- Email: [email protected]
Dupuytren Contracture
EVIDENCE-BASED MEDICINE
Evidence-Based Medicine
Dupuytren Contracture Spencer J. Stanbury, MD, Warren C. Hammert, MD THE PATIENT A 66-year-old man reports that he cannot straighten his dominant right hand and has difficulty with reaching into his pocket or shaking hands. There is diffuse palmar thickening, an 80° flexion contracture at the small finger proximal interphalangeal (PIP) joint, and a 25° flexion contracture at the middle finger metacarpophalangeal (MCP) joint. THE QUESTION What is the preferred treatment for Dupuytren disease in this patient? CURRENT OPINION For initial treatment of moderate Dupuytren disease, limited fasciectomy (LF; excision of the fascia causing contracture but not the entire diseased fascia) has been a popular treatment, whereas dermofasciectomy with skin grafting and more extensive excision of the palmar fascia is more often used in recurrent or severe cases. More recently, percutaneous needle fasciotomy (PNF) and collagenase injection are increasingly used as less invasive treatment alternatives. THE EVIDENCE Limited fasciectomy There was no difference in contracture 2 years after surgery (25° vs 24°) in a randomized trial of 79 patients comparing 2 skin incisions (Bruner with V-Y closure vs linear incision with z-plasty closure). There were no statistically significant differences in recurrence (diagnosed as any new nodule indicating disease in the operative field, not necessarily causing contracture: 33% and 18%) or complications (including 4 apparently permanent digital nerve injuries and 10 patients From the Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY. Received for publication April 10, 2011; accepted May 2, 2011. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Warren C. Hammert, MD, Department of Orthopaedic Surgery, University of Rochester Medical Center, 601 Elmwood Ave., Box 665, Rochester, NY 14642; e-mail: [email protected]. 0363-5023/11/36A12-0026$36.00/0 doi:10.1016/j.jhsa.2011.05.004
2038 䉬 © ASSH 䉬 Published by Elsevier, Inc. All rights reserved.
with disproportionate pain and stiffness labeled algodystrophy).1 Another study2 reported on LF in 196 patients at a mean of 6.6 years, with 72.5% having no MCP contracture, 20.2% a 5° to 10° PIP contracture, and 7.3% greater than a 20° PIP contracture. Complications included presumed permanent digital nerve injury in 5%; disproportionate pain and stiffness labeled chronic regional pain syndrome in 10%, and wound-healing issues and superficial infections in 15%. An average of 1.5 years after LF in 49 digits (with PIP capsulotomy in 33), the mean PIP joint flexion contracture went from 67° preoperatively to 25° (P⬍.001), with full correction maintained at all MCP joints and no recurrent contractures. Subgroup analysis found that patients with a preoperative PIP joint contracture of greater than 60° had significantly worse final deficit at more than 1 year (P ⫽ .017). The use of PIP joint release did not significantly affect final flexion contracture. Complications included 1 digital nerve injury, 1 hematoma, and 3 superficial infections.3 Denkler4 compared LF in 103 digits, with 43 performed in the hospital and 60 performed in the office with the use of epinephrine and lidocaine without a tourniquet, and with a mean follow-up of 10.6 months. The mean MCP extension deficit improved by 30.2° in the hospital group and 29.8° in office group, whereas PIP joint correction for each group was 22.5° and 25.3°, respectively. Operative complications were similar in both groups and there was no statistical difference in final motion. Shaw et al5 published the results of LF with an open palm technique in 39 digits, with a mean follow-up of 9.6 years. At final follow-up, MCP joint contracture had improved from 41° preoperatively to 1°, whereas PIP joint contracture had improved from 56° to 9°. Mean total range of movement at final follow-up was 92%. All palmar wounds healed by 3 to 5 weeks and complications included 1 digital nerve injury and 1 patient with disproportionate pain and stiffness. Bulstrode et al6 reported on complications of LF using the Skoog and open palm techniques in 253 patients, with a mean follow-up of 3.6 years. Complications occurred in 18.2% of patients and included nerve division (2.0%), arterial injury (0.8%), infection
