Aims. Dupuytren’s contracture is characterized by increased fibrosis of the palmar aponeurosis, with eventual replacement of the surrounding fatty tissue with palmar fascial fibromatosis. We hypothesized that adipocytokines produced by adipose tissue in contact with the palmar aponeurosis might promote fibrosis of the palmar aponeurosis. Methods. We compared the expression of the adipocytokines adiponectin and leptin in the adipose tissue surrounding the palmar aponeurosis of male patients with Dupuytren’s contracture, and of male patients with carpal tunnel syndrome (CTS) as the control group. We also examined the effects of adiponectin on fibrosis-related genes and proteins expressed by fibroblasts in the palmar aponeurosis of patients with Dupuytren’s contracture. Results. Adiponectin expression in the adipose tissue surrounding the palmar aponeurosis was significantly lower in patients with Dupuytren’s contracture than in those with CTS. The expression of fibrosis-related genes and proteins, such as types 1 and 3 collagen and α-smooth muscle actin, was suppressed in a concentration-dependent manner by adding AdipoRon, an adiponectin receptor agonist. The expression of fibrosis-related genes and proteins was also suppressed by AdipoRon in the in vitro model of Dupuytren’s contracture created by adding TGF-β to normal fibroblasts collected from patients with CTS. Conclusion. Fibrosis of the palmar aponeurosis in Dupuytren’s contracture in males may be associated with adiponectin expression in the adipose tissue surrounding the palmar aponeurosis. Although fibroblasts within the palmar aponeurosis are often the focus of attention when elucidating the pathogenesis of Dupuytren’s contracture, adiponectin expression in adipose tissues warrants closer attention in future research. Cite this article: Bone Joint Res 2023;12(8):486–493

Objectives. Injectable Bromelain Solution (IBS) is a modified investigational derivate of the medical grade bromelain-debriding pharmaceutical agent (NexoBrid) studied and approved for a rapid (four-hour single application), eschar-specific, deep burn debridement. We conducted an ex vivo study to determine the ability of IBS to dissolve-disrupt (enzymatic fasciotomy) Dupuytren’s cords. Materials and Methods. Specially prepared medical grade IBS was injected into fresh Dupuytren’s cords excised from patients undergoing surgical fasciectomy. These cords were tested by tension-loading them to failure with the Zwick 1445 (Zwick GmbH & Co. KG, Ulm, Germany) tension testing system. Results. We completed a pilot concept-validation study that proved the efficacy of IBS to induce enzymatic fasciotomy in ten cords compared with control in ten cords. We then completed a dosing study with an additional 71 cords injected with IBS in descending doses from 150 mg/cc to 0.8 mg/cc. The dosing study demonstrated that the minimal effective dose of 0.5 cc of 6.25 mg/cc to 5 mg/cc could achieve cord rupture in more than 80% of cases. Conclusions. These preliminary results indicate that IBS may be effective in enzymatic fasciotomy in Dupuytren’s contracture. Cite this article: Dr G. Rubin. A new bromelain-based enzyme for the release of Dupuytren’s contracture: Dupuytren’s enzymatic bromelain-based release. Bone Joint Res 2016;5:175–177. DOI: 10.1302/2046-3758.55.BJR-2016-0072

Late presentation and rapid progression of Dupuytren's contracture significantly increases operating time, complications and likelihood of incomplete correction; however, surgical timing is usually more a function of waiting list length than of clinical criteria. We sought to measure the rate of progress of Dupuytren's contracture. All patients with Dupuytren's contracture referred to the sole Consultant Hand Surgeon for Highland Region between June 1997 and February 2003 were prospectively included. Fixed flexion deformities at each finger joint and thumb-index angle to the point of firm resistance to extension were recorded by a single observer (QGNC) at presentation and immediately pre-operatively. Of 151 participants 37% had a family history. There was a male predominance of 5:1, with bilaterality in 77% at presentation. Five percent had diabetes, 3% had epilepsy, 52% acknowledged tobacco habits and 24% regular alcohol in excess of recommended limits. Angular deterioration was observed in 52% of digits, over one quarter of this occurred at the small finger joints, where 58% of PIPJs progressed. Mean delay from presentation to surgery was 11 months (2-55.5). Mean age at presentation of 62 (16-86) years did not correlate with angular deformity at presentation or with velocity of deterioration or with manual/non-manual employment. Mean severity of deformity at presentation for manual (34°) was double non-manual workers (17°) although angular deterioration was faster in the non-manual group (3.8 cf 0.7°/month respectively). Similar speeds of deterioration were seen at MCPJ and PIPJ, speed of deterioration was 2.2°/month for each of the three ulnar digits. Speed of deterioration correlated (r=0.7) with severity of deformity at presentation for ring and small fingers. This study offers the first quantification of rate of deterioration in Dupuytren's contracture. This could be used as a waiting list tool to predict the delay before a digit is likely to pose increased surgical risk

