title: Costs for collagenase injections compared with fasciectomy in the treatment of Dupuytren's contracture: a retrospective cohort study Injectable Collagenase Versus Percutaneous Needle Fasciotomy for Dupuytren Contracture in Proximal Interphalangeal Joints: A Randomized Controlled Trial. Efficacy and safety of collagenase Clostridium histolyticum injection for Dupuytren contracture: report of 40 cases Comparison of Treatment Outcome After Collagenase and Needle Fasciotomy for Dupuytren Contracture: A Randomized, Single-Blinded, Clinical Trial With a 1-Year Follow-Up. Collagenase clostridium histolyticum in patients with Dupuytren’s contracture: results from POINT X, an open-label study of clinical and patient-reported outcomes Injectable collagenase Clostridium histolyticum: a new nonsurgical treatment for Dupuytren's disease. Hand function and quality of life before and after fasciectomy for Dupuytren contracture. Surgical management of Dupuytren's contracture in Europe: regional analysis of a surgeon survey and patient chart review. Factors affecting functional recovery after surgery and hand therapy in patients with Dupuytren's disease. Surgical treatment of Dupuytren’s disease – outcome and health economy in relation to smoking and diabetes Delayed manipulation after collagenase clostridium histolyticum injection for Dupuytren contracture A single-centre cost comparison analysis of collagenase injection versus surgical fasciectomy for Dupuytren's contracture of the hand. Collagenase Clostridium Histolyticum versus Limited Fasciectomy for Dupuytren’s Contracture: Outcomes from a Multicenter Propensity Score Matched Study Injectable collagenase clostridium histolyticum for Dupuytren's contracture. Effectiveness of Conservative, Surgical, and Postsurgical Interventions for Trigger Finger, Dupuytren Disease, and De Quervain Disease: A Systematic Review. Dupuytren's Contracture. The Safety and Efficacy of Collagenase Treatment. New insights into the immediate outcome of collagenase injections for Dupuytren’s contracture The Efficacy and Safety of Concurrent Collagenase Clostridium Histolyticum Injections for 2 Dupuytren Contractures in the Same Hand: A Prospective, Multicenter Study. A comparison of the direct outcomes of percutaneous needle fasciotomy and limited fasciectomy for Dupuytren's disease: a 6-week follow-up study. Treatment of Recurrent Dupuytren Contracture in Joints Previously Effectively Treated With Collagenase Clostridium histolyticum. Pain Associated With Treatment of Dupuytren Contracture With Collagenase Clostridium histolyticum. Cost minimisation using clinic-based treatment for common hand conditions--a prospective economic analysis. The Surgical Treatment of Dupuytren’s Contracture: A Synthesis of Techniques Skin involvement in Dupuytren’s disease
abstract: Objectives To compare collagenase injections and surgery ( fasciectomy ) for Dupuytren 's contracture ( DC ) regarding actual total direct treatment costs and short-term outcomes . Design Retrospective cohort study . Setting Orthopaedic department of a regional hospital in Sweden . Participants Patients aged 65 years or older with previously untreated DC of 30 ° or greater in the metacarpophalangeal ( MCP ) and /or proximal interphalangeal ( PIP ) joints of the small , ring or middle finger . The  collagenase group comprised 16 consecutive patients treated during the first 6 months following the introduction of collagenase as treatment for DC at the study centre . The controls were 16 patients r and omly selected among those operated on with fasciectomy at the same centre during the preceding 3 years . Interventions Treatment with collagenase was given during two st and ard outpatient clinic visits ( injection of 0.9 mg , distributed at multiple sites in a palpable cord , and next-day finger extension under local anaesthesia ) followed by night-time splinting . Fasciectomy was carried out in the operating room ( day surgery ) under general or regional anaesthesia using st and ard technique , followed by therapy and splinting . Primary and secondary outcome measures Actual total direct costs ( salaries of all medical personnel involved in care , medications , material s and other relevant costs ) , and total MCP and PIP extension deficit ( degrees ) measured by h and therapists at 6–12 weeks after the treatment . Results Collagenase injection required fewer hospital outpatient visits to a therapist and nurse than fasciectomy . Total treatment cost for collagenase injection was US$ 1418.04 and for fasciectomy US$ 2102.56 . The post-treatment median ( IQR ) total extension deficit was 10 ( 0–30 ) for the collagenase group and 10 ( 0–34 ) for the fasciectomy group . Conclusions Treatment of DC with one collagenase injection costs 33 % less than fasciectomy with equivalent efficacy at 6 weeks regarding reduction in contracture PURPOSE Collagenase Clostridium histolyticum ( CCH ) injection was introduced commercially as a treatment for Dupuytren contracture following initial phase-3 investigations in 2009 with promising results . However , the efficacy of CCH has not been prospect ively investigated in a direct comparison to other active treatments of Dupuytren contracture with more than 1-year follow-up , despite a wide and increasing clinical use . METHOD In this prospect i ve , independent , open-label , r and omized controlled trial , ( Clinical trials.gov ; NCT 01538017 ) , percutaneous needle fasciotomy ( PNF ) was directly compared with CCH .  