Dupuytren’s Contracture Recurrence and Treatment Following Collagenase Clostridium Histolyticum Injection: A Longitudinal Assessment in a Veteran Population

Abstract

Introduction Dupuytren’s contracture is a connective tissue disease characterized by an abnormal proliferation of collagen in the palm and fingers, which leads to a decline in hand function because of progressive joint flexion. In addition to surgical and percutaneous interventions, collagenase clostridium histolyticum (CCH, trade name Xiaflex) is an intralesional enzymatic treatment for adults with palpable cords. The objectives of this study are to evaluate factors predictive of recurrence following treatment with CCH and to review the outcomes of repeat treatments with CCH for recurrent contracture. Materials and Methods An institutional review board–approved retrospective chart review was conducted for patients between 2010 and 2017 who received CCH injections for Dupuytren’s contracture at a Veterans Affairs hospital. Demographics, comorbidities, affected finger and joint, pre/posttreatment contracture, time to recurrence, and treatment of recurrence were recorded. Successful treatment was defined as contracture ≤5° following CCH, and improvement was defined as ≥20° reduction from baseline contracture. Study cohorts were followed after their secondary treatment, and time to recurrence was recorded and plotted using a Kaplan–Meier curve. A Cox proportional hazards model was used to compare treatment group risk factors for recurrence with a P-value less than .05 defined as statistical significance. Results Of 174 injections performed for the correction of flexion deformities in 109 patients, 70% (121) were successfully treated with CCH, and an additional 20% (35) had improvement. There was a recurrence of contractures in 43 joints (25%). Of these, 16 contractures were treated with repeat CCH, whereas another 16 underwent limited fasciectomy. In total, 75% (12 of 16) of the repeat CCH group and 75% of the fasciectomy group were successfully treated. Pre-injection contracture of ≥25° was found to be predictive of recurrence (P < .05). Conclusions Initial treatment of contracture with CCH had a 70% success rate with 25% recurrence during the study period. Compared with limited fasciectomy, CCH had decreased efficacy. Based on the findings of this study, we believe that the treatment of primary and/or recurrent Dupuytren’s contracture with CCH is a safe and less invasive alternative to fasciectomy in the era of telemedicine. CCH treatment requires no suture removal, which allows the ability to assess motion virtually, and the potential consequences of CCH treatment such as skin tears can be assessed and managed conservatively. In the veteran and active duty population, CCH can facilitate faster recovery and return to service. Strengths of this study include a large series of veteran populations with longitudinal follow-up to determine treatment efficacy for primary Dupuytren’s contracture and recurrence. Limitations include a smaller sample size compared to previous trials, a lack of standardized follow-up, and the retrospective nature of our study that prohibits randomization to compare outcomes between CCH treatment and fasciectomy efficacy over time. Directions for future research include stratification of patients by joint and specific digit involvement as well as comparison with percutaneous needle fasciotomy, another minimally invasive technique that could benefit the veteran population at increased risk for developing Dupuytren’s disease.

The Versatility of Collagen in Pharmacology: Targeting Collagen, Targeting with Collagen

“…One notable example is the collagenase from Clostridium histolyticum (CCH), which is effective and well tolerated in the short term in patients with Dupuytren’s contractures [ 42 ] and has been authorized for localized subcutaneous treatment. The recurrence of Dupuytren’s contracture treated with CCH is relatively low, demonstrating an efficacy similar to that of alternative treatments such as fasciectomy [ 43 , 44 ]. CCH is also one of the best treatments for Peyronie’s disease [ 45 ].…”

“…Fibrosis: Dupuytren's contracture [42][43][44] Fibrosis: Peyronie's disease [45] Debriding chronic dermal ulcers and severely burned areas [51,52] Phase II: efficacy not proven Adhesive capsulitis of the shoulder Phase II and III: efficacy not proven Gastric Cancer, Advanced Gastric, or GEJ Adenocarcinoma [57,58] Phase II: efficacy not proven Crohn's Disease [59] mimic of miR-29 Phase II: efficacy not proven Keloid formation [88,89] anti-Grp78 Phase I: favorable safety profile Refractory multiple myeloma [116] HSP47 siRNA Phase II: promising results Hepatic fibrosis secondary to HCV infection [124] Anti-LOXL2 Phase II: efficacy not proven Idiopathic pulmonary fibrosis [149] Primary sclerosing cholangitis [150] Primary myelofibrosis [151] Myelofibrosis secondary to polycythemia vera [151] Essential thrombocythemia [151] Bridging Fibrosis or Compensated Cirrhosis Caused by Nonalcoholic Steatohepatitis [152] Liver fibrosis in HIV and HCV-infected adults [153] Steatohepatitis pancreatic adenocarcinoma [154] Metastatic KRAS mutant colorectal cancer [155] Broad…”