Prognosis of Long-term Postoperative Complications after Surgical Treatment of Dupuytren’s Disease (Contracture)

 

Gleb I. Mikusev1*, Rustem F. Baikeev2, Ruslan O. Magomedov3, Ivan E. Mikusev3, Timur S. Mishakin4

1Department of Traumatology, City Clinical Hospital No 7 of Kazan, Kazan, Republic of Tatarstan, Russian Federation

2Department of Biochemistry, Kazan State Medical University, Kazan, Republic of Tatarstan, Russian Federation

3Republican Clinical Hospital of Tatarstan Republic Health Ministry, Kazan, Republic of Tatarstan, Russian Federation

4Department of Management in the Social Sphere, Kazan Federal University, Kazan, Republic of Tatarstan, Russian Federation

*Corresponding Author E-mail:

 

ABSTRACT:

Background Dupuytren’s disease (DD) is a proliferative fibromatosis of the hand, which causes permanent flexion contracture of the digits and, ultimately, loss of function. The treatment of DD is complex and involves surgical and nonsurgical approaches, with the goal of removing the affected tissue. Systems analysis of postoperative complications depending on combination of factors of the patient and influencing development of long-term postoperative complications (LPC) is the way which can optimize tactics of surgical treatment. Purpose To develop prognosis of long-term postoperative complications’ technology after surgical treatment of Dupuytren’s disease (contracture) on the basis of the analysis of A-factors, determining the biological status of the patient ( gender, age, terms of disease, examination period, grade of lesion by DD, heredity, accompanying diseases, surgical history and traumas, the disease beginning, laboratory analyses, etc.); B-factors, presenting life style of the patient (residence, physical and mental job, bad habits, etc.); C-factors, presenting technical-surgical components of operations and rehabilitational treatment (the experience of the surgeon, types of operations, anaesthesia, section, dermal plasty, rehabilitational treatment, healing, etc.). Methods Anamnesis, operative measures, postoperative catamnesis, mathematical modeling. Results Technology allows to prognosticate the operation outcome in 58,9–81,4% of cases. This depends on type of considered factors (a combination of factors,% of prognosticated cases): 1. A + B + C 72,8–78,7% (р=0,0001) 2. А+В 64,4–73,3% (р=0,0001); 3. C 58,9–81,4% (р ≤ 0,002). Conclusions Anamnesis, the analysis of technique of operative measures and rehabilitational treatment allow to predict the outcome of operative treatment concerning DD. Increasing (27 factors) and decreasing (12 factors) of LPC are the outstanding points for development prognosis of LPC.

 

KEYWORDS: Complications, Dupuytren’s contracture, Prognosis, Surgery.

 

 


 

 

INTRODUCTION:

Dupuytren’s disease (Dupuytren’s contracture–DC) is chronic, progressing cicatrical transformation of palmar aponeurosis (PА), accompanied by flexion contracture of fingers of hand.

 

The majority of specialists prefer to use the operative methods directed on elimination of contracture of fingers and recovery of function of hand by excision of the basic substrate of disease–palmar aponeurosis (PA). The volume of excision of palmar aponeurosis gains in therange of needdle fasciotomy[1,2], subcutaneous fasciotomy[3,4], segmental fasciectomy[5,6], limited fasciectomy[7-10], dermofasciectomy[11], total (radical) fasciectomy[12].

 

The technology of LPC detection at patients has extremely indefinite character since various authors do it variously. There are the following alternatives:

1.    Disease reappearing in node that had been operated on[13].

2.    Any new nodule of disease in the operative field under the flaps with or without contracture[14].

3.    A total passive extension deficit increase during follow-up of 30° or more compared to the immediate postoperative measurements, and occasionally in absentia[15].

4.    In a mailed questionnaire, surgery patients are asked whether their surgically corrected fingers appeared to be contracting again[16].

 

LPC were revealed according to the following criteria: complaints of the patient, visual examination and palpation of status localis.

 

Evidently that the long experience of DC treatment gained by specialists needs the quantitative analysis which has already allowed to tap some trends in LPC development at operative DC treatment, in particular, short - and long-term efficiency of surgical treatment [17]. Thus each group of researchers analyses types of operations traditional for their clinics. The extension of the detailed analysis of operative DC treatment by the methods used in our clinic, will allow to perform the further optimization of volume and operations’ technique at DC.

 

Research goal: to develop the technologies on prognosis of long-term postoperative complications at surgical treatment of patients with Dupuytren’s disease (contracture), depending on factors:

·      Biology of the patient

·      Life style of the patient

·      Technical–surgical components of operation and             rehabilitational treatment.

 

MATERIALS AND METHODS:

Design of study:

1.    Investigation is retrospective, selective; in the study were included only those patients concerning whom there was a full information regarding an object of research in the yielded work.

2.    Presence of LPC has been revealed single-passly on terms till 15 years. It has been used the first combined type of ending point which comprised such kinds of LPC as recurrence, extension, progression.

3.    A statistical analysis: distribution of patients according to the types of LPC was perfomed by means of methods of descriptive statistics. The equations of LPC prognosis based on the factors of A,B,C groups. have been resulted from the discriminant analysis that has allowed to reveal factors both promoting and interfering development of LPC. The used mathematical model was a classification one. As an output variable used presence of LPC. The class score was discrete and accepted two values–"0" there is no complication and "1"–there is complication.

 

Location of study, types of data:

Research was led on the basis of Tatarstan Republic Medical Institution (Russian Federation), in Kazan, in hand microsurgery unit of Traumatology Scientific Practice Centre of State Autonomic Healthcare Institution "Republican Clinical Hospital of Tatarstan Republic Health Ministry".

 

Data included in research concerned the patients corresponding to a single verified diagnosis-Dupuytren’s disease (contracture), cured during the period January, 1957–January, 2016. As the basic registration document the registration card of the patient with diagnosis DC, consisting of following partitions has been used:

·      A passport part;

·      Clinical signs and anamnesis data;

·      The laboratory data;

·      Operative techniques and theirs results.

 

Criterion of inclusion in research was presence of the data of all, from I to IV, partitions of a registration card. Exclusion criteria for both groups were age <18 years, pregnancy of women, and arthroplasty or arthrodesis of the treated joint. 12 patients were excluded from research. Duration of supervision has compounded from 1 year till 15 years.

 

Groups of patients:

The total quantity of the operated patients with DC has constituted 258 persons at the age of 21-80 years. In total there are 343 operated hands: in 191 cases (55,7%) there were operations on the right hands, in 152 cases (44,3%)–on the left hands.

 

Dupuytren’s disease (contracture) was divided on three grades and classified according to the grade of contracture of fingers of hand [18]:

·      I grade–induration of palmar aponeurosis without flexion contracture in joints of fingers;

·      II grade–induration of palmar aponeurosis with flexion contracture in metacarpophalangeal joint to the angle 100°;

·      III grade–induration of palmar aponeurosis with flexion contracture in metacarpophalangeal joint to the angle ˂100° and flexion contracture in proximal inter-phalanx joint. The grade of classification according to A. P. Bejul and contracture angle in grades are presented in section "Results and discussion" for the purpose of comparison to other classifications[4, 19-21].

