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

Keith A. Denkler, Justin Cheng, Siyou Song, Scott Hansen


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. 


Dupuytren’s contracture; Botulinum toxin; Severe proximal interphalangeal joint contracture

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Denkler KA, Park KM, Alser O. Treatment Options for Dupuytren’s Disease: Tips and Tricks. Plast Reconstr Surg Glob Open. 2022; 10(1):e4046.

Müller-Seubert W, Cai A, Arkudas A, Ludolph I, Fritz N, Horch RE. A Personalized Approach to Treat Advanced Stage Severely Contracted Joints in Dupuytren's Disease with a Unique Skeletal Distraction Device-Utilizing Modern Imaging Tools to Enhance Safety for the Patient. J Pers Med. 2022; 12(3):378. doi: 10.3390/jpm12030378. PMID: 35330378; PMCID: PMC8953560.

Hurst LC, Badalamente MA, Hentz VR, et al. Injectable collagenase clostridium histolyticum for Dupuytren's contracture. N Engl J Med. 2009; 361(10):968-979. doi: 10.1056/NEJMoa0810866. PMID: 19726771.

Barr V, Bhatia R, Hawkins P, Savage R. Intramuscular tenotomy of flexor digitorum superficialis in the distal forearm after surgical excision of dupuytren's disease. J Hand Surg Br. 2003; 28(1):37-39. doi: 10.1054/jhsb.2002.0860. PMID: 12531666.

De Aguiar G, Chait LA, Schultz D, et al. Chemoprotection of flexor tendon repairs using botulinum toxin. Plast Reconstr Surg. 2009; 124(1):201-209. doi: 10.1097/PRS.0b013e3181ab118c. PMID: 19568082.

Tüzüner S, Balci N, Ozkaynak S. Results of zone II flexor tendon repair in children younger than age 6 years: botulinum toxin type A administration eased cooperation during the rehabilitation and improved outcome. J Pediatr Orthop. 2004; 24(6):629-633. doi: 10.1097/01241398-200411000-00006. PMID: 15502560.

Davis SM, Chang EY. Dupuytren's contracture treated with botulinum toxin A injection. Arch Clin Cases. 2021; 7(4):63-67. doi: 10.22551/2020.29.0704.10175. PMID: 34754930; PMCID: PMC8565707..

Denkler K. Dupuytren PIP Joint Contractures Treated with Supplemental Botulinum Toxin to the Flexor Digitorum Sublimis Muscle, in AAHS Annual Meeting. 2019: Palm Springs.

Dressler D, Kopp B, Adib Saberi F. Botulinum toxin dosing in arm muscles: contextual factors. J Neural Transm (Vienna). 2021; 128(3):315-319. doi: 10.1007/s00702-021-02307-1. PMID: 33515332; PMCID: PMC7969489.

Simón-Pérez C, Alía-Ortega J, García-Medrano B, et al. Factors influencing recurrence and progression of Dupuytren's disease treated by Collagenase Clostridium histolitycum. Int Orthop. 2018; 42(4):859-866. doi: 10.1007/s00264-017-3690-0. PMID: 29170879.

David M, Smith G, Pinder R, et al. Outcomes and Early Recurrence Following Enzymatic (Collagenase) Treatment of Moderate and Severe Dupuytren Contractures. J Hand Surg Am. 2020; 45(12):1187.e1-1187.e11. doi: 10.1016/j.jhsa.2020.06.012. PMID: 32861504.


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