Gelatinase A activity in Dupuytren's disease

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.

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.

Down-regulation of collagen synthesis and matrix metalloproteinase expression in myofibroblasts from Dupuytren nodule using adenovirus-mediated relaxin gene therapy

Dupuytren's disease is a fibroproliferative connective tissue disorder characterized by contracture of the palmer fascia of the hand. Relaxin (RLN) is a multifunctional factor which contributes to the remodeling of the pelvic ligament by inhibiting fibrosis and inflammatory activities. The aim of this study was to investigate the effect of the RLN gene on the inhibition of fibrosis in myofibroblastic cells. Myofibroblast cells with adenovirus LacZ (Ad-LacZ) as a marker gene or adenovirus relaxin (Ad-RLN) as therapeutic gene showed transgene expressions in beta-galactosidase assay and Western blot analysis. Myofibroblastic cells with Ad-RLN demonstrated a 22% and 48% reduction in collagen I and III mRNA expressions respectively, a 50% decrease in MMP-1, 70% decrease in MMP-2, 80% decrease in MMP-9, and a 15% reduction in MMP-13 protein expression compared with cultures with viral control and saline control. In addition, myofibroblastic cells with Ad-RLN showed a 40% decrease in TIMP 1 and a 15% increase in TIMP 3 protein expression at 48 h compared to cultures with viral control and saline control. Also, myofibroblastic cell with Ad-RLN demonstrated a 74% inhibition of fibronectin and a 52% decrease in total collagen synthesis at 48 h compared with cultures with viral control and saline control. In conclusion, the RLN gene render antifibrogenic effect on myofibroblastic cells from Dupuytren's nodule via direct inhibition of collagen synthesis not through collagenolytic pathway such as MMP-1, -13, TIMP 1, and 3. Therefore relaxin can be an alternative therapeutic strategy in initial stage of Dupuytren's disease by its antifibrogenic effect.

The mechanical environment in Dupuytren's contracture determines cell contractility and associated MMP-mediated matrix remodeling

Matrix metalloproteinases (MMPs) are expressed in Dupuytren's contracture and play a role in matrix remodeling. We tested the role of tension on contractility and MMP expression in Dupuytren's nodule and cord cells. Cells were subjected to pre-determined loading patterns of known repeatable magnitudes (static load, unloading, and overloading) and tested for MMP gene expression (MMP-1, -2, -9, -13, and TIMP-1, -2) and force generation using a tension-culture force monitor. Matrix remodeling was assessed by addition of cytochalasin D and residual matrix tension was quantified. Nodule compared to cord and control cells demonstrate greater force generation and remodeling (p < 0.05). Nodule cells subjected to a reduced load and overloading led to threefold increase of MMP-1, -2, and -9 compared to static load, whilst cord and control cells only showed a twofold increase of MMP-9. Nodule cells subjected to overloading showed a twofold increase in TIMP-2 expression, whilst cord and control cells showed a twofold increase in TIMP-1 expression. Nodule cells differ from cord cells by increased force generation in response to changes in the mechanical environment and related MMP/TIMP-mediated matrix remodeling. In turn this may lead to permanent matrix shortening and digital contracture. Interventional therapies should be aimed at nodule cells to prevent contraction and subsequent permanent matrix remodeling.

Expression of MMP-2, TIMP-2, TGF-β1, and decorin in Dupuytren's contracture

To investigate the mechanisms underlying matrix deposition in Dupuytren's disease, the expression of gelatinase A (MMP-2), the tissue inhibitor of metalloproteinase-2 (TIMP-2), transforming growth factor beta 1 (TGF-β1), decorin (DCN), and periostin was studied. The level of relative MMP-2 activation was investigated using zymography. The mRNA expression of MMP-2, TIMP-2, TGF-β1, and DCN was detected using reverse transcription polymerase chain reaction (RT-PCR), while the presence of protein was detected using immunohistochemical (IHC) and Western blot techniques. The level of MMP-2 activation was significantly elevated in tissues with Dupuytren's contracture. RT-PCR demonstrated significantly higher expression of MMP-2, TIMP-2, TGF-β1, and DCN mRNA in the pathological tissues; and the IHC and immunoblotting studies revealed elevated expression of TGF-β1, DCN, and periostin. The balance between MMP-2 and TIMP-2 was disrupted in patients with Dupuytren's disease. TGF-β1, DCN, and periostin are involved in extracellular matrix (ECM) homeostasis in Dupuytren's contracture.