 

DC localization (DC grade - the affected finger of hand/quantity of patients with lesion of the given finger/proportion in%):

·      Right hand: I grade – 1/17/6,6; 2/15/5,8; 3/47/18,2; 4/20/7,8; 5/32/12,4. II grade–1/6/2,3; 2/5/1,9; 3/40/15,5; 4/81/31,4; 5/21/8,1. III grade–1/2/0,8; 2/2/0,8; 3/8/3,1; 4/40/15,5; 5/23/8,9.

·      Left hand: I grade–1/45/17,5; 2/17/6,6; 3/48/18,6; 4/45/17,5; 5/30/11,6. II grade–1/5/1,9; 2/8/3,1; 3/33/12,8; 4/60/23,3; 5/35/13,6. III grade–1/2/0,8; 2/3/1,2; 3/11/4,3; 4/39/15,1; 5/60/23,3.

 

Types of operations:

Following types of operative measures on palmar aponeurosis (PA), we made (Figure 1, Table 1):

·      limited (partial) fasciectomy [22, 23] (Figure 1A),

·      limited (partial) excision of proximal part of PА (Figure 1B), [24],

·      limited (partial) excision of proximal and middle parts of PА (Figure 1C), [18],

·      total (radical) fasciectomy [12] (Figure 1D),

·      limited (partial) sphenoidal excision of middle part of PА and longitudinal bands of distal part of PA with conservation of cross fibres at level of distal third of metacarpal bones (Figure 1E) [18].

 

 

Figure 1 Topographic surgery of palmar aponeurosis (PА) at DC:–Exsected part of PА; A–the partial excision of changed bands, stretched to one finger–1; to two fingers–1+2; to three fingers– 1+2+3; to four fingers–1+2+3+4; B–excision of proximal part–1; C–excision of proximal and middle parts–1+2; D–total excision– 1+2+3.E–sphenoidal excision of middle part of PА and longitudinal bands of distal department of PA with conservation of cross fibres at level of distal third of the metacarpal bones, stretched to four fingers–1+2+3+4 (Eа); to three fingers–1+2+3 (Eb); to two fingers–1+2 (Ec); to one finger – 1 (Ed); α = 20°-30°

 

Table 1 Allocation of patients by types of the operations

Operation type

The right hand (%)

The left hand (%)

A

The partial excision of the affectalbands of PА–3 (1.6)

The partial excision of the affectal bands of PА – 3 (2.0)

B

Excision of the proximal part of PА – 2 (1.0)

Excision of the proximal part of PА – 5 (3.3)

C

Excision of the proximal and middle parts of PА – 21 (11.0)

Excision of the proximal and middle parts of the PА – 17 (11.2)

D

Total excision of PА – 3 (1.6)

Total excision of PА – 7 (4.6)

E

Sphenoidal excision of middle part of PА with longitudinal bands of distal part of PA – 162 (84.8)

Sphenoidal excision of middle part of PА with longitudinal bands of distal part of PA – 120 (78.9)

 

Σ = 191 (55.7)

Σ = 152 (44.3)

Sphenoidal excision of middle part of PА perform in cross direction with deviation from a perpendicular on an angle α = 20-30, in dependence from scale of operation, the excision of PА is stretched to four(Ea), to three (Eb), to two (Ec) or to one (Ed) finger.

 

Prognosis system:

Status localis after surgical treatment was evaluated on period of 1 year and more after operation. LPC included:

1.    Recurrence;

2.    Extension;

3.    Progression.

 

Working out of prognosis system of long-term postoperative complications consisted in analysis of 222 factors and their combinations registered at follow-up of patients with DC which have been divided into three groups (Appendix A):

 

·      A (118 factors) – the factors determining the biological status of the patient (gender, age, prescription of disease, examination period, grade of DC lesion, heredity, the associated diseases, surgical history and traumas, the disease beginning, laboratory analyses, etc.);

·      B (20 factors) – the factors presenting life style of the patient (residence, physical and mental job, bad habits, etc.);

·      C (84 factors) – the factors presenting technological-surgical components of operations and rehabilitational treatment (the experience of the surgeon, types of operations, anaesthesia, section, dermal plasty, rehabilitational treatment, healing, etc.).

 

Statistical analysis:

Statistical analysis was conducted with application of SPSS software package (v.13.0). Factors of groups A, B and C in the majority of cases have been presented as categorical concepts. They were transformed into the digital form being designated as "0" if the patient was lacking of factor and "1" as its presence. Values of age, years of the seniority, the surgical experience of physician, yielded laboratory analyses, etc. used as digital quotients before units of measurements. Received data were made out in the form of template databases. Discriminative analysis has been used for working out of prognosis system of surgical treatment’s efficiency.

 

LPC has been assigned as a target variable of the analysis. In order to reveal statistically significantly factors in relation to the prognosis, procedure of so called "stepwise" incorporation of the examined factors in the equation has been applied. For evaluation test of the received equations were used size of quotient of initial correlation, Wilk’s λ (the test for, whether there is a significant difference of the average values of discriminant functions) and the classification accuracy -coincidence of quantity of patients with LPC or without it and predicted ones by means of the calculated discriminant function. Р< 0,05 has been accepted as statistically significant value.

 

Type of study. Prognostic studies: I.

 

RESULTS AND DISCUSSION:

Long-term postoperative complications (LPC) with accounting both operated and not operated hand (progression is also included) are taped at 108 (41,8%) patients operated on 156 hands. LPC are taped on 142 hands, on the right hands they have originated in 68 (35,6%) cases, on left–in 74 (48,6%) cases. The analysis of types and periods of origin of long-term postoperative complications at patients with DC on hands (the number of hands/%) is presented in the Table2.


 

Table 2 Types and period of origin of long-term postoperative complications at patients with DC on hands (number of hands / %)

Index, No

Period of origin of long-term postoperative complications (LPC)

1–2 years

3–5 years

6–10 years

11–15 years

right hand

left hand

right hand

left hand

right hand

left hand

right hand

left hand

1.1.  Recurrence (number / % (proportion from hands with LPC)

8/

57.1

6/

33.3

5/

35.7

9/

50.0

1/7.1

3/

16.7

0*/0

0/0

1.2. Recurrence (number / %-proportion from total quantity of the operated hands) (32/9,3 %) ***

8/4.2

6/3.9

5/2.6

9/5.9

1/0.5

3/1.9

0*/0

0/0

1.3. Proportion of recurrence with the cumulative total (number / %-proportion from total quantity of the operated hands)

8/4.2

6/3.9

13/

6.8

15/

9.8

14/

7.3

18/

11.7

14/

7.3

18/

11.7

2.1. Extension (number / % (proportion from hands with LPC)

10/

58.8

10/

62.5

5/

29.4

3/

18.7

1/5.9

3/

18.7

1/5.9

0/0

2.2. Extension (number / %-proportion from total quantity of the operated hands) (33/9,6 %) ***

10/

5.2

10/

6.6

5/2.6

3/1.9

1/0.5

3/1.9

1/0.5

0/0

2.3. Proportion of extension with the cumulative total (number / %-proportion from total quantity of the operated hands)

10/5.2

10/6.6

15/7.8

13/8.5

16/8.3

16/10.4

17/8.8

16/10.4

3.1. Recurrence + extension (number / % (proportion from hands with LPC)

6/

85.7

3/

75.0

0/0

1/

25.0

1/

14.3

0/0

0/0

0/0

3.2. Recurrence + extension (number/ %-proportion from total quantity of the operated hands) (11/3,2 %) ***

6/3.1

3/1.9

0/0

1/0.6

1/0.5

0/0

0/0

0/0

3.3. Proportion of LPC (recurrence + extension) with the cumulative total (number/ %-proportion from total quantity of the operated hands)

