Dupuytrenʼs Disease: An Overview:

Dupuytren's disease: where do we stand?

Dupuytren’s disease is a fibroproliferative disease that involves collagen deposition, leading to hand contractures that ultimately affect hand mobility and grip strength.

It is a benign disorder but can cause high morbidity by limiting daily activities.

Many factors have been proposed for its aetiology: namely genetics, smoking, alcohol intake and diabetes. However, there is still controversy as to the main aetiological cause of the disease.

Treatment is not yet uniform around the world and still varies with the surgeon’s experience and preference.

In this review, the authors review the pathogenesis and treatment options for Dupuytren’s disease in an attempt to summarize the current state of the art.

Cite this article: EFORT Open Rev 2019;4:63-69. DOI: 10.1302/2058-5241.4.180021.

Hand fasciae innervation: The palmar aponeurosis

There are few data in the scientific literature about the innervation of fasciae of the hand. The present study first elucidates the density and location of nervous structures in the palmar aponeurosis and, for comparison, in the flexor retinaculum (both can be considered specializations of the deep fascia of the upper limbs). Second, it compares nonpathological with pathological palmar aponeurosis. Samples of nonpathological fascia were taken from the flexor retinaculum and palmar aponeurosis of 16 upper limbs of unembalmed cadavers. Samples of pathological palmar aponeurosis were taken from seven patients with Dupuytren's disease. All samples were stained immunohistochemically with anti-S100 and anti-tubulin antibodies, and analyzed quantitatively and qualitatively by microscopy. The palmar aponeurosis showed higher median density than the retinacula of free nerve endings (22 and 20 elements/cm² , respectively), Pacinian corpuscles (2 and 0 elements/cm² ) and Golgi-Mazzoni corpuscles (1.0 and 0.5 element/cm² ). Some corpuscles were located at the intersections of the fibers in the three directions. Free nerve endings were denser in pathological palmar aponeurosis (38 elements/cm² ). The results indicate that the palmar aponeurosis is central to proprioception of the hand and that surgery should therefore avoid injuring it. The higher density of free nerve endings in pathological samples indicates that the nervous structures are implicated in the amplified fibrosis of Dupuytren's disease. Clin. Anat. 31:677-683, 2018. © 2018 Wiley Periodicals, Inc.

Surgical treatment results for dupuytren's disease

OBJECTIVE

To present the results of our cases of Dupuytren's disease treated with regional selective fasciectomy in light of the literature.

METHODS

Patients diagnosed with Dupuytren's contracture and surgically treated with regional selective fasciectomy at our institution with adequate follow-up data were included in the study. All patients were routinely followed after surgery to assess results and complications. QuickDASH scoring was used to evaluate the patients and recurrences and complications were recorded.

RESULTS

Twenty-one hands of 19 patients (13 males, 6 females) who underwent surgery and received adequate follow-up were retrospectively evaluated. Mean patient age was 65.8 (range: 41 to 86) and the mean follow-up period was 48.2 months (range: 24 to 86). Fourteen (66.6%) hands had excellent results, five (23%) hands had good results and two (9.4%) had fair results. The mean QuickDASH score for the patients at the final follow-up was 6.58 (range: 0 to 20.4).

CONCLUSION

Our study results demonstrated that regional selective fasciectomy is a reliable and efficient method to treat Dupuytren's disease with low rates of complications and recurrence and the technique can be considered the gold standard. Level of Evidence IV, Case Series.

Dupuytren's Contracture: A Bibliometric Study of the Most Cited Papers

The literature on Dupuytren's contracture is vast yet little information is known as to which papers have been the most influential. The purpose of this study was to identify the 50 most cited papers on Dupuytren's contracture and perform a citation analysis. Utilizing the Web of Science, 23 surgical, medical, plastic and hand surgery journals were searched for papers on Dupuytren's contracture. Resulting articles were ranked in order of times cited and each paper was analyzed for article-type, year of publication, country of origin, institution and level of evidence. The 50 most cited articles represent many important landmarks in Dupuytren's treatment and contain several seminal works by experts in the field. Whilst the top 50 list highlights the important papers on the condition, they certainly do not provide information about the quality of the evidence of the research, as most papers presented level 4 or 5 evidence.

