In Reply

Abstract

We appreciate the insight Dr. Denkler shares1Denkler K.A. Collagenase for recurrent Dupuytren contracture with skin-grafts.J Hand Surg Am. 2013; PubMed Google Scholar in response to our recently reported case of diffuse skin graft dehiscence after clostridial collagenase injection,2Swanson J.W. Watt A.J. Vedder N.B. Skin graft loss resulting from collagenase clostridium histolyticum treatment of Dupuytren contracture: case report and review of the literature.J Hand Surg Am. 2013; 38: 548-551Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar particularly given his considerable experience with nonoperative treatment of Dupuytren contracture. The case he shares involves a smaller skin graft and a pathologic cord well ulnar to the graft, compared with the case we report, in which the central cords ran directly under a larger graft. That collateral damage by collagenase to an incorporated skin graft may be proportional to certain factors, such as graft proximity, size of graft, and severity of disease, seems plausible. We again suggest that surgeons proceed cautiously when considering collagenase injection in the presence of a skin graft and consider the possibility of graft loss. We agree that collagenase may be particularly suitable for recurrent disease, because these patients have few good alternatives and a healed skin graft may periodically be present. We hope that with time and experience, and with more cases, indications and contraindications for collagenase will be further refined. We appreciate the insight Dr. Denkler shares1Denkler K.A. Collagenase for recurrent Dupuytren contracture with skin-grafts.J Hand Surg Am. 2013; PubMed Google Scholar in response to our recently reported case of diffuse skin graft dehiscence after clostridial collagenase injection,2Swanson J.W. Watt A.J. Vedder N.B. Skin graft loss resulting from collagenase clostridium histolyticum treatment of Dupuytren contracture: case report and review of the literature.J Hand Surg Am. 2013; 38: 548-551Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar particularly given his considerable experience with nonoperative treatment of Dupuytren contracture. The case he shares involves a smaller skin graft and a pathologic cord well ulnar to the graft, compared with the case we report, in which the central cords ran directly under a larger graft. That collateral damage by collagenase to an incorporated skin graft may be proportional to certain factors, such as graft proximity, size of graft, and severity of disease, seems plausible. We again suggest that surgeons proceed cautiously when considering collagenase injection in the presence of a skin graft and consider the possibility of graft loss. We agree that collagenase may be particularly suitable for recurrent disease, because these patients have few good alternatives and a healed skin graft may periodically be present. We hope that with time and experience, and with more cases, indications and contraindications for collagenase will be further refined. Collagenase for Recurrent Dupuytren Contracture With Skin GraftsJournal of Hand SurgeryVol. 38Issue 6PreviewDrs. Swanson, Watt, and Vedder1 reported a collagenase clostridium histolyticum (CCH) injection with diffuse skin graft dehiscence on manipulation at day 7, followed by an infection and graft loss 4 days after manipulation. The clinical photo shows a skin tear with infection. Skin tears occurred 9% of the time in clinical trials and are more common in clinical practice as a result of the routine use of local anesthetic for manipulation, which can now be more forceful, yet painless. A diabetic with severe postsurgical Dupuytren contracture is fraught with potential complications with any treatment. Full-Text PDF