A clinical, ultrastructural and immunochemical study of Dupuytren's disease

The Lambda Cord: An Anatomic Configuration of Radial-Sided Dupuytren Disease

The thumb and first webspace are involved in a relatively low proportion of cases of Dupuytren disease of the hand (3%-28%). Given the rarity, there has been a paucity of literature regarding anatomic cord configurations and the surgical technique for the management of such radial-sided diseases. There are unique anatomic considerations in the thumb that warrant understanding prior to safe surgical exploration. A case of an anatomic variant of Dupuytren disease involving the thumb and first webspace treated with a webspace skin-sparing partial fasciectomy is described. The current literature regarding surgical management of Dupuytren disease affecting the thumb and first webspace is also briefly presented.

Biological Targets for Dupuytren Disease

ABSTRACT

Dupuytren disease is a connective tissue disorder occurring on the palm, causing flexion contractures of fingers. There is a pressing need for therapeutic interventions that can slow, stop, or even incrementally reverse the progression of the disease. Numerous in vitro studies have shed light on cellular and molecular agents that contribute to contractures. This article comprehensively reviews various growth factors that can be targeted to prevent and limit the progression and recurrence of Dupuytren contracture (DC). Fibroblasts are the major cell population that has been reported for the contractures in DC, and they are also known to exacerbate the cytokine production. Limiting the fibroblast function by targeting the growth factor production will be of great benefit in treating DC. This review will focus on the studies that have shown to limit the exaggerated function of fibroblasts by reducing the expression of profibrotic growth factors by using antagonizing agents.

The Molecular Pathogenesis of Dupuytren Disease: Review of the Literature and Suggested New Approaches to Treatment

BACKGROUND

Ever since the classification of Dupuytren disease into the proliferative, involutional, and residual stages, extensive research has been performed to uncover the molecular underpinnings of the disease and develop better treatment modalities for patients. The aim of this article is to systematically review the basic science literature pertaining to Dupuytren disease and suggest a new approach to treatment.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review was conducted using the MEDLINE database to identify basic science literature on Dupuytren pathophysiology falling under 1 or more of the following categories: (1) Molecular alterations, (2) Structural alterations, and (3) Genetic predisposition.

RESULTS

A total of 177 articles were reviewed of which 77 studies met inclusion criteria. Articles were categorized into respective sections outlined in the study methods.

CONCLUSION

The pathophysiological changes involved in Dupuytren's disease can be divided into a number of molecular and structural alterations with genetic predisposition playing a contributory role. Understanding these changes can allow for the development of biologics which may disrupt and halt the disease process.

The Mechanical Properties of the Palmar Aponeurosis and their Significance for the Pathogenesis of Dupuytren’s Contracture

Normal tendons and palmar aponeuroses from patients with carpal tunnel syndrome and tissues of the palmar aponeuroses from patients with Dupuytren’s contracture were subjected to biomechanical tests. Several parameters characterizing the viscoelastic load response of the tissues were investigated. The tissues from patients with Dupuytren’s contracture were classified according to their macroscopic and histological appearance into apparently normal palmar aponeuroses, thickened fibre bundles and contracture bands. There were biomechanical differences between the normal palmar aponeuroses and the apparently normal palmar aponeuroses indicating that biomechanical changes occur before thickening of fibres or cellular proliferation can be observed. Significant biomechanical changes occurred between apparently normal palmar aponeuroses and thickened fibre bundles.

Update on the role of molecular factors and fibroblasts in the pathogenesis of Dupuytren's disease

The mechanism by which the fibroblast is able to trigger palmar fibromatosis is still not yet fully understood. It would appear certain that the "abnormal" fibroblasts continuously synthesise profibrotic cytokines which are able to determine the activation to myofibroblasts, to stimulate them to the further proliferation and synthesis of other cytokines, to modify the cells' differentiation and ultrastructural characteristics, as well as the production of matrix and other proteins. Several fibroblast growth factors have been suggested to be responsible of an abnormal cell activation with an aberrantly elevated collagen synthesis and extracellular deposition in Dupuytren's disease, as TGF-Beta, TNF-Alfa, PDGF, GM-CSF, free radicals, metalloproteinases, sex hormones, gene modified expression, mechanical stimulation. The Authors review the current state of knowledge in the field, by analyzing the role of these cytokines in the palmar fibromatosis.