Prevalence of palmar fibromatosis with and without contracture in asymptomatic patients

BACKGROUND

This retrospective study documents the proportion of hand clinic patients presenting with palmar fibromatosis with and without contracture.

METHODS

All "new" patients >18 years presenting to a single surgeon's hand clinic over a 16-month period were included, and information was abstracted from chart review regarding patient demographics, reason for presentation, presence or absence of palmar fibromatosis, contracture, and prior known diagnosis of Dupuytren's disease. The percentage of asymptomatic patients with palmar fibromatosis was calculated.

RESULTS

Of 827 patients, 306 had palmar fibromatosis. Among all patients, 33% of male and 40% of female patients had palmar fibromatosis. Only 8% had contractures, while 92% had palmar fibromatosis without contracture. Among those who had contractures, 81% presented with a primary complaint of Dupuytren's disease (symptomatic contracture). Prevalence of palmar fibromatosis increased with increasing age.

CONCLUSION

The findings demonstrate that Dupuytren's palmar fibromatosis is common and often present without overt contractures.

IGF-II and IGFBP-6 regulate cellular contractility and proliferation in Dupuytren's disease

Dupuytren's disease (DD) is a common and heritable fibrosis of the palmar fascia that typically manifests as permanent finger contractures. The molecular interactions that induce the development of hyper-contractile fibroblasts, or myofibroblasts, in DD are poorly understood. We have identified IGF2 and IGFBP6, encoding insulin-like growth factor (IGF)-II and IGF binding protein (IGFBP)-6 respectively, as reciprocally dysregulated genes and proteins in primary cells derived from contracture tissues (DD cells). Recombinant IGFBP-6 inhibited the proliferation of DD cells, patient-matched control (PF) cells and normal palmar fascia (CT) cells. Co-treatments with IGF-II, a high affinity IGFBP-6 ligand, were unable to rescue these effects. A non-IGF-II binding analog of IGFBP-6 also inhibited cellular proliferation, implicating IGF-II-independent roles for IGFBP-6 in this process. IGF-II enhanced the proliferation of CT cells, but not DD or PF cells, and significantly enhanced DD and PF cell contractility in stressed collagen lattices. While IGFBP-6 treatment did not affect cellular contractility, it abrogated the IGF-II-induced contractility of DD and PF cells in stressed collagen lattices. IGF-II also significantly increased the contraction of DD cells in relaxed lattices, however this effect was not evident in relaxed collagen lattices containing PF cells. The disparate effects of IGF-II on DD and PF cells in relaxed and stressed contraction models suggest that IGF-II can enhance lattice contractility through more than one mechanism. This is the first report to implicate IGFBP-6 as a suppressor of cellular proliferation and IGF-II as an inducer of cellular contractility in this connective tissue disease.

Fibromatosis stem cells rather than bone-marrow mesenchymal stem cells recapitulate a murine model of fibromatosis

Palmar fibromatosis is a benign fibroproliferative tumor of unknown etiology, with a high rate of recurrence after excision. The offending cells of palmar fibromatosis are myofibroblasts and the cellular origin of other myofibroblasts has previously been reported to be the bone marrow. However, further clarification of the relationship between bone marrow precursors and palmar fibromatosis is required. Stem cells (SCs) are known to exist in various tissues, but whether SCs can be isolated from fibromatosis tissue is still unclear. The purpose of this study was to isolate and identify stem cells from human palmar fibromatosis, and to evaluate the differences in the differentiation and fibrogenic capacities of bone marrow stem cells (BMSCs) and fibromatosis-derived stem cells (FSCs). We found that FSCs had better fibrogenic differentiation potential than BMSCs, whereas BMSCs had better adipogenic and chondrogenic differentiation capacities. Treatment with transforming growth factor-β1 increased the expression of α-smooth muscle actin, and types III and I collagen significantly more in FSCs than in BMSCs. An in vivo study further confirmed the results of fibrogenesis and suggested that FSCs can recapitulate the fibromatosis nodule. In summary, their myofibroblastic differentiation both in vivo and in vitro makes FSCs a potential cell source for future applications in murine models of fibromatosis or fibrogenesis.

