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The American Journal of Occupational... 2017Occupational therapy practitioners are key health care providers for people with musculoskeletal disorders of the distal upper extremity. It is imperative that... (Review)
Review
Occupational therapy practitioners are key health care providers for people with musculoskeletal disorders of the distal upper extremity. It is imperative that practitioners understand the most effective and efficient means for remediating impairments and supporting clients in progressing to independence in purposeful occupations. This systematic review provides an update to a previous review by summarizing articles published between 2006 and July 2014 related to the focused question, What is the evidence for the effect of occupational therapy interventions on functional outcomes for adults with musculoskeletal disorders of the forearm, wrist, and hand? A total of 59 articles were reviewed. Evidence for interventions was synthesized by condition within bone, joint, and general hand disorders; peripheral nerve disorders; and tendon disorders. The strongest evidence supports postsurgical early active motion protocols and splinting for various conditions. Very few studies have examined occupation-based interventions. Implications for occupational therapy practice and research are provided.
Topics: Activities of Daily Living; Adult; Arthritis, Rheumatoid; Carpal Tunnel Syndrome; Dupuytren Contracture; Forearm; Hand; Humans; Musculoskeletal Diseases; Occupational Therapy; Orthopedic Procedures; Osteoarthritis; Radius Fractures; Splints; Tendinopathy; Tendon Transfer; Treatment Outcome; Trigger Finger Disorder; Wrist
PubMed: 28027038
DOI: 10.5014/ajot.2017.023234 -
Hand (New York, N.Y.) Nov 2022With numerous treatment modalities available, it is unclear whether the treatment of recurrent Dupuytren disease is as effective as its initial treatment. We aimed to... (Meta-Analysis)
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°; = 67%; = .05) and 15.49° (95% CI = 2.67°-28.31°; = 76%; = .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.
Topics: Humans; Aged; Dupuytren Contracture; Microbial Collagenase; Treatment Outcome; Fasciotomy; Injections
PubMed: 33618538
DOI: 10.1177/1558944721994220 -
The Bone & Joint Journal Sep 2018Dupuytren's contracture is a benign, myoproliferative condition affecting the palmar fascia that results in progressive contractures of the fingers. Despite increased... (Review)
Review
AIMS
Dupuytren's contracture is a benign, myoproliferative condition affecting the palmar fascia that results in progressive contractures of the fingers. Despite increased knowledge of the cellular and connective tissue changes involved, neither a cure nor an optimum form of treatment exists. The aim of this systematic review was to summarize the best available evidence on the management of this condition.
MATERIALS AND METHODS
A comprehensive database search for randomized controlled trials (RCTs) was performed until August 2017. We studied RCTs comparing open fasciectomy with percutaneous needle aponeurotomy (PNA), collagenase clostridium histolyticum (CCH) with placebo, and CCH with PNA, in addition to adjuvant treatments aiming to improve the outcome of open fasciectomy. A total of 20 studies, involving 1584 patients, were included.
RESULTS
PNA tended to provide higher patient satisfaction with fewer adverse events, but had a higher rate of recurrence compared with limited fasciectomy. Although efficacious, treatment with CCH had notable recurrence rates and a high rate of transient adverse events. Recent comparative studies have shown no difference in clinical outcome between patients treated with PNA and those treated with CCH.
CONCLUSION
Currently there remains limited evidence to guide the management of patients with Dupuytren's contracture. Cite this article: Bone Joint J 2018;100-B:1138-45.
Topics: Dupuytren Contracture; Humans; Injections, Intralesional; Microbial Collagenase; Orthopedic Procedures; Recurrence; Treatment Outcome
PubMed: 30168768
DOI: 10.1302/0301-620X.100B9.BJJ-2017-1194.R2 -
Hand (New York, N.Y.) Sep 2022This systematic review investigates complications and recurrence of Dupuytren's contracture in metacarpophalangeal joints (MCPJs) and/or proximal interphalangeal joints...
