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Retrospective Review of the Use of Ultrasound Guidance While Injecting Collagenase Clostridium Histolyticum (Xiaflex®) into a Dupuytren's Cord
Paul J. DeMarco, MD, FACP, FACR1; Ashley D. Beall, MD1; Alan K . Matsumoto, MD1; Herbert S.B. Baraf, MD1; David R. Mandel, MD2; (1)Arthritis and Rheumatism Associates, (2)Private Practice
Arthritis and Rheumatism Associates, Wheaton , MD, USA
Introduction: Collagenase clostridium histolyticum (CCH) is approved in the US for treatment of adult patients with Dupuytren’s contracture (DC) with a palpable cord. Dupuytren’s disease is characterized by the imbalance and overproduction of collagen in the palmar fascia, causing deformity and dysfunction. This retrospective chart review assessed outcomes in patients treated with CCH utilizing musculoskeletal ultrasound (MKUS) for cord visualization and compared them with outcomes in registration trials CORD I/II (Hurst, N Engl J Med, 2009, Gilpin, J Hand Surg,2010).
Materials & Methods: 0.58 mg of CCH was administered to 27 patients (41-83 years old) with DC with palpable cords by standard protocol. 21/27 patients met inclusion criteria for CORD I/II (MCP contracture of 20°-100° and PIP contracture of 20°-80°, excluding the thumb). Clinical success was defined as a fixed flexion contracture (FFC) of 0°-5° within 30 days of last injection (maximum 3 injections). CCH injection was guided by MKUS probe placement along the long axis of the cord to avoid injury to tendon sheath. Standard protocol included 24 hours of rest and bandaging, finger extension to facilitate cord disruption, and splinting.
Results:27 patients received47 injections into 37 cords from August 2010 through March 2012. Peripheral nerve block was employed in 34/47 procedures. Medical history risk factors included: hyperlipidemia (5/27), rheumatoid arthritis (3/27), thyroid disease (3/27), diabetes mellitus (3/27), psoriatic arthritis (2/27), smoking (2/27), significant alcohol use (2/27), epilepsy (1/27), Sjögren’s (1/27), mixed connective tissue disease (1/27). Clinical success was achieved in 78% (29/37) of treated cords and in 93% (25/27) of cords that met CORD trial criteria, compared with 64% and 44% success rates in CORD I and CORD II, respectively. Procedural complications were hemorrhage bullae (2), skin tearing (4), rash (1), lymphadenopathy (1), and axillary ecchymosis (1), which all resolved.
Conclusions: This chart review suggests that MKUS may offer a safe imaging technique and should be considered in the management of DC. Additional studies are warranted to determine if CCH may be effectively and safely administered with MKUS guidance. Clinical success compared favorably with CORD trials, and complications were as expected. No patient experienced tendon rupture, however sample size was small. Average number of injections per cord was 1.3 (47/37), similar to CORD I/II (1.7). Nerve block was administered in 81% (22/27) patients. No anesthesia was given during CORD trials, as per protocol, which could have affected outcomes related to finger extension.
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