Reduction Of Contracture Research Articles

Comparative Cost Effectiveness of Clostridium Histolyticum Collagenase (Xiapex®) and Partial Fasciectomy for the Treatment of Dupuytren's Contracture in Austria

Since Dupuytren's contracture is a common disorder, the costs for its surgical treatment impose a considerable burden on the healthcare system. For the first time in the German-speaking area, this study aimed to provide a comparative cost-effectiveness analysis for partial fasciectomy vs. treatment with Clostridium histolyticum collagenase (CCH). A retrospective monocentric study of the period from 2012 to 2014 comprised 40 patients with previously untreated Dupuytren's contracture of one finger. 20 outpatients received one CCH treatment (Group 1), while 20 inpatients underwent partial fasciectomy (Group 2). The direct pre-interventional treatment and post-interventional costs were compared. The direct post-interventional and postoperative results were comparable. Group 1 (CCH) showed a mean reduction in contracture of 96.4%; in Group 2 (partial fasciectomy), this was 97.7%. There were fewer complications in Group 1 than in Group 2. Mean treatment costs in Group 1 were € 1 458.60 and in Group 2, € 5 315.20. Treatment with CCH is more cost effective than with partial fasciectomy. This is due to greater costs for personnel, time and surgical material, as well as the treatment of the more frequent complications in Group 2. Despite the limited comparability, our findings are consistent with the present international literature.

Collagenase Dupuytren Contracture: Achieving Single Treatment Success with a Hand Therapist-Based Protocol.

Background:Surgery remains the gold standard in the treatment of Dupuytren contracture but is technically demanding, carries significant risk of complications, and requires prolonged recovery time. Collagenase injection is an efficacious alternative to surgery; however, contracture release often requires multiple treatments spaced a month apart. We report our experience with a new collagenase treatment protocol aimed to minimize the total treatment time per joint contracture.Methods:We performed a single institution retrospective review of patients with Dupuytren contracture treated with collagenase using our protocol from 2011 to 2013. Patients returned 24 hours after collagenase injection for cord manipulation by a certified hand therapist while under digital block. Treatment success was defined as reduction in contracture to 5 degrees or less. Successfully treated joints were evaluated for recurrence (>10 degrees contracture) at 30-day and 6-month follow-up appointments. Serious adverse events, including skin tears, were recorded.Results:Success was achieved in 36 of 47 treated joints (76.6%) after a single injection. There were 2 recurrences in 32 joints at 30-day follow-up (6.2%) and no recurrences in 17 joints available at 6-month follow-up. Skin tears were the only serious adverse event occurring in 18 of 47 cord ruptures (38.3%). All healed secondarily without complication.Conclusions:Our protocol preserves treatment efficacy while maximizing efficiency. Achieving successful cord rupture with a single injection allows earlier return of function, reduced cost of treatment, and increased convenience for the patient. Patients, particularly those with greater contractures, should be counseled regarding the risk of skin tear during cord manipulation.

Collagenase clostridium histolyticum for the treatment of Dupuytren's contracture: systematic review and economic evaluation.