Purpose of Study: To assess the efficacy of two-stage correction (skeletal traction followed by Partial Fasciec-tomy) in treating severe Dupuytren’s contractures. Material, Methods and Results: We retrospectively reviewed sixteen fingers in fifteen patients with severe Dupuytren’s contracture (Tubiana Grade III/IV), operated between April 2000 and July 2005. The mean age was 58 years (27 – 82 years). All patients underwent an initial application of Orthofix external fixator with pins in the proximal and middle phalanx. The patients were advised to gradually distract the device 3-4 times a day, for two weeks. They were then brought back for removal of fixator and partial fasciectomy with closure of skin by V-Y plasty. The results were assessed in thirteen patients, as two were lost to follow-up. The mean follow-up period was 30 months (6 – 64 months). The total mean preopera-tive extension deficit improved from 130 degrees to 38 degrees postop.; PIP joint deformity improved from a mean of 77 degrees to 33 degrees postop. and the mean TRAM (Total range of active movements) improved from 108 degrees to 165 degrees. Functional assessment was done using Michigan Hand Outcome Questionnaire. Overall improvement in hand function was from a preoperative 34% to a postoperative 89%.; aesthetic improvement from a preop. of 46% to a postop of 81% and pain improvement from a preop of 66% to a postop of 96%. One patient had recurrence, one had features of RSD (Reflex Sympathetic Dystrophy) and one had to undergo amputation due to poor tolerance and persistent infection. Conclusion: Severe Dupuytren’s contracture is a challenging deformity to deal. The two-stage correction may be considered as an alternative method of treatment in cooperative patients. Our study has shown promising results with good patient satisfaction

Dupuytren's contracture is a common condition affecting 25% of men over the age of 65. With less advanced disease or with patients not suitable for a general or regional anaesthetic needle fasciotomy is the surgical option of choice. The aim of this audit is to see whether the Department of Trauma and Orthopaedic surgery at Wirral University Teaching Hospital NHS Foundation Trust comply with the NICE guidelines. All patients who underwent needle fasciotomy for Dupuytren's contracture at Wirral University Teaching Hospital NHS Foundation Trust from December 2008 and November 2010 were identified. The case notes of these patients were reviewed. In a 23 month period 9 patients (13 fingers), underwent needle fasciotomy. There were 6 female and 3 male patients. The mean age at the time of surgery was 70 years (61-84 years). Of the 13 MCPJ contractures 12 had a full correction. At the PIPJ 5 of the 8 had a full correction. Of the one contracture affecting the DIPJ, this was fully corrected. None of the patients undergoing needle fasciotomy had any complications recorded. At a minimum follow up 4 months and a mean follow up of 14 months, none of our patients have returned to the unit with recurrence of disease. In our unit needle fasciotomy is a safe and effective in correcting deformity. To date we have no complications or recurrence. None of these patients have returned for further surgery. We are compliant with the NICE guidelines

