Radiotherapy in Dupuytren's disease: a systematic review of the evidence

Utility of Routine Pathologic Examination for Fasciectomy for Dupuytren Contracture

PURPOSE

The objective of this study was to examine the routine pathologic examination of surgical specimens obtained during fasciectomy for Dupuytren contracture.

METHODS

A total of 376 consecutive patients who underwent surgical limited fasciectomy with the excised tissue sent for histopathologic evaluation were identified. Patients were excluded for miscoded procedures, cases where no tissue was sent for pathologic review, and excisions of nodules only. Repeat surgeries in the same patient during the study period were excluded. The rates of concordant, discrepant, and discordant diagnoses were reported. Discrepant diagnoses were defined as different clinical diagnosis and pathologic diagnosis that did not change clinical management. Discordant diagnoses were defined as a different clinical diagnosis and a pathologic diagnosis that altered the treatment plan. The reference standard for final clinical decision-making was the pathologic diagnosis.

RESULTS

The prevalence of concordant diagnoses was 97.1% (365 of 376), of discrepant diagnoses was 2.9% (11 of 376), and there were no discordant diagnoses. Of 376 patients, 43 underwent previous surgical fasciectomy before the study surgery, and pathologic examination was obtained in 10 of these patients. All 10 patients had concordant diagnoses.

CONCLUSIONS

Our results suggest that routine pathologic examination did not alter the future treatment plan for patients who underwent limited fasciectomy. Discrepant diagnoses were encountered infrequently, and rarely in the setting of revision fasciectomy. Discordant diagnoses did not occur. Given the cost associated with pathologic evaluation, this raises the question of whether routine pathologic evaluation is necessary for Dupuytren surgery, where the capability of the treating surgeon to make a clinical diagnosis accurately may render confirmatory pathologic assessment redundant.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

The role of aromatase inhibitors in slim women with breast cancer-related lymphoedema: a reflective case series

BACKGROUND

This case series follows the reflective processes undertaken, when five slim women presented with reactive oedemas of the forearm and hand, that did not respond to usual therapy.

AIM

To raise awareness about Aromatase Inhibitor (AI), Letrozole.

METHODS

Possible causes, including Cyclin-Dependent Kinase 4 and 6 (CDK4/6) inhibitors, Ribociclib and Axillary Web Syndrome, were explored and reviewed, and potential effective treatment options were then sought. New cases presented, which discounted each theory, until Letrozole was suspected.

RESULTS

Inflammatory oedemas were explained by the mechanisms-of-action relating to Aromatase Inhibitor Associated Musculoskeletal Syndrome (AIMSS), the severity of which, especially for slim women with oestrogen deprivation, causes almost 50% of women to cease treatment within 6 months; risking disease reoccurrence.

CONCLUSION

Permissions were gained, a table was collated and sent to referring consultants, requesting risk/benefit analysis of Letrozole with a medication review. If non-responsive, inflammatory oedemas present in clinic, AIs should be considered as a trigger.

[Medium-term Results after percutaneous Needle Fasciotomy in Dupuytren's Disease]

BACKGROUND

Dupuytren's disease often leads to an increasing limitation in finger extension in affected patients. As the incidence rises with age, the number of cases is expected to rise in the future due to the demographic change. Therefore, an easy and patient-oriented treatment is required. In the following study, we investigated the short and medium-term results after percutaneous needle fasciotomy (PNF).

PATIENTS AND METHODS

Overall, 65 fingers of 40 patients were treated with PNF. We evaluated the total passive deficit of extension (TPED), the passive deficit of extension of the joints (PED), the Buck-Gramcko score, rate of recurrence, DASH score and patient satisfaction. The average age of the patients was 65,9 years. Most of the patients (82%) were male.

RESULTS

Directly after the PNF, extension in the treated fingers improved significantly (TPED before PNF 74,6°±41,1 SD to 32,8°±29,0 SD after the procedure). By the time of the follow-up examination (30,2±13,9 SD months), TPED had increased again (52,7°±40,2 SD). The rate of recurrence was 29,7%, and a higher Tubiana stage before the procedure correlated significantly with a higher recurrence rate. Nevertheless, patients demonstrated a very high level of satisfaction with the procedure and almost all patients would choose to undergo PNF again.

