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Collagenase (XiapexTM) injection and Manipulation for Dupuytrens contracture Surgical Technique

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This is a detailed step by step instruction through an injection of a pretendinous Dupuytren’s cord with collagenase enzyme.

Dupuytren’s contracture is a relatively common condition which causes a histological alteration in a number of fascial structures within the palmar surface of the hand. It is a clinical diagnosis and only rarely when there is a single nodule which has not caused any contracture in the early stages can it be difficult to diagnose. 75% of cases occur in the ulna 2 digits.

There is no current cure for the disease however there are 4 main groups of treatment options to improve contractures. These options are needle fasciotomy, fasciectomy, dermo-fasciectomy and collagenase injections. Within the fasciectomy group terminology becomes confusing with many terms being used synonymously despite original descriptions differing. Examples are focal, segmental and limited fasciectomy. There is also variation in a dermo-fasciectomy with a small fire-break skin grafts or a larger graft covering a clear anatomical section e.g. volar finger between MCPJ and PIPJ creases.

In addition, adjuncts to surgery such as temporary external fixators or salvage options such as amputation are also included in the Dupuytren’s treatment armamentarium.

Collagenase clostridium hostolyticum (XiapexTM in the UK, XiaflexTM in the USA) injections have be used for Dupuytren’s contracture since FDA (food and drug administrations) approval in 2010. Collagenase is an enzyme which breaks down the peptide bonds in the collagen within Dupuytren’s tissue. AUX-I and AUX-II collagenase break the bonds within Type 1 and Type 3 collagen.

The injection is performed either in a clinic or theatre setting without any anaesthetic and then 1-3 days later (by the distributers recommendations). The finger is manipulated under local anaesthetic (LA) and then a review by the hand therapists and a thermoplastic night splint is applied for 3 months.

In July 2017 NICE (National institute for health and care excellence) in the UK produced guidance for use of collagenase in the NHS. This recommended that a palpable cord could be treated if there is moderate disease (MCPJ contracture 30-60 degrees and PIPJ less than 30 degrees) and one injection per treatment session.

A multicentre RCT the DISC trial (Dupuytren’s interventions surgery versus collagenase) began recruiting in the UK in May 2017 and will have a 2 year follow up for fasciectomy versus collagenase completed by October 2021.

Complications include failure of complete correction (common with severe PIPJ disease where the joint capsule and ligaments are contracted), recurrence (very common over time with rates of around 50% at 5 years depending on disease severity, joint involved and amount of correction achieved at manipulation), tendon rupture, neurovascular injury (rare and usually neuropraxia), skin tear during manipulation, pain and swelling post injection, infection, stiffness and allergy to collagenase.

 

Author: Mr Mark Brewster FRCS (Tr & Orth)

Institution: The Royal Orthopaedic Hospital, Birmingham, UK.

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