Skin Involvement in Dupuytren’s Disease Ryckie G Wade, Laszlo Igali, Andrea Figus Norfolk & Norwich University Hospital NHS Foundation Trust, UK BAPRAS & IAPS Winter Scientific Meeting (2013), Dublin

Introduction Surgery for Dupuytren’s disease Is common1 Associated morbidity and mortality2 Significant costs to health services3 Dupuytren’s surgery is common  both MULTIPLE SEPARATE PROCEDURES AND REVISION PROCEDURES which could be combined/avoided This study assess AF ability to diagnose subclincal skin involvement

Rationale Dermal fibromatosis may fuel recurrent disease4-8 Hueston (1963, 1969) Logan (1992, 1993, 1997) Dermofasciectomy reduces recurrence6-14 Predicting recurrence remains difficult Hueston 1963  recurrence @ 2-3yrs after fasciectomy Hueston 1969  Dermofasciectomy in 38 patients, followed up for 1-10yrs Logan 1992  Dermofasciectomy 32 patients (40 rays), follow up for 38 months. No recurrent contracture, just nodules. Logan 1993  Myofibroblasts in the dermis Logan 1997  2-5yrs follow up of Dermofasciectomy = 8% recurrence Dermofasciectomy reduce recurrence ~35% Fasciectomy reucurrence = 85%

Aim To investigate dermal fibromatosis in patients undergoing surgery for Dupuytren’s disease How often is it present? What is the relevance?

169 patients undergoing surgery 59 Dermo-fasciectomy (57.3%) Methods November 2009 – 2012 Prospective audit: Single surgeon (AF) Single digit surgery Consecutive patients Fasciectomy vs. Dermofasciectomy Incisional skin (mean 3x11 mm) analysed histologically Risk factors, outcomes & complications compared 169 patients undergoing surgery 66 patients excluded Exclusion criteria 2nd recurrence in the operated digit previous dermofasciectomy by another surgeon in a zone of recurrence bilateral surgery Patients declining the offered/advised procedure Histopathological diagnosis not reached Recurrence = Kan’s Review Type 1 = return of nodules / cords Type 2 = contracture >20degs 44 Fasciectomy (42.7%) 59 Dermo-fasciectomy (57.3%)

Demographics Table 1. Fasciectomy (n=44) Dermofascietomy (n=59) P-value Age (SD) 65.1 (9.03) 66.2 (8.10) 0.509 Men (%) 34 (33.0) 51 (49.5) 0.226 RIGHT handed (%) 36 (35.0) 58 (56.3) 0.004 Manual Worker (%) 16 (15.5) 17 (16.5) 0.371 Previous Fasciectomy (%) 18 (17.5) 38 (36.9) 0.018 Previous Dermofasciectomy (%) 9 (8.7) 20 (19.4) 0.133 Chords (%) 38 (39.6) 54 (56.2) 1.000 Nodules (%) 20 (21.6) 22 (35.2) 0.351 Right Handed Population More aggressively treatment of disease in the dominant limb ?microtrauma to the hand

9 partial (15.2%) graft losses  all managed conservatively Operative Outcomes Table 2. Fasciectomy (n=44) Dermofascietomy (n=59) P-value Anaesthetic Type (%) Local 3 (2.90) 0 (0) 0.022 Regional 16 (15.5) 31 (30.1) General 25 (24.3) 28 (27.2) Operative Time (SD) in hrs:mins 1:49 (0.40) 2:36 (0:45) <0.001 Complications (%) Infection 2 (1.94) 0.180 CRPS 1 (0.97) 1.000 Recurrence 3 (2.91) 0.649 Amputation No total graft losses 9 partial (15.2%) graft losses  all managed conservatively

Range of Movement Table 3. Fasciectomy (n=44) Dermofascietomy (n=59) P-value Mean pre-operative flexion contractures in degrees (SD) MCPJs 31.7 (16.6) 46.5 (22.8) 0.002 PIPJs 50.4 (24.7) 73.1 (17.4) <0.001 DIPJs 12.4 (19.4) 40.8 (33.1) 0.055 Mean post-operative flexion contractures in degrees (SD) 3.69 (14.2) 6.05 (13.6) 0.459 16.3 (22.1) 18.2 (21.5) 0.705 2.88 (5.49) 5.46 (10.7) 0.540 Cumulative range of movement gained from surgery in degrees (SD) 53.1 (31.1) 92.8 (42.3) Gain in ROM More to regain Longer follow up => more physio Skin may contribute to tethering IMPORTANT FINDING AS ENCOURGES SURGERY ON SEVERE CONTRACTURES

Histological Skin Involvement Not involved N=18 (30.5%) Not involved N=22 (50%) Involved N=22 (50%)

Clinical Assessment of the Skin Table 4. Dermofasciectomy for Recurrence (n=29) Histological Diagnosis Involved Not Involved Clinical Assessment 13 4 5 7 Sensitivity = 72.2% Specificity = 53.8% Positive predictive value = 76.5% Negative predictive value = 58.3% Sensitivity = ability to identify involved skin Specificity = ability to identify disease free skin

Predictors of Skin Involvement Table 5. OR P-value 95% CI Manual Worker 2.86 0.017 1.19, 6.86 Presence of Nodules 4.63 0.001 1.80, 11.9 Sensitivity = ability to identify involved skin Specificity = ability to identify disease free skin

Discussion Dermal fibromatosis: Common (61.2%) Role in disease Role in recurrence Relationship between nodules, cords and skin?

Conclusion Clinical assessment remains unreliable Dermofasciectomy appears to be safe and beneficial Improved range of movement Reduced recurrence No addition morbidity Long term studies of dermal fibromatosis required Role of dermal fibromatosis remains uncertain

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