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Collagenase Clostridium Histolyticum (CCH) for the Treatment of Dupuytren's Disease: A Delphi Report
Gary M. Pess, MD, Central Jersey Hand Surgery, Eatontown, NJ, David Hurley, MD, Endo Pharmaceuticals Inc., Malvern, PA, James R. Verheyden, MD, The Center, Bend, OR and Prosper Benhaim, MD, Division of Plastic Surgery, University of California, Los Angeles, Los Angeles, CA

Introduction
The primary objective was to develop consensus recommendations among an expert panel of surgeons on the appropriate treatment of Dupuytren's disease (DD) with collagenase clostridium histolyticum (CCH) in well-defined patient populations with varying degrees of disease severity and functional impairment.
Materials & Methods
A modified Delphi method employing three successive survey rounds captured the clinical expertise of panelists to obtain consensus. Round 1 employed 22 clinical scenarios to determine the panelists' recommendation to use CCH for treating metacarpophalangeal (MP) and/or proximal interphalangeal (PIP) joint contractures involving a single finger or two fingers, with varying degrees of contracture and clinical severity. Each scenario presented a distinct contracture(s) with a series of statements to evaluate the impact of patient- or disease-related features (age, recurrence, risk of anesthesia, diathesis, poor-quality skin, post-fasciectomy scarring) on the clinical decision to use CCH or not. Responses were captured using a five-point Likert scale ("strongly agree," "agree," "deficient information," "disagree," and "strongly disagree"). The level of agreement for each statement was determined, with a consensus threshold of ≥66.7% for agreement ("strongly agree" and "agree") or disagreement ("strongly disagree" and "disagree"). Statements failing to achieve consensus during Round 1 were revised for Round 2. These included statements pertinent to "scarring," "poor-quality skin," and "boutonnière deformity" in scenarios describing PIP contractures. Statements on the threshold of "consensus for agreement" in Round 1 were reassessed. "Impact of patient decision" on scenarios with varying contracture severity was also explored in Round 2. Statements failing to reach consensus in Round 2 will be reassessed in Round 3.
Results
A panel of 20 physicians (80% practicing medicine for ≥15 years; 90% certification of added qualification [CAQ]-certified hand surgeons) completed Round 1. Among the 22 scenarios in Round 1, 85.8% of statements reached consensus for agreement; none reached consensus for disagreement. Scenarios for patients with varying severities of MP contractures alone and patients with MP and/or interphalangeal thumb contracture reached complete consensus for agreement for use of CCH. In Round 2 (n=19 panelists), all statements pertinent to "scarring," "boutonnière deformity," and "impact of patient decision," and 94.1% pertinent to "poor quality skin" reached consensus for agreement. Only 4 of 86 (4.7%) statements in Survey 2 failed to reach consensus.
Conclusions
Consensus-based findings among expert hand surgeons point to wide-ranging application of CCH for the treatment of DD across a broad range of patients with varying degrees of disease severity and functional impairment.


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