Dupuytren’s contracture is characterised by abnormal fibroblast proliferation and extracellular matrix deposition in the palmar fascia. Fibroblast proliferation and matrix deposition in connective tissues are regulated by cytokines. A number of cytokines including transforming growth factor beta (TGFβ), basic fibroblast growth factor (bFGF), platelet derived growth factor (PDGF) and epidermal growth factor (EGF) are known to have potent anabolic effects on connective tissue. The aim of this study was to investigate the role played by anabolic cytokines in the pathogenesis of Dupuytren’s disease. Twelve specimens of Dupuytren’s contracture and six control specimens of palmar fascia obtained from patients undergoing carpal tunnel release were cultured using a serumless method under standard conditions for 72 h. Levels of TGFβ-1, bFGF, PDGF and EGF in the medium were estimated using an enzyme linked immunoabsorbent assay technique. Neither Dupuytren’s tissue nor control palmar fascia produced any EGF. The mean (±S.D.)levels of bFGF, PDGF and TGFβ-1 produced by cultured palmar fascia were: 1270 ± 832, 74 ± 24, < 7, and for Dupuytren’s tissue were 722 ± 237, 139 ± 76.6, 645 ± 332, respectively. The levels of PDGF and TGFβ-1 were significantly higher in Dupuytren’s tissue. PDGF is produced in increased amounts by Dupuytren’s tissue. This may contribute to the fibroblast proliferation and increased ECM deposition observed in this condition. TGFβ-1 is not produced by normal palmar fascia but is produced in large amounts by Dupuytren’s tissue. The major physiologic role of TGFβ-1 is to stimulate formation of fibrous tissue. It plays a major role in wound healing and also in pathological conditions where fibrosis is a prominent feature. Inappropriate production of TGFβ-1 in the palmar fascia in Dupuytren’s disease may play a central role in initiating and stimulating the abnormal fibroblast proliferation and collagen synthesis seen in this condition

Xiapex is a novel non-surgical intervention for the treatment of Dupuytren's contracture. It comprises a fixed-ratio mixture of two purified collagenolytic enzymes (AUX-I [clostridial type I collegenase] and AUX II [clostridial type II collagenase]) isolated from the medium of Clostridium histolyticum. Xiapex targets the contracture through the injection of enzymes into the pathologic diseased cords. The objectives of this study were to evaluate the safety and efficacy of Xiapex in patients with Dupuytren's Contracture, the recovery and associated use of health care resources. The study commenced in June 2011 and was completed in 11 months. 15 patients were screened for the study, 12 patients were eligible (10 male:2 female). All 12 patients completed the trial and 2 patients received multiple injections, one had two fingers affected and the other had two joints affected in one finger. Following screening visit to determine patient suitability, the patient received their first injection usually within 7 days. Xiapex was injected directly into the palpable cord. 24 hours after injection patients were reviewed and a “finger extension procedure” was performed if the cord had not spontaneously ruptured. Patients were then followed up at 7 days, 30 days and 6 months. Assessments at each visits included: Finger Goniometry, Physician and Subject Global Assessment and Satisfaction, Health Care Resource Utilization and URAM (function assessment) and adverse events. Of the 14 cords injected all ruptured after finger extension. No patient experienced any serious adverse events, but a number of more minor adverse events were recorded including skin tears, pain at injection site, swelling and bruising. At the time of final follow-up recurrence rates were 14%. In conclusion, Xiapex is suitable for appropriately selected patients who are affected by Dupuytren's contractures and who have a well-developed palpable cord

Aims: We present a prospective study, with three-year follow-up, of the incidence, course and influence on surgical outcome of the abductor digiti minimi cord in Dupuytren’s contracture of the PIP joint of the little finger. Methods: All patients presenting for surgery with primary Dupuytren’s contracture of the little finger over a six-month period were included in the study. Patterns of disease cords and joint involvement were noted. All fingers underwent fasciectomy of the central and pre-tendinous cords. If significant contracture remained the abductor cord was excised next, and the PIP joint itself released only if correction could still not be obtained. Contracture and range of movement of affected joints measured with goniometer pre-operatively, at each stage intra-operatively and at 3 months and 3 years post-op. Results: The abductor cord was present in twleve of the nineteen fingers in the study, including all of those with ulnar-sided disease. The ulnar neurovascular bundle was found to be deep to the cord in nine fingers, encased by diseased tissue in two and displaced superficially in only one finger. Mean initial flexion deformity in these twelve fingers was 59, corrected to only 51 by resection of the central and pre-tendinous cords. Excision of the abductor cord further improved the contracture to 25 while PIP join release improved it to 6. Flexion deformity was 18 at three months and 21 at three years. For the seven fingers in which no abductor cord was found, mean initial flexion deformity was 42, improving to 24 following fasciectomy and 4 with joint release. It was 16 at three months and 18 at three years. No significant difference in outcome could be identified between the groups at three months or three years. Conclusions: The abductor cord is present in roughly two-thirds of little fingers with contracture pf the PIP joint. The ulnar digital nerve usually lies deep to the abductor cord but in roughly one quarter of cases is either encased in or superficial to it. In affected fingers, resection of the cord accounts for more than half of the total correction obtained and three quarters of that obtained by fasciectomy. Presence of the ADM cord does not prejudice long-term outcome provided it is adequately resected

