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A, Clinical photograph showing the degree of Dupuytren contracture of the small finger prior to collagenase injection. B, Four weeks after the collagenase injection, the small finger has excellent extension, and the injection site is fully healed. (Reproduced from Rizzo M, Stern PJ, Benhaim P, Hurst LC: Contemporary Management of Dupuytren Contracture. Instr Course Lect 2014;63:131-142.)

AAOS Now

Published 11/1/2014
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Maureen Leahy

Treating Recurrent Dupuytren Disease

Study finds repeat treatment with CCH safe and effective

Treatment options for Dupuytren disease have increased in recent years. One newer method involves injecting collagenase clostridium histolyticum (CCH) into the cord of the affected joint; the following day the finger is manipulated to rupture the cord, thereby reducing the contracture. Regardless of the initial intervention, however, recurrences of Dupuytren disease are common and often require additional treatment.

According to data presented at the American Society for Surgery of the Hand annual meeting by Clayton A. Peimer, MD, of the College of Human Medicine at Michigan State University, recurrent Dupuytren disease in joints previously treated successfully with CCH can be safely and effectively retreated with CCH.

“One of the questions surrounding CCH is not only how it works, but if it can be used the same way other treatments—such as surgery—are for recurrent Dupuytren disease,” Dr. Peimer said.

“Younger patients, patients with diabetes, and patients with proximal interphalangeal (PIP) joint involvement are much more likely to experience a recurrence. We wanted to look at what happens when those patients are retreated,” he explained.

Study methods
The industry-sponsored, open label study included 51 patients with Dupuytren disease who, as part of a long-term follow-up study, had achieved complete correction (contracture of 0 to 5 degrees) after receiving CCH injection(s) and had a subsequent recurrence of the disease. Among the 51 patients, 31 metacarpophalangeal (MP) and 20 PIP joints were involved. The contracture in all joints had increased by 20 degrees or greater.

Each patient could receive up to three injections of CCH (0.58 mg per injection) in the recurrent cord, administered 28 days apart, until a satisfactory outcome was achieved. Overall, 35 patients (69 percent) received one CCH injection, 12 patients (24 percent) received two CCH injections, and 4 patients (8 percent) received three CCH injections.

The researchers assessed changes in fixed flexion contracture (FFC) and range of motion (ROM). Physician assessment of improvement and patient satisfaction with treatment 30 days after the final injection were also recorded. Patients were followed for 1 year to evaluate safety, and adverse events were documented throughout the study period. 

Positive outcomes, no serious adverse effects
A positive outcome was achieved in 87 percent of the MP joints and 85 percent of the PIP joints at 30 days after final injection. Positive outcomes included contracture of 0 to 5 degrees, no palpable cord, or patient satisfaction with treatment.

“Clinical success was achieved in 65 percent of the MP joints; 3 percent had no palpable cord—when you don’t have a cord you can’t use collagenase; and 19 percent of the patients were pleased with their results and declined further injections,” Dr. Peimer said.

Similarly, 45 percent of the PIP joints achieved clinical success, 30 percent had no palpable cord, and 10 percent of the patients were pleased with their results and declined further injections.

The mean percent reduction from baseline in FFC was 83 percent in MP joints and 69 percent in PIP joints. The mean increases from baseline in ROM were approximately 31 degrees in MP joints and 27 degrees in PIP joints (Table 1).

Physicians rated the level of improvement as very or much improved in 97 percent of treated MP joints and 85 percent of PIP joints. Patient satisfaction rates were similar.

“We also did not see any serious complications—such as tendon ruptures—with the secondary treatment of CCH. In addition, all related complications, such as peripheral edema, contusion, pain in the extremity or at the injection site, pruritus, lymphadenopathy, and skin laceration were mild to moderate and temporary,” Dr. Peimer said.

“Based on our results, retreatment with CCH is a safe and effective alternative to surgery for patients with recurrent flexion deformity after successful CCH treatment,” he concluded.

Dr. Peimer’s coauthors of “Treatment of Recurrent Dupuytren’s Contractures in Joints Previously Effectively Treated With Collagenase Clostridium Histolyticum: Final Results” are Lionel Chris Bainbridge, MBCrB, FRCS; Stephan Wilbrand, MD; Brian Dean, MS; James P. Tursi, MD; and Ted Smith, PhD.

Disclosures: Clayton A. Peimer, MD—Auxilium; L. Christopher Bainbridge, MBChB, FRCS— Auxilium; Stephan Wilbrand, MD—Pfizer; Brian Dean, MS—Auxilium; James P. Tursi, MD—Auxilium; Ted Smith, PhD—Auxilium

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

Bottom Line

  • Dupuytren disease recurrences are common and often require additional treatment.
  • CCH is a noninvasive treatment alternative to surgery for Dupuytren disease.
  • This industry-funded study suggests that recurrent Dupuytren disease in joints previously treated successfully with CCH can be safely and effectively retreated with CCH.

Additional Information:
Clinical Paper Session 08: Dupuytren Disease (Papers 44-48)
(See Paper 48)