Open Fasciectomy Research Articles

Dupuytren’s contracture: is a history of percutaneous needle fasciotomy a risk factor for postoperative complications after secondary open fasciectomy? A retrospective study of 62 hands

IntroductionDupuytren’s disease is a benign disorder leading to flexion contracture of the fingers and functional disability. Many treatments have been described. Open fasciectomy is the gold standard; however percutaneous needle fasciotomy (PNF) is a reliable option for uncomplicated primary contracture but it has a high rate of recurrence. HypothesisA history of PNF treatment before open fasciectomy is a risk factor for postoperative complications. Material and methodsA retrospective single-center study was conducted involving 56 patients (62 hands) who were operated for Dupuytren’s contracture by open fasciectomy between November 2016 and November 2020. We compared the outcomes of patients with history of prior PNF on the same finger (group A) to patients without history of PNF (group B). There was no significant difference between the two groups in the severity, comorbidities or preoperative finger mobility. The primary outcome was the complication rate during surgery or during the follow-up period (mean follow-up of 2 years). ResultsThe intra- and postoperative complication rate was 26% (n = 9) in group A (history of PNF) versus 9% (n = 4) in group B (no PNF) (p = 0.0482), corresponding to a relative risk for complications of 2.8 (95% CI: 1.2-6.4) in case of previous PNF. Tourniquet time per operated ray was higher in group A than in group B (34.1 min versus 24.9 min, p = 0001). DiscussionA history of PNF for Dupuytren’s disease can lead to a higher rate of major intraoperative or postoperative complications when open fasciectomy is performed compared to open fasciectomy as a first-line therapy. Level of evidenceIII; retrospective comparative study.

A 10-Year Review of Collagenase Versus Fasciectomy in the Treatment of Dupuytren Contracture.

Dupuytren disease (DD) is one of the most common disorders of the hand, affecting 5.7% to 11.7% of the global population. This study seeks to evaluate the 10-year efficacy of the 2 most prominent treatment modalities for DD in Veterans Affairs hospitals, injectable collagenase Clostridium histolyticum versus open fasciectomy. A retrospective review was conducted of all electronic medical records of patients who underwent open fasciectomy or collagenase injection to treat their persistent Dupuytren contracture between April 2011 and April 2021. All procedures were performed by 1 of 5 senior surgeons at the same Veterans Affairs Hospital. A total of 232 patients were treated for DD, with 247 collagenase injections and 44 open fasciectomies performed in this sample. Collagenase patients were, on average, 6.51 years after intervention at the time of review. Open fasciectomy patients were, on average, 4.56 years after operation at the time of review. Collagenase decreased contractures, on average, by 29.40 degrees, whereas open fasciectomy decreased contractures, on average, by 38.59 degrees. Of the contractures that were initially classified as resolved, 50 of 155 (32.2%) treated with collagenase and 6 of 56 (10.7%) treated with open fasciectomy recurred. The use of open fasciectomy compared with collagenase injections to treat contracture was associated with a 74.2% decrease in the likelihood of recurrence. This study found that treatment of DD with collagenase injection is associated with a significantly lower degree of deformity correction, lower rate of resolution, and increased rate of recurrence when compared with open fasciectomy.

Comparison of Patient Demographics, Utilization Trends, and Costs of Treatment for Dupuytren's Disease in the United States From 2012 to 2019.

