Botulinum toxin as an adjunct for severe Dupuytren’s contracture treated with collagenase injections

Even with Dupuytren's proximal interphalangeal joint (PIPJ) contractures successfully released, volar flexor muscle memory can contribute to persistent contracture.  We report using botulinum toxin (BoNTA) to the flexor digitorum superficialis muscle (FDS) to reduce flexor tone during recovery. Case Description. Two Collagenase clostridium histolyticum (CCH) injections were given to a patient with a -90° (PIPJ) contracture and a -35° degree distal interphalangeal joint (DIPJ) contracture.  At the first CCH injection, 20 µ  total of the Botulinum toxin was placed into the FDS muscle.  Manipulation occurred at one week.  A second injection of CCH followed by manipulation one week later occurred at two months, but no additional BoNTA was given.  The final follow-up measurements at 53 months showed a PIPJ of -30° and a DIPJ of 0°.  Total active motion improved from 140° to 240°. Outcomes of any treatment for severe Dupuytren's PIPJ contractures of the little finger are unpredictable and are often considered for staged external expansion or even salvage procedures.  BoNTA injections weaken flexor tone in tendon repairs and for treating hypertonic muscles after strokes.  Conclusion. We hypothesized that BoNTA injection could enhance the outcomes of DC treatment by inhibiting volar flexion forces during the recovery phase.  The following case illustrates that using a BoNTA injection may have helped treat a severe PIPJ contracture.  BoNTA injections need further research and controlled clinical trials to discover their proper role in Dupuytren's contractures treated via CCH injections, fasciotomies, and fasciectomies. 