Outcomes of Management of Recurrent Dupuytren Contracture: A Systematic Review and Meta-analysis

Background: With numerous treatment modalities available, it is unclear whether the treatment of recurrent Dupuytren disease is as effective as its initial treatment. We aimed to investigate the outcomes of management of recurrent Dupuytren contracture. Methods: Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, MEDLINE, Embase, PubMed, CINAHL, and Cochrane Central Register of Controlled Trials were searched from their inception to April 2020. Studies of patients aged above 18 years undergoing treatment for recurrent Dupuytren contractures were included. The Risk Of Bias In Non-randomized Studies-of Interventions tool was used for quality assessment. The study was registered with Open Science Foundation. Results: A systematic review identified 12 studies: 311 patients with 224 affected digits—index (n = 5; 2.2%), long (n = 17; 7.6%), ring (n = 57; 25.4%), small (n = 112; 50%), and unspecified (n = 33; 14.7%); of these, there were 76 metacarpophalangeal joints (MCPJ; 45.5%), 90 proximal phalangeal joints (PIPJ; 53.9%), and 1 distal interphalangeal joint (0.6%). Previous treatment included the following: percutaneous needle aponeurotomy (n = 103 of 311 patients; 33.1%), collagenase clostridium histolyticum-injection (CCH; n = 75 of 311; 24.1%), limited fasciectomy (LF) ± skin graft (n = 83 of 311; 26.7%), fasciotomy (n = 1 of 311; 0.3%), and unspecified (n = 64 of 311; 20.6%). Recurrence was treated by percutaneous needle aponeurotomy (n = 68 of 311 patients; 21.9%); CCH injection (n = 53 of 311; 17.0%); aponeurotomy or dermofasciectomy or LF (n = 176 of 311; 56.6%); ray/digit amputation (n = 8 of 311; 2.6%); and PIPJ arthrodesis (n = 6 of 293; 2.0%). Range of motion was improved by 23.31° (95% confidence interval [CI] = 13.13°-33.50°; I2 = 67%; P = .05) and 15.49° (95% CI = 2.67°-28.31°; I2 = 76%; P = .01) for MCPJ and PIPJ, respectively. Conclusions: There is low level of evidence that both surgical and nonsurgical treatments provide clinically important improvements for recurrent Dupuytren contracture.

Systematic Review Comparing Cost Analyses of Fasciectomy, Needle Aponeurotomy, and Collagenase Injection for Treatment of Dupuytren’s Contracture: Une analyse de coûts systématique comparant la fasciectomie, l'aponévrotomie percutanée à l'aiguille et l'injection de collagénase pou traiter la maladie de Dupuytren

Purpose: Surgeons now have a variety of treatment options for Dupuytren’s contracture including traditional partial fasciectomy (PF), percutaneous needle aponeurotomy (PNA), and collagenase Clostridium histolyticum (CCH) injection. An important factor in clinical decision making is the cost-effectiveness of the various modalities, as will be discussed in this article. Methods: A literature search was performed by 2 independent reviewers. A total of 14 articles and 3 abstracts met inclusion criteria. Papers were excluded for non-English language, insufficient breakdown of costs by treatment type, promotional materials, or works-in-progress. Cost data were extracted and subsequently converted to US dollars. Weighted means were used to objectively pool data that were sufficiently similar in methodology and population. Results: Seven observational cohort studies were pooled and found to have a weighted mean cost in favour of PNA at US$3335 per patient as compared to CCH at US$3673.14 and PF at US$4734.14. Two expected-value decision analysis models were in agreement that PF is not cost-effective, but they differed on whether PNA or CCH was the most cost-effective strategy. Two cost minimization studies agreed that CCH was less costly than PF by US$486. One cost–benefit analysis found no significant cost benefit to CCH or PF, but found significant indirect benefit to CCH. Overall 10 of 17 studies found CCH to be superior with respect to direct cost, indirect cost, or both. Only 2 of the 17 studies found PF to be the most cost-effective method. Of the 7 studies that considered PNA, 4 found it to be lowest cost. Conclusion: The vast majority of studies found PF to be the most costly treatment modality; however, it is still the treatment of choice in certain clinical scenarios. It is difficult to compare CCH to PNA, as many studies did not consider PNA. More studies, especially considering indirect costs, are required to be able to accurately determine which method is most cost-effective.

Dupuytren-Erkrankung – Vergleich der Kosteneffektivität verschiedener Behandlungsoptionen

Leafblad ND. et al. Outcomes and Direct Costs of Needle Aponeurotomy, Collagenase Injection, and Fasciectomy in the Treatment of Dupuytren Contracture. J Hand Surg Am 2019; 44: 919–927 Für die Behandlung einer Dupuytren-Erkrankung stehen verschiedene Möglichkeiten zur Verfügung. Darunter gilt die offene Aponeurektomie immer noch als „Goldstandard“, aber mittlerweile wurde eine ganze Reihe von weniger invasiven Methoden entwickelt. Zu diesen minimalinvasiven Verfahren gehören u. a. die perkutane Nadelaponeurotomie und, als jüngste Errungenschaft, die Injektion von Kollagenase aus Clostridium histolyticum. Eine Arbeitsgruppe der Mayo Clinic Rochester hat diese 3 Verfahren nun im Hinblick auf Erfolg und Kosten miteinander verglichen.

Needle aponeurotomy for dupuytren’s contracture.

Needle Aponeurotomy is a negligibly obtrusive method where the cords are debilitated through the manipulation & insertion of a small needle. To determine the frequency of recurrence of flexion contracture after correction by percutaneous needle Aponeurotomy. Study Design: Prospective longitudinal study. Setting: Department of Orthopedics, Jinnah Postgraduate Medical Centre, Karachi. Period: March 2017 to February 2018. Materials and Methods: 65 patients were collected for this study with dupuytren’s contracture from stage I-III belonging to either sex of age 18-50 years presented in outpatient department. Results: Total 65 patients were included in the study. Mean flexion contracture was 35.840 with the standard deviation of 13.070. Most of the patients 44(67.7%) had flexion contracture of >300 while 21(32.3%) patients had flexion contracture of ≤300. Majority of the patients had stage 1 of Dupuytren’s contracture, i.e. 26(40%), 25(38.5%) patients were of stage 2 contracture. Least number of patients i.e. 14 (21.5%) had stage 3 Dupuytren’s contracture. Recurrence of contracture was observed in 46(70.8%) of patients, while 19(29.2%) patients had no recurrence of contracture. Conclusion: The frequency of recurrence of flexion contracture found significant after correction with percutaneous needle aponeurotomy, so should be carried in selective patients with counseling’s that it will recur. But acute correction can be made at metacarpophalangeal and proximal interphalangeal joint with needle aponeurectomy.