Dupuytren's disease is a fibroproliferative disorder of the palm leading to flexion deformities of the digits that impair hand function. Studies have evaluated treatment trends for patients with Dupuytren's disease; however, most conclude in 2012 shortly after collagenase clostridium histolyticum (CCH) injection was introduced to the market. It is unknown how provider preferences have been influenced since its introduction. We aimed to compare treatment options with regard to (1) patient demographics, (2) annual utilization rates, and (3) costs. The PearlDiver nationwide administrative claims database from 2012 to 2019 was analyzed for patients diagnosed with Dupuytren's disease (N = 47,813). Patients receiving procedural treatment were identified using codes for percutaneous needle aponeurotomy (PNA) (current procedural terminology [CPT] 26040), open fasciotomy (CPT 26045), open fasciectomy (CPT 26121, 26123, 26125), and CCH injection (CPT 20527). Fasciectomies were further analyzed by examining the number of patients receiving release of 1 or more digits (CPT 26123, 26125) versus palmar-only surgery (CPT 26121). Outcomes included comparing patient comorbidities comprising the Elixhauser Comorbidity Index (ECI), frequencies of each procedure annually, and costs. Linear regressions evaluated changes in utilization over time. Analysis of variance compared costs. P values less than 0.05 were significant. Patient demographics for each treatment differed with respect to age, sex, and the presence of multiple comorbidities comprising the ECI. Open fasciectomy (60.7%) was the predominant treatment, followed by CCH injection (22.9%), PNA (10.1%), and open fasciotomy (6.3%) (P < 0.001). Multiple patient comorbidities comprising the ECI differed for each treatment. Relative to total annual procedures from 2012 to 2019, PNA declined (10.2% to 9.5%, P = 0.037), open fasciotomy declined (6.8% to 5.6%, P = 0.007), palmar fasciectomy remained constant (14.5% to 14.2%, P = 0.710), fasciectomy of digits increased (46.3% to 47.5%, P = 0.030), and CCH injection remained constant (22.2% to 23.3%, P = 0.623). Day of procedure costs were significantly different for PNA ($573), open fasciotomy ($1176), palmar open fasciectomy ($1410), open fasciectomy digits ($1560), and CCH injection ($1250) (P < 0.001). The overall annual Dupuytren's disease treatment did not change over time. Treatment with open fasciectomy continues to be preferred. Collagenase clostridium histolyticum utilization has remained constant since its introduction. This study may assist hand surgeons in educating patients on the treatment and costs related to Dupuytren's disease.

Patient-Reported Outcome in Dupuytren’s Disease Treated With Fasciectomy, Collagenase or Needle Fasciotomy: A Swedish Registry Study

This registry study compares the patient-reported outcomes of 3 treatments for Dupuytren´s disease: open fasciectomy (OF), collagenase injection (CCH) and percutaneous needle fasciotomy (PNF). From the Swedish national quality registry for hand surgery (HAKIR) we included 2,585 procedures (in 2,414 patients): 1,200 treatments were OF, 918 CCH, and 467 PNF. The choice between CCH and PNF varied mainly because of regional differences in reimbursement of CCH. We report the results of the validated patient-reported outcome instrument HQ-8. HQ-8 evaluates symptoms in the treated hand and is issued before treatment, 3 and 12 months after treatment and is used for all patients in HAKIR. At 3-month follow-up, patients treated with CCH or PNF experienced less stiffness, weakness, numbness, tingling and sensitivity to cold. At 12 months, the differences among the 3 treatments were smaller, but CCH patients experienced less stiffness and weakness compared to PNF-treated patients. Most randomized controlled trials have not shown significant differences in recurrence rates or patient-reported outcomes between CCH and PNF, but the number of patients has been limited and no randomized controlled trials have included all 3 treatments. In the present study, we compared registry data on patient-reported outcomes for OF, CCH, and PNF in a real-life clinical setting. Our results confirm that the noninvasive treatments (CCH and PNF) cause less disability than OF and indicate a possible advantage of CCH compared to PNF regarding stiffness and weakness at 1 year after treatment based on patient-reported outcomes. Patient-reported residual symptoms are important to consider when informing patients and selecting treatment for Dupuytren´s disease. Observational registry study III.

