Cost-Effectiveness of Open Partial Fasciectomy, Needle Aponeurotomy, and Collagenase Injection for Dupuytren Contracture

doi:10.1016/j.jhsa.2011.08.004

The Journal of Hand Surgery

Volume 36, Issue 11, November 2011, Pages 1826-1834.e32

https://doi.org/10.1016/j.jhsa.2011.08.004 Get rights and content

Purpose

We undertook a cost-utility analysis to compare traditional fasciectomy for Dupuytren with 2 new treatments, needle aponeurotomy and collagenase injection.

Methods

We constructed an expected-value decision analysis model with an arm representing each treatment. A survey was administered to a cohort of 50 consecutive subjects to determine utilities of different interventions. We conducted multiple sensitivity analyses to assess the impact of varying the rate of disease recurrence in each arm of the analysis as well as the cost of the collagenase injection. The threshold for a cost-effective treatment is based on the traditional willingness-to-pay of $50,000 per quality-adjusted life years (QALY) gained.

Results

The cost of open partial fasciectomy was $820,114 per QALY gained over no treatment. The cost of needle aponeurotomy was $96,474 per QALY gained versus no treatment. When we performed a sensitivity analysis and set the success rate at 100%, the cost of needle aponeurotomy was $49,631. When needle aponeurotomy was performed without surgical center or anesthesia costs and with reduced hand therapy, the cost was $36,570. When a complete collagenase injection series was priced at $250, the cost was $31,856 per QALY gained. When the injection series was priced at $945, the cost was $49,995 per QALY gained. At the market price of $5,400 per injection, the cost was $166,268 per QALY gained.

Conclusions

In the current model, open partial fasciectomy is not cost-effective. Needle aponeurotomy is cost-effective if the success rate is high. Collagenase injection is cost-effective when priced under $945.

Type of study/level of evidence

Economic and Decision Analysis II.

Section snippets

General model overview

This cost-effectiveness model and analysis follows the guidelines of the Panel on Cost-Effectiveness in Health and Medicine developed by the United States Public Health Service in 1993.16, 17 These guidelines help ensure consistency among cost-effectiveness analyses. Our model compared the cost-effectiveness of needle aponeurotomy, collagenase injection, and open partial fasciectomy in adults. The model assumed that the mean age of presentation, as derived from the literature, would be 63 years.

Utilities

We surveyed 50 subjects. The mean age was 60 ± 6 years. A total of 27 subjects were men. Utilities for interventions for Dupuytren contracture were universally high, ranging from 0.971 to 0.994 (Table 1). The outcome with the worst utility was open partial fasciectomy complicated by chronic regional pain syndrome (utility = 0.971). The outcome with the highest utility was successful collagenase injection (utility = 0.994). In the standard gamble method, a utility of 1 represents perfect health,

Discussion

This study is an analysis of 3 treatment options for Dupuytren contracture: open partial fasciectomy, needle aponeurotomy, and collagenase injection. In this model, the first hypothesis was rejected: Open partial fasciectomy did not meet cost-effectiveness thresholds based on traditional standards of $50,000 per QALY. The second and third hypotheses were conditionally accepted: Needle aponeurotomy is cost-effective only when the success rate is near 100% or when it is performed in an outpatient

