Aims. Dupuytren’s contracture is a benign, myoproliferative condition affecting the palmar fascia that results in progressive contractures of the fingers. Despite increased knowledge of the cellular and connective tissue changes involved, neither a cure nor an optimum form of treatment exists. The aim of this systematic review was to summarize the best available evidence on the management of this condition. Materials and Methods. A comprehensive database search for randomized controlled trials (RCTs) was performed until August 2017. We studied RCTs comparing open fasciectomy with percutaneous needle aponeurotomy (PNA), collagenase clostridium histolyticum (CCH) with placebo, and CCH with PNA, in addition to adjuvant treatments aiming to improve the outcome of open fasciectomy. A total of 20 studies, involving 1584 patients, were included. Results. PNA tended to provide higher patient satisfaction with fewer adverse events, but had a higher rate of recurrence compared with limited fasciectomy. Although efficacious, treatment with CCH had notable recurrence rates and a high rate of transient adverse events. Recent comparative studies have shown no difference in clinical outcome between patients treated with PNA and those treated with CCH. Conclusion. Currently there remains limited evidence to guide the management of patients with Dupuytren’s contracture. Cite this article: Bone Joint J 2018;100-B:1138–45

In Canada, Dupuytren's contracture is managed with partial fasciectomy or percutaneous needle aponeurotomy (PNA). Injectable collagenase will soon be available. The optimal management of Dupuytren’s contracture is controversial and trade-offs exist between the different methods. Using a cost-utility analysis approach, our aim was to identify the most cost-effective form of treatment for managing Dupuytren’s contracture it and the threshold at which collagenase is cost-effective. We developed an expected-value decision analysis model for Dupuytren’s contracture affecting a single finger, comparing the cost-effectiveness of fasciectomy, aponeurotomy and collagenase from a societal perspective. Cost-effectiveness, one-way sensitivity and variability analyses were performed using standard thresholds for cost effective treatment ($50 000 to $100 000/QALY gained). Percutaneous needle aponeurotomy was the preferred strategy for managing contractures affecting a single finger. The cost-effectiveness of primary aponeurotomy improved when repeated to treat recurrence. Fasciectomy was not cost-effective. Collagenase was cost-effective relative to and preferred over aponeurotomy at $875 and $470 per course of treatment, respectively. . In summary, our model supports the trend towards non-surgical interventions for managing Dupuytren’s contracture affecting a single finger. Injectable collagenase will only be feasible in our publicly funded healthcare system if it costs significantly less than current United States pricing. Cite this article: Bone Joint J 2013;95-B:1094–1100

1. Surveys of a working community, of a group of elderly people, and of an urban population show an incidence of Dupuytren's contracture among men varying from 0·1 per cent in the age group fifteen to twenty-four, to 18·1 per cent in those aged seventy-five and over; and among women from 0·5 per cent in the age group forty-five to fifty-four, to 9 per cent over seventy-five. It is estimated that in the population aged fifteen and over in Lancashire and Cheshire there will be 4·2 per cent of the men and 1·4 per cent of the women with some degree of palmar contracture. 2. There appears to be no relationship between the type of occupation and the incidence or severity of contracture in men, except that among those engaged in light manual work the proportion of mildly affected hands is higher, and of bilateral contracture lower, than among either non-manual or heavy manual workers. 3. Evidence is provided that rheumatoid arthritis, past polyarthritis, osteoarthritis, cervical spondylosis and Paget's disease occur no more often in those with Dupuytren's contracture than in other members of the community. 4. Examination of the patients in an epileptic colony confirms a strong association between Dupuytren's contracture and epilepsy. Knuckle-pads, plantar nodules and periarthritis of the shoulder are all more frequent in epileptic than in non-epileptic patients with Dupuytren's contracture. Epileptics also show a higher proportion with bilateral contractures and a greater tendency to a symmetrical pattern of contracture in the two hands. A strong constitutional factor, probably genetic, thus operates in persons with both diseases. Nevertheless, the frequency of a positive family history of contracture is lower in the epileptic cases, and reasons for this are discussed. 5. From the limited material available in the literature there would appear to be an inverse relationship between the population of certain countries and the prevalence in them of Dupuytren's contracture. The possible significance of this is briefly discussed