Dupuytren's disease is a slowly progressive condition of the hand, characterised by the formation of nodules in the palm that gradually develop into fibrotic cords. Contracture of the cords produces deformities of the fingers. Surgery is recommended for moderate and severe contractures, but complications and/or recurrences are frequent. Collagenase clostridium histolyticum (CCH) has been developed as a minimally invasive alternative to surgery for some patients. To assess the clinical effectiveness and cost-effectiveness of collagenase as an alternative to surgery for adults with Dupuytren's contracture with a palpable cord. We searched all major electronic databases from 1990 to February 2014. Randomised controlled trials (RCTs), non-randomised comparative studies and observational studies involving collagenase and/or surgical interventions were considered. Two reviewers independently extracted data and assessed risk of bias of included studies. A de novo Markov model was developed to assess cost-effectiveness of collagenase, percutaneous needle fasciotomy (PNF) and limited fasciectomy (LF). Results were reported as incremental cost per quality-adjusted life-year (QALY) gained. Deterministic and probabilistic sensitivity analyses were undertaken to investigate model and parameter uncertainty. Five RCTs comparing collagenase with placebo (493 participants), three RCTs comparing surgical techniques (334 participants), two non-randomised studies comparing collagenase and surgery (105 participants), five non-randomised comparative studies assessing various surgical procedures (3571 participants) and 15 collagenase case series (3154 participants) were included. Meta-analyses of RCTs assessing CCH versus placebo were performed. Joints randomised to collagenase were more likely to achieve clinical success. Collagenase-treated participants experienced significant reduction in contracture and an increased range of motion compared with placebo-treated participants. Participants treated with collagenase also experienced significantly more adverse events, most of which were mild or moderate. Four serious adverse events were observed in the collagenase group: two tendon ruptures, one pulley rupture and one complex regional pain syndrome. Two tendon ruptures were also reported in two collagenase case series. Non-randomised studies comparing collagenase with surgery produced variable results and were at high risk of bias. Serious adverse events across surgery studies were low. Recurrence rates ranged from 0% (at 90 days) to 100% (at 8 years) for collagenase and from 0% (at 2.7 years for fasciectomy) to 85% (at 5 years for PNF) for surgery. The results of the de novo economic analysis show that PNF was the cheapest treatment option, whereas LF generated the greatest QALY gains. Collagenase was more costly and generated fewer QALYs compared with LF. LF was £1199 more costly and generated an additional 0.11 QALYs in comparison with PNF. The incremental cost-effectiveness ratio was £10,871 per QALY gained. Two subgroup analyses were conducted for a population of patients with moderate and severe disease and up to two joints affected. In both subgroup analyses, collagenase remained dominated. The main limitation of the review was the lack of head-to-head RCTs comparing collagenase with surgery and the limited evidence base for estimating the effects of specific surgical procedures (fasciectomy and PNF). Substantial differences across studies further limited the comparability of available evidence. The economic model was derived from a naive indirect comparison and was hindered by a lack of suitable data. In addition, there was considerable uncertainty about the appropriateness of many assumptions and parameters used in the model. Collagenase was significantly better than placebo. There was no evidence that collagenase was clinically better or worse than surgical treatments. LF was the most cost-effective choice to treat moderate to severe contractures, whereas collagenase was not. However, the results of the cost-utility analysis are based on a naive indirect comparison of clinical effectiveness, and a RCT is required to confirm or refute these findings. This study is registered as PROSPERO CRD42013006248. The National Institute for Health Research Health Technology Assessment programme.

Efficacy and Safety of Collagenase Clostridium Histolyticum in the Treatment of Proximal Interphalangeal Joints in Dupuytren Contracture: Combined Analysis of 4 Phase 3 Clinical Trials

To examine the results of proximal interphalangeal (PIP) joint contractures from 4 phase 3 clinical trials of collagenase clostridium histolyticum (CCH) injection for Dupuytren contracture. Patients enrolled in Collagenase Option for Reduction of Dupuytren I/II and JOINT I/II with one or more PIP joint contractures (20° to 80°) received CCH 0.58 mg/0.20 mL or placebo (Collagenase Option for Reduction of Dupuytren I/II only) injected directly into a palpable cord. The percentage of PIP joints achieving clinical success (0° to 5° of full extension), clinical improvement (50% or more reduction in baseline contracture), and range of motion improvement at 30 days after the first and last CCH injections was assessed. The PIP joint contractures were classified into low (40° or less) and high (more than 40°) baseline severity. Adverse events were recorded. A total of 506 adults (mean age, 63 ± 10 y; 80% male) received 1,165 CCH injections in 644 PIP joint cords (mean, 1.6 injections/cord). Most patients (60%) received 1 injection, with 24%, 16%, and 1% receiving 2, 3, and 4 injections, respectively. Clinical success and clinical improvement occurred in 27% and 49% of PIP joints after one injection and in 34% and 58% after the last injection. Patients with lower baseline severity showed greater improvement and response was comparable between fingers, as were improvements in range of motion. Adverse events occurring in more than 10% of patients were peripheral edema (58%), contusion (38%), injection site hemorrhage (23%), injection site pain (21%), injection site swelling (16%), and tenderness (13%). This incidence was consistent with data reported in phase 3 trials. Two tendon ruptures occurred. No further ruptures occurred after a modified injection technique was adopted. Collagenase clostridium histolyticum was effective and well tolerated in the short term in patients with Dupuytren PIP joint contractures. Therapeutic II.

