Collagenase Injection of the Dupuytren Hand

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Author: Philip Blazar
Published:
Specialties: Orthopedic Surgery, Plastic Surgery
Schools: Brigham and Women's Hospital, Harvard Medical School
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Basic Info

Contributor: John Zhao

Collagenase clostridium histolyticum (CCH) injections were FDA approved in 2010 for use in Dupuytren’s contracture.  Interest among surgeons in this office-based treatment has rapidly increased in the past 5 years due to its shorter recovery time and limited complication rates compared to open fasciectomy.

DOI: http://dx.doi.org/10.17797/qps5cwzfgu

Editor Recruited By: David Bozentka, MD

Advanced

Procedure

The CCH injection procedure is divided into 4 major steps over 2 visits: 1) Selection of injection sites on the Dupuytren cords 2) Preparing the collagenase solution 3) Injection of CCH 4) Manipulation of the digits.

1. First, select optimal injection sites along the Dupuytren cord (0:08). Each cord should be injected in 2 or more sites, with equal distribution of the CCH solution among all planned sites. CCH injection sites are chosen based on: 1) maximal distance from flexor tendons 2) away from adherent scars and skin creases 3) sites where the cord is easily palpable and technically easy to insert a needle.

2. The CCH medication (Xiaflex) arrives lyophilized and must be reconstituted in its provided diluent. The Xiaflex product label (Reference 1) suggests diluting the vial of lyophilized drug (0.9mg) into 0.39mL diluent for MP joints and 0.31 mL for PIP joints, with final injection of 0.25mL for MP joints and 0.20mL for PIP joints. From the senior author¢s clinical experience of over 600 injections, we find that each vial typically provides adequate medication for up to 2 cords without affecting clinical response. Likewise, the volume of diluent can be increased or decreased depending upon the number of injection sites along the cord. We have used a minimum volume of 0.05ml per injection site and a maximum volume of 0.6mL/vial with clinical success.

Use a 1mL 27-gauge inch fixed needle to reconstitute the medication. While reconstituting, avoid shaking or vigorously agitating the enzyme solution to prevent denaturation. Use a gentle swirling motion to mix until all of the lyophilized medication is dissolved (0:25). Carefully draw up the required amount of the CCH solution into the same 1mL needle, while removing any extraneous air bubbles. Note: double check that the solution, and not air, has been drawn into the syringe as the two may be easily mistaken.

3. The senior author¢s clinical experience has found that local anesthesia of the hand prior to CCH injection allows better localization of each Dupuytren cord at multiple sites while improving patient comfort. Thus, we suggest the optional step of either a field block or a digital nerve block with 3-5cc of 2% lidocaine (0:44).

After confirming injection sites, antiseptically prepare each area. The angle of injection can be in any plane and in fact may be safer in some cords from ulnar to radial or dorsal to volar rather than volar to dorsal. Carefully insert the 1mL needle, appreciating a ¢firm and gritty¢ tactile feel as it enters the cord (1:17). Test the plunger for resistance to ensure proper localization of the needle inside the cord. If no resistance is felt, reposition the needle before proceeding. Unlike injecting into a potential space (e.g. flexor sheath for a trigger digit), injecting into a cord will have significant resistance. Repeat this for all planned injection sites. Upon completing the last injection, a bulky, gentle compressive bandage is applied and instruct the patient to ice and elevate the hand overnight.

4. The Xiaflex product label suggests manipulation between 24hrs and 72hrs after injection; however, prior studies have shown similar efficacy at 2 to 4 days (Reference 2), and the senior author has observed less swelling and edema in patients at 5-7 days, allowing for easier manipulation. Some patients will present at this later time period having spontaneously ruptured a cord or cords. It is our practice to still manipulate these patients unless they have achieved full correction.

Prior to manipulation, remind patients that skin tears occur frequently but rarely require any treatment. First, anesthetize the affected digits as previously described. After ensuring the patient¢s hand is adequately anesthetized, manipulate the MP joint into extension with the PIP joint flexed (2:11). Next, extend the PIP joint with the MP joint in flexion. Finally, apply composite extension to the digit. Abduct and adduct the fingers to target cords within the webspace. For MP contractures, extension of the adjacent digits may lead to further rupture of fascia. Successful cord rupture will often result in an audible ¢pop¢ or ¢snap¢, and significant force may be required. Repeat manipulation maneuvers as necessary to maximally reduce the contracture.

Skin tears may result during the digit manipulation (3:03). This complication almost never requires stitches, and even relatively large tears will heal by secondary intention over a few weeks. We treat skin tears with bacitracin ointment for 2-3 days and then dressing changes until healed.

Night-time splinting with a hand orthosis for 3 months is thought to help prevent immediate contracture recurrence and should begin after manipulation (3:13).

Indications

Dupuytren¢s contracture with a fixed-flexion contraction of >20 degrees, patient-reported limitations, and a palpable cord.

Contraindications

CCH injection is not be suitable in Dupuytren patients without a palpable cord. Collagenase is not considered effective in reducing Dupuytren nodules.

Instrumentation

Setup

The hand is placed in the supine position upon the exam table, with many injections in the volar-to-dorsal direction. For some cords (most commonly abductor digiti minimi cords), injecting in the dorsal-to-volar or ulnar-to-radial directions may be technically easier and/or safer for flexor tendons.

Preoperative Workup

Inquire about the patient¢s treatment history for Dupuytren¢s contracture. Measure and document the patient¢s fixed flexion contractures via manual goniometry prior to treatment.

Anatomy and Landmarks

Dupuytren cords are located in the palmar fascia, deep to the cutaneous skin and superficial to the flexor tendons.

Advantages/Disadvantages

CCH injection reduces fixed-flexion contractures in Dupuytren patients with less morbidity, complication risk, and recovery time than open fasciectomy. While long-term data for CCH is currently limited to 5 years (Reference 3), the 5-year recurrence rate is in the range of recurrence rates reported for open fasciectomy.

Complications/Risks

Bruising, swelling of the hand, lymphedema (entire arm), skin tears, infection, tendon rupture.

Disclosure of Conflicts

Bruising, swelling of the hand, lymphedema (entire arm), skin tears, infection, tendon rupture.

Acknowledgements

None

References

1. Auxilium Pharmaceuticals Inc. XIAFLEX- collagenase clostridium histolyticum. 2015. http://www.endo.com/File Library/Products/Prescribing Information/Xiaflex_prescribing_information.html. Accessed February 3, 2016.
2. Kaplan FTD, Badalamente MA, Hurst LC, Merrell GA, Pahk R. Delayed manipulation after collagenase clostridium histolyticum injection for Dupuytren contracture. Hand (N Y). 2015;10(3):578-582. doi:10.1007/s11552-014-9714-y.
3. Peimer CA, Blazar P, Coleman S, Kaplan FTD, Smith T, Lindau T. Dupuytren Contracture Recurrence Following Treatment With Collagenase Clostridium Histolyticum (CORDLESS [Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study]): 5-Year Data. J Hand Surg Am. 2015;40(8):1597-1605. doi:10.1016/j.jhsa.2015.04.036.

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