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Indications for collagenase clostridium histolyticum in the treatment of Dupuytren’s disease must be defined
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The launch of collagenase clostridium histolyticum for the treatment of Dupuytren’s disease almost 10 years ago not only represented a completely new treatment approach for this difficult and still unsolved hand surgical problem, but also triggered a huge wave of related research. Surgeons were confronted with an effective non-surgical treatment that could change completely the approach to this disease.
Like many other surgical and medical treatments, collagenase clostridium histolyticum (CCH) also went through the well-known Rogers’ curve of innovation adoption. After early enthusiasm, some limitations and problems became evident. In particular, some aspects like recurrence vs. extension, recurrence rate, complication rate and cost-effectiveness were better analyzed and newly defined. These studies also contributed to and improved the level of evidence unlike the older papers in this area.
The data available in the literature demonstrate that collagenase is effective and safe in the treatment of Dupuytren’s disease in patients with a subcutaneous palpable cord. The results are comparable to needle fasciotomy and open surgery. However, the CCH treatment has some problematic aspects like a higher recurrence rate and unclear cost-effectiveness.
The complication rate reported in the early papers was evaluated with hard parameters, including many typical side effects of surgery, such as swelling and hematomas. However, when only the major complications are considered, CCH has a lower rate of complications compared to other techniques. The recurrence rate at 5 years is almost double, which is similar to the recurrence rate of needle fasciotomy. Cost-effectiveness studies, despite all the efforts, are based on assumptions and models that cannot fully reflect reality, which leads to contrasting results in different countries.
Therefore, the indication for this treatment remains highly dependent on the preferences of the hand surgeons and patients rather than on clear scientific evidence. The treatment is less-invasive and has a shorter recovery time compared to open surgery, but in complex cases in which there is involvement of many joints, the treatment can be time-consuming.
In conclusion, CCH has a strong beneficial effect on the treatment of Dupuytren’s disease and has increased not only the interest in this problematic hand condition and offering a completely new treatment approach, but also stimulating discussion about all the earlier techniques even though it does not represent the ultimate solution. Future studies, especially long-term follow-up, are still needed to better define the best indication for this treatment.
- For more information:
- Maurizio Calcagni, MD, can be reached at Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; email: maurizio.calcagni@usc.ch.
Disclosure: Calcagni reports he is a consultant and speaker for Sobi.