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Collagenase Treatment Versus Needle Fasciotomy for Single-Digit Dupuytren Contractures: A Meta-Analysis of Randomized Controlled Trials
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The objective of this systematic review and meta-analysis was to synthesize the available randomized controlled trial data comparing needle fasciotomy and collagenase treatment for single-digit Dupuytren contractures with a minimum of 3-year follow-up and determine whether one treatment is superior regarding contracture correction and functional outcomes.
A systematic review and meta-analysis was conducted by searching four databases for randomized controlled trials investigating the single-digit treatment outcomes for Dupuytren contracture comparing collagenase treatment and needle fasciotomy with a minimum of 3-year follow-up. The risk of bias of included studies was assessed using the Cochrane risk-of-bias tool. A meta-analysis was performed using a random effects model in anticipation of unobserved heterogeneity. The primary outcome measure was contracture recurrence. Secondary outcome measures included final fixed flexion contracture (FFC), Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) scores, and Unité Rhumatologique des Affections de la Main (URAM) scores.
After screening 264 articles, 4 randomized clinical trials were eligible for final inclusion. One trial had a high risk of bias, and two trials had some concern for bias. The final meta-analysis included 347 patients, 169 who underwent collagenase treatment and 178 who underwent needle fasciotomy. No significant differences were noted between the groups in contracture recurrence, FFC, and URAM scores. The pooled data showed a higher QuickDASH score in the collagenase treatment group compared with the needle fasciotomy group, but the observed difference was less than what would be expected to be clinically relevant.
Needle fasciotomy and collagenase treatment have similar outcomes with regards to contracture recurrence, final FFC, QuickDASH scores, and URAM scores for the single-digit treatment for Dupuytren contracture at a minimum of 3-year follow-up. Relevant factors that may be considered during the shared decision-making process for treatment selection include surgeon and patient preferences, costs of treatment, and the disparate complication profiles of these two treatments.
Therapeutic II.
Five-Year Results of a Randomized, Controlled Trial of Collagenase Treatment Compared With Needle Fasciotomy for Dupuytren Contracture
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Over the past decade, collagenase treatment and needle fasciotomy (NF) have gained widespread popularity in the treatment of Dupuytren contracture. This prospective study was designed to compare the results of these treatments in terms of clinical and patient-reported outcomes.
A prospective, randomized, controlled trial included patients with a contracture of 20° or more in a single metacarpophalangeal joint. Patients were allocated to treatment with either NF or collagenase Clostridium histolyticum. The primary outcome was a reduction in the metacarpophalangeal joint contracture to less than 5°. Secondary outcomes included recurrence, the presence of Dupuytren cords, and changes in patient-reported outcomes. The participants were examined 5 years after the intervention.
The study cohort comprised 156 patients divided into 2 equally sized groups. After 5 years, data were collected from 143 (92 %) of the initially enrolled participants. The mean time for the clinical follow-up was 5.1 years. In the remaining cohort without a second procedure, 51% (23 patients) in the collagenase Clostridium histolyticum group and 47% (27 patients) in the NF group still had extension deficits of less than 5°. Among the participants with a successful initial procedure, the recurrence rate was 56% (36 patients) in the collagenase Clostridium histolyticum group and 45% (30 patients) in the NF group. There were no differences between the 2 treatments in regard to passive joint extension, reduction of contracture, range of motion, or patient-reported outcomes.
The 5-year outcomes for NF are similar to those for collagenase in terms of sustained correction, recurrence, presence of Dupuytren cords, and patient-reported outcomes for the treatment of metacarpophalangeal joint contractures.
Therapeutic I.
Dupuytren Contractures: An Update of Recent Literature
2021, Journal of Hand Surgery
Dupuytren disease is a fibroproliferative disorder that affects the palmar fascia of the hand and results in varying degrees of nodule and cord formation. Over time, patients may develop progressive contractures, impairing their ability to type, to perform with fine instruments, or to participate in social activities such as shaking hands. Treatment options for Dupuytren contractures include needle aponeurotomy (NA), injection of collagenase Clostridium histolyticum (CCH) with manipulation of the digits, and surgical fasciectomy. Over the past decade, the use of CCH has increased. Recent studies have provided additional data regarding the pathophysiology, indications, outcomes, and costs associated with the treatment for Dupuytren contractures, and this review highlights these advances.
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Health technology assessment provides a means to assess the technical properties, safety, efficacy, cost-effectiveness, and ethical/legal/social impact of a novel technology. An important component of health technology assessment is the cost-effectiveness analysis (CEA), which can be performed using model-based CEA. This study used the CEA model to compare the cost-effectiveness of a novel ligament augmentation device with the standard technique for primary repair of complete ulnar collateral ligament (UCL) tears.
A model was developed for complete UCL tear requiring acute surgical repair, comparing the cost-effectiveness of standard technique primary repair and repair using a ligament augmentation device from a societal perspective. Primary outcomes included quality-adjusted life years (QALYs), cost, net monetary benefit (NMB) and incremental NMB. A cost-effectiveness threshold of CAD $50,000/QALY was used to compare the 2 techniques. Sensitivity analyses were conducted to assess the parameter uncertainty, specifically the impact of device cost, time off work, probability of complication, and postoperative outcome.