Dupuytren's disease confined to the interphalangeal joints: a case report

A typical case of Dupuytren's contracture confined to the interphalangeal joints of the right little finger, occurred in a 79-year-old man. No past history of risk factors or family history of Dupuytren's disease could be detected. Excisions of the abnormal cords lead to good clinical outcome.

Activation markers of connective tissue in Dupuytren's contracture: relation to postoperative outcome

We investigated 103 consecutive patients operated on for Dupuytren's contracture (DC) to find out the relation between the expression of activation markers of connective tissue in surgical specimens obtained prospectively and recurrence of disease. The history of the disease and present state of the operated hand were obtained a mean of 4 years (range 2.5-6) after the latest operation. Immunohistochemical staining for anticollagen type IV, integrin alpha5, laminin, smooth muscle beta-actin, procollagen type I, and desmin was evaluated. Almost half of the patients noticed recurrences during the study period, one fifth within six months of operation. No differences in the expression of any of the markers investigated were found, either earlier or later than six months postoperatively, in patients with or without recurrent bending. Furthermore, there were no associations between sex, age at onset, number of operations, heredity, diabetes mellitus, or drugs taken for cardiovascular disease, and the expression of any of the immunohistochemical markers. The individual characteristics that place a person at high risk are not obviously related to ongoing production of connective tissue at the time of operation or to connective tissue activity in its conventionally-used sense.

Ulnar-based skin flap for Dupuytren's fasciectomy

The mainstay of treatment for symptomatic Dupuytren's disease is operation. Various skin incisions have been described, showing that there is no single best incision. We describe an ulnar-based skin flap for excision of palmar disease. This flap allows excellent exposure of the diseased area, and provides good access to the palmar aponeurosis including the difficult area on the ulnar side of the little finger. Healing is reliable and digital disease can be approached with a skin extension as required. Recurrent disease can be treated by raising the same flap again.

Postoperative hand therapy in Dupuytren's disease

BACKGROUND

Postoperative hand therapy in patients after surgery for Dupuytren's contracture is common medical practice to improve outcomes. Until now, patients are referred for postoperative hand rehabilitation on an empirical basis.

PURPOSE

To evaluate whether referral criteria after surgery because of Dupuytren's disease were actually adhered to, and, to analyse differences in outcomes between patients who were referred according to the criteria (correctly referred) and those who were not referred but should have been (incorrectly not referred).

METHODS

Referral pattern was evaluated prospectively in 46 patients. Total active/passive range of joint motion (TAM/ TPM), sensibility, pinch force, Disability Arm Shoulder Hand questionnaire (DASH) and Michigan Hand outcomes Questionnaire (MHQ) were used as outcome measures preoperatively and 10 months postoperatively.

RESULTS

In total 21 patients were referred correctly and 17 patients were incorrectly not referred. Significant improvements on TAM/TPM, DASH and MHQ were found at follow-up for the total group. No differences in outcomes were found between patients correctly referred and patients incorrectly not referred for postoperative hand therapy.

CONCLUSION

Referral criteria were not adhered to. Given the lack of differences in outcomes between patients correctly referred and patients incorrectly not referred, postoperative hand therapy in Dupuytren's disease should be reconsidered.

Type-1 Collagen differentially alters beta-catenin accumulation in primary Dupuytren's Disease cord and adjacent palmar fascia cells

Background

Dupuytren's Disease (DD) is a debilitating contractile fibrosis of the palmar fascia characterised by excess collagen deposition, contractile myofibroblast development, increased Transforming Growth Factor-β levels and β-catenin accumulation. The aim of this study was to determine if a collagen-enriched environment, similar to in vivo conditions, altered β-catenin accumulation by primary DD cells in the presence or absence of Transforming Growth Factor-β.