Dupuytren’s contracture treated with collagenase Clostridium histolyticum

Treatment of Dupuytren’s contracture improves the quality of life of patients, but standard open fasciectomy surgery is traumatic and requires long-term rehabilitation. The study aimed to determine whether injectable treatment with collagenase preparations was effective in comparison with open fasciectomy. Forty patients were examined. Of these, 15 were treated with Clostridium histolyticum collagenase preparations (the main group), and 25 underwent limited fasciectomy (the control group). In 11 (73.3%) patients of the main group, restoration of mobility of the affected joints was achieved after the first injection, in 3 (20%) – after the second, and in 1 (6.7%) – after the third. Patients in the main group remained able to work after treatment and did not require rehabilitation; the function of the upper limb was fully restored on the day of intervention. During the observation period, 12 (80%) patients in the main group were concerned about dry skin at the intervention site, and 5 (33.3%) patients were concerned about itching and discolouration of the skin at the intervention site. In 25 (100%) patients of the control group, joint mobility was fully restored. The ability to use the hand after surgery in patients of the control group was limited for 6 (4.5; 10) days. All patients in the control group required rehabilitation to relieve stiffness and restore the functional capabilities of the hand. The period of disability in these patients lasted 16 (12; 24.5) days. 11 (44%) patients had complaints of pain or discomfort in the intervention area during the follow-up, and 24 (96%) patients were bothered by itching. Satisfaction with the choice of treatment method in the main group was more frequent compared to the control group. Relapses during the observation period were absent in both groups. Thus, the efficacy of Clostridium histolyticum collagenase preparations are comparable to the results of surgical treatment. Minimally invasive treatment is optimal for patients with mild disease, as well as for those who have a low risk of contracture recurrence. The results of this study can be useful for surgeons when choosing the optimal method of treating Dupuytren’s contracture

What's New in Hand and Wrist Surgery.

What's New in Hand and Wrist Surgery.

Additional Treatment after Collagenase Injections and Needle Fasciotomy for Dupuytren’s Disease: A Retrospective Cohort Study

Introduction The aim of this study was to assess the rate of additional treatment after collagenase injection and needle fasciotomy, and what factors are associated with additional procedures for recurrence.Materials and Methods We retrospectively identified 201 adult patients who underwent collagenase injection and 19 patients who underwent needle fasciotomy for Dupuytren’s disease from 2012 to 2014. Outcomes included additional treatment of the same ray for either recurrence or persistence of contracture. To evaluate associated factors, we performed a bivariate analysis.Results Additional treatment after collagenase injection for recurrence was performed in 24% of fingers at a median of 23 months (interquartile range [IQR]: 10.8–36.1) and was associated with bilateral disease (p = 0.008). Additional treatment for persistence was performed in 5.6% at a median of 1.9 months (IQR: 1.1–3.2). Additional treatment for recurrence after needle fasciotomy was performed in 13% of fingers at a median of 28.2 months (IQR: 27.5–28.2) and 4.2% for persistence at 1.1 months. Fingers treated with needle fasciotomy were more likely to undergo secondary open fasciectomy (13% vs. 5.1%, p = 0.022).Conclusion Additional treatment after collagenase injections was performed in 29% of fingers, mostly another collagenase injection, and was associated with bilateral disease. After needle fasciotomy, 17% of patients underwent additional treatment, primarily open partial fasciectomy.

Report on the Evidence-Based Practice Committee’s Survey on Dupuytren Disease

PurposeThe Evidence-Based Practice Committee of the American Society for Surgery of the Hand (ASSH) set out to assess the membership’s practice patterns (PPs) and knowledge of evidence-based principles for Dupuytren disease (DD).MethodsA 21-item multiple-choice survey was distributed to all ASSH members via email in June 2020. Questions were divided into 2 types: evidence-based practice (EBP) and PPs. The survey addressed the following subtopics: nonsurgical, percutaneous, and open surgical management of DD.ResultsThe response rate was 18% (n = 419). Of 13 EBP questions, 5 were answered with the preferred response by >75% of surgeons. The remaining 8 EBP questions had greater frequencies of less preferred responses, which concerned the current evidence for percutaneous management, as well as nonsurgical and postoperative management of DD. Of the PP questions, there were differences in opinion on how to manage a painful nodule, the percutaneous technique (eg, collagenase injection vs percutaneous needle aponeurotomy), and the choice of surgical incision for open fasciectomy (eg, Bruner incision with Z-plasties, partial closure with an open transverse palmar component, or longitudinal incision with Z-plasties).ConclusionsHand surgeons continue to be well informed about current evidence-based practices for treating DD and can improve their knowledge by familiarizing themselves with current data on percutaneous and nonsurgical methods. There exist differences in PPs for DD in the ASSH membership, specifically with less invasive management; and knowledge of peer practices can help navigate differences, critically interpret the evidence, and optimize patient care.Type of study/level of evidenceEconomic/Decision Analyses V.

