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Cureus Jan 2024Dupuytren's disease (DD) is a fibroproliferative disorder that manifests as an abnormal growth of myofibroblasts, causing nodule formation and contractures and affecting... (Review)
Review
Comparing Complications and Patient Satisfaction Following Injectable Collagenase Versus Limited Fasciectomy for Dupuytren's Disease: A Systematic Review and Meta-Analysis.
Dupuytren's disease (DD) is a fibroproliferative disorder that manifests as an abnormal growth of myofibroblasts, causing nodule formation and contractures and affecting digit function. If left untreated, these contractures can lead to a loss of mobility and potentially impact hand function. This systematic review critically compares and evaluates the existing literature on the complications and patient satisfaction following injectable collagenase (CCH) versus limited fasciectomy (LF) for DD. We performed a comprehensive search of the PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), The Cochrane Library, and Excerpta Medica database (EMBASE) databases from 2006 to August 2023. This research targeted all clinical studies involving adults who underwent injectable collagenase and/or limited fasciectomy in the management of DD. Out of the 437 identified studies, only 53 were considered eligible for our analysis, and merely 14 met our inclusion criteria. These selected studies encompassed a total of 967 patients with 1,344 treated joints, with an average follow-up duration of 19.22 (ranging from one to 84.06) months. Within this cohort, 498 joints from 385 patients underwent LF, while 846 joints from 491 patients received CCH injections. Notably, among the 491 patients treated with CCH, 1,060 complications were reported, averaging 2.15 complications per patient, with the most common being contusion/bruising/hematoma/ecchymosis (22.54%), and edema/swelling (18.96%). In contrast, among the 385 patients treated with LF, only 97 complications were reported, translating to 0.25 complications per patient, with the most frequent being paraesthesia or numbness (23.7%), scar sequelae like skin laceration, tear, fissure, or hypertrophic scar (23.7%), and neuropraxia or nerve injury (22.6%). Our meta-analysis indicates that paraesthesia or numbness is more frequently observed in LF than CCH injections, although without statistical significance, with a risk ratio (RR) of 0.39 (95% confidence interval (CI) 0.13-1.18, p-value 0.1). However, scar sequelae (hypertrophic scar, skin laceration, tear, or fissure) show a contrasting pattern, being more commonly associated with CCH injections than LF, with an RR of 1.98 (95% CI 0.26-14.85, p-value 0.51), which, upon eliminating the source of heterogeneity, becomes statistically significant, with an RR of 4.98 (95% CI 1.40-17.72, p-value 0.01). Our data revealed a higher frequency of complications with CCH compared to LF, although more severe adverse effects were observed in the LF group, such as neuropraxia or nerve injury. Scar sequelae were more common with CCH injections. Despite both treatments showing increased patient satisfaction at the final follow-up, CCH injection resulted in earlier improvements in satisfaction.
PubMed: 38420076
DOI: 10.7759/cureus.53147 -
Hand Surgery & Rehabilitation Sep 2023Dupuytren's disease is a progressive hand disorder characterized by the formation of pathologic nodules and cords in the palm, often leading to progressive flexion... (Review)
Review
Dupuytren's disease is a progressive hand disorder characterized by the formation of pathologic nodules and cords in the palm, often leading to progressive flexion contractures. Hand surgery is currently the only efficient treatment to restore hand function, however, reported recurrence rates vary widely. Currently, it remains unclear which type of fasciectomy is associated with the lowest recurrence rate. Therefore, a systematic review was conducted to compare recurrence rates after limited fasciectomy, open palm technique, or dermofasciectomy with a full-thickness skin graft. 79 studies were included, and results suggest that a dermofasciectomy with a full-thickness skin graft is associated with a lower recurrence rate. However, most studies were case series in which a wide range of definitions of recurrence was used. Moreover, all studies had a high risk of bias. Therefore, additional comparative clinical trials are recommended that use an unambiguous definition of recurrence. LEVEL OF EVIDENCE III: .
Topics: Humans; Dupuytren Contracture; Skin Transplantation; Hand; Fasciotomy
PubMed: 37336491
DOI: 10.1016/j.hansur.2023.06.002 -
Plastic Surgery (Oakville, Ont.) Nov 2021Surgeons now have a variety of treatment options for Dupuytren's contracture including traditional partial fasciectomy (PF), percutaneous needle aponeurotomy (PNA), and...
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...
PURPOSE
Surgeons now have a variety of treatment options for Dupuytren's contracture including traditional partial fasciectomy (PF), percutaneous needle aponeurotomy (PNA), and collagenase (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.
PubMed: 34760842
DOI: 10.1177/2292550320963111 -
Annals of Plastic Surgery Nov 2019Ever since the classification of Dupuytren disease into the proliferative, involutional, and residual stages, extensive research has been performed to uncover the...
BACKGROUND
Ever since the classification of Dupuytren disease into the proliferative, involutional, and residual stages, extensive research has been performed to uncover the molecular underpinnings of the disease and develop better treatment modalities for patients. The aim of this article is to systematically review the basic science literature pertaining to Dupuytren disease and suggest a new approach to treatment.
METHODS
Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review was conducted using the MEDLINE database to identify basic science literature on Dupuytren pathophysiology falling under 1 or more of the following categories: (1) Molecular alterations, (2) Structural alterations, and (3) Genetic predisposition.
RESULTS
A total of 177 articles were reviewed of which 77 studies met inclusion criteria. Articles were categorized into respective sections outlined in the study methods.
CONCLUSION
The pathophysiological changes involved in Dupuytren's disease can be divided into a number of molecular and structural alterations with genetic predisposition playing a contributory role. Understanding these changes can allow for the development of biologics which may disrupt and halt the disease process.