Methods

Primary DD and patient matched, phenotypically normal palmar fascia (PF) cells were cultured in the presence or absence of type-1 collagen and Transforming Growth Factor-β1. β-catenin and α-smooth muscle actin levels were assessed by western immunoblotting and immunofluorescence microscopy.

Results

DD cells display a rapid depletion of cellular β-catenin not evident in patient-matched PF cells. This effect was not evident in either cell type when cultured in the absence of type-1 collagen. Exogenous addition of Transforming Growth Factor-β1 to DD cells in collagen culture negates the loss of β-catenin accumulation. Transforming Growth Factor-β1-induced α-smooth muscle actin, a marker of myofibroblast differentiation, is attenuated by the inclusion of type-1 collagen in cultures of DD and PF cells.

Conclusion

Our findings implicate type-1 collagen as a previously unrecognized regulator of β-catenin accumulation and a modifier of TGF-β1 signaling specifically in primary DD cells. These data have implications for current treatment modalities as well as the design of in vitro models for research into the molecular mechanisms of DD.

The lateral digital flap for Dupuytren's fasciectomy at the proximal interphalangeal joint--a study of 84 consecutive patients

Fasciectomy is the most common operation performed for Dupuytren's disease. However, as the joint contracture increases, issues of skin deficiency following release become significant. For severe or recurrent disease dermafasciectomy is advised, but a digital transposition flap provides a viable alternative without the need for a skin graft for less-severe disease with moderate skin deficiency. A retrospective review identified 84 patients who had undergone this operation. The flap used was proximally based on the midlateral aspect of the finger allowing direct closure of the donor site. Ninety hands with 134 digits were operated on and 83% of the patients had a full correction. About 70% remained fully corrected at 1 year. All flaps were performed for proximal interphalangeal joint involvement. The mean pre-operative contracture was 34 degrees, corrected postoperatively to 5 degrees. The recurrence rate was 9%. Two percent of the patients had local infection but no flap necrosis was seen. A lateral digital transposition flap is a very stable operation for Dupuytren's disease with moderate skin deficiency and our patients achieved favourable results when compared to other studies that used local flaps combined with skin graft.

Identification of biomarkers in Dupuytren's disease by comparative analysis of fibroblasts versus tissue biopsies in disease-specific phenotypes

PURPOSE

Biomarkers are molecular mediators that can serve as indicators of normal biological processes, pathologic processes, and therapeutic interventions. This study aims to identify potential biomarkers in Dupuytren's disease (DD), a fibroproliferative benign tumor with an unknown etiology and high recurrence after surgery.

METHODS

Bioinformatic analytical techniques were employed to identify candidate genes that may be differentially expressed in DD, which included gene expression analysis of microarray data and thorough literature searches in genetic linkage and other related biomolecular studies. All DD cases were males with advanced DD (n = 5, 66 years +/- 14). RNA was extracted from biopsies and corresponding cultures of normal fascia (unaffected transverse palmar fascia), palmar nodule and cord from each patient. Real-time reverse transcription-polymerase chain reactions were performed to determine the gene expression levels for disease-related transcripts.

RESULTS

The bioinformatic analysis revealed 25 candidate genes, which were further short-listed to 6 genes via functional annotation. The 6 selected candidate genes included: A disintegrin and metalloproteinase domain (ADAM12), aldehyde dehydrogenase 1 family member (ALDH1) A1, Iroquois homeobox protein 6 (IRX6), proteoglycan 4 (PRG4), tenascin C (TNC), and periostin (POSTN). The culturing treatments were shown to have significant impact on the gene expression for ALDH1A1, PRG4, and TNC. In tissue biopsies, significant fold changes were observed for ADAM12, POSTN, and TNC in the cord and/or nodule when compared with that of normal fascia. ADAM12 and POSTN are associated with accelerated or abnormal cell growth, whereas TNC has been associated with fibrotic diseases and cell migration.