6/3.1

3/1.9

6/3.1

4/2.5

7/4.6

4/2.5

7/4.6

4/2.5

4.1. Progression on not operated hand, without complications on the operated hand (number / % (proportion from hands with LPC)

7/

35.0

11/

42.3

8/

40.0

10/

38.5

4/

20.0

5/

19.2

1/5.0

0/0

4.2. Progression on not operated hand, without complications on the operated hand (number / %-proportion from total quantity of the operated hands) (46/13,4 %) ***

7/3.7

11/

7.2

8/4.2

10/

6.6

4/2.1

5/3.3

1/0.5

0/0

4.3. Progression proportion on not operated hand, without complications on the operated hand with the cumulative total (number / %-proportion from total quantity of the operated hands)

7/3.7

11/

7.2

15/

7.9

21/

13.8

19/

10.0

26/

17.1

20/

10.5

26/

17.1

5.1. Progression on not operated hand, with complications on the operated hand (number / % (proportion from hands with LPC)

4/

40.0

5/

50.0

2/

20.0

3/

30.0

3/

30.0

2/

20.0

1/

10.0

0/0

5.2. Progression on not operated hand, with complications on the operated hand (number / % proportion from total quantity of the operated hands) (20/5,8 %) ***

4/2.1

5/3.3

2/1.0

3/1.9

3/1.6

2/1.3

1/0.5

0/0

5.3. Progression proportion on not operated hand, with complications on the operated hand with the cumulative total (number / %-proportion from total quantity of the operated hands)

4/2.1

5/3.3

6/3.1

8/5.2

9/4.7

10/

6.5

10/

5.2

10/

6.5

6. Frequency of LPC ** / hand

12.6

12.5

5.2

8.5

1.6

3.9

0.5

0

7. Proportion of hands with LPC in various periods of observation, (%)

18.3

23.0

10.5

17.1

5.2

8.5

1.6

0

8. Proportion of hands with LPC in various periods of observation, with the cumulative total (%)

18.3

23.0

28.8

40.1

34.0

48.6

35.6

48.6

Note: *–absence of LPC at patients on given periods; **–LPC on the operated hand (points 1.1. – 5.3.), ***–Total (number / % proportion from total quantity of the operated hands).

 

 

 


Adequate mathematical analysis has allowed to develop the system on prognosis of origin of long-term postoperative complications in the postoperative period at the patient with Dupuytren’s disease (contracture) in the form of the equations (Table 3) based on the impact analysis of:

 

1.    Factors of groups A + B + C:

1.1.    The right, left or both hands are operated (LPC origin at the patient, without dependence from the operated hand) (Equation No. 1, Table 3);

1.2.    The right hand is operated (LPC origin only on the right hand) (Equation No. 2, Table 3);

1.3.    The left hand is operated (LPC origin only on the left hand) (Equation No. 3, Table 3).

2.    Factors of groups A + B:

2.1.    The right, left or both hands are operated (LPC origin at the patient, without dependence from the operated hand) (Equation No. 4, Table 3);

2.2.    The right hand is operated (LPC origin only on the right hand) (Equation No .5, Table 3);

2.3.    The left hand is operated (LPC origin only on the left hand) (Equation No. 6, Table 3).

3.    Factors of group C:

3.1.    The operation type (LPC origin at the patient without dependence from the operated hand) (Equation No. 7, Table 3);

3.2.    The right, left or both hands are operated (LPC origin at the patient without dependence from the operated hand) (Equation No. 8, Table 3);

3.3.    The left hand is operated (LPC origin only on the left hand) (Equation No. 10, Table 3);

3.4.    Both hands are operated (LPC origin only on the left hand) (Equation No. 11.2, Table 3);

3.5.    Both hands are operated (LPC origin on both hands) (Equation No. 11.3, Table 3).

The clinical example on prognosis of origin of long-term postoperative complications after interventions concerning Dupuytren’s disease (contracture) of patient Z., based on the analysis of combination of factors A + B+C (the left hand is operated) (Equation No. 3, Table 3) (Appendix B) is presented.

 

 

 

 

The choice of operative measure, the grade of contracture expression, terms of disease, heredity, social premises, age, type of job of the patient and so on influence the resulting effect of DC treatment. The complications of surgical treatment of DC originating in the long-term postoperative period are classified as:

1.    Disease recurrence;

2.    Disease extension.

 

Disease progression (origin or augmentation of pathological process on not operated hand) [25] does not refer to the group of postoperative complications as it can originate without the fact of the realized operation. However if it happens after operation, it is reasonable to consider it as LPC for two reasons:

 

1.    Importance of recovery for the patient (total absence of signs of disease).

2.    The adequate understanding of the correct approach on method, range and tactics of operative treatment at palmar fibromatosis should be based on the fact that the palmar fibromatosis is а benign fibroproliferative tumour with genetic background [26, 27] according to ICD–Х – a fascial fibromatosis of unknown etiology (М-720) [28], and recurrence, extension, progression are clinical implication of development dynamics of tumorous process.

 

Set of several outcomes (recurrence, extension and progression of disease) have compounded the combined ending point – LPC. Thus, the final point – LPC falls into to the first type of the combined ending points. The cause of it consists that LPC describe proceeding process of disease and are used in clinical researches on treatment of DC for an assessment of efficacy of treatment.

 

The basic question at treatment’s estimation of DC touches periods of observation after operation. The treatment observation periods are divided at efficiency analysis: ˂ 6 months – short-term, > 6 months – long-term observations [17]. Periods of treatment and follow-up after operation concerning DC to the point of readaptation to job constitute 45-82 days.

 


Table 3 Prognosis of origin of long-term postoperative complications(LPC) at DC

Medical parameter

Factors

No

Combination of operations (localization of LPC)

Canonical Discriminant Equation (CDE) (A – the factors determining the biological status of the patient; B – life style of the patient; C – technical-surgical components of operations–treatment)*

Р

Meaning of CDE as criterion of prognosis of LPC in the postoperative period (N – are not presented; P – are presented)

Accuracy of classification

%

Long-term postoperative complications, ≥ 1 year (are present, aren’t present)

Consequence of combination of factors А+В+С

1

operated right, left or both hands (origin of LPC at the patient in general, without dependence from the operated hand)

CDE = -1.904+3.079∙A15

+2.583∙С62+2.323∙С13

+2.188∙С33+2.087∙С25+2.025∙А67

+1.454∙С68+1.275∙А10+1.266∙А71

+1.159∙С1+0.987∙А64+0.907∙А66

-0.651∙A73-0.715∙A33

-0.760С76-2.179A30-2.974A55

0.0001

N<0.124 <P

78.7

2

operated right hand (origin of LPC only on the right hand)

CDE = -1.656+3.451∙A15+2.818∙С13

+1.543∙С15+1.498∙В1+1.413∙А66

+0.902∙А90–0.883∙А81–1.152∙В5

0.0001

N<0.072 <P

72.8

3

operated left hand (LPC only on the left hand)

