Current Trends in the Treatment of Dupuytren Disease in Spain

Abstract

Objective Assessment of the treatment trends of Spanish surgeons in clinical practice by making clinical assumptions in Dupuytren's disease (DD).

Material and Method A survey was sent to the members of the Spanish Society for Surgery of the Hand (Sociedad Española de Cirugía de la Mano, SECMA) posing primary and secondary clinical cases. A relationship is established between the selected treatment, the characteristics of the participating surgeons, and the characteristics of the primary clinical cases. Treatment preferences in recurrences are assessed descriptively.

Results In total, 127 surveys were answered. 62.2% of the participants had experience with the use of collagenase and were the basis of the analysis. In primary cases, surgeons with more practice time tended to choose collagenase as treatment for DD. Surgeons who reported higher frequency of collagenase use (67.4% vs. 25.7%) were up to 6 times more likely to indicate such treatment. The patient's age under 50 years was the variable with the greatest association strength for the choice of collagenase treatment (OR = 3.8; CI95% 1.9–7.6). In recurrences, among all clinical cases, the most common answer given by the surgeons was partial fasciectomy.

Conclusions Partial fasciectomy continues to be the most widely used treatment for DD in Spain. In primary cases, collagenase is an alternative adopted by experienced surgeons, and in treatments for young patients. In recurrences, partial fasciectomy is the preferred technique.

Keywords

dupuytren disease - faciectomy - collagenase - survey - treatment

Introduction

The survey sent by the Spanish Society for Surgery of the Hand (Sociedad Española de Cirugía de la Mano, SECMA) regarding the treatment of Dupuytren's disease (DD), included a series of clinical assumptions in which was posed the assessment of the current trend of treatment, considering practical cases. Comparison with previous data from the study of Muñoz-Peñin[1] is not strictly applicable in this case, since that study design is different from this article, although we will refer to it when referring to the use of the different techniques used by surgeons. In the current medical literature only one article,[2] recently done, performs an assessment using an international survey to assess current perspectives of DD treatment in a similar way. This survey, based on clinical cases, establishes a regional difference regarding the preference of hand surgeons for treatment with DD, encompassing the most common treatments today for primary processes: partial fasciectomy (PFSC), the needle aponeurotomy (NA) and treatment with Clostridium Histolyticum collagenase (CCH). The survey and the obtaining of results were carried out before the suspension of the commercialization of the CCH in late 2019.

Our objective is to assess, by carrying out clinical cases in the survey promoted by SECMA, and adapted to the most common therapeutic solutions today in our geographical area, the trend of Spanish surgeons in the treatment of DD.

Material and Methods

Recruitment

This study has been approved by SECMA and is part of the SPAINCOL project for the assessment of long-term CCH treatment. It was approved by the Institutional Ethical Committee (code CEI m38/19) and the Spanish Association of Medicines and Health Products (code AEMPS RSC-COL-2019–01).

The survey was tested on two members of the medical staff of the lead author's hospital; their responses were not included in the results. After that, it was sent by email to SECMA partners. A brief description of the survey, details of anonymity and the intention to publish the identified data was made on the first page. Both the general questions and the clinical assumptions were drawn up by the lead author and agreed with various hand surgeons and the SECMA research committee. It should be borne in mind that the survey was drafted, carried out and analyzed in the time before CCH was withdrawn from the European market.

Instrument

The variables analyzed in this study correspond to the block of questions from the survey provided by SECMA ranging from number 13 to 20. Of these eight questions, the first four correspond to primary clinical cases and the following four to recurrences.

The questions were structured into five possible answers, leaving the last one open for the introduction of other treatment alternatives, which was analyzed separately but was considered unique for statistical analysis.

The results of these questions were analyzed in relation to the group of questions (5,6,9–12,21–23 25–27) about the general opinion of DD treatment (Annex 1).

Interest groups

For the study of the primary cases, the characteristics selected as representative were based on criteria of supposed severity or a higher rate of recurrence of the patients, such as: age younger than 50 years as a factor of greater aggressiveness present in cases of Dupuytren diathesis,[3] involvement of one or more fingers, involvement of the 5^th finger, involvement of PIP and/or of the MCP and contracture less than or equal to 45° considered mild, and greater as severe. This last value has been considered based on the severity criteria established in the CORD studies[4] to which was applied a variation of 5° for possible measurement errors.[5] [6] [7] The characteristics studied for each case are summarized in [Table 1].