This systematic review investigates complications and recurrence of Dupuytren's contracture in metacarpophalangeal joints (MCPJs) and/or proximal interphalangeal joints (PIPJs) of fingers treated with collagenase clostridium histolyticum (CCH). A review of the literature on Dupuytren's disease was performed using PRISMA guidelines. Included publications described complications and/or recurrences for contractures ≥20° in MCPJs and/or PIPJs treated with CCH. Successful treatments reduced contractures to ≤5° immediately. Treatment-related adverse events (AEs) were classified as minor, major surgical, and major nonsurgical. Contracture recurrence involved return of fixed-flexion contracture ≥20° in a successfully treated finger in patients with ≥12 months of follow-up. Of 2675 patients (3753 joints), 94% experienced ≥1 treatment-related AE, most commonly peripheral edema (64%), pain in extremity (53%), and contusion (51%). Major surgical complications occurred in 9 patients (1.0%). Major nonsurgical complications occurred in 2 patients, specifically nonrupture tendon injury and anaphylaxis. Of 1488 patients (2069 joints), recurrences were reported in 23% of successfully treated joints (n = 466; 20% MCPJs, 28% PIPJs), on average 12 to 24 months after treatment. MCPJs achieved greater success than PIPJs in initial contracture reduction (77% versus 36%). CCH is a safe, effective treatment to improve hand function in Dupuytren's contracture. Most AEs are minor and self-resolving, although the risk of major AEs still exists. Following treatment, 23% of successfully treated joints experience recurrence, typically within 12 to 24 months but sometimes as early as 6 months. Surgeons are encouraged to discuss these risks with patients for shared decision-making regarding optimal treatment modalities.
Topics: Collagenases; Dupuytren Contracture; Humans; Injections, Intralesional; Microbial Collagenase; Recurrence
PubMed: 33478271
DOI: 10.1177/1558944720974119 -
Cureus Jan 2022Unité Rhumatologique des Affections de la Main (URAM) is a novel and disease-specific questionnaire for Dupuytren contracture, a fibroproliferative disease that affects... (Review)
Review
BACKGROUND
Unité Rhumatologique des Affections de la Main (URAM) is a novel and disease-specific questionnaire for Dupuytren contracture, a fibroproliferative disease that affects hands causing progressive contracture in flexion of the fingers.
OBJECTIVES
To evaluate the sensitivity and specificity of the URAM scale in Dupuytren contracture.
MATERIALS AND METHODS
We performed meta-analyses of 10 articles published in PubMed, Embase, Cochrane, Google Scholar, Latin American and Caribbean Health Sciences Literature (LILACS), and in various grey literature databases that describe the use of the URAM and Tubiana scales to assess treatment outcomes in Dupuytren contracture. We built three models: a hierarchical summary receiver operating characteristic (HSROC) model to determine the optimal threshold for defining Dupuytren contracture, a difference in means model to assess the magnitude of the effect of different treatment modalities, and a meta-regression model to determine the effect on patient quality of life questionnaires such as the URAM, according to variations in Tubiana scores after treatment.
RESULTS
The HSROC and bivariate models showed a sensitivity of 80.23% (95% CI: 75.66 to 84.14) and an overall specificity of 2.61% (95% CI: 1.11 to 6.05). The second model showed an overall difference in means of 1.95 (95% CI: -2.86 to -1.04) for partial fasciectomy and collagenase (CCH) injections, and -1.30 (95% CI: -1.77 to -0.83) for partial fasciectomy, and -2.75 (95% CI: -4.73 to -0.78) for CCH. The coefficient obtained in the meta-regression model was -1.666 (95% CI: -4.183 to 0.851).
CONCLUSION
The URAM scale is highly sensitive to changes in Dupuytren contracture but has low specificity. It also showed a strong correlation with worsening of finger contracture as measured by the Tubiana scale.
PubMed: 35233314
DOI: 10.7759/cureus.21636 -
Journal of Hand and Microsurgery Oct 2022This study aimed to compare the outcomes of hand therapy alone versus additional splinting post fasciectomy for Dupuytren's contracture patients. A systematic review and...
This study aimed to compare the outcomes of hand therapy alone versus additional splinting post fasciectomy for Dupuytren's contracture patients. A systematic review and meta-analysis were conducted, and a search was performed identifying all relevant studies comparing the two groups. Primary outcome measures included Total active flexion and extension (TAF and TAE) and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Secondary outcome measures included pain intensity, grip strength, and global perceived effect and patients' satisfaction. A random effects model was used for the analysis. Four RCTs were identified enrolling 295 patients. There were no significant differences between hand therapy and splintage groups in terms of all outcomes (both primary and secondary). Splintage offers no added functional benefit to hand therapy alone for post fasciectomy patients with Dupuytren's contracture, however, orthotic regimes may still be applied on an intention to treat basis in those patients who develop an extension deficit postoperatively.
PubMed: 36994455
DOI: 10.1055/s-0041-1725221 -
Hand (New York, N.Y.) May 2023Dupuytren disease is a common fibroproliferative disease that affects the palmar fascia of the hands. Currently, there is limited consensus regarding the optimal therapy...
BACKGROUND
Dupuytren disease is a common fibroproliferative disease that affects the palmar fascia of the hands. Currently, there is limited consensus regarding the optimal therapy for this condition, with treatment decisions based largely on surgeon preference. Therefore, the aim of this study was to determine which treatments are the most effective for Dupuytren disease.
