Androgen receptors in Dupuytren's contracture.

Palmar fascia tissue and cultured cells from patients with Dupuytren's contracture and from normal subjects were characterized and analyzed for androgen receptor expression. Androgen receptors have never been studied in Dupuytren's myofibroblasts and may have a role in its high male predominance. Surgical samples were collected from eight patients undergoing surgery for Dupuytren's contracture and from four patients with carpal tunnel syndrome, used as control tissue. Immunohistochemical analysis was performed on tissue samples and on cell cultures with anti-androgen receptor, anti-alpha-smooth muscle actin, anti-fibronectin, and anti-type I and III collagen antibodies using the biotin avidin peroxidase method as revelatory system. Immunostaining for androgen receptors in tissue samples and cultured cells revealed nuclear reaction in many Dupuytren's myofibroblasts, but in few fibroblasts of the normal palmar fascia. In a double-labeling study, androgen receptors were seen to co-localize with alpha-actin in both cell cultures and tissue samples. We present the first evidence that the palmar fascia is a target tissue for androgen action and that the expression of androgen receptors in Dupuytren's contracture is considerably higher than in the normal palmar fascia. Further studies will need to evaluate whether the androgen-responsive state of the tissue is related to the high incidence of Dupuytren's contracture in the male sex.     

Responsiveness of Dupuytren's disease fibroblasts to 5 alpha-dihydrotestosterone

PURPOSE: We recently showed that androgen receptors are expressed in Dupuytren's contracture. The aim of the present work was to test the responsiveness of Dupuytren's fibroblasts to 5 alpha-dihydrotestosterone (5 alpha-DHT), the active form of testosterone. RESULTS: Cultured palmar fascia cells from 10 patients with Dupuytren's contracture and 4 normal subjects were exposed to 5 alpha-DHT (10 or 100 ng/mL) for 1, 3, 7, and 15 days. Their phenotype was analyzed immunohistochemically for alpha-smooth muscle actin and androgen receptor expression and proliferation rates were studied. RESULTS: At 15 days the higher concentration of 5 alpha-DHT induced an increase in Dupuytren's fibroblast proliferation, whereas anti-alpha-smooth muscle actin exhibited the strongest expression. At the same time point androgen receptor expression decreased with the lower concentration and disappeared altogether with the higher dose of 5 alpha-DHT. CONCLUSIONS:The palmar fascia is a target tissue for androgen action via androgen receptors. Further studies are required to determine whether control of androgen receptor may control the evolution of Dupuytren's disease.     

The collagen changes of Dupuytren's contracture

In Dupuytren's contracture there is an increase in the ratio of type III to type I collagen. The objective of this study was to determine if fibroblasts from patients with Dupuytren's contracture have an intrinsic aberration in collagen production or whether local factors govern the collagen changes in Dupuytren's contracture. Using a new collagen micro-method, we found that fibroblasts cultured from palmar fascia affected by Dupuytren's contracture produced similar collagen to fibroblasts derived from the palmar fascia of age- and sex-matched patients with carpal tunnel syndrome. Furthermore, the collagen changes of Dupuytren's contracture could be reproduced in all cell lines by increasing fibroblast density. At high fibroblast density, type I collagen production was inhibited: a finding that could account for the increased types III/I collagen ratio in Dupuytren's contracture. These results suggest that a genetic defect in collagen production is unlikely and that the important phenomenon is an increase in fibroblast density.     