CDE = 4.479+2.998∙В10+2.240∙А72

+1.862∙А66+1.773∙В11+1.347∙А97

+1.045∙А82–1.250∙А73–2.224∙С61

-2.861С66

0.0001

N<0.026 <P

76.3

 

 

 

 

Consequence of combination of factors А+В

4

operated right,

left or both hands

(LPC at the patient in general, without dependence from the operated hand)

CDE = –0.511+2.972 ∙ А15+2.178 ∙А23+1.799∙ А66+1.718 ∙ А10+1.436 ∙ А1+1.190 ∙А64+1.183 ∙ А71–0.844 ∙А33–0.916∙ А73

0.0001

N<0.084 <P

69.0

5

perated right hand

(LPC only on the right hand)

CDE = -0.979+2.258∙A66

+1.634∙А1+1.250∙В1–0.991∙А81–1.155∙В8

0.0001

N<0.054 <P

64.4

6

operated left hand

(LPC only on the left hand)

CDE = -0.360+3.028∙B10

+2.198∙А66+1.614∙В11

+1.310∙А97+0.927∙А82

-1.300∙A73-2.483∙A55

0.0001

N<0.022 <P

73.3

Consequence of factors C

7

operation type

(LPC at the patient in general, without dependence from the operated hand)

CDE = –0.110+9.466∙ С83

0.002

N<0.116 <P

76.7

8

operated right, left or both hands

(LPC at the patient in general, without dependence from the operated hand)

CDE = -0.658+6.001∙C4+5.830∙C42

+3.210∙С33+1.027∙С68

 

0.0001

N<0.197 <P

58.9

9

operated right hand

(LPC only on the right hand)

is not approximated

___

___

___

10

operated

 left hand (LPC only on the left hand)

CDE =-0.253+6.288∙C42+2.809∙C43

 

0.001

 

N<0.170 <P

 

 

77.0

11

Both hands are operated

11.1.

(LPC only on the right hand)

is not approximated

___

___

___

11.2.

(LPC only on the left hand)

CDE =-1.856+2.455∙C46

 

0.001

P<-0.411 <N

 

79.1

11.3.

(LPC on both hands)

CDE = – 1.355+1.860∙C6 -3.939∙С27

 

0.001

P<-0.395 <N

 

81.4

Note: *–the factors’ determination is presented in Appendix A and Table 4

 


However, from our point of view, period of the beginning of the analysis after 6 months is inexpedient, as process of healing and recovery of hand’s function after operation can constitute more than 6 months, especially at intra (neurapraxia, nerve injury, arterial injury, flexor tendon injury), or short-term (haematoma, infection, skin) postoperative complications; therefore observation period ≥ 1 year is justified. The efficiency criterion is not the general notion today. Such status estimation is used:

·      Finger[13,29, 30];

·      Hand[13, 29];

·      Joint[31-35];

·      Arm[6, 36-38].

 

Additional complication for standardization of treatment’s results is application of several classifications on DC stages that complicates standardization of results’ estimation. DC separation into three grades [4], four grades [20] is used. The majority of clinics use DC classification in five grades[19, 21].

 

LPC origin was observed for up to ≥ 1 year till 15 years. DC is featured by a high share of LPC. DC has LPC in 41,8%, and their proportion, taking into account progression, has constituted 35,6% on the right hand and 48,6% on the left hand (Table 2). It depends on both of localisation of DC and duration of the postoperative period.The maximum value of indices 1, 2, 3, 4, 5, 6, 7 is observed on both hands in period till 5 years, indices 4, 5 on the right hand keep high in period of 6-10 years.

 

The data obtained by us testifies that DC is characterised by high frequency of LPC, share of which is the highest on terms till five years. Thus patients needs in more thorough supervision, especially in these terms.

 

Frequency allocation of recurrence and extension on the right hand is almost similar to that on the left, except the cases of recurrence combined with extension. The recurrence proportion has constituted: 9,3%; on the right hand - 7,3%. on left - 11,7% (Table 2, indices 1.2., 1.3.). The extension proportion has constituted: 9,6%; on the right hand - 8,8%, on left - 10,4% (Table 2, indices 2.2., 2.3.). The proportion of combination of recurrence with extension has constituted: 3,2%; on the right hand - 4,6% on left - 2,5% (Table 2, indices 3.2., 3.3.).

 

Absence of a significant difference in frequency of localisation of LPC on the right and left hands specifies in necessity of a careful assessment of both hands of patients at the current examination.

 

Proportion (%) of recurrence is presented in the literature in details. As to indicators theirs values are differed in several folds. The comparison to our data has given the following result (period after operation, the literature data% / our data%): 1-2 years: 2%[39], 18%[14], 65%[15] / on the right hand - 4,2%, on the left hand - 3,9% (Table 2, indice 1.3.). 3-5 years: 11%[40], 12%[41,42], 33%[43], 41%[32,33], 45%[44], 47%[16], 58%[37]/ on the right hand-6,8%, on the left hand - 9,8% (Table 2, indice 1.3.). 6–10 years: 39%[13], 68%[45] / on the right hand - 7,3%, on the left hand - 11,7% (Table 2, indice 1.3.).

Indicators of extension were different depending on the period of supervision after operation also.

 

Comparison of proportion (%) of (primary) with our data has given the following result (period after operation, the literature data% / our data%): 1-2 years: 33%[42] / on the right hand - 5,2%, on the left hand - 6,6% (Table 2, indice 2.3.). 3-5 years: 8,9%[46], 10%[42], 12% [47] / on the right hand - 7,8%, on the left hand - 8,5% (Table 2, indice 2.3.). 6-10 years: there is no data / on the right hand-8,3%, on the left hand - 10,4% (Table 2, indice 2.3.). 11-15 years: there is no data/on the right hand-8,8%, on the left hand - 10,4% (Table 2, indice 2.3.).

 

The lower share of generated LPC recorded in our study is perhaps connected with technical features of the applied operations. In most of cases have been applied sphenoidal excision of middle part of PА with longitudinal bands of the distal part of PA, unlike the techniques applied by other experts (in the range from limited[15,37] till extensive invasions[33,44]) what may let to introduce it as а more preferable.

 

Common frequency of progression was lower than 19,2% (Table 2, indices 4.2., 5.2.)/against 54,8%[48] versus of the literary data.

 

The progression proportion on not operated hand without recurrence and extension on the operated hand has constituted: 13,4%, on the right hand-10,5%, on the left hand - 17,1% (Table 2, indices 4.2., 4.3.).

 

The progression proportion on not operated hand with recurrence and extension on the operated hand has constituted: 5,8%, on the right hand - 5,2%, on left-6,5% (Table 2, indices 5.2., 5.3.).

 

Generation and evolution of DC’s progression on the unoperated hand is highly likely connected with inherited factors and the biological status of the individual patient. 68% of patients are liable to recurrence on periods more than 10 years according to model[45]. According to the same author, almost all patients will be exposed to progression on both hands that make the question of DC treatment inseparably linked with genetic-biological factors[49].

 

The estimation of treatment outcomes of the patients by various groups of specialists concerning DC, by means of descriptive statistics, of finger[13,29,30], hand[13,29], joint [31-35], arm [6,36-38] and the one-parameter analysis[43,44,48] does not allow to gain the analytical analysis of results, i.e. outcome prognosis for the individual patient.

