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Fasciotomy, collagenase injection had same Dupuytren’s contracture recurrence rate
At 3-year follow-up, more patients in the collagenase injection group continued to have contractures compared with the needle fasciotomy group.
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SAN FRANCISCO — Results presented at the American Society for Surgery of the Hand showed no significant differences in recurrence rates among patients with Dupuytren’s contracture treated with either needle fasciotomy or collagenase injection.
Peter Scherman MD, PhD, and his colleagues randomly assigned 96 rays with Dupuytren’s contracture to receive either needle fasciotomy or collagenase injections. Re-evaluation data at 3-years were available for 76 rays.
“Baseline extension deficits were 65° and 60°, with 55° from the [metacarpophalangeal] MCP joints in both groups,” Scherman said.
Both groups had a reduction of contractures of almost 80% at 3 months. Recurrence was defined as rays that were retreated or had an increase of 30° or more in total passive extension deficit from the 3-month time point. Recurrence rates were 34% in the injection group and 33% in the needle fasciotomy group. Results shows that before 3 years, 10% of the injection group and 24% of the needle fasciotomy group had been retreated, according to Scherman.
“Looking at the retreated rays, there were more of them in the needle fasciotomy group, although not significantly,” Scherman said.
Results showed there was a mean increase in total extension deficit of 24° in the needle fasciotomy group and 34° in the collagenase group from 3 months to the time of retreatment. There was a mean increase in extension deficit of 11° in the needle fasciotomy group and 17° in the injection group from 3 months to 36 months postoperatively.
“Looking at the remaining contractures we could measure at 36 months, they were largely in the collagenase group,” Scherman said.
As this was an open label study with a moderate sample size, larger studies where patients are randomly assigned to surgery, needle fasciotomy or collagenase injection are needed, Scherman told Orthopedics Today. He said the results of this study contribute to evidence that shows “the increased costs and side-effects seen with collagenase injections are becoming more difficult to justify.” – by Casey Tingle
Reference:
Scherman P, et al. J Hand Surg Eur Vol. 2016;doi:10.1177/1753193415617385.
Scherman P, et al. Paper #1. Presented at: American Society for Surgery of the Hand Annual Meeting; Sept. 7-9, 2017; San Francisco.
For more information:
Peter Scherman, MD, PHD, can be reached at Lund University, Box 117, 221 00 Lund, Sweden; email: peter.scherman@med.lu.se.
Disclosure: Scherman reports no relevant financial disclosures.
Perspective
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Warren C. Hammert, MD
One of the challenges the authors allude to is the difference in definitions across the literature. While this is not unique to Dupuytren’s, it does make it difficult to compare results to previously published studies. In addition, treatment is focused on the contracture rather than curing the condition.
The study involved primarily metacarpophalangeal contractures, which have a better track record and lower recurrence rates than proximal interphalangeal joints, yet there still was a recurrence of contracture in one-third to one-half of the patients treated. This underscores the problem with Dupuytren’s contracture — we don't have a great treatment. Ongoing research to understand the disease will hopefully enable someone to figure out a way to turn the gene “off,” making the hand surgeons’ treatment of the condition of historical importance.
As we move toward bundled payments in the U.S. for many musculoskeletal conditions, I can foresee a time where there is a Dupuytren’s bundle and the surgeon is paid a certain amount for the episode of care for patients with Dupuytren’s disease. The decision about treatment will be made and profits would increase when treatment is done in the least costly manner. This should involve care for a period of time long enough for recurrence rates to be a consideration, and would therefore help balance the increased cost of collagenase and fasciectomy.
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