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.     

The effect of plantar fascia release on strain in the spring and long plantar ligaments

The effect of plantar fascia release on strain in the spring and long plantar ligaments was investigated in 11 cadaveric feet. Strain gauges were placed in the spring and long plantar ligaments of each specimen, and cyclic axial loading was applied until reproducible hysteresis curves were observed in the ligaments before and after plantar fascia release. After release of the plantar fascia, the average strain observed in the spring ligaments at 920N of axial load increased by 52% (p < .001) and in the long plantar ligaments by 94% (p = .04). Longer resting lengths of the ligaments were also observed. Release of the plantar fascia significantly changed force distributions in the foot which may explain the development of deformities and symptoms observed clinically following this procedure.     

The Effects of Collagenase Clostridium histolyticum on Plantar Fibromatosis: A Case Study

Plantar fibromatosis, also known as Ledderhose's disease, is a rare disorder of benign fibroblast proliferation involving the plantar aponeurosis (i.e., plantar fascia). Traditionally, surgical intervention has been the most common treatment for plantar fibromatosis. However, numerous studies have reported high recurrence rates of plantar fibromatosis after surgical intervention, as well as wound healing difficulties and nerve injury. Plantar fibromatosis often coexists with other superficial fibrous diseases such as Dupuytren's contracture and Peyronie's disease; immunohistochemical and ultrastructural analyses suggest a relationship between Ledderhose's disease and Dupuytren's contracture. The US Food and Drug Administration approved collagenase Clostridium histolyticum for the treatment of Dupuytren's contracture in 2010 and Peyronie's disease in 2013. This case study presents the successful treatment of Ledderhose's disease almost 4 years (45.5 months) after off-label use of collagenase C. histolyticum injection in a 22-year-old white female who had recurrent plantar fibromatosis after surgical intervention.     

Pathogenesis of Dupuytren's contracture--a review]

Dupuytren's disease is a palmar fibromatosis bringing about irreversible finger contracture. Histopathologically, the disease is characterized by the presence of the two types of structures: nodules, containing of intensively proliferating cells, and fibrous cords, formed by thick bundles of collagen fibers. It seems that key role in the development of Dupuytren's contracture play alterations of palmar fibroblasts activity. These cells begin intensively proliferate and transform to myofibroblasts. The later ones sharing phenotypic features of fibroblasts and smooth muscle cells take part in remodelling of extracellular matrix and are a source of palmar contracture. The pivotal factors involved in changes of palmar fibroblasts functions seem to be growth factors (mainly TGF beta, PDGF and bFGF). However, the participation of reactive forms of oxygen in mentioned process is also considered.     

Silikonabriebassoziierte Dupuytren-Kontraktur bei Spätversagen einer Lunatumspacerprothese

The pathophysiological mechanisms of palmar fibromatosis (Dupuytren’s contracture) are still not yet fully understood. In the vast majority of cases, however, reactive changes and reparative processes of tendon tissue can easily be ruled out by clinical and histopathological investigations. This article presents the case of a 62-year-old male patient suffering from palmar fibromatosis associated with a failed silicon spacer of the lunate bone 30 years after index surgery. Although silicon wear particles were observed in distal locations, proximal tendon tissues showed changes consistent with a degenerative palmar fibromatosis in the absence of a pathological wear reaction. The findings are discussed in the light of the current literature on Dupuytren’s contracture.     

Platelet-derived growth factor in fibrous musculoskeletal disorders: A study of pathologic tissue sections and in vitro primary cell cultures

Despite the great variability in the clinical behavior of fibrous lesions of the musculoskeletal system, they are composed of cytologically similar fibrocytes. Receptors for estrogen or progesterone, or both, are present in some of these lesions and some increase their rate of growth during periods of high levels of sex steroid hormones. The platelet-derived growth factor-B (PDGF-B) proto-oncogene encodes the B chain of PDGF, a mitogen for fibrocytes. Tissue from aggressive fibromatosis, fibrous dysplasia, plantar fibromatosis, and recurrent plantar fibromatosis was analyzed with use of the polymerase chain reaction and in situ hybridization for the expression of PDGF-B and PDGF beta receptor. Cell culture was used to determine if estrogen and progesterone stimulation modulated the expression of PDGF-B. Aggressive fibromatosis, fibrous dysplasia, and recurrent plantar fibromatosis expressed PDGF-B; plantar fibromatosis, normal plantar fascia, normal fascia lata, and mature scar did not. All of the tissues expressed PDGF beta receptor. The level of expression in aggressive fibromatosis and fibrous dysplasia was four times that in the recurrent plantar fibromatosis. Estrogen and progesterone stimulation in aggressive fibromatosis resulted in an increase in the level of expression. Therefore, the detection of PDGF-B may be an adjunct in the pathologic identification of locally invasive lesions. Its production may be a common mechanism leading to a fibroproliferative response through deregulation of the control of growth by both paracrine and autocrine mechanisms.     

