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Surgeon Volume and the Outcomes of Dupuytren’s Surgery

Results from a Dutch Multicenter Study

Zhou, Chao, M.D., Ph.D.; Ceyisakar, Iris E., M.Sc.; Hovius, Steven E. R., M.D., Ph.D.; Feitz, Reinier, M.D.; Slijper, Harm P., Ph.D.; Lingsma, Hester F., Ph.D.; Selles, Ruud W., Ph.D.

Plastic and Reconstructive Surgery: May 2019 - Volume 143 - Issue 5 - p 1126e–1127e
doi: 10.1097/PRS.0000000000005546
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Department of Plastic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands, Xpert Clinic, Amsterdam, Rotterdam, and Eindhoven, The Netherlands

Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands

Xpert Clinic, Amsterdam, Rotterdam, and Eindhoven, The Netherlands

Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands

Departments of Rehabilitation Medicine and Plastic and Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands

Correspondence to Dr. Zhou, Erasmus Medical Center, Dr. Molewaterplein 50, Rotterdam 3015GE, The Netherlands, zhou.chao@me.com

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Sir:

We thank Drs. Boriani and Raposio for their interest in our study, which demonstrated that, among practicing hand surgeons, individual surgical outcomes varied greatly and that these depend, in part, on the number of surgical procedures a surgeon performs for Dupuytren’s disease.1 With these findings, we contribute to the discussion about how Dupuytren’s disease care should be organized. We appreciate the ability to engage in this discussion with our Italian colleagues.

As of this writing, the awareness about clostridium collagenase histolyticum as an alternative to the more established surgical treatments for Dupuytren’s disease is growing.2 Drs. Boriani and Raposio argue that clostridium collagenase histolyticum is easier to learn and will soon replace current treatments. Hence, they ask what weighs more heavily for the medical community: “to create tremendous surgeons, irrespective of the time, efforts, and costs to attain this, or is the priority to achieve the benefit for the patient, through the least invasive treatments, after the least complex training for the growing physicians and their mentors?” We are intrigued by this question.

In considering this question, understanding what evidence exists regarding the comparative effectiveness of clostridium collagenase histolyticum is paramount.3–5 Previous studies have shown that, as compared with fasciectomy, clostridium collagenase histolyticum is less invasive, has a shorter recovery period, and has fewer serious complications.6,7 However, these are advantages percutaneous needle aponeurotomy has already offered for decades.8,9 Disadvantages of clostridium collagenase histolyticum in comparison with limited fasciectomy, however, include its inferior effectiveness for proximal interphalangeal joint contractures.7 Furthermore, while percutaneous needle aponeurotomy and limited fasciectomy are procedures that effectively treat multiple affected joints and rays in a single session, two or more sequential clostridium collagenase histolyticum injections with 4-week intervals in between may be required in these cases.10,11 With regard to the long-term comparative results of clostridium collagenase histolyticum, current knowledge remains incomplete.7 Recent randomized trials have shown that clostridium collagenase histolyticum and percutaneous needle aponeurotomy have similar 2-year and 3-year recurrence rates.12,13 However, percutaneous needle aponeurotomy had a much worse 5-year recurrence rate than limited fasciectomy in the only randomized controlled trial comparing these two treatments (85 percent versus 21 percent, p < 0.001).14 In the absence of direct comparative studies, it is reasonable to assume that clostridium collagenase histolyticum also has a worse recurrence rate than limited fasciectomy. From an evidence-based medicine perspective, it is therefore not obvious that clostridium collagenase histolyticum will replace surgery, and we believe that patients should be counseled appropriately when deciding between treatments. When surveying 506 randomly selected patients about their own preferences in a discrete choice experiment, we recently reported that low recurrence rates and a complete contracture correction were the most important attributes for treatment decision making, again favoring surgical treatment.15

Given the abovementioned body of evidence, we remain convinced that surgical fasciectomy and needle aponeurotomy techniques will continue to play important roles in the treatment of Dupuytren’s contracture. This not only implies the need for surgeons to accrue experience in these surgical techniques, it also underlines the importance of maintaining this experience, as shown by our study.1 Evidence-based medicine concerns “the conscientious, explicit, and judicious use of current best evidence, combined with individual clinical expertise and patient preferences and values, in making decisions about the care of individual patients.”16 When both medical and surgical alternatives become available, we should rigorously evaluate the pros and cons of all alternatives through valid comparisons. Until comparative studies are published that increase our understanding of the long-term effectiveness and outcomes of clostridium collagenase histolyticum, particularly for those with advanced or multiray contractures, we believe that the question raised by Boriani and Raposio is somewhat preliminary. Of course, the extent to which clostridium collagenase histolyticum will replace surgery around practices across the globe will vary, as it depends on factors other than scientific evidence. These may include financial incentives, the legitimacy of which is left up to the readers of the Journal to judge.