[Dupuytren's disease: state of knowledge and research in physiopathology]

From Baron Dupuytren's historical description up to the advent of molecular biology, many hypotheses about the etiology of Dupuytren's disease have been proposed. This bibliography of the last ten years' publications describes tissue anomalies from the macroscopic down to the ultrastructural level of pathology. The myofibroblast, which is the principal cell of the disease, is the seat of genetics anomalies involving proto-oncogenes (c-myc and MafB). Similarly, glycoproteins implicated in cellular adhesion like fibronectins and catenins are modified and overexpressed in the disease. Extracellular proteins of the metalloproteinase family exhibit many dysfunctions responsible for collagenic proliferation. Finally, growth factors like Transforming Growth Factor (TGF) and Epidermal Growth Factor (EGF) receptor maintain and worsen the disease and could be therapeutic targets in the future.

The role of an MMP inhibitor in the regulation of mechanical tension by Dupuytren's disease fibroblasts

Mechanical tension and contracture are two related facets of tissue biology. This study assessed the effect of ilomastat, a broad-spectrum matrix metalloprotease (MMP) inhibitor, on generation of tension by Dupuytren's disease fibroblasts. Nodule and cord-derived fibroblasts were isolated from five patients with Dupuytren's disease; flexor retinaculum acted as the control. A culture force monitor (CFM) provided an in vitro model of tissue organization to assess development of mechanical tension, lattice contraction and spatial remodelling by fibroblasts. Responses to ilomastat were compared to treatment with a control peptide. Nodule and cord-derived fibroblasts exhibited a two-fold increase in tension compared with flexor retinaculum. Ilomastat significantly inhibited development of tension by nodule and cord but not flexor retinaculum derived fibroblasts at 100 microM. These results imply that MMP activity mediates regulation of tensile strength by Dupuytren's disease fibroblasts and may be an important therapeutic target in patients with Dupuytren's disease.

Applications of statistical tests in hand surgery

During the 19th century, with the emergence of public health as a goal to improve hygiene and conditions of the poor, statistics established itself as a distinct scientific field important for critically interpreting studies of public health concerns. During the 20th century, statistics began to evolve mathematically and methodologically with hypothesis testing and experimental design. Today, much of medical investigation centers around clinical trials and observational studies, and with the application of statistical formulas, the collected data are summarized, weighed, interpreted, and presented to direct both physicians and the public toward evidence-based medicine. Having a basic understanding of statistics is mandatory in evaluating the validity of published literature and applying it to patient care. In this review, we discuss basic statistical tests to assist the investigator in choosing the correct statistical test and present examples relevant to hand surgery research.

Expression of matrix metalloproteinases and their inhibitors in cords and nodules of patients with Dupuytren's disease

INTRODUCTION

Dupuytren's disease is a fibroproliferative disorder characterized by thickening of the palmar fascia. Several studies indicate that MMPs and TIMPs may play a key role in the onset or progression of Dupuytren's disease and related disorders. In this study, we used a quantitative reverse-transcription PCR methodology to profile the expression of TIMP1, TIMP2, MMP2, and MMP9 in nodule and cord tissue from patients with Dupuytren's disease and compared this with normal palmar fascia taken at carpal tunnel release.

MATERIALS AND METHODS

Tissue from patients with Dupuytren's disease was taken at fasciectomy (n = 30; 23 men and 7 women; average age 61.3 +/- 9.5 years). Samples were divided into regions of nodule and cord according to gross morphology. Normal fascia was taken from patients without Dupuytren's contracture who had carpal tunnel release (n = 30; 14 men and 16 women; average age 63 +/- 11 years). Expression of mRNA was calculated using a relative quantification method (Pfaffl). Statistical analysis was performed using the Mann-Whitney test. The level of significance was considered to be P < 0.05.