Identification of histological patterns in clinically affected and unaffected palm regions in dupuytren's disease

Dupuytren's disease is a fibro-proliferative disease characterized by a disorder of the extracellular matrix (ECM) and high myofibroblast proliferation. However, studies failed to determine if the whole palm fascia is affected by the disease. The objective of this study was to analyze several components of the extracellular matrix of three types of tissues—Dupuytren's diseased contracture cords (DDC), palmar fascia clinically unaffected by Dupuytren's disease contracture (NPF), and normal forehand fascia (NFF). Histological analysis, quantification of cells recultured from each type of tissue, mRNA microarrays and immunohistochemistry for smooth muscle actin (SMA), fibrillar ECM components and non-fibrillar ECM components were carried out. The results showed that DDC samples had abundant fibrosis with reticular fibers and few elastic fibers, high cell proliferation and myofibroblasts, laminin and glycoproteins, whereas NFF did not show any of these findings. Interestingly, NPF tissues had more cells showing myofibroblasts differentiation and more collagen and reticular fibers, laminin and glycoproteins than NFF, although at lower level than DDC, with similar elastic fibers than DDC. Immunohistochemical expression of decorin was high in DDC, whereas versican was highly expressed NFF, with no differences for aggrecan. Cluster analysis revealed that the global expression profile of NPF was very similar to DDC, and reculturing methods showed that cells corresponding to DDC tissues proliferated more actively than NPF, and NPF more actively than NFF. All these results suggest that NPF tissues may be affected, and that a modification of the therapeutic approach used for the treatment of Dupuytren's disease should be considered.

Increased Metabolic Activity of Fibroblasts Derived from Cords Compared with Nodule Fibroblasts Sampling from Patients with Dupuytren??s Contracture

BACKGROUND

The pathogenesis of Dupuytren's contracture is characterized by progress in several stages. The disease process includes two structurally distinct fibrotic elements, the so-called nodule and the cord. Several hypotheses have been proposed regarding the cause. Until now, there has been ongoing discussion regarding whether cords or nodules are the primary source of the disease.

METHODS

Tissues from 24 patients with Dupuytren's disease were obtained during hand surgery, providing samples from nodules and cords for cell culture. Tissue from the flexor retinaculum excised from healthy patients during surgical procedures on the hand served as control. By using the explant culture technique, fibroblasts were isolated and grown in standard medium. Besides morphological analysis, XTT proliferation tests were performed at various time periods to measure the metabolic activity of the cultivated fibroblasts.

RESULTS

Statistical analysis revealed significant differences of nodule- and cord-derived fibroblasts after 1 hour (p = 0.0150), 8 hours (p < 0.0001), and 16 hours (p < 0.0001).

CONCLUSIONS

The authors suggest that distinct proliferative properties of Dupuytren-derived fibroblasts are dependent on the cells' origin. Conclusions about the cause or pathogenesis cannot yet be drawn. Further investigation concerning their apparently different fibroproliferative properties is necessary.

Musculoskeletal disorders in diabetes mellitus: an update

Diabetes mellitus (DM) is associated with several musculoskeletal disorders. The incidence of DM and the life expectancy of the diabetic patient have both increased, resulting in the increased prevalence and clinical importance of musculoskeletal alterations in diabetic subjects. The exact pathophysiology of most of these musculoskeletal disorders remains obscure. Connective tissue disorders, neuropathy, vasculopathy or combinations of these problems, may underlie the increased incidence of musculoskeletal disorders in DM. The development of musculoskeletal disorders is dependent on age and on the duration of DM; however, it has been difficult to show a direct correlation with the metabolic control of DM. Most of these disorders can be diagnosed clinically, but some radiological examination may help, especially in differential diagnosis. No specific treatment is available, and treatments used in the general population are also recommended for diabetic subjects. Infectious complications affecting the musculoskeletal system are common in DM subjects, and these, possibly life-threatening, complications should be systematically discussed.

