Examining the Frequency and Size of Skin Tears Following Collagenase Injection for Dupuytren's Contracture Related to Pre-Manipulation Contracture Size and Time to Manipulation
Anil Akoon, MD1; Louis C. Grandizio, DO2; Kirsten A Sumner, MD1; Joel C. Klena, md3; (1)Geisinger Medical Center, Danville, PA, (2)Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, (3)Orthopedic Surgery, Geisinger Medical Center, Danville, PA
Introduction: Dupuytren's contracture is a fibromatosis of the palmar fascia which can result in digital contractures that interfere with hand function. Injection of CCH followed by digital manipulation 24 hours later has been proven to be a safe and effective treatment. Recent publications demonstrated that manipulation up to a week post-injection provides similar efficacy. A common complication of CCH is volar skin tearing during manipulation. We hypothesize that manipulation in a delayed fashion will result in fewer skin tears and that the size and frequency of tears are directly associated with the degree of pre-manipulation contracture.
Methods: 201 consecutive digits with Dupuytren's contracture treated with injection of collagenase clostridium histolyticum were studied. Inclusion criteria were digits with a palpable cord and a contracture of at least 20 degrees in the metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joint. A single fellowship trained hand surgeon performed the collagenase injections utilizing a single dose of collagenase. Patients were randomly assigned to return between 1-7 days post-injection for manipulation. Pre-and post-treatment contracture size as well as the presence and size of skin tears were recorded after manipulation.
Results: Skin tears occurred in 34 of 201 digits (20.4 %). All skin tears resolved with local wound care without further sequelae. The average contracture in patients without skin tears was 64° (32° at the MCP and 32° at the PIP, respectively). The average contracture in patients with skin tears was 96° (51° at the MCP and 45° at the PIP, respectively). The presence of a skin tear correlated with the size of pre-treatment contracture. Total pre-treatment contractures for patients treated with delayed manipulation were similar to those treated with earlier manipulation 61° versus 69°, respectively (p =0.10). There was a reduced frequency of skin tears between those manipulated at a time greater than 4 days (14%) versus those manipulated less than 4 days after injection (22%). The average skin tear size was 24 mm2. The average skin tear for manipulations prior to 4 days was 26 mm2 versus 11 mm2 after 4 days (p=0.15).
Conclusion: Skin tears occurred in 20.4% of digits with an average size of 24mm2. Greater pre-treatment contractures increased the risk for post-manipulation skin tears. Performing manipulations in a delayed fashion resulted in a reduced rate of skin tears. We recommend manipulation greater than 4 days post injection and counseling patients with larger contractures about an increased risk for skin tear.
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