CONCLUSION

Although it is associated with a relatively high recurrence rate, PNF represents an effective and patient-oriented treatment of Dupuytren's contracture.

Advanced Dupuytren Contracture: Approach to Management

Dupuytren disease is a common pathologic condition that can be especially challenging to hand surgeons in recurrent or severe contractures. Recurrence risk may be reduced with a variety of techniques, including skin grafting, external fixator application, radiation, and many others described in this article. Management of recurrence requires special attention to anatomy at risk. Adjuvant therapy may help to prevent the progression or recurrence of severe disease.

Considerations on surgery invasiveness and response and toxicity patterns in classic palliative radiotherapy for acrometastases of the hand: a hint for a potential role of stereotactic body radiation therapy? A case report and literature review

Background

The rarity of hand acrometastases hampers the consensus-building for their optimal management among the involved oncology professionals. In the current literature, demolitive surgery overcomes the use of palliative radiotherapy, which proved to be ineffective in more than 30% of cases treated with classic palliative dose schemes, carrying also a not negligible radiation-related adverse event rate. Against this background, stereotactic body radiation therapy (SBRT) could emerge as a well-balanced therapeutic option.

Case summary

Here we describe the methods and outcomes of a SBRT treatment of a painful and function-limiting hand acrometastasis in a patient with a history of stage IIIB lung adenocarcinoma. We delivered a total dose of 30 Gy in five daily fractions to a soft-tissue metastasis abutting the fifth metacarpal bone through the SBRT protocol generally used for intracranial treatments. A few weeks later, the patient reported a clinical complete response with acrometastasis and pain disappearance, function recovery, and no significant toxicity. The acrometastasis was the first sign of an atypical cancer progression.

Conclusions

SBRT for hand acrometastases is feasible and might have the best therapeutic profile among the currently available treatment options for this rare clinical scenario. Larger investigations are needed to confirm the present single-case experience.

The Effect of Ex-Vivo Hyaluronic Acid on Myofibroblast and Collagen in Dupuytren Disease

Background: Dupuytren disease (DD) is characterised by increased myofibroblast/fibroblast activity and type3/type1 collagen ratios. Hyaluronic acid (HA) is major component of the extracellular matrix and some studies have showed that HA limits myofibroblast activity and decreases type3/type1 collagen ratio. The aim of this study is to determine the effect of the ex-vivo application of HA on cultured fibroblasts obtained from normal and diseased tissue from patients with DD. This is the initial step towards defining the use of HA as a new approach for medical treatment of DD. Methods: Tissue samples were obtained from both healthy forearm (C) and unhealthy palmar (D) fascia of patients undergoing surgery for DD. Tissue samples were cultured and divided into four groups depending on the addition of HA [C(HA-), C(HA+), D(HA-) and D(HA+)]. The tissues were evaluated using Western blot to detect effect of HA on myofibroblast (by measuring alpha smooth muscle actin [α-SMA) and on the ratio of type3/type1 collagen by measuring collagen type1 alpha 1 Chain (COL1A1) and collagen type3 alpha 1 Chain (COL3A1). Results: The rate of the average α-SMA value in the D(HA+) group was significantly lower compared to that of the D(HA-) group. The average ratio of type3/type1 collagen in the D(HA+) group was significantly lower compared to the D(HA-) group. Conclusions: The ex-vivo application of HA on cultured fibroblasts obtained from patients with DD resulted in a decrease in myofibroblast/fibroblast activity and type3/type1 collagen ratios. This may pave the way for clinical application of HA in the treatment of DD.

Cost-effectiveness of adalimumab for early-stage Dupuytren’s disease

Aims

To estimate the potential cost-effectiveness of adalimumab compared with standard care alone for the treatment of early-stage Dupuytren’s disease (DD) and the value of further research from an NHS perspective.

Methods

We used data from the Repurposing anti-TNF for Dupuytren’s disease (RIDD) randomized controlled trial of intranodular adalimumab injections in patients with early-stage progressive DD. RIDD found that intranodular adalimumab injections reduced nodule hardness and size in patients with early-stage DD, indicating the potential to control disease progression. A within-trial cost-utility analysis compared four adalimumab injections with no further treatment against standard care alone, taking a 12-month time horizon and using prospective data on EuroQol five-dimension five-level questionnaire (EQ-5D-5L) and resource use from the RIDD trial. We also developed a patient-level simulation model similar to a Markov model to extrapolate trial outcomes over a lifetime using data from the RIDD trial and a literature review. This also evaluated repeated courses of adalimumab each time the nodule reactivated (every three years) in patients who initially responded.