The Contractile Properties and Responses to Tensional Loading of Dupuytren???s Disease???Derived Fibroblasts Are Altered: A Cause of the Contracture?

Dupuytren's disease causes disability because of the development of finger flexion deformities, with distinct nodule and cord formation. This results in physical shortening of the diseased fascial tissue through a combination of cell-mediated contraction and matrix remodeling. It is this fixed tissue fabric shortening that prevents finger extension. In this experimental study, the relative contractile properties of Dupuytren nodule- and cord-derived fibroblasts were quantified in a culture force monitor model, in comparison with normal carpal ligament fibroblasts. Nine nodule, 10 cord, and four carpal ligament fibroblast cell lines were studied; each cell line was derived from a separate patient. The contractile forces generated by nodule and cord fibroblasts were significantly greater than the force generated by carpal ligament fibroblasts. There were also significant differences between nodule- and cord-derived fibroblasts, with the nodule cells demonstrating the greatest contractile force generation. The contraction profiles of both cord and nodule Dupuytren fibroblasts demonstrated delays in the attainment of tensional homeostasis, with an absence of a plateau phase by 20 hours. After the contraction phase, cell-seeded constructs were subjected to a series of four uniaxial mechanical overloads and cellular responses were monitored during each subsequent 30-minute period. Dupuytren nodule and cord fibroblast responses were significantly altered, compared with carpal ligament fibroblasts, exhibiting an increased and opposite response. Dupuytren fibroblasts, particularly nodule fibroblasts, exhibited increased force generation and a delay in reaching tensional homeostasis. The data suggest that these cells have an inherently higher basal tension and contractile ability. This results in increased shortening of the matrix, and the delay in reaching tensional homeostasis might exacerbate this response. These results represent a theoretical framework regarding the fundamental processes involved in the pathogenesis and progression of clinical flexion deformities in Dupuytren disease.

The different characteristics of Dupuytren's disease fibroblasts derived from either nodule or cord: expression of alpha-smooth muscle actin and the response to stimulation by TGF-beta1

Mechanisms behind the onset and progression of Dupuytren's disease are poorly understood. Both myofibroblasts and transforming growth factor beta 1 (TGF-beta(1)) have been implicated. We studied fibroblast cultures derived from nodules or cords of Dupuytren's contracture tissue to determine the proportion of myofibroblasts present in comparison with flexor retinaculum fibroblast cultures. We identified myofibroblasts by immunohistochemical staining for alpha-SMA. We then investigated the effects of TGF-beta(1) stimulation on these fibroblasts. Basal myofibroblast/fibroblast proportions were 9.7% in nodule cell cultures, 2.7% in cord cell cultures and only 1.3% in flexor retinaculum cell cultures. Nodule and cord myofibroblast proportions increased to 25.4% and 24.2%, respectively, in response to TGF-beta(1) treatment. Flexor retinaculum cell cultures showed no response to TGF-beta(1) stimulation. Fibroblasts cultured from specific regions of Dupuytren's tissue retain myofibroblast features in culture. TGF-beta(1) stimulation causes an increased myofibroblast phenotype to similar levels in both nodule and cord, suggesting that previously quiescent cord fibroblasts can be reactivated to become myofibroblasts by TGF-beta(1). This could be an underlying reason for high recurrence rates seen after surgery or progression following injury.

Changes of biochemical and biomechanical properties in Dupuytren disease

BACKGROUND

The major biochemical characteristic of Dupuytren disease is the progressive and irreversible deposition of excess fibrous collagen characterized by an enhanced type III collagen proportion.

OBJECTIVE

To investigate the influence of changes of the collagen spectrum on the biophysical properties of the palmar aponeurosis.

DESIGN

Variably affected palmar regions from 30 individuals with Dupuytren disease were classified according to histologic test results and clinical stage. Biochemical, biomechanical, and thermal contracture studies were performed.

