We enjoyed reading the article by Zhou and colleagues on the correlation between outcomes in Dupuytren’s surgery and surgeon’s expertise based on surgical volume.1 We congratulate the authors on their important contribution. Dupuytren’s surgery is not a trivial, minor operation. It requires deep knowledge of hand anatomy and advanced skills and experience in microsurgical dissection and differential diagnosis between normal and pathological fascial/cordal tissues. Importantly, Zhou et al.’s article emphasizes these concepts and acknowledges the necessity of reserving this sophisticated surgery to experienced hand surgeons. The authors declare that surgery is the mainstay of treatment for Dupuytren’s disease. However, this role has been or is likely to be replaced soon by collagenase clostridium histolyticum in many hand units worldwide. Collagenase was already available during the recruitment period of Zhou et al.’s study and therefore should have been mentioned. This option is associated with similar results, but fewer serious adverse events and, particularly, a more rapid recovery of hand function.2,3 With regard to the correlation between experience and results, again collagenase is a preferable option, as the modalities of drug administration are perfectly standardized and therefore the learning curve for this treatment is very short and smooth, even for the beginner in hand surgery.
The question now is, is the priority for the scientific 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? This question extends beyond the limits of Dupuytren’s disease and addresses the whole world of medicine and particularly surgery (which is technically more difficult and takes longer to learn). Training efforts are an enormous expense of time, energy, and money for institutions and for doctors, for both the newer generation who are learning and the older generation who are teaching. Advancements in treatments that reduce these charges are welcome both for the patients, who know that their treatment is safer in nearly everybody’s hands, and for the health institutions and the physicians, who can deliver equally or even more effective treatments with fewer risks and lower time expenditure for formation. The issue is whether to prefer teaching and improving surgical skills in humans on humans (as simulators are not yet capable of replacing direct experience) or developing simpler (and often less invasive) treatments in laboratories and through high-quality studies, thereby transferring efforts from doctors’ training to high-level basic and clinical research. The former involves higher risks for both patients and doctors; the latter is not devoid of risks, but they are more predictable, controlled, and avoidable thanks to high-quality study designs.
In our daily practice, we are obliged not only to explain all possible therapeutic alternatives to patients but also to orient them toward the preferable ones based on outcomes, risks, and recovery after treatment. Published literature should also reflect this ethical attitude and never forget to mention the complete range of treatment alternatives, particularly those of growing and widely agreed validity.
Neither of the authors has a financial interest to declare in relation to the content of this communication.
Filippo Boriani, M.D., Ph.D.Plastic and Hand SurgeryPrivate practiceBologna, Italy
Edoardo Raposio, M.D., Ph.D.Department of Medicine and SurgeryPlastic Surgery DivisionUniversity of ParmaParma, ItalyCutaneous, Mininvasive, Regenerative, and Plastic Surgery UnitParma University HospitalParma, Italy
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. Peimer CA, Wilbrand S, Gerber RA, Chapman D, Szczypa PP. Safety and tolerability of collagenase Clostridium histolyticum
and fasciectomy for Dupuytren’s contracture. J Hand Surg Eur Vol. 2015;40:141–149.
3. 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. 2015;136:87–97.