Bias in published randomized trials that compare collagenase injection with percutaneous needle fasciotomy in the treatment of Dupuytren disease: a systematic review.

Purpose: Controversy exists regarding the comparative efficacy of collagenase injection and percutaneous needle fasciotomy in the treatment of Dupuytren contracture. The randomized controlled trials (RCTs) that have compared the two treatment methods have reported results mostly implying similar treatment efficacy, durability, and complications. We aimed to review these RCTs regarding methodical quality and risk of bias. Methods: We searched PubMed and Cochrane Library databases up to May 2023. All RCTs comparing collagenase injection with needle fasciotomy were included. Eligible articles were reviewed by two researchers, of whom one was blinded to each article's title, authors, year of publication, journal, and source of the studies. To assess methodical quality, we used the modified Jadad scale yielding a score of 0 (lowest quality) to 5 (highest quality). We assessed risk of bias with the Cochrane risk-of-bias tool (RoB 2). Results: Five studies were eligible, comprising 204 patients treated with collagenase injection and 209 patients treated with needle fasciotomy. The modified Jadad score ranged from 1 to 2 points in the five studies, and the overall risk of bias was high in all studies. Pretrial protocols could be retrieved for only two studies, revealing important discrepancies with the published articles. Conclusion: The published RCTs that have compared collagenase injection with needle fasciotomy in the treatment of Dupuytren contracture demonstrate a high risk of bias.

Responsiveness of the patient-specific Canadian occupational performance measure and a fixed-items activity limitations measure in patients with dupuytren disease.

BACKGROUND: Patients with Dupuytren disease experience various activity limitations. Treatment aims to reduce finger joint contractures to improve hand function and activity performance. For assessing improvement different patient-centered measures have been used. The Canadian Occupational Performance Measure (COPM) was developed as an interview-based outcome measure to detect changes over time in patients' perception of their performance and satisfaction in self-identified activity issues. The 11-item disabilities of the arm, shoulder and hand (QuickDASH) scale consists of fixed items that ask patients to rate the difficulty in performing specific daily activities. Few studies have compared the responsiveness of these two types of patient-reported measures in Dupuytren disease. PATIENTS AND METHODS: We included 30 patients with Dupuytren disease enrolled in a prospective cohort study of collagenase injection. We used the COPM (score range 1-10), the QuickDASH (score range 0-100) and measurement of finger joint contracture before and 5 weeks after treatment. RESULTS: Using the COPM the patients identified 107 activity problems (55 in self-care, 19 in productivity and 33 in leisure). The two most common activity problems were to wash self (21 patients) and to don gloves (19 patients). A clinically important improvement with 3 points or greater from baseline to 5 weeks was seen for performance in 77 activities (72%). The median COPM performance score improved from 4.4 at baseline to 9.0 at 5 weeks and the median QuickDASH score improved from 13.6 to 2.5. Responsiveness (Cohen's d) for the COPM performance was 2.6 (95% CI 1.9-3.3) and for the QuickDASH 0.6 (95% CI 0.1-1.1). CONCLUSION: The COPM had about 6-fold larger responsiveness than the QuickDASH, which supports use of an individualized measure when assessing treatment effects in Dupuytren disease.

Risk Factors for Long-Term Contracture Recurrence after Collagenase Injection for Dupuytren Disease: A Prospective Cohort Study.

In Dupuytren disease, little is known about the long-term outcomes of collagenase injection or risk factors for contracture recurrence. In this prospective study, 159 patients (242 fingers) with Dupuytren disease and active extension deficit (AED) ≥20° in a metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joint were treated with collagenase injection during a 14-month period. At 5 years, 18 patients were deceased, 2 could not be contacted, and 13 had undergone fasciectomy. The remaining 126 patients (199 treated fingers) participated in a follow-up evaluation at 52-96 (mean 65) months after injection, with physical examination (114 patients) or telephone interview (12 patients). Recurrence was defined as subsequent treatment (surgery or repeat injection) or ≥20° AED worsening in a treated joint between the 6-week and 5-year measurements. The mean AED at baseline was 42° (SD 24) for MCP joints and 31° (SD 29) for PIP joints and at 5 years 11° (SD 17) and 17° (SD 23), respectively. Recurrence occurred in 17% of MCP joints and 25% of PIP joints. Statistically significant risk factors for PIP joint contracture recurrence were greater baseline AED (odds ratio 1.04, 95% CI 1.02-1.06) and small finger treatment (OR 4.6, 95% CI 1.5-14.3), with no significant risk factors found for MCP contracture recurrence.

