The present data clearly indicate that open surgery has a favourable effect for finger flexion contracture in Dupuytren’s disease at one-year post surgery. In addition, the data concerning characteristics of the subjects are consistent with a previous study with a larger population of subjects [18], indicating that our population is relevant in European context. However, one should keep in mind that recurrences are common after surgical treatment of finger flexion contracture in Dupuytren’s disease [12]; an aspect that is not addressed or was an aim in the present study. The present study also reveals that smokers, who were younger than non-smokers, were treated at a more severe stage of the disease, but smoking as a risk factor did not have any negative impact on the outcome of the surgical treatment of finger flexion contracture in Dupuytren’s disease. Furthermore, subjects with diabetes were also younger than those without diabetes, but again the outcomes did not differ. Specialists in hand surgery operated ten minutes faster than residents, but outcomes after open surgery were no different, irrespective of the presence of the risk factors smoking or diabetes among the subjects.
Smoking and surgical treatment of finger flexion contracture in Dupuytren’s disease
In our study, 15% of the patients were smokers, which correlates well with a larger European study in which the number of smokers with Dupuytren’s disease in the Nordic region was 18% [18]. In the rest of Europe, percentages of smokers with Dupuytren’s disease differ widely, i.e. 41-49% smokers [18]. Interestingly, the data in that European survey also indicate that the stage of Dupuytren’s disease in the treated subjects was more severe in the Nordic countries, which is consistent with a tradition that the indication for surgery in the Nordic region is a more advanced Tubiana stage or even that smoking speeds up the progression of the disease.
The effects of smoking on Dupuytren’s disease are contested [7, 19]. The present data indicate that smokers are treated at a later stage of Dupuytren’s disease, but we have no explanation for this observation. It may be caused by factors related to the subjects, i.e. individual factors or a direct pathophysiological mechanism(s), or to the surgeons, or both. The smokers had a higher preoperative QuickDASH score, although they were younger than the non-smokers. One may speculate that Dupuytren’s disease develops earlier in smokers than in non-smokers; thus, smoking may be a risk factor for development of finger flexion contracture in Dupuytren’s disease. In one study, where a connection between Dupuytren’s disease and smoking was shown, the risk was adjusted for age [7]; we did not make any adjustments of that sort in our study. Nevertheless, there were no significant differences in postoperative QuickDASH score or in improvement of QuickDASH score between smokers and non-smokers, indicating that open surgical treatment can be performed later without jeopardizing the outcome, the postoperative Tubiana score or the extension deficit. In addition, the present smokers did not have a higher percentage of complications, such as necrosis of skin flaps (including delayed healing) or infections, but one cannot entirely exclude the possibility that the limited number of subjects in the present study may have precluded the detection of any difference in complications. Therefore, the present findings should be interpreted with some caution and the results should be confirmed in larger populations from national registries.
Diabetes and surgical treatment of finger flexion contracture in Dupuytren’s disease
Dupuytren’s disease is more frequently seen in subjects with type 2 diabetes [5], but the disease may be less severe and progress more slowly in subjects with diabetes than in healthy subjects [1]. Our treated subjects with diabetes were younger indicating, in accordance with other studies [1], that the disease occurs earlier in subjects with diabetes. The percentage of the present subjects with diabetes, consisting mainly of subjects with type 2 diabetes, was 11%, which was lower than in the European survey (17% in Nordic countries and 26-36% in the rest of Europe [18]), and implies that fewer subjects with diabetes are treated surgically at our department. However, there were no differences in any outcome variables between the subjects with and without diabetes, except that subjects with diabetes were younger. Again, this may indicate that Dupuytren’s disease develops earlier in patients with diabetes, but a favourable outcome is still to be expected. Subjects with diabetes may have a higher incidence of postoperative complications [1], but this is in contrast to our study results. Taken together, our results imply that despite an earlier development of the disease, diabetes does not impact the outcome of surgical treatment of finger flexion contracture in Dupuytren’s disease. This is notable in view of an estimated global increase in the number of subjects with diabetes and thus an expected worldwide increase in the need for treatment of Dupuytren’s disease in subjects with diabetes.