 

From 1 (Equation No. 7; 11.2) to 17 factors of groups A, B, C (Equation No. 1) of parameters (Table 3) became essential to individual efficiency prognosis of surgical treatment, depending on operation type from 222 parameters of the anamnesis and follow-up of the patient.

 

The equations on LPC prognosis are characterized by accuracy of classification 58, 9-81, 4% (Table 3). Following cases are not approximated in the form of the equation: operation on the right hand (LPC only on the right hand) Equation No. 9; and cases of operations on both hands (LPC only on the right hand) Equation No. 11.1 (Table 3).

 

The gained results have solved a series of tasks:

1.    There is a possibility to prognosticate the result of operative treatment of DC in terms of LPC, as recurrence, extension, progression, and its combinations:

1.1.    recurrence + extension;

1.2.    progression on not operated hand, without recurrence and extension on the operated hand;

1.3.    progression on not operated hand, with recurrence and extension on the operated hand (Table 3) depending on DC localization, type of operation, technique of section etc.

2.    The increasing factors (27 factors: A factors – 12; B factors – 3; C factors – 12) and decreasing factors (12 factors: A factors – 5; B factors – 2; C factors – 5) of LPC have been detected (Table 4).

3.    The resource of the surgeon in LPC preventive maintenance is restricted by choice of operative technique and by algorithm of postoperative follow-up at the stage of surgical treatment of DC. The conducted research has framed possibility to adjust result of treatment on preoperative stage in operatively–technical and rehabilitational parts of follow-up of the patient (Table 4).


 

Table 4 Consequence of factors of groups A, B, C on origin of long-term postoperative complications at DC

No.

The factors raising the probability of origin of LPC

The factors decreasing the probability of origin of LPC

1

А1 – period of examination of the right hand: 1-2 years

А30– DC diagnosis on the righthand(affected finger/DC grade) 3/III grades (an angle of contracture ˂1000)

2

А10 – period of examination of the left hand: 11-15 years

А33– DC diagnosis on the righthand(affected finger/DC grade) 4/III grades (contracture angle ˂ 100 0)

3

А15 – age of the patient: 20-30 years

А55–DC presence in the inheritance at: the sister

4

А23 – DC diagnosis on the righthand(affected finger/DC grade) 1/II grades (an angle of contracture from 1790 to 1000)

А73– associated diseases (location): central nervous system

5

А64 – Ledderhose disease

А81–surgical history and traumas on: the right upper extremity

6

А66–epiarticular of fingers pulps: the left hand

В5–physical job during: 11-20 years

7

А67–Peyronie disease

В8–physical job during: 41-50 years

8

А71– associated diseases: osteochondrosis

С6–operation on the right hand: sphenoidal excision of average part of PА with longitudinal bands of distal department of PA

9

А72– associated diseases: diabetes

С46–operation on the lefthand: sphenoidal excision of average part of PА with longitudinal bands of distal department of PA

10

А82–surgical history and traumas on: the left upper extremity

С61– type of anesthesia at operation on the left hand: intravenous regional

11

А90– prescription of origin of disease on the righthand: 6 – 10 years

С66– section type on palm of the left hand: curly

12

А97– prescription of origin of disease on the left hand: 11 – 15 years

С76–postoperative rehabilitation on the left hand: electrophoresis (phonophoresis), Lydasums

13

В1–place of residence of the patient: city

 

14

В10–mental job during: 1-5 years

 

15

В11–mental job during: 11-20 years

 

16

С1–operation on the right hand

 

17

С4–operation on the right hand: excision of apex of PА

 

18

С13– common experience of the surgeon making operation on the right hand: more than 30 years

 

19

С15–specialized experience of the surgeon making operation on the right hand: 3 – 5 years

 

20

С25–section type on palm of the right hand: the linear

 

21

С27– section type on fingers of the right hand: the linear

 

22

С33–free dermal plastyon the right hand on: the fourth finger

 

23

С42-operation on the left hand: the partial excision of PА

 

24

С43–operation on the left hand: total excision of PА

 

25

С62-type of anesthesia at operation on the left hand: conduction anesthesia

 

26

С68-section type on fingers of the left hand: curly

 

27

С83–partial excision of palmar aponeurosis on one hand and sphenoidal excision of middle part of PА with longitudinal bands of distal department of PA on other hand

 

 


 

 

A. It is not recommended: to carry the operative treatment on the right hand by the surgeon with general surgical experience more than 30 years (С5) and the special experience less than 5 years (С6), to apply the linear section on palm (С7) and fingers (С8), to apply operation – resection of apex of PA (С3), to carry conduction anesthesia at operative treatment on the left hand (С19), to apply a curly section on fingers (С21), to apply operation of partial (С12) or total excision of PА (С13).

 

B. It is recommended: to make sphenoidal excision of middle part of PA with longitudinal band of distal department of PA (С4) at operation on the right hand; to make an operative measure under i.v. regional anaesthesia (С18) with application of curly section on a palm (С20) and sphenoidal excision of middle part of PA with longitudinal band of distal department of PA (С15) at operation on the left hand.

 

Factors "C" (technical - operative components) have the maximum effect on the operation outcome in LPC where the accuracy of classification attains 81,4%, against 78,7% at the analysis of factors А+В+С and 73,3% at the analysis of factors А+В (Table 3).

 

The most important factors of group "C" at LPC prognosis are С4 - on the right hand (sphenoidal excision of middle part of PA with longitudinal bands of distal department of PA) and С8 - on the right hand (the linear section on fingers) (Equation No. 11.3., Table 3).

 

CONCLUSION:

1.    The efficiency analysis of used alternatives of surgical treatment allows to state that the number of long-term postoperative complications on periods of observation till 15 years attains 41,8%, including: recurrence–9,3%, extension–9,6%, recurrence with extension–3,2%, progression on not operated hand without complications, on the operated hand–13,4%, progression on not operated hand with complications on the operated hand–5,8%.

2.    Factors of groups A, B, C influencing the long-term postoperative complications are defined.

3.    Information content of prognosis technology on the basis of factors A, B, C of patients constitutes: А+В+С: 72,8 – 78,7% (р = 0,0001); А+В: 64,4 – 73,3% (р = 0,0001); C: 58,9 – 81,4% (р ˂ 0,002).

 

ETHICAL APPROVAL:

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional (the protocol of meeting №8. October, 28th, 2014) and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.

 

REFERENCES:

1.     Badois FJ, Lermusiaux JL, Masse AC and Kuntz D. Nonsurgical treatment of Dupuytren’s disease using needle fasciotomy. Rev. Rhum. Ed. Engl. 60; 1993: 692-697.

2.     Lermusiaux JL, Lellouche H, Badois JF and Kuntz D. How should Dupuytren's contracture be managed in 1997? Rev. Rhum. Ed. Engl. 64(12); 1997: 775-776.

3.     Kelly AP Jr and Clifford RH. Subcutaneous fasciotomy in the treatment of Dupuytren's contracture. Plast. Reconstr. Surg. Transplant Bull. 24; 1959: 505-510.

4.     Luck JV. Dupuytren's contracture. A new concept of the pathogenesis correlated with surgical management. J Bone Joint Surg Am. 41-A(4); 1959: 635-664.

