Dupuytren’s Disease on the Radial Aspect of the Hand: Report on 135 Hands in Japanese Patients

Limited Fasciectomy Versus Collagenase Clostridium histolyticum for Dupuytren Contracture: A Propensity Score Matched Study of Single Digit Treatment With Minimum 5 Years of Telephone Follow-Up

PURPOSE

The purpose of this study was to compare reintervention and perceived recurrence, with minimum 5 years of telephone follow-up, after limited fasciectomy or collagenase Clostridium histolyticum (CCH) in the treatment of Dupuytren contracture affecting a single digit.

METHODS

We performed a retrospective cohort study of 48 patients with single digit treatment who underwent limited surgical fasciectomy at one hospital and 111 patients who underwent CCH treatment at a second hospital from 2010 to 2013. Patients were contacted by telephone about reintervention and perceived recurrence. Average length of telephone follow-up was 7.3 years in the CCH group and 7.4 years in the surgery group. The 2 groups were compared using 2 methods to control for potential confounding bias: (1) propensity score matching and (2) multivariable analysis accounting for potential confounders.

RESULTS

After propensity score matching, there were 44 patients in each group with similar disease and demographic characteristics. Rates of reintervention and perceived recurrence were significantly higher in the CCH group than the surgery group at a minimum of 5 years following treatment.

CONCLUSIONS

Long-term overall reintervention and perceived recurrence following treatment of Dupuytren contracture affecting a single digit were higher with CCH treatment than surgical fasciectomy when comparing groups with similar baseline characteristics. Our findings may be used to counsel patients on the durability of the outcomes of treatment when considering treatment options for Dupuytren contractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Durability of Collagenase Treatment for Dupuytren Disease of the Thumb and First Web After at Least 2 Years' Follow-Up

PURPOSE

The aim of this study was to analyze the durability of the treatment results of the thumb and first web contractures in Dupuytren disease with collagenase Clostridium histolyticum.

METHODS

Twelve patients (14 hands) were followed for an average of 35 months (range, 24-42 months). Two patients (3 hands) were excluded, yielding 11 hands available for assessment. Nondurability was defined as a worsening of at least 20° of passive extension deficit at a treated joint or any decrease greater than 5 mm in intermetacarpal head distance, both relative to 30 days after injection or as intervention to correct new/worsening contracture. Durability was compared with that of a historic cohort of treated finger contractures.

RESULTS

Five out of 11 patients with a metacarpophalangeal or interphalangeal joint contracture or first web contracture had a nondurable result at an average of 35 months. Results obtained at metacarpophalangeal joints of thumbs were more durable than those of interphalangeal joints. Most of the recurrences occurred in interphalangeal joints.

CONCLUSIONS

Treatment of thumb and first web contractures was not durable in nearly half of the cases at an average follow-up of 35 months, and durability was clearly less than that of treated finger contractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Patterns of Dupuytren disease in fingers: studying correlations with a multivariate ordinal logit model

BACKGROUND

Dupuytren disease affects fingers in a variable fashion. Knowledge about specific disease patterns (phenotype) based on location and severity of the disease is lacking.

METHODS

In this cross-sectional study, 344 primary affected hands with Dupuytren disease were physically examined. The Pearson correlation coefficient between the coexistence of Dupuytren disease in pairs of fingers was calculated, and agglomerative hierarchical clustering was applied to identify possible clusters of affected fingers. With a multivariate ordinal logit model, the authors studied the correlation on severity, taking into account age and sex, and tested hypotheses on independence between groups of fingers.

RESULTS

The ring finger was most frequently affected by Dupuytren disease, and contractures were seen in 15.1 percent of affected rays. The severity of thumb and index finger, middle and ring fingers, and middle and little fingers was significantly correlated. Occurrences in pairs of fingers were highest in the middle and ring fingers and lowest in the thumb and index finger. Correlation between the ring and little fingers and a correlation between fingers from the ulnar and radial sides could not be demonstrated.

CONCLUSIONS

Rays on the ulnar side of the hand are predominantly affected. The middle finger is substantially correlated with other fingers on the ulnar side, and the thumb and index finger are correlated; however, there was no evidence that the ulnar side and the radial side were correlated in any way, which suggests that occurrence on one side of the hand does not predict Dupuytren disease on the other side of the hand.

CLINCIAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Correction of contracture and recurrence rates of Dupuytren contracture following invasive treatment: the importance of clear definitions

PURPOSE

To call attention to the wide variety of definitions for recurrence that have been employed in studies of different invasive procedures for the treatment of Dupuytren contracture and how this important limitation has contributed to the wide range of reported results.

METHODS

This study reviewed definitions and rates of contracture correction and recurrence in patients undergoing invasive treatment of Dupuytren contracture. A literature search was carried out in January 2011 using the terms "Dupuytren" AND ("fasciectomy" OR "fasciotomy" OR "dermofasciectomy" OR "aponeurotomy" OR "aponeurectomy") and limited to studies in English.

