Screening tool development for hand surgery referrals in systemic sclerosis

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

Variables	Total (n= 51)	Surgical Indication		p-value
		Yes (n= 35)	No (n= 16)
Age^a a Mean ± standard deviation. (years)	50.0 ± 12.0	49.9 ± 12.7	50.0 ± 10.7	0.988^ST ST Student's t test.
Time since diagnosis^b b Median (1st quartile ‒ 3rd quartile or frequency of occurrence [number (%)]). (years)	8.0 [4.0‒16.0]	7.0 [4.0‒11.8]	8.0 [4.0‒16.0]	0.597^MW MW U Mann Whitney test.
Rodnan^a a Mean ± standard deviation.	23.2 ± 8.9	24.2 ± 9.1	20.9 ± 8.3	0.229^ST ST Student's t test.
HAQ-DI^a a Mean ± standard deviation. (score)	1.25 ± 0.67	1.39 ± 0.67	0.96 ± 0.58	0.032^ST ST Student's t test.
SHAQ^a a Mean ± standard deviation. (score)	1.06 ± 0.56	1.16 ± 0.58	0.86 ± 0.45	0.073^ST ST Student's t test.
CHFS^b b Median (1st quartile ‒ 3rd quartile or frequency of occurrence [number (%)]). (score)	18.0 [9.0‒38.0]	25.0 [10.0‒46.0]	12.0 [5.0‒17.0]	0.005^MW MW U Mann Whitney test.
Gender
Male	7.8% (44/51)	3 (8.57%)	1 (6.25%)	1.000^FE FE Fisher's Exact Test.
Female	92.2% (47/51)	32 (91.43%)	15 (93.75%)	1.000^FE FE Fisher's Exact Test.
Systemic sclerosis
Limited	62.7% (32/51)	21 (60.00%)	11 (68.75%)	0.549^CS CS Chi-Square test; HAQ-DI, Health Assessment Questionnaire Disability Index; SHAQ, Scleroderma HAQ; CHFS, Cochin Hand Functional Scale; Delta FTP, Delta Finger-to-Palm.
Diffuse	37.3% (19/51)	14 (40.00%)	5 (31.25%)
Raynaud's Phenomenon
Present	98.0% (50/51)	34 (97.14%)	16 (100.00%)	1.000^FE FE Fisher's Exact Test.
Absent	2.0% (1/51)	1 (2.86%)	0 (0.00%)	1.000^FE FE Fisher's Exact Test.
Digital ulcer
Present	68.6% (35/51)	32 (91.43%)	3 (18.75%)	<0.001^CS CS Chi-Square test; HAQ-DI, Health Assessment Questionnaire Disability Index; SHAQ, Scleroderma HAQ; CHFS, Cochin Hand Functional Scale; Delta FTP, Delta Finger-to-Palm.
Absent	31.4% (16/51)	3 (8.57%)	13 (81.25%)
Calcinosis
Present	41.2% (21/51)	21 (60.00%)	0 (0.00%)	<0.001^CS CS Chi-Square test; HAQ-DI, Health Assessment Questionnaire Disability Index; SHAQ, Scleroderma HAQ; CHFS, Cochin Hand Functional Scale; Delta FTP, Delta Finger-to-Palm.
Absent	58.8% (30/51)	14 (40.00%)	16 (100.00%)
Vasodilator Use
Yes	92.2% (47/51)	35 (100.00%)	12 (75.00%)	0.007^FE FE Fisher's Exact Test.
No	7.8% (4/51)	0 (0.00%)	4 (25.00%)	0.007^FE FE Fisher's Exact Test.
Delta FTP
< 40 mm	19.6% (10/51)	10 (28.57%)	0 (0.00%)	0.017^CS CS Chi-Square test; HAQ-DI, Health Assessment Questionnaire Disability Index; SHAQ, Scleroderma HAQ; CHFS, Cochin Hand Functional Scale; Delta FTP, Delta Finger-to-Palm.
≥ 40 mm	80.4% (41/51)	25 (71.43%)	16 (100.00%)
VAS pain
> 70	17.6% (9/51)	7 (20.00%)	2 (12.50%)	0.514^CS CS Chi-Square test; HAQ-DI, Health Assessment Questionnaire Disability Index; SHAQ, Scleroderma HAQ; CHFS, Cochin Hand Functional Scale; Delta FTP, Delta Finger-to-Palm.
≤ 70	82.4% (42/51)	28 (80.00%)	14 (87.50%)

Model	B	p-value	OR	CL 95%
Digital ulcers
Absent			1.00	[Reference]
Present	3.83	< 0.001	46.22	8.23 to 259.49
Constant	−1.47	0.022	0.23	‒

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[1] * Corresponding author. E-mail address:marcosmarcatto@hc.unicamp.br (M.F. Marcatto de Abreu).