Collagenase Injections for Dupuytren's Contracture

Dupuytren's contracture is a condition that creates scar-like tissue in the hand and causes the fingers to be pulled into a clenched position. Dupuytren's contracture occurs in hundreds of thousands of Americans and millions of people worldwide. The condition prevents those affected from being able to fully straighten their fingers, and severity can range from very mild, with mostly normal finger mobility, to severe cases where fingers become stuck in the palm of the hand.

Dupuytren's contracture is a manifestation of Dupuytren's disease, a syndrome that can also cause contractures of the soft-tissues on the sole of the feet (Lederhose disease) or, in men, in the penis (Peyronie's disease). There is no known cure for Dupuytren's disease, and little is understood about the cause of this condition. Until recently, there were also very few treatment options for patients who suffer from these conditions.

Collagenase Injections

Collagenase has emerged as a useful treatment for some patients with Dupuytren's contracture. The type of tissue that contracts in the palm and fingers is made of collagen. The contracture forms both nodules and cords that make the skin on the palm of the hand tight, pulling the fingers in to the palm. Collagenase is an enzyme that is produced by a bacteria called Clostridium histolyticum. This enzyme can be used to eat away at collagen, causing its structure to weaken. This type of collagenase can be extracted from the bacteria and used to inject the Dupuytren's cords. One day after the injection, after the enzyme has done its work, you will return to the healthcare provider to have the finger manipulated to break up the tightened tissue, restoring finger mobility.

The collagenase injection is sold under the trade name Xiaflex. It comes prepackaged in a syringe that is delivered directly to your treating practitioner. Any healthcare provider can become certified to administer Xiaflex injections, but this procedure is most commonly done by orthopedic surgeons, hand surgeons, and rheumatologists.

Complications of Collagenase

Collagenase injections are generally considered to be safe procedures. However, while the risks associated with collagenase injections are minimal, they are not nonexistent, and there are some potential problems the patient should be aware of prior to undergoing injection of collagenase. These risks include the following.

• Pain: Pain can occur at the time of the initial injection, but also at the time of the manipulation. Most people can tolerate the discomfort, but there are some people who cannot undergo treatment because the pain from either the injection or the manipulation is too severe.
• Skin injury: When Dupuytren's contracture pulls the fingers down, the skin around the abnormal tissue can also contract. Aggressive manipulation of the fingers can lead to damage of the skin, including tears. Typically these will gradually close with time, but people undergoing manipulation should be aware of possible skin injury.
• Tendon rupture: Collagenase will help to break up the abnormal Dupuytren's tissue, but can also cause damage to the tendons that lie in close proximity to the abnormal Dupuytren's tissue.
• Swelling/hematoma: Fluid and blood can build up underneath the skin at the site of the injection and the manipulation.

When complications do occur, further intervention is sometimes necessary. Typically, these complications can be well managed. Finding a provider who has experience performing collagenase injections can help to minimize the risk of these occurring. Complications can also be avoided when providers are careful to use collagenase only in the appropriate setting. When collagenase is injected in situations that are pushing the boundaries of the ability of these injections, complications are more likely to occur.

Treatment Options for Dupuytren's Contracture

Until recently, the only options for treatment of Dupuytren's contracture were observation or surgery. Because the surgery is highly invasive and can involve protracted rehabilitation, most healthcare providers recommended waiting as long as possible, then having surgery only when absolutely necessary. Things have changed, however, and as less-invasive treatments have become available, many practitioners are trying to treat Dupuytren's contracture in the earlier stages to prevent progression to a more severe deformity that is much harder to correct.

In general, there are four treatment options for Dupuytren's contracture.

• Observation: Observation is the standard initial treatment for Dupuytren's. Most people with minimal contractures are not bothered by the condition, and if progression is slow, treatment may not be needed. These patients may have their condition regularly monitored to assess for progression.
• Needle aponeurotomy: Needle aponeurotomy has been performed in Europe for several decades and has become more popular in the U.S. over the last 10 years. In this procedure, your healthcare provider uses the tip of a needle to carefully break up the contracted cords of tissue, allowing the finger to straighten. Large incisions are not needed. Some practitioners and patients prefer this procedure because it is by far the least expensive of the treatments (other than observation), and can often be done in only one visit, with minimal recuperation.
• Collagenase: Collagenase injections have become more popular since 2010, when the FDA approved the first medication for this use (Xiaflex) in the United States. Xiaflex must be injected by a certified physician who has been trained in the use of the medication. Collagenase injections are expensive (over $3,000 per vial), and may require more than one vial of medication in more extensive contractures. That said, this treatment is almost always less expensive than having surgery.
• Surgery: As stated, until recently, surgery was the only treatment available for Dupuytren's contracture. While surgery is often the best treatment for more severe contractures, there are some downsides. Surgery is more invasive and more painful, and often involves a much longer rehabilitation than less-invasive options. That said, less-invasive options tend to do best in patients with mild to moderate contractures, whereas results after more severe deformities are often better treated with surgery. In addition, surgery has been shown to provide longer-lasting relief, with a longer time until recurrence of deformity.

Which Is Best?

There really is no "best treatment," as all of these options have pros and cons. Certainly, if a less-invasive option is appropriate, then most patients will prefer such options. Unfortunately, some patients require more extensive treatment; in those cases, surgery may be the best choice. Whichever option you choose, it is important to identify a physician who uses the treatment regularly and has regular experience with your chosen procedure. Some practitioners are skilled in more than one technique, but if you want to compare options, you may have to see more than one healthcare provider.

No matter what treatment is chosen, patients need to understand there is at present no cure for Dupuytren's disease, only treatments for the manifestations of the condition (the contracture). Therefore, no matter what treatment is performed, recurrence of the contracture is likely. Recurrence after needle aponeurotomy occurs in an average of three years, while after surgery the average is five years. There is not enough data at this time to know how well collagenase injection treatments will work in terms of recurrence.