METHOD
A systematic review and network meta-analyses were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. Medline, EMBASE, and Web of Science were searched for randomized trials comparing treatments for Dupuytren disease in adults. Eligible treatments included open limited fasciectomy, collagenase injection, and percutaneous needle fasciotomy. Study selection, data extraction, and quality appraisal were performed in duplicate. The methodological quality was evaluated with the Cochrane risk-of-bias critical appraisal tool.
RESULTS
Eleven randomized clinical trials were included in this study. At short-term (1-12 weeks) and long-term (2-5 years) time points, fasciectomy improved contracture release more than collagenase and needle fasciotomy as inferred by a lower total passive extension deficit. However, there was no difference between the groups regarding the best possible outcome at any time point. Fasciectomy was also superior in terms of recurrence and patient satisfaction compared with collagenase and needle fasciotomy, but only at later time points. There was no difference in skin damage-related and nerve damage-related complications following fasciectomy compared with other modalities. Risk of bias was generally moderate.
CONCLUSIONS
Fasciectomy provides superior long-term advantages in terms of patient outcomes when compared with collagenase and needle fasciotomy. Larger trials with better blinding of outcome assessors are needed in the future.
PubMed: 37246411
DOI: 10.1177/15589447231174175 -
British Medical Bulletin Jun 2016In the last few years, the use of collagenase clostridium histolyticum for management of Dupuytren's contracture has increased. The procedure of enzymatic fasciectomy... (Review)
Review
INTRODUCTION
In the last few years, the use of collagenase clostridium histolyticum for management of Dupuytren's contracture has increased. The procedure of enzymatic fasciectomy has become popular because it is non-invasive, safe and fast to perform.
SOURCES OF DATA
A systematic search was performed on Medline (PubMed), Web of Science and Scopus databases using the combined keywords 'Dupuytren collagenase' and 'Dupuytren clostridium histolyticum'. Forty-three studies were identified. The quality of the studies was assessed using the Coleman Methodological Score.
AREAS OF AGREEMENT
The use of collagenase clostridium histolyticum provides better outcomes in patients with mild-moderate joint contracture, with lower complications and side effects than open fasciectomy. Manipulation can be performed 2-7 days after the injection. The use of collagenase is cost-effective.
AREAS OF CONTROVERSY
Most of the studies did not report patient-related outcomes. The role of dynamic splint has to be investigated with randomized clinical trials.
GROWING POINTS
The shorter recovery time and the low incidence of serious or major adverse effects are the main advantages of this new technology.
AREAS TIMELY FOR DEVELOPING RESEARCH
There is a need to perform studies with longer follow-up because the recurrence rate seems to increase with time. Further investigations are necessary to assess whether it is safe and effective to inject two or more cords at the same time.
Topics: Clostridium histolyticum; Cost-Benefit Analysis; Dupuytren Contracture; Fasciotomy; Humans; Injections, Intralesional; Microbial Collagenase; Range of Motion, Articular; Treatment Outcome
PubMed: 27151958
DOI: 10.1093/bmb/ldw020 -
Health Technology Assessment... Oct 2015Dupuytren's disease is a slowly progressive condition of the hand, characterised by the formation of nodules in the palm that gradually develop into fibrotic cords.... (Review)
Review
BACKGROUND
Dupuytren's disease is a slowly progressive condition of the hand, characterised by the formation of nodules in the palm that gradually develop into fibrotic cords. Contracture of the cords produces deformities of the fingers. Surgery is recommended for moderate and severe contractures, but complications and/or recurrences are frequent. Collagenase clostridium histolyticum (CCH) has been developed as a minimally invasive alternative to surgery for some patients.
OBJECTIVES
To assess the clinical effectiveness and cost-effectiveness of collagenase as an alternative to surgery for adults with Dupuytren's contracture with a palpable cord.
DATA SOURCES
We searched all major electronic databases from 1990 to February 2014.
REVIEW METHODS
Randomised controlled trials (RCTs), non-randomised comparative studies and observational studies involving collagenase and/or surgical interventions were considered. Two reviewers independently extracted data and assessed risk of bias of included studies. A de novo Markov model was developed to assess cost-effectiveness of collagenase, percutaneous needle fasciotomy (PNF) and limited fasciectomy (LF). Results were reported as incremental cost per quality-adjusted life-year (QALY) gained. Deterministic and probabilistic sensitivity analyses were undertaken to investigate model and parameter uncertainty.
