The study also showed that if the contracture was corrected to 0˚ to 5˚ of flexion, recurrence rates were significantly lower and required no additional therapy.12 In addition, most patients maintain a correction of 0˚ to 5˚ flexion for at least 30 days duration following a CCH injection, with the majority achieving relief greater than one year.11 Larger, long-term studies are necessary to assess the extent and recurrence rates of Dupuytren contracture following CCH injection, but at present this seems to be an acceptable treatment method for both patients and practitioners.

Dupuytren disease is important to recognize in the primary care setting, because many patients are unaware of initial symptoms of the disorder. Even though there is no definitive treatment, early recognition, observation, and management may preserve hand function and limit disease progression.1

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In reference to the opening case study, the patient was unaware of her developing condition until there was significant contracture formation and loss of hand function. Had her shortening fascia been recognized earlier in the disease process and referral to a hand specialist occurred, contracture formation may have been reduced or avoided.

Even though recurrence is likely for a disease state as advanced as the case presentation, needle aponeurotomy may be beneficial in decreasing flexion and restoring some hand function when considering those with long-standing disease. Our case demonstrates the importance of primary care recognition of the parameters for referral.

Conclusion

At present, no published direct comparison has examined needle aponeurotomy vs. CCH. Individual trials demonstrate that hand specialists cannot reach a consensus as to the superior treatment method. A 2013 analysis demonstrated similar clinical success and mean reduction of contracture.

However, CCH may require more treatments to achieve the same result as needle aponeurotomy, and it is more expensive. Until the recent FDA approval for multiple site CCH injections, needle aponeurotomy was a more effective option. Although CCH can have a lower short-term recurrence rate, it has a higher rate of minor adverse events and is more costly and time intensive than needle aponeurotomy.10,13

CCH injections may require up to three office visits for initial evaluation and insurance approval, injection of the contracture, and manipulation of the digit. However, patient satisfaction seems to be similar for both treatment groups. Given the low complication rate of each procedure, needle aponeurotomy and CCH are both viable options for Dupuytren treatment.7 Additional long-term comparative studies may demonstrate superiority in contracture reduction and decrease of recurrence. Until then, Dupuytren disease treatment remains a collaborative clinical decision between the patient and the provider to fully grip this “hands-on” scenario.

Kelly Blount, MBA, PA-S  is a PA student, and Michael Felz, MD, FAAFP, is an associate professor at Georgia Regents University in Augusta, Georgia.

References

  1. Dibenedetti D, Nguyen D, Zografos L, et al. Prevalence, incidence, and treatments of Dupuytren’s disease in the United States: results from a population-based study. Hand (N Y). 2011;6(2):149-158.
  2. Hindocha S, McGrouther DA, Bayat A. Epidemiological evaluation of Dupuytren’s disease incidence and prevalence rates in relation to etiology. Hand (N Y). 2009; 4(3):256-269.
  3. Beaudreuil J, Lellouche H, Orcel P, Bardin T. Needle aponeurotomy in Dupuytren’s disease. Joint Bone Spine. 2012;79(1):13-16.
  4.  Trojian T, Chu S. Dupuytren’s disease: diagnosis and treatment. Am Fam Physician. 2007;76(1):86-89.
  5.  Eaton C. Evidence-based medicine: Dupuytren contracture. Plast Reconstr Surg. 2014;133(5):1241-1251.
  6. Black EM, Blazar PE. Dupuytren disease: An evolving understanding of an age-old disease. J Am Acad Orthop Surg. 2011;19(12):746-757.
  7.  Nydick JA, Olliff BW, Garcia MJ, et al. A comparison of percutaneous needle fasciotomy and collagenase injection for Dupuytren disease. J Hand Surg Sm. 2013;38(12):2377-2381.
  8. Van Demark RE Jr, Van Demark RE 3rd. Needle aponeurotomy: a treatment alternative for Dupuytren’s disease. S D Med. 2011;64(11):411, 413, 415 passim.
  9. Coleman S, Gilpin D, Tursi J, et al. Multiple concurrent collagenase clostridium histolyticum injections to Dupuytren’s cords: an exploratory study. BMC Musculoskelet Disord. 2012;13:61.
  10. Azzopardi E, Boyce D. Clostridium histolyticum collagenase in the treatment of Dupuytren’s contracture. Br J Hosp Med (Lond). 2012;73(8):432-436.
  11. Gilpin D, Coleman S, Hall S, et al. Injectable collagenase Clostridium histolyticum: a new nonsurgical treatment for Dupuytren’s disease. J Hand Surg Am. 2010;35(12):2027-2038. 

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