Comparison of operation types: early results of needle fasciotomy vs limited fasciectomy for Dupuytren's disease

Patient or population: 125 hands in 121 participants with Dupuytren's disease of the fingers for early outcomes (van Rijssen 2006)

Settings: single‐centre Dutch study

Intervention: needle fasciotomy

Comparison: limited fasciectomy

DASH hand function score at 5 weeks

Major outcome group 1 (hand function)

(scores between 0 and 100, where 0 represents no impairment in hand function and 100 represents maximum impairment in hand function)

97
(1 study)

⊕⊕⊝⊝
Low^c

P value = 0.017 as quoted in van Rijssen 2006

24/121 participants in the study did not adequately complete the DASH PROM tools

Insufficient detail in article to allow calculation of 95% CI (standard deviations not provided)

Unclear whether this is the most appropriate time point for study of 'early' outcome

Patient satisfaction at 6 weeks

Major outcome group 2 (other PROM)

(scores from "0 (no/very negative) to 10 (yes/very positive)")

121
(1 study)

⊕⊕⊝⊝
Low^d

Data not described in van Rijssen 2006. Only level of significance provided

P value = 0.002 as quoted in van Rijssen 2006

Early angular outcome at 6 weeks for Tubiana grade I disease

(total passive extension deficit (TPED) of the MCPJ, PIPJ and DIPJ for preoperative contractures with a TPED of 0 to 45 degrees)

Early angular outcome at 6 weeks for Tubiana grade II disease

(total passive extension deficit (TPED) of the MCPJ, PIPJ and DIPJ for preoperative contractures with a TPED of 45 to 90 degrees)

Early angular outcome at 6 weeks for Tubiana grade III disease

(total passive extension deficit (TPED) of the MCPJ, PIPJ and DIPJ for preoperative contractures with a TPED of 90 to 135 degrees)

Early angular outcome at 6 weeks for Tubiana grade IV disease

(total passive extension deficit (TPED) of the MCPJ, PIPJ and DIPJ for preoperative contractures with a TPED > 135 degrees)

Major outcome group 3 (early objective measurement)

For grade I disease, 57

(1 study)

For grade II disease, 70

(1 study)

For grade III disease, 27

(1 study)

For grade IV disease, 10

(1 study)

⊕⊕⊝⊝
Low^e

For grade I disease, P value = 0.329 in van Rijssen 2006

For grade II disease, P value = 0.071 in van Rijssen 2006

For grade III disease, P value = 0.000 in van Rijssen 2006

For grade IV disease, P value = 0.004 in van Rijssen 2006

Major outcome group 4 (recurrence)

See comment

See comment

Not studied in van Rijssen 2006

Paraesthesia at 1 week

Major outcome group 5 (adverse effects)

Defined as "tingling sensations at any part of the treated digit without objective disturbance of sensation at the tip of the digit" per hand

117
(1 study)

⊕⊕⊝⊝
Low^f

P value = 0.013 in van Rijssen 2006

Relative effect not calculated as only study available

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; DASH: Disabilties of the Arm, Shoulder and Hand Scale; DIPJ: Distal interphalangeal joint; MCPJ: Metacarpophalangeal joint; PIPJ: Proximal interphalangeal joint; PROM: Patient‐reported outcome measures; RR: Risk ratio; TPED: Total passive extension deficit.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

Comparison of operation types: late results of needle fasciotomy vs limited fasciectomy for Dupuytren's disease

Patient or population: 93 participants (van Rijssen 2012a)

Settings: single‐centre Dutch study

Intervention: needle fasciotomy

Comparison: limited fasciectomy

DASH hand function score at 5 years

Major outcome group 1 (hand function)

(scores between 0 and 100, where 0 represents no impairment in hand function and 100 represents maximum impairment in hand function)

See comment

See comment

Not studied in van Rijssen 2012a

Patient satisfaction at 5 years

Major outcome group 2 (other PROM)

(scores between "1 (not at all), 10 (excellent)")

93
(1 study)

⊕⊕⊝⊝
Low^a

P value < 0.001 as quoted in van Rijssen 2012a

Likelihood of selecting treatment again significantly higher after fasciectomy (P value = 0.008)

Insufficient detail in article to allow calculation of 95% CI (standard deviations not provided)

Major outcome group 3 (early angular outcome)^b

See comment

See comment

This major outcome group is not relevant to a late outcome comparison

Recurrence at 5 years

Major outcome group 4 (recurrence)

Defined as reoperation or progressive angular deformity of 20 degrees in a successfully treated joint

