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Results From Around the World Treating Dupuytren's Contracture

Thirty-seven hand surgeons from around the world worked together over a period of years to gather data on the long-term results of using collagenase (Xiaflex) injection for Dupuytren's contracture. This report is a summary of their findings using recurrence rate as the main measuring stick for success/failure.

Dupuytren's contracture is a fairly common disorder of the fingers. The condition usually shows up as a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger. More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened. Dupuytren's contracture usually affects only the ring and little fingers. The contracture spreads to the joints of the finger, which can become permanently immobilized.

The condition is noted to be secondary to an increase in fibroblast density a complex biochemical and cellular interaction. The disorder may occur suddenly but more commonly progresses slowly over a period of years. The disease usually doesn't cause symptoms until after the age of 40.

The areas affected most often are the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. Flexion contractures usually develop at the metacarpophalangeal (MCP) joints first. The MCP joints are what we usually refer to as the "knuckles." As the disease spreads from the palm down to the fingers, the proximal interphalangeal (PIP) joints start to be affected as well. The PIP joints are the middle joints between the knuckles and the joints at the tips of the fingers.

Nonsurgical and surgical treatments are to treat the contracture itself. This does not cure the disease. Dupuytren's disease continues to slowly form the bands although it may be years before the contracture presents itself again. Conservative care with bracing and stretching of the fingers has not been proven to help in the long term progression of this condition.

Surgery to remove the palmar fascia (palmar fasciotomy) is the "gold standard" in treatment for advanced (severe) contractures. But the development of a less invasive method of treatment called enzymatic fasciotomy is being used with mild to moderate cases. By injecting an enzyme directly into the cords formed by the disease, the tissue dissolves and starts to weaken. Then the patient can stretch the fingers and break apart the cord himself/herself.

There are a few possible (minor) side effects but very few major or long-term complications with this treatment. When the product was first being studied, there were reports of a local skin reaction (swelling, redness, skin tears, itching or stinging) where the injection went into the skin. A small number of more serious problems developed in a few patients including skin infection, tendon rupture, finger deformity, complex regional pain syndrome (pain and stiffness), and hives that had to be treated with medication.

Early studies showed a good success rate in reducing MCP contractures using this injection treatment. Almost everyone treated this way was able to straighten the MCP joints with less than a 30-degree flexion contracture. Results were not quite as good for the PIP joints. Less than half of the patients with PIP contractures had regained full motion of the affected joint.

This study of 1,080 joints treated with collagenase injection provided some good feedback. The long-term results (after three to five years) measured by recurrence rates with enzyme fasciotomy were not quite as good as responses in the short-term. For example, one-third of the MCP joints and two-thirds of the PIP joints that were corrected had a recurrence. And of the joints that were only partially corrected in the first study, half had a worsening in the years to follow.

Recurrence was defined as a 20-degree (or more) flexion contracture (finger won't straighten and remains flexed by at least 20-degrees). These are fingers that were able to straighten within five degrees of normal after the injection.

Adverse effects of this injection treatment for Dupuytren's contracture are minimal and in the long-term, nothing worse than recurrence occurs. This was true even when up to eight injections were used and bloodworm showed antibodies in response to the collagenase. No systemic allergic reactions occurred.

The authors concluded that the treatment is safe and effective for mildly involved joints. Their study will continue on and collect further long-term information. The treatment is certainly worth a try if it can prevent patients from having surgery. Results are not as good with PIP joints but repeat injections or even surgery are always follow-up options.

Reference: Clayton A. Peimer, MD, et al. Dupuytren Contracture Recurrence Following Treatment with Collagenase Clostridium Histolyticum (CORDLESS Study): 3-Year Data. In The Journal of Hand Surgery. January 2013. Vol. 38A. No. 1. Pp. 12-22.

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