Fifty patients with primary isolated proximal interphalangeal joint Dupuytren contractures were enrolled and followed for 2 years . The primary outcome was clinical improvement defined as a reduction in contracture by 50 % or more relative to baseline . Secondary outcomes included change in contracture , recurrence , adverse events , complications , and Disabilities of the Arm , Shoulder , and H and question naire score . RESULTS Clinical improvement at 2 years was maintained in 7 % of CCH patients ( 2 of 29 ) and 29 % of PNF patients ( 6 of 21 ) . Collagenase Clostridium histolyticum led to more , mainly transient , complications , in 93 % of patients versus 24 % of the patients treated with PNF . No other differences were observed . CONCLUSIONS This study provides evidence that CCH is not superior to PNF in the treatment of isolated proximal interphalangeal joint Dupuytren contracture regarding clinical outcome , and it led to more complications than PNF . TYPE OF STUDY /LEVEL OF EVIDENCE Therapeutic Abstract Background Dupuytren ’s disease ( DD ) is a fibroproliferative pathology that affects the palmar aponeurosis causing the development of nodules and collagen cords and the progressive flexion of the fingers . The st and ard procedure is surgical fasciectomy , followed by high recurrence rates . Collagenase Clostridium histolyticum ( CCH ) injection represents an innovative noninvasive approach to the treatment of DD . This prospect i ve study was design ed to examine the efficacy and safety of CCH injection performed in the outpatient , using local anesthesia . Material s and methods Forty patients [ 32 metacarpophalangeal ( MP ) , 8 proximal interphalangeal ( PIP ) ] with Dupuytren ’s contracture of at least 20 ° for MP joint and any degree for PIP joint were included . The mean age was 66 . All joints were treated with a single vial of collagenase injection and manual breaking of the cord 24 h after . All adverse effects ( AEs ) were monitored . Patients were checked 7 , 30 , 90 , and 180 days after the injection . Primary endpoint was a reduction in digit contracture within 0 ° –5 ° of normal extension . Secondary endpoints were the improvement of range of motion , the evaluation of AEs incidence , and cost-effectiveness of collagenase treatment . Results About 67.5 % of patients obtained a clinical success . At 6 months , a further 7.5 % attained the same result . The mean contracture of treated joints was 5.3º for MP and 6.8 ° for PIP joints . Twenty-three patients had one or more mild-to-moderate side effects . Conclusions The use of collagenase appears to be an effective and safe method for the treatment of Dupuytren ’s contracture . Therapeutic success was achieved in a significant percentage of patients . The incidence of side effects was higher , but they were local reactions of short duration . The use of a single collagenase vial in patients treated in day surgery appears more cost-effective than surgery PURPOSE This study compared the efficacy of collagenase treatment and needle fasciotomy for contracture of the metacarpophalangeal ( MCP ) joint in Dupuytren disease . METHODS This is a prospect i ve , single-blinded , r and omized study with follow-up 1 week and 1 year after treatment . One hundred and forty patients with an MCP contracture of 20 ° or more in a single finger were enrolled , of whom 69 patients were r and omized to collagenase treatment and 71 patients to needle fasciotomy .  The patients were followed at 1 week and were examined by a physiotherapist after 1 year . Measurements of joint movement and grip strength were recorded as well as patient-perceived outcomes measured by the Unité Rhumatologique des Affections de la Main ( URAM ) question naire and a visual analog scale ( VAS ) for the estimation of procedural pain and subjective treatment efficacy . RESULTS Eighty-eight percent of the patients in the collagenase group and 90 % of the patients in the needle fasciotomy group had a reduction in their MCP contracture to less than 5 ° 1 week after treatment , and the median gains in passive MCP movement were 48 ° and 46 ° , respectively . The median VAS score for procedural pain was 4.9 of 10 in the collagenase group and 2.7 of 10 in the needle fasciotomy group . After 1 year , 90 % of the patients in both groups had full extension of the treated MCP joint . One patient in each group had a recurrence of the contracture . The median improvement in URAM score was 8 units in both groups and the VAS estimation of treatment efficacy by the patients was 8.7 of 10 in both groups . CONCLUSIONS There was no significant difference between the treatment outcomes after collagenase and needle fasciotomy treatment after 1 year . TYPE OF STUDY /LEVEL OF EVIDENCE Therapeutic In POINT X , a study design ed to reflect clinical practice and patient treatment choices , 254 European patients received  open-label collagenase  for Dupuytren ’s contracture . The most severely affected joint was treated first in 74 % of patients . In total , 52 % , 41 % , 7 % , and 1 % of patients selected the little , ring , middle , and index finger , respectively ; 79 % had one or two joints treated . Only 9 % of patients ( n = 24 ) received 4 or 5 injections . The mean improvement in total passive extension deficit ( TPED ) was 34 ° on day 1 , improving further by day 7 to 42 ° . This secondary improvement was maintained by day 90 and month 6 . The mean number of injections/joint was 1.2 for the metacarpophalangeal joint and 1.25 for the proximal interphalangeal joint . Median time to recovery was 4 days ; the mean improvement in h and function was clinical ly relevant as measured by the Unité Rhumatologique des Affections de la Main ( URAM ) score . In total , 87 % and 86 % of patients and physicians , respectively , were