Isolated and spontaneous correction of proximal interphalangeal joint contractures in Dupuytren's disease: an exploratory analysis of the efficacy and safety of collagenase Clostridium histolyticum.

BACKGROUND AND OBJECTIVE: Dupuytren's contractures affecting proximal interphalangeal (PIP) joints are challenging to treat. We explored the effects of collagenase Clostridium histolyticum (CCH) on PIP joint contractures after injection of an affected metacarpophalangeal (MP) joint in the same finger and after injection of an isolated PIP joint contracture. METHODS: Two patient subsets were evaluated: those with MP/PIP joints contractures in the same finger, but only the MP joint contractures were treated (Group A); and those with isolated PIP joint contractures that were treated (Group B). Endpoints included correction and improvement in contracture. Fixed-flexion contracture (FFC) and range of motion (ROM) were also assessed; adverse events (AEs) were monitored. RESULTS: In Group A, 28 and 43 % of PIP contractures spontaneously corrected after the first and last injection of CCH, respectively, for MP contractures; 40 and 63 %, respectively, improved. In Group B, 31 and 39 % of PIP joint contractures corrected after the first and last injection of CCH, respectively, 56 and 66 %, respectively, improved. In Groups A and B, FFC improvements were largest after the last injection; ROM improvements were largest after the last injection in Group A and third injection in Group B. For 46 and 44 % of patients in Groups A and B, respectively, the first injection was the last injection. In Group B, the median (minimum, maximum) injections/joint was 1.0 (1.0, 4.0). Nearly all patients (98 %) experienced ≥1 AE; most were injection-site reactions. CONCLUSIONS: The efficacy of CCH for improving PIP joint contracture was similar whether treated in isolation or after treatment of an MP joint contracture.

Recognition, diagnosis and referral of patients with Dupuytren's disease: a review of current concepts for general practitioners in Europe.

BACKGROUND: Dupuytren's disease (DD) is a fairly prevalent yet under-recognised disorder of the palmar fascia, resulting in fixed-flexion contractures of joints in the hand. Numerous population-based studies have been conducted in countries around the world, and published prevalence estimates vary widely. Nevertheless, most studies have shown that the prevalence of DD increases with age. Because the global population is aging, the prevalence of DD will also continue to increase. SCOPE: Patients with DD typically present to a variety of physicians, generalists and specialists alike. Thus, it is critical that providers have clear guidance on the early recognition of signs and symptoms, comprehensive evaluation of potential risk factors, differential diagnosis and when to refer a patient for treatment. Treatment options range from minimally invasive injections with collagenase to surgery. FINDINGS: Results from a large-scale study of the surgical management of DD in Europe indicate that most DD diagnoses and referrals are made by general practitioners, but there is much inter-country variation. Different patient- and physician-based factors affect diagnosis rates and referral pathways. Different healthcare systems and regulations are also influential. A simple management algorithm is provided herein and explained. CONCLUSION: It is important for generalists to understand the natural history of DD and the potential benefits of early referral and treatment. General practitioners should diagnose and/or refer patients with DD to a specialist as early as possible to optimise disease management and treatment outcomes.

Efficacy of collagenase in patients who did and did not have previous hand surgery for Dupuytren's contracture.

Collagenase Clostridium histolyticum (CCH) is a non-surgical, efficacious therapy for Dupuytren's contracture (DC). This study evaluated the efficacy and safety of CCH in patients with previous DC surgery. Data from 12 CCH clinical trials were pooled. At screening, patients provided details about the type/date of previous DC surgery. Reviewers coded descriptions to the Operated Hand, finger, and joint. Of 1082 patients, 422 (39%) had previous DC surgery. For these patients with previous surgery, the CCH treatment was coded on the Operated (n = 206) or Non-operated Hand (n = 196). End-points included changes in fixed-flexion contracture (FFC) and range of motion (ROM). Adverse events (AEs) were monitored. After treatment with CCH, FFC at metacarpophalangeal joints was reduced by 75% in previously Operated Hands and by 80% for Non-operated Hands (p = 0.6). Improvements in ROM were 32° and 32°, respectively (p = 0.9). For proximal inter-phalangeal joints, the reductions in FFC for the Operated and Non-operated Hands were 52% and 50%, respectively (p = 0.6); improvements in ROM were 24° and 26°, respectively (p = 0.3). Some AE rates were significantly higher in the Operated vs Non-operated Hand groups, but were not clinically relevant. There were no between-group significant differences in AE duration (p > 0.08). Previous surgery for DC does not affect efficacy or safety of CCH, suggesting CCH is an option in patients with recurring DC. Some AE rates were significantly higher, but not clinically relevant.

