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Comparative Efficacy of Interventions for Dupuytren's Contracture: A National Analysis
Jennifer K Shah, BS, BAH
1, Max L Silverstein, MD
2; Anna Luan, MD, MS
3(1)Geisel School of Medicine at Dartmouth College, Hanover, NH, (2)Division of Plastic & Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, (3)Plastic Surgery, Stanford University, Stanford, CA
Introduction: Dupuytren's contracture is a common, progressive fibroproliferative disorder of the hand that impairs hand function and quality of life. Optimal management of Dupuytren's contracture often involves surgical interventions, including partial fasciectomy, needle aponeurotomy, and collagenase clostridium histolyticum (CCH) injection with subsequent manipulation of fibrous cords. This study investigates the relative utilization of these techniques as primary interventions for Dupuytren's contracture as well as factors associated with need for secondary interventions.
Materials & Methods: Using the Merative MarketScan Research Databases, a large multi-payer database, International Classification of Disease (ICD) codes were utilized to identify adult patients with Dupuytren's contracture who underwent interventions (CCH injection, needle aponeurotomy, or partial fasciectomy) identified by Current Procedural Terminology (CPT) codes between 2007 and 2022. Specialties of primary intervention providers, including orthopedic surgery, plastic surgery, and family medicine, were recorded. Any secondary interventions performed at least six months following the primary intervention were identified. Outcomes included need for and timing of secondary interventions. Statistical analysis included univariate analysis, log-rank testing, and multivariate logistic regression.
Results: Overall, 33,053 patients with Dupuytren's contracture underwent CCH injection (9.9%), needle aponeurotomy (12.1%), or partial fasciectomy (78.0%) as a primary intervention. Median time to second intervention, which was performed in 8.0% of patients, was 511 days for CCH injection, 721 days for needle aponeurotomy, and 712.5 days for partial fasciectomy (p<0.01). Undergoing partial fasciectomy as a primary intervention (relative to CCH injection) decreased odds of undergoing a secondary intervention (OR 0.81; 95% CI: 0.68-0.97; p=0.02), as did younger age, female sex, and increasing year (p<0.01). Undergoing a primary intervention performed by an orthopedic surgeon or a plastic surgeon, relative to other providers, reduced odds of secondary interventions (p?0.02).
Conclusions: Dupuytren's contracture is a chronic condition that often recurs following initial interventions. CCH injections, which were introduced in 2010 as a less invasive treatment modality, may be inferior to partial fasciectomy given increased odds of and earlier timing of additional interventions. Interventions performed by qualified specialists may improve intervention efficacy and reduce the need for additional procedures.
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