Beware of the Small Finger and/or the Proximal Interphalangeal Joint? Skin Lacerations following Collagenase Injection in Dupuytren Contracture

Abstract

Sir:FigureWe read with great interest the recent Viewpoint by Dr. Hallock highlighting a skin laceration of the small finger necessitating full-thickness skin grafting following collagenase injection in Dupuytren contracture.1 As reported in the Collagenase Option for Reduction of Dupuytren's I randomized controlled trial, skin lacerations occurred in 10.8 percent of all collagenase-treated patients.2 In addition, ecchymosis occurred in every fourth treated patient in the Collagenase Option for Reduction of Dupuytren's I study, and blood blisters occurred in 3.4 percent. In addition, two flexor tendon ruptures have been reported in the Collagenase Option for Reduction of Dupuytren's I study, both occurring at the small finger following proximal interphalangeal joint–targeted collagenase injections.3 The reported skin laceration in Dr. Hallock's case also occurred following proximal interphalangeal joint–targeted collagenase injection. One is tempted to ask whether the small finger proximal interphalangeal joint in Dupuytren contracture is a hazardous area. After the European approval of collagenase histolyticum in May of 2011, we have so far encountered two skin lacerations in collagenase-treated patients. The first female patient treated in our institution presented with a long-standing fourth ray Dupuytren contracture of 135 degrees following 15 Gy of radiotherapy. Immediately following cord breaking, a blood blister and subsequently a skin laceration occurred over her proximal phalanx. Using Steri-Strips and a custom-made plaster, healing by secondary intention was achieved within 10 days, surprisingly, in the previously irradiated hand. The second patient suffering with a skin laceration following collagenase injection was a 58-year-old man who had been previously operated on, with a fixed contracture of 120 degrees following selective fasciectomy of his ring finger (Fig. 1, above, left). A colleague had previously suggested ring finger amputation. He was treated with collagenase injection and, during cord breaking, a skin laceration occurred near the proximal interphalangeal joint of his ring finger. (See Video, Supplemental Digital Content 1, which demonstrates skin laceration during cord breaking 24 hours after collagenase injection in a male patient with recurrent Dupuytren contracture of this ring finger following selective fasciectomy, https://links.lww.com/PRS/A519.) Using Repithel ointment and daily dressing changes on a customized Dupuytren glove (Fixxglove) (Fig. 1, above, right, and below, left), the wound healed within 10 days albeit with exposed flexor tendons using a McCash open palm4 analogon (Fig. 1, below, right).Fig. 1: (Above, left) Male patient with recurrent Dupuytren contracture of his ring finger before collagenase injection. (Above, right) Forty-eight hours after skin laceration during cord breaking. (Below, left) Customized Fixxglove for postinterventional splinting following collagenase injection. (Below, right) Ten days after skin laceration with exposed flexor tendons at the proximal interphalangeal joint, complete reepithelialization following collagenase injection is shown.Video: Supplemental Digital Content 1 demonstrates skin laceration during cord breaking 24 hours after collagenase injection in a male patient with recurrent Dupuytren contracture of this ring finger following selective fasciectomy, https://links.lww.com/PRS/A519.In 2004, the Journal published an interesting prospective though nonrandomized clinical comparison of the McCash open palm technique and full-thickness skin grafting.5 Disabilities of the Arm, Shoulder and Hand scores improved in both groups from 37 to 30. Healing time was significantly faster in the full-thickness skin graft group compared with the McCash group (28 days versus 40 days). Furthermore, the recurrence rate was 50 percent for the McCash open palm group and 0 percent for the full-thickness group. Similar results in terms of reduced recurrence rates following full-thickness skin grafts have been reported by a number of authors in nonrandomized trials.6,7 However, a randomized trial with 79 patients with proximal interphalangeal joint Dupuytren contractures randomized to either firebreak full-thickness skin grafting or fasciectomy did not find any significant difference in recurrence rates at 3-year follow-up.8 Coming back to Dr. Hallock's case, it is tempting to speculate on how the recurrence rate will be influenced, if at all, by full-thickness skin grafting for skin lacerations following collagenase injections. The published 8-year follow-up results of eight patients report a 66 percent metacarpophalangeal joint and a 100 percent proximal interphalangeal joint recurrence rate.9 Therefore, we should follow the patients especially following skin lacerations with or without skin grafting in the future to elucidate the aforementioned question. Karsten Knobloch, M.D., Ph.D. Peter M. Vogt, M.D., Ph.D. Plastic, Hand, and Reconstructive Surgery and, Burn Center, Hannover Medical School, Hannover, Germany DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.