Collagenase Extensor Tenotomy for Boutonniere Deformity in Dupuytren Disease
Carolyn Jane Vaughn, MD; Scott L. Hansen, MD; Keith Denkler, MD
University of California, San Francisco, Larkspur, CA
Dupuytren contracture with Boutonniere deformity is a difficult problem in hand surgery which his particularly resistant to treatment. Boutonniere deformity is characterized by flexion of the proximal interphalangeal (PIP) joint and hyperextension of the distal interphalangeal (DIP) joint. Hyperextension of the DIP joint in Dupuytren disease may be through pathological involvement of the transverse retinacular ligaments pulling the lateral bands volarly, or a secondary effect of PIP joint contracture, which creates an imbalance in the flexor and extensor tendons as they act across the DIP joint with progressive overstretching of the DIP joint volar plate. Boutonniere deformity may be treated with open tenotomy, or has been released with needle tenotomy.
In addition to these approaches, we describe the use of collagenase clostridium histolyticum as a treatment methodology for 13 patients with Dupuytren Boutonniere deformity. Twelve patients had Boutonniere deformity of the small finger, and one patient had deformity of the ring finger. Average preoperative flexion contracture at the MCP joint was 30 degrees, at the PIP joint was 70 degrees, and average DIP joint hyperextension was 27 degrees. Preoperative arc of motion at the MCP, PIP, and DIP joints were 69, 22, and 29 degrees, respectively.
Patients received a single treatment with injection of collagenase at the MCP joint, PIP joint and DIP joint. A dose of 0.1mg of collagenase was used for injection at the DIP joint. Average postoperative flexion contracture at the MCP joint was 12 degrees (P>0.05), and average PIP joint flexion contracture was 48 degrees (P<0.05). Average DIP joint hyperextension deformity was 9 degrees (P<0.05). The average postoperative arc of motion at the MCP, PCP, and DIP joint was 80 degrees (P>0.05), 45 degrees (P<0.05), and 36 degrees (P>0.05). This correlates to improvement in arc of motion on average of 11 degrees at the MCP joint, 23 degrees at the PIP joint, and 7 degrees at the DIP joint. Average length of follow up was 5.7 months.
Collagenase injection at the PIP and DIP joint led to statistically significant improvement in the degree of joint contracture, and statistically significant improvement in the arc of motion at the PIP joint, with a trend toward significance in the MCP and DIP joint arc of motion. While collagenase has been previously used for flexion contractures in Dupuytren disease, we believe it has a role in treating DIP joint hyperextension deformity associated with Boutonniere in Dupuytren disease as well.
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