Cost Analysis and National Trends in the Treatment of Dupuytren Contracture Comparing Collagenase Injection, Needle Fasciotomy, and Open Fasciectomy Procedures.

Dupuytren contracture (DC) is a common disorder characterized by progressive fibrosis of palmar fascia. This study analyzed cost trends of 3 common treatments for DC: fasciotomy, fasciectomy, and collagenase injection (CI)/cord manipulation. The Vizient Clinical Data/Resource Manager electronic database was reviewed for all procedures for the treatment of DC at participating hospitals in the United States (US) from October 1, 2015, to September 1, 2019. Cases were placed into 1 of 3 categories: (1) CI, (2) needle fasciotomy (NF), and (3) open fasciectomy (OF). Total and direct costs were averaged for each procedure and compared nationally and regionally. Temporal trends and specific market share were analyzed. One-tailed t test and Pearson correlation analysis was performed (P < 0.05 and r > 0.9 or r < -0.9 was considered significant). A total of 22,974 total cases were identified. A total of 16,966 OF, 3962 NF, and 2046 CI were performed. There was a nearly a 4-fold increase in number of procedures to treat DC from 2015 to 2018. Market share percentage of each procedure stayed relatively similar over time. However, market share percentage differed between procedures. Needle fasciotomy had the lowest market share percentage approximately 7%. Collagenase injection had the highest average cost at US $4453.66 and was significantly higher than OF at US $3394.90 and NF at US $2010.75. Cost and distribution of procedures were further analyzed by geographic regions. In 2018, 32% of procedures performed were in the Northeastern US, 29% in the Midwestern US, 23% in the Southern US, and 16% in the Western US. Total number of Dupuytren procedures increased more than 300% in all regions across the US from 2015 to 2018. In every region, NF was the lowest cost intervention. Cost of OF and CI varied between regions and was often the most expensive intervention. Treatment of DCs with NF seems to be the least costly treatment option. Needle fasciotomy seems to be the least commonly performed procedure. Regional data show variations in the cost of OF and CI. However, OF has the majority market share nationally and regionally. Although the cost of these procedures seems to vary regionally, the type of procedures being performed seem to be similar across regions.

Clinical and morphological outcomes after percutaneous needle fasciotomy in Dupuytren's disease according to the contracture severity.

Background and Objectives: Dupuytren’s disease (DD) is a chronic progressive disorder causing contractures in the palmar and digital fascia. The primary aim of management is to correct the deformity while reducing the risk of recurrence and avoiding complications. The purpose of our retrospective study was to validate the efficacity, safety and the rate of recurrence of DD after percutaneous needle fasciotomy (PNF). Patients, Materials and Methods: We present results for a population of 40 patients, divided into three groups, based on the severity of the contracture according to Tubiana staging. We analyzed patient demographic data, encountered complications and the degree of release achieved both post-procedure and at one-year follow-ups. Results: From a total of 98 joints we treated, we obtained satisfactory release [passive extension deficit (PED) ≤10°] in 85% of joints, while full release was obtained in 70% of joints. Full release was obtained mostly in metacarpophalangeal (MCP) joint (95%) rather than proximal interphalangeal (PIP) joint (50%) or distal interphalangeal (DIP) joint (60%). Our patient preferred PNF in comparison to open fasciectomy because of its minimum invasive approach and the quick recovery time. Conclusions: The study shows that PNF has great short-term results and it is suitable for patients who prefer minimally invasive care.