Collagenase treatment of Dupuytren’s contracture using a modified injection method

Background and purpose — Treatment of Dupuytren’s contracture (DC) with collagenase Clostridium histolyticum (CCH) consists of injection followed by finger manipulation. We used a modified method, injecting a higher dose than recommended on the label into several parts of the cord, which allows treatment of multiple joint contractures in 1 session and may increase efficacy. We studied the occurrence of skin tears and short-term outcome with this procedure.Patients and methods — We studied 164 consecutive hands with DC, palpable cord, and extension deficit of ≥ 20º in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint (mean patient age 70 years, 82% men). A hand surgeon injected all the content of 1 CCH vial (approximately 0.80 mg) into multiple spots in the cord and performed finger extension under local anesthesia after 1 or 2 days. A nurse recorded skin tears on a diagram and conducted a standard telephone follow-up within 4 weeks. A hand therapist measured joint contracture before injection and at a median of 23 (IQR: 7–34) days after finger extension.Results — A skin tear occurred in 66 hands (40%). The largest diameter of the tear was ≤ 5 mm in 30 hands and > 10 mm in 14 hands. Hands with skin tear had greater mean pretreatment MCP extension deficit than those without tear: 59º (SD 26) as opposed to 32º (SD 23). Skin tear occurred in 21 of 24 hands with MCP contracture of ≥ 75º. All tears healed with open-wound treatment. No infections occurred. Mean improvement in total (MCP + PIP) extension deficit was 55º (SD 28).Interpretation — Skin tears occurred in 40% of hands treated with collagenase injections, but only a fifth of them were larger than 1 cm. Tears were more likely in hands with severe MCP joint contracture. All tears healed without complications. Short-term contracture reduction was good.

The Results of Fetal Chondrocytes Transplantation in Patients with Rheumatoid Arthritis.

IntroductionNowadays anti-inflammatory and immunosuppressive therapy has significantly improved the quality of life and prognosis of rheumatoid arthritis (RA). Nevertheless, there are still many patients with progressive rheumatoid inflammation, resulting in the destruction of joints. Cell therapy seems like a promising direction in rheumatology. The aim of our research was to evaluate the efficacy of fetal chondrocyte transplantation in patients with RA.MethodsWe examined 60 patients with rheumatoid arthritis (I – III stages) between 20 and 63 years of age. They were divided into 2 groups: the first group underwent the fetal chondrocytes transplantation (n = 40), and the second was a control group who got conservative therapy (n = 20). Donor cells were taken from the chondrogenic layer of the humerus or femur heads and hip condyles of human embryos in gestation for 17–20 weeks. A suspension of fetal chondrocytes injected into affected areas of the articular surfaces under X-ray control. Cell viability was determined before the injection. Efficacy of the therapy was assessed by clinical, instrumental, and laboratory tests. This clinical trial was allowed by The Ministry of Public Health and Ethics Committee. All of our patients gave informed consent for the fetal chondrocytes transplantation.ResultsEvaluation of the clinical manifestations of RA in the first group of patients showed 3.7 times decrease in pain and 1.6 times relief of synovitis. Complete reduction of contracture was observed in 82% of patients in the first group. Morphometric changes in X-ray demonstrated inhibition of the destruction in articular cartilage and surfaces of bones after transplantation of fetal chondrocytes. The dynamics of morphological changes in synovium showed 2.5 times reduction of the inflammatory reaction. Transplantation of fetal chondrocytes led to a significant reduction in ESR, CRP, fibrinogen, γ-globulin after a period of 12 months (p < 0.03). Furthermore, patients in the second group had 2.7 times higher risk of ankylosis compared to the first group. We did not observe any complications of fetal chondrocytes transplantation.ConclusionsApplication of fetal chondrocytes therapy had the desired clinical effect, which was confirmed by reduction of the RA activity and decrease of cartilage and bone destruction.

Delayed manipulation after collagenase clostridium histolyticum injection for Dupuytren contracture.