RESULTS

The relative type III collagen content increased with increasing tissue involvement and was found to correlate with calorimetric and biomechanical properties with the exception of the Young modulus. In experiments on the thermal isometric contracture, the collagen denaturation temperature decreased with increasing type III collagen content, ie, increasing involvement. To study the dependence of biophysical properties from the collagen type distribution independent of structural changes, as seen in Dupuytren disease, we investigated rat skins from animals of an age range characterized by dramatic changes in type III collagen content (0-18 months). Biomechanical data also correlated significantly with type III collagen content in rat skin with the exception of the time constant of stress relaxation.

CONCLUSION

In light of these results, we suggest that structural changes, such as reduced collagen fibril diameters, associated with alterations in the type III collagen proportion may influence biophysical properties of connective tissues in the involved palmar aponeurosis in addition to alterations of the cross-linking pattern.

New insights in the development of Dupuytren's contracture: a review

Recent advances in the understanding of myofibroblast histology and function, the activity of fibrogenic cytokines, the role of the extracellular matrix and of free radicals are contributing to an understanding of the aetiology of Dupuytren's disease but not yet to its treatment. Surgical excision remains the best treatment.

Comparison of palmar aponeuroses from individuals with diabetes mellitus and Dupuytren's contracture

It is well known that Dupuytren's contracture is often associated with diabetes mellitus. Palmar fascia from individuals with diabetes mellitus and/or Dupuytren's contracture as well as controls were subjected to differential scanning calorimetry, biomechanical and biochemical analysis. The collagen denaturation temperature of the palmar aponeurosis from individuals with diabetes mellitus in the presence (71.0 degrees C) or absence of Dupuytren's contracture (70. 6 degrees C) was increased as compared with controls (68.5 degrees C), while this parameter was significantly reduced (about 3.5 degrees C) in contracture bands of Dupuytren's contracture. Stress relaxation experiments revealed that the viscous fraction was slightly reduced in diabetes mellitus (6.5%) vs. controls (8.3%), whereas in Dupuytren's contracture, irrespective of additional diabetes mellitus, a pronounced increase of this parameter was seen (36.5% vs. 24.5%) in the presence of diabetes mellitus. The time constants were significantly elevated by both disorders, this increase being more pronounced in Dupuytren's contracture. Taken together, these changes can be explained by increased cross-linking in diabetes mellitus, while in Dupuytren's contracture other structural changes, such as increased collagen type III content and loss of fascicular organization, play an additional role besides the finding of reduced cross linking.

Cell behavior and cell-matrix interactions of human palmar aponeurotic cells in vitro

The present investigation has been performed to better characterize, in vitro, normal aponeurotic cells in comparison with dermal fibroblasts and with cells derived from Dupuytren's affected aponeuroses. Cells were cultured in monolayer and/or into three-dimensional collagen gels. Cell structure, adhesion, and spreading capability on different substrates, as well as integrin expression were investigated by light and electron microscopy and by flow cytometry. Cell-matrix interactions were also analyzed by gel retraction experiments in the presence, or absence, of RGD peptides and anti-integrin antibodies. Normal aponeurotic cells, compared with dermal fibroblasts, exhibited in vitro peculiar structural features, which were substantially maintained in Dupuytren's aponeurotic cells, irrespective of the substrate they were grown on. By contrast, the aponeurotic cell behavior was different in normal and diseased cells, these latter approaching that of dermal fibroblasts. Normal aponeurotic cells, in fact, were characterized by low efficiency in retracting the collagen gel, low alpha 2, alpha 1, and alpha 5 integrin subunit expression and low adhesion properties onto collagen and fibronectin, whereas cells isolated from the aponeuroses of Dupuytren's patients exhibited higher capability of retracting the collagen gel, increased adhesion properties toward collagen and fibronectin, and higher levels of integrin expression. No differences were observed between dermal fibroblasts from Dupuytren's patients or from normal subjects. These in vitro results are consistent with those previously obtained in situ, suggesting that palmar aponeurotic cells have a peculiar phenotype and that changes in cell-matrix interactions occur in Dupuytren's contracture. Moreover, by comparing data obtained from the retracted fibrotic cords and the still clinically unaffected aponeuroses of the same patients, it may be noted that Dupuytren's disease is not only confined to the clinically involved branches, but includes the whole aponeurosis of the affected hand.

