Main Article Content
Dupuytren contracture, collagenases, clostridium histolyticum, fasciotomy, injections
Background: Dupuytren’s disease is a disorder of abnormal collagen production that may manifest in the palmar fascia. Treatment options vary according to clinical circumstances but surgical fasciectomy remains the gold standard. Collagenase, an enzyme produced by clostridium histolyticum (CCH), is a relatively new injection able to cleave collagen strands in vitro. While the drug is not yet available on the Pharmaceutical Benefits Scheme, its side effect profile and risk of recurrence are comparable to fasciectomy in appropriately selected patients. In this study, we aimed to demonstrate the safety and cost-effectiveness of collagenase for the treatment of Dupuytren’s disease.
Method: Twenty-five patients at our hospital received collagenase injections for treatment of their Dupuytren’s disease. Data from this cohort was compared to a hypothetical group extrapolated from the literature.
Results: Surgical treatment, excluding outpatient visits, costs on average AU$5852 per patient and collagenase costs AU$1176 per patient (gross cost difference AU$4676). Moderating this cost difference by the effect of complications using the incremental cost effectiveness ratio, the cost saving is AU$1137.71 per unit decrease in complications with collagenase treatment. Surgical fasciectomy has a lower risk of recurrence than collagenase but costs up to AU$543 more for patients for whom the condition does not recur within five years of treatment. In our cohort, 25 patients had 31 cords injected with collagenase. All but two patients achieved full range of motion of their affected joint and 20 per cent sustained minor skin tears requiring dressings.
Conclusion: This analysis suggests that the investment of public health funds in the treatment of suitable patients with collagenase should produce a substantial cost saving without increasing the risk of complications.
2. Dolmans GH, de Bock GH, Werker PM. Dupuytren diathesis and genetic risk. J Hand Surg Am. 2012;37(10):2106-111. https://doi.org/10.1016/j.jhsa.2012.07.017 PMid:23021175
3. Mandel DR, DeMarco PJ. Overview of the pathogenesis, diagnosis and treatment of Dupuytren’s disease. Int J Clin Rheumatol. 2014;9:217-25. https://doi.org/10.2217/ijr.14.14
4. Abe Y, Rokkaku T, Ofuchi S, Tokunaga S, Takahashi K, Moriya H. Dupuytren’s disease on the radial aspect of the hand: report on 135 hands in Japanese patients. J Hand Surg Br. 2004;29(4):359-62. https://doi.org/10.1016/J.JHSB.2003.12.007 PMid:15234500
5. Hindocha S, Stanley JK, Watson S, Bayat A. Dupuytren’s diathesis revisited: evaluation of prognostic indicators for risk of disease recurrence. J Hand Surg Am. 2006;31(10):1626-634. https://doi.org/10.1016/j.jhsa.2006.09.006 PMid:17145383
6. Shih B, Bayat A. Scientific understanding and clinical management of Dupuytren disease. Nat Rev Rheumatol. 2010;6(12):715-26. https://doi.org/10.1038/nrrheum.2010.180 PMid:21060335
7. Coert JH, Nerin JP, Meek, MF. Results of partial fasciectomy for Dupuytren disease in 261 consecutive patients. Ann Plast Surg. 2006;57:13-17. https://doi.org/10.1097/01.sap.0000205819.53215.52 PMid:16799301
8. French MF, Mookhtiar KA, Van Wart HE. Limited proteolysis of type I collagen at hyperreactive sites by class I and II. Biochem. 1987;26:681-87. https://doi.org/10.1021/bi00377a004
9. Hurst LC, Badalamente MA,, Hentz VR, Hotchkiss RN, Kaplan FT, Meals RA, Smith TM, Rodzvilla J, CORD I Study Group.Injectable collagenase clostridium histolyticum for Dupuytren’s contracture. N Engl J Med. 2009;361(10):968-79. https://doi.org/10.1056/NEJMoa0810866 PMid:19726771
10. Gilpin D, Coleman S, Hall S, Houston A, Karrasch J, Jones N. Injectable collagenase clostridium histolyticum: a new nonsurgical treatment for Dupuytren’s disease. J Hand Surg Am. 2010;35(12):2027-038 e1.
11. Baltzer H, Binhammer PA. Cost-effectiveness in the management of Dupuytren’s contracture. A Canadian cost-utility analysis of current and future management strategies. Bone Joint J. 2013;95B(8):1094-100. https://doi.org/10.1302/0301-620X.95B8.31822 PMid:23908426
12. Sanjuan Cerveró R, Franco Ferrando N, Poquet Jornet J. Use of resources and costs associated with the treatment of Dupuytren’s contracture at an orthopedics and traumatology survey department in Denia (Spain): collagenase clostridium hystolyticum versus subtotal fasciectomy. BMC Musculoskelet Disord. 2013;14(1):293. https://doi.org/10.1186/1471-2474-14-293 PMid:24125161 PMCid:PMC3852948
13. Chen NC, Shauver MJ, Chung KC. Cost-effectiveness of open partial fasciectomy, needle aponeurotomy, and collagenase injection for Dupuytren contracture. J Hand Surg Am. 2011;36(11):1826-1834 e32.
14. Peimer CA, Blazar P, Coleman S, Kaplan FT, Smith T, Lindau T. Dupuytren contracture recurrence following treatment with collagenase clostridium histolyticum (CORDLESS [Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study]): 5-year data. J Hand Surg Am. 2015;40(8):1597-605. https://doi.org/10.1016/j.jhsa.2015.04.036 PMid:26096221
15. Denkler K. Surgical complications associated with fasciectomy for Dupuytren’s disease: a 20-year review of the English literature. Eplasty. 2010;10:e15. PMid:20204055 PMCid:PMC2828055
16. Rodrigues JN, Becker GW, Ball C, Zhang W, Giele H, Hobby J et al. Surgery for Dupuytren’s contracture of the fingers. Cochrane Database Syst Rev. 2015(12):CD010143. PMid:26648251
17. Beilan J, Strakosha R, Palacios DA, Rosser CJ. The postoperative morbidity index: a quantitative weighing of postoperative complications applied to urological procedures. BMC Urol. 2014;14:1. https://doi.org/10.1186/1471-2490-14-1 PMid:24383457 PMCid:PMC3893398
18. van Rijssen AL, ter Linden H, Weker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: percutaneous needle fasciotomy versus limited fasciectomy. Plast Reconstr Surg. 2012;129:469-77. https://doi.org/10.1097/PRS.0b013e31823aea95 PMid:21987045
19. Actelion Pharmaceuticals Australia Pty Limited. Physicians guide: administration of Xiaflex for Dupuytren’s contracture. Frenchs Forest, New South Wales, Australia: Actelion Pharmaceuticals Australia, July 2013.
20. Tubiana R. Dupuytren’s disease of the radial side of the hand. Hand Clin. 1999;15(1):149-19. PMid:10050250