Date of Graduation

Spring 3-7-2016

Degree Type

Capstone Project

Degree Name

Master of Science in Physician Assistant Studies

First Advisor

Brent Norris

Second Advisor

AJ Sommers

Abstract

Background: Dupuytren’s contracture is a common debilitating fibroproliferative disease of the hand. The current standard of care for moderate or severe Dupuytren’s is surgical fasciectomy. However, while surgery yields a significant initial correction of the contracture, the recurrence rate is as high as 71% bringing into question the efficacy of surgery and whether it is worth the surgical risk. Collagenase Clostridium histolyticum (CCH) injections were approved by the FDA in February 2010 for the treatment of Dupuytren’s contracture. This review evaluates the current literature that directly compares the efficacy of CCH injections to surgical fasciectomies.

Methods: An exhaustive literature search using MEDLINE-Ovid, Web of Science, and CINAHL was conducted. The following search terms were used: “Dupuytren’s contracture,” “collagenase,” and “fasciectomy.” The search was further narrowed to include only English-language articles. Inclusion criteria consisted of studies evaluating patients who initially present with a contracture of at least 30° and articles directly evaluating the post interventional contracture degrees between CCH injections and fasciectomies. Studies were excluded if their follow-up was less than 3 months and if multiple interventions were attempted during the study. The studies were then evaluated for their quality using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group Guidelines.

Results: Two studies were included in this systematic review, meeting both the inclusion and exclusion criteria. One case-control retrospective study followed 142 patients with Dupuytren’s contracture and found at latest follow-up that 46% of metacarpophalangeal (MCP) joints treated with CCH injections and 68% of MCP joints treated with fasciectomy maintained joint contracture. Another propensity score matched study evaluated 132 subjects and found that there was no significant residual contracture at MCP at latest followup between fasciectomy and CCH injection groups. Fasciectomies did slightly better at the proximal interphalangeal (PIP) joint compared to CCH injections.

Conclusion: CCH injections are a viable non-surgical option in the treatment of moderate to severe Dupuytren’s contracture. Surgical fasciectomies are the current standard of care, but are subject to high scrutiny due to the high level of recurrence that occurs post-procedurally, the relatively high risk of major adverse events, and increased incidence of comorbidities found in the population with Dupuytren’s contracture. It is difficult to discern how CCH injections compares to surgical fasciectomies, but early research, such as the aforementioned discussed, suggest they are strong alternatives based on relative efficacy, patient tolerance, and favorable safety profile. Further research will be needed to elucidate the clinical importance of CCH injections in the treatment of Dupuytren’s contracture.

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