Collagenase clostridium histolyticum (CCH) injection for Dupuytren contracture was approved in the USA in 2010. Current FDA guidelines stipulate that finger manipulation occurs the day following injection. To investigate the safety and efficacy of delaying manipulation to 2 or 4days following CCH injection, we conducted a prospective, randomized trial at two sites. Patients with Dupuytren contracture involving the metacarpophalangeal (MCP) joint ≥20° caused by a palpable cord participated. All patients received one dose of CCH (0.58mg/0.25ml) and were followed for 90days. The primary end point was the percent of patients maintaining clinical success (reduction of contracture to 0°-5°) at 90days post-injection. Adverse events and change in Michigan Hand Questionnaire (MHQ) score were recorded as secondary end points. Thirty-seven patients enrolled; 13 were manipulated on day 1, 11 on day 2, and 13 on day 4. At 30days after injection, the percentage of patients obtaining reduction of contracture to <0°-5° extension was 92, 82, and 85% in groups 1, 2, and 3, respectively, with no significant difference. At 90days follow-up, the percentage of patients maintaining 0°-5° extension was 91, 82, and 83% in groups 1, 2, and 3, respectively, with no significant difference. Adverse events were comparable to rates in prior studies. There were no serious adverse events. There was no statistical difference in MHQ scores between groups at any time point. Delaying manipulation to day 2 or 4 following CCH injection for MCP joint contractures does not increase adverse events or result in loss of efficacy. Therapeutic, Level II.

Analysis of Efficacy and Safety of Treatment With Collagenase Clostridium histolyticum Among Subgroups of Patients With Dupuytren Contracture

Collagenase Clostridium histolyticum (CCH) injection is a nonoperative treatment of hand contractures from Dupuytren disease. This study assessed the efficacy and safety of CCH in several subgroups of patients with increased surgical risk.Data were pooled from 3 randomized, placebo-controlled, double-blind trials. This analysis included 271 patients with metacarpophalangeal (n = 167) or proximal interphalangeal (n = 104) joint contractures greater than or equal to 20 degrees treated with CCH (0.58 mg collagenase per injection). Subgroups included age, sex, and diabetes status. End points included rate of clinical success (reduction in contracture to 0-5 degrees of normal) and percentage of adverse events.There was no significant difference in clinical success by age, diabetes status, or sex with 63% reaching the end point. There was no difference in adverse events among the subgroups, with peripheral edema, contusion, and injection-site hemorrhage being most common.High-risk subgroups do not demonstrate differences in efficacy or safety with CCH treatment of Dupuytren-related contractures.

Costs for collagenase injections compared with fasciectomy in the treatment of Dupuytren's contracture: a retrospective cohort study

ObjectivesTo compare collagenase injections and surgery (fasciectomy) for Dupuytren's contracture (DC) regarding actual total direct treatment costs and short-term outcomes.DesignRetrospective cohort study.SettingOrthopaedic department of a regional hospital in Sweden.ParticipantsPatients aged...

Pulsed Acoustic Cellular Expression (PACE) Reduces Capsule Formation Around Silicone Implants

Capsular contracture remains a major complication after reconstructive or aesthetic breast augmentation. Formation of capsular fibrosis is a multifactorial process. An initial inflammatory reaction appears to be key to the development of capsular contracture. Recent studies have shown that pulsed acoustic cellular expression (PACE) has significant antiinflammatory effects. Thus, this study aimed to determine the potential of PACE to prevent or attenuate capsular contracture around silicone implants in a rodent model. For this study, 36 Lewis rats were divided into two groups, and a textured silicone implant was placed in a dorsal submuscular pocket. One group received PACE treatment, whereas the other group served as the control group and received no treatment. Follow-up evaluations were performed after 10, 35, and 100days. Capsule thickness, collagen density, myofibroblasts, vascular density, and a semiquantitative real-time polymerase chain reaction that addressed differential gene expression were assessed. The PACE treatment significantly reduced capsule thickness on days 10, 35, and 100 compared with the control group (day 10: 632.9±164.5 vs 932.6±160.8, p<0.05; day 35: 709.5±175 vs 825.9±313.3, p<0.0.5; day 100: 736.3±198.1 vs 1,062.3±151.9, p<0.05). This was accompanied by a significant suppression of proinflammatory genes (cluster of differentiation 68, monocyte chemotactic protein-1, CCL4) and synergistic alterations of pro- and antifibrotic proteins (transforming growth factor-beta 1, matrix metalloproteinase-2). This study showed that the PACE application significantly reduces capsular contracture around silicone implants. A decrease in capsular thickness after PACE treatment seems to be associated with a downregulation of proinflammatory genes and proteins. The study identifies PACE technology as a potential low-cost technique that is easy to use for reduction of capsular contracture after augmentation using silicone implants. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Efficacy and safety of collagenase Clostridium histolyticum injection for Dupuytren contracture: report of 40 cases

