Review Question - QID 211776

CCH has little effect against type IV collagen, which forms the basement membrane of nerves and blood vessels.

CCH is indicated for symptomatic cords causing >30 degrees of flexion contractures. Treatment with CCH typically entails a minimum dose of 10,000 units, suspended in 0.2-0.25mL, and injected with a 22-25g needle into pathologic cords. The hand is then manipulated 24-48 hours after the injection. Skin tears are common but usually asymptomatic. CCH is more effective against metacarpophalangeal joint (MCPJ) as compared to proximal interphalangeal joint (PIPJ) contracture. Although CCH treatment has revolutionized the management of Dupuytren's disease, there is some concern over potential increased surgical difficulty after a patient has received a CCH injection.

Chung et al. present a review of the molecular mechanisms of collagenase. The authors describe how MMP-1, a prototypic collagenase, binds and unwinds the triple-helical collagen structure to permit bond hydrolysis. They conclude with the importance of understanding the underlying mechanisms in relation to the various biologic and disease processes.

Gaston et al. prospectively evaluated 715 patients who received CCH injections for fixed flexion contractures (FFC) secondary to Dupuytren's disease present in two joints of the same finger. The authors found that at one month, FFCs decreased on average from 98 to 27 degrees, and range of motion improved. The clinical success rate in MCPJ contracture was 65% as compared to 29% for PIPJ contracture. The authors reported that the most common adverse events included skin tears (22%), edema, and pain. They recommended CCH as a treatment for Dupuytren's disease in those with 2 joints affected with FFC in the same finger.

Desai and Hentz reviewed the treatment for Dupuytren's disease. The authors noted that treatment for Dupuytren's disease has historically been surgical, and limited palmar fasciectomy is currently the most common treatment option. However, they discuss that CCH is now an FDA approved treatment for Dupuytren's disease and provides an excellent non-surgical alternative.

Incorrect answers:
Answer 1: CCH is most effective against types I and III collagen.
Answer 2: CCH has limited effect on type II collagen, HOWEVER this is not present in neurovascular structures but is instead the predominant type of collagen found in articular cartilage.
Answer 3: CCH is effective against types I and III collagen. Type III collagen is furthermore the predominant type of collagen associated with Dupuytren's disease.
Answer 5: CCH is effective against types I and III collagen, but not type IV.