We investigated the association of Dupuytren’s contracture with smoking and with alcohol by a case-control study in which 222 patients having an operation for this condition were matched for age, operation date and gender with control patients having other orthopaedic operations. Fifty of the cases were also each matched with four community controls. Data were collected by postal questionnaire. Dupuytren’s contracture needing operation was strongly associated with current cigarette smoking (adjusted odds ratio 2.8 (95% confidence interval (CI) 1.5 to 5.2)). The mean lifetime cigarette consumption was 16.7 pack-years for the cases compared with 12.0 pack-years for the controls (p = 0.016). Dupuytren’s contracture was also associated with an Alcohol Use Disorders Test score greater than 7 (adjusted odds ratio 1.9 (95% CI 1.02 to 3.57)). Mean weekly alcohol consumption was 7.3 units for cases and 5.4 units for controls (p = 0.016). The excess risk associated with alcohol did not appear to be due to a confounding effect of smoking, or vice versa. Smoking increases the risk of developing Dupuytren’s contracture and may contribute to its prevalence in alcoholics, who tend to smoke heavily

1. On the basis of, first, a mathematical analysis of the age-specific and sex-specific prevalence of Dupuytren's contracture; second, the genetical aspects; and last, the pathology, it is concluded that Dupuytren's contracture is probably a spontaneous disturbed-tolerance auto-immune disease. 2. The proportion of predisposed individuals at birth is about 20 per cent of males and females in the population studied by Early (1962), although it differs between populations and races. 3. The disease is probably initiated by four random, dependent-type, autosomal somatic gene mutations in a stem cell of the lymphoid system. With the accumulation of the fourth and final somatic mutation, a "forbidden-clone" of lymphocytes is probably generated. There is a latent period between the occurrence of the last initiating event and diagnosis. 4. In men the average latent period is about fifteen years, in women it is about thirty years. 5. The target tissue primarily attacked by forbidden lymphocytes is unknown, although proliferating fibroblasts are evidently a consequence of the auto-immune attack

1. The results in 138 hands operated on for Dupuytren's contracture are analysed and compared with those in other series. 2. Contracture ofthe metacarpo-phalangeal joint can be expected to respond well to operation, whereas the outlook in the case of contracture of the proximal interphalangeal joint is generally poor. 3. The reasons for this difference are examined. 4. The advantages of early operation for contracture of the proximal interphalangeal joint are stressed

Aims. In the UK, fasciectomy for Dupuytren’s contracture is generally performed under general or regional anaesthetic, with an arm tourniquet and in a hospital setting. We have changed our practice to use local anaesthetic with adrenaline, no arm tourniquet, and perform the surgery in a community setting. We present the outcome of a consecutive series of 30 patients. Methods. Prospective data were collected for 30 patients undergoing open fasciectomy on 36 digits (six having two digits affected), over a one-year period and under the care of two surgeons. In total, 10 ml to 20 ml volume of 1% lidocaine with 1:100,000 adrenaline was used. A standard postoperative rehabilitation regime was used. Preoperative health scores, goniometer measurements of metacarpophalangeal (MCP), proximal interphalangeal (PIP) contractures, and Unité Rheumatologique des Affections de la Main (URAM) scores were measured pre- and postoperatively at six and 12 weeks. Results. The mean preoperative contractures were 35.3° (0° to 90°) at the metacarpophalangeal joint (MCPJ), 32.5° (0° to 90°) at proximal interphalangeal joint (PIPJ) (a combined deformity of 67.8°). The mean correction was 33.6° (0° to 90°) for the MCPJ and 18.2° (0° to 70°) for the PIPJ leading to a combined correction of 51.8°. There was a complete deformity correction in 21 fingers (59.5%) and partial correction in 14 digits (37.8%) with no correction in one finger. The mean residual deformities for the partial/uncorrected group were MCP 4.2° (0° to 30°), and PIP 26.1° (0° to 85°). For those achieving a full correction the mean preoperative contracture was less particularly at the PIP joint (15.45° (0° to 60°) vs 55.33° (0° to 90°)). Mean preoperative URAM scores were higher in the fully corrected group (17.4 (4 to 31) vs 14.0 (0 to 28)), but lower at three months post-surgery (0.5 (0 to 3) vs 4.40 (0 to 18)), with both groups showing improvements. Infections occurred in two patients (three digits) and both were successfully treated with oral antibiotics. No other complications were noted. The estimated cost of a fasciectomy under local anaesthetic in the community was £184.82 per patient. The estimated hospital theatre costs for a fasciectomy was £1,146.62 under general anaesthetic (GA), and £1,085.30 under an axillary block. Conclusion. This study suggests that a fasciectomy performed under local anaesthetic with adrenaline and without an arm tourniquet and in a community setting is safe, and results in favourable outcomes regarding the degree of correction of contracture achieved, functional scores, and short-term complications. Local anaesthetic fasciectomy in a community setting achieves a saving of £961.80 for a GA and £900.48 for an axillary block per case. Cite this article: Bone Joint J 2020;102-B(10):1354–1358

