What is the best way to treat Dupuytren's contracture in an office setting?

Treatment of Dupuytren's Contracture in the Office Setting

Collagenase clostridium histolyticum injection is the recommended first-line office-based treatment for Dupuytren's contracture, offering significant reduction in contractures and improved range of motion with minimal invasiveness. 1, 2

Diagnostic Assessment

• Perform a focused clinical examination to identify contracture cords, measure joint angles, and assess functional limitations 3
• Document the degree of contracture at metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints using goniometry 1
• Evaluate for risk factors that may affect treatment outcomes, including diabetes and smoking history 2

Non-Surgical Management Options

Collagenase Clostridium Histolyticum Injection

• Administer 0.58 mg collagenase injection directly into the palpable Dupuytren's cord 1
• Schedule manipulation of the finger 24 hours after injection to rupture the cord under local anesthesia 2
• Results show significant improvement:
  • MCP joint contractures can improve from an average of 51° to 0° 4
  • PIP joint contractures typically improve from an average of 63° to 15° 4
  • Long-term studies show sustained improvement after 5.7 years with contracture reduction from 42° to 17° in MCP joints and 56° to 33° in PIP joints 2

Needle Aponeurotomy

• Consider percutaneous needle fasciotomy as an alternative minimally invasive option 4
• This technique involves using a needle to divide the cord through multiple punctures 3
• Less effective than collagenase for severe contractures but can be performed immediately in the office 3

Post-Procedure Management

• Initiate hand therapy immediately following the procedure to maintain range of motion 5
• Provide resting hand/wrist splints along with regular stretching to prevent recurrence 6
• Monitor for common adverse effects:
  • Local edema (most common) 4
  • Bruising and skin tears (typically heal without intervention) 5, 4
  • Transient regional lymph node enlargement 1

Considerations for Specific Joint Involvement

• MCP joint contractures respond better to collagenase treatment than PIP joint contractures 2, 7
• For combined MCP and PIP contractures, expect better outcomes at the MCP joint 4
• PIP joints may require additional treatments or alternative approaches if severely contracted 4

Follow-up and Monitoring

• Evaluate treatment success at 30 days post-procedure 1
• Define success as reduction in contracture to 0-5° of full extension 1
• Long-term follow-up shows recurrence rates of approximately 11% for MCP joints and 19% for PIP joints after 5.7 years 2

Potential Complications and Management

• Serious adverse events are rare but may include:
  • Tendon rupture (reported in <1% of cases) 1
  • Complex regional pain syndrome (very rare) 1
• Most common adverse events are mild and self-limiting:
  • Skin tears occur in approximately 18% of cases but heal without intervention 4
  • No significant changes in flexion or grip strength have been reported 1
  • No systemic allergic reactions or nerve injuries have been observed in clinical trials 1

Clinical Pearls

• Collagenase treatment is most effective for MCP joint contractures 4, 7
• Patients with diabetes and smokers may have worse long-term outcomes 2
• The office-based procedure significantly reduces surgical waiting lists 5
• Patient satisfaction rates are high with collagenase treatment compared to placebo 7