Gelatinase A activity in Dupuytren's disease

PURPOSE: Dupuytren's contracture is a fibroproliferative disorder of the hand characterized by an abnormal myofibroblast and fibroblast proliferation and extracellular matrix deposition leading to retraction and deformation of the palm. Recent studies have shown that molecules of extracellular matrix may coordinate morphogenesis, cell differentiation, and most importantly, fibrogenesis in tissue. Gelatinase A (MMP-2) is a member of the matrix metalloproteinase family of proteolytic enzymes that contribute to remodeling the extracellular matrix by degrading its components. The aim of this study was to determine the level of MMP-2 activation in the palmar fascia of patients with Dupuytren's contracture with reference to the clinical stages of disease progression and recurrence of the contracture after surgery. METHODS: The level of relative MMP-2 activation, expressed by the active to latent MMP-2 ratio, was investigated with use of zymography and computerized densitometry in 16 normal and 71 pathologic tissues characterizing different clinical stages of the disease progression. RESULTS: We found that the level of MMP-2 activation was significantly elevated in the palmar fascias with Dupuytren's contracture compared with normal tissues. We did not find statistically significant differences between groups with different stages of the disease progression. We also did not find a relation between a high level of MMP-2 activation and the recurrence in the area of surgically treated Dupuytren's contracture. CONCLUSIONS: The differences in MMP-2 activation between contractured and normal fascia suggest a participation of this enzyme in the promotion of Dupuytren's disease. We did not find a relationship, however, between the level of MMP-2 activation and the secondary contracture.     

Dupuytren's contracture: an update of biomolecular aspects and therapeutic perspectives

The so-called fibrogenic cytokines, able to induce the growth of fibroblasts and their differentiation into myofibroblasts and to stimulate their production of extracellular matrix, are involved in the genesis of Dupuytren's contracture. Although many studies have been made of biomolecular aspects of palmar fibromatosis, practical applications from them are still far from imminent because of the real difficulty of blocking their action in vivo, even in a chronic, progressive lesion such as Dupuytren's disease. Consequently, surgical excision of the palmar fascia still remains the treatment of choice.     

Chromosomal abnormalities in Dupuytren's contracture and carpal tunnel syndrome.

The cytogenetics of cell cultures derived from Dupuytren's tissue, adjacent palmar fascia and palmar skin from patients undergoing fasciectomy have been examined and the results compared to cell cultures established from palmar fascia, flexor retinaculum and palmar skin of patients undergoing carpal tunnel decompression. Chromosomal abnormalities were detected in cell cultures from Dupuytren's tissue in eight of the nine patients studied. Clones of cells trisomic for chromosome 8 were found in five of the nine patients. Trisomy 8 was also present in two of five flexor retinaculum cultures from carpal tunnel syndrome cases. These findings in both Dupuytren's contracture and carpal tunnel syndrome suggest the presence of chromosomal instability in the palmar fascia. The significance of the chromosomal abnormalities is however unclear, but they indicate a possible common pathway in the onset of pathological fibrosis.     

Gene expression analysis of Dupuytren's disease: the role of TGF-beta2

Dupuytren's disease is characterised by nodular fibroblastic proliferation of the palmar fascia leading to contracture of the hand. Transforming growth factor beta (TGF-beta) is thought to play a role in its pathogenesis. We performed a cDNA microarray analysis of Dupuytren's diseased cord tissue with an emphasis on TGF-beta isoforms. Normal-appearing transverse ligament of the palmar fascia from adjacent to the diseased cord and palmar fascia from patients undergoing carpal tunnel release were used as controls. TGF-beta gene expression was confirmed by quantitative real-time polymerase chain reaction. Over 20 unique genes were found to be significantly up-regulated, including several previously reported genes. A dominant increase in TGF-beta2 expression was seen in the cord tissue, whereas TGF-beta1 and TGF-beta3 were found not to be significantly up-regulated. Quantitative real-time polymerase chain reaction confirmed these findings. This gene expression profile allows for further experiments that may eventually lead to gene therapy to block the development and progression of Dupuytren's disease clinically.     

