CCH injections

An even less invasive treatment modality for Dupuytren contractures is CCH injections. The only FDA-approved injection in the U.S. is CCH, which is a preparation of two distinct collagenases that cleave collagen strands at different sites. CCH treatment is intended for flexion contractures exceeding 30˚ with palpable cords and is generally well tolerated.9-11 The palpable cord is infiltrated with less than 1 mg of CCH per injection.

Following injection of the cord, the digit is passively extended for 24 to 72 hours to facilitate cord release. The British Journal of Hospital Medicine recommends up to three injections and extensions per contracture, each lasting at least four weeks following the prior injection.10 However, the CORDLESS (Collagenase Optimal Reduction of Dupuytren’s—Long-term Evaluation of Success Study) data reinforced efficacy and safety of up to eight CCH injections.12 No concrete guideline has been established as to the appropriate number of CCH injections to attempt contracture correction.

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In October 2014, the FDA approved the use of Xiaflex for up to two Dupuytren contracture joints in the same hand during a single visit. This provides a new opportunity to treat multiple contractures at the same time. Adverse effects of the procedure include peripheral edema, contusion, injection site hemorrhage, injection site pain, nerve injury, hypersensitivity reaction, and upper extremity pain. A small incidence (less than 1%) of chronic regional pain syndrome and tendon rupture was exhibited in various trials.10

CCH tends to have a higher incidence of adverse effects compared with more invasive surgical techniques. In one phase III study recently conducted in the United Kingdom, 97% of study participants experienced at least one of the aforementioned side effects. However, these events tend to be less severe than those associated with surgical intervention.

A 2010 U.S. study of 501 patients from 10 academic and community practice sites revealed no major adverse effects from CCH injection and noted only minor side effects of erythema, epicondylitis, injection site vesicles, lymphadenopathy, petichiae, hypersensitivity, and skin laceration. 13

Recurrence rates of CCH injections range from 19% to 41% in various trials within the last four years.10,13 CORDLESS data demonstrate a 65% success rate of durable contracture improvement following CCH injections with an overall three-year recurrence rate of 35%. Comparing the areas treated, a lower rate of 27% in MCP joints and 56% in PIP joints was observed, with a mean number injection rate of 1.4.