very satisfied or satisfied with treatment at month 6 , although correlation between TPED and patient satisfaction was weak ( Spearman −0.18 , 95 % CI −0.32 to  −0.06 ) . Collagenase  was well tolerated , with 10 ( 3.9 % ) patients experiencing severe adverse events . As a real-world study , the POINT X findings can be generalized to the at-large population PURPOSE The Collagenase Option for the Reduction of Dupuytren 's ( CORD ) II study investigated the efficacy and safety of injectable Xiaflex ( collagenase clostridium histolyticum ) , in patients with Dupuytren 's contracture . METHODS This was a prospect i ve , r and omized , placebo-controlled trial with 90-day double-blind and 9-month open-label phases . We r and omized patients with contractures affecting metacarpophalangeal ( MCP ) or proximal interphalangeal ( PIP ) joints 2 to 1 to collagenase ( 0.58 mg ) or placebo . Cords received a maximum of 3 injections . Cord disruption was attempted the day after injection using a st and ardized finger extension procedure . Primary end point was reduction in contracture to 0 ° to 5 ° of normal 30 days after the last injection . RESULTS We enrolled 66 patients ; 45 cords ( 20 MCP to 25 PIP joints )  received collagenase and 21 cords ( 11 MCP to 10 PIP joints ) received placebo in the double-blind phase . Statistically significantly more cords injected with collagenase than placebo met the primary end point ( 44.4 % vs 4.8 % ; p < . 001 ) . The mean percentage decrease in degree of joint contracture from baseline to 30 days after last injection was 70.5 % ± 29.2 % in the collagenase group and 13.6 % ± 26.1 % in the placebo group ( p < .001 ) . The mean increase in range of motion was significantly greater in the collagenase ( 35.4 ° ± 17.8 ° ) than in the placebo ( 7.6 ° ± 14.9 ° ; p < .001 ) group . Efficacy after open-label treatment was similar to that after the double-blind phase : 50.7 % of all joints achieved 0 ° to 5 ° of normal . More patients were satisfied with collagenase ( p < .001 ) . No joint had recurrence of contracture . One patient had a flexion pulley rupture and one patient underwent routine fasciectomy to address cord proliferation and sensory abnormality . No tendon ruptures or systemic allergic reactions were reported . Most adverse events were related to the injection or finger extension procedure . CONCLUSIONS Collagenase clostridium histolyticum is the first Food and Drug Administration-approved , nonsurgical treatment option for adult Dupuytren 's contracture patients with a palpable cord that is highly effective and well tolerated . TYPE OF STUDY /LEVEL OF EVIDENCE Therapeutic PURPOSE To describe changes in joint motion , sensibility , and scar pliability and to investigate the patients ' expectations , self-reported recovery , and satisfaction with h and function , disability , and quality of life after surgery and h and therapy for Dupuytren disease . METHODS This prospect i ve cohort study collected measurements before surgery and 3 , 6 , and 12 months after surgery and h and therapy .  Ninety patients with total active extension deficits of 60 ° or more from Dupuytren contracture were included . Outcomes measures were range of motion ; sensibility ; scar pliability ; self-reported outcomes on expectations , recovery , and satisfaction with h and function ; Disabilities of the Arm , Shoulder , and H and scores ; safety and social issues of h and function ; physical activity habits ; and quality of life with the Euroqol . RESULTS The extension deficit decreased , and there was a transient decrease in active finger flexion during the first year after surgery . Sensibility remained unaffected . Generally , patients with surgery on multiple fingers had worse scar pliability . The majority of the patients had their expectations met , and at 6 months , 32 % considered h and function as fully recovered , and 73 % were satisfied with their h and function . Fear of hurting the h and and worry about not trusting the h and function were of greatest concern among safety and social issues . The Disability of the Arm , Shoulder , and H and score and the Euroqol improved over time . CONCLUSIONS After surgery and h and therapy , disability decreased independent of single or multiple operated fingers . The total active finger extension improved enough for the patients to reach a functional range of motion despite an impairment of active finger flexion still present 12 months after treatment . TYPE OF STUDY /LEVEL OF EVIDENCE Therapeutic IV AIM We explored regional variations in the surgical management of patients with Dupuytren 's contracture ( DC ) in 12 European countries using a surgeon survey and patient chart review . METHODS Twelve countries participated : Denmark , Finl and , Sweden ( Nordic region ) ; Czech Republic , Hungary , Pol and ( East ) ; France , Germany , the Netherl and s , UK ( West ) ; Italy , Spain ( Mediterranean ) . For the survey , a r and om sample of orthopaedic/plastic surgeons ( n = 687 ) with 3 - 30 years ' experience was asked about DC procedures performed during the previous 12 months . For the chart review ( n = 3357 ) , information from up to five consecutive patients was extracted . Descriptive statistics are reported . RESULTS Ninety-five per cent of all surgeons used fasciectomy for DC , followed by fasciotomy ( 70 % ) , dermofasciectomy ( 38 % ) and percutaneous needle fasciotomy ( 35 % ) . Most surgeons were satisfied with fasciectomy over other procedures . Recommended time away from work and duration of physical therapy  increased with the invasiveness of the procedure . The intra-operative complication rate was 4.0 % ; the postoperative complication rate was 34 % . Overall , ≥ 97 % of the procedures were rated by surgeons as having a positive outcome . Across all regions , 54 % of patients had no nodules or contracture after the procedures . Only 2 % of patients required retreatment within the first year of surgery . Important inter- and intraregional differences in these aspects of patient management are described . CONCLUSIONS Underst and ing current regional treatment patterns and their relationships to country-specific health systems may facilitate earlier identification of , and intervention for , DD and help to optimise the overall treatment for patients with this chronic condition STUDY DESIGN Prospect i ve cohort study . INTRODUCTION The evidence of the relationship between functional recovery and impairment after surgery and h and therapy are inconsistent . PURPOSE OF THE STUDY To explore factors that were most related to functional recovery as measured by DASH in patients with Dupuytren 's disease . METHODS Eighty-one patients undergoing surgery and h and therapy were consecutively recruited .  Functional recovery was measured by the Disability of the Arm , Shoulder and H and ( DASH ) question naire . Explanatory variables : range of motion of the finger joints , five questions regarding safety and social issues of h and function , and health-related quality of life ( Euroqol ) . RESULTS The three variables " need to take special pre caution s " , " avoid using the h and in social context " , and health-related quality of life ( EQ-5D index ) explained 62.1 % of the variance in DASH , where the first variable had the greatest relative effect . DISCUSSION Safety and social issues of h and function and quality of life had an evident association with functional recovery . LEVEL OF EVIDENCE IV Background The conventional treatment for Dupuytren ’s disease is surgery . The introduction of alternative treatment strategies creates a need to track outcomes and costs relating to surgical treatment and risk factors , such as smoking and diabetes . This was the aim of the present study . Methods In a prospect i ve study , the outcome of open surgical treatment for finger flexion contracture in Dupuytren ’s disease ( 175 patients ; 182 surgical procedures ) was studied by evaluating valid QuickDASH forms answered by subjects before surgery and one year postoperatively . Data were also obtained from medical records , and preoperative declarations concerning health . Results In all subjects ( median [ 25 % - 75 % percentiles ] age 68 [ 62 - 73 ] ) , the QuickDASH score improved from 22 [ 9 - 36 ] to 5 [ 0 - 18 ] . Smokers ( 27/179 procedures ) were younger and had a more severe degree of disease and dysfunction preoperatively than non-smokers , but the outcome of surgery did not differ between the groups . Subjects with diabetes ( 20/181 procedures ) were younger than those without diabetes , but their disease severity or outcome did not differ . H and specialists operated faster than residents , but the surgical outcome did not differ . Healthcare costs for surgery for Dupuytren ’s contracture were $ 2392 ( € 1859 ) , which were not higher among smokers or subjects with diabetes . Only 22 patients remained in hospital ( 2 [ 1 - 2.3 ] days ) and 28 patients needed sick leave ( 28 [ 21 - 31 ] days ) . The occurrence of necrosis of skin flaps ( 12 % ) or infections ( 6 % ) was no more frequent among smokers or those with diabetes . Conclusions There is no difference in surgical outcome for finger flexion contracture in Dupuytren ’s disease between smokers and non-smokers or between subjects with or without diabetes , although smokers had more severe preoperative contracture . The costs for surgical treatment for finger flexion contracture in Dupuytren ’s disease should be viewed in relation to that for other treatment strategies Background Collagenase clostridium histolyticum ( CCH ) injection for Dupuytren contracture was approved in the USA in 2010 . Current FDA guidelines stipulate that finger manipulation occurs the day following injection . To investigate the safety and efficacy of delaying manipulation to 2 or 4 days following CCH injection , we conducted a prospect i ve , r and omized trial at two sites . Methods Patients with Dupuytren contracture involving the metacarpophalangeal ( MCP ) joint ≥20 ° caused by a palpable cord participated . All patients received one dose of CCH ( 0.58 mg/0.25 ml ) and were followed for 90 days . The primary end point was the percent of patients maintaining clinical success ( reduction of contracture to 0 ° –5 ° ) at 90 days post-injection . Adverse events and change in Michigan H and Question naire ( MHQ ) score were recorded as secondary end points . Results Thirty-seven patients enrolled ; 13 were manipulated on day 1 , 11 on day 2 , and 13 on day 4 . At 30 days after injection , the percentage of patients obtaining reduction of contracture to < 0 ° –5 ° extension was 92 , 82 , and 85 % in groups 1 , 2 , and 3 , respectively , with no significant difference . At 90 days follow-up , the percentage of patients maintaining 0 ° –5 ° extension was 91 , 82 , and 83 % in groups 1 , 2 , and 3 , respectively , with no significant difference . Adverse events were comparable to rates in prior studies . There were no serious adverse events . There was no statistical difference in MHQ scores between groups at any time point . Conclusions Delaying manipulation to day 2 or 4 following CCH injection for MCP joint contractures does not increase adverse events or result in loss of efficacy . Level of Evidence : Therapeutic , Level II BACKGROUND AND AIM The options