Response to: Revisiting the Methodology and Implications of the Network Meta-analysis on Dupuytren Disease Treatments: A Letter to the Editor

To the editor,

We are writing in response to the letter submitted to the HAND journal, which addressed our recently published article titled “Surgical Management of Dupuytren Disease: A Systematic Review and Network Meta-analyses.” ¹ We would like to express our gratitude to our colleagues for their keen interest in our research and for their positive feedback. We concur that this field of surgery is indeed interesting and would benefit from continued research endeavors and additional clinical trials.

Regarding the criticisms raised by Dr Seth and Dr Rozen, we would like to address these points in further detail. First, the study by Zhou et al, ² which was referenced, was excluded from our analysis as it did not meet the criteria of a randomized trial. We carefully reviewed our research methods regarding the study by Kan et al, ³ and this was excluded during the full-text review stage because it combined percutaneous aponeurotomy with lipofilling. This represented a distinct and different technique compared to the focus of our investigation. We acknowledge the inconsistency in our approach, as the study by Selles et al ⁴ (which also involved lipofilling) was included. However, even if the study by Kan et al had been included in the meta-analysis, it would not have influenced the conclusions presented in our paper. The quoted study by Kan et al had a follow-up period of only 1 year and lacked data beyond this time frame. Our meta-analysis primarily demonstrates the superiority of fasciectomy across all outcomes after 3 to 5 years, and this particular study could not contribute data to that specific analysis. At all other timepoints, the outcomes from various treatment modalities were equivocal. Arguably, the 3- to 5-year cohort holds the greatest clinical significance, as it offers insights into the long-term outcomes associated with different treatment strategies.

In response to the question of using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach, ⁵ we acknowledge that it could have offered a different perspective compared with the Cochrane risk of bias tool. ⁶ However, it is important to emphasize that our choice to employ the Cochrane risk of bias tool was based on several considerations that we believe are significant in the context of our study.

The Cochrane risk of bias tool holds a well-established and widely accepted position as a method for evaluating study quality and bias within the research community. Its widespread use ensures consistency and facilitates comparisons with other studies. A primary focus in the review was to assess the methodological quality and potential sources of bias within individual studies. In this regard, the Cochrane risk of bias tool was better suited to align with our research objectives. However, we want to emphasize that the GRADE framework has its merits, particularly in evaluating the overall certainty of evidence and making recommendations. We fully support its application in future research endeavors and guideline development.

Last, we wish to acknowledge that there were other elements that could have been included in the final publication, such as a network plot. After conducting our comprehensive analysis, we generated substantial data, including interval plots, pattern graphs, and forest plots for each of the outcomes studied. In the interest of conciseness and relevance, we made careful selections of the most pertinent graphs for inclusion in our article. It is important to note that we have retained all the additional data and graphs that were generated during our research. Should there be a need or interest from readers and researchers, we are more than willing to provide access to these omitted materials upon request.

We want to express our gratitude once again to Dr Seth and Dr Rozen for their keen interest in our research and their valuable insights. Their engagement with our work has been greatly appreciated, and we remain open to any further inquiries or discussions related to our study.