The NMB for the standard technique was CAD $42,598, and the NMB for repair using the ligament augmentation device was CAD $41,818. The standard technique was the preferred strategy for primary repair of complete UCL tears. One-way sensitivity analyses demonstrated that the ligament augmentation device became cost-effective if individuals return to work in <18 days (base case 23 days). The device was also favored when the cost was less than CAD $50 and the difference in time to return to work was at least 1 day.
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Economic/Decision Analysis II.
Versatility of percutaneous needle fasciotomy for Dupuytren's disease across a spectrum of disease severity: A single-surgeon experience of 118 rays
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Percutaneous needle fasciotomy (PNF) represents the only minimally invasive approach for treatment of Dupuytren's disease in Europe since withdrawal of collagenase from European markets. Though well-established, surgeon preference and uncertainty regarding safety and efficacy, results in limited provision in favour of open fasciectomy.
A retrospective review of 74 patients who self-opted to receive PNF between 2017 and 2020 was conducted. Demographic data, complications and degree of release achieved were compared across three cohorts based on contracture severity as per Tubiana staging (TS): Stage 1, 0–45°; Stage 2, 46–90°; Stage 3, 91–130° with χ² analysis.
One hundred and eighteen rays were treated amongst 74 patients (mean age, 68 years (R, 32–86), males: 74%) with mean follow-up 51 weeks (IQR 28–76 weeks) with no significant difference in baseline characteristics across cohorts. No cases of permanent sensory disturbance, flexor tendon rupture, arterial transection nor infection were observed. Neuropraxia was seen in six patients, resolving with mean recovery of 6 weeks. 86% (n = 166) of joints had satisfactory release (residual passive extension deficit (PED) ≤10°) with full release in 67%. Full release was most likely in metacarpophalangeal joint (MCPJ; 93%) than distal interphalangeal joint (DIPJ; 67%) or proximal interphalangeal joint (PIPJ; 45%; p<0.0001). Mean release was 54° in MCPJ and 56° in PIPJ. All TS1 patients achieved release with ≤10° residual PED versus 75% of TS2 patients and 22% of TS3 patients (p<0.05), the latter of whom had a mean residual PED of 12° Ninety-two percent of patients stated they would undergo PNF again if necessary, in preference to open fasciectomy.
We find PNF to facilitate a safe, effective yet minimally invasive approach amongst patients of varying disease severity, across different age groups, with recurrent disease, associated comorbidities or concurrent anticoagulation therapy. Patients reported high satisfaction in preference to open procedures. We, therefore, intend to recommend PNF first-line to all patients regardless of disease severity.
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Citation Excerpt :
If the latter estimates are accepted, offering 3 injections would almost always be preferred by all health payers. These estimates are based on some of the most conservative valuations found in the hand literature.20,36–38 Notably, other studies using rigorous health state valuation methodologies arrived at similar valuations as in our base case, which suggests that hand conditions have discernable impacts on quality of life.20,39–43
To evaluate the cost-effectiveness of corticosteroid injection(s) versus open surgical release for the treatment of trigger finger.
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Offering 3 steroid injections before surgery was the optimal strategy for both commercially insured and Medicare Advantage patients. The probabilistic sensitivity analysis showed that this strategy was cost-effective 67% and 59% of the time for commercially insured and Medicare Advantage patients, respectively. Our results were sensitive to the probability of injection site fat necrosis, success rate of steroid injections, time to symptom relief after a steroid injection, and cost of treatment. Immediate surgical release became cost-effective when the cost of surgery was below $902 or $853 for commercially insured and Medicare Advantage patients, respectively.
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: The authors thank Kate Chang, MA, for assistance with statistics and Lillian Bellfi, BS, Phillip Clapham, BA, and Pouya Entezami, BS, for interviewing participants. The authors also thank David Alvarez, MD, Asheesh Bedi, MD, James Carpenter, MD, Laurie Donaldson, MD, Jolie Holschien, MD, Jeffrey Housner, MD, Bruce Miller, MD, Waldomar Roeser, MD, Jon Sekiya, MD, and Edward Wojtys, MD, for contributing subjects for clinical interviews.

: Supported in part by a Midcareer Investigator Award in Patient-Oriented Research (K24 AR053120) from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (to K.C.C.).

: No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

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Scientific articleCost-Effectiveness of Open Partial Fasciectomy, Needle Aponeurotomy, and Collagenase Injection for Dupuytren Contracture

Purpose

Methods

Results

Conclusions

Type of study/level of evidence

Section snippets

General model overview

Utilities

Discussion

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Arthroplasty

Am J Gastroenterol

Hand Clin

Histological staging and Dupuytren's disease recurrence or extension after surgical treatment: a retrospective study of 124 patients

J Hand Surg

Results of partial fasciectomy for Dupuytren disease in 261 consecutive patients

Ann Plast Surg

Does a “firebreak” full-thickness skin graft prevent recurrence after surgery for Dupuytren's contracture?A prospective, randomised trial

J Bone Joint Surg

Non-surgical treatment of Dupuytren disease using needle fasciotomy

Rev Rhum Ed Fr

Percutaneous needle fasciotomy in Dupuytren disease

Tech Hand Up Extrem Surg

Scientific article
Cost-Effectiveness of Open Partial Fasciectomy, Needle Aponeurotomy, and Collagenase Injection for Dupuytren Contracture