Rationale

There is no consensus on the most effective treatment for DD. Currently, the two most common treatments for DD are partial palmar fasciectomy and collagenase injection.¹ Fasciectomy involves the surgical excision of the diseased cords, while injections with collagenase from Clostridium histolyticum degrade collagen within the cords, allowing them to be subsequently broken by forced digital extension.²

Clinical comment

Fasciectomy procedures are more invasive, historically requiring operating room access under general anesthesia, use of a tourniquet, and a more prolonged rehabilitation period. In contrast, collagenase injection has a faster patient recovery time and can be easily performed in an office or clinic setting without sedation, and requires fewer follow‐up appointments. This reduces healthcare costs and improves patient access to treatment.³,⁴

Available literature and quality of the evidence

The highest level of evidence comparing palmar fasciectomy with collagenase is available from four retrospective cohort studies (level III).⁴–⁷

Findings

Two retrospective cohort studies comparing these treatment modalities found that treatment with limited fasciectomy (LF) is superior in correcting extension deficits.⁵,⁶ In the study by Muppavarapu et al., the researchers analyzed results from 117 patients who underwent treatment with either LF or collagenase injection.⁵ After a mean follow‐up duration of 14.2 months for the collagenase group, and 16.3 months for the LF group, significantly more joints treated with LF met the primary outcome measure of contracture reduction to 0–5° (p = 0.0001). The mean residual contracture for all joints was 28.4° in the collagenase group and 11.8° in the LF group (p = 0.001), although the MCP joints generally responded better to both treatments than PIP joints.⁵ Similarly, in a retrospective analysis of 37 patients, Wei et al. found greater contracture corrections in patients treated with LF, compared to collagenase.⁶ The mean passive extension deficit achieved in joints treated with LF and collagenase was 3.9° and 6.5°, respectively, in MCP joints (p = 0.02), and 6.5° and 40.6°, respectively, in PIP joints (p = 0.0001).⁶

In contrast, Zhou et al. used a propensity‐matched score to compare 66 patients treated with collagenase to 66 patients treated with fasciectomy between 6 and 12 weeks postoperatively.⁷ They found no difference in correction of MCP joint contractures; however, LF was superior in correcting PIP joint contractures (25° vs 15° contracture correction, p = 0.01).⁷ In a much smaller study, Naam compared 25 patients treated with collagenase to 21 fasciectomy patients and found post‐treatment range of motion (ROM) at the MCP joint was greater for collagenase‐treated patients.⁴ However, when the researchers compared the mean increase in ROM from baseline, no significant difference was found between the two groups. Overall, the study found no significant differences in post‐treatment contractures between the two groups.⁴

Resolution of clinical scenario

• Currently, available evidence suggests that LF is equal, or superior, to collagenase in correcting extension deficits.
  
• LF is superior to collagenase in correcting PIP joint deformities.
  
• Therefore, your patient should be advised that LF may be better than collagenase to correct their extension deficits, especially at the PIP joint.

Rationale

Safety is paramount when deciding upon an appropriate treatment, particularly when a variety of treatment modalities exist. When deciding between comparably efficacious treatments, the physician should aim to choose the intervention that is safest. In DD patients, disease recurrence is a common post‐treatment event, and is to be expected as currently available treatments do not definitively cure the condition. The surgeon should consider the intervention that will reduce disease recurrence, or prolong the time to re‐contracture. Comprehensive knowledge backed by high‐quality evidence is essential when counseling patients.

Clinical comment

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