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Screening tool development for hand surgery referrals in systemic sclerosis

Abstract

Background

Systemic Sclerosis (SSc) patients may need hand surgery.

Objective

To develop a screening tool for rheumatologists to identify potential candidates with systemic sclerosis for hand surgery, optimizing referrals.

Methods

A pilot cross-sectional study from January 2015 to December 2016. Sample size: 51 participants. Inclusion criteria: ≥ 18 years old, meeting the 2013 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria for SSc and hand impairment. Data collected: age, sex, race, disease duration, SSc subtypes, vasodilator use, skin thickness, finger stiffness, presence of Digital Ulcers (DU) and/or calcinosis, presence of Raynaud's Phenomenon (RP) attacks, health status and disability, disease status, pain intensity and functional status of the hands. Data were analyzed by a multivariate logistic regression model.

Results

Fulfillment of surgical criteria: 68.8%. The surgical group had higher scores on the HAQ-DI (1.39 vs. 0.96, p =0.032) and CHFS (25.0 vs. 12.0, p =0.005) questionnaires, and a higher frequency of DU (91.43% vs. 18.75%, p <0.0010), calcinosis (60.0% vs. 0.0%, p <0.001), use of vasodilators (100.0% vs. 75.0%, p =0.007) and digital stiffness (28.57% vs. 0.0%, p =0.017). The presence of DU increased the chance of surgical indication by 46.2 times (ORIC 95% = 8.23 to 259.49). The statistical model showed good accuracy (86.3%, p <0.001), sensitivity (91.4%), and specificity (81.2%).

Conclusion

The presence of DU in SSc could be used as a screening feature for early identification and referral of potential candidates for hand surgery.

Keywords
Scleroderma, systemic; Orthopedic procedures; Cross-sectional studies; Skin ulcer; Referral and consultation

Highlights

  • Identification of potential candidates for hand surgery in Systemic Sclerosis.

  • Presence of digital ulcers increases the likelihood of surgical indication.

  • Development of a predictive tool to identify candidates for surgical treatment.

Highlights

  • Identification of potential candidates for hand surgery in Systemic Sclerosis.

  • Presence of digital ulcers increases the likelihood of surgical indication.

  • Development of a predictive tool to identify candidates for surgical treatment.

Introduction

Communication between physicians and hand surgeons is essential in the multidisciplinary approach of SSc patients. Timely referral to a hand surgery specialist can ensure that those with hand manifestations receive the most appropriate treatment as they tend to be in better general and hand conditions should a surgical procedure be required. On the other hand, late referrals can lead to less satisfactory results, both due to the greater involvement of the hand and the more deteriorated clinical conditions of these individuals.11 Daigeler A, Meyer M, Joneidi-Jafari H, Möcklinghoff C, Steinau HU, Lehnhardt M. Manifestations of scleroderma at the hand ‒ options for hand surgery in an interdisciplinary concept. Handchir Mikrochir Plast Chir. 2007;39(2):128-34. Although there is no established perfect “Window” for referral to be made, early identification of potential surgical candidates could optimize surgical outcomes and the quality of life for these individuals.

Systemic sclerosis is a rare multisystem disease caused by immune-mediated endothelial dysfunction, characterized by tissue ischemia and fibrosis.22 Fox P, Chung L, Chang J. Management of the hand in systemic sclerosis. J Hand Surg. 2013;38(5):1012-6.