for treating patients with Dupuytren 's contracture have broadened with the introduction of collagenase . Although the literature would suggest that collagenase treatment is effective , has few complications and is popular with patients , it has not been widely commissioned by the National Health Services of the United Kingdom and other European countries due to concerns about cost . The aim of this study was to compare the cost of surgical fasciectomy to collagenase injections for the treatment of Dupuytren 's contracture in a single centre . METHOD Prospect i ve data on 40 patients undergoing fasciectomy or collagenase injection ( 20 patients in each group ) were collected between January and March 2013 . Financial data on the costs of the procedures , equipment , theatre time and follow-up appointments were calculated . RESULTS The average cost of an open partial fasciectomy pathway was £ 7115.34 and that of a collagenase pathway was £ 2110.62 . Eight collagenase patients had physician-led follow-up appointments and only three had h and physiotherapy appointments . By contrast , every fasciectomy patient had at least one physician and one physiotherapist follow-up appointment routinely . CONCLUSION The results of this study demonstrate that collagenase treatment for Dupuytren 's contracture of a single digit in selected patients is just over £ 5000 less than treatment for the same condition using surgical fasciectomy . Collagenase-treated patients require much less physician- and physiotherapist-led postoperative follow-up Background : Controversy exists about the relative effectiveness of injectable collagenase ( collagenase clostridium histolyticum ) and limited fasciectomy in the treatment of Dupuytren ’s contracture . The authors compared the effectiveness of both techniques in actual clinical practice . Methods : This study evaluated all subjects treated with collagenase clostridium histolyticum or limited fasciectomy for metacarpophalangeal and /or proximal interphalangeal joint contractures between 2011 and 2014 at seven practice sites . The authors compared the degree of residual contracture ( active extension deficit ) , Michigan H and Outcomes Question naire scores , and adverse events at follow-up visits occurring between 6 and 12 weeks after surgery or the last injection with the use of propensity score matching . Results : In 132 matched subjects who were treated with collagenase ( n = 66 ) or fasciectomy ( n = 66 ) , the degree of residual contracture at follow-up for affected metacarpophalangeal joints was not significantly different ( 13 degrees versus 6 degrees ; p = 0.095 ) and affected proximal interphalangeal joints had significantly worse residual contracture in the collagenase group compared with those in the fasciectomy group ( 25 degrees versus 15 degrees ; p = 0.010 ) . Collagenase subjects experienced fewer serious adverse events than did fasciectomy subjects and reported larger improvements in the Michigan H and Outcomes Question naire subscores evaluating satisfaction with h and function , activities of daily living , and work performance . Conclusions : This propensity score – matched study showed that collagenase clostridium histolyticum was not significantly different from limited fasciectomy in reducing metacarpophalangeal joint contractures , whereas proximal interphalangeal joint contractures showed slightly better reduction following limited fasciectomy . Collagenase provided a more rapid recovery of h and function than did fasciectomy and was associated with fewer serious adverse events . CLINICAL QUESTION /LEVEL OF EVIDENCE : Therapeutic , III BACKGROUND Dupuytren 's disease limits h and function , diminishes the quality of life , and may ultimately disable the h and . Surgery followed by h and therapy is st and ard treatment , but it is associated with serious potential complications . Injection of collagenase clostridium histolyticum , an office-based , nonsurgical option , may reduce joint contractures caused by Dupuytren 's disease . METHODS We enrolled 308 patients with joint contractures of 20 degrees or more in this prospect i ve , r and omized , double-blind , placebo-controlled , multicenter trial . The primary metacarpophalangeal or proximal interphalangeal joints of these patients were r and omly assigned to receive up to three injections of collagenase clostridium histolyticum ( at a dose of 0.58 mg per injection ) or placebo in the contracted collagen cord at 30-day intervals . One day after injection , the joints were manipulated . The primary end point was a reduction in contracture to 0 to 5 degrees of full extension 30 days after the last injection . Twenty-six secondary end points were evaluated , and data on adverse events were collected . RESULTS Collagenase treatment significantly improved outcomes . More cords that were injected with collagenase than cords injected with placebo met the primary end point ( 64.0 % vs. 6.8 % , P < 0.001 ) , as well as all secondary end points ( P < or = 0.002 ) . Overall , the range of motion in the joints was significantly improved after injection with collagenase as compared with placebo ( from 43.9 to 80.7 degrees vs. from 45.3 to 49.5 degrees , P < 0.001 ) . The most commonly reported adverse events were localized swelling , pain , bruising , pruritus , and transient regional lymph-node enlargement and tenderness . Three treatment-related serious adverse events were reported : two tendon ruptures and one case of complex regional pain syndrome . No significant changes in flexion or grip strength , no systemic allergic reactions , and no nerve injuries were observed . CONCLUSIONS