The contractility of knuckle pads. An in vitro study

Strips of tissue from knuckle pads contract in response to the myofibroblast stimulant mepyramine in a reversible, repeatable and dose-dependent manner. The significance of this finding is discussed.

Contraction of collagen lattices by cells from Dupuytren's nodules

The aim of this study was to see if nodular cells in Dupuytren's disease differed from dermal cells in their contractile capacity and motility. Ten surgical specimens from patients with Dupuytren's disease and contracture of the finger of more than 45 degrees were harvested and the nodular cells were explanted and cultured. Dermal fibroblasts from the forearm were used as control cells. Both types of cell had the same growth pattern. The morphology on confocal laser scanning microscopy was also similar in both types of cell. Dermal control cells caused significantly more contraction of collagen lattices compared with fibroblasts from nodules of Dupuytren's contracture. The F-actin content was equal in both groups. Platelet derived growth factor, PDGF-BB (but not PDGF-AA), increased the chemotactic activity of both cell types, but there were no differences between them. The results indicate that at a late state of the disease cells from Dupuytren's nodules lose their contractile capacity and regain a phenotype resembling that of dermal fibroblasts.

Differential expression of fibronectin splice variants, oncofetal glycosylated fibronectin and laminin isoforms in nodular palmar fibromatosis

The tissue formation process in nodular palmar fibromatosis (Morbus Dupuytren) was investigated by the demonstration of fibronectin splice variants (ED-A and ED-B fibronectin), de novo glycosylated fibronectin and laminin isoforms (A, M, B1, B2, s chains) in association to the proliferative activity (Ki-67 antigen) and the occurrence of myofibroblast phenotype (alpha-smooth muscle actin, desmin). The proliferative noduli of the fibromatosis were characterized by a diffuse immunostaining for alpha-smooth muscle actin, and single cells positive for desmin and the Ki-67 antigen. In contrast to the surrounding aponeurosis as extracellular matrix, components of the whole proliferative noduli were defined: ED-A, ED-B and de novo glycosylated fibronectin, B1 and B2 laminin chain, tenascin and collagen type IV. The demonstration of the A and M laminin chain was restricted to a few cells of the proliferative noduli. S laminin could be visualized in the majority of palmar aponeurotic fibroblasts. As revealed by mRNA, in situ hybridization a de novo synthesis of fibronectin could only be detected within proliferative noduli. There is a positive correlation between the myofibroblast phenotype formation, cellular proliferation and the occurrence of ED-A and ED-B containing fibronectin, as well as de novo glycosylated fibronectin in Dupuytren's disease. The ultrastructural irregularities of myofibroblastic basal lamina and the heterogeneity of the myofibroblast phenotype are equivalent to the variability of laminin isoform immunostaining.

A picropolychrome staining technique applied to Dupuytren's tissue

Although the histology of Duputyren's tissue is well-documented, conventional stains do not distinguish between the different types of collagen which biochemistry and immunochemistry suggest are present. Duputyren's specimens [nodules (n = 26), cords (n = 15) and dermofasciectomies (n = 6)] were stained with haematoxylin and eosin, Van Gieson's Mallory's, Masson's, and Herovici's picropolychrome stain, and examined for both cellularity and collagen staining characteristics. All stains illustrated the marked cellularity of the nodules, contrasting with a paucity of cells within the cords. The first four stains demonstrated uniformity of the collagen staining within the tissues. Herovici's picropolychrome, however, showed distinct staining patterns for the dermis, nodules and cords, with both purple/red and blue areas. Other studies suggest that those fibres stained purple/red and blue are types I and III collagens respectively. These findings may shed further light on the tissue of origin of Duputyren's disease.