3 Young A, Namas R, Dodge C, Khanna D. Hand impairment in systemic sclerosis: various manifestations and currently available treatment. Curr Treatm Opt Rheumatol. 2014;2(3):252-69.
-44 Tägil M, Dieterich J, Kopylov P. Wound healing after hand surgery in patients with systemic sclerosis ‒ a retrospective analysis of 41 operations in 19 patients. J Hand Surg Eur Vol. 2007;32(3):316-9. Hand manifestations include skin thickening, joint contractures, calcium deposits, Raynaud's Phenomenon (RP) attacks, nervous compressive symptoms, pain, digital gangrene, and bone infection, all of which contribute to disease-related disability and disfigurement.33 Young A, Namas R, Dodge C, Khanna D. Hand impairment in systemic sclerosis: various manifestations and currently available treatment. Curr Treatm Opt Rheumatol. 2014;2(3):252-69. The treatment of these alterations is mainly conservative, based on the use of immunosuppressive and anti-inflammatory medications, vasodilators, prostacyclin, and phosphodiesterase-5 inhibitors, rehabilitation and education programs.55 Hachulla E, Agard C, Allanore Y, Avouac J, Bader-Meunier B, Belot A, Servettaz A. French recommendations for the management of systemic sclerosis. Orphanet Journal of Rare Diseases. 2021;16(Suppl 2):1-61. https://doi.org/10.1186/s13023-021-01844-y.
https://doi.org/10.1186/s13023-021-01844...
,66 Beldner S, Rabinovich RV, Polatsch DB. Scleroderma of the hand: evaluation and treatment. J Am Acad Orthopc Surg. 2020;28(16):E686-E695. However, in certain scenarios when non-surgical treatments have failed, selected surgeries can help relieve pain, improve function, and provide better cosmesis.66 Beldner S, Rabinovich RV, Polatsch DB. Scleroderma of the hand: evaluation and treatment. J Am Acad Orthopc Surg. 2020;28(16):E686-E695. Among possible surgical procedures are listed: arterial sympathectomies ‒ to improve hand perfusion ‒ arthrodesis of interphalangeal and wrist joints, and resection arthroplasties of the metacarpophalangeal joint and the trapezius ‒ to improve hand position and function ‒ calcinosis resection ‒ for pain relief ‒ nerve decompressions, and fingertip amputations ‒ for intractable ulcers or bone infection.11 Daigeler A, Meyer M, Joneidi-Jafari H, Möcklinghoff C, Steinau HU, Lehnhardt M. Manifestations of scleroderma at the hand ‒ options for hand surgery in an interdisciplinary concept. Handchir Mikrochir Plast Chir. 2007;39(2):128-34.,77 Hebert RA. Hand surgery in the context of scleroderma. Inter J Med Sci Clin Res Studies. 2022;2(10 SE-Articles):1051-3. However, despite its frequent involvement, general practitioners and rheumatologists often neglect the treatment of hand manifestations and their surgical solutions. This is related not only to the general health problems of the patient but also to insufficient knowledge and training of the doctors in the available surgical options.88 Franzblau LE, Liang X, Wang K, Li Z, Li Y, Shauver M, et al. Barriers to reconstructive hand surgery for rheumatoid arthritis in China: a multicenter survey of patients and physicians. Plast Reconstr Surg Glob Open. 2016;4(11):e1126.,99 Franzblau LE, Wang K, Liang X, Guo Y, Li Y, Lin Y, et al. Identifying barriers to the care of the rheumatoid hand in China: comparing attitudes of rheumatologists and hand surgeons. Inter J Rheum Dis. 2018;21(11):1970-6. Some clinical signs and assessment tools have been applied to disease monitoring and evaluation of therapeutic intervention results.1010 Pope J. Measures of systemic sclerosis (scleroderma): health assessment questionnaire (HAQ) and scleroderma HAQ (SHAQ), physician and patient-rated global assessments, symptom burden index (SBI), University of California, Los Angeles, scleroderma clinical trials. Arthritis Care Res (Hoboken). 2011;63(Suppl 11):S98-S111. However, none of them has been used to assist in referral to a hand surgery specialist.

Therefore, given the low rates of timely referrals to the hand surgeon, we carried out a pilot study to develop and propose a practical tool that could assist in the early identification and referral of those individuals who could benefit from hand surgery, making surgical referrals part of a more evidence-based approach.

Methods

Study design

The study was approved by the local research ethics committee (protocol number: 23261013.8.0000.5404).

We performed a cross-sectional evaluation of individuals registered at the scleroderma unit of our institution (Hospital de Clínicas of the State University of Campinas - HC UNICAMP) between January 2015 and December 2016.