CONCLUSIONS

This study demonstrated differential gene expression results in DD tissue biopsies compared with that of their corresponding cultures. ADAM12, POSTN, and TNC were identified from the cord and nodule biopsy samples as potential biomarkers in relation to DD development.

Lack of association of iron metabolism and Dupuytren's disease

BACKGROUND

Iron accumulation as seen in genetic haemochromatosis is a major cause of hepatic fibrogenesis. A link between chronic liver disease and Dupuytren's disease (DD) is well established, especially in alcoholics.

AIM

The aim of the present study was to test the hypothesis that iron accumulation might cause fibrosis of the palmar aponeurosis leading to DD.

PATIENTS AND METHODS

We examined iron metabolism, mutations of the HFE gene, serum cholesterol, alcohol consumption, presence of chronic liver disease, diabetes and history of severe manual work in a group of 90 patients who had undergone surgery for a severe form of DD. The tissue removed during surgery was histologically examined to confirm the diagnosis of DD. For a control group, we used 33 healthy subjects with similar profiles.

RESULTS

The DD group consisted of 82 men and 8 women. Chronic liver disease was found in 27% of DD patients, compared with 6.1% of control subjects (P = 0.013). A history of hand traumatization was present in 33% of DD patients vs. 15% of control subjects (P = 0.048). Excessive alcohol consumption was present in 35.5% of DD patients compared with 15.1% of controls (P = 0.029). None of the other tested parameters, including the prevalence of HFE gene mutations, showed a significant difference between the two groups.

CONCLUSIONS

Iron accumulation does not play a major role in the pathogenesis of DD. However, sex, age, manual labour and alcohol consumption are risk factors for progression of DD. We observed a high incidence of chronic liver disease in patients with DD.

Results of surgical treatment of Dupuytren's disease in women: a review of 109 consecutive patients

PURPOSE

Dupuytren's disease is not as commonly reported in women as in men. Our literature search yielded only two such studies. The purpose of this study was to further examine the presentation and surgical outcome of Dupuytren's disease in women, including complications and to compare these outcomes to a similar cohort of men and to previous studies of Dupuytren's disease in women.

METHODS

A retrospective case series review was undertaken, and we identified all women who were admitted for surgical correction of Dupuytren's disease since 1990. Comparison was made with men operated during the same period. Pre- and postoperative measurements for lack of extension at the metacarpophalangeal joint (MCPJ), proximal interphalangeal (PIP) joint, and distal interphalangeal (DIP) joint were made by the senior author. SPSS (Statistical Package for the Social Sciences, SPSS Inc., Chicago, Il) was used for statistical analysis. The t test was used to compare the two groups.

RESULTS

One hundred nine women were identified, with 119 operated hands, out of a total of 657 patients operated. Comparisons were made with 548 men. The average age at presentation was 63 years in women, and there was no significant difference between the two groups. One hundred five of the patients had digital involvement. The little and ring fingers were involved most frequently. Thirty-four had involvement of the MCPJ. Mean preoperative contracture was 35 degrees . Mean postoperative contracture was 1 degrees . Proximal interphalangeal joint involvement was seen in 66 patients. Mean preoperative contracture was 42 degrees . Mean postoperative contracture was 7 degrees . Distal joint involvement was identified in only 4 digits. There was no statistical difference with the men as regards digital involvement and joint involvement; however, correction at the PIP joint was significantly lower. Fasciectomy was performed in 107 cases (90%), fasciectomy and local flap in 7 cases (6%), and dermafasciectomy in 5 cases (4%). The most common complication was digital nerve/artery injury (6 patients), and disease recurrence rate was 22%. These were statistically similar to the men.

CONCLUSIONS

Dupuytren's disease is less prevalent in women but its symptomatic presentation is similar to that in men, with more severe involvement of the PIP joint and a similar recurrence rate. The surgical outcomes, however, were equivalent with regard to final contracture correction, recurrence, and complication rates.

Dupuytren's disease involving the wrist

There is a well-established association with ectopic fibrosis in Dupuytren's disease, but involvement of the wrist is rare. To our knowledge there have been only 5 cases reported in the literature. The authors present a patient with Dupuytren's disease involving only the proximal palm and wrist who presented with functional limitation and a rapid clinical progression.