Results

The within-trial economic evaluation found that adalimumab plus standard care cost £503,410 per quality-adjusted life year (QALY) gained versus standard care alone over a 12-month time horizon. The model-based extrapolation suggested that, over a lifetime, repeated courses of adalimumab could cost £14,593 (95% confidence interval £7,534 to £42,698) per QALY gained versus standard care alone. If the NHS was willing to pay £20,000/QALY gained, there is a 77% probability that adalimumab with retreatment is the best value for money.

Conclusion

Repeated courses of adalimumab are likely to be a cost-effective treatment for progressive early-stage DD. The value of perfect parameter information that would eliminate all uncertainty around the parameters estimated in RIDD and the duration of quiescence was estimated to be £105 per patient or £272 million for all 2,584,411 prevalent cases in the UK. Cite this article: Bone Jt Open 2022;3(11):898–906.

Non-Oncological Radiotherapy: A Review of Modern Approaches

Despite being usually delivered in oncological patients, radiotherapy can be used as a successful treatment for several non-malignant disorders. Even though this use of radiotherapy has been scarcely investigated since the 1950s, more recent interest has actually shed the light on this approach. Thus, the aim of this narrative review is to analyze the applications of non-oncological radiotherapy in different disorders. Key references were derived from a PubMed query. Hand searching and clinicaltrials.gov were also used. This review contains a narrative report and a critical discussion of non-oncological radiotherapy approaches. In conclusion, non-oncological radiotherapy is a safe and efficacious approach to treat several disorders that needs to be further investigated and used in clinical practice.

Treatment Options for Dupuytren’s Disease: Tips and Tricks

Dupuytren's disease (DD) is a common fibroproliferative condition of the hand.

Report on the Evidence-Based Practice Committee’s Survey on Dupuytren Disease

Purpose

The Evidence-Based Practice Committee of the American Society for Surgery of the Hand (ASSH) set out to assess the membership’s practice patterns (PPs) and knowledge of evidence-based principles for Dupuytren disease (DD).

Methods

A 21-item multiple-choice survey was distributed to all ASSH members via email in June 2020. Questions were divided into 2 types: evidence-based practice (EBP) and PPs. The survey addressed the following subtopics: nonsurgical, percutaneous, and open surgical management of DD.

Results

The response rate was 18% (n = 419). Of 13 EBP questions, 5 were answered with the preferred response by >75% of surgeons. The remaining 8 EBP questions had greater frequencies of less preferred responses, which concerned the current evidence for percutaneous management, as well as nonsurgical and postoperative management of DD. Of the PP questions, there were differences in opinion on how to manage a painful nodule, the percutaneous technique (eg, collagenase injection vs percutaneous needle aponeurotomy), and the choice of surgical incision for open fasciectomy (eg, Bruner incision with Z-plasties, partial closure with an open transverse palmar component, or longitudinal incision with Z-plasties).

Conclusions

Hand surgeons continue to be well informed about current evidence-based practices for treating DD and can improve their knowledge by familiarizing themselves with current data on percutaneous and nonsurgical methods. There exist differences in PPs for DD in the ASSH membership, specifically with less invasive management; and knowledge of peer practices can help navigate differences, critically interpret the evidence, and optimize patient care.

Type of study/level of evidence

Economic/Decision Analyses V.

Dupuytren Contractures: An Update of Recent Literature

Dupuytren disease is a fibroproliferative disorder that affects the palmar fascia of the hand and results in varying degrees of nodule and cord formation. Over time, patients may develop progressive contractures, impairing their ability to type, to perform with fine instruments, or to participate in social activities such as shaking hands. Treatment options for Dupuytren contractures include needle aponeurotomy (NA), injection of collagenase Clostridium histolyticum (CCH) with manipulation of the digits, and surgical fasciectomy. Over the past decade, the use of CCH has increased. Recent studies have provided additional data regarding the pathophysiology, indications, outcomes, and costs associated with the treatment for Dupuytren contractures, and this review highlights these advances.

