Dupuytren PIP Joint Contractures Treated with Supplemental Botulinum Toxin to the Flexor Digitorum Sublimis Muscle
Keith Denkler, MD
Divsion of Plastic Surgery, University of California, San Francisco, Private Practice in Larkspur, CA
Successful treatment of Dupuytren proximal interphalangeal joint (PIP) joint contractures remains a problem. Options for treatment include presurgical fasciotomy, preliminary soft-tissue distraction, checkrein ligament release, joint capsulotomies, release of the digital flexor sheath, joint pinning, tendon lengthening, and early hand therapy.
Onaotulinum toxin A, already FDA approved for muscle spasticity of the fingers after stokes (30-50 u) has a role in weakening the contracted flexor digitorum sublimis muscle found in longstanding, severe PIP joint Dupuytren contractures.
METHODS
Four patients with more than 60-degree Dupuytren PIP joint contractures that failed previous treatments were administered one dose 10 to 20 u of botulinum toxin administered to the sublimis muscle of the involved PIP finger contracture during their treatment. For NA it was at the time of the procedure and for collagenase it was at the time of the initial administration of collagenase.
RESULTS
Significant improvement in little finger severe PIP contractures at early follow-up
CONCLUSION
Onabotulinum toxin A injections into the sublimis tendon helps PIP contractures during the early postoperative stage. Botulinum toxin may be used with all three techniques for release of Dupuytren contracture: Fasciotomy, fasciectomy, and collagenase. With collagenase, an on-label repeat treatment would be of benefit during the period (approx. four months) of botulinum toxin effect. 
Fig. 1 Eight-month F/U after NA and 20u Botulinum toxin to R little FDS
Fig. 2 PIP -100 to PIP -25-degree PIP with full passive extension (not shown).
Fig. 3 Three month follow-up after NA/Fat grafting and 20 u Botulinum to FDS left little finger
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