Table 1

Case	Age >50 years	Number of affected fingers	Is the 5th finger affected?	More than 45° contracture (single joint or combined in only 1 finger)	Is PIP affected?
1 (p13)	Yes	One	Yes	Yes	No
2 (p14)	No	One	No	No	No
3 (p15)	N/A	Two	Yes	Yes	Yes
4 (p16)	No	One	No	No	Yes

For the study of recurrences, the analysis focused on the choice of technique, with assumptions that included recurrences after treatment with CCH or FSC and with the same variables as in primary cases. The definition of recurrence was made based on Felici's criteria.[8]

Statistical Analysis

Statistical analyzes were carried out using SPSS v.22. The results were shown as absolute and relative frequency. To assess whether there were differences between the number of times each technique was chosen according to the group, an analysis of X² was used. To assess the strength of association between the variables, the Odds ratio (OR) was used for dichotomous variables and Cramer's V for ordinal variables. For all analyzes, statistical significance was considered for p values less than 0.05.

For the assessment of preferences in cases of recurrence we have not performed a statistical analysis, considering the descriptive analysis sufficiently representative.

Results

Sample

The survey was sent to a total of 332 members of the Society. Of these, 127 (38.2%) answered the survey, of which 79 (62.2% of the respondents) had experience with the use of CCH and were chosen to assess preferences in primary cases. For the final evaluation of the primary clinical cases, only the surveys in which the CCH or FSC options had been selected were considered, since the number relative to the other options was marginal and not relevant for the analysis ([Table 2]). Thus, 61 (48%) of the surveys were analyzed.

Table 2

Clinical case	N	CCH	FSC	DFSC	NA	Other
13	120	24 (19.4)	95 (76.6)	4 (3.2)	4 (3.2)	10 (8.1)
14	124	56 (45.5)	54 (43.9)	1 (0.8)	8 (6.5)	4 (3.3)
15	123	23 (19)	91 (75.2)	1 (0.8)	1 (0.8)	5 (4.1)
16	121	27 (22.5)	80 (66.7)	2 (1.7)	5 (5.0)	5 (4.2)

Results of Individual Preferences in Primary Cases

When we analyze the influence of the characteristics of the surgeon and the treatment used, we find an association between this and the time he has been practicing the specialty since he finished his residency (X[2] p = 0.027), however that association has been weak (V = 0.16). ([Table 3])

Table 3

Treatment selected in each case
Variable	Group (N = 61)[θ]	CCH[*]	FSC[*]	p (X 2)	OR	CI	p (V Cramer)	V Cramer
Surgeon's age	< 30 years (21)	34 (40.5%)	50 (59.5%)	0.976	–	–	0.977[**]	0.01
	30–40 years (18)	30 (41.7%)	42 (58.3%)
	40–50 years (22)	37 (42%)	51 (58%)
How many years have you been practicing your specialty since your residency ended?	< 3 years(2)	0 (0.0%)	8 (100%)	0.027	–	–	0.098[**]	0.16
	3–6 years(8)	12 (37.5%)	20 (62.5%)
	6–15 years (21)	36 (42.9%)	48 (57.1%)
	>15 years (30)	53 (44.2%)	67 (55.8%)
And as a surgeon dedicated to hand surgery?	< 3 years (2)	2 (25%)	6 (75%)	0.816	–	–	0.686[**]	0.08
	3–6 years (9)	15 (41.7%)	21 (58.3%)
	6–15 years (27)	48 (44.4%)	60 (55.6%)
	> 15 years (18)	28 (38.9%)	44 (61.1%)
	General Orthopedic/Plastic surgeon (5)	8 (40%)	12 (60%)
In Dupuytren's disease, which of the following treatments do you use most frequently?	CCH (23)	62 (67.4%)	30 (32.6%)	<0.001	6.0	3.3–10.6	–	–
	FSC (38)	39 (25.7%)	113 (74.3%)
Regardless of frequency, what is your preferred treatment?	CCH (30)	75 (62.5%)	45 (35.7%)	<0.001	–	–	–	–
	FSC (30)	23 (19.2%)	97 (80.8%)
	NA (1)	3 (75%)	1 (25%)

