%) had skin tearing. Older age was associated with skin tearing. At an average 7.2-year follow-up, the mean satisfaction was 7.1 ± 2.6 on a 1 to 10 Likert scale for patients with skin tearing and 6.5 ± 3.4 for patients without skin tearing. Eighty-one percent of patients with skin tearing expressed willingness to undergo CCH treatment again, compared with 68% of patients without skin tearing. Perceived recurrence of contracture occurred in 82% of digits with skin tearing and 80% of digits without skin tearing. Additional treatment was performed in 45% of digits with skin tearing and 54% of digits without skin tearing. No difference was statistically significant. Conclusions: Although skin tearing at CCH manipulation complicates the short-term course following CCH treatment, it does not affect long-term perceived contracture recurrence or patient satisfaction.
Purpose:
To determine factors associated with skin tearing at the time of manipulation in patients undergoing collagenase Clostridium histolyticum (CCH) treatment for Dupuytren contractures.
Methods:
We identified 368 digits in 261 patients who underwent a total of 469 CCH treatments at a tertiary care referral center from April, 2010 to December, 2013. Medical records were reviewed for the primary outcome, skin tearing at manipulation. Patient-related and disease-specific explanatory variables were collected. We used bivariate analysis to screen for risk factors and multivariable logistic regression to determine associated risk factors for skin tearing.
Results:
The overall rate of skin tearing with CCH treatment was 12%. Multivariable logistic regression analysis showed older age (odds ratio = 1.04; 95% confidence interval, 1.00-1.07) and amount of contracture correction (odds ratio = 1.02; 95% confidence interval, 1.01-1.04) to be associated with skin tearing at manipulation.
Conclusions:
A 10-year increase in age results in a 1.5 times increase in the odds of skin tearing. A 30° increase in contracture correction results in a 1.8 times increase in the odds of skin tearing. Patients can be counseled before CCH treatment that older age and increased contracture correction are risk factors for this common complication.
Type of study/level of evidence:
Prognostic II.
Background:
Dupuytren's disease is a slowly progressive condition of the hand, characterised by the formation of nodules in the palm that gradually develop into fibrotic cords. Contracture of the cords produces deformities of the fingers. Surgery is recommended for moderate and severe contractures, but complications and/or recurrences are frequent. Collagenase clostridium histolyticum (CCH) has been developed as a minimally invasive alternative to surgery for some patients.
Objectives:
To assess the clinical effectiveness and cost-effectiveness of collagenase as an alternative to surgery for adults with Dupuytren's contracture with a palpable cord.
Data sources:
We searched all major electronic databases from 1990 to February 2014.
Review methods:
Randomised controlled trials (RCTs), non-randomised comparative studies and observational studies involving collagenase and/or surgical interventions were considered. Two reviewers independently extracted data and assessed risk of bias of included studies. A de novo Markov model was developed to assess cost-effectiveness of collagenase, percutaneous needle fasciotomy (PNF) and limited fasciectomy (LF). Results were reported as incremental cost per quality-adjusted life-year (QALY) gained. Deterministic and probabilistic sensitivity analyses were undertaken to investigate model and parameter uncertainty.
Results:
Five RCTs comparing collagenase with placebo (493 participants), three RCTs comparing surgical techniques (334 participants), two non-randomised studies comparing collagenase and surgery (105 participants), five non-randomised comparative studies assessing various surgical procedures (3571 participants) and 15 collagenase case series (3154 participants) were included. Meta-analyses of RCTs assessing CCH versus placebo were performed. Joints randomised to collagenase were more likely to achieve clinical success. Collagenase-treated participants experienced significant reduction in contracture and an increased range of motion compared with placebo-treated participants. Participants treated with collagenase also experienced significantly more adverse events, most of which were mild or moderate. Four serious adverse events were observed in the collagenase group: two tendon ruptures, one pulley rupture and one complex regional pain syndrome. Two tendon ruptures were also reported in two collagenase case series. Non-randomised studies comparing collagenase with surgery produced variable results and were at high risk of bias. Serious adverse events across surgery studies were low. Recurrence rates ranged from 0% (at 90 days) to 100% (at 8 years) for collagenase and from 0% (at 2.7 years for fasciectomy) to 85% (at 5 years for PNF) for surgery. The results of the de novo economic analysis show that PNF was the cheapest treatment option, whereas LF generated the greatest QALY gains. Collagenase was more costly and generated fewer QALYs compared with LF. LF was £1199 more costly and generated an additional 0.11 QALYs in comparison with PNF. The incremental cost-effectiveness ratio was £10,871 per QALY gained. Two subgroup analyses were conducted for a population of patients with moderate and severe disease and up to two joints affected. In both subgroup analyses, collagenase remained dominated.
