The Rationale for Treating the Nodule in Dupuytren’s Disease

Abstract

Background:Dupuytren’s disease encompasses a spectrum of fibroblastic disorders from the presence of 1–2 nodules in the palm of a hand with no joint contracture to grotesque, crippling and disabling deformities of hands. Over the last 50 years, many enlightening studies have been forthcoming, which, through techniques of histopathology, biochemistry, tissue culture, and electron microscopy, have shed pearls of light on various aspects of the disease process.Methods:A comprehensive review of the literature on Dupuytren’s disease was undertaken, stringing together results from numerous studies to establish a table of events and their location in the development of the disease.Results:What will be seen is a credible scenario of events which will enable the clinician to be more proactive in the earlier treatment of the disease and more aware of factors that increase or decrease recurrence rates postoperatively.Conclusions:The most effective management of Dupuytren’s disease is early recognition and treatment of the nodule, before the development of a joint contracture, particularly of a proximal interphalangeal joint. As there is evidence of a significant inflammatory role in the development of the nodule, the process of fibroplasia can be minimized by altering the macrophage > fibroblast > collagen cascade by the intralesional injection of a potent anti-inflammatory agent such as triamcinolone, which also blocks tissue inhibitors of collagenase, thus enhancing the action of native collagenase, and reduces the size and firmness of nodules and, at least temporarily, arrests their progression.

Efficacy and safety of collagenase clostridium histolyticum for Dupuytren disease nodules: a randomized controlled trial

“…In addition, nodules may be painful in some patients and impair their ability to grip objects or use their hands successfully. Although the pathophysiology underlying Dupuytren disease remains a controversial topic, inflammatory and growth factor signals likely play a role through the augmentation of specific aspects of the disease (eg, myoblast proliferation and collagen production) [ 5 , 6 , 8 , 9 ]. Dupuytren nodules are rich in collagen type I and III (ie, the substrates for CCH) [ 15 ] and in vitro, CCH has been shown to reduce the expression of extracellular matrix components, cytokines, and growth factors that may contribute to nodule formation and progression [ 15 ].…”

“…It is characterized by the formation of thick collagen nodules that can progress to fibrous cords capable of producing digital flexion contractures and reducing hand function [ 4 ]. Dupuytren disease exhibits three clinical phases known as the proliferative, contractile, and residual phases [ 5 ]. In the early proliferative phase, nodules form as myofibroblasts and proliferate around microvessels [ 5 ].…”

“…Dupuytren disease exhibits three clinical phases known as the proliferative, contractile, and residual phases [ 5 ]. In the early proliferative phase, nodules form as myofibroblasts and proliferate around microvessels [ 5 ]. This myofibroblast proliferation may lead to vessel occlusion and hypoxia, and signal infiltration of immune cells [ 5 ].…”

“…In the early proliferative phase, nodules form as myofibroblasts and proliferate around microvessels [ 5 ]. This myofibroblast proliferation may lead to vessel occlusion and hypoxia, and signal infiltration of immune cells [ 5 ]. Expression of inflammatory signals and growth factors (eg, transforming growth factor-β) by immune cells may stimulate myofibroblast differentiation [ 6 ] and contraction [ 7 ] and augment the production of extracellular matrix proteins, such as fibronectin and collagen within nodules [ 8 , 9 ].…”

Percutaneous needle aponeurotomy for the treatment of Dupuytren’s contracture

“…Conservative treatment options include physical therapy and rehabilitation, radiotherapy, steroid injection, 5-fluorouracil injection, and oral tamoxifen use. [2][3][4][5][6] Surgical treatment methods include percutaneous needle aponeurotomy (PNA), open fasciotomy, partial fasciectomy (PF), radical fasciectomy, and dermofasciectomy. [7][8][9][10][11] Complete fasciectomy is the most invasive intervention with the highest rate of complications, but has consistently lower recurrence rates.…”