We randomised 79 patients (84 hands, 90 fingers) with Dupuytren’s contracture of the proximal interphalangeal joint to have either a ‘firebreak’ skin graft (39 patients, 41 hands, 44 fingers) or a fasciectomy (40 patients, 43 hands, 46 fingers) if, after full correction, the skin over the proximal phalanx could be easily closed by a Z-plasty. Patients were reviewed after three, six, 12, 24 and 36 months to note any complications, the range of movement and recurrence. Both groups were similar in regard to age, gender and factors considered to influence the outcome such as bilateral disease, family history, the presence of diabetes, smoking and alcohol intake. The degree of contracture of the metacarpophalangeal and interphalangeal joints of the operated fingers was similar in the two groups and both were comparable in terms of grip strength, range of movement and disability at each follow-up. The recurrence rate was 12.2%. We did not identify any improvement in correction or recurrence of contracture after firebreak dermofasciectomy up to three years after surgery

The fine structure of palmar fascia from patients with Dupuytren's contracture (DC) was compared with that from patients with carpal tunnel syndrome (CTS). In contrast to previous assumptions, the ultrastructure of fibroblasts both in vivo and in vitro from DC and CTS appeared identical, indicating that myofibroblasts are not specific to DC. The major differences between DC and CTS were: 1) a sixfold and fortyfold increase in fibroblast density in cord and nodular areas of DC compared with CTS; 2) a more disorganised pattern of collagen fibrils in DC; and 3) markedly narrowed microvessels surrounded by thickened, laminated basal laminae and proliferating fibroblasts in DC compared with CTS. To account for these morphological changes a hypothesis is presented which proposes that oxygen-free radicals cause pericytic necrosis and fibroblastic proliferation. This hypothesis provides a potential avenue for therapy of DC and other fibrotic conditions

1 . A case of plantar Dupuytren's disease in a woman aged twenty-three is described.

2. A review of the literature has shown that the histology and rapid recurrence have led to an erroneous diagnosis of fibrosarcoma and treatment by amputation on several occasions.

Our aims were to describe the distribution of α-smooth muscle actin (SMA)-containing cells in Dupuytren’s tissue in vivo and to determine the effects of selected agents in regulating the expression of SMA in Dupuytren’s cells in vitro.

In selected hypercellular zones of Dupuytren’s nodules up to 40% of the cells contained SMA, as shown by immunohistochemistry. A lower percentage (20%) of SMA-containing cells was found in regions of lower cellularity. A notable finding was that treatment in vitro of Dupuytren’s cells with platelet-derived growth factor significantly reduced the content of SMA. Cells from the same patients showed a significant increase in expression of SMA in response to treatment with transforming growth factor, which confirmed recent findings. In addition, interferon-γ, which has been previously used as a treatment for Dupuytren’s disease in a clinical study, had no reproducible effect on the expression of this actin isoform. Our findings are of significance for the conservative management of contractures.

Aims

The aim of this retrospective study was to evaluate the rate of conversion to surgical release after a steroid injection in patients with a trigger finger, and to analyze which patient- and trigger finger-related factors affect the outcome of an injection.

We report the case of an 82-year-old man who underwent fasciectomy for a severe Dupuytren’s contracture, during which an ossified lesion was encountered within the contracture and surrounding the neurovascular bundle. The abnormal tissue was removed with difficulty and heterotopic ossification was confirmed histologically. We believe this is the first report of heterotopic ossification in Dupuytren’s disease

1 . An epileptic patient with Dupuytren's contracture of the palms, severe plantar fibromatosis, prominent knuckle pads, periarthritis of the shoulders and hyperplasia of the gums is described. 2. The plantar lesions recurred despite radical excision. The knuckle pads on one hand disappeared after radiotherapy. 3. The association of each of these conditions with epilepsy and with Dupuytren's contracture is reviewed, and it is suggested that the hyperplasia of the gums may be a hitherto unrecognised feature. 4. The characteristic histological appearances of the plantar lesions are described and the risk of confusion with fibrosarcoma is emphasised

1. The modifications of standard Z-plasty technique that are necessary for its successful use in hand surgery are discussed with particular reference to the limiting factors imposed by the anatomical characteristics of the hand. 2. The use of the Z-plasty in Dupuytren's contracture and contracted scars is discussed

A case of Dupuytren's contracture is described, in which, both clinically and histologically, knuckle pad lesions involved the extensor tendons. Surgical excision of the Dupuytren's tissue from the dorsal aspect of the proximal interphalangeal joints, freeing of the lateral extensor slips and posterior capsulotomy resulted in marked functional improvement