Limitations:
The main limitation of the review was the lack of head-to-head RCTs comparing collagenase with surgery and the limited evidence base for estimating the effects of specific surgical procedures (fasciectomy and PNF). Substantial differences across studies further limited the comparability of available evidence. The economic model was derived from a naive indirect comparison and was hindered by a lack of suitable data. In addition, there was considerable uncertainty about the appropriateness of many assumptions and parameters used in the model.
Conclusions:
Collagenase was significantly better than placebo. There was no evidence that collagenase was clinically better or worse than surgical treatments. LF was the most cost-effective choice to treat moderate to severe contractures, whereas collagenase was not. However, the results of the cost-utility analysis are based on a naive indirect comparison of clinical effectiveness, and a RCT is required to confirm or refute these findings.
Study registration:
This study is registered as PROSPERO CRD42013006248.
Funding:
The National Institute for Health Research Health Technology Assessment programme.
To critically review the efficacy, recurrence rate, and complications of needle aponeurotomy (NA) for the treatment of Dupuytren contracture.
This was a retrospective study of the results of NA for the treatment of Dupuytren contracture. We included in the study all patients who had NA performed for metacarpophalangeal (MP) or proximal interphalangeal (PIP) joint contracture of 20° or greater between March 2005 and May 2008. There were 474 patients with 1,013 fingers treated. The average age was 62 years (range, 33-92 y). Pre-procedure MP joint contracture averaged 35° (range, 15° to 95°), and PIP joint 50° (range, 15° to 110°). Immediately postprocedure and at least 3 years after treatment (range, 3.0-6.2 y), we measured MP and PIP joint contractures and reviewed records for complications.
MP joint contractures were corrected an average of 99% and PIP contractures an average of 89% immediately postprocedure. At final follow-up, 72% of the correction was maintained for MP joints and 31% for PIP joints. The difference between the final corrections for MP versus PIP joints was statistically significant. When we compared the final results of patients age 55 years and older versus under 55 years, we found a statistically significant difference at both MP and PIP joints, with greater correction maintained in the older group. Gender differences were not statistically significant. Needle aponeurotomy provided successful correction to 5° or less contracture immediately postprocedure in 98% (791) of MP joints and 67% (350) of PIP joints. There was recurrence of 20° or less over the original postprocedure corrected level in 80% (646) of MP joints and 35% (183) of PIP joints. Complications were rare except for skin tears, which occurred in 3.4% (34) of digits.
This study shows that NA is a safe procedure that can be performed in an outpatient setting. The complication rate was low, but recurrences were frequent in younger patients and for PIP contractures.
Therapeutic IV.
Dupuytren's tissue has typically been described as being composed of myofibroblast-rich palmar nodules and relatively acellular tendon-like cords. We aimed to determine myofibroblast distribution (alpha-smooth muscle actin [alpha-SMA] positive cells) within Dupuytren's tissue and to correlate histologically defined alpha-SMA-positive nodules with digital contracture and recurrent disease.
One hundred and three digital Dupuytren's cords (72 fasciectomy, 31 dermofasciectomy) were stained with anti-alpha-SMA antibody. The presence of alpha-SMA-positive nodules, their surface area, and alpha-SMA-positive cells were quantified throughout excised Dupuytren's tissue. Clinical data on diathesis, flexion deformity, and previous surgeries were collected.