Feasibility of aponeurectomy in combination with perioperative 192Ir high dose rate brachytherapy for Dupuytren's disease

PURPOSE

Partial aponeurectomy (PA) is a standard procedure for Dupuytren's contracture (DC). Here we report a novel approach using surgery combined with perioperative high dose rate (¹⁹²Ir-HDR) brachytherapy.

METHODS AND PATIENTS

From March 2018 until February 2020, thirteen rays of 6 patients with Dupyutren's contractures underwent PA followed by HDR brachytherapy. After removal of fibrous tissue and mobilization of the tendons, one to three catheters per patient were placed intraoperatively. Immediately after surgery, a planning computer tomography with 3D-planning was performed. Then 10-12 Gy were given to 0-2 mm from the catheters' surface and the catheters were removed 6-12 h after brachytherapy.

RESULTS

No complications were observed. The mean contractures were reduced from 55.4° (standard error SE 19.6) to 15.4° (SE 6.7; p < 0.01). One patient showed progressive fibrosis of a nontreated ray during follow-up.

CONCLUSIONS

HDR brachytherapy in combination with surgery is feasible and harbors the potential for combined modality therapy to reduce relapse rates of advanced or relapsing DC. Controlled studies are warranted to investigate the role of bimodal therapy compared with PA alone.

Current Concepts in the Management of Dupuytren Disease of the Hand

Dupuytren disease is a fibroproliferative disorder of the palmar fascia of the hand. Little agreement and remarkable variability exists in treatment algorithms between surgeons. Because the cellular and molecular etiology of Dupuytren has been elucidated, ongoing efforts have been made to identify potential chemotherapeutic targets that could modulate the phenotypic expression of the disease. Although these efforts may dramatically alter the approach to treating this disease in the future, these approaches are largely experimental at this point. Over the past decade, the mainstay nonsurgical options have continued to be percutaneous needle aponeurotomy and collagenase Clostridium hystoliticum, and the most common surgical option is limited fasciectomy.

Limited progression of subclinical Dupuytren's disease

AIMS

With novel promising therapies potentially limiting progression of Dupuytren's disease (DD), better patient stratification is needed. We aimed to quantify DD development and progression after seven years in a population-based cohort, and to identify factors predictive of disease development or progression.

METHODS

All surviving participants from our previous prevalence study were invited to participate in the current prospective cohort study. Participants were examined for presence of DD and Iselin's classification was applied. They were asked to complete comprehensive questionnaires. Disease progression was defined as advancement to a further Iselin stage or surgery. Potential predictive factors were assessed using multivariable regression analyses. Of 763 participants in our original study, 398 were available for further investigation seven years later.

RESULTS

We identified 143/398 (35.9%) participants with DD, of whom 56 (39.2%) were newly diagnosed. Overall, 20/93 (21.5%) previously affected participants had disease progression, while 6/93 (6.5%) patients showed disease regression. Disease progression occurred more often in patients who initially had advanced disease. Multivariable regression analyses revealed that both ectopic lesions and a positive family history of DD are independent predictors of disease progression. Previous hand injury predicts development of DD.

CONCLUSION

Disease progression occurred in 21.5% of DD patients in our study. The higher the initial disease stage, the greater the proportion of participants who had disease progression at follow-up. Both ectopic lesions and a positive family history of DD predict disease progression. These patient-specific factors may be used to identify patients who might benefit from treatment that prevents progression. Cite this article: Bone Joint J 2021;103-B(4):704-710.

Efficacy of Single-Dose Radiotherapy in Preventing Posttraumatic Tendon Adhesion

Background and Aim

Posttraumatic peritendinous adhesion is the greatest obstacle to achieve normal tendon function following lacerations of extrinsic flexor tendons of the hand. In this study, we aimed to evaluate whether single-dose radiotherapy (RT) has the potential to modulate intrasynovial tendon adhesions.

Materials and Methods

A total of 80 tendons from the third to fourth flexor profundus of both hind paws of 20 adult New Zealand rabbits were used in this study. Rabbits in the RT group received 3 Gy of X-irradiation in a single fraction. Histopathological evaluation of longitudinal sections of tendons was made using the Tang grading system for peritendinous adhesions. Intratendinous quality of the healing tissue in the laceration zone was assessed using a modified Movin scale.