Frozen shoulder is a chronic fibrosing condition of the capsule of the joint. The predominant cells involved are fibroblasts and myofibroblasts which lay down a dense matrix of type-I and type-III collagen within the capsule. This subsequently contracts leading to the typical features of pain and stiffness. Cytokines and growth factors regulate the growth and function of the fibroblasts of connective tissue and remodelling of the matrix is controlled by the matrix metalloproteinases (MMPs) and their inhibitors. Our aim was to determine whether there was an abnormal expression or secretion of cytokines, growth factors and MMPs in tissue samples from 14 patients with frozen shoulder using the reverse transcription/polymerase chain reaction (RT/PCR) technique and to compare the findings with those in tissue from four normal control shoulders and from five patients with Dupuytren’s contracture. Tissue from frozen shoulders demonstrated the presence of mRNA for a large number of cytokines and growth factors although the frequency was only slightly higher than in the control tissue. The frequency for a positive signal for the proinflammatory cytokines Il-1β and TNF-α and TNF-β, was not as great as in the Dupuytren’s tissue. The presence of mRNA for fibrogenic growth factors was, however, more similar to that obtained in the control and Dupuytren’s tissue. This correlated with the histological findings which in most specimens showed a dense fibrous tissue response with few cells other than mature fibroblasts and with very little evidence of any active inflammatory cell process. Positive expressions of the mRNA for the MMPs were also increased, together with their natural inhibitor TIMP. The notable exception compared with control and Dupuytren’s tissue was the absence of MMP-14, which is known to be a membrane-type MMP required for the activation of MMP-2 (gelatinase A). Understanding the control mechanisms which play a part in the pathogenesis of frozen shoulder may lead to the development of new regimes of treatment for this common, protracted and painful chronic fibrosing condition

Aims

The results of surgery for Dupuytren’s disease can be compromised by the potential for disease recurrence and loss of function. Selecting which patients will benefit from repeat surgery, when to operate, and what procedure to undertake requires judgement and an understanding of patient expectations and functional needs. We undertook this study to investigate patient outcomes and satisfaction following repeat limited fasciectomy for recurrent Dupuytren’s disease.

Aims

Following cast removal for nonoperatively treated distal radius fractures, rehabilitation facilitated by advice leaflet and advice video were compared to a course of face-to-face therapy.

Aims

The aim of this study was to assess the quality and scope of the current cost-effectiveness analysis (CEA) literature in the field of hand and upper limb orthopaedic surgery.

Injectable collagenase is an alternative to surgical treatment for Dupuytren’s disease. Previous studies have reported on the effectiveness of collagenase in finger contractures. This prospective study reports on the short-term safety and efficacy of collagenase treatment in five thumb and first web space Dupuytren’s contractures. The thumb and first web space contractures were treated with injectable collagenase in four consecutive patients (five hands) with experience of previous surgical digital fasciectomy. The thumb contracture was measured by angle and span in two planes of thumb extension and abduction before injection and after manipulation. Collagenase treatment resulted in release of the contracture with a mean increase in thumb to index angle from 23° (10° to 35°) to 56° (45° to 60°) in extension and from 30° (10° to 50°) to 58° (50° to 65°) in abduction and a mean increase in span from 1.9 cm (1 to 3.5) to 3.9 cm (3 to 5) in extension and from 2.4 cm (1.5 to 3.5) to 3.9 cm (3 to 4.5) in abduction. All patients reported an increased range of movement and function and described collagenase therapy as preferable to surgery. In the short-term collagenase is an effective, well-tolerated and safe alternative to surgery for Dupuytren’s disease of the thumb.

Aims

Manipulation under anaesthetic (MUA) is a recognised form of treatment for patients with a frozen shoulder. However, not all patients benefit. Some have persistent or recurrent symptoms. There are no clear recommendations in the literature on the optimal management of recurrent frozen shoulder after a MUA. We aimed to address this issue in this study.

The objective of this study was to determine the effectiveness of screening and successful treatment of methicillin-resistant Staphylococcus aureus (MRSA) colonisation in elective orthopaedic patients on the subsequent risk of developing a surgical site infection (SSI) with MRSA.

We screened 5933 elective orthopaedic in-patients for MRSA at pre-operative assessment. Of these, 108 (1.8%) were colonised with MRSA and 90 subsequently underwent surgery. Despite effective eradication therapy, six of these (6.7%) had an SSI within one year of surgery. Among these infections, deep sepsis occurred in four cases (4.4%) and superficial infection in two (2.2%). The responsible organism in four of the six cases was MRSA. Further analysis showed that patients undergoing surgery for joint replacement of the lower limb were at significantly increased risk of an SSI if previously colonised with MRSA.

We conclude that previously MRSA-colonised patients undergoing elective surgery are at an increased risk of an SSI compared with other elective patients, and that this risk is significant for those undergoing joint replacement of the lower limb. Furthermore, when an infection occurs, it is likely to be due to MRSA.