Abe Scoring System for Predicting Recurrence and Extension
Abe scores for both treatment groups were calculated. Four of 10 patients with recurrence or extension in the limited fasciectomy group had an Abe score higher than 4; in the percutaneous needle fasciotomy group, nine of 45 had an Abe score higher than 4. These scores did not influence the chances of recurrence (limited fasciectomy group, p = 0.23; percutaneous needle fasciotomy group, p = 0.19). Therefore, our study does not support the Abe hypothesis; a higher score did not correlate with recurrence in our study.
Choice of Treatment for Recurrent Disease
In the limited fasciectomy group, four of nine patients chose to have their recurrences treated with percutaneous needle fasciotomy. Six patients (five with recurrences and one with extension) chose not to be treated. None of the patients in the limited fasciectomy group who presented with recurrent disease chose limited fasciectomy again.
Twenty-six of 45 patients with recurrent disease in the percutaneous needle fasciotomy group chose to undergo a second treatment with percutaneous needle fasciotomy. Seven patients preferred limited fasciectomy. The remaining 12 patients did not opt for treatment of recurrent disease.
The average patient satisfaction score was significantly higher in the limited fasciectomy group (8.3), as compared with the percutaneous needle fasciotomy group (6.2; p < 0.001). The score for choosing the same procedure as preferred future treatment was 8.7 in the limited fasciectomy group, which was significantly higher than the score of 7.0 in the percutaneous needle fasciotomy group (p = 0.008). The scores for both questions were strongly correlated to recurrent disease. In patients with recurrence, satisfaction with treatment results was significantly less (p < 0.001) as compared with the patients without recurrence (odds ratio, 0.61). These patients also expressed less preference for the same treatment (p = 0.02; odds ratio, 0.83).
This study focused on Dupuytren's disease recurrence rates that occurred during a 5-year follow-up period after treatment by percutaneous needle fasciotomy or limited fasciectomy. A number of definitions can be found in the literature for recurrence after treatment for Dupuytren's disease. For example, McFarlane and McGrouther used the definition “recurrent joint contracture sufficient to require further operation.8 Hueston used “appearance of new Dupuytren's tissue within the area cleared at operation,” and this definition is the most widely used one.20 Some authors, such as Mäkelä et al. and Badois et al. did not define recurrence.8,21–23
Hueston's definition of recurrence could not be used because, in percutaneous needle fasciotomy, no tissue is removed. Therefore, recurrence was defined indirectly, as an increase of the total passive extension deficit of 30 degrees or more in a ray compared with the result at 6 weeks after treatment. This measure is reproducible and clinically more relevant than the other definitions. A worsening of digital extension of 30 degrees was chosen because it corresponds to the Hueston tabletop test and is considered the minimal contracture with which to qualify for surgery at our center.
Recurrence after Limited Fasciectomy
In a previous study on the 3-year results of the same cohort of patients, we found a recurrence rate of 9 percent.6 At 5 years, the recurrence rate had increased to 20.9 percent. This figure compares favorably with other studies, although comparison is hampered because of varying definitions and a lack of 5-year follow-up data from other studies. We found only two studies with long-term data that we consider to some extent relevant for comparison. Jurisić et al. retrospectively studied the population of Primorsko-Goranska County in Croatia and found a 73 percent recurrence rate after limited fasciectomy and a mean follow-up of 7 years.13 However, they had defined recurrence as the development of new Dupuytren's disease lesions in the area where fasciectomy had been performed, including the smallest palpable nodule irrespective of a presenting contracture. Thirty-four percent of these recurrences required further surgery. Foucher described his results on the open palm technique in 54 patients in 1992 with a 5.6-year follow-up period. Recurrence was not clearly defined. The recurrence rate in his study was 41 percent.
Recurrence after Percutaneous Needle Fasciotomy
In our study, 85 percent of the patients developed recurrence over the 5-year follow-up period. This recurrence rate is the highest ever published for percutaneous needle fasciotomy. Nevertheless, we believe that the results of others would have been similar if their cohorts had been followed for 5 years and had a comparable definition been used. In our analysis at 3 years, the recurrence rate was 63 percent. This figure is very similar to that of previously published series with the same follow-up period. In our pilot, we found a 65 percent recurrence rate after a mean of 33 months,5 whereas Foucher et al. reviewed 100 rays after a mean of 3.2 years and found a recurrence rate of 58 percent.4 The only study that reported 5-year results was from the group of Badois et al.23 They reported a recurrence rate of only 50 percent, but their definition of recurrence is unclear.