The treatment used also corresponded to the frequency of use of the treatment options and their preference. Surgeons who reported higher frequency of CCH use (67.4% vs. 25.7%) were up to 6 times more likely to indicate such treatment in primary cases. ([Table 3])

When the patients were 50 years old or younger (53.3% vs. 23%), the 5th finger was free of disease (53.3% vs. 29.5%) and contracture was less than 50° (53.3% vs. 29. 5%), participating surgeons preferred CCH treatment. The age of patients under 50 years was the variable with the strongest association with the choice of CCH as treatment (OR = 3.8; CI95% 1.9–7.6) ([Table 4]).

Table 4

Selected treatments in each case
Variable	Group	CCH[*]	%	FSC[*]	%	p	OR	CI
Age	Less than or equal to 50 years	65	53.3	57	46.7	<0.001	3.8	1.9–7.6
	Over 50 years	14	23.0	47	77.0
Number of affected fingers	One finger	79	43.2	104	56.8	0.37	1.3	0.7–2.4
	Two or more fingers	22	36.1	39	63.9
Is the 5th finger affected?	No	65	53.3	57	46.7	<0.001	2.7	1.6–4.6
	Yes	36	29.5	86	70.5
Does it have more than 45° of contracture?	No	65	53.3	57	46.7	<0.001	2.7	1.6–4.6
	Yes	36	29.5	86	70.5
Is PIP affected?	No	58	47.5	64	52.5	0.069	1.6	0.9–2.7
	Yes	43	35.2	79	64.8

Results of Recurrence Preferences

In all cases, the preferred response by surgeons was FSC, ranging from 54.8% (question # 20) to 83.7% (question # 17). The predominant response was FSC in cases with involvement considered severe and patients over 50 years of age, as well as in those with combined involvement of the metacarpophalangeal joint (MCP) and the proximal interphalangeal joint (PIP). Question 19, which presented by a 72-year-old patient with combined involvement (MCP + PIP) of the 5th finger, was the only one in which the dermophasciectomy (DFSC) has had a considerable response rate (8.7%) as well as other alternatives (6.1%), including amputation among free field responses. Treatment with CCH was considered as an alternative in cases of recurrence in those cases of young patients, with isolated involvement of the MCP and central radius mild contracture, independently of the treatment previously performed with FSC (31%) or CCH (29.3%). The results are consistent with the subjective opinions of the surgeons, in which 82.2% (88) preferred FSC as the technique of choice. ([Table 5]).

Table 5

CASE	Age	Finger	Severity	Joint	Previous Treatm	CCH[*]	FSC[*]	DFSC[*]	NA[*]	Other[*]
17	>50	5	>45	MCP + PIP	CCH	6.8	83.8	0.9	3.4	5.1
18	<50	4	≤45	MCP	CCH	29.3	63.8	0.9	3.4	2.6
19	>50	5	>45	MCP + PIP	FSC	12.2	70.4	8.7	2.6	6.1
20	<50	4	≤45	MCP	FSC	31	54.9	8	3.5	2.7

Discussion

Our results indicate that the preferred and most used treatment for DD continues to be FSC. However, we have defined that CCH has been established as a second treatment option. There is also a clear decrease in DFSC.

If we compare our results with those previously published in Spain[1] ([Table 6]), FSC is considered the treatment of choice today in even more cases. A curious fact from the 2011 study is that almost 12% of surgeons advocate the use of a radical FSC, a technique little used today and not without serious complications[9] [10] [11] [12] for primary cases. The trend of our surgeons seems to guide the current preference towards minimally invasive techniques in the treatment of DD, since they allow a quick recovery of the patient with the minimum impact, leaving only the most demanding techniques for those severe cases and pronounced recurrences, as various authors have sustained.[13] [14]