(9.6%), hematoma (2.0%), sympathetic dystrophy (2.4%), and skin slough (2.4%). Percutaneous needle fasciotomy Percutaneous needle fasciotomy was the original treatment for Dupuytren disease, but it fell out of favor owing to a high rate of recurrence. In the late 1970s, French rheumatologists began to advocate this treatment and it has been increasingly used. Foucher et al7 described PNF in 311 fingers of 211 patients. In the short term, 79% had improved at the MCP joint and 65% at the PIP joint. Three years later, 59 of 100 hands available for review had recurrence. Nerve problems occurred in 6 fingers. In another study,8 PNF in 74 fingers in 52 patients reduced the MCP contracture an average of 88% and the PIP contracture an average of 46%. Long-term follow-up (33 mo) revealed recurrence of 65%, with 42% of digits undergoing additional procedures. Complications included a reduction of flexion in 2 patients and diminished light touch sensation in 2 patients. Twenty-two months after PNF, in 13 fingers there was a mean improvement of 70% at the MCP joint and 41% at the PIP joints, which was a worsening from 100% and 76%, respectively, immediately after the procedure.9 van Rijssen et al performed a prospective randomized study of 115 hands comparing LF with PNF 6 weeks after treatment.10 LF had a significantly greater decrease in the total passive extension deficit (79% vs 62%; P⫽.001) but more discomfort and lower patient satisfaction. Limited fasciectomy was better for Tubiana stage III and IV disease. Total (30% vs 50%) and major (5% vs 0%) complication rates were comparable. Collagenase injection In the initial clinical investigation of collagenase injection, 30 of 34 patients with MCP contracture and 4 of 9 patients with PIP contracture corrected to within 5° of full extension, with 4 recurrences at an average of 20 months’ follow-up.11 A randomized, double-blind, placebo-controlled study of collagenase versus placebo including 36 patients with MCP contracture and 13 with PIP contracture documented significantly more patients within 5° of full extension 1 month after injection at the MCP joint (14 of 18 collagenase vs 2 of 18 placebo; P⫽.001) and the PIP joint (5 of 7 vs 0 of 6). A third of the patients receiving collagenase had elbow lymphadenopathy.12 In another randomized trial,13 21 of 23 patients had extension within 5° after up to 3 injections of collage-
2039
nase, compared with 0 of 12 patients receiving placebo (P⬍.001). The mean number of injections for clinical success was 1.4 and 70% of collagenase patients achieved clinical success after 1 injection. The success rate for all patients receiving collagenase was 90% at the MCP joint and 84% at the PIP joint, with recurrence in 5 joints within 24 months. In another randomized trial,14 64% of collagenaseinjected joints (77% at the MCP and 40% at the PIP joint) were reduced to 0° to 5° of full extension after up to 3 injections, compared with 6.8% of placebo-injected joints (P⬍.002), with better results for lesser contractures. Adverse events occurred in 96.6% of collagenase- and 21.2% of placebo-injected patients. There were 2 tendon ruptures, both involving the small finger after injection of a PIP joint contracture. An 8-year follow-up of 8 patients identified recurrence in 4 of 6 MCP and both PIP contractures.15 SHORTCOMINGS OF THE EVIDENCE The definitions of success and recurrence are inconsistent. It is not clear whether the angular measurement of contracture is reliable or accurate. All existing studies focus on measurements of contracture and rates of success, recurrence, and complications. We need studies that address disability, patient satisfaction, and value. There are no studies comparing collagenase injection with LF or PNF. The 1 randomized trial comparing LF with PNF observed patients for only 6 weeks. DIRECTIONS FOR FUTURE RESEARCH To date, treatment of Dupuytren disease is aimed at the resultant contracture rather than the disease. Ideally, we would have a method to treat the disease and prevent contractures from developing. Current data suggest that regardless of treatment, the results are worse and the risk of recurrence is greater at the PIP