A new surgical approach to Dupuytren's disease

[Incisions in surgical Treatment of Dupuytren's Disease]

Therapeutic options to treat Dupuytren`s disease vary considerably. Nevertheless, limited fasciectomy remains the method of choice in advanced disease. Correct incisions are of crucial importance in this kind of surgery.With the inclusion of relevant literature, we present principles of correct incisions and our personal approach in different stages of the disease. History and a subtle clinical examination are essential to plan the surgery. Important details are quality of skin and extent and characteristics of pathological tissue. Generally accepted basic incisions are longitudinal incisions with subsequent Z-plasties and Zig-Zag-Incisions with several modifications. Extensive deficit of skin necessitates local flaps. In the palm we prefer an ulnar-based flap design and in special cases a Z-plasty. Depending on the extent of the disease, various combinations of these basic techniques are necessary. Incisions must respect general principles in hand surgery, allow exposition of the pathological tissue, utilise mobile parts of skin for usage as flaps and respect vascularisation of resulting flaps.In complex cases, individualised incisions or general hand surgical principles and correction of the resulting skin deficit are crucial elements necessary for successful surgery. By sticking to these principles, experienced hand surgeons can implement different solutions.

What are we measuring? A critique of range of motion methods currently in use for Dupuytren's disease and recommendations for practice

BACKGROUND

Range of motion is the most frequently reported measure used in practice to evaluate outcomes. A goniometer is the most reliable tool to assess range of motion yet, the lack of consistency in reporting prevents comparison between studies. The aim of this study is to identify how range of motion is currently assessed and reported in Dupuytren's disease literature. Following analysis recommendations for practice will be made to enable consistency in future studies for comparability. This paper highlights the variation in range of motion reporting in Dupuytren's disease.

METHODS

A Participants, Intervention, Comparison, Outcomes and Study design format was used for the search strategy and search terms. Surgery, needle fasciotomy or collagenase injection for primary or recurrent Dupuytren's disease in adults were included if outcomes were monitored using range of motion to record change. A literature search was performed in May 2013 using subject heading and free-text terms to also capture electronic publications ahead of print. In total 638 publications were identified and following screening 90 articles met the inclusion criteria. Data was extracted and entered onto a spreadsheet for analysis. A thematic analysis was carried out to establish any duplication, resulting in the final range of motion measures identified.

RESULTS

Range of motion measurement lacked clarity, with goniometry reportedly used in only 43 of the 90 studies, 16 stated the use of a range of motion protocol. A total of 24 different descriptors were identified describing range of motion in the 90 studies. While some studies reported active range of motion, others reported passive or were unclear. Eight of the 24 categories were identified through thematic analysis as possibly describing the same measure, 'lack of joint extension' and accounted for the most frequently used.

CONCLUSIONS

Published studies lacked clarity in reporting range of motion, preventing data comparison and meta-analysis. Percentage change lacks context and without access to raw data, does not allow direct comparison of baseline characteristics. A clear description of what is being measured within each study was required. It is recommended that range of motion measuring and reporting for Dupuytren's disease requires consistency to address issues that fall into 3 main categories: Definition of terms, Protocol statement, Outcome reporting.

Optimal functional outcome measures for assessing treatment for Dupuytren's disease: a systematic review and recommendations for future practice

BACKGROUND

Dupuytren's disease of the hand is a common condition affecting the palmar fascia, resulting in progressive flexion deformities of the digits and hence limitation of hand function. The optimal treatment remains unclear as outcomes studies have used a variety of measures for assessment.

METHODS

A literature search was performed for all publications describing surgical treatment, percutaneous needle aponeurotomy or collagenase injection for primary or recurrent Dupuytren's disease where outcomes had been monitored using functional measures.

RESULTS

Ninety-one studies met the inclusion criteria. Twenty-two studies reported outcomes using patient reported outcome measures (PROMs) ranging from validated questionnaires to self-reported measures for return to work and self-rated disability. The Disability of Arm, Shoulder and Hand (DASH) score was the most utilised patient-reported function measure (n=11). Patient satisfaction was reported by eighteen studies but no single method was used consistently. Range of movement was the most frequent physical measure and was reported in all 91 studies. However, the methods of measurement and reporting varied, with seventeen different techniques being used. Other physical measures included grip and pinch strength and sensibility, again with variations in measurement protocols. The mean follow-up time ranged from 2 weeks to 17 years.

CONCLUSIONS

There is little consistency in the reporting of outcomes for interventions in patients with Dupuytren's disease, making it impossible to compare the efficacy of different treatment modalities. Although there are limitations to the existing generic patient reported outcomes measures, a combination of these together with a disease-specific questionnaire, and physical measures of active and passive individual joint Range of movement (ROM), grip and sensibility using standardised protocols should be used for future outcomes studies. As Dupuytren's disease tends to recur following treatment as well as extend to involve other areas of the hand, follow-up times should be standardised and designed to capture both short and long term outcomes.