Recurrence after Limited Fasciectomy and Percutaneous Needle Fasciotomy Compared with Those after Treatment with Collagenase
In the past decade, the results of various studies on the application of collagenase for Dupuytren's disease have been published.15–19 The results of these studies have been presented in a manner different from ours. All collagenase studies looked at the effect of treatment at each joint individually. The treatment is defined as “clinically successful” when correction of the deformity decreases to within 0 to 5 degrees of full extension.
If we reanalyze our data accordingly, 94 percent of the treated metacarpophalangeal joints in the limited fasciectomy group and 55 percent of those in the percutaneous needle fasciotomy group reached this endpoint. In the proximal interphalangeal joint, the corresponding figures are 47 percent following limited fasciectomy and 26 percent following percutaneous needle fasciotomy. Our results were achieved with only one treatment, whereas patients treated with collagenase often needed multiple treatment sessions. In the study by Hurst et al., 76 percent of metacarpophalangeal joints and 40 percent of proximal interphalangeal joints reached the primary endpoints.18 A comparison with our data shows that the results we achieved with limited fasciectomy were better than those obtained by Hurst et al. with collagenase. A single treatment with percutaneous needle fasciotomy, however, seems to be somewhat inferior to up to three injections with collagenase.
At present, there are only two long-term follow-up studies available in which collagenase was used, one with 8 years' follow-up and the other with 2 years' follow-up.18,19 One of the studies19 also used another definition of recurrence (i.e., it was defined as any degree of loss of extension as compared with full extension). If we apply this definition in our study, the recurrence rate for the metacarpophalangeal joint would be 21 percent in the limited fasciectomy group and 57 percent in the percutaneous needle fasciotomy group (p = 0.00). For the proximal interphalangeal joint, rates are 21 percent for the limited fasciectomy group and 70 percent for the percutaneous needle fasciotomy group (p = 0.00). In Watt's study, recurrence rates were 68 percent in the metacarpophalangeal joint and 100 percent in the proximal interphalangeal joint after 8 years. Recurrence rates of collagenase therapy at 8 years are therefore comparable to, if not worse than, our percutaneous needle fasciotomy results after 5 years.
In a study conducted by Hurst and Badalamente in 2007, the recurrence rate, defined as a return of contracture of at least 20 degrees in successfully treated joints, was 19 percent after 2 years. If we would apply this in our study, recurrence rates would be as follows. In the metacarpophalangeal joint, we reached “success” in 72.1 percent (132 of 183 joints). The recurrence rate would be 5.3 percent (four of 76 joints) in the limited fasciectomy group and 21.8 percent (12 of 55 joints) in the percutaneous needle fasciotomy group after 5 years. In the proximal interphalangeal joint, we reached success in 34.3 percent. The recurrence rate would be 5.3 percent (one of 19 joints showed recurrence) in the limited fasciectomy group and 23.5 percent (four of 17 joints) in the percutaneous needle fasciotomy group. These results indicate that the recurrence rate after collagenase is considerably higher than after limited fasciectomy and percutaneous needle fasciotomy, even after a considerably shorter follow-up period.
Age versus Recurrence
As Hindocha et al. pointed out in their study, age of onset younger than 50 years increases the chances for recurrent disease.24 To our knowledge, our study is the first to show a general correlation between age and disease recurrence.
Our findings do not corroborate those of many authors supporting the view that Dupuytren's diathesis is a risk factor for recurrence or extension. We were unable to find a statistically significant influence of fifth digit involvement, early onset, radial disease, familial predisposition, ectopic lesions, sex, or comorbidities such as diabetes and epilepsy on the appearance of recurrence.
McFarlane and McGrouther reported 5-year results on limited fasciectomy with the open-palm technique and were also unable to prove the effect of Hueston's diathesis. This finding, along with the establishment of an effect of age on recurrence, suggests that their findings are consistent with ours.8
Patient satisfaction was high for both percutaneous needle fasciotomy and limited fasciectomy treatments. Patients who had received limited fasciectomy were significantly more satisfied at 5 years with their treatment than those with percutaneous needle fasciotomy. The outcomes were influenced in a negative way when recurrence took place. However, many patients who suffered recurrent disease chose to undergo percutaneous needle fasciotomy again. This indicates that many patients are likely to prefer a minor procedure with fast recovery at the expense of a higher chance of an early recurrence.
Although percutaneous needle fasciotomy is equally effective for mild to moderate Dupuytren's disease (Tubiana stages I and II), as we have shown in previous studies, recurrence rates are significantly higher than after limited fasciectomy. A higher age at disease presentation correlates with a lower tendency for recurrence. For this reason, we believe that percutaneous needle fasciotomy treatment is best suited for well-informed elderly patients with relatively mild contractures (Tubiana stages I and II) and for those who are willing to accept a higher recurrence risk in the context of a lower complication rate, a faster recovery, and minimal invasiveness.