5.     Moermans JP. Segmental aponeurectomy in Dupuytren's disease. J. Hand Surg. Br. 16(3); 1991: 243-254.

6.     Moermans JP. Long-term results after segmental aponeurectomy for Dupuytren's disease. J. Hand Surg. Br. 21(6); 1996: 797-800.

7.     Chick LR and Lister GD. Surgical alternatives in Dupuytren's contracture. Hand. Clin. 7(4); 1991: 715-719.

8.     Lubahn JD and Lister GD, Wolfe T. Fasciectomy and Dupuytren's disease: a comparison between the open-palm technique and wound closure. J. Hand Surg. Am. 9A(1); 1984: 53-58.

9.     Maravic M and Landais P. Dupuytren's disease in France-1831 to 2001-from description to economic burden. J. Hand Surg. Br. 30(5); 2005: 484-487.

10.   McCash CR. The open palm technique in Dupuytren's contracture. Br. J. Plast. Surg. 17; 1964: 271-280.

11.   Hueston JT. Recurrent Dupuytren's contracture. Plast. Reconstr. Surg. 31; 1963: 66-69.

12.   McIndоe AH and Beare RL. The surgical management of Dupuytren's contracture. Am. J. Surg. 95(2); 1958: 197-203.

13.   Foucher G, Cornil A C, Lenoble E and Citron N. A modified open palm technique for Dupuytren’s disease. Short and long term results in 54 patients. Int. Orthop. 19(5); 1995: 285-258.

14.   Citron ND and Nunez V. Recurrence after surgery for Dupuytren’s disease a randomized trial of two skin incisions. J. Hand. Surg. Br. 30(6); 2005: 563-566.

15.   van Rijssen AL and Werkr PM. Percutaneous needle fasciotomy in Dupuytren’s disease. J. Hand Surg. Br. 31(5); 2006: 498-501.

16.   Wilbrand S, Flodmark AC, Ekbom A and Gerdin B. Activation markers of connective tissue in Dupuytren’s contracture: relation to postoperative outcome. Scand. J. Plast. Reconstr. Surg. Hand Surg. 37(5); 2003: 283-292.

17.   Crean SM, Gerber RA, Hellio Le Graverand MP, Boyd DM and Cappelleri JC. The efficacy and safety of fasciectomy and fasciotomy for Dupuytren's contracture in European patients: a structured review of published studies. J. Hand Surg. Eur. 36(5); 2011: 396-407.

18.   Mikusev GI, Magomedov RO, Osmonaliev I, Baikeev RF and Mikusev IE. Dupuytren's contracture: epidemiology, etiology, pathogenesis, diagnozis and treatment. Kazan Medical Journal. 92(6); 2001: 896-900.

19.   Henry W and Meyerding MD. Dupuytren's contracture. Arch. Surg. 32(2); 1936: 320-333.

20.   Iselin M and Iselin F. Maladie de Duputren. Traité de Chirugie de la Main. Flammarion, Brussels. 1967.

21.   Tubiana R. Evaluation of deformities in Dupuytren's disease. Annales de Chirurgie de la Main. 5(1); 1986: 5-11.

22.   Brenner P. Dupuytren-kontraktur. In: Berger A. (ed.). Plastische chirurgie – handchirurgie. Breitnersche Operationslehre. XIV. München Wien Baltimore, Urban AND Schwarzenberg. 1997; pp. 13-27.

23.   Hueston JT. Limited fasciectomy for Dupuytren's contracture. Plast. Reconstr. Surg. 27; 1961: 569-585.

24.   Dabrowski T. Treatment of Dupuytren's contracture by excision of the base of the palmar aponeurosis. Acta Med. Pol. 8(4); 1967: 499-504.

25.   Мikusev GI., Baykeev RF, Mikusev IE and Magomedov RO. Dupuytren’s disease. The register of ТR. Bulletin of Traumatology and Orthopedy of N.N. Priorov. 4; 2007: 65-69.

26.   Becker K, Tinschert S, Lienert A, Bleuler PE, Staub F, Meinel A, Rößler J, Wach W, Hoffmann R, Kühnel F, Damert HG, Nick HE, Spicher R, Lenze W, Langer M, Nürnberg P and Hennies HC. The importance of genetic susceptibility in Dupuytren's disease. Clin. Genet. 87(5); 2015: 483-487.

27.   Ten Dam EP, van Beuge MM, Bank RA and Werker PM. Further evidence of the involvement of the Wntsignalling pathway in Dupuytren's disease. J Cell Commun Signal. 10(1); 2016: 33-40.

28.   World Health Organization. International statistical classification of diseases and related health problems. 2010. Available from: URL: http://www.who.int/classifications/icd/ICD10Volume2_en_2010.pdf

29.   Smith P and Breed AC. Central slip attenuation in Dupuytren’s contracture: a cause of persistent flexion of the proximal interphalangeal joint. J. Hand Surg. Am. 19(5); 1994: 840-843.

30.   Tripoli M and Merle M. The "Jacobsen Flap" for the treatment of stages III-IV Dupuytren's disease: a review of 98 cases. J. Hand Surg. Eur. 33(6); 2008: 779-782.

31.   Coert JH, Nerin JP and Meek MF. Results of partial fasciectomy for Dupuytren’s disease in 261 consecutive patients. Ann. Plast. Surg. 57(1); 2006: 13-17.

32.   Foucher G, Cornil AC and Lenoble E. Open plam technique for Dupuytren’s disease. Postoperative complications and results after more than 5 years. Chirurgie. 118(4); 1992: 189-194.

33.   Foucher G, Cornil AC and Lenoble E. Open palm technique for Dupuytren’s disease. A five-year followup. Ann. Chir. Main Memb. Super. 11(5); 1992: 362-366.

34.   Kjeldal I and Nygaard HP. Out-patient surgery for Dupuytren’s disease under intravenous regional anaesthesia. J. Hand Surg. Br. 13(3); 1988: 257-258.

35.   Macnicol MF. The open palm technique for Dupuytren's contracture. Int. Orthop. 8(1); 1984: 55-89.

36.   Constantinou E and Deutinger M. Results after surgical treatment of Dupuytren’s contracture. Acta Chirurgica Austriaca. 28; 1996: 163-165.

37.   Foucher G, Medina J and Navarro R. Percutaneous needle aponeurotomy: complications and results. J. Hand Surg. Br. 28(5); 2003: 427-431.

38.   Makela EA, Jaroma H, Harju A, Anttila S and Vainio J. Dupuytren's contracture: the long-term results after day surgery. J. Hand Surg. Br. 16(3); 1991: 272-274.

39.   Foucher G, Shuind F and Lemarechal P. The open palm technique in the management of Dupuytren’s contracture. Ann. Chir. Plast. Esthet. 30; 1985: 211-215.

40.   Hogemann A, Wolfhard U, Kendoff D, Board TN and Olivier LC. Results of total aponeurectomy for Dupuytren’s contracture in 61 patients: a retrospective clinical study. Arch. Orthop. Trauma Surg. 129(2); 2009: 195-201.

41.   Armstrong JR, Hurren JS and Logan AM. Dermofasciectomy in the management of Dupuytren's disease. J. Bone. Joint. Surg. Br. 82(1); 2000: 90-94.

42.   Tonkin MA, Burke FD and Varian JP. Dupuytren's contracture: a comparative study of fasciectomy and dermofasciectomy in one hundred patients. J. Hand Surg. Br. 9(2); 1984: 156-162.

