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Improved Outcomes With Injectable Clostridial Collagenase For Dupuytren's Contracture: A Single Surgeon's Experience
Arezou Yaghoubian, MD; Jusin Koh, BS; Elizabeth Zielens, MD; Raul Cortes, MD; Matt Kwan, MD; Prosper Benhaim, MD
Plastic Surgery, UCLA, Los Angeles, CA

Background: Historically, surgery has been the most effective treatment for Dupuytren's contracture, but this is fraught with disadvantages. In addition, not all patients with Dupuytren's contracture are appropriate candidates for surgery. Injectable collagenase Clostridium histolyticum (Xiaflex;Auxilium Pharmaceuticals, Inc, Malvern, PA) is a FDA-approved, office-based, nonsurgical treatment for adult patients with a palpable Dupuytren's cord. Several trials have evaluated the efficacy of Xiaflex. The CORD trials demonstrated that 44-66% of patients achieved the primary endpoint of less than 5 degrees of residual contracture. The results achieved may have been limited, by lack of use of local anesthetic for manipulations to rupture the Dupuytren’s cords, limitation of injections sites, and lack of forceful manipulation of the digits.

Purpose of Study: The purpose of our study is to demonstrate superior efficacy at our institution than previously recorded in the CORD trials, based on use of local anesthetics to allow for more forceful manipulations and a more widespread injection approach. Adverse side effects within 30 days of injection was also evaluated.

Methods: Retrospective chart review of all patients who underwent Xiaflex by a single surgeon at a University Medical Center from 2010-present was performed. Factors evaluated included demographic information, extent of Dupuytren’s disease, number of cords injected, response to injection, adverse side effects, and days to cord disruption. Outcomes measures included % joint correction and complications.

Results: 13 patients were identified, with an average age of 66. 63% of the patients were male. 32% percent of the patients had previous treatment for Dupuytren’s, including Xiaflex, needle aponeurotomy and steroid injection. Fingers affected included: 60/139 small finger, 32/139 ring finger and 16/97 middle finger. The average MCP degree of contracture was 47 degrees, PIP 47 degrees, and DIP 40 degrees. Overall, patients had 3.8 joints affected, 2.9 joints injected and 3.7 joints manipulated. Post injection, all joints affected had 100% correction, including even some joints not originally injected. The average time between injection and manipulation was 2.8 days. All patients did have a minor complication, most commonly, ecchymosis in 100 patients (72%) and 69 (50%) had a minor skin laceration treated with local wound care. Five patients had an exposed tendon, which was also treated with local wound care only.

Conclusion: This study demonstrates improved results following several modifications of the FDA protocol, including digital block, forceful digital manipulation, and full-dose injection of Xiaflex. We achieved full extension on all joints manipulated, with minimal complications.

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