This information prepared by Dr. Raymond Janevicius is intended to provide coding guidance.
* A percutaneous fasciotomy is reported with code 26040. If an open fasciotomy is performed, use code 26045.
* Fasciectomy for Dupuytren's contracture is reported with codes 26121, 26123, and 26125.
* If disease is limited to the palm, with no finger involvement, use code 26121.
* If disease involves the palm and a single digit, report code 26123. Codes 26121 and 26123 are not used together, as code 26123 includes what is done in code 26121.
* Each additional digit fasciectomy is reported with code 26125. This is an add-on code and will never stand alone. Code 26125 must always used with code 26123.
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3. Van Rijssen AL, Gerbrandy FS, Ter Linden H, Klip H, Werker PM. A comparison of the direct outcomes of percutaneous needle fasciotomy and limited fasciectomy for Dupuytren's disease: A 6-week follow-up study. J Hand Surg Am. 2006;31:717–725.
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6. Van Rijssen AL, Ter Linden H, Werker PM. Three year results of first-ever randomised clinical trial on treatment in Dupuytren's disease: Percutaneous needle fasciotomy versus limited fasciectomy. In: Charles Eaton M, Seegenschmiedt H, Bayat A, Gabbiani G, Werker P, Wach W, eds. Dupuytren's Disease and Related Hyperproliferative Disorders. Philadelphia: Elsevier (in press).
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8. McFarlane RM, McGrouther DA. Complications and their management. In: McFarlane RM, McGrouther DA, Flint M, eds. Dupuytren's Disease: Biology and Treatment. Edinburgh: Churchill Livingstone; 1990:377–382.
9. Rodrigo JJ, Niebauer JJ, Brown RL, Doyle JR. Treatment of Dupuytren's contracture: Long-term results after fasciotomy and fascial excision. J Bone Joint Surg Am. 1976;58:380–387.
10. Tubiana R. Surgical management. In: Tubiana R, Leclercq C, Hurst LC, Badalamente MA, Mackin EJ, eds. The Hand. Philadelphia: Saunders; 1999:239–250.
11. Coert JH, Nérin JP, Meek MF. Results of partial fasciectomy for Dupuytren disease in 261 consecutive patients. Ann Plast Surg. 2006;57:13–17.
12. Ullah AS, Dias JJ, Bhowal B. Does a ‘firebreak’ full-thickness skin graft prevent recurrence after surgery for Dupuytren's contracture? A prospective, randomised trial. J Bone Joint Surg Br. 2009;91:374–378.
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14. Abe Y, Rokkaku T, Ofuchi S, Tokunaga S, Takahashi K, Moriya H. An objective method to evaluate the risk of recurrence and extension of Dupuytren's disease. J Hand Surg Br. 2004;29:427–430.
15. Badalamente MA, Hurst LC. Enzyme injection as nonsurgical treatment of Dupuytren's disease. J Hand Surg Am. 2000;25:629–636.
16. Badalamente MA, Hurst LC, Hentz VR. Collagen as a clinical target: Nonoperative treatment of Dupuytren's disease. J Hand Surg Am. 2002;27:788–798.
17. Badalamente MA, Hurst LC. Efficacy and safety of injectable mixed collagenase subtypes in the treatment of Dupuytren's contracture. J Hand Surg Am. 2007;32:767–774.
18. Hurst LC, Badalamente MA, Hentz VR, et al.. Injectable collagenase Clostridium histolyticum
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21. Mäkelä EA, Jaroma H, Harju A, Anttila S, Vainio J. Dupuytren's contracture: The long-term results after day surgery. J Hand Surg Br. 1991;16:272–274.
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Evidence-Based Medicine: Questions and Answers
Q: What papers are amenable to Level of Evidence grading? What if my paper is not amenable to grading? Will PRS consider it for publication?
A: A good rule of thumb is as follows (these papers are not amenable to LOE grading):
* Animal studies
* Cadaver studies
* Basic science studies
* Review articles
* Instructional course lectures
* CME courses
As far as what is or is not ratable, the standard is to exclude basic science, bench work, animal, and cadaveric studies because the information gained from these studies is not something that can be applied directly to patient treatment decisions.
PRS definitely welcomes such papers, and such papers will be considered for publication. As indicated above, the LOE grade is a number, a quantitative designation for data. Papers that cannot be graded for Level of Evidence grade are not “worse” than those that can be graded.
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