On minimally invasive treatment of Dupuytren's contacture

Abstract

Dupuytren’s disease is a common, benign disease in which myofibroblasts in the aponeurosis of the hand start to proliferate, contract and produce pathological collagen. This results in a Dupuytren cord, which eventually tethers the involved finger and reduces the extension of the involved joints- a Dupuytren contracture. The Dupuytren cord can be divided either mechanically through percutaneous needle fasciotomy (PNF) or by chemical digestion using injectable collagenase Clostridium Histolyticum (CCH). The latter treatment is considerably more expensive.

Aim The overall aim of this thesis was to compare the clinical and morphological results after percutaneous needle fasciotomy and collagenase treatment for Dupuytren’s contracture.

Methods A randomized, single-blinded controlled study was designed and enrolled 156 patients with a Dupuytren contracture of at least 20° in the metacarpophalangeal (MCP) joint in a single finger. Between 2012 and 2014, 78 patients were randomized to needle fasciotomy, and 78 to treatment with collagenase. A single surgeon administered all the treatments, and all the patients were seen after one week and blinded to further follow-up. Between November 2013 and October 2014, 39 patients were also examined by ultrasound before and after treatment in order to compare the morphological appearance of the cord rupture. The patients were assessed after six months, one year and two years by a single physiotherapist who was blinded to the treatment each patient had received. Outcome measures included measurements (joint motion, recurrence, prevalence of a Dupuytren cord) and patient reported outcome measures (URAM, Quick-DASH and VAS scales).

Study I reported the immediate results after treatment and at the one-year follow-up in 140 of the patients (71 treated by needle fasciotomy and 69 by collagenase), while Study III reported the final results at the two-year follow up for all 156 patients. The ultrasonographic evalutation before and after treatment in 39 patients was reported in Study II and these results were correlated to the clinical results in 38 of these patients after two years in Study IV.

Results The ultrasonographic evaluation of the cord showed no significant difference in the rupture length of the cord between the CCH and PNF groups (Study II). The patients treated by CCH had significantly more pain and larger skin ruptures than the patients treated by PNF, but there were no other significant differences between the two methods after one year (Study I). Ninety-seven percent of the patients were examined after two years and 58 patients (76%) treated by CCH and 60 (79%) treated by PNF still had a straight MCP joint in the treated finger. In over 50 percent of the patients, no cords were detectable after two years. There were no significant differences in the reduction of PIP contracture, range of motion and patient reported outcomes between the two treatments (Study III) Correlations between the ultrasonographic properties of the cord before treatment showed that the vast majority of patients with recurrence or residual disease had iso-or hyperechogenic cords with nodular components at treatment two years earlier (Study IV).

Conclusions To summarize, there were no significant differences between PNF and CCH in terms of treatment effect at any time during this study, except for significantly larger skin ruptures and higher levels of pain reported by patients in the CCH group immediately after treatment. Both treatments disrupt the Dupuytren cord in a similar way and most patients were satisfied and retained a straight finger after two years. CCH was not found to have any superior results that could justify the difference in cost in a government-funded health-care system.