The response of elderly human articular cartilage to mechanical stimuli in vitro

OBJECTIVE: To investigate the biosynthetic response of elderly human femoral head articular cartilage to mechanical stimulation in vitro and its variation with site. METHOD: Full-depth cartilage biopsies of articular cartilage were removed from defined sites on 10 femoral heads from patients aged 68-95 years. Cartilage explants were subjected to either static or cyclic (2s on/2s off) loading in unconfined compression at a stress of 1MPa for 24h, or no load. Metabolic activity was assessed by adding medium containing (35)S-sulphate and (3)H-leucine during the last 4h of loading and measuring the incorporated radioisotope. Matrix composition was measured in terms of the amounts of collagen, sulphated glycosaminoglycans (GAG) and water content. RESULTS: Loading of elderly human articular cartilage at 1MPa significantly inhibited incorporation of (35)S-sulphate (P=0.023) into cartilage explants. Pairwise comparisons showed that the difference in incorporation was only for static loading (43% decrease compared to unloaded) (P<0.05). (3)H-leucine incorporation appeared to follow the same trends but neither static nor cyclic load was significantly different from control (P=0.31). Significant topographical variation was found for % GAG wet and GAG:collagen but not water content, % GAG dry or collagen. Isotope incorporation rates were in the order anterior>superior>posterior. CONCLUSION: Static loading inhibits matrix biosynthesis in elderly human cartilage, and cyclic loading is not stimulatory. This is in contrast to previous studies on young bovine tissue where cyclic loading is stimulatory.     

Protein kinase C is a mediator of the adaptation of vascular endothelial cells to cyclic strain in vitro.

BACKGROUND. The mechanism by which hemodynamic forces influence the function of the endothelium lining a blood vessel are unknown. The aim of this study was to determine the effect of in vitro cyclic strain on endothelial cell (EC) activation of protein kinase C (PKC). METHODS. Confluent bovine aortic ECs grown on flexible-bottomed culture plates were subjected to 24% maximum strain at a frequency of 60 cycles/min for 24 hours. Changes in PKC activity and evidence of translocation from cytosol to membrane fractions were assessed by immunocytochemical staining of ECs with antibodies specific to PKC and direct measurement of PKC activity in cytosol and membrane. To determine whether activation of PKC was responsible for some effects of cyclic stretch on ECs, a specific PKC inhibitor, calphostin C, was added to ECs subjected to cyclic stretch for 5 days and control ECs grown under static conditions. RESULTS. Immunocytochemical staining of ECs demonstrated translocation of PKC alpha- and beta-antibody fluorescence from the cytosol to the perinuclear and nuclear regions in ECs subjected to cyclic strain. This was confirmed by direct measurements of PKC activity, which demonstrated an early transient translocation of PKC activity from cytosol to membrane fraction at 10 seconds followed by a sustained elevation in PKC activity in the membrane at 100 seconds. Calphostin C abrogated the increase in EC proliferation that occurs in response to stretch. CONCLUSIONS. We conclude that cyclic stretch of ECs results in activation of PKC, which may be responsible for mediating the effects of cyclic stretch on EC growth.     

Differential Gene Expression Analysis of Subcutaneous Fat, Fascia, and Skin Overlying a Dupuytren’s Disease Nodule in Comparison to Control Tissue

Dupuytren’s disease (DD) is a benign fibroproliferative tumor with an unknown etiology and high recurrence postsurgery. Several observations suggest the possible involvement of skin overlying nodule (SON) and the subcutaneous fat in the pathogenesis of DD. This study aims to (1) compare the gene expression levels of SON and subcutaneous fat in DD and normal subjects and (2) to compare transverse palmar fascia (Skoog’s fibers) from DD patients as internal control tissue, with palmar fascia (transverse carpal ligament) from patients undergoing carpal tunnel release as external control. Skin, fat, and fascia were obtained from five DD patients of Caucasian origin (age = 66 ± 14) and from five control subjects (age = 57 ± 19) undergoing carpal tunnel release. Total ribonucleic acids was extracted from each sample and used for complementary deoxyribonucleic acid synthesis. Real-time quantitative polymerase chain reaction was used to assess the gene expression levels of six candidate genes: A disintegrin and metalloproteinase domain (ADAM12), aldehyde dehydrogenase 1 family member A1 (ALDH1A1), iroquois homeoboxprotein 6 (IRX6), periostin, osteoblast specific factor, proteoglycan 4, and tenascin C. Using independent t test, ADAM12, ALDH1A1, and IRX6 expression levels in DD fats were significantly (p < 0.05) higher than those in the controls. There is no significant difference in the gene expression levels of all six genes when comparing disease and control fascia and skin. Interestingly, ADAM12 up-regulation has also been observed in several other fibrotic and proliferative disorders. In conclusion, this study demonstrates potential roles for subcutaneous fat in DD pathogenesis as well as supports the use of transverse palmar fascia as appropriate control tissues in DD research.     