Cords were nodular (66%) or non-nodular (34%). Nodular cords contained 1 (55%), 2 (33%), or 3 or more nodules (12%) composed of localized collections of cells. The mean total nodule surface area was 23 mm(2) (range, 1.3-105 mm(2)). Nodules contained the highest number of alpha-SMA-positive cells (mean 97%, 2374 cells/mm(2)) compared to peri-nodular areas (mean 32%, 763 cells/mm(2)), and more distant cord (mean 8%, 495 cells/mm(2)). Non-nodular cords contained 9% to 17% alpha-SMA-positive cells (mean 475-663 cells/mm(2)), with higher numbers distally. There was greater digital contracture in patients with non-nodular cords. Thirty-six of 38 proximal interphalangeal (PIP) joint-marked samples had a nodule that co-localized with the PIP joint. Nodule size did not correlate with flexion deformity or with primary or recurrent disease.
We found that two thirds of digital cords were nodular. Nodules were hypercellular, the majority being alpha-SMA-positive cells. Nodules varied in size and co-localized with the PIP joint. Cord was relatively cellular throughout; a proportion of these cells were alpha-SMA-positive and cells aligned with collagen fibers. Non-nodular cords correlated with significantly greater digital flexion contracture. We propose that cells in nodular cords contract and deposit extracellular matrix components. The matrix is then remodeled in shortened configuration, and as fixed flexion deformity develops, stress shielding eventually leads to myofibroblast apoptosis, and cord becomes less cellular.
Local treatment of Dupuytren's contracture, either by collagenase or needle fasciotomy, allows disruption of the pathological cord during forced extension. The purpose of this study was to investigate the cord before and after both treatments by ultrasound. A total of 39 patients with a minimum of 20° contracture in the metacarpophalangeal joint were included and randomized to treatment with either collagenase (20 patients) or needle fasciotomy (19 patients). The distance between the distal and the proximal parts of the ruptured cord was measured by ultrasound and the difference in passive joint movement before and after treatment was measured with a goniomenter. There were no significant differences between the collagenase and needle fasciotomy groups in the size of the rupture or gain of mobility. Most cords treated with collagenase and subsequent forced extension had the same ultrasonographic appearance as cords disrupted mechanically by needle fasciotomy.
Level of evidence:
III.
Purpose:
Collagenase Clostridium histolyticum (CCH) injection was introduced commercially as a treatment for Dupuytren contracture following initial phase-3 investigations in 2009 with promising results. However, the efficacy of CCH has not been prospectively investigated in a direct comparison to other active treatments of Dupuytren contracture with more than 1-year follow-up, despite a wide and increasing clinical use.
Method:
In this prospective, independent, open-label, randomized controlled trial, (Clinicaltrials.gov; NCT 01538017), percutaneous needle fasciotomy (PNF) was directly compared with CCH. Fifty patients with primary isolated proximal interphalangeal joint Dupuytren contractures were enrolled and followed for 2 years. The primary outcome was clinical improvement defined as a reduction in contracture by 50% or more relative to baseline. Secondary outcomes included change in contracture, recurrence, adverse events, complications, and Disabilities of the Arm, Shoulder, and Hand questionnaire score.
Results:
Clinical improvement at 2 years was maintained in 7% of CCH patients (2 of 29) and 29% of PNF patients (6 of 21). Collagenase Clostridium histolyticum led to more, mainly transient, complications, in 93% of patients versus 24% of the patients treated with PNF. No other differences were observed.
Conclusions:
This study provides evidence that CCH is not superior to PNF in the treatment of isolated proximal interphalangeal joint Dupuytren contracture regarding clinical outcome, and it led to more complications than PNF.
Type of study/level of evidence:
Therapeutic I.
Purpose:
The U.S. Food and Drug Administration approved the use of collagenase Clostridium histolyticum (CCH) in the United States in February 2010. This study addresses the impact of that approval on the number of Dupuytren contracture (DC) encounters and treatment patterns in the United States.
Methods:
Using the Intercontinental Marketing Services Health Office-Based Medical Claims database, we identified the monthly number of DC encounters and DC procedures between January 2007 and December 2013. Collagenase Clostridium histolyticum usage data from March 2010 to December 2013 was derived from the U.S. CCH manufacturer's data warehouse. Using the combined data, the yearly increasing trends in DC encounters and treatment volume were compared before and after the introduction of CCH. Time trends in the relative procedure frequencies were then examined. Finally, the presence of seasonal variation was tested for in each treatment type.
