Percutaneous Needle Fasciotomy Versus Collagenase Treatment for Dupuytren Contracture

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.

Percutaneous Needle Fasciotomy for Dupuytren Contracture

“…The results of PNF have shown an excellent rate of reduction of the contracture, and a majority (79%) of the patients retained a straight joint after 2 years 11 . Dupuytren contracture is, however, notorious for recurrence, regardless of treatment method.…”

“…However, PNF is a simple procedure that can be performed repeatedly, and 53% of the patients with recurrence in the latter study chose another PNF procedure. Patient-reported outcome measures have shown a significant improvement in a disease-specific questionnaire, the Unité Rhumatologique des Affections de la Main (URAM), in a general upper extremity questionnaire (Quick-DASH [an abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire]), and with visual analog scales, indicating that most patients are very satisfied with the method 4,6,11 .…”

Collagenase injections for Dupuytren's contracture: prospective cohort study in a public health setting

“…The authors acknowledge that the alternative outpatient procedure, needle fasciotomy, in a recent randomized controlled trial 35 showed comparative outcomes with CCH. This treatment modality would theoretically incur less cost and requires further investigation into its applicability in the Australian public system.…”

Recent advances in the understanding of Dupuytren’s disease

“…Collagenase histolyticum (CCH) injections 52 benefit from being less invasive than surgery with more rapid recovery and can be performed in the office, and complications are transient 53– 55 . CCH enzymatically disrupts the cord, and more widespread use has galvanized recent efforts to develop a more robust evidence base for its role 52, 56– 60 . Although CCH has been shown to reduce joint contracture and improve the range of joint motion compared with placebo and appears as efficacious as percutaneous needle fasciotomy (PNF), it may not be cost-effective, at least in the US 61, 62 .…”

“…A number of studies have demonstrated improvement in flexion deformities with PNF, but with a relatively high risk of recurrence of about 30% at 5 years compared with 6% for limited fasciectomy 69 . A randomized controlled trial of PNF demonstrated efficacy comparable to that of CCH injection for correction of flexion contraction deformity but with the potential for a higher risk of recurrence 56, 70 .…”