Dupuytren's disease (DD) is a fibroproliferative pathology that affects the palmar aponeurosis causing the development of nodules and collagen cords and the progressive flexion of the fingers. The standard procedure is surgical fasciectomy, followed by high recurrence rates. Collagenase Clostridium histolyticum (CCH) injection represents an innovative noninvasive approach to the treatment of DD. This prospective study was designed to examine the efficacy and safety of CCH injection performed in the outpatient, using local anesthesia. Forty patients [32 metacarpophalangeal (MP), 8 proximal interphalangeal (PIP)] with Dupuytren's contracture of at least 20° for MP joint and any degree for PIP joint were included. The mean age was 66. All joints were treated with a single vial of collagenase injection and manual breaking of the cord 24 h after. All adverse effects (AEs) were monitored. Patients were checked 7, 30, 90, and 180 days after the injection. Primary endpoint was a reduction in digit contracture within 0°-5° of normal extension. Secondary endpoints were the improvement of range of motion, the evaluation of AEs incidence, and cost-effectiveness of collagenase treatment. About 67.5 % of patients obtained a clinical success. At 6 months, a further 7.5% attained the same result. The mean contracture of treated joints was 5.3º for MP and 6.8° for PIP joints. Twenty-three patients had one or more mild-to-moderate side effects. The use of collagenase appears to be an effective and safe method for the treatment of Dupuytren's contracture. Therapeutic success was achieved in a significant percentage of patients. The incidence of side effects was higher, but they were local reactions of short duration. The use of a single collagenase vial in patients treated in day surgery appears more cost-effective than surgery.

Morbus Dupuytren - Patientenzufriedenheit und funktionelle Ergebnisse ein Jahr nach partieller Aponeurektomie und Injektion von Kollagenase

The gold standard in the treatment of Dupuytren's disease is the partial fasciectomy (PF). Injection of a collagenase directly into the Dupuytren cord is an alternative method. In contrast to needle fasciotomy, destruction of the cord is achieved enzymatically and not mechanically. 24 h after injection, the treated finger can be extended passively to disrupt the Dupuytren cord. Functional outcome and patient satisfaction were prospectively analysed in 2 comparable groups of patients with the same stage of disease. Follow-up was one year. Patients in the first group underwent partial fasciectomy (PF) (n=13), whereas patients in the second group were treated by an injection of collagenase (CG) in the diseased tissue (n=14). Besides clinical examination, outcome was evaluated by validated questionnaires (DASH/MHQ) and a customised questionnaire. Extension after PF (mean residual contracture 7.5°) was better than after collagenase injection (mean residual contracture 13.2°). Side-effects like numbness, impaired blood circulation and pain were less after injection of collagenase than after PF and of shorter duration. Recovery of grip strength was faster in the CG than after PF and collagenase injection was regarded as less discomforting. The results of the questionnaires showed a reduction of hand function 1 month after surgery, whereas better results were observed 1 month after collagenase injection. Recovery in the CG was significantly faster than after PF. Collagenase injection, as a less invasive technique, has less and milder side-effects than surgery and demonstrated a better total reduction of Dupuytren's contracture initially, although the residual contractures were higher in the CG after follow-up of 1 year. Patient satisfaction was higher after collagenase injection due to subjectively perceived less negative impact and a comparable functional outcome.

A Comparison of Percutaneous Needle Fasciotomy and Collagenase Injection for Dupuytren Disease

To compare percutaneous needle fasciotomy (PNF) with collagenase injection in the treatment of Dupuytren contracture. A retrospective review was performed for patients with Dupuytren disease treated with PNF or collagenase. Range of motion, patient satisfaction, and complications were recorded. There were 29 patients in the collagenase group with mean baseline contractures of 40° for 22 affected metacarpophalangeal joints and 50° for 12 affected proximal interphalangeal joints. The PNF group was composed of 30 patients with mean baseline contractures of 37° for 32 affected metacarpophalangeal joints and 41° for 18 affected proximal interphalangeal joints. All patients were observed for a minimum of 3 months. Clinical success (reduction of contracture within 0° to 5° of normal) was accomplished in 35 of 50 joints (67%) in the PNF group and in 19 of 34 joints (56%) in the collagenase group. Patient satisfaction was similar between groups. Only minor complications were observed, including skin tears, ecchymosis, edema, pruritus, and lymphadenopathy. In the short term, both PNF and collagenase have similar clinical outcomes and patient satisfaction. Therapeutic III.