Versatility of percutaneous needle fasciotomy for Dupuytren's disease across a spectrum of disease severity: A single-surgeon experience of 118 rays

BackgroundPercutaneous needle fasciotomy (PNF) represents the only minimally invasive approach for treatment of Dupuytren's disease in Europe since withdrawal of collagenase from European markets. Though well-established, surgeon preference and uncertainty regarding safety and efficacy, results in limited provision in favour of open fasciectomy. MethodsA retrospective review of 74 patients who self-opted to receive PNF between 2017 and 2020 was conducted. Demographic data, complications and degree of release achieved were compared across three cohorts based on contracture severity as per Tubiana staging (TS): Stage 1, 0–45°; Stage 2, 46–90°; Stage 3, 91–130° with χ2 analysis. ResultsOne hundred and eighteen rays were treated amongst 74 patients (mean age, 68 years (R, 32–86), males: 74%) with mean follow-up 51 weeks (IQR 28–76 weeks) with no significant difference in baseline characteristics across cohorts. No cases of permanent sensory disturbance, flexor tendon rupture, arterial transection nor infection were observed. Neuropraxia was seen in six patients, resolving with mean recovery of 6 weeks. 86% (n = 166) of joints had satisfactory release (residual passive extension deficit (PED) ≤10°) with full release in 67%. Full release was most likely in metacarpophalangeal joint (MCPJ; 93%) than distal interphalangeal joint (DIPJ; 67%) or proximal interphalangeal joint (PIPJ; 45%; p<0.0001). Mean release was 54° in MCPJ and 56° in PIPJ. All TS1 patients achieved release with ≤10° residual PED versus 75% of TS2 patients and 22% of TS3 patients (p<0.05), the latter of whom had a mean residual PED of 12° Ninety-two percent of patients stated they would undergo PNF again if necessary, in preference to open fasciectomy. ConclusionWe find PNF to facilitate a safe, effective yet minimally invasive approach amongst patients of varying disease severity, across different age groups, with recurrent disease, associated comorbidities or concurrent anticoagulation therapy. Patients reported high satisfaction in preference to open procedures. We, therefore, intend to recommend PNF first-line to all patients regardless of disease severity.

Fasciectomy under local anaesthetic and adrenaline for Dupuytren's contracture in a community setting in the UK with a cost analysis.

In the UK, fasciectomy for Dupuytren's contracture is generally performed under general or regional anaesthetic, with an arm tourniquet and in a hospital setting. We have changed our practice to use local anaesthetic with adrenaline, no arm tourniquet, and perform the surgery in a community setting. We present the outcome of a consecutive series of 30 patients. Prospective data were collected for 30 patients undergoing open fasciectomy on 36 digits (six having two digits affected), over a one-year period and under the care of two surgeons. In total, 10 ml to 20 ml volume of 1% lidocaine with 1:100,000 adrenaline was used. A standard postoperative rehabilitation regime was used. Preoperative health scores, goniometer measurements of metacarpophalangeal (MCP), proximal interphalangeal (PIP) contractures, and Unité Rheumatologique des Affections de la Main (URAM) scores were measured pre- and postoperatively at six and 12 weeks. The mean preoperative contractures were 35.3° (0° to 90°) at the metacarpophalangeal joint (MCPJ), 32.5° (0° to 90°) at proximal interphalangeal joint (PIPJ) (a combined deformity of 67.8°). The mean correction was 33.6° (0° to 90°) for the MCPJ and 18.2° (0° to 70°) for the PIPJ leading to a combined correction of 51.8°. There was a complete deformity correction in 21 fingers (59.5%) and partial correction in 14 digits (37.8%) with no correction in one finger. The mean residual deformities for the partial/uncorrected group were MCP 4.2° (0° to 30°), and PIP 26.1° (0° to 85°). For those achieving a full correction the mean preoperative contracture was less particularly at the PIP joint (15.45° (0° to 60°) vs 55.33° (0° to 90°)). Mean preoperative URAM scores were higher in the fully corrected group (17.4 (4 to 31) vs 14.0 (0 to 28)), but lower at three months post-surgery (0.5 (0 to 3) vs 4.40 (0 to 18)), with both groups showing improvements. Infections occurred in two patients (three digits) and both were successfully treated with oral antibiotics. No other complications were noted. The estimated cost of a fasciectomy under local anaesthetic in the community was £184.82 per patient. The estimated hospital theatre costs for a fasciectomy was £1,146.62 under general anaesthetic (GA), and £1,085.30 under an axillary block. This study suggests that a fasciectomy performed under local anaesthetic with adrenaline and without an arm tourniquet and in a community setting is safe, and results in favourable outcomes regarding the degree of correction of contracture achieved, functional scores, and short-term complications. Local anaesthetic fasciectomy in a community setting achieves a saving of £961.80 for a GA and £900.48 for an axillary block per case. Cite this article: Bone Joint J 2020;102-B(10):1354-1358.

