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=====Title=====
Outcomes and Direct Costs of Needle Aponeurotomy, Collagenase Injection, and Fasciectomy in the Treatment of [[md:dupuytrens|Dupuytren Contracture]]

====Abstract====


Purpose


The aims of our study were to evaluate the rates and predictors of reinterventions and direct costs of 3 common treatments of Dupuytren contractures—needle aponeurotomy, collagenase injection, and surgical fasciectomy.



Methods


A retrospective review identified 848 interventions for Dupuytren contracture in 350 patients treated by a single surgeon from 2005 to 2016. The treatments included needle aponeurotomy (NA) (n = 444), collagenase injection (n = 272), and open fasciectomy (n = 132). We collected information on demographics, contracture details, and comorbidities. Outcomes included reintervention rates, time to reintervention, and direct cost of treatments. Standardized costs were calculated by applying 2017 Medicare reimbursement to professional services and cost-to-charge ratios to hospital charges.



Results


Demographics were similar among the 3 treatment groups. The fifth finger was the most commonly affected digit including 43% of the NA, 60% of the collagenase, and 45% of the fasciectomy groups. The 2-year rates of reintervention following NA, collagenase, and fasciectomy were 24%, 41%, and 4%, respectively, and the 5-year rates were 61%, 55%, and 4%, respectively. Younger age and severity of preintervention proximal interphalangeal (PIP) joint contracture were predictive of reintervention in the NA and collagenase groups. The standardized direct costs for NA, collagenase, and fasciectomy were $624, $4,189, and $5,291, respectively. Including all reinterventions, the cumulative costs per digit following NA, collagenase, and surgery at 5 years were $1,540, $5,952, and $5,507, respectively.



Conclusions


Treatment with collagenase resulted in the highest rate of reintervention at 2 years, comparable reintervention rates to NA at 5 years, and the highest cumulative costs. The NA was the least expensive and resulted in longer duration before reintervention compared with collagenase. More severe PIP joint contractures and younger age at time of initial intervention were predictive of reintervention after collagenase and NA. Fasciectomy has a high initial cost but the lowest reintervention rate.



Type of study/level of evidence


Therapeutic IV.

====Commentary====

  * retrospective study
  * 2005-2016: collagenase only recently available; earlier cases only had two options
  * 5 year NA reintervention similar to collagenase (55-60%) vs ~ 5% for OF -- 11-12x difference
  * Collagenase most expensive
  * There are other comparison studies out there.

====Source=====
Leafblad, N. D., Wagner, E., Wanderman, N. R., Anderson, G. R., Visscher, S. L., Maradit Kremers, H., … Rizzo, M. (2019). Outcomes and Direct Costs of Needle Aponeurotomy, Collagenase Injection, and Fasciectomy in the Treatment of Dupuytren Contracture. The Journal of Hand Surgery, 44(11), 919–927. https://doi.org/10.1016/j.jhsa.2019.07.017

See also [[md:dupuytrens]]
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