joint than the MCP joint; thus, we need a method to improve outcomes at the PIP joint. Current techniques such as the use of preoperative stretching using external fixation (Digit Widget; Hand Biomechanics Lab, Sacramento, CA) may help, but they must be tested in clinical trials. We need reliable and accurate methods to measure contracture and randomized trials comparing collagenase with LF or PNF. The average change in angle with time is probably more important than an arbitrary definition of success or recurrence. We need long-term follow-up data to better understand the risk of disease recurrence after various treatments. Most important, we need a better understanding of the relationship of contracture to disability in Dupuytren disease, and we need to study the impact of various treatments on disability
JHS 䉬 Vol A, December
Evidence-Based Medicine
DUPUYTREN CONTRACTURE: EVIDENCE
2040
DUPUYTREN CONTRACTURE: EVIDENCE
Evidence-Based Medicine
and patient satisfaction. We also need to compare the value provided by various treatments in terms of quality (decreased disability or increased wellness) for a given cost. OUR CURRENT CONCEPTS FOR THIS PATIENT Treatment with PNF and collagenase offers a less invasive treatment with an easier recovery process, but this may be at the expense of higher recurrence. Across all treatments, contractures at the MCP joint are easier to correct and less likely to recur than those at the PIP joint. If the contracture were isolated to the MCP joint, we would offer the patient PNF in the office. We do not feel comfortable with the cost of collagenase, given that PNF can also be done as an office procedure. If welldesigned studies demonstrate improved outcomes with lower recurrence, the cost may be justified. We prefer limited fasciectomy for PIP joint contractures, with capsulotomy of the PIP joint for contractures greater than 30°, and that would be our recommendation for this patient. REFERENCES 1. Citron ND, Nunez V. Recurrence after surgery for Dupuytren’s disease: a randomized trial of two skin incisions. J Hand Surg 2005;30A:563–566. 2. Mavrogenis AF, Spyridonos SG, Ignatiadis IA, Antonopoulos D, Papagelopoulos PJ. Partial fasciectomy for Dupuytren’s contractures. J Surg Orthop Adv 2009;18:106 –110.
3. Misra A, Jain A, Ghazanfar R, Johnston T, Nanchahal J, et al. Predicting the outcome of surgery for the proximal interphalangeal joint in Dupuytren’s disease. J Hand Surg 2007;32A:240 –245. 4. Denkler K. Dupuytren’s fasciectomies in 60 consecutive digits using lidocaine with epinephrine and no tourniquet. Plast Reconstr Surg 2005;115:802– 810. 5. Shaw DL, Wise DI, Holms W. Dupuytren’s disease treated by palmar fasciectomy and an open palm technique. J Hand Surg 1996;21A:484 – 485. 6. Bulstrode NW, Jemec B, Smith PJ. The complications of Dupuytren’s contracture surgery. J Hand Surg 2005;30A:1021–1025. 7. Foucher G, Medina J, Navarro R. Percutaneous needle aponeurotomy: complications and results. J Hand Surg 2003;28:427– 431. 8. van Rijssen AL, Werker PM. Percutaneous needle fasciotomy in Dupuytren’s disease. J Hand Surg 2006;31A:498 –501. 9. Cheng HS, Hung LK, Tse WL, Ho PC. Needle aponeurotomy for Dupuytren’s contracture. J Orthop Surg 2008;16:88 –90. 10. van Rijssen AL, Gerbrandy FS, Ter Linden H, Klip H, Werker PM. A comparison of the direct outcomes of percutaneous needle fasciotomy and limited fasciectomy for Dupuytren’s disease: a 6-week follow-up study. J Hand Surg 2006;31A:717–725. 11. Badalamente MA, Hurst LC. Enzyme injection as nonsurgical treatment of Dupuytren’s disease. J Hand Surg 2000;25A:629 – 636. 12. Badalamente MA, Hurst LC, Hentz VR. Collagen as a clinical target: nonoperative treatment of Dupuytren’s disease. J Hand Surg 2002; 27A:788 –798. 13. Badalamente MA, Hurst LC. Efficacy and safety of injectable mixed collagenase subtypes in the treatment of Dupuytren’s contracture. J Hand Surg 2007;32A:767–774. 14. Hurst LC, Badalamente MA, Hentz VR, Hotchkiss RN, Kaplan FT, Meals RA, et al. Injectable collagenase clostridium histolyticum for Dupuytren’s contracture. N Engl J Med 2009;361:968 –979. 15. Watt AJ, Curtin CM, Hentz VR. Collagenase injection as nonsurgical treatment of Dupuytren’s disease: 8-year follow-up. J Hand Surg 2010;35A:534 –539, 539-e1.