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DISCLOSURE

The authors have no financial interest to declare in relation to the content of this communication. No funding was received for this work.

Chao Zhou, M.D., Ph.D.

Department of Plastic Surgery

Maastricht University Medical Center+

Maastricht, The Netherlands

Xpert Clinic

Amsterdam, Rotterdam, and Eindhoven, The Netherlands

Iris E. Ceyisakar, M.Sc.

Department of Public Health

Erasmus Medical Center

Rotterdam, The Netherlands

Steven E. R. Hovius, M.D., Ph.D.

Reinier Feitz, M.D.

Harm P. Slijper, Ph.D.

Xpert Clinic

Amsterdam, Rotterdam, and Eindhoven, The Netherlands

Hester F. Lingsma, Ph.D.

Department of Public Health

Erasmus Medical Center

Rotterdam, The Netherlands

Ruud W. Selles, Ph.D.

Departments of Rehabilitation Medicine and Plastic and Reconstructive and Hand Surgery

Erasmus Medical Center

Rotterdam, The Netherlands

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REFERENCES

1. Zhou C, Ceyisakar IE, Hovius SER, et al. Surgeon volume and the outcomes of Dupuytren’s surgery: Results from a Dutch multicenter study. Plast Reconstr Surg. 2018;142:125–134.
2. Zhao JZ, Hadley S, Floyd E, Earp BE, Blazar PE. The impact of collagenase clostridium histolyticum introduction on Dupuytren treatment patterns in the United States. J Hand Surg Am. 2016;41:963–968.
3. Hovius SER, Zhou C. Advances in minimally invasive treatment of Dupuytren disease. Hand Clin. 2018;34:417–426.
4. Rodrigues JN, Becker GW, Ball C, et al. Surgery for Dupuytren’s contracture of the fingers. Cochrane Database Syst Rev. 2015;12:CD010143.
5. Chen NC, Shauver MJ, Chung KC. Cost-effectiveness of open partial fasciectomy, needle aponeurotomy, and collagenase injection for dupuytren contracture. J Hand Surg Am. 2011;36:1826–1834.e32.
6. Hurst LC, Badalamente MA, Hentz VR, et al; CORD I Study Group. Injectable collagenase clostridium histolyticum for Dupuytren’s contracture. N Engl J Med. 2009;361:968–979.
7. Zhou C, Hovius SE, Slijper HP, et al. Collagenase clostridium histolyticum versus limited fasciectomy for Dupuytren’s contracture: Outcomes from a multicenter propensity score matched study. Plast Reconstr Surg. 2014;134:822e–829e.
8. Murphy A, Lalonde DH, Eaton C, et al. Minimally invasive options in Dupuytren’s contracture: Aponeurotomy, enzymes, stretching, and fat grafting. Plast Reconstr Surg. 2014;134:822e–829e.
9. 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.
10. Xiaflex (collagenase clostridium histolyticum) [prescribing information]. February 2012.Malvern, Pa.; Auxilium Pharmaceuticals, Inc.
11. Coleman S, Gilpin D, Kaplan FT, et al. Efficacy and safety of concurrent collagenase clostridium histolyticum injections for multiple Dupuytren contractures. J Hand Surg Am. 2014;39:57–64.
12. Strömberg J, Ibsen Sörensen A, Fridén J. Percutaneous needle fasciotomy versus collagenase treatment for Dupuytren contracture: A randomized controlled trial with a two-year follow-up. J Bone Joint Surg Am. 2018;100:1079–1086.
13. Scherman P, Jenmalm P, Dahlin LB. Three-year recurrence of Dupuytren’s contracture after needle fasciotomy and collagenase injection: A two-centre randomized controlled trial. J Hand Surg Eur Vol. 2018;43:836–840.
14. van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: Percutaneous needle fasciotomy versus limited fasciectomy. Plast Reconstr Surg. 2012;129:469–477.
15. Kan HJ, de Bekker-Grob EW, van Marion ES, et al. Patients’ preferences for treatment for Dupuytren’s disease: A discrete choice experiment. Plast Reconstr Surg. 2016;137:165–173.
16. Swanson JA, Schmitz D, Chung KC. How to practice evidence-based medicine. Plast Reconstr Surg. 2010;126:286–294. Plast Reconstr Surg. 2015 Jul;136(1):87–97.
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