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  5. Assessing the outcome of surgery for Dupuytren’s disease of the hand

Project title: Assessing the outcome of surgery for Dupuytren’s disease of the hand

Grant Holder:

Mr Jeremy N Rodrigues

Position:

NIHR Academic Clinical Fellow in Plastic Surgery, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford

Date of award

01/08/2011

Date of report

28/02/2017

Grant Awarded (i.e. £10,000)

£50 000

Is this an interim, or final, report

final

Summary of progress /findings (approx 300 words)

This award supported one year of a full-time doctoral research project at the University of Nottingham.  Local funding from Nottingham was provided for a second year.  The project investigated the outcome of treatment for Dupuytren’s disease performed in the NHS.

Different treatments exist ranging from dividing cords (needle aponeurotomy) through disease excision (fasciectomy) to disease excision with resurfacing with a skin graft (dermofasciectomy). A range of outcome measurements has been used in Dupuytren’s disease, including angular measurements of finger joints and patient-reported outcome measures (PROMs).

This thesis hypothesised that the leading candidate outcome measures are inadequate (subject to bias, invalid, and/or uninterpretable) and that currently there is insufficient evidence to inform patient-centred treatment choice in Dupuytren’s disease.

To investigate this, existing evidence was appraised and studies of validity and interpretability of outcomes were conducted. This comprised a systematic review and meta-analysis of surgical trials, a systematic review of interpretability of outcome measures, cross sectional studies of the validity of leading candidate outcome measures (joint angles, the Disabilities of the Arm, Shoulder and Hand tool (DASH), and the Unité Rhumatologique des Affections de la Main scale (URAM)), and a prospective cohort study of outcome interpretability and variables associated with functional outcome.

The project was completed and a thesis defended for PhD.  This was successfully completed in 2016.

What is the relevance/value of this research to hand surgery:

This project involved multi-centre collaboration across the UK, and has delivered findings that will inform clinical practice and future clinical research in one of the most common hand conditions.

If final report, please provide bullet point list of conclusions/important findings

  • There were too few trials comparing treatments to inform practice in
  • Dupuytren’s disease, and methodological quality was generally poor
  • There were limited interpretability data to guide the design of future studies
  • Dynamism was present in 89% of digits, with mean MCPJ dynamism of 6 degrees and PIPJ dynamism of 14 degrees; 11% of digits exhibited over 30 degrees of dynamism
  • Patients had virtually unique goals for surgery, with 26% captured by the URAM
  • The DASH and the URAM were not structurally valid in factor analysis
  • The DASH was uninterpretable; the URAM’s minimal important change was 10.5
  • The factors associated with poor functional outcome differ from those associated with recurrence

Please list presentations based on work performed in this study

International Oral:

Rodrigues J, Becker G, Ball C, Zhang W, Giele H, Hobby J, Davis TRC.  The effect of postoperative splinting in Dupuytren’s disease: a meta-analysis of randomised controlled trials. Joint BSSH-IHSS Autumn Meeting, London, October 2014.

Rodrigues J, Zhang W, Scammell B, Davis TRC.  Recovery, responsiveness and minimal important differences after fasciectomy and dermofasciectomy.

Joint BSSH-IHSS Autumn Meeting, London, October 2014.

Rodrigues J, Mabvuure N, Nikkhah D, Shariff Z, Davis TRC.  Minimal important differences in elective hand surgery: a systematic review.

Joint BSSH-IHSS Autumn Meeting, London, October 2014.

Rodrigues J, Zhang W, Scammell BE, Russell P, Davidson D, Chakrabarti I, Fullilove S, Davis TRC.  Validating patient-reported outcome measures (PROMs) in Dupuytren’s disease

Joint BAPRAS-IAPS Winter Scientific Meeting, Dublin, Ireland, November 2013.

International poster:

Rodrigues J, Lawton G.  The uptake of NICE’s Fellows and Scholars Programme by plastic surgeons.

Joint BAPRAS-IAPS Winter Scientific Meeting, Dublin, Ireland, November 2013.

National Oral:

Rodrigues J, Zhang W, Scammell BE, Chakrabarti I, Davidson D, Russell P, Fullilove S, Davis TRC.  The correlation between the DASH and the QuickDASH in Dupuytren’s disease.

BSSH Spring Meeting, Newcastle, May 2014.

Rodrigues J, Zhang W, Scammell BE, Davidson D, Fullilove S, Russell P, Chakrabarti I, Davis TRC.  Complication rates following different Dupuytren’s disease treatments, and associated factors.  A multi-centre case-control study

BSSH Spring Meeting, Newcastle, May 2014.

Rodrigues J, Zhang W, Scammell BE, Fullilove S, Russell P, Chakrabarti I, Davidson D, Davis TRC.  Which is the most valid patient-reported outcome measure for studying Dupuytren’s disease?

BSSH Autumn Meeting, London, October 2013.

Rodrigues J, Zhang W, Scammell BE, Davis TRC.  How dynamic are Dupuytren’s contractures?

BSSH Autumn Meeting, London, October 2013.

Rodrigues J. Linking NICE and hand surgery: underused opportunities from NICE’s Fellows and Scholars Programme.

BSSH Spring Meeting, Harrogate, April 2013.

Rodrigues J, Scammell B, Davis T.  The true indications for Dupuytren’s disease surgery: a study of patient determined goals.

BSSH Autumn Meeting, York, October 2012.

National Poster:

Rodrigues J, Zhang W, Scammell BE, Fullilove S, Chakrabarti I, Russell P, Davidson D, Davis TRC.  Five-year outcomes and associated factors following Dupuytren’s disease surgery: A multi-centre retrospective cohort study in the UK.

BSSH Autumn Meeting, London, October 2013.