Setting

We obtained a convenience sample of individuals with SSc during their routine consultation at the scleroderma unit at HC-UNICAMP.

Participants

Potential participants were approached while in the waiting room or after their appointment. After signing the informed consent, the individuals were surveyed by a hand surgeon and a hand therapist.

Only individuals over 18 years of age, fulfilling the 2013 ACR/EULAR classification criteria for SSc,1111 Van Den Hoogen F, Khanna D, Fransen J, Johnson SR, Baron M, Tyndall A, et al. 2013 classification criteria for systemic sclerosis: an American college of rheumatology/European league against rheumatism collaborative initiative. Arthritis Rheum. 2013;65(11):2737-47. and without a previous hand operation were included in the study. Those with other forms of scleroderma and unwilling to participate were excluded.

Data collection

The survey instruments captured participants’ demographic, disease, and hand function information. The demographic data collected were age, sex, and race. Information about disease duration, SSc subtype,1212 LeRoy EC, Black C, Fleischmajer R, Jablonska S, Krieg T, Medsger Jr TA, et al. Scleroderma (systemic sclerosis): classification, subsets and pathogenesis. J Rheumatol. 1988;(2):202-5. vasodilator use, RP attacks in the previous week, skin thickness (mRSS),1313 Khanna D, Furst DE, Clements PJ, Allanore Y, Baron M, Czirjak L, et al. Standardization of the modified Rodnan skin score for use in clinical trials of systemic sclerosis. J Scleroderma Relat Disord. 2017;2(1):11-18. finger motion (delta FTP distance),1414 Torok KS, Baker NA, Lucas M, Domsic RT, Boudreau R, Medsger Jr TA. Reliability and validity of the delta finger-to-palm (FTP), a new measure of finger range of motion in systemic sclerosis. Clin Exp Rheumatol. 2010;28(2):28-36. digital ulcer and calcinosis presence, digital gangrene or infection, pain intensity (VAS),1515 Breivik H. Fifty years on the Visual Analogue Scale (VAS) for pain-intensity is still good for acute pain. But multidimensional assessment is needed for chronic pain. Scand J Pain. 2016;11:150-2. forearm limitation, and carpal tunnel symptoms were also collected. Finally, participants answered the HAQ-DI, SHAQ,1010 Pope J. Measures of systemic sclerosis (scleroderma): health assessment questionnaire (HAQ) and scleroderma HAQ (SHAQ), physician and patient-rated global assessments, symptom burden index (SBI), University of California, Los Angeles, scleroderma clinical trials. Arthritis Care Res (Hoboken). 2011;63(Suppl 11):S98-S111. and CHFS1616 Chiari A, de Souza Sardim CC, Natour J. Translation, cultural adaptation, and reproducibility of the cochin hand functional scale questionnaire for Brazil. Clinics (Sao Paulo). 2011;66(5):731-6. questionnaires. The questionnaires used are validated for the Portuguese language.

The surgical indications and the corresponding proposed procedures were as follows:
  • a)

    Ischemia (digital ischemia accompanied by severe pain, ulceration, or infection) ‒ sympathectomy or amputation.

  • b)

    Calcinosis (calcium deposits associated with extrusion, severe pain, or infection) ‒ excision of calcium deposits.

  • c)

    Contracture (finger, wrist, and first web contraction associated with ulceration due to skin break, and poor finger motion) ‒ arthrodesis of the proximal interphalangeal joint or wrist, arthroplasty of the metacarpophalangeal joint, trapezium resection.

  • d)

    Carpal tunnel syndrome (carpal tunnel symptoms unresponsive to conservative treatment) ‒ carpal tunnel release.11 Daigeler A, Meyer M, Joneidi-Jafari H, Möcklinghoff C, Steinau HU, Lehnhardt M. Manifestations of scleroderma at the hand ‒ options for hand surgery in an interdisciplinary concept. Handchir Mikrochir Plast Chir. 2007;39(2):128-34.,1717 Bogoch ER, Gross DK. Surgery of the hand in patients with systemic sclerosis: outcomes and considerations. J Rheumatol. 2005;32(4):642-8.