43.   Bulstrode NW, Jemec B and Smith PJ. The complications of Dupuytren's contracture surgery. J. Hand Surg. Am. 30(5); 2005: 1021-1025.

44.   Nieminen S and Lehto M. Resection of the palmarislongus tendon in surgery for Dupuytren's contracture. Ann. Chir. Gynaecol. 75(3); 1986: 164-167.

45.   Moermans JP. Recurrences after surgery for Dupuytren's disease. Eur. J. Plastic. Surg. 20(5); 1997: 240-245.

46.   Roy N, Sharma D, Mirza AH, Fahmy N., Fasciectomy and conservative full thickness skin grafting in Dupuytren’s contracture. The fish technique. ActaOrthop. Belg., 72(6); 2006: 678-682.

47.   Ullah AS, Dias JJ and Bhrowal B. (Does a "firebreak" full-thickness skin graft prevent recurrence after surgery for Dupuytren’s contracture?: A prospective, randomized trial. J. Bone Joint Surg. Br. 91(3); 2009: 374-378.

48.   Norotte G, Apoil A and Travers V. A ten years follow-up of the results of surgery for Dupuytren’s disease. A study of fifty-eight cases. Ann. Chir. Main. 7(4); 1988: 277-281.

49.   Lee H. The Lived Experience of Clinical Nurse Specialist: A Phenomenological Study. Research Journal of Pharmacy and Technology. 11(3); 2018: 857-862.

 

APPENDICES:

Appendix A. Supplement 1: Factors of the anamnesis and follow-up of the patient, surveyed at development of prognosis technology of surgical treatment efficiency of Dupuytren’s disease (contracture):

A-factors determining the biological status of the patient (gender, age, disease prescription, examination period, grade of DC lesion, heredity, the associated diseases, surgical history and traumas, the disease beginning, laboratory analyses, etc.):

·      Period of examination of the right hand:

А1 – 1–2 years, А2 – 3–5 years, А3 – 6-10 years, А4 – 11-15 years, А5 – 16-20 years, А6 – more than 20 years;

·      Period of examination of the left hand:

А7 1–2 year, А8 3–5 years, А9 – 6-10 years, А10 11-15 years, А11–16-20 years, А12 – more than 20 years;

·      Gender of the patient:

А13 – male, А14 – female;

·      Age of the patient:

А15 20–30 years, А16 31–40 years, А17 41–50 years, А18 51–60 years, А19 61–70 years, А20 71–80 years, А21 more 80 years;

·      DC diagnosis on the right hand (affected finger/ DC grade):

А22 – 1/I grade, А23 – 1/II grade, А24 – 1/III grade, А25 – 2/I grade, А26 – 2/II grade, А27 – 2/III grade, А28 – 3/I grade, А29 – 3/II grade, А30 – 3/III grade, А31 – 4/I grade, А32 – 4/II grade, А33 – 4/III grade, А34 – 5/I grade, А35 – 5/II grade, А36 – 5/III grade, А37 – atypical form of DC on the right hand;

·      DC diagnosis on the left hand (affected finger/DC grade):

А38 – 1/I grade, А39 – 1/II grade, А40 – 1/III grade, А41 – 2/I grade, А42 – 2/II grade, А43 – 2/III grade, А44 – 3/I grade, А45 – 3/II grade, А46 – 3/III grade, А47 – 4/I grade, А48 – 4/II grade, А49 – 4/III grade, А50 – 5/I grade, А51 – 5/II grade, А52 – 5/III grade, А53– atypical form of DC on the left hand;

·      DC presence in the inheritance at:

А54 – mother, А55 –sister, А56 – father, А57– brother, А58 – grandmothers, А59 – aunts, А60 – cousin sister, А61– grandfathers, А62 – uncles, А63 – cousin brother;

·      А64 Leclderhose disease, presence of epiarticular fingers’ pulps: А65 – the right hand, А66 – the left hand;

·      А67 – Peyronie disease, Associated diseases:

А68 cardio–vascular system, А69 – respiratory organs, А70 –gastro-intestinal tract, А71–osteochondrosis, А72– diabetes, А73– central nervous system, А74 pneumatic hammer disease, А75 – oncology, А76– general diseases, А77 blade-humerusperiarthritis, А78 – other;

·      Surgical history and traumas on:

А79 gastro-intestinal tract, А80 – respiratory organs, А81 – the right upper extremities, А82 – the left upper extremities, А83 – fracture of ribs, А84 – pelvic fracture, А85 – fracture of spinal column;

·      DC origin in the anamnesis:

А86 – acute trauma, А87 – chronic trauma, А88 – spontaneous DC origin;

·      Prescription of origin of disease on the right hand:

А89 – 1-5 years, А90 6-10 years, А91 –11-15 years, А92 16-20 years, А93 21-30 years, А94 – more than 30 years;

·      Prescription of origin of disease on the left hand:

А95 – 1-5 years, А96 6-10 years, А97 11-15 years, А98 16-20 years, А99 21-30 years, А100 – more than 30 years;

·      Rhesus factor of blood of the patient:

А101 – positive, А102 – negative;

·      Blood group of the patient:

А103 – O (I), А104 – A (II), А105 – B (III), А106– AB (IV);

·      Common analysis of blood, meaning:

А107–haemoglobin, А108 – leucocytes, А109 – ESR;

·      Common analysis of urine, meaning:

А110 – specific gravity, А111 – response, А112 – transparency, А113 – colour, А114 – fiber, А115 – glucose, А116 – epithelium, А117 – leucocytes, А118 –crystals.B-factors presenting life style of the patient (residence, physical and mental job, bad habits, etc.):

·      Place of residence of the patient:

В1– city, B2-village;

·      Physical job during lifetime:

В3 – 1-5 years, В4– 6-10 years, В5 – 11–20 years, В6 – 21-30 years, В7 – 31–40 years, В8 – 41–50 years, В9 – more 50 years;

·      mental job during lifetime:

В10 – 1-5 years, В11 – 6-10 years, В12 – 11-20 years, В13 – 21-30 years, В14 – 31-40 years, В15 – 41-50 years, В16 – more than 50 years;

·      В17 – smoking, В18 – alcohol intake;

·      В19 – physical job in everyday life;

·      В20 – playing sports. C- factors presenting technical-surgical components of operations, treatment (the experience of the surgeon, types of operations, anesthesia, section, dermal plasty, rehabilitational treatment, healing, etc.):

·      С1– operated on the right hand;

·      the operative measure on the right hand: С2– the partial excision of PA, С3 – total excision of PA, С4 – excision of apex of PA, С5 – excision of proximal and middle parts of PA, С6 – sphenoidal excision of middle part of PA with longitudinal bands of distal department of PA;

·      Common experience of the surgeon making operation on the right hand: С7 – 1-2 years, С8 3-5 years, С9 6-10 years, С10 11-15 years, С11 16-20 years, С12 21-30 years, С13 – more than 30 years;

·      Specialized experience of the surgeon making operation on the right hand: С14 1-2 year, С15 3-5 years, С16 6-10 years, С17 11-15 years, С18 16-20 years, С19 21-30 years, С20 – more than 30 years;

·      Type of the anesthesia at operation on the right hand: С21 – intravenous regional, С22 – conduction, С23 – intubation narcosis, С24 – intravenous narcosis;

