Physician-authored summaries and commentary on the most important medical research, provided by the NEJM Group, a division of the Massachusetts Medical Society.
© Massachusetts Medical SocietyDecember 2024
Outcomes in a randomised trial favoured limited fasciectomy over collagenase injections.
Progressive Dupuytren’s contracture can be managed in three ways – surgery, needle fasciotomy or collagenase injection. A 2024 randomised trial showed that surgery was superior to collagenase injections or needle fasciotomy after two years (NEJM JW Gen Med Mar 15 2024 and Ann Intern Med 2024; 177: 280290); however, some patients wish to avoid surgery. Now, a randomised UK trial has been conducted to compare collagenase injection with limited fasciectomy in 600 people with moderate Dupuytren’s contracture (i.e. discrete palpable collagen cord causing a 30-degree or more, but less than 130-degree, contracture of a metacarpophalangeal or proximal interphalangeal joint).
The mean baseline score on a validated hand-health questionnaire (range, 0 to 100, with higher scores worse) was about 34. At one year after treatment, mean scores were higher with collagenase than with limited fasciectomy (18 vs 12), suggesting that collagenase was probably inferior to fasciectomy in this ‘noninferiority’ trial. Similar results were obtained at two years and for secondary outcomes, including passive and active extension joint measure ments. Complications were significantly lower in the collagenase group (1.8% vs 5.1%). However, recurrent contracture resulting in reintervention was significantly more common in the collagenase group (14.6% vs 3.4%).
Comment: Collagenase clostridium histolyticum (Xiaflex) was approved by the US FDA in 2010 for managing Dupuytren’s contractures (NEJM JW Gen Med 15 Oct 2009 and N Engl J Med 2009; 361: 968-979). Although randomised trials have shown that surgery results in better outcomes than collagenase injection or fasciotomy, patients still might choose collagenase because of concerns about cost, convenience and surgical risk.
Paul S. Mueller, MD, MPH, FACP, The Dr. Lowell Henry Lebermann Endowed Chair in Internal Medicine and Professor of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, USA.
Dias J, et al. Collagenase injection versus limited fasciectomy for Dupuytren’s contracture. N Engl J Med 2024; 391: 1499-1510.
This summary is taken from the following Journal Watch titles: General Medicine, Ambulatory Medicine.