Topics: Dupuytren Contracture; Humans
PubMed: 31232804
DOI: 10.1097/SAP.0000000000001918 -
EFORT Open Reviews Jul 2024Controversy exists regarding the comparative efficacy of collagenase injection and percutaneous needle fasciotomy in the treatment of Dupuytren contracture. The...
PURPOSE
Controversy exists regarding the comparative efficacy of collagenase injection and percutaneous needle fasciotomy in the treatment of Dupuytren contracture. The randomized controlled trials (RCTs) that have compared the two treatment methods have reported results mostly implying similar treatment efficacy, durability, and complications. We aimed to review these RCTs regarding methodical quality and risk of bias.
METHODS
We searched PubMed and Cochrane Library databases up to May 2023. All RCTs comparing collagenase injection with needle fasciotomy were included. Eligible articles were reviewed by two researchers, of whom one was blinded to each article's title, authors, year of publication, journal, and source of the studies. To assess methodical quality, we used the modified Jadad scale yielding a score of 0 (lowest quality) to 5 (highest quality). We assessed risk of bias with the Cochrane risk-of-bias tool (RoB 2).
RESULTS
Five studies were eligible, comprising 204 patients treated with collagenase injection and 209 patients treated with needle fasciotomy. The modified Jadad score ranged from 1 to 2 points in the five studies, and the overall risk of bias was high in all studies. Pretrial protocols could be retrieved for only two studies, revealing important discrepancies with the published articles.
CONCLUSION
The published RCTs that have compared collagenase injection with needle fasciotomy in the treatment of Dupuytren contracture demonstrate a high risk of bias.
PubMed: 38949161
DOI: 10.1530/EOR-23-0211 -
Annals of Plastic Surgery Apr 2024Collagenase clostridium histolyticum (collagenase) was introduced in 2010 creating a nonoperative treatment option for Dupuytren disease with promising results in... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Collagenase clostridium histolyticum (collagenase) was introduced in 2010 creating a nonoperative treatment option for Dupuytren disease with promising results in sponsored clinical trials. A meta-analysis was performed to investigate industry sponsorship bias.
METHODS
A systematic review of collagenase treatment of Dupuytren contracture was conducted. Articles containing mesh terms including "microbial collagenase" and "Dupuytren's contracture" were searched and limited to only clinical trials with similar protocols for inclusion. Meta-analysis of treatment endpoints of correction of contracture to 0-5 degrees after first and last injection was conducted comparing sponsored versus nonsponsored studies.
RESULTS
Sixteen of the 29 identified articles met criteria for inclusion. Nonsponsored studies reported a significantly higher rate of meeting the primary treatment endpoint compared to sponsored studies after single injection for all joints (69.6% vs 56% P < 0.01), metacarpophalangeal joint (96% vs 64% P < 0.01), and proximal interphalangeal joint (67% vs 36% P = 0.011). The correction in contracture rates was similar between groups with studies evaluating more than one injection.
CONCLUSIONS
Nonsponsored studies published higher success rates in meeting the primary endpoint of full correction after single injection than sponsored studies; however, similar results with multiple injections. This study demonstrated that sponsored studies of collagenase produced highly powered studies that may be reliably depended on for evidence-based clinical application.
Topics: Humans; Dupuytren Contracture; Treatment Outcome; Injections, Intralesional; Microbial Collagenase
PubMed: 38527344
DOI: 10.1097/SAP.0000000000003831 -
Journal of Hand Therapy : Official... Jan 2024Limitations to proximal interphalangeal joint (PIPJ) motion can result in significant functional impairment for people with hand injuries and conditions. The role of...
BACKGROUND
Limitations to proximal interphalangeal joint (PIPJ) motion can result in significant functional impairment for people with hand injuries and conditions. The role of orthotic intervention to improve PIPJ motion has been studied; however, high-quality systematic reviews and meta-analyses are lacking.
PURPOSE
This study aimed to determine the effectiveness of orthotic intervention for restoring PIPJ extension/flexion following hand injuries or conditions.
STUDY DESIGN
Systematic review.
METHODS
A comprehensive literature search was completed in MEDLINE, CINAHL, Embase, Cochrane Central, and PEDro using terms related to orthoses, finger PIPJ range of motion, and randomized controlled trial design. Methodological quality was assessed using the PEDro score, study outcomes were pooled wherever possible using random effects meta-analysis, and certainty of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation.
RESULTS
Twelve trials were included (PEDro score: 4-7/10). The addition of orthotic intervention was not more effective than hand therapy alone following Dupuytren's release for improving total active extension (mean difference [MD] -2.8°, 95% confidence interval [CI]: -9.6° to 4.0°, p = 0.84), total active flexion (MD -5.8°, 95% CI: -12.7° to 1.2°, p = 0.70), Disability of the Arm, Shoulder and Hand scores (MD 0.4, 95% CI: -2.7 to 3.6, p = 0.79), or patient satisfaction (standardized MD 0.20, 95% CI: -0.49 to 0.09, p = 0.17). Orthotic intervention was more effective than hand therapy alone for improving PIPJ extension for fixed flexion deformities following traumatic finger injury or surgery (MD -16.7°, 95% CI: -20.1° to -13.3°, p < 0.001). No studies evaluated orthotic intervention to improve PIPJ flexion.
CONCLUSION
The addition of an extension orthosis following procedures to manage Dupuytren's contracture is no better than hand therapy alone for improving PIPJ extension. In contrast, the addition of a PIPJ extension orthosis in the presence of traumatic PIPJ fixed flexion deformities is more effective for improving PIPJ extension than hand therapy alone. Future studies are needed to evaluate the role of orthotic intervention for improving PIPJ flexion.
PubMed: 38278697
DOI: 10.1016/j.jht.2023.12.018