Collagenase Injection Promising Treatment for Some Dupuytren's Disease Contractures
Dupuytren's disease is a condition where the tissue just under the skin in the palm of your hand becomes thick and shrinks, pulling very tight. In some cases, this causes lumping or uneveness of the palm of the hand and in others, it can cause a signficant contracture of the hand, making the hand look as if it is permanently holding on to something. Right now, the regularly accepted treatment for Dupuytren's is surgery, but despite surgical intervention, there is a high recurrence rate for the disease.

Surgery for Dupuytren's, as with all surgery, has its risks, such as skin complications, hematoma (blood collecting in one area under the skin) and skin necrosis (dead skin), injury to the fingers, and complex regional pain syndrome, another condition that causes intense pain and burning sensations in the affected area. Nerve injuries were reported to occur from zero to nine percent of the time. As well, the recurrence following surgery was found to range from 41 percent to 54 percent after five years, with about 15 percent of the patients require a repeat surgery for treatment. Repeat, or revision, surgeries are more difficult and come with a 12 percent chance of nerve injury. Because of this relatively high complication rate, surgeons are constantly looking for ways to treat Dupuytren's without surgery.

Nonsurgical treatments that have been tried include radiation, vitamins, corticosteroids, and ultrasound, but nothing has yet been found to be consistently successful. One other type using collagenase injection, an enzyme that causes changes through chemical interaction. This procedure was first tried in 1996. Complications included pain at the injections site and from manipulating the hand, edema (swelling), lymphadenopathy (swelling of the lymph glands), and tears in the skin. However, the initial trials showed that 90 percent patients experienced results that reduced their contractures to zero to 5 degrees of normal. The authors of this article provide an eight-year follow-up of patients with Dupuytren's who had received collagenase injections in a phase II clinical trial.

Researchers were able to assess eight of the 23 patients who had participated in the trial. Two patients received treatment in the proximal interphalangeal (PIP) joint, the so-called middle joint of the fingers. The six other patients received treatment in a metacarapophalngeal (MCP) joint, the one closest to the hands, that allow the entire finger to bend into the palm of the hand.

The researchers reviewed the patients' records, noting the angles of the contractures before the injections, their response to the injection, and dose response to the injection. The mean age at time of the injection for PIP joint was 74 years, ranging from 70 to 78, while for the MCP joint, it was 60 years, ranging from 46 to 62. The mean degree of contraction before the injection in the PIP joint was 45 degrees, ranging from 35 to 55 degrees; for the MCP joint, it was 57 degrees, ranging from 30 to 76 degrees. One week following the injection, the mean angle for the PIP joint was eight degrees, ranging from zero to 15 degrees; for the MCP, it was nine degrees, ranging from zero to 35 degrees. One year after, the mean angle for the PIP joint was 15 degrees, ranging from zero to 30 degrees; for the MCP joint, it was 11 degrees, with a range of zero to 35 degrees.

The patients were asked to rate the success of their procedure on a scale of zero to 100, with 100 being the most satisfied possible, with maximum benefit and resolution of the contracture. The overall average reported was 60 percent and seven of the eight patients said they would have another injection to treat the disease if it recurred or worsened. Measuring the angles eight years after, the researchers found that the mean angle for the PIP joint was 60 degrees, with a range from 50 to 70 degrees and for the MCP joint, it was 22 degrees, with a range of zero to 55 degrees.

The findings showed a long-term recurrence rate of 100 percent among the PIP joints and 67 percent among the MCP joints. Although the rates are high, the contractures for the MCP joints were not as severe as before the injection and 88 percent of the patients said they would undergo the procedure again. Among the PIP contractures, the recurrence was significant but the group was very small (two patients), so larger studies need to be done before drawing any concrete conclusions.
Andrew J. Watt, MD, Catherine M. Curtin, MD, and Vincent R. Hentz, MD. Collagenase Injection as Nonsurgical Treatment of Dupuytren's Disease: 8-Year Follow-Up. In Journal of Hand Surgery. April 2010. Vol. 35. No 4. Pp. 534-539.