Biomechanical properties of normal tendons, normal palmar aponeuroses, and tissues from patients with Dupuytren's disease subjected to elastase and chondroitinase treatment

Normal tendons, normal palmar aponeuroses and palmar aponeuroses from patients with Dupuytren's disease were subjected to elastase or chondroitinase treatment. Young's modulus was derived from the linear portion of stress-strain graph. It showed the lowest value for the apparently normal palmar aponeuroses and the highest value for tendon samples. Elastase treatment caused an increase of extensibility and a reduction of Young's modulus of normal palmar aponeuroses and tendons, but not of contracture bands. In normal tendons, normal palmar aponeuroses and apparently normal palmar aponeuroses residual strain and hysteresis loop increased significantly as a linear function of the amount of digested elastin. In contrast these biomechanical parameters were not affected significantly in contracture bands. In normal and apparently normal areas incubation with chondroitinase ABC resulted in a significant increase of residual strain and, as opposed to elastase, a decrease of normalized hysteresis loop. In contracture bands, however, these biomechanical parameters remained unchanged. RELEVANCE: The increasing evidence of a correlation between morphological changes of palmar elastin and ground substance with the progress of Dupuytren's disease emphasizes the need to determine the relative importance of these connective tissue components for the pathogenesis of Dupuytren's disease.

Biomechanical properties of normal tendons, normal palmar aponeuroses and palmar aponeuroses from patients with Dupuytren's disease subjected to elastase and chondroitinase treatment

Normal tendons, normal palmar aponeuroses and specimens from patients with Dupuytren's disease, namely apparently normal palmar aponeuroses and contracture bands were subjected to elastase and chondroitinase ABC digestion. Maximum Young's modulus, normalized hysteresis loop and residual elongation were determined before and after enzyme treatment. In normal tendons, normal and apparently normal palmar aponeuroses both normalized hysteresis loop and residual elongation increased significantly after elastase treatment, whereas the stiffness decreased. Normalized hysteresis loop and residual elongation display changes corresponding to the amount of digested elastin. The increased viscosity of untreated contracture bands containing less elastin, as compared to normal palmar aponeurosis, was not affected by elastase. Obviously, the elastic fibers in normal shape and distribution are responsible for maintaining an elastic status with a low viscous stress component. With the exception of contracture bands chondroitinase ABC caused a minor increase of residual elongation and as opposed to elastase a decrease of normalized hysteresis loop indicating an increased mobility of the tissue fibers.

Ultrastructural and immunocytochemical study on normal human palmar aponeuroses

BACKGROUND

Human palmar aponeurosis can be affected by a fibrotic process whose aetiopathology is unknown. As the organization of that normal tissue has not been completely investigated, the aim of the present study was to define the ultrastructure of the aponeurosis in order to better understand its biology and behaviour in pathology.

METHODS

Bioptic samples from normal subjects of different ages were analysed by optical and electron microscopy and by immunocytochemistry.

RESULTS

The aponeurotic branches consisted of thick, almost parallel collagen bundles containing columns of prominent cells, characterized by long cytoplasmic projections. Cells did not change in number and distribution with age and appeared longer and slighter in the old than in the young subjects. They exhibited plasma membrane almost completely decorated by pinocytic vesicles, intracytoplasmic bundles of thin filaments with zonal thickenings close to the cell membrane, and well-developed subcellular structures. Cells expressed smooth muscle cell alpha-actin, as revealed by immunostaining. The external surface of the plasma membrane was underlined by a discontinuous basement membrane-like structure and by a thick coat of interwoven filaments, highly positive to hyaluronan-recognizing antibodies. Immunocytochemical analyses revealed that collagen fibrils were positive for collagen types I, III, and VI and that elastin fiber composition was rather complex.

CONCLUSIONS

Independently of the age, normal palmar aponeurotic cells show peculiar morphological features and peculiar cell-matrix interactions, very likely mediated by hyaluronan. These findings indicate that normal aponeurotic cells cannot be regarded as typical tenocytes and suggest the need for a better definition of their phenotype in order to understand their behaviour in pathological processes.