Hyperglycaemia is a causal risk factor for upper limb pathologies

BACKGROUND

Diabetes (regardless of type) and obesity are associated with a range of musculoskeletal disorders. The causal mechanisms driving these associations are unknown for many upper limb pathologies. We used genetic techniques to test the causal link between glycemia, obesity and musculoskeletal conditions.

METHODS

In the UK Biobank's unrelated European cohort (N = 379 708) we performed mendelian randomisation (MR) analyses to test for a causal effect of long-term high glycaemia and adiposity on four musculoskeletal pathologies: frozen shoulder, Dupuytren's disease, carpal tunnel syndrome and trigger finger. We also performed single-gene MR using rare variants in the GCK gene.

RESULTS

Using MR, we found evidence that long-term high glycaemia has a causal role in the aetiology of upper limb conditions. A 10-mmol/mol increase in genetically predicted haemoglobin A1C (HbA1c) was associated with frozen shoulder: odds ratio (OR) = 1.50 [95% confidence interval (CI), 1.20-1.88], Dupuytren's disease: OR = 1.17 (95% CI, 1.01-1.35), trigger finger: OR = 1.30 (95% CI, 1.09-1.55) and carpal tunnel syndrome: OR = 1.20 (95% CI, 1.09-1.33). Carriers of GCK mutations have increased odds of frozen shoulder: OR = 7.16 (95% CI, 2.93-17.51) and carpal tunnel syndrome: OR = 2.86 (95% CI, 1.50-5.44) but not Dupuytren's disease or trigger finger. We found evidence that an increase in genetically predicted body mass index (BMI) of 5 kg/m2 was associated with carpal tunnel syndrome: OR = 1.13 (95% CI, 1.10-1.16) and associated negatively with Dupuytren's disease: OR = 0.94 (95% CI, 0.90-0.98), but no evidence of association with frozen shoulder or trigger finger. Trigger finger (OR 1.96 (95% CI, 1.42-2.69) P = 3.6e-05) and carpal tunnel syndrome [OR 1.63 (95% CI, 1.36-1.95) P = 8.5e-08] are associated with genetically predicted unfavourable adiposity increase of one standard deviation of body fat.

CONCLUSIONS

Our study consistently demonstrates a causal role of long-term high glycaemia in the aetiology of upper limb musculoskeletal conditions. Clinicians treating diabetes patients should be aware of these complications in clinic, specifically those managing the care of GCK mutation carriers. Upper limb musculoskeletal conditions should be considered diabetes complications.

External Fixation Prior to Fasciectomy Leads to Substantial Improvement of Advanced Dupuytren's PIP Contractures at Mean Follow-up 15 Months

BACKGROUND

The Digit Widget is an external fixation device that can be used to reverse proximal interphalangeal joint (PIPJ) contractures in the hand. Our hypothesis is that usage of the Digit Widget prior to fasciectomy in patients with severe Dupuytren's proximal interphalangeal (PIP) contractures will result in short-term improvement and maintenance of the PIPJ contracture after fasciectomy.

METHODS

Patients who underwent placement of the Digit Widget soft tissue distractor prior to fasciectomy for Dupuytren's disease were identified between January 2015 and December 2018. Multiple fingers were considered separately. Patient Reported Outcome Measurement Information System (PROMIS) Physical Function (PF), Pain Interference, and Depression scores were collected. Patients treated for contractures from etiologies other than Dupuytren's were not included. Multiple linear regression was used to compare initial PIP contractures, PF scores, and final contractures.

RESULTS

There were 28 fingers in 24 patients with average age of 56 ± 12 (30.5-69.9) years. Initial mean PIPJ contracture was 81° (50°-120°), which had corrected to 23° at time of removal. Average time between application and fasciectomy was 58 (28-112) days. At final follow-up, average 449 (58-1641) days, the average contracture was 39° (0°-105°). Contracture immediately following fasciectomy was found to be strongly correlated with the contracture at final follow-up. There was no statistical relationship between final PROMIS PF scores and final change in contracture.

CONCLUSIONS

Digit Widget external fixation is an effective treatment for the correction of advanced PIPJ contractures related to Dupuytren's disease, with an average of 52% improvement in contracture at 15 months.

The effectiveness of manipulation of fingers with Dupuytren's contracture 7 days after collagenase clostridial histolyticum injection

Timing of manipulation of digits after collagenase injection for Dupuytren's disease varies and often takes place within the first few days post-injection. We prospectively investigated the effectiveness of performing manipulation under local anaesthesia 7 days after injection in 100 patients. Demographic data, passive extension deficit, and patient-reported outcome measures were recorded before collagenase injection. Four to 7 weeks after manipulation, passive extension deficit and patient-reported outcome measures improved significantly without the development of any tendon ruptures. Clinical success was achieved in 41% and clinical improvement in 76% of the patients. Adverse events were reported by 85%. The outcomes were comparable with studies with early manipulation, and demonstrate a safe and effective variation to current protocols. We conclude that delaying manipulation to 7 days after collagenase injection is safe and efficient, which allows for flexibility in clinical appointments without negatively affecting outcome. Level of evidence: III.