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.     

手汗症患者胸交感神经干脑源性神经营养因子和神经调节因子-1基因表达与有髓神经纤维密度及横截面积的关系

目的 观察手汗症患者胸交感神经干脑源性神经营养因子(BDNF)和神经调节因子-1(NRG-1)基因表达及对有髓神经纤维密度和单个纤维横截面积的影响,探讨与手汗症发病机制的关系.方法 采用核固红-固绿髓鞘染色法显示有髓神经纤维,通过显微图像分析系统观察30例手汗症患者T3胸交感神经干有髓神经纤维密度和单个有髓神经纤维的横截面积,以及用逆转录-聚合酶链反应(RT-PCR)法检测BDNF和NRG-1基因表达强度,并与8例非手汗症患者进行对照研究.结果 手汗症患者T3胸交感神经干中有髓神经纤维密度和单个有髓神经纤维的横截面积较非手汗症患者明显增高(t=7.023,P<0.05;t=7.462,P<0.05);BDNF和NRG-1基因在手汗症患者T3胸交感神经干中mRNA水平的相对表达强度比值分别为1.17600±0.028 70、1.216 10±0.075 39,较非手汗症患者的比值1.037 50±0.053 79、1.042 70±0.043 57明显增高(t=9.940,P<0.05;t=6.195,P<0.05).结论 BDNF和NRG-1基因表达强度增高促使胸交感神经干的有髓神经纤维密度增高以及单个有髓神经纤维的横截面积增大,从而导致胸交感神经传导速度增快、兴奋性增高,可能为手汗症的发病基础之一.     

Biomechanical evaluation of two clinical tests for plantar heel pain: the dorsiflexion-eversion test for tarsal tunnel syndrome and the windlass test for plantar fasciitis

BACKGROUND: Plantar heel pain may result from several conditions such as tarsal tunnel syndrome (TTS) and plantar fasciitis. The dorsiflexion-eversion test is used to diagnose TTS, whereas the windlass test is used for plantar fasciitis. Given the similarity between both tests, the purpose of this study was to evaluate whether these tests are able to selectively load the structures which they aim to examine. METHODS: Both tests were evaluated in six cadavers by measuring strain in the plantar fascia, tibial nerve, lateral plantar nerve (LPN), and medial plantar nerve (MPN) using miniature displacement transducers. Longitudinal excursion of the nerves was measured with a digital caliper. RESULTS: With the dorsiflexion-eversion test, dorsiflexion and eversion of the ankle in combination with extension of the metatarsophalangeal (MTP) joints significantly increased strain in the tibial nerve (+1.1%), LPN (+2.2%), and MPN (+3.3%) but also in the plantar fascia (+1.2%) (all: p=0.016). Both components (dorsiflexion-eversion and MTP extension) resulted in significant increases. With the windlass test, extension of all MTP joints significantly increased strain in the plantar fascia (+0.4%, p=0.016), but also in the tibial nerve (+0.4%, p=0.016), LPN (+0.8%, p=0.032) and MPN (+2.0%, p=0.016). Excursion of the nerves was always in the distal direction but only reached significance for the tibial nerve (6.9 mm, p=0.016) and LPN (2.2 mm, p=0.032) during the dorsiflexion-eversion test. CONCLUSIONS: Both tests mechanically challenge various structures that have been associated with plantar heel pain. This questions the usefulness of the tests in the differential diagnosis of plantar heel pain.     

Influence of short-term hydrostatic pressure on organization of stress fibers in cultured chondrocytes

The present study describes changes in the organization of stress fibers that occur in articular cartilage chondrocytes subjected to hydrostatic pressure. Primary cultures of chondrocytes from bovine articular cartilage, grown on coverslips, were subjected to 5, 15, or 30 MPa hydrostatic pressure at 37°C. The pressure was applied continuously or cyclically at two frequencies: 0.125 Hz (4 seconds of pressure and 4 seconds of no pressure) or 0.05 Hz (1 second of pressure and 19 seconds of no pressure) for a period of 2 hours. Control chondrocytes showed a polygonal form with prominent stress fibers extending across the cells. The exposure of cells to 30 MPa pressure caused a nearly total disappearance of stress fibers and retraction of the cells from each other. With pressure at 15 MPa or cyclic pressure, the number of cells with stress fibers was decreased. In cells subjected to 5 MPa pressure, the stress fibers resembled those in control chondrocytes. The pressure effects were reversible after 2 hours. Pressure had no effect on the staining pattern of vinculin, which suggests that microfilaments are more vulnerable to pressure than vinculin. The results indicate that cytoskeletal changes may be an integral part of the response of chondrocytes to hydrostatic pressure.     