Dupuytren's contracture: morphological and biochemical changes in palmar aponeurosis

The palmar aponeurosis removed from ten patients with Dupuytren's contracture was studied using morphological and biochemical approaches. The histological characteristic of Dupuytren's contracture is the presence of numerous nodules among the lamellar structures of the collagen fibres. In the nodules, there are many active fibroblasts which are surrounded by immature fibres and metachromatic substances demonstrated by toluidine blue staining. Ultrastructurally, the active fibroblasts have the characteristics of myofibroblasts, as previously reported by Dr. Gabbiani. We found that some fibroblasts have intracellular collagen fibrils in the cytoplasm. When assayed by Siegel and Martin's method, lysyl oxidase activity of the palmar aponeurosis was significantly higher in Dupuytren's contracture than in normal hands. Biochemical studies such as electrophoretic analysis of mucopolysaccharides, determination of uronic acid and collagen contents were undertaken to compare the aponeurosis of Dupuytren's contracture with normal cases. The uronic acid contents were higher in Dupuytren's contracture than in the controls. However, no difference between the two groups was found in the collagen contents and in the composition of the mucopolysaccharides. These characteristic features; existence of myofibroblasts and intracellular collagen fibrils and increase in the activity of lysyl oxidase probably play a significant role in the establishment of flexion contracture of the fingers in Dupuytren's contracture.     

Epidermal growth factor receptor (EGF-R) in Dupuytren's disease

The aim of this paper was to examine participation of the epidermal growth factor receptor (EGF-R) signal pathway in the pathogenesis of Dupuytren's disease. The study showed changes in the ratio of membrane EGF-R to its intracellular level during the different clinical stages of Dupuytren's contracture progression. Our observations of a high ratio of surface to intracellular EGF-R in the palmar aponeurosis of patients with second degree of Dupuytren's disease (Iselin's classification), which was significantly higher than this ratio in control palmar fascia (P=0.022), would suggest that EGF-R has a role in the involutional phase of the disease.     

The effect of 5-fluorouracil on Dupuytren fibroblast proliferation and differentiation

INTRODUCTION: Dupuytren's disease is a proliferative disease with contractile properties, prone to recur after surgery. Intra-operatively applied 5-fluorouracil has been used to avoid scar problems in the eye after glaucoma filtration surgery and was therefore investigated as a means to inhibit proliferation and myofibroblast differentiation in Dupuytren fibroblasts in vitro. METHOD: Primary cell lines were obtained by explants from Dupuytren's tissue (n = 6), non-diseased palmar fascia from patients with Dupuytren's disease (n = 3) and carpal ligament from patients undergoing carpal tunnel release (n = 3). The effect of 5-fluorouracil on proliferation was assessed by cell counting. Myofibroblast differentiation, an intergral part of Dupuytren's contracture, was investigated by staining for alpha smooth muscle actin, a marker for contractile cells, using immunohisto-chemical methods. RESULTS: A single exposure to 5-fluorouracil caused a sustained inhibition of proliferation in Dupuytren's and non-diseased fascia cultures, whilst the effect on carpal ligament cultures was transient. Untreated Dupuytren's fibroblasts exhibited the highest myofibroblast differentiation, whilst differentiation in non-diseased fascia cultures was shown to be proportional to cell density and virtually non-existent in carpal ligament cultures. After 5-fluorouracil exposure, the differentiation was significantly reduced in Dupuytren's fibroblasts cultures, reduced at high cell densities in non-diseased fascia and unchanged in carpal ligament cell cultures. DISCUSSION: 5-fluorouracil inhibits both proliferation and myofibroblast differentiation in Dupuytren's cell cultures and may have a potential use as an adjuvant treatment to Dupuytren surgery in order to reduce the rate of recurrence and contracture.     

A population study of Dupuytren's contracture

Nine hundred and nineteen patients attending orthopaedic clinics in the rural areas of the Cotswolds and Chilterns were examined for evidence of Dupuytren's contracture. Five per cent of men and 3.5 per cent of women showed evidence of the disease which was largely bilateral but confined to the palm in forty per cent of men and eighty per cent of women. A positive correlation between repeated stretching of the palmar fascia and the presence of Dupuytren's contracture confined to the palm was established.     