Resources and costs for surgical treatment of finger flexion contracture in Dupuytren’s disease
The costs, if the subject was admitted, were higher [$ 2392 (€ 1859) compared to $ 3414 (€ 2654)] than if the procedure was performed as outpatient surgery. The length of stay at the ward in subjects who were admitted differed from that for northern Europe in general (i.e. one night), while it is longer in other parts of Europe [18]. A reduction in the number of unnecessary days on the ward may reduce costs for the healthcare system since admission to a ward in connection with a surgical treatment is expensive and resource intensive, which is an important point in view of a lower financial support to hospitals and an increased population globally. However, admission to a ward may be required if the procedure is a reoperation with a risk of surgical complications, or the subject has a complicated health condition (e.g. non-optimal value of PT/INR). Interestingly, smokers had a shorter stay at the ward and thus potentially lower costs. Finally, some of the treated subjects were still on the labour market and needed sick leave after the surgery, resulting in a loss of production; thus, a further cost for the society. The loss of production should be taken into account when considering the treatment of choice for a patient with finger flexion contracture due to Dupuytren’s disease in view of the shorter rehabilitation after percutaneous needle fasciotomy or pharmacological treatment (i.e. collagenase injections) of the contracture, but with the risk of a faster recurrence after the latter two procedures than after open surgical treatment. One should also consider the costs for collagenase treatment; i.e. costs for one vial of drug $ 951 (€ 739) in Sweden. It has been estimated that the average patient needs to treat 1.2 fingers with collagenase (personal communication Pfizer Inc., Sweden), which will result in a total costs for treatment of $ 1768 (€ 1374) [i.e. 1.2 fingers × (two outpatient visits + two visits to rehabilitation unit + cost collagenase vial) = total costs for collagenase treatment]. In accordance, the costs for a percutaneous needle fasciotomy would be $ 522 (€ 405) [i.e. one extended (x 2) outpatient visit and two visits to rehabilitation unit]. However, the complexity of the disease, with various severity of the disease, makes it difficult to judge the exact costs for treatment in a simple way [20], since the recurrence after collagenase treatment and percutaneous needle fasciotomy may be faster than after surgery, which should be taken into account. Surgery may also require admission to a ward in some patients, where the other two procedures can be performed as outpatient procedures.
The surgical procedures that were performed by a specialist took 10 minutes less than those done by residents, but the pre- or post-operative clinical status did not differ, indicating that the severity of the Dupuytren’s disease was similar in the patients treated. In addition, the outcomes did not differ with respect to QuickDASH scores or improvement. These results are interesting from a cost point of view as well as logistically. One may suggest that more surgical procedures on cases of Dupuytren’s disease could be performed by residents, freeing more time for specialists to deal with more severe cases, but without jeopardizing outcomes.
Limitations of the study
The data concerning the number of treatment sessions by nurses, physiotherapists and occupational therapists may possibly be an underestimation, since the data recorded in the medical charts may be incomplete and such categories of staff may have treated some subjects outside the department. A similar limitation, related to an underestimation of the costs, is that we had no information about how many outpatient visits the subjects made to their GP before referral, but approximately half of the subjects were referred from a GP. Around 10% of the subjects also wrote “their own referral letter” because of their symptoms and limitations on their activities due to finger flexion contracture caused by Dupuytren’s disease. The rest of the subjects were or had been treated for another hand condition at the department. Therefore, we could not with 100% certainty calculate the costs that included pre-referral costs. However, these are probably low in comparison with the treatment costs; i.e. total costs for treatment consisting of a) health care costs (e.g. outpatient visits to surgeon, nurses and hand therapists) and b) loss of production (e.g. sick-leave).
Another limitation is the time period (i.e. one-year follow up) during which the subjects were collected. Had the time period for data collection been longer a more accurate evaluation of costs could have been made. However, forms with declarations of health together with QuickDASH data were only available during the selected time period. Thus, in future it would be interesting to evolve the study to include a longer time period with more subjects, including a 100% cover of e.g. Tubiana staging, and additional relevant information about other treatment options, such as percutaneous needle fasciotomy or pharmacological treatment (i.e. collagenase injections). Such a focus, including long-term recurrence of the disease and contracture, could be achieved by assessing national registries to include a large number of subjects nationally (http://www.hakir.se).
The final limitation is that we used the generic assessment scale QuickDASH for evaluation of the treatment. Finger flexion contracture in Dupuytren’s disease has a distinct impact on the patients’ activities and quality of life [2] and at present there is no suitable assessment scale that is specific for this disease. We, therefore, used the QuickDASH questionnaire to evaluate the outcome of surgery. However, in the near future a specific scale for evaluating the outcomes of various treatment strategies will be developed [2].