Results:
Dupuytren contracture encounters increased on average by 19,015 per year between 2007 and 2009, whereas between 2011 and 2013, DC encounters increased on average by 34,940 per year. In terms of absolute procedure counts, the surgery trend line began decreasing in 2010 with the release of CCH. Meanwhile, CCH continuously increased between 2010 and 2013, and needle aponeurotomy (NA) remained relatively stable. By the year 2013, minimally invasive techniques (NA and CCH) comprised 39% of all treatment, compared with only 14% in 2007. Lastly, there was a statistically significant seasonal increase in the number of surgical procedures during the wintertime but no seasonal variation in NA or CCH.
Conclusions:
After the introduction of CCH, the number of Dupuytren encounters increased at a greater annual rate. The introduction and growth of CCH coincided with a decrease in surgery. The number of NA procedures remained steady throughout the study period. The number of open surgery cases followed a predictable seasonal variation with more procedures during the winter months, but this seasonal variation was not seen with less invasive techniques.
Type of study/level of evidence:
Economic/Decision Analysis II.
Purpose:
This study compared the efficacy of collagenase treatment and needle fasciotomy for contracture of the metacarpophalangeal (MCP) joint in Dupuytren disease.
Methods:
This is a prospective, single-blinded, randomized study with follow-up 1 week and 1 year after treatment. One hundred and forty patients with an MCP contracture of 20° or more in a single finger were enrolled, of whom 69 patients were randomized to collagenase treatment and 71 patients to needle fasciotomy. The patients were followed at 1 week and were examined by a physiotherapist after 1 year. Measurements of joint movement and grip strength were recorded as well as patient-perceived outcomes measured by the Unité Rhumatologique des Affections de la Main (URAM) questionnaire and a visual analog scale (VAS) for the estimation of procedural pain and subjective treatment efficacy.
Results:
Eighty-eight percent of the patients in the collagenase group and 90% of the patients in the needle fasciotomy group had a reduction in their MCP contracture to less than 5° 1 week after treatment, and the median gains in passive MCP movement were 48° and 46°, respectively. The median VAS score for procedural pain was 4.9 of 10 in the collagenase group and 2.7 of 10 in the needle fasciotomy group. After 1 year, 90% of the patients in both groups had full extension of the treated MCP joint. One patient in each group had a recurrence of the contracture. The median improvement in URAM score was 8 units in both groups and the VAS estimation of treatment efficacy by the patients was 8.7 of 10 in both groups.
Conclusions:
There was no significant difference between the treatment outcomes after collagenase and needle fasciotomy treatment after 1 year.
Type of study/level of evidence:
Therapeutic I.
Unlabelled:
The objective of this study was to compare early and 1 year outcome of needle fasciotomy and collagenase injection for Dupuytren's disease. Inclusion criteria were primary Dupuytren's contracture excluding the thumb with a palpable cord and a total extension deficit, i.e. a fixed flexion from 30° to 135° with less than 60° in the proximal interphalangeal joint. The most affected ray was randomized to either treatment at two centres. Passive extension deficits for each joint before and after treatment, and at 3 and 12 months, were recorded together with complications. A total of 96 rays in 93 patients were included. The average total extension deficits before treatment were 60° or more in both groups, and were largely made up of contractures at the metacarpophalangeal joints. The deficits were reduced by 75% in both groups at 3 months and by 70% in both groups at 12 months. Four patients in the needle fasciotomy group and eight patients in the collagenase group had skin ruptures. At 3 months and 1 year, the outcomes of needle fasciotomy and collagenase injection are the same in Dupuytren's disease with predominantly metacarpophalangeal joint involvement.
Level of evidence:
2.
Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study was a 5-year noninterventional follow-up study to determine long-term efficacy and safety of collagenase clostridium histolyticum (CCH) treatment for Dupuytren contracture.
Patients from previous CCH clinical studies were eligible. Enrolled patients were evaluated annually for contracture and safety at 2, 3, 4, and 5 years after their first injection (0.58 mg) of CCH. In successfully treated joints (≤ 5° contracture following CCH treatment), recurrence was defined as 20° or greater worsening (relative to day 30 after the last injection) with a palpable cord or any medical/surgical intervention to correct new/worsening contracture. A post hoc analysis was also conducted using a less stringent threshold (≥ 30° worsening) for comparison with criteria historically used to assess surgical treatment.