Table 6

Year	parcial FSC	radical FSC	DFSC	NA	CCH
2011	51.70	11.80	12.20	12.20	N/A
2019	73	N/A	0.8	2.4	23

Regarding primary cases, we have observed that the participating surgeons with more time as specialists in hand surgery tend to choose CCH as treatment for DD. Similarly, those who report higher frequency of its use in routine practice are more likely to select CCH as the treatment method. The baseline characteristics of the patients influence this choice, the most important being age. In the USA, a survey sent to members of the American Society for Surgery of the Hand (ASSH),[15] indicates that for simple primary cases, the technique preferred by surgeons is CCH, leaving FSC for more complex cases with combined involvement of MCP and PIP, and seeing how minimally invasive techniques are predominant in cases of primary involvement and with the consideration of “best treatment,” results similar to the trend that we are observing in Spain. In Switzerland,[16] CCH use has also been increasing in recent years, especially by younger surgeons, unlike what happens here, although FSC is still the treatment of choice.

Observing our results, it is curious that in those young patients (under 50 years of age in our study), CCH is increasing as a technique of choice in both primary and secondary cases. Although it is true that the clinical cases presented in both primary and recurrence situations represent relatively simple cases, with the predominant involvement of a central and major finger of the MCP, young age has been classically considered as one of the factors of poor prognosis in DD, with more aggressive techniques being endorsed due to the possibility of recurrences due to the concept of Dupuytren diathesis established by Hueston.[11] All these regional variations are influenced by regulatory, political, economic or logistical factors[17] [18] therefore the data shown in our study cannot be extrapolated to other populations.

The only reference to an article that bases its conclusions on clinical assumptions and that includes CCH as an alternative treatment is established by McMillan.[2] In his case, the variables analyzed are the thickness of the cord, the severity of the contracture, the age, and the affected joint. Although this is a study covering surgeons from various countries, the number of respondents is relatively small (36 surgeons with expertise in hand surgery), so the results may not show the reality of treatment worldwide. As it is the only study at the international level, in its discussion it mentions how CCH is most used in the USA and Australia, indicating a certain predisposition of surgeons in northern Europe to use NA. We agree in his statement that there is little consistency in the DD treatment recommendations, and the lack of consensus among the scientific community and our results support this.

Currently the assessment of the need for treatment is often based on the decision of the patients' need or not,[19] leaving aside the classic assessment of the degree of contracture and making those assessments for treatment planning, as we saw in the results of the global survey carried out in Spain. Proof of this is the assessment of pre and post treatment states with tools such as PROM (Patient Reported Outcome Measures) and PREM (Patient Reported Experience Measures),[20] [21] [22] [23] although like everything with DD there is inconsistency in terms of results and consensus.[24]

In the recurrences section, the preferred technique in all cases is FSC by far. Drawing conclusions with the results of four standardized clinical cases is somewhat risky, but in our opinion we see how the more aggressive techniques are detrimental in favor of performing a new FSC in the event of recurrence and that CCH is an alternative in those cases in which it has demonstrated its efficacy, that is, isolated involvement of the MCP with non-severe contraction in the central radius. Although it is true that more and more treatment is individualized for the patient, recurrence tends to be valued as another primary disease (whenever conditions allow), not neglecting any therapeutic alternative if its use is possible. Recurrence as a workhorse of DD, and the prospect of maintaining viable tissues in the face of the possibility of new future involvement, is a determining factor at the time of determining the treatment of recurrences.

As for the limitations of our study, they are the same as those presented in the gross results of the general survey, that is: the results of a survey that shows only the subjective opinions of the participants, the lack of uniformity of the responses presented allows only a partial comparison of the results obtained, fatigue in conducting the survey, biases produced by unanswered responses, and sample error produced with the recruitment of participants.

In conclusion, we can say that FSC is still the most used treatment for DD in Spain based on clinical assumptions. In primary cases, CCH has displaced other techniques as a second treatment option for DD. The selection of CCH as the primary treatment was associated with a longer time as a specialist in hand surgery, with choosing CCH as the most frequently used treatment, and with the age of the patient being less than 50 years. In recurrences, FSC is, without a doubt, the most widely used technique.

Conflict of interests

The authors declare that have no conflict of interests.

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