Dupuytren’s contracture (DC) is a non-lethal disabling disease, characterised by a progressive fibrosis of the deep palmar fascia, produced by an increased deposition of collagen within the extracellular matrix (ecm). Matrix metalloproteinases (MMPs) are a family of zinc-dependent endopeptidases that degrade ecm proteins. Their activity is regulated by growth factors, cytokines and by specific tissue inhibitors (TIMPs). An imbalance in the normal relationship between expression of MMPs and TIMPs is believed to contribute to the pathogenesis of other fibroproliferative diseases. We have performed a detailed immunohistochemical analysis of DC tissue which provides the most comprehensive profile to date of the MMP and TIMP expression in DC. Sections were immunostained using antibodies against a panel of MMPs and TIMPs. Normal palmar fascia from patients undergoing carpal tunnel release or from cadaveric hands was used as controls. There was a marked increase in the expression of MMPs and TIMPs within the different areas of DC tissue compared with controls. Both MMPs and TIMPs were expressed in an angiocentric pattern within areas of hypercellularity (corresponding to the proliferative stages of nodules). In some hypercellular areas expression of TIMP1 and TIMP2 exceeded that for the MMPs. Hypocellular cords, which were predominantly composed of collagen, were weakly immunopositive for MMP-2 and MMP-9, but were immunonegative for TIMPs. Areas of MMP-1 and MMP-2 expression were more intense in the stroma surrounding nodules, and also within the “invading” DC tissue at the dermo-epidermal junction (DEJ) of the skin. Here expression of MMPs was observed around abnormally high numbers of small blood vessels, beneath the rete ridges of the epidermal layer, and also within foci of inflamation.TIMP1 and TIMP-2 were not expressed within the DEJ. These changes were most marked where clinically there was obvious ‘skin pit’ involvement. Currently the only treatment for DC is surgical. Alternative non-surgical therapeutic protocols might involve manipulating the fibrotic process pharmacologically, for example by seeking to regulate expression of MMPs and their inhibitors

Introduction and Aims: Severe Dupuytren’s contracture of the proximal interphalangeal (PIP) joint is a difficult condition to treat; a two-stage technique has been advocated by some surgeons for such cases. The present study set out to determine the early results of this technique. Method: Thirteen patients (11 with primary and two with recurrent disease) with a severe Dupuytren’s contracture of the proximal interphalangeal (PIP) joint were treated by geometric correction (in line distraction followed by angular correction) using the OrthofixTM mini external fixator followed by its removal and partial fasciectomy (without collateral ligament or volar plate release). The mean duration of distraction was 14 days. Results: In the PIP joint the mean true fixed flexion deformity pre-operatively was 75 degrees (range 45–90). At a mean follow-up of 21 months, the mean residual flexion deformity was 35 degrees (range 10–90). The mean arc of motion increased from 26 (range 10–55) to 51 degrees (range 0–90). At follow-up, the mean arc of motion was 33 degrees (range 0–70) and 73 degrees (range 45–110) at the distal interphalangeal and meta-carpophalangeal joints respectively. There were no cases of reflex sympathetic dystrophy or neurovascular damage. One patient had a fracture of the proximal phalanx and a second patient had an early recurrence, which led to a poor clinical outcome. The rest had an excellent clinical outcome according to the Michigan Hand Questionnaire. Conclusion: Although the technique is challenging, the early results are promising and we recommend it for the management of this difficult problem