Dupuytren's disease: A reality in Black Africa

Long regarded as a disease exclusively found amongst Northern Europeans, Dupuytren's disease was seldom studied amongst Black Africans. Thus, we sought to study the impact of Dupuytren's disease, its etiological, clinical and evolutionary peculiarities on a segment of the Senegalese population. This study analyzed data derived from clinical observations carried out between January 2006 and December 2018. It involved Senegalese subjects with Dupuytren's disease, the patients’ history, profession, habitus, clinical findings, therapeutic modalities and disease staging. The population included 20 men and 6 women averaging 63.5 years of age (range 45–77). None of the patients reported a family of Dupuytren's disease. Twelve patients had diabetes, 11 were smokers and 22 were engaged exclusively in manual labor. The condition was bilateral in 14 cases. Tubiana stages N, I, II, III and IV were found in 31, 15, 9, 5 and 6 rays, respectively. Conservative treatment was done in 11 patients. Surgical treatment was carried out in the other 15 patients: needle fasciotomy (N=10) including two bilateral involvement and open fasciectomy (N=7). Functional outcomes were satisfactory. Lesions were all stable in the short and medium term. Two patients had progressive lesions on a longer-term basis. Dupuytren's disease is real among Afro-descendants from Senegal even though it is seldom studied. Based on the patients’ recollection of Dupuytren's disease in their families, heredity is not yet a proven factor. The early forms are more common, and the lesions remain stable for a long time.

Outcomes and Direct Costs of Needle Aponeurotomy, Collagenase Injection, and Fasciectomy in the Treatment of Dupuytren Contracture

The aims of our study were to evaluate the rates and predictors of reinterventions and direct costs of 3 common treatments of Dupuytren contractures-needle aponeurotomy, collagenase injection, and surgical fasciectomy. A retrospective review identified 848 interventions for Dupuytren contracture in 350 patients treated by a single surgeon from 2005 to 2016. The treatments included needle aponeurotomy (NA) (n= 444), collagenase injection (n= 272), and open fasciectomy (n= 132). We collected information on demographics, contracture details, and comorbidities. Outcomes included reintervention rates, time to reintervention, and direct cost of treatments. Standardized costs were calculated by applying 2017 Medicare reimbursement to professional services and cost-to-charge ratios to hospital charges. Demographics were similar among the 3 treatment groups. The fifth finger was the most commonly affected digit including 43% of the NA, 60% of the collagenase, and 45% of the fasciectomy groups. The 2-year rates of reintervention following NA, collagenase, and fasciectomy were 24%, 41%, and 4%, respectively, and the 5-year rates were 61%, 55%, and 4%, respectively. Younger age and severity of preintervention proximal interphalangeal (PIP) joint contracture were predictive of reintervention in the NA and collagenase groups. The standardized direct costs for NA, collagenase, and fasciectomy were $624, $4,189, and $5,291, respectively. Including all reinterventions, the cumulative costs per digit following NA, collagenase, and surgery at 5 years were $1,540, $5,952, and $5,507, respectively. Treatment with collagenase resulted in the highest rate of reintervention at 2 years, comparable reintervention rates to NA at 5 years, and the highest cumulative costs. The NA was the least expensive and resulted in longer duration before reintervention compared with collagenase. More severe PIP joint contractures and younger age at time of initial intervention were predictive of reintervention after collagenase and NA. Fasciectomy has a high initial cost but the lowest reintervention rate. Therapeutic IV.