JHS 䉬 Vol A, December
Evidence-Based Medicine
Dupuytren Contracture Spencer J. Stanbury, MD, Warren C. Hammert, MD THE PATIENT A 66-year-old man reports that he cannot straighten his dominant right hand and has difficulty with reaching into his pocket or shaking hands. There is diffuse palmar thickening, an 80° flexion contracture at the small finger proximal interphalangeal (PIP) joint, and a 25° flexion contracture at the middle finger metacarpophalangeal (MCP) joint. THE QUESTION What is the preferred treatment for Dupuytren disease in this patient? CURRENT OPINION For initial treatment of moderate Dupuytren disease, limited fasciectomy (LF; excision of the fascia causing contracture but not the entire diseased fascia) has been a popular treatment, whereas dermofasciectomy with skin grafting and more extensive excision of the palmar fascia is more often used in recurrent or severe cases. More recently, percutaneous needle fasciotomy (PNF) and collagenase injection are increasingly used as less invasive treatment alternatives. THE EVIDENCE Limited fasciectomy There was no difference in contracture 2 years after surgery (25° vs 24°) in a randomized trial of 79 patients comparing 2 skin incisions (Bruner with V-Y closure vs linear incision with z-plasty closure). There were no statistically significant differences in recurrence (diagnosed as any new nodule indicating disease in the operative field, not necessarily causing contracture: 33% and 18%) or complications (including 4 apparently permanent digital nerve injuries and 10 patients From the Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY. Received for publication April 10, 2011; accepted May 2, 2011. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Warren C. Hammert, MD, Department of Orthopaedic Surgery, University of Rochester Medical Center, 601 Elmwood Ave., Box 665, Rochester, NY 14642; e-mail: [email protected]. 0363-5023/11/36A12-0026$36.00/0 doi:10.1016/j.jhsa.2011.05.004
2038 䉬 © ASSH 䉬 Published by Elsevier, Inc. All rights reserved.
with disproportionate pain and stiffness labeled algodystrophy).1 Another study2 reported on LF in 196 patients at a mean of 6.6 years, with 72.5% having no MCP contracture, 20.2% a 5° to 10° PIP contracture, and 7.3% greater than a 20° PIP contracture. Complications included presumed permanent digital nerve injury in 5%; disproportionate pain and stiffness labeled chronic regional pain syndrome in 10%, and wound-healing issues and superficial infections in 15%. An average of 1.5 years after LF in 49 digits (with PIP capsulotomy in 33), the mean PIP joint flexion contracture went from 67° preoperatively to 25° (P⬍.001), with full correction maintained at all MCP joints and no recurrent contractures. Subgroup analysis found that patients with a preoperative PIP joint contracture of greater than 60° had significantly worse final deficit at more than 1 year (P ⫽ .017). The use of PIP joint release did not significantly affect final flexion contracture. Complications included 1 digital nerve injury, 1 hematoma, and 3 superficial infections.3 Denkler4 compared LF in 103 digits, with 43 performed in the hospital and 60 performed in the office with the use of epinephrine and lidocaine without a tourniquet, and with a mean follow-up of 10.6 months. The mean MCP extension deficit improved by 30.2° in the hospital group and 29.8° in office group, whereas PIP joint correction for each group was 22.5° and 25.3°, respectively. Operative complications were similar in both groups and there was no statistical difference in final motion. Shaw et al5 published the results of LF with an open palm technique in 39 digits, with a mean follow-up of 9.6 years. At final follow-up, MCP joint contracture had improved from 41° preoperatively to 1°, whereas PIP joint contracture had improved from 56° to 9°. Mean total range of movement at final follow-up was 92%. All palmar wounds healed by 3 to 5 weeks and complications included 1 digital nerve injury and 1 patient with disproportionate pain and stiffness. Bulstrode et al6 reported on complications of LF using the Skoog and open palm techniques in 253 patients, with a mean follow-up of 3.6 years. Complications occurred in 18.2% of patients and included nerve division (2.0%), arterial injury (0.8%), infection