Systematic Review of Contracture Reduction in the Lower Extremity with Dynamic Splinting

IntroductionJoint contractures are relatively common disorders that can result in significant, long-term morbidity. Initial treatment is non-operative and often entails the use of mechanical modalities such as dynamic and static splints. Although widely utilized, there is a paucity of data that support the use of such measures. The purpose of this systematic review was to evaluate the safety and efficacy of dynamic splinting as it is used to treat joint contracture in lower extremities, and to determine if duration on total hours of stretching had an effect on outcomes.MethodsReviews of PubMed, Science Direct, Medline, AMED, and EMBASE websites were conducted to identify the term ‘contracture reduction’ in manuscripts published from January 2002 to January 2012. Publications selected for inclusion were controlled trials, cohort studies, or case series studies employing prolonged, passive stretching for lower extremity contracture reduction. A total of 354 abstracts were screened and eight studies (487 subjects) met the inclusion criteria. The primary outcome measure was change in active range of motion (AROM).ResultsThe mean aggregate change in AROM was 23.5º in the eight studies examined. Dynamic splinting with prolonged, passive stretching as home therapy treatment showed a significant direct, linear correlation between the total number of hours in stretching and restored AROM. No adverse events were reported.DiscussionDynamic splinting is a safe and efficacious treatment for lower extremity joint contractures. Joint specific stretching protocols accomplished greater durations of end-range stretching which may be considered to be responsible for connective tissue elongation.

SAT0425 Multiple, concurrent injections of collagenase clostridium histolyticum injections into dupuytren’s cords in the same hand

BackgroundDupuytren’s disease is a progressive, fibroproliferative disorder resulting in nodules and collagenous cords within the palmar fascia of the hand. Until recently, surgery was the only treatment option for patients...

SAT0424 Use of collagenase clostridium histolyticum in early- versus advanced-stage dupuytren’s disease results in better outcomes

BackgroundDupuytren’s disease is a progressive condition, as the contracture angle and related disease stage often increase with time. Treatment with ≥1 injection of collagenase Clostridium histolyticum (CCH) has been shown...

Efficacy and tolerability of Day 2 manipulation and local anaesthesia after collagenase injection in patients with Dupuytren’s contracture

In clinical trials, treating Dupuytren's contracture with collagenase injection involves manipulation the day after injection, without local anaesthesia. We evaluated the efficacy and tolerability of manipulation 2 days after injection with local anaesthesia. Forty-five patients received 50 injections into cords contracting metacarpophalangeal and proximal interphalangeal joints; follow-up visits were at 3 and 14 weeks. For the metacarpophalangeal joints there were >90% reduction in contracture at both visits. The proximal interphalangeal joints that improved spontaneously after metacarpophalangeal injection or received direct injections showed 51-55% reduction in contracture. Changes in scores on the Patient Evaluation Measure suggest that patients perceived improvements in their hand function was good and they were satisfied with the procedure. Collagenase and local anaesthesia injections were well tolerated; adverse events were localized to the injection site and were mild and transient in nature. These findings provide another viable option for practising surgeons and may help with the logistics of patient care.

Examining the Efficacy and Maintenance of Contracture Correction after Collagenase Clostridium Histolyticum Treatment for Dupuytren's Disease

This study examined the efficacy, complications, and contracture recurrence in patients who received injectable collagenase clostridium histolyticum (CCH) for Dupuytren's-induced metacarpophalangeal (MP) and proximal interphalangeal (PIP) joint contractures. A retrospective chart review at one center compared the degree of MP and PIP joint contracture pre-injection, post-cord rupture, and at final follow-up after a minimum duration of 6months. Recurrence was defined as a 20° or greater increase in contracture above the minimum value achieved. Of 102 eligible patients, 48 patients (47%) (31 males, 17 females) were available for review. 53 digits and 64 joints (46 MP joints and 18 PIP joints) were studied. The mean patient age was 66years (range, 48-87years) and mean follow-up duration was 15months (range, 6 to 25months). The mean MP joint contracture was 51 ± 20° at baseline, 4 ± 8° post-cord rupture, and 9 ± 15° at latest follow-up. The mean PIP joint contracture was 39 ± 23° at baseline, 14 ± 14° at cord rupture, and 29 ± 20° at latest follow-up. Of the 46 MP joints and 18 PIP joints, 11 MP (24%) and 7 (39%) PIP joints met the recurrence criteria. Of 102 patients, 1 patient had a small finger flexor tendon rupture. Despite the dramatic initial reduction in contracture, recurrence developed in a high proportion of patients over the study period. While initially effective, CCH may not provide durable contracture reduction. However, CCH remains a viable nonsurgical treatment for Dupuytren's disease.

