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Outcomes Following Surgical Fasciectomy and Collagenase Enzymatic Fasciotomy for Dupuytren's Contracture
Stacey Lynne Gold, BS1; Michael J. Waters, BMBS, BPhysio2; Raghuveer C. Muppavarapu, MD3; David E. Ruchelsman, MD2; Matthew I. Leibman, MD2; Mark R. Belsky, MD2
1School of Medicine, Tufts University, Boston, MA; 2Hand Surgery PC, Newton Wellesley Hospital, Newton, MA; 3Orthopedic Surgery, Tufts Medical Center, Boston, MA

Introduction: Following FDA approval in February 2010, collagenase enzymatic fasciotomy has become an accepted non-surgical treatment for disabling hand contractures caused by Dupuytren’s disease. This study compares clinical outcomes following treatment with either collagenase or more traditional open fasciectomy at a single academic hand surgical practice.

Methods: Database repository of 62 fasciectomy and 96 Xiaflex patients. In the collagenase group, a total of 135 joints (81 MP, 54 PIP) were treated in 96 patients. In the fasciectomy group, a total of 125 joints (68 MP, 57 PIP) were treated in 63 patients. 18 patients who underwent fasciectomy and 36 patients who underwent collagenase injections were identified that achieved minimum one year follow up. The mean preoperative contractures in the surgical group measured: 42° (range, 10°-86°) for MCP, and 41° (range, 15°-85°) for PIP. The mean preoperative contractures in the collagenase group measured: 47° (range, 20°-90°) for MCP, and 58° (range, 30°-90°) for PIP. The primary endpoint was reduction in primary joint contracture to within 5° of full extension. Recurrence was defined as an increase in joint contracture to 20° or more in the presence of a palpable cord at any time during the study. Exclusion criteria are children under the age of 18 years, pregnant women, breastfeeding women, and PIP fusion.

Results: At a mean of 24 months following fasciectomy, the mean joint contracture was 8° (P < 0.05). In contrast, at a mean 17 months following collagenase treatment, the mean joint contracture was 35° (P < 0.05). This represents an 81% and 33% improvement in contracture for fasciectomy and collagenase, respectively. At latest follow-up, MCP joint contractures in both treatment groups responded more reliably than PIP joints. 9 joints (5 MCPs, 4 PIPs) in the collagenase received more than 1 injection; 4 of these joints were recurrences. Two patients in the collagenase group ultimately underwent surgical fasciectomy. The most common adverse events after collagenase were skin tears (20.5%), local swelling (16.0%) and ecchymosis (18.2%). Status post fasciectomy, there was wound breakdown (7.0%) and decreased sensation/ numbness in the fingers (4.7%).

Summary: Overall, fasciectomy yields a greater magnitude of correction for digital contractures when compared to collagenase injections. Although there is a trend toward greater recurrence of contracture in those treated with collagenase, it seems to be a reasonable alternative for those who would like to avoid a surgical procedure at the initiation of treatment for Dupuytren’s disease.

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