Aim: This study involved a postal questionnaire survey to know the attitude of consultant orthopaedic surgeons in U.K. with regards to their postoperative management of Dupuytren’s surgery patients. Methods & Results: A questionnaire was sent to Orthopaedic surgeons practising in UK. 573 consultants replied to the questionnaire. 169 surgeons (29.49%) stated to have special interest in hand surgery. 357 surgeons (62.3%) stated having no interest in hand surgery. 43 surgeons did not reply to the questionnaire. 81 surgeons (14.13%) always used post operative splintage.109 surgeons (19.03) used splintage most of the time, 126 surgeons (21.98%) rarely used it and 89 surgeons (15.53%) stated never using any form of splintage. Most of them used static splintage (45.20%) and only 5.23% used dynamic splintage.11 surgeons stated using both the types of splintage. 267 surgeons did not questionnaire. Majority of the surgeons applied a static splint (pop slab, thermoplastic splint) after the surgery while others applied it after reducing the dressing within 2 weeks of the operation. 264 (46.07%) surgeons did not reply to the question. In majority of cases the splint was applied by the occupational therapist. The surgeon, physiotherapist, and orthotist in some cases also applied the splint. Individual comments from surgeons made an interesting reading. After an initial period of continuous splintage majority of the surgeons used night splintage only. 265 surgeons did not reply to the question. Mostly the splint-age was used for 4–6 weeks. Although the spectrum of splintage varied from 2 weeks to 24 weeks. Some of the surgeons stated their own clinical practice in their comments. 179 surgeons stated always referring their patient for postoperative physiotherapy. 13 surgeons (2.26%) never referred their patients for physiotherapy. 77 surgeons on very odd occasions had postoperative physiotherapy for their patients. Majority of surgeons started the physiotherapy between 1 and 2 weeks, after the stitches have been removed. 107 surgeons favoured early commencement of hand exercises within first week of surgery. 224 surgeon did not reply to this question. Most of the surgeons followed the patients for two to four months. Longer follow up was done for patients with recurrence, severe or bilateral disease. Also those patients, who had proximal interphalangeal joint contracture and other risk factors, were followed for a longer period. Some of the surgeons commented following them for life in their clinical practice. Conclusion: This survey revealed interesting facts regarding the management of Dupuytren’s contracture surgery patients. The disparity in reply clearly indicates the need for further research with attention to long term funtional results

Introduction: Dupuytren’s contracture is a common disease in Northern Europe. Partial fasciectomy is often used to treat the whole spectrum of Dupyutren’s disease, although high recurrence rates have been reported. In our department, the majority of patients are treated by total aponeurectomy, which is defined as the complete removal of palmar tissue. It has been found out that apparently normal-looking aponeurosis can also contain an increased proportion of collagen, which may lead to recurrent disease. Consequently, the perceived advantage of total aponeurectomy over partial aponeurectomy is the potential for a lower recurrence rate as all diseased tissue is potentially removed. Against this background, we have reviewed the effectiveness of total aponeurectomy performed on 61 patients. Patients and Methods: The group of patients available for review consisted of 51 men and ten women with a mean age of 63.0 (range 42–79 years) and with a mean period of 3.45 years (range 1.03–6.39 years) between operation and review. No patient had follow-up of less than 1 year. At follow-up evaluation hands were examined for nodules, cords and retractions of the skin. The active mobility of the joints was determined with a goniometer and the Jamar hand dynamometer was used to measure grip strength in both hands. Sensitivity was examined by means of two-point-discrimination and the DASH-score was used for the analysis of rehabilitation. Patients were also asked about common risk factors for Dupuytren’s disease. Results: Post-operative complications including haematoma, seroma or necrosis were found in 13.8% of the patients. Recurrence of contracture occurred in 10.8% of the patients and 4.6% of the operated patients presented with a nerve lesion. Nerve irritation was found in 6.2% of the patients. The mean DASH-score was 3.85 (range 0–52.5). Family pre-disposition was an important risk factor for Dupuytren’s disease with 44.3% of patients having a positive family history. Conclusion: We suggest that total aponeurectomy is a promising alternative to partial fasciectomy with low risk for recurrent disease and slightly increased risk for a nerve lesion

Study. This is a prospective double blind, placebo controlled trial. Collagenase Clostridium Histolyticum was effective and well tolerated used in well palpable cords of Dupuytren's Contracture. Concurrent fingers treatment with early complications have been reported. Patients reported outcome measures have been obtained. Materials & Method. 143 fingers were treated in 125 patients. Deformity of more than 30° at metacarpo phalangeal joints and more than 20° at proximal interphalangeal joints with well palpable cord were selected in this study. Finger straightening procedure was undertaken at 24–72 hours post injection. Prospectively evaluated for early complications, extent of correction, residual deformity and recurrence rate at 3 years and 6 months follow up. Concurrent fingers were treated without serious side effects. Results. Full correction was achieved in 130 fingers (91%). Residual flexion deformity noted in mainly in PIPJ with flexion 80° or more. At four years follow up, the recurrence rate was noted in Metacarpophalangeal Joints in 4(3%)fingers and Proximal Inter Phalangeal Joints in 12(9%) fingers. Patient reported outcome measures have been collected and expressed high degree of satisfaction. Conclusion. Most local complications resolved within two weeks of the injection. Isolated MPJ deformity is more likely to be corrected fully. Isolated Proximal Interphalangeal Joints and combined Proximal Interphalangeal Joints and Metacarpo Phalangeal Joints contractures are mostly end up in residual flexion. Concurrent finger treatment was uneventful