RESULTS

The search returned 218 studies, of which 21 had definitions, quantitative results for contracture correction and recurrence, and a sample size of at least 20 patients. Definitions for correction of contracture and recurrence varied greatly among articles and were almost always qualitative. Percentages of patients who achieved correction of contracture (ie, responder rate) when evaluated at various times after completion of surgery ranged from 15% to 96% for fasciectomy/aponeurectomy. Responder rates were not reported for fasciotomy/aponeurotomy. Recurrence rates ranged from 12% to 73% for patients treated with fasciectomy/aponeurectomy and from 33% to 100% for fasciotomy/aponeurotomy. Review of these reports underscored the difficulty involved in comparing correction of contracture and recurrence rates for different surgical interventions because of differences in definition and duration of follow-up.

CONCLUSIONS

Clearly defined objective definitions for correction of contracture and for recurrence are needed for more meaningful comparisons of results achieved with different surgical interventions.

CLINICAL RELEVANCE

Recurrence after surgical intervention for Dupuytren contracture is common. This study, which evaluated reported rates of recurrence following surgical treatment of Dupuytren contracture, provides clinicians with practical information regarding expected long-term outcomes of surgical treatment choices.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and decision analysis III.

Bilateral Dupuytren's contractures of the thumb interphalangeal joints

Dupuytren's disease was first described by Baron Guillaume Dupuytren in 1831. He outlined the pathology of palmar fascia thickening and contracture resulting in flexion of one or more digits. Dupuytren's disease usually affects the little or ring fingers, with the thumb rarely affected. Furthermore, the thumb in isolation is only affected in 0.5% of cases, with contracture at the metacarpophalangeal joint. We present a unique and interesting case of Dupuytren's disease predominantly of the thumbs, with isolated contractures bilaterally at the interphalangeal joints, in a 59 year old lady with epilepsy who was otherwise fit and well. To our knowledge this disease pattern has never been reported in the literature. Furthermore a relevant literature review of Dupuytren's disease affecting the thumb, in particular the interphalangeal joint, is presented. Our interesting and unique case reinforces the notion that the disease pathogenesis is diverse and multifactorial, and provides a further interesting example for the literature.

Review: Dupuytren's disease in Asia and the migration theory of Dupuytren's disease

BACKGROUND

The presentation of a Chinese patient with unilateral Dupuytren's disease (DD) prompted a literature search and a review of the epidemiology of DD in the Asian population as it has never been cumulatively reported. The purpose of this paper is to review all the reported cases of DD in the literature and aetiological links to DD elsewhere.

METHODS

The literature was searched with a wide variety of terms, and subsequent references were analysed and further references investigated for other reported cases of DD in the Asian population.

RESULTS

This review found 595 cases and has shown that DD is present to a variable extent in China (96 cases), Thailand (19 cases), Vietnam (one case), India (15 cases) and Japan (474 cases). A total of 54% had bilateral disease. Risk factors (diabetes, trauma, epilepsy, alcoholism, manual labour) were reportedly present in 65% of the patients, and a positive family history was reported in 9%. The average patient age was 67 years.

CONCLUSION

This review shows that there is a low but significant incidence of DD across Asia, which supports the hypothesis of a widespread genetic susceptibility to the disease. Therefore, the prevalence of DD in this community is not likely due to sporadic genetic mutation as previously presumed but rather individual genetic susceptibility and that risk factors play a major role in the expression of DD in this population.

Genome-wide association scan of Dupuytren's disease

PURPOSE

Dupuytren's disease (DD) has a strong genetic component that is suggested by population studies and family clustering. Genetic studies have yet to identify the gene(s) involved in DD. The purpose of this study was to identify regions of the entire genome (chromosomes 1-23) associated with the disease by performing a genome-wide association scan on DD patients and controls.

METHODS

We isolated genomic DNA from saliva collected from 40 unrelated DD patients and 40 unaffected controls. We conducted the genotyping using CytoSNP-Infinium HD Ultra genotyping assay on the Illumina platform. Using both log regression and mapping by admixture linkage disequilibrium analysis methods, we analyzed the single nucleotide polymorphism genotyping data.

RESULTS

Single nucleotide polymorphism analysis revealed a significant association in regions for chromosomes 1, 3 through 6, 11, 16, 17, and 23. Mapping by admixture linkage disequilibrium analysis showed ancestry-associated regions in chromosomes 2, 6, 8, 11, 16, and 20, which may harbor DD susceptibility genes. Both analysis methods revealed loci association in chromosomes 6, 11, and 16.

CONCLUSIONS

Our data suggest that chromosomes 6, 11, and 16 may contain the genes for DD and that multiple genes may be involved in DD. Future genetic studies on DD should focus on these areas of the genome.

An objective method to evaluate the risk of recurrence and extension of Dupuytren's disease

This study was undertaken to assess the influence of the factors related to Dupuytren's diathesis on the rates of recurrence and extension of Dupuytren's disease after surgery. The records of 65 patients who underwent surgery for Dupuytren's disease were retrospectively studied and the presence of factors related to diathesis were recorded. The sensitivity and specificity of each factor for predicting recurrence and extension were calculated. Odds ratios and 95% confidence intervals were also calculated and a discriminant analysis was performed to explore correlations between recurrence and extension and the significant variables. Our results confirmed the prognostic value of diathesis. The results have been used to develop a new scoring system for evaluating the risk of recurrence and extension.