RESULTS

In comparison to normal fascia, the cords and nodules from patients with Dupuytren's disease showed significant upregulation for TIMP1 and TIMP2 (P < 0.05). The expression of TIMP1 was significantly higher in nodules in comparison to cord tissue (P < 0.05). The expression of MMP2 was significantly upregulated in tissue of patients with Dupuytren's contracture in comparison to normal tissue (P < 0.05). The expression of MMP2 was significantly higher in nodules in comparison to cord tissue (P < 0.05). There was no significant difference in the relative expression of MMP9 in nodules and cord tissue of patients with Dupuytren's contracture in comparison to normal fascia from patients with carpal tunnel syndrome.

CONCLUSIONS

The balance between MMPs and their natural inhibitors is disturbed in patients with Dupuytren's disease. The decrease in MMP-to-TIMP expression can cause increased synthesis and deposition of collagen, leading to palmar fibromatosis. The high expression of MMP2 may represent an unsuccessful attempt to reduce collagen deposition. In the future, a treatment that downregulates TIMPs but increases the activity of MMPs may be an appropriate therapy for Dupuytren's disease.

The fascia of the limbs and back--a review

Although fasciae have long interested clinicians in a multitude of different clinical and paramedical disciplines, there have been few attempts to unite the ensuing diverse literature into a single review. The current article gives an anatomical perspective that extends from the gross to the molecular level. For expediency, it deals only with fascia in the limbs and back. Particular focus is directed towards deep fascia and thus consideration is given to structures such as the fascia lata, thoracolumbar fascia, plantar and palmar fascia, along with regional specializations of deep fascia such as retinacula and fibrous pulleys. However, equal emphasis is placed on general aspects of fascial structure and function, including its innervation and cellular composition. Among the many functions of fascia considered in detail are its ectoskeletal role (as a soft tissue skeleton for muscle attachments), its importance for creating osteofascial compartments for muscles, encouraging venous return in the lower limb, dissipating stress concentration at entheses and acting as a protective sheet for underlying structures. Emphasis is placed on recognizing the continuity of fascia between regions and appreciating its key role in coordinating muscular activity and acting as a body-wide proprioceptive organ. Such considerations far outweigh the significance of viewing fascia in a regional context alone.

Matrix metalloproteinase inhibition reduces contraction by dupuytren fibroblasts

PURPOSE

Dupuytren's disease is a common fibroproliferative condition of the hand characterized by fibrotic lesions (nodules and cords), leading to disability through progressive digital contracture. Although the etiology of the disease is poorly understood, recent evidence suggests that abnormal matrix metalloproteinase (MMP) activity may play a role in cell-mediated collagen contraction and tissue scarring. The aim of this study was to investigate the efficacy of ilomastat, a broad-spectrum MMP inhibitor, in an in vitro model of Dupuytren fibroblast-mediated contraction.

METHODS

Nodule-derived and cord-derived fibroblasts were isolated from Dupuytren patients; carpal ligament-derived fibroblasts acted as control. Stress-release fibroblast-populated collagen lattices (FPCLs) were used as a model of contraction. FPCLs were allowed to develop mechanical stress (48 hours) during treatment with ilomastat (0-100 micromol/L), released, and allowed to contract over a 48-hour period. Contraction was estimated by measuring lattice area compared with untreated cells or treatment with a control peptide. MMP-1, MMP-2, and MT1-MMP levels were assessed by zymography, Western blotting, and enzyme-linked immunosorbent assay.

RESULTS

Nodule-derived fibroblasts contracted lattices (69% +/- 2) to a greater extent than did cord-derived (55% +/- 3) or carpal ligament-derived (55% +/- 1) fibroblasts. Exposure to ilomastat led to significant inhibition of lattice contraction by all fibroblasts, although a reduction in lattice contraction by nodule-derived fibroblasts was most prominent (84% +/- 8). In addition, treatment with ilomastat led to a concomitant suppression of MMP-1 and MMP-2 activity, whereas MT1-MMP activity was found to be upregulated.

CONCLUSIONS

Our results demonstrate that inhibition of MMP activity results in a reduction in extracellular matrix contraction by Dupuytren fibroblasts and suggest that MMP activity may be a critical target in preventing recurrent contracture caused by this disease.