    18 Jones NF, Imbriglia JE, Steen VD, Medsger TA. Surgery for scleroderma of the hand. J Hand Surg Am. 1987;12(3):391-400.

    19 Williams AA, Carl HM, Lifchez SD. The scleroderma hand: manifestations of disease and approach to management. J Hand Surg Am. 2018;43(6):550-7.

    20 Gilbart MK, Jolles BM, Lee P, Bogoch ER. Surgery of the hand in severe systemic sclerosis. J Hand Surg Am. 2004;29(6):599-603.
    -2121 Mendelson BC, Linscheid RL, Dobyns JH, Muller SA. Surgical treatment of calcinosis cutis in the upper extremity. J Hand Surg Am. 1977;2(4):318-24.

Data analysis

For statistical purposes, we considered poor finger movement for delta-FTP values less than 40 mm1414 Torok KS, Baker NA, Lucas M, Domsic RT, Boudreau R, Medsger Jr TA. Reliability and validity of the delta finger-to-palm (FTP), a new measure of finger range of motion in systemic sclerosis. Clin Exp Rheumatol. 2010;28(2):28-36.,1616 Chiari A, de Souza Sardim CC, Natour J. Translation, cultural adaptation, and reproducibility of the cochin hand functional scale questionnaire for Brazil. Clinics (Sao Paulo). 2011;66(5):731-6. and severe pain for values greater than 7 in the VAS.2222 Schieir O, Thombs BD, Hudson M, Boivin JF, Steele R, Bernatsky S, Mittoo S. Prevalence, severity, and clinical correlates of pain in patients with systemic sclerosis. Arthritis Care Res (Hoboken). 2010;62(3):409-17.

Only one event (indication for surgical treatment) was considered for each person. Participants were grouped according to eligibility for surgical treatment.

We calculated descriptive statistics for participant characteristics. The Shapiro-Wilk test was used to verify data distribution and the Levene test for the homogeneity of variances. Comparisons between continuous variables were done using t Student and Mann-Whitney U tests and between categorical variables using the Chi-Square and Fisher's exact tests, as appropriate. Those variables demonstrating significant statistical differences between the groups were included in a stepwise multivariate binary regression model. The Hosmer-Lemeshow test was used to verify the model's goodness of fit, and the Wald test to analyze the significance of coefficients in the model. The strength of the association between each variable in the model was presented using an Odds Ratio (OR) with a Confidence Level of 95% (95% CI). We constructed Receiver Operating Characteristic (ROC) curves from the values predicted by the logistic regression model and analyzed the Area Under the Curve (AUC). Sensitivity and specificity tests were used to verify the accuracy of the model. The AUC was considered “excellent” (0.9 ≤ AUC < 1), “good” (0.8 ≤ AUC < 0.9), “fair” (0.7 ≤ AUC < 0.8), or “poor” (AUC < 0.7). All analyzes were performed using PASW statistics 18.0 software (Statistical Package for the Social Sciences Inc. Chicago, USA), with a significance level (α) of 5% (p <0.05).

Results

Participants

Fifty-four subjects were selected and 51 (27‒76 years old) were included in the study. Three individuals were excluded for not meeting the 2013 ACR/EULAR classification criteria for SSc.

Descriptive and outcome data

Women represented 92.2% of the sample size, and the mean age of the participants was 50 years old (27‒76). Regarding racial division, 65% declared themselves as white, 27.5% as brown, and 7.5% as black.

Established surgical criteria were met by 68.8% of the participants. These individuals presented higher scores on HAQ-DI (mean score = 1.39 vs. 0.96, p =0.032), and CHFS (median score = 25.0 vs. 12.0, p =0.005) questionnaires. They also presented higher frequency of DU (91.43% vs. 18.75%, p <0.0010), calcinosis (60.0% vs 0.0%, p <0.001), use of vasodilators (100.0% vs. 75.0%, p =0.007), and digital stiffness (28.57% vs. 0.0%, p =0.017) (Table 1).

