Salvage palmar fasciectomy after initial treatment with collagenase clostridium histolyticum.

BACKGROUND

Collagenase clostridium histolyticum was approved for clinical use in 2010 and has become an accepted treatment modality for Dupuytren's contracture. Because longitudinal experience with injectable collagenase remains limited, the effect of treatment on future surgery is not well defined.

METHODS

A retrospective review of the senior author's practice from February of 2010 through March of 2014 was performed. Eleven patients were identified who had digital or palmar fasciectomy after at least one previous injection of collagenase clostridium histolyticum. Cases were reviewed for functional outcomes and operative difficulty.

RESULTS

Seven metacarpophalangeal joints and 12 proximal interphalangeal joints in 11 patients were treated. Nine of the 11 patients were referred to the senior author after collagenase clostridium histolyticum injections by other hand surgeons; two patients had previous injections by the senior author. The average interval between most recent injection and salvage fasciectomy was 12 months. Intraoperative findings demonstrated disruption of normal architecture and areolar tissue, with extensive scar in the dissection planes after previous injection. Mean preoperative/postinjection joint contracture for metacarpophalangeal and proximal interphalangeal joints was 42 and 60 degrees, respectively; after surgery, joint contractures were 0 and 21 degrees, respectively. Significant improvement in postoperative range of motion was seen for both metacarpophalangeal and proximal interphalangeal joints after palmar fasciectomy.

CONCLUSIONS

Collagenase clostridium histolyticum injections may produce a deeply scarred bed and increase the technical difficulty of salvage fasciectomy. However, results of palmar fasciectomy are comparable to those of primary fasciectomy even in the setting of recurrent or progressive disease.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.