Dear Sir,
We thank Dr Cilli for their comments1 on our recent article, ‘Percutaneous needle fasciotomy for Dupuytren's disease: A one-stop approach incidentally suited to the era of COVID-19’.2 Additionally, we are delighted hear of their adaptations to practice, towards percutaneous needle fasciotomy (PNF), such that treatment for Dupuytren's may be continued throughout this ‘second wave’ of the pandemic.
We would concur that there is an associated learning curve when adopting PNF and it is a procedure which does require skill. However, we find that the technique can be used successfully in both proximal and distal interphalangeal joints. In our recently published series of PNF in 118 rays,3 mean contracture release was not significantly dissimilar when undertaken in the proximal or distal interphalangeal joints in comparison to the metacarpophalangeal joint. Indeed, clinically satisfactory release of the PIPJ was achieved in 79% of cases with no major complications observed including no incidence of permanent sensory disturbance. Beyond this, the ability to achieve full passive extension may be limited by contracture of the collateral ligaments and volar plate over a period of fixed flexion.
The recent withdrawal of Clostridium Histolyticum collagenase therapy across European markets is indeed regrettable. However, it may be important to note that collagenase injection is not an insignificant undertaking. Patients will need to be informed of possible failures, allergic reactions as well as a perceived recurrence of up to 80%.4 Furthermore, in a time of widespread scarcity of healthcare resources, it is important to consider a population perspective. Xiapex® when available, was associated with significant cost – approximately £780 per injection, with the majority of cases requiring at least two vials. In comparison, the material cost of PNF is rather inconsequential and has shown to be highly cost-effective especially in recurrent or high-severity PIPJ contracture.5 Ultimately however, decisions regarding mode of treatment should be tailored to the requirements and preferences of the patient as well as the operator's ability, skill and training.
Funding
No funding has been obtained for this work.
Ethical approval
N/A.
Declaration of Competing Interest
The authors would like to confirm that there are no conflicts of interest.
References
- 1.Cilli V. Dupuytren's disease treatment during the second wave of COVID-19 pandemic. J Plast Reconstr Aesthet Surg. 2020 Dec 24 doi: 10.1016/j.bjps.2020.12.030. S1748-6815(20)30697-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
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