Of 950 eligible patients, 644 enrolled (1,081 treated joints). At year 5, 47% (291 of 623) of successfully treated joints had recurrence (≥ 20° worsening)-39% (178 of 451) of metacarpophalangeal and 66% (113 of 172) of proximal interphalangeal joints. At year 5, 32% (198 of 623) of successfully treated joints had 30° or greater worsening (metacarpophalangeal 26% [119 of 451] and proximal interphalangeal 46% [79 of 172] joints). Of 105 secondary interventions performed in the successfully treated joints, 47% (49 of 105) received fasciectomy, 30% (32 of 105) received additional CCH, and 23% (24 of 105) received other interventions. One mild adverse event was attributed to CCH treatment (skin atrophy [decreased ring finger circumference from thinning of Dupuytren tissue]). Antibodies to clostridial type I and/or II collagenase were found in 93% of patients, but over the 5 years of follow-up, this did not correspond to any reported clinical adverse events.
Five years after successful CCH treatment, the overall recurrence rate of 47% was comparable with published recurrence rates after surgical treatments, with one reported long-term treatment-related adverse event. Collagenase clostridium histolyticum injection proved to be an effective and safe treatment for Dupuytren contracture. For those receiving treatment during follow-up, both CCH and fasciectomy were elected options.
Therapeutic II.
Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
Objective
To test the convergent validity and ease of use of the Unité Rhumatologique des Affections de la Main (URAM) scale for patients with Dupuytren's disease.
Methods
Patients were prospectively included. We compared the convergent validity of the URAM scale, the Cochin Hand Function Scale (CHFS) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, in terms of their correlation with the Tubiana score and self-assessed disability on a visual analog scale (VAS). Pearson's correlation was used for the convergent validity study. The response time for questionnaire completion was the outcome for ease of implementation.
Results
We included 53 patients with Dupuytren's disease in the convergent validity study and 30 other patients with the disease in the time-response assessment. The URAM scale showed strong convergence with the Tubiana scale (r = 0.64) and self-assessed disability on a VAS (r = 0.69). Convergence with the Tubiana and self-assessed disability was higher for the URAM scale than the CHFS or DASH questionnaire. The mean [SD] response time was shorter for the URAM scale than the CHFS or DASH questionnaire (42 [20] vs 71 [35] and 103 [59] s, respectively, P < 0.0001).
Conclusions
The results reinforce the psychometric merits of the URAM scale. Furthermore, the response time for assessing disability was shorter with the URAM scale than the CHFS or DASH questionnaire. This evidence supports the high recommendation for the use of the URAM scale in clinical practice and clinical studies to assess disability in Dupuytren's disease.
In Canada, Dupuytren's contracture is managed with partial fasciectomy or percutaneous needle aponeurotomy (PNA). Injectable collagenase will soon be available. The optimal management of Dupuytren’s contracture is controversial and trade-offs exist between the different methods. Using a cost-utility analysis approach, our aim was to identify the most cost-effective form of treatment for managing Dupuytren’s contracture it and the threshold at which collagenase is cost-effective. We developed an expected-value decision analysis model for Dupuytren’s contracture affecting a single finger, comparing the cost-effectiveness of fasciectomy, aponeurotomy and collagenase from a societal perspective. Cost-effectiveness, one-way sensitivity and variability analyses were performed using standard thresholds for cost effective treatment (100 000/QALY gained). Percutaneous needle aponeurotomy was the preferred strategy for managing contractures affecting a single finger. The cost-effectiveness of primary aponeurotomy improved when repeated to treat recurrence. Fasciectomy was not cost-effective. Collagenase was cost-effective relative to and preferred over aponeurotomy at 470 per course of treatment, respectively.
In summary, our model supports the trend towards non-surgical interventions for managing Dupuytren’s contracture affecting a single finger. Injectable collagenase will only be feasible in our publicly funded healthcare system if it costs significantly less than current United States pricing.