Collagenase clostridium histolyticum significantly reduced contractures and improved the range of motion in joints affected by advanced Dupuytren 's disease . ( Clinical Trials.gov number , NCT00528606 . OBJECTIVES To provide an evidence -based overview of the effectiveness of conservative and (post)surgical interventions for trigger finger , Dupuytren disease , and De Quervain disease . DATA SOURCES Cochrane Library , Physiotherapy Evidence Data base , PubMed , Embase , and CINAHL were search ed to identify relevant systematic review s and r and omized controlled trials ( RCTs ) . DATA SELECTION Two review ers independently applied the inclusion criteria to select potential studies . DATA EXTRACTION Two review ers independently extracted the data and assessed the method ologic quality . DATA SYNTHESIS A best- evidence synthesis was performed to summarize the results . Two review s ( trigger finger and De Quervain disease ) and 37 r and omized controlled trials ( RCTs ) ( trigger finger : n=8 ; Dupuytren disease : n=14 , and De Quervain disease : n=15 ) were included . The trials reported on oral medication ( Dupuytren disease ) , physiotherapy ( De Quervain disease ) , injections and surgical treatment ( trigger finger , Dupuytren disease , and De Quervain disease ) , and other conservative ( De Qervain disease ) and postsurgical treatment ( Dupuytren disease ) . Moderate evidence was found for the effect of corticosteroid injection  on the very short term for trigger finger , De Quervain disease , and for injections with collagenase ( 30d ) when looking at all joints , and no evidence was found when looking at the PIP joint for Dupuytren disease . A thumb splint as additive to a corticosteroid injection seems to be effective ( moderate evidence ) for De Quervain disease ( short term and midterm ) . For Dupuytren disease , use of a corticosteroid injection within a percutaneous needle aponeurotomy in the midterm and tamoxifen versus a placebo before or after a fasciectomy seems to promising ( moderate evidence ) . We also found moderate evidence for splinting after Dupuytren surgery in the short term . CONCLUSIONS In recent years , more and more RCTs have been conducted to study treatment of the aforementioned h and disorders . However , more high- quality RCTs are still needed to further stimulate evidence -based practice for patients with trigger finger , Dupuytren disease , and De Quervain disease BACKGROUND Our main goal was to see if treatment with collagenase injection is safe and effective and to assess patient satisfaction with this new treatment . METHODS We prospect ively followed 77 consecutive patients , treated for contracture in 91 fingers and 142 joints that received total of 109 collagenase injections .  The patients were review ed on the first and second day and at 4 and 12 months . A contracture reduced to five degrees or less at 12 months after the last injection , was considered to be a successful outcome . RESULTS A mean of 1.2 injections were used per patient and 0.8 injections per joint . There was a significant improvement in mean passive extension deficit . Out of the 142 joints treated , 84 ( 59 % ) met our criterion for a successful outcome ; 56 ( 80 % ) out of 70 MCP joints and 28 ( 39 % ) out of 72 PIP joints . There were also significant improvements in both h and function and pain . No serious adverse events were observed . The mean patient satisfaction with the treatment at the 12-month follow up was a VAS score of 78 ( 0 = none ; 100 = complete ) and only 11 % stated that they would not have consented to the treatment if they had known the outcome in advance . CONCLUSIONS Treatment of Dupuytren 's disease with collagenase injection is both safe and effective . It is now our primary treatment for Dupuytren 's disease Collagenase clostridium histolyticum is now established as an effective and safe option to treat patients with a single joint affected with Dupuytren ’s contracture . We have extended its use to  natatory and combined cords .  In a prospect i ve consecutive series of 298 cords in 237 patients , the mean total extension loss improved in cords crossing the metacarpophalangeal joint from 46 ° to 1 ° , in cords crossing the proximal interphalangeal joint from 56 ° to 7 ° , in natatory cords from 130 ° to 25 ° and in combined cords from 102 ° to 16 ° . The immediate correction of combined cords and natatory cords was less reliable than that obtained in cords crossing the metacarpophalangeal joint or proximal interphalangeal joint . Less severe pre-intervention contractures tended to correct better . We found a high complication rate , which may cause alarm . A total of 21 % developed skin splits , with the risk of skin splits generally increasing with more severe pre-injection deformity . Blood blisters were only encountered after manipulation of the more severe contractures . A total of 23 patients ( 8 % ) had a spontaneous rupture and 57 patients ( 19 % ) had a partial spontaneous rupture . Only 4.9 % needed a second injection . We noticed a learning curve , with seven of the first 20 cords ( 35 % ) needing a second injection to achieve a satisfactory correction and then only seven ( 2.5 % ) in the rest . Level of evidence : PURPOSE To evaluate efficacy and safety of concurrent administration of 2 collagenase clostridium histolyticum ( CCH ) injections to treat 2 joints in the same h and with Dupuytren fixed flexion contractures ( FFCs ) . METHODS Patients with 2 or more contractures in the same h and caused by palpable cords participated in a 60-day , multicenter , open-label , phase 3b study . Two 0.58 mg CCH doses were injected