Efficacy and Safety of Collagenase Clostridium Histolyticum Injection for Dupuytren Contracture: Short-Term Results From 2 Open-Label Studies

The JOINT I (United States) and JOINT II (Australia and Europe) studies evaluated the efficacy and safety of collagenase clostridium histolyticum (CCH) injection for the treatment of Dupuytren contracture. Both studies used identical open-label protocols. Patients with fixed-flexion contractures of metacarpophalangeal (MCP) (20° to 100°) or proximal interphalangeal (PIP) joints (20° to 80°) could receive up to three 0.58-mg CCH injections per cord (up to 5 total injections per patient). We performed standardized finger extension procedures to disrupt injected cords the next day, with follow-up 1, 2, 6, and 9 months thereafter. The primary end point (clinical success) was reduction in contracture to within 0° to 5° of full extension 30 days after the last injection. Clinical improvement was defined as 50% or more reduction from baseline contracture. Dupuytren cords affecting 879 joints (531 MCP and 348 PIP) in 587 patients were administered CCH injections at 14 U.S. and 20 Australian/European sites, with similar outcomes in both studies. Clinical success was achieved in 497 (57%) of treated joints using 1.2 ± 0.5 (mean ± SD) CCH injections per cord. More MCP than PIP joints achieved clinical success (70% and 37%, respectively) or clinical improvement (89% and 58%, respectively). Less severely contracted joints responded better than those more severely contracted. Mean change in contracture was 55° for MCP joints and 25° for PIP joints. With average contracture reductions of 73% and improvements in range of motion by 30°, most patients (92%) were "very satisfied" (71%) or "quite satisfied" (21%) with treatment. Physicians rated change from baseline as "very much improved" (47%) or "much improved" (35%). The CCH injections were well tolerated, causing no tendon ruptures or systemic reactions. Collagenase clostridium histolyticum was an effective, minimally invasive option for the treatment of Dupuytren contracture of a broad range of severities. Most treated joints (625 of 879) required a single injection. Treatment earlier in the course of disease provided improved outcomes. Therapeutic IV.

Quo vadis? Brustimplantate - aktuelle Entwicklungen und neue Konzepte

Breast augmentation is one of the most frequent surgical procedures performed by plastic surgeons. Furthermore, in the majority of breast reconstructions implants are still in use. With the focus on surface modifications and biomaterials, the article provides an overview of the latest trends and concepts in increase of implant biocompatibility and reduction of capsular contracture. Because of the recent events regarding PIP® implants, a short report on this topic is presented as well. The literature was searched for experimental and clinical studies, as well as meta-analysis and reviews, using the databases PubMed, Embase and Cochrane Collaboration. Based on the title, year of publication and abstracts, thematically relevant and recent publications in English or German were selected and full text articles were studied. According to the classification, 4-5 generations of breast implants have been developed since the 1960s. Modifications affected diverse areas including various surface textures as well as coatings with polyurethane or titanium. Some of these changes were able to reduce capsular contracture, however, without resolving the issue sufficiently. Recent experimental studies mostly evaluated different surface coatings with antifibrotic and antibacterial substances. For the local drug release various carrier substances were used. Furthermore, drugs were covalently bonded to the implant surface or applied by surface impregnation. In different approaches biocompatibility could be increased by biomimicry or nanotechnologically modified biomaterials, which could additionally contribute to the reduction of capsular contracture. The development of coating technologies for the locally controlled sustained drug release using the implant surface as drug delivery system could potentially enable the local administration of drugs, which were orally delivered in clinical trials, and effectively reduced capsular contracture. This kind of application could potentially minimize the risk of adverse side effects. However, there are still some questions concerning controlled drug release systems for implant surfaces, as well as long-term results and possible side effects of drugs in a continuous local administration to be answered in further studies.