1. 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

2. 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

3. 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  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%

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

5. 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%)

6. 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

7. 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

8. 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

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

10. 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

11. 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

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

16. 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

17. References
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Wilbrand, S., A. Ekbom, and B. Gerdin. A cohort study linked increased mortality in patients treated surgically for Dupuytren's contracture. J Clin Epidemiol 2005; 58(1):
Gerber, R.A., R. Perry, R. Thompson, et al. Dupuytren's contracture: a retrospective database analysis to assess clinical management and costs in England. BMC Musculoskelet Disord 2011; 12(12): 73
Hueston, J.T. Digital Wolfe grafts in recurrent Dupuytren's contracture. Plast Reconstr Surg 1962; 29:
Hueston, J.T. The control of recurrent Dupuytren’s contracture by skin replacement. Brit J Plast Surg 1969; 22:
Hall, P.N., A. Fitzgerald, G.D. Sterne, et al. Skin replacement in Dupuytren's disease. J Hand Surg Br 1997; 22(2):
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Kelly, C. and J. Varian. Dermofasciectomy: a long term review. Ann Chir Main Memb Super 1992; 11:
Ebelin, M., D. Leviet, E. Auclair, et al. The treatment of recurrent Dupuytren’s disease by scalar incision and firebreak graft. Ann Chir Plast Esthet 1991; 36:
Tonkin, M.A., F.D. Burke, and J.P. Varian. Dupuytren’s contracture: A comparative study of fasciectomy and dermatofasciectomy. J Hand Surgery Br 1984; 9:
Kan, H.J., F.W. Verrijp, B.M. Huisstede, et al. The consequences of different definitions for recurrence of Dupuytren's disease. J Plast Reconstr Aesthet Surg 2013; 66(1):

18. Thank you