·      Section type on palm of the right hand: С25 – linear, С26 – curly;

·      Section type on fingers of the right hand: С27 – linear, С28 – curly;

·      On the right hand – the free dermal plasty on: С29 – palms, С30 – the first finger, С31 – the second finger, С32 – the third finger, С33 – the fourth finger, С34 – the fifth finger;

·      Postoperative aftertreatment on the right hand: С35 – diadynamic currents, alternating electric field of ultra high frequency, ultra-violet irradiation, С36 – electrophoresis (phonophoresis) Lydasums, С37 – physiotherapy exercises, massage, С38 paraffin therapy, fangotherapy;

·      Healing on the right hand: С39 – primary, С40 – secondary; С41 operated left hand;

·      Operative measure on the left hand: С42 – the partial excision of PA, С43 – total excision of PA, С44 – excision of apex of PA, С45 – excision of proximal and middle parts of PA, С46 – sphenoidal excision of middle part of PA with longitudinal bands of distal department of PA;

·      Common experience of the surgeon making operation on the left hand: С47 – 1-2 years, С48 –3-5 years, С49 6-10 years, С50 11-15 years, С51 16-20 years, С52 21-30 years, С53 – more than 30 years;

·      Specialized experience of the surgeon making operation on the left hand: С54 1-2 year, С55 –3-5 years, С56 6-10 years, С57 11-15 years, С58 16-20 years, С59 21-30 years, С60 – more than 30 years;

·      Type of anesthesia at operation on the left hand: С61 – intravenous regional, С62 – conduction, С63 – intubation narcosis, С64 – intravenous narcosis;

·      Section type on a palm of the left hand: С65 linear, С66 – Curly;

·      Section type on fingers of the left hand: С67 – linear, С68 – curly;

·      On the left hand – the free dermal plasty on: С69 – palms, С70 – the first finger, С71 – the second finger, С72 – the third finger, С73 – the fourth finger, С74 – the fifth finger;

·      On the left hand – postoperative after treatment: С75–diadynamic currents, alternating electric field of ultra high frequency, ultra-violet irradiation, С76–electrophoresis (phonophoresis), Lydasums, С77 – physiotherapy exercises, massage, С78–paraffin therapy, fangotherapy;

·      Healing on the left hand: С79–primary, С80–secondary;

·      С81– excision of apex of PA (on the right or left hand);

·      С82– the partial excision of PA on one hand and total excision of PA on other hand;

·      С83 – the partial excision of PA on one hand and sphenoidal excision of middle part of PA with longitudinal bands of distal department of PA on other hand;

·      С84 – section on fingers linear + the curly.

 

Appendix B. Supplement 2 Patient Z., 47 years old, case history №1814/12384, the citizen:

Patient’s complaints at admission: callosity of palmar surface of the left hand in projection of 4-5 fingers, periodic pain in fingers after an exercise stress, flexion contracture of 4-5 fingers that frames difficulties during work and self-service.

Anamnesis morbi. Patient has damaged palmar surface of the left hand by the fork spanner about three years ago. Contracture of 4 finger has developed after this accident.

Anamnesis vitae:

Previous diseases: Acute respiratory diseases

Associated diseases: osteochondrosis (А71), Ledderhose disease (А64) and Peyronie disease (А67). Factors entering into the equation matching to clinical alternative were indexed by signs A, B, C hereinafter in clinical instances.

Epidemiological anamnesis: Patient did not contact to infections; wasn’t operated earlier. Patient refuses tuberculosis, syphilis, virus hepatitis. Allergological anamnesis is not confounded. Hemo-transfusions were not made earlier.

Data of physical examinations:

Common status is satisfactory. Consciousness: clear. Skin integuments: of physiologic colour. Tongue: pure, wet. Breath: vesicular, respiratory frequency is16 per minute, conducted from both sides. Both hemithorax participate in breath symmetrically. Arterial pressure is 120/60 mm of mercury. Pulse is 74 beats per minute, rhythmic, filling up is satisfactory. Abdomen: shapely, participates in the breath act, at palpation is soft, painless. Lien: is not palpated. Pasternatsky symptom is negative from both sides. Liver: is not palpated. Defecation and diuresis are not broken.

Status localis:

 

The right hand:

Visually: changes are not determined. Small local inspissations in the form of nodes from 0,5 × 0,5 to 0,5 × 1,5 х 10-2 m are determined palpatory on palmar surface of hand in the area of distal palmar cord at level of 3 - 4 - 5 MTP joints under skin. Function of fingers is complete.

 

The left hand:

Visually: local hyperkeratosis of the oval form on palmar surface of hand in the area of distal palmar cord at level of 4 MTP joint of 0,7 × 1,0 х 10-2 m, band is spread from area of hyperkeratosis of palm on middle phalanx of 4 finger. A flexion contracture of 4 finger in MTP joint at an angle 1050 in proximal interphalanx joint at an angle 1250, flexion contracture of 5 finger in MTP joint at an angle 1500.

Palpatory: Dense bands, going in direction to 4 and 5 fingers and passing on basic and middle phalanxes of 4 finger and on the basic phalanx of 5 finger; skin above bands is thickened. Small local inspissations are determined: at level of 3d MTP joint in the form of node from 0,5 × 0,7 х 10-2 m, on ulnar edge of 1 finger at level of MTP joint in the form of node from 0,3 × 0,6 х 10-2 m on palmar surface of hand in the area of distal palmar cord under skin. Function of 1, 3 fingers is complete; 4 and 5 fingers are total flexible, the extension to angles presented above.

The diagnosis: Dupuytren’s (contracture) disease of 3, 4, 5 fingers of I grade of the right hand; 1, 3 fingers of Igrade, 4 finger of III grade, 5 finger of II grade of the left hand.

It is planned to operate the left hand, sphenoidal excision of middle part of PA with longitudinal bands of distal department of PA, curly section on 4 finger of the left hand (С68) with physiotherapeutic treatment (electrophoresis, phonophoresis)(С76) in the postoperative period.

Mathematical calculation on prognosis of long-term postoperative complications is made:

Canonical Discriminant Equation (CDE) =–1,904+2,025 ∙ (1) + 1,454 ∙ (1)+1,266 (1)+0,987 (1)–0,760 ∙ (1) = 3,07

According to СDE meaning=0,124 for the given equation (Equation No. 1, Table 3) we conclude that patient Z. will have LPC.

Operation: sphenoidal excision of middle part of PA with longitudinal bands of distal department of PA to 3, 4, 5 fingers, elimination of flexion contracture of 4, 5 fingers, dermal "Z" plasty on 4 finger.

Dressings, physiotherapeutic treatment were made in the postoperative period. Wounds had primary healing. The patient was discharged in satisfactory status.

Follow-up examination took place in 4 years. The diagnosis: the left hand – DC recurrence of 3, 4, 5 fingers of II grade, DC progression on 1 finger of II grade; the right hand – DC progression on 1 finger of I grade, on 3, 4, 5 fingers of II grade.

Thus, correctness of calculation is demonstrated.

 

 

 

 

 

 

 

 

Received on 17.10.2018         Modified on 18.12.2018

Accepted on 05.01.2019      © RJPT All right reserved

Research J. Pharm. and Tech. 2019; 12(3):1055-1065.

DOI: 10.5958/0974-360X.2019.00174.4