93
(1 study)

⊕⊕⊝⊝
Low^c

Progressive angular deformity defined in van Rijssen 2006 as an increase in TPED ≥ 30 degrees. In van Rijssen 2012a, different definitions used (increase of 20 degrees in a successfully treated joint) in other studies of Dupuytren's disease, such as Hurst 2009, acknowledged and applied

P value < 0.001 in van Rijssen 2012a

Relative effect not calculated, as only study available

Recurrence rate influenced by the definition of recurrence used, and by length of follow‐up period

Major outcome group 5 (adverse effects)^d

see comment

see comment

Not discussed in van Rijssen 2012a; analysed in van Rijssen 2006

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; DASH: Disabilities of the Arm, Shoulder and Hand Scale; PROM: Patient‐reported outcome measure; RR: Risk ratio; TPED: Total passive extension deficit.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

Comparison of operation types: firebreak skin grafting vs z‐plasty closure of fasciectomy for Dupuytren's disease

Patient or population: 79 participants (Ullah 2009)

Settings: single‐centre UK study

Intervention: firebreak skin grafting to close incision

Comparison: z‐plasty closure of incision

PEM hand function score at 3 years

Major outcome group 1 (hand function)

(scores between 0 and 77, where 0 represents no impairment in hand function and 77 represents maximum impairment in hand function)

79

(1 study)

⊕⊕⊝⊝
Low^a

Data represented graphically only; differences between groups described as not statistically significant; no P value provided

Major outcome group 2 (patient satisfaction and other PROM)

See comment

See comment

Not studied in Ullah 2009

Correction of MCPJ and PIPJ deformities at
2 weeks

Major outcome group 3 (early angular outcomes)

79

(1 study)

⊕⊕⊝⊝
Low^b

Progressive contracture by 3 years

Major outcome group 4 (recurrence)

79

(1 study)

⊕⊕⊝⊝
Low^c

P value = 0.17 in Ullah 2009

Rates assessed per finger (90 fingers treated among 79 participants)

Hypoaesthesia

Major outcome group 5 (adverse effects)

79

(1 study)

⊕⊕⊝⊝
Low^d

P value = 0.2 for radial digital nerve territory in Ullah 2009

P value = 0.03 for ulnar digital nerve territory in Ullah 2009

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; MCPJ: Metacarpophalangeal joint; PEM: Patient Evaluation Measure; PIPJ: Proximal interphalangeal joint; PROM: Patient‐reported outcome measure; RR: Risk ratio.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

Refining rehabilitation: three months of postoperative night splinting with hand therapy vs hand therapy alone for rehabilitation following surgery for Dupuytren's disease

Patient or population: 210 participants with Dupuytren's disease of the fingers in 2 studies (225 digits reported across all studies) (Collis 2013; Jerosch‐Herold 2011)

Settings: multi‐centre UK RCT and single‐centre New Zealand RCT

Intervention: three months of night splinting in extension in addition to hand therapy ("splint")

Comparison: hand therapy alone ("no splint")

DASH hand function score at 3 months

Major outcome group 1 (hand function)

(scores between 0 and 100, where 0 represents no impairment in hand function and 100 represents maximum impairment in hand function)

205 participants
(2 studies)

⊕⊕⊝⊝
Low^a

Unclear whether this is the most appropriate time point for study of 'early' outcome

Major outcome group 2 (patient satisfaction)

See comment

See comment

Not assessed in these studies

Total active extension at 3 months

Major outcome group 3 (early objective measurement)

Total active extension (TAE) of MCPJ, PIPJ and DIPJ; higher value indicates loss of extension and a worse outcome

225 digits
(2 studies)

⊕⊕⊝⊝
Low^b

Unclear whether this is the most appropriate time point for study of 'early' outcome

Major outcome group 4 (recurrence)

See comment

See comment

Not assessed in these studies

Total active flexion at three months

Major outcome group 5 (adverse effects)

Total active flexion (TAF) of MCPJ, PIPJ and DIPJ; lower value indicates loss of flexion and a worse outcome

225 digits
(2 studies)

⊕⊕⊝⊝
Low^c

Conflicting findings from subgroups

Unclear whether this is the most appropriate time point for study of 'early' outcome

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; DASH: Disabilities of the Arm, Shoulder and Hand Scale; DIPJ: Distal interphalangeal joint; MCPJ: Metacarpophalangeal joint; PIPJ: Proximal interphalangeal joint; RCT: Randomised controlled trial; TAE: Total active extension; TAF: Total active flexion.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.