Treatment of Dupuytren Contracture With Injectable Collagenase Within the Veterans Affairs System

Dupuytren contracture is a debilitating disease involving abnormal thickening of the palmar fascia, resulting in pits, nodules, and cords that lead to contracture of the digits. Prevalence in the veteran population is approximately 306 per 100 000 individuals.¹ Surgical management of Dupuytren contracture includes removal or release of the fascia via open fasciectomy, open fasciotomy, closed fasciotomy, and most recently, injectable collagenase. A double-blind placebo-controlled trial published in 2010 showed a significantly greater mean increase in range of motion in the group that received collagenase (35.4°) than in the group that received placebo (7.6°) (P < .001); in addition, 50.7% of all joints treated with collagenase achieved a range of motion 0° to 5° of normal.² With the US Food and Drug Administration approval of collagenase from Clostridium histolyticum in 2010, it was predicted that there would be increased use of collagenase, with an associated decrease in palmar fasciectomy and fasciotomy within the Veterans Affairs (VA) system.

The Veterans Health Administration Services Support Center database was used to examine treatment for Dupuytren contracture in the past 8 fiscal years (October 1, 2006, to September 30, 2014). Because the database was part of a quality improvement initiative and contained no patient identifiers, the Richard L. Roudebusch Veterans Affairs Medical Center Institutional Review Board waived approval. The data were collected retrospectively and informed patient consent was not required. We examined the database for Current Procedural Terminology codes associated with collagenase injection (code 20527 [Xiaflex injection]), as well as fasciotomy (codes 26040 [fasciotomy, closed] and 26045 [fasciotomy, open]) and fasciectomy (codes 26121 [palmar fasciectomy], 26123 [fasciectomy, single digit], and 26125 [fasciectomy, additional digit]). Data were trended by fiscal year. Each procedure was calculated as a percentage of total treatments for Dupuytren contracture among all modalities. Comparison of means with one-way analysis of variance was performed using SPSS, version 22 (IBM Corp).

When the VA system began to use injectable collagenase as treatment for Dupuytren contracture in fiscal year 2012, a total of 131 injections were performed; in fiscal year 2014, a total of 536 injections were performed. The total number of cases of Dupuytren contracture treated within the VA system increased from 1133 in 2007 to 1976 in 2014 (P = .02) (Table). Rates of fasciotomy (open or closed) to treat Dupuytren contracture decreased from 29.4% (n = 333) in 2007 to 18.1% (n = 358) in 2014 and rates of open fasciectomy decreased from 70.6% (n = 800) in 2007 to 54.6% (n = 1082) in 2014 (Figure). Injectable collagenase comprised 131 treatments (7.5%) in 2012 and increased to 536 (27.1%) in 2014.

Use of injectable collagenase for the treatment of Dupuytren contracture has increased within the VA system since its introduction in 2012. There was an associated decrease in surgical interventions performed, both minimally invasive fasciotomies and open fasciotomy and fasciectomy, but an overall increase in total interventions to treat Dupuytren contracture during the study period. Convenience for the patient and the fact that it is an office-based intervention may be driving the increase in the use of injectable collagenase. A recent study examining outcomes in the general population showed that injectable collagenase and fasciectomy had similar rates of patient satisfaction, but the group that received collagenase returned to normal activities much sooner than the group that underwent fasciectomy (1.9 vs 37.4 days; P < .001).³ To our knowledge, this finding has not been validated in the veteran population and is the focus of additional studies.

The cost difference between collagenase and fasciectomy in the VA system is currently unclear. A study from Sweden concluded that treatment with 1 injection of collagenase costs 33% less than fasciectomy, with equivalent efficacy at reducing contracture at 6 weeks,⁴ but more study is needed in the United States and, specifically, within the VA system. A recent study in the general population has shown that fasciectomy had a greater correction for digital contractures at the latest follow-up of at least 1 year when compared with collagenase,⁵ while another study had mixed results in comparing the 2 types of treatment.⁶

Limitations to our study include its retrospective nature, coding errors, and lack of functional outcomes. General population studies may not accurately represent the veteran population and future studies should focus on cost differences between treatments in the VA system, functional outcomes, and patient satisfaction within the veteran population.

Corresponding Author: Sunil S. Tholpady, MD, PhD, Division of Plastic Surgery, Richard L. Roudebush Veterans Affairs Medical Center, 705 Riley Hospital Dr, Room RI 2514, Indianapolis, IN 46202 (stholpad@iupui.edu).

Published Online: October 19, 2016. doi:10.1001/jamasurg.2016.3605

Author Contributions: Drs Tholpady and Duquette had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Duquette, Evans, Wooden, Cohen, Tholpady.

Acquisition, analysis, or interpretation of data: Duquette, Kuster, Evans, Wooden, Munshi, Tholpady.

Drafting of the manuscript: Duquette, Kuster, Evans, Wooden, Tholpady.

Critical revision of the manuscript for important intellectual content: Duquette, Evans, Munshi, Cohen, Tholpady.

Statistical analysis: Duquette, Kuster, Evans, Tholpady.

Administrative, technical, or material support: Kuster, Munshi, Cohen, Tholpady.

Study supervision: Wooden, Munshi, Cohen, Tholpady.

Conflict of Interest Disclosures: None reported.

Previous Presentation: This paper was presented at the 2016 Association of VA Surgeons Annual Meeting, April 10, 2016; Virginia Beach, Virginia.