Joint and skeletal deformities in Parkinson's disease, multiple system atrophy, and progressive supranuclear palsy

The objective of this study is to characterize clinical features of joint and skeletal deformities in Parkinson's disease (PD), multiple system atrophy (MSA), and progressive supranuclear palsy (PSP). Clinical information including age, gender, presence of deformity, initial symptom side, neuropsychological and motor features, family history, and treatment with levodopa/dopamine agonists was collected on consecutive patients with PD, MSA, and PSP evaluated at the Movement Disorders Clinic at Baylor College of Medicine. In this series of 202 patients, 36.1% had deformities of the limbs, neck, or trunk, including 33.5% of PD, 68.4% of MSA, and 26.3% of PSP patients. "Striatal" hand and foot deformities were present in 13.4%, involuntary trunk flexion in 12.9%, anterocollis in 9.4%, and scoliosis in 8.4% of all patients. Patients with these joint and skeletal deformities had higher mean Unified Parkinson's Disease Rating Scale scores (57.4 vs. 46.6; P < 0.01) and were more often treated with levodopa (69.9% vs. 50.4%; P < 0.01) than patients without deformity, independent of disease duration. Patients with striatal deformity were younger than patients without deformity (mean 60.4 vs. 68.6 years; P < 0.01), and they tended to have an earlier age of onset of initial parkinsonian symptoms (mean 54.7 vs. 62.5 years; P < 0.01). Furthermore, the side of striatal deformity correlated with the side of initial parkinsonian symptoms in all patients (100%) with striatal hand and in 83.3% of patients with striatal foot. Joint and skeletal deformities are common and frequently under-recognized features of PD, MSA, and PSP that often cause marked functional disability independent of other motor symptoms.

The heritability of Dupuytren's disease: familial aggregation and its clinical significance

PURPOSE

Dupuytren's disease (DD) is a benign, fibroproliferative disease affecting the hands. The familial occurrence of DD and its presence in identical twins suggests a genetic basis for the condition. Our aims in this study were (1) to provide evidence for familial aggregation of DD by estimating the sibling recurrence-risk ratio and (2) to link previously associated environmental risk factors with family history of DD.

METHODS

Patients diagnosed with DD between the ages of 58 and 81 years (N = 92) were interviewed to assess potential risks and the severity of their conditions. A clinical history and examination were performed and we attempted to interview every family member either in person or through a postal questionnaire.

RESULTS

The sibling recurrence-risk ratio (lambda(s)) equaled 2.9 and ranged from 2.6 to 3.3 based on the 95% confidence intervals for the population prevalence. This suggests a high genetic basis for the causation of DD. A lower age of onset and greater severity of DD were associated significantly with a positive family history of DD. Other factors showed no statistical significance with familial aggregation of DD.

CONCLUSIONS

The familial clustering observed in DD likely is due to genetic influence rather than shared environment, as shown by the lack of association with exposure to environmental risk factors and family history. Understanding the genetic basis of DD is important for developing novel diagnostic, preventative, and therapeutic regimens in the future.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic, Level II.

Striatal deformities of the hand and foot in Parkinson's disease

Striatal deformities of the hand and foot are abnormal postures that are common in patients with advanced Parkinson's disease (PD); they can present in the early stages of PD and in other parkinsonian disorders. Over a century ago, Charcot and Purves-Stewart recognised these deformities, which cause substantial functional disability and discomfort. The term striatal is used because pathology in the neostriatum (putamen and caudate) has been suggested to cause the deformities, but the pathogenesis is unknown. Misdiagnosis of the deformities is common-particularly when they occur early and in the absence of cardinal parkinsonian signs, such as tremor, bradykinesia, and rigidity-because the hand deformities are similar to those in rheumatoid arthritis, equinovarus foot deformity typically suggests an orthopaedic problem, and toe extension may be thought to be the Babinski sign of upper-motor-neuron syndromes. Here we review the background and clinical features of these deformities to highlight these commonly unrecognised and poorly understood parkinsonian signs.

