Systematic review of non-surgical treatments for early Dupuytren’s disease

Abstract

BackgroundDupuytren’s disease is a common fibrotic disorder of the palm characterized by the development of progressive flexion deformities in the digits, leading to significant functional impairment. Surgical excision remains the most common treatment. However, this is only indicated in patients with established contractures rather than those with early disease. Early disease is generally characterized by the presence of palmar nodules with limited or no contracture of the fingers. The ideal treatment would be directed at patients with early progressive disease to prevent future deterioration. Various non-surgical treatment modalities have been described but there is currently no systematic assessment of the role and efficacy of these treatments in patients with early disease.MethodsUsing a PICOS analysis we reviewed publications of studies of patients with early disease who had received physical therapies, pharmacological treatment, or radiotherapy. Following PRISMA guidelines titles and abstract were screened using predefined criteria to identify those reporting outcomes specifically relating to the treatment of early disease. In the absence of a definition of early disease studies were included if early DD was described clinically, with digital contractures not exceeding 30°, Tubiana grades N to 1, and which reported identifiable data. Studies were excluded if data for early DD patients could not be extracted for analysis.ResultsIn this systematic review, 26 studies were identified and analyzed to evaluate the effect of pharmacological therapy (n = 11), physical therapy (n = 5) and radiotherapy (n = 10) on early Dupuytren’s disease. The studies comprised 20 case series, 1 cohort study with the remainder reporting case studies. All publications were graded level of evidence 4 or 5 assessed using the Oxford Centre for Evidence Based Medicine grading. Narrative descriptions of the data are presented.ConclusionsPhysical therapies were the most robustly assessed, using objective measures but the studies were under powered, providing insufficient evidence of efficacy. Intralesional steroid injection and radiotherapy appeared to lead to softening of nodules and to retard disease progression but lacked rigorous evaluation and studies were poorly designed. There is an urgent need for adequately powered double blinded randomized trials for this common disorder which affects 4 % of the population.Trial registrationThe protocol was registered (CRD42015008986 16 November 2015) with the PROSPERO international prospective register of systematic reviews.Electronic supplementary materialThe online version of this article (doi:10.1186/s12891-016-1200-y) contains supplementary material, which is available to authorized users.

Dupuytren’s contracture: the status and impact of collagenase Clostridium histolyticum treatment in Austria

“…This result is in line with most of the literature, where publications call for further studies in a specific topic concerning treatment of Dupuytren's disease with Xiapex. Thus, for example, Thomas and Bayat (2010) postulate further data on long-term results, recurrence rate and complications, whereas Ball et al (2016) demand clear definitions of the disorder or objective, reproducible methods for outcome measurement [19,35].…”

Therapie der Dupuytren’schen Kontraktur mit Kollagenase

“…ohne Funktionsbehinderung der Hand und vor dem Auftreten digitaler Kontrakturen, erhalten die meisten Patienten keine Behandlung, Dehnungsübungen werden verschiedentlich empfohlen, allerdings besteht keine Evidenz für die Wirksamkeit solcher Übungen. Alternative Methoden wie Steroidinjektionen und Röntgentrahlenbehandlung werden in der Literatur erwähnt, jedoch fehlt der Nachweis einer nachhaltigen Wirksamkeit insbesondere bei manifester Fibromatose [9,29]. Die Strahlentherapie sollte nur in frühen Stadien i.e.…”

“…In der Behandlung der DK kommen vor allem perkutane und offene chirurgische Verfahren zum Einsatz [8]. Im frühen Stadium werden auch medikamentöse Therapien, physikalische Methoden und die Radiotherapie als Optionen diskutiert, allerdings ist deren Stellenwert im Management der DK umstritten [9]. Seit Februar 2011 steht in der Europäischen Union mit der enzymatischen Injektionsbehandlung (Collagenase Clostridium histolyticum/CCH; Xiapex®) eine neue alternative, nichtchirurgische Therapie für erwachsene Patienten (≥ 18 Jahre) zur Verfügung.…”

An overview on therapeutic potential and various applications of microbial collagenases

“…Contracture of the cords produces deformities of the fingers [94]. This deformity results in considerable disability and can limit patient activities of daily living, manual activities, sporting hobbies and finally markedly reducing patients' quality of life and the prevalence of Duputyren's disease in the general population increases with age [95]. To restore the function fully, contractures have been treated by cutting the causative strands for nearly 200 years, ever since Baron Guillaume Dupuytren demonstrated his technique at the beginning of the nineteenth century.…”

“…Surgery can be minimal [fasciotomy] or quite invasive [96]. It's the ongoing mainstay being surgical correction involving either release or excision of the affected palmar fascia though complications and recurrences are frequent [94,95]. However, considerable attention has been paid for the non-operative treatment of Dupuytren disease.…”