First-Line Therapy for Dupuytren's Contracture
Collagenase clostridium histolyticum (CCH) injection is the first-line therapy for adults with a palpable Dupuytren's cord causing MCP or PIP joint contracture, offering a minimally invasive alternative to surgery with proven efficacy.
Treatment Approach
Primary Intervention: Collagenase Injection
CCH injection (0.58 mg) directly into the palpable cord is the recommended initial treatment, followed by a standardized finger extension procedure 24 hours later to disrupt the enzymatically weakened cord 1, 2, 3.
Most patients (60%) require only a single injection per cord, with 24% requiring 2 injections and 16% requiring 3 injections to achieve optimal results 4.
Treatment can address multiple cords concurrently in the same hand, eliminating the traditional 30-day wait between treatments and allowing rapid correction of multiple contractures 1.
Expected Outcomes by Joint Type
Metacarpophalangeal (MCP) Joints:
- Clinical success (reduction to 0-5° of full extension) achieved in 70% of treated MCP joints 2.
- Mean contracture reduction of 55° with 73% improvement from baseline 2.
- Immediate resolution occurs in 95% of MCP joints (improving from 50° to 1.5°) 5.
Proximal Interphalangeal (PIP) Joints:
- Clinical success achieved in 34-37% of treated PIP joints after final injection 2, 4.
- Mean contracture reduction of 25° with clinical improvement in 58% of joints 2, 4.
- Less severely contracted joints (≤40° baseline) respond significantly better than those with higher baseline severity 4.
Post-Injection Protocol
Night splinting and home-based stretching exercises are essential following the manipulation procedure to maintain correction 5.
Avoid joint overuse for 24 hours following injection, but immobilization is discouraged beyond this initial period 6.
Follow-up assessments at 6 weeks, 4 months, 1 year, and 2 years to monitor for recurrence 5.
Important Clinical Considerations
Recurrence Patterns
Recurrence (≥20° increase in contracture) occurs in approximately 25% of successfully treated joints within 2 years, with MCP and PIP joints showing similar recurrence rates 5.
Older age and multiple digit involvement are associated with higher recurrence rates 5.
Most recurrences occur within the first 6 weeks, requiring vigilant early follow-up 5.
Safety Profile
CCH is well-tolerated with no systemic reactions or tendon ruptures when proper injection technique is used 2, 3.
Common local adverse events include peripheral edema (58%), contusion (38%), injection site hemorrhage (23%), and injection site pain (21%) 4.
Two tendon ruptures occurred in early trials; no further ruptures after modified injection technique was adopted 4.
Patient Satisfaction
92% of patients report being "very satisfied" (71%) or "quite satisfied" (21%) with CCH treatment 2.
Physicians rate outcomes as "very much improved" (47%) or "much improved" (35%) 2.
When to Consider Surgery
Surgery should be reserved for patients with structural abnormalities when CCH and other treatment modalities have not been sufficiently effective in relieving pain or restoring function 7.
Trapeziectomy for thumb base involvement and arthrodesis or arthroplasty for interphalangeal joints are surgical options 7.
Critical Pitfalls to Avoid
Do not confuse Dupuytren's contracture with hand osteoarthritis—intra-articular glucocorticoid injections are NOT indicated for Dupuytren's disease and should only be considered for painful interphalangeal joints in hand OA 7.
Earlier treatment in the disease course provides improved outcomes—do not delay intervention until severe contractures develop 2.
Ensure proper injection technique directly into the palpable cord, not into the joint space, to avoid complications 4, 3.