A histological and anatomical profile of pacinian corpuscles from Dupuytren's contracture and the expression of nerve growth factor receptor

The etiology of Dupuytren's disease is unknown. The causes of the fibroplastic response of nodules, fibrosis of cords, and prominence of pacinian corpuscles are not evident. Histological and immunohistology differences in pacinian corpuscles from the hands of five patients with Dupuytren's disease compared with 17 Dupuytren's-free patients are presented. Histological sections of pacinian corpuscle specimens were stained with hematoxylin and eosin and immunostained for nerve growth factor receptor. The length and width of intact pacinian corpuscles were measured, and the number of layers within each corpuscle was counted and recorded. Grossly, the pacinian corpuscles from Dupuytren's patients were larger and more numerous compared with those from unaffected patients. When measured microscopically, the pacinian corpuscles from Dupuytren's diseased fascia were significantly larger (2.0 x 1.1 mm) compared with controls (1.5 x 0.78 mm). The pacinian corpuscles from Dupuytren's-affected patients had significantly more layers (64 +/- 14) compared with those from control patients (40 +/- 9). Nerve growth factor receptor staining of pacinian corpuscles from patients affected with Dupuytren's disease showed greater intensity and more area stained compared with unaffected controls. It is suggested that nerve growth factor may be involved in the increased size of pacinian corpuscles in Dupuytren's-affected fascia. It is proposed that the cellular outgrowth from pacinian corpuscles may generate the cells that develop into Dupuytren's nodules.

A prospective study linked both alcohol and tobacco to Dupuytren's disease

OBJECTIVE

To address the role of alcohol intake and tobacco smoking and the combination of the two on subsequent risk of Dupuytren's disease.

STUDY DESIGN AND SETTING

Cohort study of 7,254 subjects enrolled in the Copenhagen City Heart Study (1981-1983). Both self-reported information on lifestyle and objective measures at the baseline examination were linked to presence of Dupuytren's disease at a subsequent examination (1991-1994) using multivariate logistic regression analysis.

RESULTS

A total of 772 subjects had signs of Dupuytren's disease at follow-up. After adjustment for age, sex, educational level, diabetes, and either alcohol or tobacco consumption, respectively, odds ratios for having the disease increased in a dose-dependent manner with increasing levels of alcohol or tobacco intake; however, there was no statistical interaction between heavy smoking and heavy drinking.

CONCLUSION

Alcohol intake and tobacco smoking are independently associated with increased risk of Dupuytren's disease, and the combination of the two conveys a very large risk.

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 Surgical Treatment of Dupuytren???s Contracture: A Synthesis of Techniques

Dupuytren's disease is an affliction of the palmar fascia. Selective fasciectomy is recommended once contracture has occurred. Alternatives for wound closure include tissue rearrangement, the open palm technique, and full-thickness skin grafting. In this prospective study, a new "synthesis" technique was used to treat a cohort of patients with advanced Dupuytren's disease. The results were then compared with those of a second cohort of patients who underwent the open palm technique. Thirty consecutive patients were selected. Ten patients (nine men and one woman; average age, 67 years) underwent the open palm technique, and 20 patients (18 men and two women; average age, 70 years) underwent the synthesis method. Follow-up was 3.5 years for the open palm group and 2.7 years for the synthesis group. All patients in both groups improved with respect to motion, function, appearance, and satisfaction. Objectively, for the open palm technique, metacarpophalangeal joint contracture decreased from 50 degrees to 0 degrees, and proximal interphalangeal joint contracture decreased from 40 degrees to 6 degrees. Using the synthesis method, metacarpophalangeal joint contracture decreased from 57 degrees to 0 degrees, and proximal interphalangeal joint contracture decreased from 58 degrees to 10 degrees. The Disabilities of the Arm, Shoulder, and Hand Test scores decreased from 37 to 30 in both groups. There were no significant differences between groups in these parameters. The two significant intergroup differences were healing time (40 days for the open palm technique versus 28 days for the synthesis method) and recurrence rate (50 percent for open palm versus 0 percent for synthesis). The synthesis technique combines with success the best features of current methods for the surgical treatment of advanced Dupuytren's disease.