RESULTS
Five RCTs comparing collagenase with placebo (493 participants), three RCTs comparing surgical techniques (334 participants), two non-randomised studies comparing collagenase and surgery (105 participants), five non-randomised comparative studies assessing various surgical procedures (3571 participants) and 15 collagenase case series (3154 participants) were included. Meta-analyses of RCTs assessing CCH versus placebo were performed. Joints randomised to collagenase were more likely to achieve clinical success. Collagenase-treated participants experienced significant reduction in contracture and an increased range of motion compared with placebo-treated participants. Participants treated with collagenase also experienced significantly more adverse events, most of which were mild or moderate. Four serious adverse events were observed in the collagenase group: two tendon ruptures, one pulley rupture and one complex regional pain syndrome. Two tendon ruptures were also reported in two collagenase case series. Non-randomised studies comparing collagenase with surgery produced variable results and were at high risk of bias. Serious adverse events across surgery studies were low. Recurrence rates ranged from 0% (at 90 days) to 100% (at 8 years) for collagenase and from 0% (at 2.7 years for fasciectomy) to 85% (at 5 years for PNF) for surgery. The results of the de novo economic analysis show that PNF was the cheapest treatment option, whereas LF generated the greatest QALY gains. Collagenase was more costly and generated fewer QALYs compared with LF. LF was £1199 more costly and generated an additional 0.11 QALYs in comparison with PNF. The incremental cost-effectiveness ratio was £10,871 per QALY gained. Two subgroup analyses were conducted for a population of patients with moderate and severe disease and up to two joints affected. In both subgroup analyses, collagenase remained dominated.
LIMITATIONS
The main limitation of the review was the lack of head-to-head RCTs comparing collagenase with surgery and the limited evidence base for estimating the effects of specific surgical procedures (fasciectomy and PNF). Substantial differences across studies further limited the comparability of available evidence. The economic model was derived from a naive indirect comparison and was hindered by a lack of suitable data. In addition, there was considerable uncertainty about the appropriateness of many assumptions and parameters used in the model.
CONCLUSIONS
Collagenase was significantly better than placebo. There was no evidence that collagenase was clinically better or worse than surgical treatments. LF was the most cost-effective choice to treat moderate to severe contractures, whereas collagenase was not. However, the results of the cost-utility analysis are based on a naive indirect comparison of clinical effectiveness, and a RCT is required to confirm or refute these findings.
STUDY REGISTRATION
This study is registered as PROSPERO CRD42013006248.
FUNDING
The National Institute for Health Research Health Technology Assessment programme.
Topics: Adult; Cost-Benefit Analysis; Dupuytren Contracture; Humans; Microbial Collagenase; Postoperative Complications; Quality-Adjusted Life Years
PubMed: 26524616
DOI: 10.3310/hta19900 -
BMC Musculoskeletal Disorders Jan 2018Dupuytren's disease (DD) is a common and progressive, fibroproliferative disorder of the palmar and digital fascia of the hand. Various treatments have been recommended... (Review)
Review
BACKGROUND
Dupuytren's disease (DD) is a common and progressive, fibroproliferative disorder of the palmar and digital fascia of the hand. Various treatments have been recommended for advanced disease or to retard progression of early disease and to prevent deterioration of the finger contracture and quality of life. Recent studies have tried to evaluate the clinical and cost-effectiveness of therapies for DD, but there is currently no systematic assessment and appraisal of the economic evaluations.
METHODS
A systematic literature review was conducted, following PRISMA guidelines, to identify studies reporting economic evaluations of interventions for managing DD. Databases searched included the Ovid MEDLINE/Embase (without time restriction), National Health Service (NHS) Economic Evaluation Database (all years) and the National Institute for Health Research (NIHR) Journals Library) Health Technology Assessment (HTA). Cost-effectiveness analyses of treating DD were identified and their quality was assessed using the CHEERS assessment tool for quality of reporting and Phillips checklist for model evaluation.
RESULTS
A total of 103 studies were screened, of which 4 met the study inclusion criteria. Two studies were from the US, one from the UK and one from Canada. They all assessed the same interventions for advanced DD, namely collagenase Clostridium histolyticum injection, percutaneous needle fasciotomy and partial fasciectomy. All studies conducting a cost-utility analysis, two implemented a decision analytic model and two a Markov model approach. None of them were based on a single randomised controlled trial, but rather synthesised evidence from various sources. Studies varied in their time horizon, sources of utility estimates and perspective of analysis. The overall quality of study reporting was good based on the CHEERS checklist. The quality of the model reporting in terms of model structure, data synthesis and model consistency varied across the included studies.
CONCLUSION
Cost-effectiveness analyses for patients with advanced DD are limited and have applied different approaches with respect to modelling. Future studies should improve the way they are conducted and report their findings according to established guidance for conducting economic modelling of health care technologies.
TRIAL REGISTRATION
The protocol was registered ( CRD42016032989 ; date 08/01/2016) with the PROSPERO international prospective register of systematic reviews.
Topics: Clinical Trials as Topic; Cost-Benefit Analysis; Databases, Factual; Disease Management; Dupuytren Contracture; Humans
PubMed: 29370792
DOI: 10.1186/s12891-018-1949-2