Cite this article: Bone Joint J 2013;95-B:1094–1100.
An extensive and growing number of reviews of the published literature demonstrate that health research publications have frequent deficiencies. Of particular concern are poor reports of randomised trials, which make it difficult or impossible for readers to assess how the research was conducted, to evaluate the reliability of the findings, or to place them in the context of existing research evidence. As a result, published reports of trials often cannot be used by clinicians to inform patient care or to inform public health policy, and the data cannot be included in systematic reviews. Reporting guidelines are designed to identify the key information that researchers should include in a report of their research. We describe the history of reporting guidelines for randomised trials culminating in the CONSORT Statement in 1996. We detail the subsequent development and extension of CONSORT and consider related initiatives aimed at improving the reliability of the medical research literature. Copyright © 2012 John Wiley & Sons, Ltd.
We undertook a cost-utility analysis to compare traditional fasciectomy for Dupuytren with 2 new treatments, needle aponeurotomy and collagenase injection.
We constructed an expected-value decision analysis model with an arm representing each treatment. A survey was administered to a cohort of 50 consecutive subjects to determine utilities of different interventions. We conducted multiple sensitivity analyses to assess the impact of varying the rate of disease recurrence in each arm of the analysis as well as the cost of the collagenase injection. The threshold for a cost-effective treatment is based on the traditional willingness-to-pay of 820,114 per QALY gained over no treatment. The cost of needle aponeurotomy was 49,631. When needle aponeurotomy was performed without surgical center or anesthesia costs and with reduced hand therapy, the cost was 250, the cost was 945, the cost was 5,400 per injection, the cost was 945.
Economic and Decision Analysis II.
To our knowledge, no functional outcome measure has been developed and validated for Dupuytren's disease. We aimed to develop and validate a patient-reported functional outcome measure for Dupuytren's disease.
Patients with Dupuytren's disease (n = 9) and medical experts (n = 7) provided input and opinions about limiting activities that were difficult to perform because of Dupuytren's disease for item generation. The provisional scale was studied in an independent sample of patients (n = 85) for item reduction according to response distribution, reliability, redundancy, and loading in a 1-factor solution. The final scale was evaluated as follows: reliability using Cronbach's alpha coefficient and test-retest intraclass correlation coefficient from the previous 85-patient population, and construct validity and responsiveness after needle aponeurotomy in another independent 53-patient sample. For construct validity, convergent validity and divergent validity were tested. The clinically important change was estimated relative to a 1-point categorical change on the Tubiana scale.
A 52-item provisional scale was generated and reduced to the final 9-item scale called the Unité Rhumatologique des Affections de la Main (URAM) scale (total score 0-45). The scale showed good to excellent reliability and suitable construct validity. The URAM score improved after needle aponeurotomy: the standardized effect size was 0.56. The estimated clinically important change of the URAM scale was 2.9 points.
We provide the first patient-reported functional measure for Dupuytren's disease. The URAM scale demonstrated suitable psychometric properties, and is short and convenient enough for easy use in daily practice and in clinical studies.
Retrospective Cohort.
There is currently no validated patient reported outcome measure (PROM) for Dupuytren's disease. We have performed a retrospective analysis of QuickDASH scores taken before and after surgery for Dupuytren's disease to assess the validity and responsiveness of the QuickDASH and evaluate its suitability to being a PROM for this condition.
To determine the eligibility of the QuickDASH score as a Patient Reported Outcome Measure for Dupuytren's disease.
Patients were identified from the hand therapy database that had surgery performed between January 2006 and April 2008 who had documented pre- and post-operative QuickDASH scores.
69 patients were identified with complete datasets with a mean change in QuickDASH score of -7.14 (p < 0.001) and an improvement of extension deficit by 68.1 degrees (p < 0.001) at a mean 110 day follow-up. The change in QuickDASH score did not correlate with the change in extension deficit. The effect size was 0.545 and the standardised response mean was 0.580.
The QuickDASH is an acceptable PROM for Dupuytren's surgery with limitations. Further research is needed examining PROMs with this common condition.
n/a.
