Worldwide Results of Injection Therapy for Dupuytren Contracture
Dupuytren's contracture is a fairly common disorder of the fingers. It most often affects the ring or little finger, sometimes both, and often in both hands. It occurs most often in middle-aged, white men. This condition is seven times more common in men than women. Although more common in men of Scottish, Scandinavian, Irish, or Eastern European ancestry researchers agree that genes are not a direct cause of this disease, but predisposes them to this condition.

The condition commonly first shows up as a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger. More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened. Dupuytren's contracture usually affects only the ring and little finger. The contracture spreads to the joints of the finger, which can become permanently immobilized.

The areas affected most often are the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. The MCP joints are what we usually refer to as the knuckles. The PIP joints are the middle joints between the knuckles (MCPs) and the joints at the tips of the fingers (distal interphalangeal joints). As the disease spreads from the palm down to the fingers, the proximal interphalangeal (PIP) joints start to be affected as well.

Surgery to release the cords has long been the standard treatment for this condition. But more recent research has resulted in a less invasive method of treatment called an enzymatic fasciotomy. This approach can be used if only one or two cords are involved. This type of injection therapy may eventually replace surgery.

Researchers in the United States, Australia, and Europe have joined together to study the effectiveness and safety of injection therapy with a product known as collagenase clostridium histolyticum (CCH or Xiaflex). By injecting an enzyme directly into the cords formed by the disease, the tissue dissolves and starts to weaken.

Most often the patient or the surgeon is able to break apart the cord the next day if spontaneous disruption does not occur. Just actively moving the fingers and using the hand are often enough to accomplish this. Almost 600 patients (total of 879 joints) were evaluated using this type of treatment. Finger motion was used as the primary measure of improvement. Patient satisfaction was a secondary measure of success.

As with other studies already published, Xiaflex was shown to be very successful with 92 per cent of the group either quite satisfied or very satisfied with the results. Although the researchers were prepared to inject up to three injections per site, only 11 per cent needed three injections.

Three-fourths of the group responded well with the first injection and maintained those results for the nine month period of follow-up of this study. Contractures affecting motion of the metacarpal phalangeal (MCP) joints seem to respond better than cords that cross the proximal interphalangeal (PIP) joints.

There were a few adverse reactions that pointed to the need to study the safety of this treatment more carefully. A few patients had a local skin reaction (rash and swelling) at the site of the injection. Two patients developed serious blood clots. But no one had any tendon ruptures and only four per cent of the group had a recurrence of the problem.

This study expands the data base (number of patients) with Dupuytren contracture successfully treated with Xiaflex. Two factors that point to the likelihood of success include treatment early on (first predictive factor) for less severe contractures (second predictive factor).

In summary, xiaflex injections for Dupuytren contractures are less expensive and less invasive than surgery. It is considered safe and effective, especially if the contracture is not severe and is treated early. Complications can occur (most often in severe contractures) and patients should be aware of these potential problems before treatment. Most adverse events after treatment are mild and go away in 10 to 14 days. Patients probably won't need hand therapy after the injection treatment but may need to wear a splint at night for a few months.
Jörg Witthaut, MD, et al. Efficacy and Safety of Collagenase Clostridium Histolyticum Injection for Dupuytren Contracture: Short-Term Results from 2 Open-Label Studies. In The Journal of Hand Surgery. January 2013. Vol. 38A. No. 1. Pp. 2-11.