(9.6%), hematoma (2.0%), sympathetic dystrophy (2.4%), and skin slough (2.4%). Percutaneous needle fasciotomy Percutaneous needle fasciotomy was the original treatment for Dupuytren disease, but it fell out of favor owing to a high rate of recurrence. In the late 1970s, French rheumatologists began to advocate this treatment and it has been increasingly used. Foucher et al7 described PNF in 311 fingers of 211 patients. In the short term, 79% had improved at the MCP joint and 65% at the PIP joint. Three years later, 59 of 100 hands available for review had recurrence. Nerve problems occurred in 6 fingers. In another study,8 PNF in 74 fingers in 52 patients reduced the MCP contracture an average of 88% and the PIP contracture an average of 46%. Long-term follow-up (33 mo) revealed recurrence of 65%, with 42% of digits undergoing additional procedures. Complications included a reduction of flexion in 2 patients and diminished light touch sensation in 2 patients. Twenty-two months after PNF, in 13 fingers there was a mean improvement of 70% at the MCP joint and 41% at the PIP joints, which was a worsening from 100% and 76%, respectively, immediately after the procedure.9 van Rijssen et al performed a prospective randomized study of 115 hands comparing LF with PNF 6 weeks after treatment.10 LF had a significantly greater decrease in the total passive extension deficit (79% vs 62%; P⫽.001) but more discomfort and lower patient satisfaction. Limited fasciectomy was better for Tubiana stage III and IV disease. Total (30% vs 50%) and major (5% vs 0%) complication rates were comparable. Collagenase injection In the initial clinical investigation of collagenase injection, 30 of 34 patients with MCP contracture and 4 of 9 patients with PIP contracture corrected to within 5° of full extension, with 4 recurrences at an average of 20 months’ follow-up.11 A randomized, double-blind, placebo-controlled study of collagenase versus placebo including 36 patients with MCP contracture and 13 with PIP contracture documented significantly more patients within 5° of full extension 1 month after injection at the MCP joint (14 of 18 collagenase vs 2 of 18 placebo; P⫽.001) and the PIP joint (5 of 7 vs 0 of 6). A third of the patients receiving collagenase had elbow lymphadenopathy.12 In another randomized trial,13 21 of 23 patients had extension within 5° after up to 3 injections of collage-
2039
nase, compared with 0 of 12 patients receiving placebo (P⬍.001). The mean number of injections for clinical success was 1.4 and 70% of collagenase patients achieved clinical success after 1 injection. The success rate for all patients receiving collagenase was 90% at the MCP joint and 84% at the PIP joint, with recurrence in 5 joints within 24 months. In another randomized trial,14 64% of collagenaseinjected joints (77% at the MCP and 40% at the PIP joint) were reduced to 0° to 5° of full extension after up to 3 injections, compared with 6.8% of placebo-injected joints (P⬍.002), with better results for lesser contractures. Adverse events occurred in 96.6% of collagenase- and 21.2% of placebo-injected patients. There were 2 tendon ruptures, both involving the small finger after injection of a PIP joint contracture. An 8-year follow-up of 8 patients identified recurrence in 4 of 6 MCP and both PIP contractures.15 SHORTCOMINGS OF THE EVIDENCE The definitions of success and recurrence are inconsistent. It is not clear whether the angular measurement of contracture is reliable or accurate. All existing studies focus on measurements of contracture and rates of success, recurrence, and complications. We need studies that address disability, patient satisfaction, and value. There are no studies comparing collagenase injection with LF or PNF. The 1 randomized trial comparing LF with PNF observed patients for only 6 weeks. DIRECTIONS FOR FUTURE RESEARCH To date, treatment of Dupuytren disease is aimed at the resultant contracture rather than the disease. Ideally, we would have a method to treat the disease and prevent contractures from developing. Current data suggest that regardless of treatment, the results are worse and the risk of recurrence is greater at the PIP joint than the MCP joint; thus, we