Current trends in the surgical management of Dupuytren's disease in Europe: the surgeon's perspective.

INTRODUCTION: Dupuytren's disease (DD), commonly affecting European men, is generally treated with surgery. METHODS: Orthopaedic and plastic surgeons who had been practicing for >3 and <30 years and operated on ≥5 patients with DD between September and December 2008 were surveyed in 12 European countries (Czech Republic, Denmark, Finland, France, Germany, Hungary, Italy, The Netherlands, Poland, Spain, Sweden and UK). The survey assessed procedures performed, factors influencing choice of procedure, use of physical therapy and recurrence. Descriptive statistics are reported. RESULTS: A total of 687 surgeons participated, including 579 orthopaedic and 108 plastic surgeons; 383 (56%) were hand surgeons. About 37% of surgeons performed percutaneous needle fasciotomy (PNF), 77% fasciotomy, 95% fasciectomy and 40% dermofasciectomy (DF). Surgeons' choice of procedure was influenced by patient preferences, age, degree of contracture and recurrent disease. The percentage of surgeons prescribing physical therapy and the mean (standard deviation [SD]) duration of therapy increased with procedure complexity: PNF = 82%, 5.2 (3.9) weeks; fasciotomy = 94%, 5.3 (3.6); fasciectomy = 97%, 6.7 (5.1); and DF = 99%, 8.5 (6.4). Using survey responses, mean (SD) estimated recurrence rates decreased and estimated time to recurrence increased with procedure complexity-PNF = 44% (27%), 17 (15) months; fasciotomy = 30% (24%), 20 (18); fasciectomy = 20% (17%), 29 (23); and DF = 20% (19%), 33 (27). CONCLUSIONS: Across Europe, patient and surgical factors influence the intention to use a surgical procedure. Fasciectomy was the most commonly performed procedure type and was associated with lower recurrence than PNF or fasciotomy. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s12570-012-0091-0) contains supplementary material, which is available to authorized users.

Current trends in the surgical management of Dupuytren's disease in Europe: an analysis of patient charts.

INTRODUCTION: Dupuytren's disease (DD) causes progressive digital flexion contracture and is more common in men of European descent. METHODS: Orthopaedic and plastic surgeons in 12 European countries (the Czech Republic, Denmark, Finland, France, Germany, Hungary, Italy, The Netherlands, Poland, Spain, Sweden and the UK) with >3 and <30 years experience reviewed the medical charts of five consecutive patients they had treated surgically for DD in 2008. Descriptive statistics are reported. RESULTS: In total, 3,357 patient charts were reviewed. Mean (standard deviation) patient age was 61.9 (10.2) years; 81% were men. At the time of the procedure, 11% of patients were at Tubiana stage Ia (0-20° total flexion); 30%, stage Ib (21-45°); 34%, stage II (46-90°); 17%, stage III (91-135°); and 5%, stage IV (>135°). Percutaneous needle fasciotomy was performed in 10%, fasciotomy in 13%, fasciectomy in 69% and dermofasciectomy (DF) in 6% of patients. After surgery, fingers improved a mean of 1.9 Tubiana stages, and 54% of patients had no nodules or contracture. The rate of reported complications during the procedure was 4% overall (11% in patients undergoing DF). The most common postoperative complications reported were haematoma (8%), wound healing complications (6%) and pain (6%). No postoperative complications were reported in 77% of patients. CONCLUSIONS: In this European study of more than 3,000 patients with DD, most patients were diagnosed at Tubiana stage I or II, the majority received fasciectomy and more than half had no nodules or contracture remaining after surgery. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s12570-012-0092-z) contains supplementary material, which is available to authorized users.