Microarray gene analysis and expression profiles of Dupuytren's contracture

Dupuytren's disease, although not altogether uncommon, has eluded scientists who have sought to explain the cause of this palmar fibroproliferative disorder. It can lead to severe limitations of hand function if left untreated. This study is the first broad genetic survey using microarray technology to find gene products that are overexpressed or underexpressed in diseased tissues. The authors found 23 genes with levels that differ consistently from control levels. Nine were selected for further verification using reverse transcription-polymerase chain reaction. These genes hold potential promise in explaining some of the demographic trends seen with disease, such as correlation with alcoholism and the striking predisposition for the male gender.

Dupuytren's disease: physiologic changes in nodule and cord fibroblasts through aging in vitro

The pathogenesis of the fibrotic disease Dupuytren's contracture remains unclear. The disease process includes two structurally distinct fibrotic elements, the nodule and the cord. It has been proposed that as the disease progresses, nodules develop into cords. To corroborate that hypothesis, the authors took advantage of cultured fibroblast differences found between gap junction intercellular communication and fibroblast-populated collagen lattice contraction. Paired fibroblast cell lines of nodules and cords derived from four patients with Dupuytren's disease were maintained in culture for at least eight passages. The presence of gap junction intercellular communication in nodule- and cord-derived fibroblasts was documented and reported as a coupling index. The contraction of free-floating nodule- or cord-derived collagen lattices was also documented and reported. Early passage (passage 4) cord-derived fibroblasts showed a significant increase in coupling index compared with passage 4 nodule-derived fibroblasts (4.0 +/- 0.4 versus 2.5 +/- 0.3, respectively), where p < or = 0.01. However, late passage (passage 8) nodule- and cord-derived fibroblasts were equivalent in their coupling index (4.1 +/- 0.4 versus 4.4 +/- 0.4, respectively). Early passage nodule-derived fibroblast-populated collagen lattices contracted by 64 percent, whereas late passage nodule-derived lattices showed less contraction, at only 40 percent. Early and late passage cord-derived lattices contracted 46 and 37 percent, respectively. All nodule- and cord-derived cell lines were statistically equivalent at lattice contraction by passage 8. These in vitro studies support the hypothesis that fibroblasts derived from Dupuytren's contracture nodules change their phenotype after undergoing repeated cell passage, acquiring a cord-like fibroblast phenotype. Dupuytren's nodules represent the early, active form of fibrosis in which cells are more proliferative, better at fibroblast-populated collagen lattice contraction, and display less gap junction intercellular communication. The speculation is that alterations in gap junction intercellular communication may be involved in the progression of Dupuytren's nodules to cords as the disease progresses.

Differences in alpha smooth muscle actin expression between fibroblasts derived from Dupuytren's nodules or cords

Dupuytren's contracture is a fibrotic lesion of the palmar fascia that includes two distinct structures, the nodule and the cord. Histologically the Dupuytren's nodule has a high cell density with numerous myofibroblasts (alpha smooth muscle actin-expressing fibroblasts). The Dupuytren's cord has a rich connective tissue matrix containing a low density of elongated spindle-shaped fibroblasts. The cytoskeletal structures of cultured fibroblasts derived from Dupuytren's nodules and cords of surgically treated patients were studied and compared. Immunohistology showed no obvious morphological differences between Dupuytren's nodule and cord cultured cells, when focal adhesions (vinculin), intermediate filaments (vimentin), microtubules (alpha tubulin), or microfilaments (filamentous actin) were viewed. However, a greater proportion of nodule cultured cells were positive for alpha smooth muscle actin compared to cord-derived cells. The increased expression in nodule cells of alpha smooth muscle actin was confirmed by Western blot analysis. It appears that fibroblasts derived from Dupuytren's nodules or cords retain in vivo cytoskeletal characteristics, when grown in tissue culture.