Table 1
Participants' characteristics.

Main results

A predictive model for surgery indication

The multivariate binary logistic regression model identified the presence of DU as an independent predictor for the surgical indication (Table 2), increasing its chance by 46.2 times (ORIC 95%= 8.23 to 259.49).

Table 2
Multivariate binary logistic regression for prediction of surgery indication.

Other tested variables (HAQ-DI, CHFS, delta FTP <40 mm, calcinosis, and vasodilator use) did not show an important contribution to the model for predicting the need for surgery in the presence of a DU.

Other analysis

This model based on the presence of DU demonstrated good accuracy (86.3%, p <0.001) in predicting the need for hand surgical treatment in the studied population, with relevant values of sensitivity (91.4%) and specificity (81.2%) (Fig. 1).

Fig. 1
ROC curve analysis of values derived from the multivariate binary logistic regression model for prediction of surgical indication. The symbol “●” represents the sensitivity and specificity for surgery indication based on presence of digital ulcer. ROC, Receiver Operating Characteristic; AUC, Area Under the Curve.

Discussion

Synopsis of the key findings

Treatment of hand involvement in SSc can be uncomfortable and frustrating for patients and rheumatologists, especially when conservative treatment fails. In situations like this, a non-pharmacological approach is often necessary to enhance results. But often, the surgical option for the hands is sometimes underutilized as a treatment modality by rheumatologists. This can be explained by several factors, such as a lack of knowledge of rheumatologists regarding the existing surgical possibilities, inability to identify potential surgical candidates, inconsistent literature on possible surgical benefits, disagreement related to the ideal time for the referral and surgical efficacy, or even the lack of a reference hand surgeon to refer their patients.88 Franzblau LE, Liang X, Wang K, Li Z, Li Y, Shauver M, et al. Barriers to reconstructive hand surgery for rheumatoid arthritis in China: a multicenter survey of patients and physicians. Plast Reconstr Surg Glob Open. 2016;4(11):e1126.,2323 Satteson ES, Chung MP, Chung LS, Chang J. Microvascular hand surgery for digital ischemia in scleroderma. J Scleroderma Relat Disord. 2020;5(2):130-6.

In addition to this, for various reasons, many professionals fail to practice more evidence-based medicine, sometimes guiding their practices mainly on personal experience. As a result, some patients do not receive the best treatment at the most appropriate time.2424 Kvien TK, Puhl W. How important is collaboration between orthopedic surgeons and rheumatologists for optimizing the management of joint disease? Nat Clin Pract Rheumatol. 2007;3(10):535.

Efforts to promote collaboration and referral between rheumatologists and hand surgeons to improve awareness of the possible advantages of operative management and to develop a more robust referral network could ensure that patients who may benefit from surgical treatment have an opportunity to be evaluated.

Also, early referral of such patients has the potential to a more effective management of the hand problem, lessen years of suffering and hand impairment of the patients, optimize resources in hand treatment, and may also result in better surgical outcomes due to less advanced disease.2323 Satteson ES, Chung MP, Chung LS, Chang J. Microvascular hand surgery for digital ischemia in scleroderma. J Scleroderma Relat Disord. 2020;5(2):130-6.,2525 Wolff A, Weinstock-Zlotnick G, Gordon J. SSc management ‒ in person appointments and remote therapy (SMART): a framework for management of chronic hand conditions. J Hand Ther. 2014;27(2):143-51.

Previous studies have validated clinical signs and assessment tools to monitor SSc progression and assess the results of therapeutic interventions.1010 Pope J. Measures of systemic sclerosis (scleroderma): health assessment questionnaire (HAQ) and scleroderma HAQ (SHAQ), physician and patient-rated global assessments, symptom burden index (SBI), University of California, Los Angeles, scleroderma clinical trials. Arthritis Care Res (Hoboken). 2011;63(Suppl 11):S98-S111. However, to our knowledge, no study has used these monitoring tools to identify potential candidates for hand surgery.