Ultrasonographic examination of the ruptured cord after collagenase treatment or needle fasciotomy for Dupuytren's contracture

Local treatment of Dupuytren's contracture, either by collagenase or needle fasciotomy, allows disruption of the pathological cord during forced extension. The purpose of this study was to investigate the cord before and after both treatments by ultrasound. A total of 39 patients with a minimum of 20° contracture in the metacarpophalangeal joint were included and randomized to treatment with either collagenase (20 patients) or needle fasciotomy (19 patients). The distance between the distal and the proximal parts of the ruptured cord was measured by ultrasound and the difference in passive joint movement before and after treatment was measured with a goniomenter. There were no significant differences between the collagenase and needle fasciotomy groups in the size of the rupture or gain of mobility. Most cords treated with collagenase and subsequent forced extension had the same ultrasonographic appearance as cords disrupted mechanically by needle fasciotomy.

LEVEL OF EVIDENCE

III.

Connective Tissue Degeneration: Mechanisms of Palmar Fascia Degeneration (Dupuytren's Disease)

Dupuytren's disease is a connective tissue disorder of the hand causing excessive palmar fascial fibrosis with associated finger contracture and disability. The aetiology of the disease is heterogeneous, with both genetic and environmental components. The connective tissue is abnormally infiltrated by myofibroblasts that deposit collagen and other extracellular matrix proteins. We describe the clinical profile of Dupuytren's disease along with current therapeutic schemes. Recent findings on molecular and cellular parameters that are dysregulated in Dupuytren's disease, which may contribute to the onset of the disease, and the role of resident inflammation promoting fibrosis, are highlighted. We review recent literature focusing on non-myofibroblast cell types (stem cell-like cells), their pro-inflammatory and pro-fibrotic role that may account for abnormal wound healing response.

Skin involvement in Dupuytren's disease

Whether the palmar skin has a role in the development, propagation or recurrence of Dupuytren's disease remains unclear. Clinical assessment for skin involvement is difficult and its correlation with histology uncertain. We prospectively biopsied the palmar skin of consecutive patients undergoing single digit fasciectomy (for primary Dupuytren's disease without clinically involved skin) and dermofasciectomy (for clinically involved skin or recurrence) in order to investigate this relationship. We found dermal fibromatosis in 22 of 44 patients (50%) undergoing fasciectomy and 41 of 59 patients (70%) undergoing dermofasciectomy. Dermal fibromatosis appeared to be associated with greater preoperative angular deformity, presence of palmar nodules and occupations involving manual labour. Dermal fibromatosis exists in the absence of clinical features of skin involvement and we hypothesize that the skin may have a greater role in the development and propagation of Dupuytren's disease than previously thought.

LEVEL OF EVIDENCE

III.

Prevalence, incidence, and treatments of Dupuytren's disease in the United States: results from a population-based study

BACKGROUND

This large population-based study was conducted to estimate the prevalence of Dupuytren's disease in US adults and describe associated treatment patterns.

METHODS

A total of 23,103 individuals from an Internet-based research panel representative of the US population completed a brief online survey designed to identify individuals with symptoms, diagnoses, and/or treatment experience indicative of Dupuytren's disease (mean age = 50 years).

RESULTS

The prevalence of Dupuytren's disease defined as a self-reported physician diagnosis and/or surgical treatment was estimated as 1% (95% CI = 0.8-1.2), but the estimated prevalence is much higher (7.3%) when including self-reported symptoms of ropelike growth or hard bumps on the hand. The annual incidence proportion was estimated at about 3 cases per 10,000 adults. A total of 326 participants who reported relevant Dupuytren's symptoms, treatment, and/or diagnosis completed a more in-depth survey focusing on timing of medical treatments after first symptom noticed, description of functional impairment, treatment patterns, and family history. From the second survey, most patients who reported seeking treatment for hand symptoms initially saw a primary care physician, and the mean time from noticing the first hand symptom to seeing a doctor was 23.1 months. At their first doctor visit for hand symptoms, only 9% of patients received a diagnosis of Dupuytren's disease and 48% were advised to "wait and see" or received no treatment.

CONCLUSIONS

Results from the current study indicate a number of unmet medical needs, so strategies to raise physician awareness of disease symptoms and effective treatment options may be helpful.