Efficacy of Injectable Collagenase in the Treatment of Dupuytren's Contracture in Comparison to Partial Fasciectomy

Background: Dupuytren's disease as a benign fibroproliferativedisease with an abnormal slowly progressive thickeningand shorting of the palmar aponeurosis leads to severe functionallimitations in the finger movements particularly of theMetacarpophalangeal (MCP) joints and/or the Proximal Interphalangeal(PIP) joints. The authors aimed to evaluate therole of injectable collagenase (CCH) in the treatment ofDupuytren's contracture in comparison to surgical treatment.Material and Methods: This study included 15 patients(33 rays), they were divided into two groups, Group A: 26rays underwent open fasciectomy. (10 patients) and Group B:7 rays were treated by collagenase injection. (5 patients).Exclusion criteria for group B were contraindications ofinjection of CCH. The primary efficacy variable was clinicalsuccess, contracture correction to within 5o of normal (normal=0o) by using goniometry. Additional efficacy variablesincluded the time and number of injections required to achievesuccess in the primary joint. Recurrence rate and adverseeffects were recorded.Results: Initial clinical experience was recorded of 5patients (7 rays) (mean age 57 years) and compared to previouslysurgically managed 10 patients (26 rays) (mean age 59years). Of all population, 51% for little, 47% for ring, 1% formiddle and 1% for index fingers. The mean of the preinterventionfixed flexion contracture in the MCP joint was39o and improved to one-year postintervention 14o, and in thePIP joint 47o to 19o. In group B one ray with no improvementat all and recurrence in one ray. Partial stretching was achievedin one ray. No serious complications were observed afterinjections. In cases of group A (26 rays) that was treated bypartial fasciectomy, recurrence occurred in 6 rays and nerveinjuries as nerve division and neuropraxia occurred in 2 rays.Conclusion: The treatment of Dupuytren's disease withinjectable collagenase is safe and effective. However, thefinancial aspects should be considered especially in developing

Use of Acellular Dermal Matrix Following Fasciectomy for the Treatment of Dupuytren's Disease.

Background:Recurrence rates following surgical intervention for Dupuytren's disease (DD) remains high. In this study, we investigate the use of acellular dermal matrix (ADM) to reduce recurrence and improve long-term clinical outcome.Methods:We examined 132 patients undergoing open fasciectomy for DD from 2007 to 2017. The experimental group had a sheet of ADM (FlexHD) sutured into the surgical bed controls were not closed with ADM. Patient characteristics, range of motion, and complications were examined.Results:Twenty-eight (21.2%) patients were treated with acellular dermal matrix, whereas 104 (78.8%) patients were not. The median age was 67.0 years (range 34–91 years). with no differences between group regarding age, comorbidities, and laterality. The mean preoperative interphalangeal joint flexion contracture in the ADM group of 66.5 ± 29.9 degrees was corrected to 9.7 ± 12.4 degrees, whereas the mean metacarpophalangeal joint preoperative flexion contracture of 51.4 ± 23.9 degrees was corrected to 7.8 ± 14.1 degrees at postoperative examination (P < 0.05). The median follow-up was 18.7 months, during which the recurrence of contracture was observed in 1 of 28 patients in the group receiving ADM compared with 9 of 104 in the control group (P = 0.37). There were no differences in the incidence of minor wound complications observed.Conclusion:The adjunct placement of acellular dermal matrix into the wound bed following fasciectomy for DD may be an important surgical strategy to reduce recurrence rates as well as augment coverage of exposed vital structures in cases of severe flexion contracture.

Treatment of Dupuytren's contracture: a systematic review.

Dupuytren's contracture is a benign, myoproliferative condition affecting the palmar fascia that results in progressive contractures of the fingers. Despite increased knowledge of the cellular and connective tissue changes involved, neither a cure nor an optimum form of treatment exists. The aim of this systematic review was to summarize the best available evidence on the management of this condition. A comprehensive database search for randomized controlled trials (RCTs) was performed until August 2017. We studied RCTs comparing open fasciectomy with percutaneous needle aponeurotomy (PNA), collagenase clostridium histolyticum (CCH) with placebo, and CCH with PNA, in addition to adjuvant treatments aiming to improve the outcome of open fasciectomy. A total of 20 studies, involving 1584 patients, were included. PNA tended to provide higher patient satisfaction with fewer adverse events, but had a higher rate of recurrence compared with limited fasciectomy. Although efficacious, treatment with CCH had notable recurrence rates and a high rate of transient adverse events. Recent comparative studies have shown no difference in clinical outcome between patients treated with PNA and those treated with CCH. Currently there remains limited evidence to guide the management of patients with Dupuytren's contracture. Cite this article: Bone Joint J 2018;100-B:1138-45.