In the present study, the authors hypothesized that one of these measures2626 Rannou F, Poiraudeau S, Berezné A, Baubet T, Le-Guern V, Cabane J, et al. Assessing disability and quality of life in systemic sclerosis: construct validities of the cochin hand function scale, health assessment questionnaire (HAQ), systemic sclerosis HAQ, and medical outcomes study 36-item short form health survey. Arthritis Rheum. 2007;57(1):94-102. could be used for this purpose.

The idea was to use the findings to improve collaboration between the clinical and surgical teams, making surgical referrals earlier and faster.

The hypothesis was corroborated by multivariate analysis. A statistical association was found between the presence of DU and the eligibility for surgical treatment of the hand.

It was also found that potential surgical candidates had higher scores on the HAQ-DI and CHFS questionnaires, higher frequencies of calcinosis, use of vasodilators, and finger stiffness. However, no statistical association was found between these indicators and the expected outcome, perhaps a trend.

Consideration of possible mechanisms and explanation

Patients with SSc have been experiencing higher survival rates in the last two decades because of the increase in knowledge about the disease and its treatment.2727 The Lancet. Systemic sclerosis: advances and prospects. Lancet. 2017. https://doi.org/10.1016/S0140-6736(17)32594-1.
https://doi.org/10.1016/S0140-6736(17)32...
As a result, the effects of disease-related disabilities have increased. In this context, hand manifestations are a well-known cause of disease-related disability, and their management is quite challenging.

One of the main characteristics of hand involvement in SSc is the presence of DU, which results from vasculopathy, cutaneous fibrosis, and joint contractures. It is present in 5% to 10% of patients, and about 50% of SSc patients will have a DU during their lifetime.2828 Hughes M, Allanore Y, Chung L, Pauling JD, Denton CP, Matucci-Cerinic M. Raynaud phenomenon and digital ulcers in systemic sclerosis. Nat Rev Rheumatol. 2020;16(4):208-21.

The results of the multivariate analysis suggest that hands with DU respond more poorly to conservative treatment, which comes along with the fact that these patients have the disease for longer (mean 13.4 years vs. 6.4 years in our study), their hands are usually more deformed and have a worse function, especially when accompanied by pain.2929 Guillevin L, Hunsche E, Denton CP, Krieg T, Schwierin B, Rosenberg D, et al. Functional impairment of systemic scleroderma patients with digital ulcerations: results from the DUO registry. Clin Exp Rheumatol. 2013;31(2 Suppl.76):71-80.,3030 Toffolo SR, Furtado RNV, Klein A, Watanabe S, Andrade LEC, Natour J. Measurement of upper limb ulcers in patients with systemic sclerosis: reproducibility and correlation with pain, function, and quality of life. Nurs Res. 2008;57(2):84-92.

We believe that the results obtained could be extrapolated to other patients with SSc since the demographic characteristics of the studied group are comparable to those of other epidemiological studies done on SSc.3131 Lo Monaco A, Bruschi M, La Corte R, Volpinari S, Trotta F. Epidemiology of systemic sclerosis in a district of northern Italy. Clin Exp Rheumatol. 2011;29(2 Suppl. 65):S10-S14.

32 Mayes MD, Lacey JV, Beebe-Dimmer J, Gillespie BW, Cooper B, Laing TJ, et al. Prevalence, incidence, survival, and disease characteristics of systemic sclerosis in a large US population. Arthritis Rheum. 2003;48(8):2246-55.
-3333 Horimoto AMC, Matos ENN, da Costa MR, Takahashi F, Rezende MC, Kanomata LB, et al. Incidence and prevalence of systemic sclerosis in campo grande, state of Mato Grosso do Sul, Brazil. Revi Bras Reumatol Engl Ed. 2017;57(2):107-14.