Dupuytren disease (DD) is a fibroproliferative disorder of unknown etiology that often results in shortening and thickening of the palmar fascia, leading to permanent and irreversible flexion contracture of the digits. This Review provides a detailed update of the scientific understanding of DD and its clinical management, with perspectives on emerging research and therapy. Established risk factors include genetic predisposition and ethnicity, as well as sex and age. Several environmental risk factors (some considered controversial) include smoking, alcohol intake, trauma, diabetes, epilepsy and use of anticonvulsant drugs, and exposure to vibration. DD has been variously attributed to the presence of oxygen free radicals, trauma to the palmar fascia, or aberrant immune responses with altered antigen presentation, or to interactions between these proposed mechanisms. The presence of immune cells and related phenomena in DD-affected tissue suggests that DD is possibly immune-related. Mechanically, digital contracture is caused by myofibroblasts in the DD palmar fascia; however, the exact origin of this cell type remains unknown. The mainstay of treatment is surgical release or excision of the affected palmodigital tissue, but symptoms often recur. Nonsurgical correction of DD contractures can be achieved by Clostridium histolyticum collagenase injection, although the long-term safety and recurrence rate of this procedure requires further assessment.
Dupuytren's disease limits hand function, diminishes the quality of life, and may ultimately disable the hand. Surgery followed by hand therapy is standard treatment, but it is associated with serious potential complications. Injection of collagenase clostridium histolyticum, an office-based, nonsurgical option, may reduce joint contractures caused by Dupuytren's disease.
We enrolled 308 patients with joint contractures of 20 degrees or more in this prospective, randomized, double-blind, placebo-controlled, multicenter trial. The primary metacarpophalangeal or proximal interphalangeal joints of these patients were randomly assigned to receive up to three injections of collagenase clostridium histolyticum (at a dose of 0.58 mg per injection) or placebo in the contracted collagen cord at 30-day intervals. One day after injection, the joints were manipulated. The primary end point was a reduction in contracture to 0 to 5 degrees of full extension 30 days after the last injection. Twenty-six secondary end points were evaluated, and data on adverse events were collected.
Collagenase treatment significantly improved outcomes. More cords that were injected with collagenase than cords injected with placebo met the primary end point (64.0% vs. 6.8%, P < 0.001), as well as all secondary end points (P < or = 0.002). Overall, the range of motion in the joints was significantly improved after injection with collagenase as compared with placebo (from 43.9 to 80.7 degrees vs. from 45.3 to 49.5 degrees, P < 0.001). The most commonly reported adverse events were localized swelling, pain, bruising, pruritus, and transient regional lymph-node enlargement and tenderness. Three treatment-related serious adverse events were reported: two tendon ruptures and one case of complex regional pain syndrome. No significant changes in flexion or grip strength, no systemic allergic reactions, and no nerve injuries were observed.
Collagenase clostridium histolyticum significantly reduced contractures and improved the range of motion in joints affected by advanced Dupuytren's disease. (ClinicalTrials.gov number, NCT00528606.)
Short-term and five-year outcomes after nonsurgical treatment of Dupuytren's contracture by needle fasciotomy were studied. Among the 138 patients who were evaluated, 90 (123 hands) were seen five years after the procedure. Outcome was excellent or good in 81% of cases in the short term and 69% of cases after 5 years. Adverse events included skin breaks (20 hands, 16% of cases), digital dysesthesia due to nerve damage (3 patients, 2% of cases), and local infection (3 patients, 2% of cases). Five-year recurrence rate was 50.4%. These findings demonstrate the value of needle fasciotomy especially in the early stages of Dupuytren's disease.
Five-year results of a randomized clinical trial on treatment in Dupuytren's disease: percutaneous needle fasciotomy versus limited fasciectomy
- H R Budd
- D Larson
- A Chojnowski
- L Shepstone
Budd HR, Larson D, Chojnowski A, Shepstone L. The QuickDASH score: a
patient-reported outcome measure for Dupuytren's surgery. J Hand Ther. 2011 Jan-Mar;24(1):15-20; quiz 21. Epub 2010 Nov 24.
20. van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized
clinical trial on treatment in Dupuytren's disease: percutaneous needle fasciotomy
versus limited fasciectomy. Plast Reconstr Surg. 2012 Feb;129(2):469-77.