into 1 or 2 cords in the same h and ( 1 injection per affected joint ) during the same visit . Finger extension was performed approximately 24 , 48 , or 72 or more hours later . Changes in FFC and range of motion , incidence of clinical success ( FFC ≤ 5 ° ) , and adverse events ( AEs ) were summarized . RESULTS The study enrolled 715 patients ( 725 treated joint pairs ) , and 714 patients ( 724 joint pairs ) were analyzed for efficacy . At day 31 , mean total FFC ( sum of 2 treated joints ) decreased 74 % , from 98 ° to 27 ° . Mean total range of motion increased from 90 ° to 156 ° . The incidence of clinical success was 65 % in metacarpophalangeal joints and 29 % in proximal interphalangeal joints . Most treatment-related AEs were mild to moderate , resolving without intervention ; the most common were swelling of treated extremity , contusion , and pain in extremity . The incidence of skin lacerations was 22 % ( 160 of 715 ) . Efficacy and safety were similar regardless of time to finger extension . CONCLUSIONS Collagenase clostridium histolyticum can be used to effectively treat 2 affected joints concurrently without a greater risk of AEs than treatment of a single joint , with the exception of skin laceration . The incidence of clinical success in this study after 1 injection per joint was comparable to phase 3 study results after 3 or more injections per joint . Two concurrent CCH injections may allow more rapid overall treatment of multiple affected joints , and the ability to vary the time between CCH injection and finger extension may allow physicians and patients greater flexibility with scheduling treatment PURPOSE The dem and for percutaneous needle fasciotomy ( PNF ) as treatment for Dupuytren 's disease is increasing because of its limited invasiveness , good outcome , limited number of complications , quick recovery , and overall patient satisfaction . This r and omized controlled trial was design ed to test whether these short-term expectations are sound by comparing this treatment with limited fasciectomy ( LF ) with regard to these aspects . METHODS We treated 166 rays : 88 by PNF and 78 by LF .  Total passive extension deficit ( TPED ) improvement at 1 week and at 6 weeks were the primary outcome parameters ; patient satisfaction , h and -function recovery , and complication rate were secondary outcome parameters . We used the Disabilities of the Arm , Shoulder , and H and question naire to measure disabilities of the upper extremity before and after treatment and all adverse effects and complications were recorded . RESULTS Overall TPED improvement was best at 6 weeks . In the PNF group TPED improved by 63 % versus 79 % in the LF group ; this difference was statistically significant . Results at the proximal interphalangeal joint were worse than those at the metacarpophalangeal and distal interphalangeal joints for both the PNF and LF groups . The rays classified before surgery as Tubiana stages I and II showed no difference between these treatments , but for rays higher than stage II LF clearly was superior to PNF as a treatment modality . The rate of major complications in the LF group was 5 % versus 0 % in the PNF group . Patient satisfaction was almost equal but direct h and function after treatment was considered better in the PNF group , as was the degree of discomfort that patients experienced . This was underscored by the Disabilities of the Arm , Shoulder , and H and scores in the PNF group , which were significantly lower than those in the LF group at all time points measured . CONCLUSIONS In the short term and in cases with a TPED of 90 degrees or less PNF is a good treatment alternative to LF for treatment of Dupuytren 's disease . TYPE OF STUDY /LEVEL OF EVIDENCE Therapeutic , Level PURPOSE Collagenase Clostridium histolyticum ( CCH ) is approved for the treatment of adults with Dupuytren contracture with a palpable cord . This open-label , phase 4 study evaluated the safety and efficacy of CCH for the retreatment of recurrent contractures in joints that were previously effectively treated with CCH . METHODS Patients participating in a long-term follow-up study who had contracture recurrence ( increased ≥ 20 ° with a palpable cord ) after successful treatment in the previous study were eligible . Recurrent joint contractures were treated with up to 3 CCH injections ( ∼ 1 month apart ) . Patients were followed for 1 year to evaluate safety . Assessment s included change in joint contracture , range of motion , and the percentage of joints that achieved contracture of 5 ° or less at day 30 after the last injection . RESULTS The efficacy analysis included 51 patients with 1 treated joint per patient ( 31 metacarpophalangeal , 20 proximal interphalangeal ) . A total of 35 joints ( 69 % ) received 1 injection , 12 ( 24 % ) received 2 injections , and 4 ( 8 % ) received 3 injections . Fifty-seven percent of joints achieved contracture of 5 ° or less ( 29 of 51 ) . Overall , 86 % ( 43 of 50 ) patients had a 20 ° or greater increase in range of motion . The adverse event profile was consistent with previous studies . One ligament injury was reported . CONCLUSIONS At a short-term follow-up of 1 year , recurrent contracture in joints previously successfully treated with CCH may be effectively retreated with up to 3 injections of CCH . TYPE OF STUDY /LEVEL OF EVIDENCE Therapeutic IV PURPOSE The primary objective of this study was to quantify the degree of pain associated with collagenase Clostridium histolyticum ( CCH ) injection and to determine whether it is related to other factors in the intervention . METHODS A prospect i ve study of 135 