Limitations of the study

Our study is not without limitations. The results reported are from pilot observational research, not a randomized trial. As such, the clinical data collection was completed at the time of clinical care, which adds time limitations to the extent of data collected.

We also acknowledge that our patient population was limited, so the generalization of our findings should be taken with caution. However, this approach provides a basis to expand and confirm the results in a larger population of SSc patients.

Although we recognize that the clinical aspects of the disease influence the surgical treatment of the hand, our study limited itself to identifying potential candidates for hand surgery, regardless of their clinical condition.

A brief section that summarizes the implications of the work for practice and research

The result of our study helps to shed some light on the matter of late surgical referrals for potential surgical candidates with SSc and hand problems, with the potential to assist in the interaction between the clinical and surgical teams, leading to more effective management and optimization of resources as part of a more evidence-based approach.

Therefore, the presence of DU in patients with SSc may be a screening tool to identify potential candidates for hand surgery, helping to enhance the collaboration between rheumatologists and hand surgeons as a part of a more evidence-based approach.

Compliance with ethical standards

The following research was approved by the local Research Ethics Committee (protocol number: 23261013.8.0000.5404). All subjects received informed consent.

Abbreviations

  • SSc  systemic sclerosis
  • RP  raynaud phenomenon
  • DU  digital ulcer
  • HAQ  health assessment questionnaire
  • SHAQ  scleroderma health assessment questionnaire
  • CFHS  cochin functional hand scale
  • Delta FTP distance  delta finger-to-palm distance
  • HC-UNICAMP  hospital de Clínicas da Universidade Estadual de Campinas
  • ACR/EULAR  American college of rheumatology/European league against rheumatism
  • Funding
    This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References