Results

Adhesion and inflammatory response were greater in the RT group (p˂0.001). Tendon healing in the radiation group was found to be more uniform and organized compared with the control group. However, this difference was not statistically significant. The nuclei of the tenocytes in the radiation group showed a closer resemblance to normal tendon tissue when compared with the control group (p=0.007).

Conclusions

Despite RT’s certain advantages such as extracorporeal use, anti-inflammatory effect, and homogenous tissue penetration, 3-Gy X-irradiation resulted in increased peritendinous posttraumatic adhesion, possibly due to dose imbalance. Increased roundness in the tenocyte nuclei was present in the RT group. Studies with different dosing regimens and a higher number of subjects are necessary to establish an ideal dose suppressing the synovial response without compromising tendon healing.

Secondary Effects of Radiation Therapy to the Hand for Benign Conditions

Background: Emerging literature introduces radiation therapy for benign hand conditions. However, hand surgeons are wary recommending radiation therapy for nonmalignant conditions. In our practice, we have used radiation therapy for patients who present with infiltrative or recurrent giant cell tumor of the tendon sheath (GCTTS) since 1998. The purpose of this study is to examine the secondary effects of radiation to the hand through the critical lens of a hand surgeon. Methods: A case series of patients who received radiation therapy for GCTTS were reviewed. The Radiation Oncology/Toxicity Grading Late Radiation Morbidity Scoring Schema was used, and patients were questioned about symptoms and examined for physical findings involving their irradiated digits. Results: A total of 8 patients with GCTTS presented for follow-up. The average patient age was 59.1 years, and the average time since radiation therapy was 5.4 years. Patients had an average of 2.3 surgeries on the affected digit prior to receiving radiation therapy. The average Disabilities of the Arm, Shoulder, and Hand score was 8.1. The most common sign of radiation was nail changes. All patients complained of sensibility changes, although only 2 of the 8 patients had abnormal moving 2-point discrimination tests. There were no confirmed recurrences of GCTTS and no skin cancers. Conclusions: Patients who received radiation therapy to the hand report high levels of satisfaction with the therapy. Radiation therapy is tolerated well by these patients and has a low level of morbidity in our population.

Dupuytren's Contracture - Current Concepts

Dupuytren's contracture is a common condition that has the potential to be debilitating. It presents in a variety of manners and can be mild or more aggressive in its progression. There are a large number of management options currently available. In this review of the evidence, non-operative and operative management options are examined, with a consideration of post-operative rehabilitation and complications. A summary of the current concepts in the management of Dupuytren's contracture is presented.

Tenosynovial giant cell tumours of the hand: A multicentre case-control study

Many factors have been proposed to contribute to the risk of recurrent tenosynovial giant cell tumours (TSGCT); however, we remain unable to predict those at risk, which formed the rationale for this multicentre retrospective case-control study of 28 patients with recurrence. We included cases of recurrence in a 1:1 ratio matched for age and sex with controls over 10 years. Using Cox regression, we present hazard ratios (HRs) for recurrence with 95% confidence intervals (CIs). Out of 285 cases, 28 individuals developed recurrence after a median of 2.4 years. Recurrent TSGCT had a higher mitotic count/mm² in the primary tumour (median increase of 3 [IQR 1, 7]). Mitotic count in the primary tumour was associated with the risk of recurrence (adjusted HR 1.1 [95% CI 1.1, 1.2]) meaning that for every additional mitosis, the risk of recurrence increased by 10% per annum. We recommend a prospective cohort study to validate our findings.

Alternative and Adjunctive Treatments for Dupuytren Disease

Clinicians struggle with limited efficacy and durability of standard treatments when treating patients with Dupuytren disease diathesis. Alternative treatments such as low-dose radiation therapy in early phase of disease, supplemental pharmacotherapy with anti-inflammatory and/or anti-mitotic drugs, as well as other pharmacologic targets, and more aggressive surgery such as dermofasciectomy all have been reported with variable success or with serious side effects that hamper their standard use. This article gives an overview of the available literature.