Surgeon Volume and the Outcomes of Dupuytren's Surgery: Results from a Dutch Multicenter Study.

For many major surgical procedures, the outcomes are better when performed by surgeons with higher procedure volumes. The purpose of this study was to examine the relations between surgeon procedure volume and the outcomes of Dupuytren's surgery. The authors conducted an observational study from 2011 to 2014 at six dedicated hand surgery practice sites in The Netherlands. Five hundred eighty-eight patients underwent surgery for Dupuytren's contracture performed by one of the 16 surgeons. The main exposure variable was annual surgeon volume. Outcome measures were the degree of residual contracture, full release rate, and any postoperative adverse event examined within 3 months of surgery. Mean annual surgeon volume was 51 among the 16 surgeons(range; 4-86) procedures. The majority of patients had primary disease (79 percent) and underwent open fasciectomy (74 percent). Multivariable regression analyses showed that surgeon volume was linearly related to all three outcomes, and identified no optimal volume threshold. Performing 10 additional procedures annually was independently associated with nearly 0.8 degree less residual contracture (p = 0.002), 9 percent higher odds of attaining a full release (p = 0.037), and 11 percent lower odds of an adverse event (p < 0.001). Nonetheless, patient-related factors had larger impacts on all three clinical outcomes than surgeon volume. In this study of practicing hand surgeons, surgeon volume varied widely, and a higher volume was associated with less postoperative residual contracture, higher full release rates, and fewer adverse events. This implies that increasing surgeon's procedure volume provides an opportunity for improving the outcomes of Dupuytren's surgery. Therapeutic, III.

A case of Dupuytren’s disease managed with viable cryopreserved placental membrane adjunct to open palmar fasciectomy

Dupuytren’s disease (DD) is a rare connective tissue disorder resulting in progressive fibrosis and thickening of the palmar fascia, and contracture of the fingers due to excessive collagen deposition. Staged surgical interventions are reserved for severe cases, yet worsening of fibrosis and contracture of fingers post-surgery, has been reported to have a recurrence rate as high as 85%. Here, the authors report on use of viable cryopreserved placental membrane (vCPM) allograft as an adjunct to open fasciectomy. In a patient with debilitating bilateral DD contractures of >20 years duration, this novel approach resulted in a 34.8% range of motion (ROM) improvement and ability to fully extend all digits of the right hand. No adverse events were recorded. At 1 year post-surgery, the patient has no decrease in ROM. Results indicate that vCPM incorporation in open fasciectomy may provide benefit in reducing contracture recurrence in DD patients.

Collagenase clostridium histolyticum in Dupuytren's contracture: a systematic review.

In the last few years, the use of collagenase clostridium histolyticum for management of Dupuytren's contracture has increased. The procedure of enzymatic fasciectomy has become popular because it is non-invasive, safe and fast to perform. A systematic search was performed on Medline (PubMed), Web of Science and Scopus databases using the combined keywords 'Dupuytren collagenase' and 'Dupuytren clostridium histolyticum'. Forty-three studies were identified. The quality of the studies was assessed using the Coleman Methodological Score. The use of collagenase clostridium histolyticum provides better outcomes in patients with mild-moderate joint contracture, with lower complications and side effects than open fasciectomy. Manipulation can be performed 2-7 days after the injection. The use of collagenase is cost-effective. Most of the studies did not report patient-related outcomes. The role of dynamic splint has to be investigated with randomized clinical trials. The shorter recovery time and the low incidence of serious or major adverse effects are the main advantages of this new technology. There is a need to perform studies with longer follow-up because the recurrence rate seems to increase with time. Further investigations are necessary to assess whether it is safe and effective to inject two or more cords at the same time.