  • 1
    Daigeler A, Meyer M, Joneidi-Jafari H, Möcklinghoff C, Steinau HU, Lehnhardt M. Manifestations of scleroderma at the hand ‒ options for hand surgery in an interdisciplinary concept. Handchir Mikrochir Plast Chir. 2007;39(2):128-34.
  • 2
    Fox P, Chung L, Chang J. Management of the hand in systemic sclerosis. J Hand Surg. 2013;38(5):1012-6.
  • 3
    Young A, Namas R, Dodge C, Khanna D. Hand impairment in systemic sclerosis: various manifestations and currently available treatment. Curr Treatm Opt Rheumatol. 2014;2(3):252-69.
  • 4
    Tägil M, Dieterich J, Kopylov P. Wound healing after hand surgery in patients with systemic sclerosis ‒ a retrospective analysis of 41 operations in 19 patients. J Hand Surg Eur Vol. 2007;32(3):316-9.
  • 5
    Hachulla E, Agard C, Allanore Y, Avouac J, Bader-Meunier B, Belot A, Servettaz A. French recommendations for the management of systemic sclerosis. Orphanet Journal of Rare Diseases. 2021;16(Suppl 2):1-61. https://doi.org/10.1186/s13023-021-01844-y
    » https://doi.org/10.1186/s13023-021-01844-y
  • 6
    Beldner S, Rabinovich RV, Polatsch DB. Scleroderma of the hand: evaluation and treatment. J Am Acad Orthopc Surg. 2020;28(16):E686-E695.
  • 7
    Hebert RA. Hand surgery in the context of scleroderma. Inter J Med Sci Clin Res Studies. 2022;2(10 SE-Articles):1051-3.
  • 8
    Franzblau LE, Liang X, Wang K, Li Z, Li Y, Shauver M, et al. Barriers to reconstructive hand surgery for rheumatoid arthritis in China: a multicenter survey of patients and physicians. Plast Reconstr Surg Glob Open. 2016;4(11):e1126.
  • 9
    Franzblau LE, Wang K, Liang X, Guo Y, Li Y, Lin Y, et al. Identifying barriers to the care of the rheumatoid hand in China: comparing attitudes of rheumatologists and hand surgeons. Inter J Rheum Dis. 2018;21(11):1970-6.
  • 10
    Pope J. Measures of systemic sclerosis (scleroderma): health assessment questionnaire (HAQ) and scleroderma HAQ (SHAQ), physician and patient-rated global assessments, symptom burden index (SBI), University of California, Los Angeles, scleroderma clinical trials. Arthritis Care Res (Hoboken). 2011;63(Suppl 11):S98-S111.
  • 11
    Van Den Hoogen F, Khanna D, Fransen J, Johnson SR, Baron M, Tyndall A, et al. 2013 classification criteria for systemic sclerosis: an American college of rheumatology/European league against rheumatism collaborative initiative. Arthritis Rheum. 2013;65(11):2737-47.
  • 12
    LeRoy EC, Black C, Fleischmajer R, Jablonska S, Krieg T, Medsger Jr TA, et al. Scleroderma (systemic sclerosis): classification, subsets and pathogenesis. J Rheumatol. 1988;(2):202-5.
  • 13
    Khanna D, Furst DE, Clements PJ, Allanore Y, Baron M, Czirjak L, et al. Standardization of the modified Rodnan skin score for use in clinical trials of systemic sclerosis. J Scleroderma Relat Disord. 2017;2(1):11-18.
  • 14
    Torok KS, Baker NA, Lucas M, Domsic RT, Boudreau R, Medsger Jr TA. Reliability and validity of the delta finger-to-palm (FTP), a new measure of finger range of motion in systemic sclerosis. Clin Exp Rheumatol. 2010;28(2):28-36.
  • 15
    Breivik H. Fifty years on the Visual Analogue Scale (VAS) for pain-intensity is still good for acute pain. But multidimensional assessment is needed for chronic pain. Scand J Pain. 2016;11:150-2.
  • 16
    Chiari A, de Souza Sardim CC, Natour J. Translation, cultural adaptation, and reproducibility of the cochin hand functional scale questionnaire for Brazil. Clinics (Sao Paulo). 2011;66(5):731-6.
  • 17
    Bogoch ER, Gross DK. Surgery of the hand in patients with systemic sclerosis: outcomes and considerations. J Rheumatol. 2005;32(4):642-8.
  • 18
    Jones NF, Imbriglia JE, Steen VD, Medsger TA. Surgery for scleroderma of the hand. J Hand Surg Am. 1987;12(3):391-400.
  • 19
    Williams AA, Carl HM, Lifchez SD. The scleroderma hand: manifestations of disease and approach to management. J Hand Surg Am. 2018;43(6):550-7.
  • 20
    Gilbart MK, Jolles BM, Lee P, Bogoch ER. Surgery of the hand in severe systemic sclerosis. J Hand Surg Am. 2004;29(6):599-603.
  • 21
    Mendelson BC, Linscheid RL, Dobyns JH, Muller SA. Surgical treatment of calcinosis cutis in the upper extremity. J Hand Surg Am. 1977;2(4):318-24.
  • 22
    Schieir O, Thombs BD, Hudson M, Boivin JF, Steele R, Bernatsky S, Mittoo S. Prevalence, severity, and clinical correlates of pain in patients with systemic sclerosis. Arthritis Care Res (Hoboken). 2010;62(3):409-17.
  • 23
    Satteson ES, Chung MP, Chung LS, Chang J. Microvascular hand surgery for digital ischemia in scleroderma. J Scleroderma Relat Disord. 2020;5(2):130-6.
  • 24
    Kvien TK, Puhl W. How important is collaboration between orthopedic surgeons and rheumatologists for optimizing the management of joint disease? Nat Clin Pract Rheumatol. 2007;3(10):535.
  • 25
    Wolff A, Weinstock-Zlotnick G, Gordon J. SSc management ‒ in person appointments and remote therapy (SMART): a framework for management of chronic hand conditions. J Hand Ther. 2014;27(2):143-51.
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Publication Dates

  • Publication in this collection
    20 Oct 2023
  • Date of issue
    2023

History

  • Received
    01 Feb 2023
  • Reviewed
    03 July 2023
  • Accepted
    26 July 2023
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