Regional:

Rodrigues J, Zhang W, Scammell B, with Hand Surgeons of Derriford Hospital, Pulvertaft Hand Centre, Rotherham Hospital, QMC & St John’s Hospital. 

Accurate assessment of outcome following Dupuytren’s disease surgery and the factors that influence it, a five-centre study

Oral presentation at Malkin Memorial Research Meeting, Nottingham, July 2013.

Rodrigues J, Zhang W, Scammell B, with Hand Surgeons of Derriford Hospital, Pulvertaft Hand Centre, Rotherham Hospital, QMC & St John’s Hospital.  Which is the most valid patient-reported outcome measure for studying Dupuytren’s disease?

Poster presentation at Malkin Memorial Research Meeting, Derbyshire, July 2013.

Rodrigues J, Zhang W, Scammell B, Davis T.  How dynamic are Dupuytren’s contractures?

Poster presentation at Malkin Memorial Research Meeting, Derbyshire, July 2013.

Rodrigues J, Scammell B, Davis T.  The true indications for Dupuytren’s disease surgery: a study of patient-specified goals.

Oral presentation at East Midlands Orthopaedic Research Meeting, Chesterfield, December 2012.

Please list publications based on work performed in this study

Rodrigues J, Zhang W, Scammell B, Davidson D, Fullilove S, Chakrabarti I, Russell P, Davis TRC.  Recovery, responsiveness and interpretability of patient-reported outcome measures after surgery for Dupuytren’s disease.

The Journal of Hand Surgery (European Volume) (Epub ahead of print). PMID: 27872343

Rodrigues J, Zhang W, Scammell B, Chakrabarti I, Russell P, Fullilove S, Davidson D, Davis TRC.  Functional outcome and complications following surgery for Dupuytren’s disease: a multi-centre cross sectional study

The Journal of Hand Surgery (European Volume) (Epub ahead of print). PMID: 27474501

Rodrigues J, Zhang W, Scammell B, Russell P, Chakrabarti I, Fullilove S, Davidson D, Davis TRC.  Validity of the disabilities of the arm, shoulder and hand patient-reported outcome measure (Dash) and the Quickdash when used in Dupuytren’s disease.

The Journal of Hand Surgery (European Volume) (2016) 41(6): 589-99.  PMID: 26307142

Rodrigues JN, Becker GW, Ball C, Zhang W, Giele H, Hobby J, Pratt AL, Davis T. Surgery for Dupuytren’s contracture of the fingers.

Cochrane Database of Systematic Reviews 2015, Issue 11.

Art. No.: CD010143. DOI: 10.1002/14651858.CD010143.pub2  PMID: 26648251

Rodrigues J, Zhang W, Scammell B, Davis T, Akhavani M, Muir L. Re: Akhavani MA, McMurtrie A, Webb M, Muir L.  A review of the classification of Dupuytren’s Disease. J Hand Surg Eur. 2015, 40: 155–65 and Rodrigues JN, Zhang W, Scammell BE, Davis TRC. What patients want from the treatment of Dupuytren’s Disease – is the Unité Rhumatologique des Affections de la Main (URAM) scale relevant?

The Journal of Hand Surgery (European Volume) (2015) 40(5): 544-5. PMID: 26199970

Rodrigues J, Mabvuure N, Nikkhah D, Shariff Z, Davis TRC.  Minimal clinically important changes and differences in elective hand surgery.

The Journal of Hand Surgery (European Volume) (2015) 40(9): 900-12.  PMID: 25320122

Rodrigues J, Zhang W, Scammell BE, Davis TRC.  The dynamism of Dupuytren’s contractures

The Journal of Hand Surgery (European Volume) (2015) 40(2): 166-70.  PMID: 24664160

Rodrigues J, Zhang W, Scammell BE, Davis TRC.  What patients want from the treatment of Dupuytren’s disease – is the Unité Rhumatologique des Affections de la Main (URAM) scale relevant?

The Journal of Hand Surgery (European Volume) (2015) 40(2): 150-4.  PMID: 24563499

Rodrigues J, Zhang W, Scammell BE, Davis TRC. Re: What patients want from the treatment of Dupuytren’s disease – is the Unité Rhumatologique des Affections de la Main (URAM) scale relevant?

The Journal of Hand Surgery (European Volume) (2014) 39(6): 673-675. PMID: 24939553

Please state what additional research this study has/is leading to

  •  Completing this PhD was critical to my appointment to an integrated academic training programme in plastic surgery in Oxford.
  • This has laid the foundation for further research into outcome measurement in hand surgery, including the development of one current DPhil project, and the preparation of a second DPhil project.
  • It supported a multi-centre bid to NIHR’s HTA programme to run a multi-centre trial of treatment in Dupuytren’s disease
  • It has led to further research into treatment of Dupuytren’s disease in Nottingham, including an NIHR RfPB grant

Please list any further funding or grant applications (with outcome), which have resulted from the award of this grant

  • NIHR Academic Clinical Fellowship at University of Oxford.  Successful
  • FLEXED: application to NIHR HTA for £1.5million for RCT of collagenase vs fasciectomy.  Unsuccessful
  • Arthritis Research UK Research fellowship: for £50 000 for DPhil candidate supervision.  Unsuccessful
  • BSSH Research Fellowship: for £50 000 for DPhil candidate supervision.  Successful
  • RCSEng 1-year Research Fellowship: for £50 000 for DPhil candidate supervision.  Successful
  • NIHR Doctoral Research Fellowship: for £335 000 for DPhil candidate supervision.  Successful

How has this grant awards helped your career development?

  • This award has been the springboard for my academic career.
  • This award supported my work towards a research doctorate, and success in obtaining it contributed to my transfer from MD to PhD.
  • The legacy of this award includes my seeking further clinical academic training with a focus on hand surgery in Oxford.
     

 

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