Introduction. In Europe, injectable collagenase clostridium histolyticum (CCH) is a novel, minimally invasive, non-surgical therapy with efficacy in correcting Dupuytren's contracture (DC). We evaluated the efficacy and tolerability of 5 CCH injections using a protocol designed to follow clinical practice. Methods. This was a 20-center, 9-month, open-label study in which DC patients with primary flexion deformities 20° (100° for MP; 80° for PIP) received 3 CCH (0.58 mg) injections/joint (5 injections/patient) at 30-day intervals. The primary endpoint was clinical success, defined as a reduction in contracture to 5° 30 days after the last injection (“Day 30”). After first injection into a prioritized joint, patients opted to receive up to 2 more injections into the same cord or cords from other affected joints whether or not they achieved clinical success with the first joint. Adverse events (AEs) were monitored. Results. For the primary endpoint, 71% of MP (n=343) and 41% of PIP (n=244) joints showed a reduction in contracture to 5° with CCH injections. Of joints that did not achieve clinical success, 66% of MP (n=100) and 38% of PIP joints (n=144) showed 50% reduction in contracture after CCH. For range of motion (ROM), mean±SD increase from baseline to Day 30 was 33.0±16.2° for MP and 27.5±18.5° for PIP joints. Most commonly reported AEs were localized edema, bruising, pain, swelling, and tenderness; most resolved without intervention. Two serious AEs, deep vein thrombosis in the leg and tendonitis with partial tendon/ligament injury, were deemed possibly and probably related to treatment, respectively. Conclusions. Results from this open-label study, designed to follow clinical practice, provide support for the efficacy of CCH in correcting the flexion deformity of MP/PIP joints caused by DC. Clinical success and ROM improvements were comparable to those observed in randomized, placebo-controlled trials. This study was funded by Auxilium Pharmaceuticals, Inc

Introduction. Injectable collagenase clostridium histolyticum (CCH) is a minimally invasive non-surgical therapy with efficacy in correcting Dupuytren's contracture (DC). In the concurrently run JOINT I and JOINT II studies, designed to follow clinical practice, we evaluated the efficacy of ?5 CCH injections in patients with DC. Methods. JOINT I and II were multicenter, 9-month, open-label studies in which DC patients with primary flexion deformities ?20° received ?3 CCH (0.58 mg) injections/joint (?5 injections/patient) at 30-day intervals into joints prioritized by extent of contracture. After the first injection, patients could opt to receive up to 2 additional injections in same cord or other cords regardless of outcome for the first joint. The primary endpoint was reduction in contracture to ?5° 30 days after the last injection. Data from JOINT I and II were pooled. Results. For the primary endpoint, 70% of MP (371/531) and 37% of PIP (128/348) joints showed a reduction in contracture to ?5° with CCH injections; 42% (223/531) of MP and 20% (69/348) of PIP joints reached success within 7 days of the first injection. Overall, 89% of MP (470/531) and 58% (202/348) of PIP joints showed clinical improvement (ie, ?50% reduction in contracture). Mean±SD percentage changes in contracture were 84±25% for MP joints and 55±41% for PIP joints. The 2 most common treatment-related adverse events (AEs) localized to the injection site were edema peripheral and contusion. Two patients had treatment-related serious AEs (deep vein thrombosis; tendonitis), but no tendon ruptures or systemic reactions were noted. Conclusions. Pooled results from the JOINT studies designed to follow clinical practice, provide support for the efficacy of CCH in correcting DC. Efficacy and safety data from this analysis are comparable to those observed in randomized, placebo-controlled trials

In December 2012 the orthopaedic Hand and wrist unit at Derriford hospital introduced the use of collagenase injections for the treatment of Dupuytrens' contracture, and currently remains the only centre to use it in the southwest peninsula.

We present the short term results of our first year of use of the therapy. There was a statistically significant improvement in PEM scores by 1 and 3 months post-treatment (P: 0.0001 and 0.0016 with 95% confidence).

Full correction was obtained in 81% of all MCPJ contractures included in the analysis. Success with PIPJ contractures was more limited, however there was still an average correction of 30 degrees achieved.