Oestrogen and progesterone hormone receptors in Dupuytren''s disease

Dupuytren's disease is associated with alcoholism and chronic liver disease, conditions frequently associated with deranged steroid hormone metabolism. The possible influence of endogenous sex steroid hormones on the development of Dupuytren's disease has therefore been investigated. An analysis of diseased palmar fascia for oestrogen and progesterone receptors was undertaken in fifteen patients. Hormone specific receptors were not found in the palmar fascia of our patients with Dupuytren's disease, thus suggesting that other mechanisms or factors contribute to the pathogenesis of this fibrotic process.     

The role of the fibroblast in Dupuytren's contracture.

Ultrastructural, immunohistochemical, and biochemical studies to date show that the fibroblast in Dupuytren's contracture is identical to palmar fascia fibroblasts in patients unaffected by Dupuytren's contracture, and to all other fibroblasts. The major difference relating to fibroblasts is that in Dupuytren's contracture there are more of them, and they are clustered around narrowed microvessels. It is probable that these two phenomena are linked because recent studies indicate a greater potential for ischemia-induced oxygen free radical generation in Dupuytren's contracture, and because oxygen free radicals in these concentrations can stimulate fibroblast proliferation. The major source of oxygen free radicals is likely to be from microvascular endothelial xanthine oxidase-catalyzed reactions. These observations also account for many of the epidemiologic associations of Dupuytren's contracture, because (1) age, race, and diabetes are associated with microvessel narrowing and (2) age, diabetes, alcohol consumption, HIV infection, cigarette smoking, and trauma are associated with increased free radical generation. Nonsteroidal anti-inflammatory drugs and allopurinol are two agents that decrease oxygen free radical release and may inhibit or prevent Dupuytren's contracture.     

An investigation into the role of inflammatory cells in Dupuytren's disease

An immunohistochemical study was performed on nodules excised from the palmar fascia of patients with Dupuytren's contracture. In cellular nodules, antibodies to actin (used as a marker for myofibroblasts), desmin, vimentin, Mac 387 (a macrophage marker) and leucocyte common antigen were used. A correlation was demonstrated between the numbers of macrophages and the presence of myofibroblasts. The presence of myofibroblasts is generally considered to indicate the active stage of the disease. Inflammatory cells other than macrophages were largely absent from the nodules, although lymphocytes were frequent in the tissue around the nodules. Microvascular changes were prominent in the nodules and pericyte proliferation was observed around occluded capillaries. Release of growth factors from macrophages may be important in Dupuytren's contracture, as is the case in other fibrotic diseases. The possible role of macrophages in the aetiology of Dupuytren's disease is discussed.     

Langerhans cells in Dupuytren's contracture

We have examined biopsies of Dupuytren's contracture palmar fascia, overlying subcutis and skin, and have correlated the distribution of gross macroscopic changes in the hand, mapped pre- and intraoperatively, with light microscopic immunohistochemical findings. We report increased numbers of S100 positive Langerhans cells (an epidermal cell of dendritic lineage) and CD45 positive cells, both in "nodules" and at dermo-epidermal junctions, in the biopsied tissues. This suggests that Langerhans cells migrate from the epidermis into Dupuytren's contracture tissue, possibly in response to local changes in levels of inflammatory cytokines within the tissue. Our findings, together with other reports of increased numbers of dermal dendrocytes and inflammatory cells in Dupuytren's contracture tissue, lend circumstantial support to the "extrinsic theory" of the pathogenesis of Dupuytren's contracture. However, the earliest stages of the disease process have not been defined, and therefore the events which ultimately produce fibrosis in the palmar fascial complex in susceptible individuals could begin in the skin and/or within deeper tissues, especially where there is dysregulation of the immune system.     