Finger Joint Contractures 5 Years After Treatment for Dupuytren Disease: A Comparative Cohort Study of Collagenase Injection Versus Surgical Fasciectomy.

PURPOSE: To compare collagenase injection with surgical fasciectomy in Dupuytren disease (DD) for the prevalence of contracture in treated fingers 5 years after treatment. METHODS: This was a single-center, comparative cohort study comprising 2 cohorts of patients treated for DD in 1 or more of 3 ulnar fingers with collagenase injection (159 patients) or surgical fasciectomy (59 patients). At 5 years after treatment, 13 collagenase-treated and 8 fasciectomy-treated patients had undergone subsequent treatment on the treated fingers and were considered to have current contracture. Of the remaining patients, 112 collagenase-treated patients (128 hands, 180 fingers) and 46 fasciectomy-treated patients (49 hands, 63 fingers) attended follow-up evaluation performed by 2 independent examiners (participation rate 84% and 93%, respectively). We defined current contracture in a treated finger as an active extension deficit of ≥20° in the metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joint or a total (MCP + PIP) active extension deficit (TAED) of ≥30°. We used linear mixed models to analyze differences between the cohorts over time. RESULTS: In the collagenase cohort, current contracture was present in 45 (25%) MCP and 60 (33%) PIP joints, and in the fasciectomy cohort, current contracture was present in 12 MCP (19%) and 30 PIP (48%) joints; a TAED of ≥30° was present in 79 (44%) of the collagenase-treated and 30 (48%) of the fasciectomy-treated fingers. In MCP and PIP joints with ≥20° pretreatment contracture, complete correction was observed in 82 (56%) MCP and 30 (30%) PIP joints in the collagenase cohort and 23 (70%) MCP and 5 (16%) PIP joints in the fasciectomy cohort. There was no statistically significant difference between the 2 cohorts in the TAED change over time. CONCLUSIONS: In patients with DD, collagenase injection and surgical fasciectomy improved finger joint contracture over the pretreatment status but had a high prevalence of joint contracture in the treated fingers 5 years after treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Surgical treatment of Dupuytren's disease - outcome and health economy in relation to smoking and diabetes.

BACKGROUND: The conventional treatment for Dupuytren's disease is surgery. The introduction of alternative treatment strategies creates a need to track outcomes and costs relating to surgical treatment and risk factors, such as smoking and diabetes. This was the aim of the present study. METHODS: In a prospective study, the outcome of open surgical treatment for finger flexion contracture in Dupuytren's disease (175 patients; 182 surgical procedures) was studied by evaluating valid QuickDASH forms answered by subjects before surgery and one year postoperatively. Data were also obtained from medical records, and preoperative declarations concerning health. RESULTS: In all subjects (median [25% - 75% percentiles] age 68 [62-73]), the QuickDASH score improved from 22 [9-36] to 5 [0-18]. Smokers (27/179 procedures) were younger and had a more severe degree of disease and dysfunction preoperatively than non-smokers, but the outcome of surgery did not differ between the groups. Subjects with diabetes (20/181 procedures) were younger than those without diabetes, but their disease severity or outcome did not differ. Hand specialists operated faster than residents, but the surgical outcome did not differ. Healthcare costs for surgery for Dupuytren's contracture were $ 2392 (€ 1859), which were not higher among smokers or subjects with diabetes. Only 22 patients remained in hospital (2 [1-2.3] days) and 28 patients needed sick leave (28 [21-31] days). The occurrence of necrosis of skin flaps (12%) or infections (6%) was no more frequent among smokers or those with diabetes. CONCLUSIONS: There is no difference in surgical outcome for finger flexion contracture in Dupuytren's disease between smokers and non-smokers or between subjects with or without diabetes, although smokers had more severe preoperative contracture. The costs for surgical treatment for finger flexion contracture in Dupuytren's disease should be viewed in relation to that for other treatment strategies.