Complications were limited to skin tears, all of which healed at subsequent follow-up, and 2 failures of therapy. We will continue to use this therapy and as experience and expertise build we hope we can improve our outcomes further.

Dupuytren's disease is often disabling and traditionally has been managed with various surgical methods, with recurrence rates up to 50 %. Recently clostridial collagenase injection has been licensed for use in the NHS.

We prospectively analysed the results of clostridial collagenase injection in 62 patients with varying degrees of Metacarpo phalangeal (MCP) and Proximal interphalangeal (PIP) joint contractures. There were 48 males and 14 females with an average age of 66 years. The average MCPJ and PIPJ deformities were 33 and 17 degrees respectively. Following the infiltration and subsequent manipulation under local anaesthetic and night splinting for 3 months, patients were followed up at 4 weeks and 6 months. Deformities persisted in 5 patients and later required surgical correction. MCPJ deformities were more amenable for correction than PIPJ and in those with recurrence. The average residual deformity was 7 degrees. Common complications include bruising, swelling, pain not responding to routine analgesia, lymphangitis and skin break in some but none required any additional interventions. 14 patients had completed 6 month follow up and there was no recurrence. Subjective assessment through questionnaires revealed high patient satisfaction rate with early return to work within 1 week in most patients. Patients with previous operations preferred injections over operative correction. Collagenase injections are effective in deformity correction with higher satisfaction rate and low morbidity. Early results are encouraging but long term follow up is required to assess recurrence rates.

Aim

To determine effectiveness of Collagenase Clostridium Histolyticum (CCH) in deformity correction and hand function for patients with Dupuytren's disease.

This study aimed to determine if the adoption of collagenase treatment is economically viable.

Xiapex collagenase was trialled at Gloucestershire Hospitals NHS Trust in 50 patients suitable for fasciectomy, with a palpable cord and up to two affected joints. Retrospective data for contracture angle pre-injection, immediately post-manipulation and at an average 6 weeks (range 2–17) clinic follow up was collected from medical notes. At follow up the post-procedure number of days required for return to activities of daily living (ADLs) and/or work were recorded, along with overall patient satisfaction rating.

Complete data was obtained for 43 patients of average age 67 (range 45–82). At follow up 88% had ≤ 20° residual contracture. Average days return to full ADLs was 9 and work was 11. Overall satisfaction was 8.6 out of 10. Xiapex patients required an average 1 hand physiotherapy appointment post-manipulation compared to 6 for fasciectomy, saving £172.20. Total cost for one treatment course, excluding physiotherapy, was £1166 for Xiapex compared to £2801 for palmar fasciectomy and £5352 for digital fasciectomy.

The level of contracture after one Xiapex treatment course permitted return of hand function in the majority of patients whose overall treatment course required less financial and hospital resources.

Introduction: Common pathologies seen in hand clinics include Dupuytren’s contracture, ganglia and trigger digits. Some patients can be treated in the out patient department by percutaneous fasciotomy, aspiration, or percutaneous A1 pulley release. The effectiveness and safety of these procedures has been documented in the literature. There are no studies investigating the cost effectiveness these of treatments. Aim: Our aim was to compare the cost of treatment of Dupuytren’s contracture, ganglia and trigger digits in the out-patient department with the operating theatre. Methods: All patients seen in a new patient hand clinic with a diagnosis of Dupuytren’s contracture, trigger digit or ganglion of the wrist or hand were prospectively identified over a 6 month period.. The number undergoing a procedure in the out-patient clinic or theatre was recorded. Costings of theatre time and out-patient time were obtained from the hospital management. Results: 80, 26, and 52 patients were treated with regard to Dupuytrens contracture, ganglia, and trigger digits respectively over the 6-month period. Of these, 37, 23, and 44 were treated by an out patient procedure, and 43, 3 and 8 underwent a formal operation. Based on a cost of £216 per out-patient clinic session, the cost of the out-patient procedures was calculated at £1872 over 6 months, or £3744 per annum. Based on a theatre cost of £1785 per session, to perform all the clinic procedures as formal operations would have cost £60,690 over 6 months, or £121380 per annum. The cost savings were therefore £117636 per annum. Discussion: We conclude that outpatient interventions for dupuytrens disease, ganglions and trigger digits results in significant cost savings over formal surgical treatment