Skin tension in the aetiology of Dupuytren's disease; a prospective trial

Tension in the palmar fascia has been proposed as a factor causing Dupuytren's disease. If tension does stimulate the growth of new Dupuytren's tissue, relieving longitudinal tension should reduce the recurrence rate following surgery. Thirty patients with palmar Dupuytren's contracture of a single ray that affected only the metacarpophalangeal joint were divided into two groups. Both groups had a fasciotomy: one group through a transverse incision that was closed directly and the other through a longitudinal incision with Z-plasty closure. Half the patients (seven of 14) who had direct closure had recurrence at 2 years as compared to two of the 13 in the Z-plasty group. The trial was stopped at the interim analysis stage due to the high recurrence rate in the first group. These results are consistent with the tension hypothesis for the aetiology of Dupuytren's disease.     

The proximal interphalangeal joint in Dupuytren''s disease

In one hundred patients with Dupuytren's disease, one hundred and fifty-four operations were performed. The average pre-operative proximal interphalangeal joint contracture was 42 degrees and the average percentage improvement in proximal interphalangeal joint extension at post-operative review was 41%. Fourteen amputations were performed (9.1%). The primary deformity is caused by disease involvement of the palmar fascial structures. Secondary changes may prevent correction of the deformity despite excision of the contracted fascia. The anatomy of the joint is reviewed together with the primary and secondary mechanisms of joint contracture in Dupuytren's disease. Arthrodesis, osteotomy of the proximal phalanx and joint replacement are considered as alternatives to amputation when a systematic surgical approach fails to correct the flexion contracture.     

Fibrin/fibrinogen and fibrinolytic activity of the palmar fascia in Dupuytren's contracture

Considering the proved interaction of fibrin with fibroblasts and the seemingly decisive role of structural and functional changes ("modulation") of these cells in the evolution of Dupuytren's contracture, research has been carried out in order to investigate the fibrinolytic capacity and the possible presence of fibrin/fibrinogen in the palmar fascia of subjects operated upon for Dupuytren's Disease. Fibrin/fibrinogen were detected by a direct immunofluorescence technique and fibrinolytic activity was assessed by a fibrin plate method. A remarkable decrease of fibrinolytic activity and the presence of fibrin/fibrinogen were observed in small nodules in the early stage of disease, whereas large nodules showed a high amount of plasminogen activator enzymes. Small nodules seem to form and increase by progressive adhesion of fibroblasts to the polymerizing fibrin, while high fibrinolytic activity of large nodules probably results from "modulation" of many fibroblasts into contractile myofibroblasts and could therefore be considered as a biochemical sign of the evolutionary phase of Dupuytren's contracture.     

Pathologic anatomy.

The typical case shows one or more thickened bands overlying the flexor tendons in the palm that connect with one another via the transverse palmar fascia. Vertical septae fix the bands securely to the underlying fascia and transverse metacarpal ligaments. These septae pass deep between the tendon and neurovascular tunnel. Bands running into the fingers represent thickening and fibrosis of the natatory ligaments. Typically, a central band continues into the finger, forks, and dissipates just distal to the PIP joint. This dissipation occurs with bifurcation of the central band into two thickened bundles that pass deep to the neurovascular bundle and attach to the flexor sheath of the middle phalanx. There are also thickenings of Grayson's ligaments that run from the central cord laterally and dorsally. Understanding the anatomy of the palmar aponeurosis is essential to the effective treatment of Dupuytren's contracture. Because the cause is unknown, treatment is best directed at anatomic deformities. Although not systemic or lethal, poorly treated Dupuytren's contracture can lead to significant morbidity and long-term disability. The palmar aponeurosis and its substructures are more than just passive barriers. They integrate hand parts and when pathologically fibrosed can contract joints, deform skin, and deviate neurovascular structures. The best treatments are recognition of the contracture, meticulous dissection, and local radical fasciectomy. Special attention is directed toward protecting spiralling neurovascular bundles. Difficult releases are enhanced by judicious release of checkreins, tendon sheath attachments, and disease on the radial side of the hand.