need a method to improve outcomes at the PIP joint. Current techniques such as the use of preoperative stretching using external fixation (Digit Widget; Hand Biomechanics Lab, Sacramento, CA) may help, but they must be tested in clinical trials. We need reliable and accurate methods to measure contracture and randomized trials comparing collagenase with LF or PNF. The average change in angle with time is probably more important than an arbitrary definition of success or recurrence. We need long-term follow-up data to better understand the risk of disease recurrence after various treatments. Most important, we need a better understanding of the relationship of contracture to disability in Dupuytren disease, and we need to study the impact of various treatments on disability
JHS 䉬 Vol A, December
Evidence-Based Medicine
DUPUYTREN CONTRACTURE: EVIDENCE
2040
DUPUYTREN CONTRACTURE: EVIDENCE
Evidence-Based Medicine
and patient satisfaction. We also need to compare the value provided by various treatments in terms of quality (decreased disability or increased wellness) for a given cost. OUR CURRENT CONCEPTS FOR THIS PATIENT Treatment with PNF and collagenase offers a less invasive treatment with an easier recovery process, but this may be at the expense of higher recurrence. Across all treatments, contractures at the MCP joint are easier to correct and less likely to recur than those at the PIP joint. If the contracture were isolated to the MCP joint, we would offer the patient PNF in the office. We do not feel comfortable with the cost of collagenase, given that PNF can also be done as an office procedure. If welldesigned studies demonstrate improved outcomes with lower recurrence, the cost may be justified. We prefer limited fasciectomy for PIP joint contractures, with capsulotomy of the PIP joint for contractures greater than 30°, and that would be our recommendation for this patient. REFERENCES 1. Citron ND, Nunez V. Recurrence after surgery for Dupuytren’s disease: a randomized trial of two skin incisions. J Hand Surg 2005;30A:563–566. 2. Mavrogenis AF, Spyridonos SG, Ignatiadis IA, Antonopoulos D, Papagelopoulos PJ. Partial fasciectomy for Dupuytren’s contractures. J Surg Orthop Adv 2009;18:106 –110.
3. Misra A, Jain A, Ghazanfar R, Johnston T, Nanchahal J, et al. Predicting the outcome of surgery for the proximal interphalangeal joint in Dupuytren’s disease. J Hand Surg 2007;32A:240 –245. 4. Denkler K. Dupuytren’s fasciectomies in 60 consecutive digits using lidocaine with epinephrine and no tourniquet. Plast Reconstr Surg 2005;115:802– 810. 5. Shaw DL, Wise DI, Holms W. Dupuytren’s disease treated by palmar fasciectomy and an open palm technique. J Hand Surg 1996;21A:484 – 485. 6. Bulstrode NW, Jemec B, Smith PJ. The complications of Dupuytren’s contracture surgery. J Hand Surg 2005;30A:1021–1025. 7. Foucher G, Medina J, Navarro R. Percutaneous needle aponeurotomy: complications and results. J Hand Surg 2003;28:427– 431. 8. van Rijssen AL, Werker PM. Percutaneous needle fasciotomy in Dupuytren’s disease. J Hand Surg 2006;31A:498 –501. 9. Cheng HS, Hung LK, Tse WL, Ho PC. Needle aponeurotomy for Dupuytren’s contracture. J Orthop Surg 2008;16:88 –90. 10. van Rijssen AL, Gerbrandy FS, Ter Linden H, Klip H, Werker PM. A comparison of the direct outcomes of percutaneous needle fasciotomy and limited fasciectomy for Dupuytren’s disease: a 6-week follow-up study. J Hand Surg 2006;31A:717–725. 11. Badalamente MA, Hurst LC. Enzyme injection as nonsurgical treatment of Dupuytren’s disease. J Hand Surg 2000;25A:629 – 636. 12. Badalamente MA, Hurst LC, Hentz VR. Collagen as a clinical target: nonoperative treatment of Dupuytren’s disease. J Hand Surg 2002; 27A:788 –798. 13. Badalamente MA, Hurst LC. Efficacy and safety of injectable mixed collagenase subtypes in the treatment of Dupuytren’s contracture. J Hand Surg 2007;32A:767–774. 14. Hurst LC, Badalamente MA, Hentz VR, Hotchkiss RN, Kaplan FT, Meals RA, et al. Injectable collagenase clostridium histolyticum for Dupuytren’s contracture. N Engl J Med 2009;361:968 –979. 15. Watt AJ, Curtin CM, Hentz VR. Collagenase injection as nonsurgical treatment of Dupuytren’s disease: 8-year follow-up. J Hand Surg 2010;35A:534 –539, 539-e1.
JHS 䉬 Vol A, December