patients was performed to evaluate pain at 3 points during treatment : ( 1 ) after CCH injection , using a numerical rating scale ( NRS ) , ( 2 ) a binary ( positive/negative ) assessment before manipulation 24 hours after CCH and after removing the b and age , and ( 3 ) after joint manipulation performed with wrist block anesthesia . RESULTS The average NRS for pain during infiltration was 4.7 . Pain was present before manipulation in 52.6 % of patients . Pain from manipulation showed an average NRS score of 3.6 . The amounts of pain at CCH infiltration , pain after 24 hours , and pain from the manipulation were correlated because patients who experienced pain during CCH infiltration were more likely to report experiencing pain during manipulation . CONCLUSIONS Collagenase Clostridium histolyticum injection for treating Dupuytren contracture can be a painful process . There is a clear relationship between a patient 's level of pain during injection of CCH and the likelihood that the patient will experience pain during manipulation , even with the use of local anesthesia . TYPE OF STUDY /LEVEL OF EVIDENCE Prognostic IV INTRODUCTION The purpose of this study was to compare the cost of treatment of Dupuytren 's disease , ganglia and trigger digits in the out-patient department with the operating theatre . PATIENTS AND METHODS All patients seen in a new patient h and clinic with a diagnosis of Dupuytren 's disease , trigger digit or ganglion of the wrist or h and requiring treatment were prospect ively identified over a 6-month period . The numbers undergoing a procedure in the out-patient clinic or theatre were recorded . Costings of theatre time and out-patient time  , as well as national tariff income , were obtained from the hospital management . RESULTS Over the 6-month period , 80 , 26 , and 52 patients were treated with regard to Dupuytren 's disease , ganglia and trigger digits , respectively . Of these , 37 , 23 , and 44 were treated by an out-patient procedure , and 43 , 3 and 8 underwent a formal operation . The total cost of the out-patient procedures was calculated at pound 1560 over 6 months . To perform these as formal operations would have cost pound 64,896 . The cost savings were , therefore , pound 63,336 , or pound 126,672 per annum . CONCLUSIONS Out-patient interventions for Dupuytren 's disease , ganglia and trigger digits result in significant cost savings over formal surgical treatment Dupuytren ’s disease is an affliction of the palmar fascia . Selective fasciectomy is recommended once contracture has occurred . Alternatives for wound closure include tissue rearrangement , the open palm technique , and full-thickness skin grafting . In this prospect i ve study , a new “ synthesis ” technique was used to treat a cohort of patients with advanced Dupuytren ’s disease . The results were then compared with those of a second cohort of patients who underwent the open palm technique . Thirty consecutive patients were selected . Ten patients ( nine men and one woman ; average age , 67 years ) underwent the open palm technique , and 20 patients ( 18 men and two women ; average age , 70 years ) underwent the synthesis method .  Follow-up was 3.5 years for the open palm group and 2.7 years for the synthesis group . All patients in both groups improved with respect to motion , function , appearance , and satisfaction . Objective ly , for the open palm technique , metacarpophalangeal joint contracture decreased from 50 degrees to 0 degrees , and proximal interphalangeal joint contracture decreased from 40 degrees to 6 degrees . Using the synthesis method , metacarpophalangeal joint contracture decreased from 57 degrees to 0 degrees , and proximal interphalangeal joint contracture decreased from 58 degrees to 10 degrees . The Disabilities of the Arm , Shoulder , and H and Test scores decreased from 37 to 30 in both groups . There were no significant differences between groups in these parameters . The two significant intergroup differences were healing time ( 40 days for the open palm technique versus 28 days for the synthesis method ) and recurrence rate ( 50 percent for open palm versus 0 percent for synthesis ) . The synthesis technique combines with success the best features of current methods for the surgical treatment of advanced Dupuytren ’s disease Whether the palmar skin has a role in the development , propagation or recurrence of Dupuytren ’s disease remains unclear . Clinical assessment for skin involvement is difficult and its correlation with histology uncertain . We prospect ively biopsied the palmar skin of consecutive patients undergoing single digit fasciectomy ( for primary Dupuytren ’s disease without clinical ly involved skin ) and dermofasciectomy ( for clinical ly involved skin or recurrence ) in order to investigate this relationship . We found dermal fibromatosis in 22 of 44 patients ( 50 % ) undergoing fasciectomy and 41 of 59 patients ( 70 % ) undergoing dermofasciectomy .  Dermal fibromatosis appeared to be associated with greater preoperative angular deformity , presence of palmar nodules and occupations involving manual labour . Dermal fibromatosis exists in the absence of clinical features of skin involvement and we hypothesize that the skin may have a greater role in the development and propagation of Dupuytren ’s disease than previously thought . Level of evidence :
target: Outcomes , such as range of motion , recurrence , and clinical success , were frequently defined , however many different definitions were used .
background: This systematic review summarizes the outcome reporting st and ards in Dupuytren ’s disease treatment research .