Glucocorticoids suppress proteoglycan production by human tenocytes

BACKGROUND: The role of glucocortiocid injection therapy in spontaneous tendon rupture is controversial. We hypothesized that glucocorticoids suppress proteoglycan production in tendon and studied the in vitro effects of dexamethasone and triamcinolone on proteoglycan production by cultured human tenocytes. MATERIAL AND METHODS: We obtained primary cultures of human tenocytes from explants of healthy human patellar tendon. The human tenocytes were treated with 1 microM dexamethasone or 1 microM triamcinolone. The amount of proteoglycan production was measured by 35S-sulfate incorporation assay and compared with control cultures. The reversibility of the effect of dexamethasone by co-incubation with 10 ng platelet-derived growth factor (PDGFBB) was also tested. RESULTS: Treatment with 1 microM triamcinolone reduced the amount of 35S-sulfate incorporation to 80% of control cultures (p = 0.007), whereas 1 microM dexamethasone reduced it to 72% (p = 0.01). Co-incubation of 10 ng/mL PDGFBB with 1 microM dexamethasone returned the 35S-sulfate incorporation to a level that was significantly higher than for dexamethasone treatment alone (108%; p = 0.01). INTERPRETATION: Glucocorticoids suppressed proteoglycan production in cultured human tenocytes. The suppression by dexamethasone was reversed by simultaneous addition of PDGFBB. Suppressed proteoglycan production may affect the viscoelastic properties of tendon and increase the risk of spontaneous rupture.     

Cyclic stretching of human osteoblasts affects proliferation and metabolism: A new experimental method and its application

We developed an experimental system to stimulate cell cultures by uniform and cyclic biaxial strain of the cell culture surface. The studies reported here were designed to determine the uniformity of the strain distribution, the suitability of the surface for the growth of human osteoblasts, and the effects of strain magnitude on cell proliferation and alkaline phosphatase (AP) activity. Subconfluent cell cultures were grown in rectangular silicone dishes that were stretched cyclically (1 Hz) in the long axis by an electromechanical apparatus that controlled peak stretch and cycle frequency. We applied cyclic strains (1.0, 2.4, 5.3, and 8.8% surface strains) for 15 minutes per day on 3 consecutive days. Phase contrast microscopy confirmed the transfer of dish surface strain to the cells. Stretching of the dish resulted in a homogeneous strain distribution that deviated approximately 0.05% from the applied strain. In comparison with plastic dishes, there was a 20% reduction of cell proliferation on the silicone substrate whereas morphology, AP activity, and total protein content of the cells were similar. The proliferation of human osteoblasts was increased significantly (16.4–100%) by 1% strains, although higher strain magnitudes had lesser (nonsignificant) effects or decreased the mitotic activity of the cells. AP and lactate dehydrogenase activities were not influenced significantly by cyclic strains. This study demonstrates that the cell stretching system is suitable for the investigation of the effects of well defined cyclic strains.     

Glucocorticoids suppress proteoglycan production by human tenocytes

Background?The role of glucocortiocid injection therapy in spontaneous tendon rupture is controversial. We hypothesized that glucocorticoids suppress proteoglycan production in tendon and studied the in vitro effects of dexamethasone and triamcinolone on proteoglycan production by cultured human tenocytes.

Material and methods?We obtained primary cultures of human tenocytes from explants of healthy human patellar tendon. The human tenocytes were treated with 1 μM dexamethasone or 1 μM triamcinolone. The amount of proteoglycan production was measured by ³⁵S-sulfate incorporation assay and compared with control cultures. The reversibility of the effect of dexamethasone by co-incubation with 10?ng platelet-derived growth factor (PDGFBB) was also tested.

Results?Treatment with 1 μM triamcinolone reduced the amount of ³⁵S-sulfate incorporation to 80% of control cultures (p = 0.007), whereas 1 μM dexamethasone reduced it to 72% (p = 0.01). Co-incubation of 10?ng/mL PDGFBB with 1 μM dexamethasone returned the ³⁵S-sulfate incorporation to a level thatwas significantly higher than for dexamethasone treatment alone (108%; p = 0.01).

Interpretation?Glucocorticoids suppressed proteoglycan production in cultured human tenocytes. The suppression by dexamethasone was reversed by simultaneous addition of PDGFBB. Suppressed proteoglycan production may affect the viscoelastic properties of tendon and increase the risk of spontaneous rupture.

?     

Plantar fibromatosis: an immunohistochemical and ultrastructural study

The analogies between plantar fibromatosis and Dupuytren's disease (palmar fibromatosis) are well known. The latter is clinically more frequent and has been the object of extensive immunohistochemical and ultrastructural studies, with a view to investigating its pathogenesis. By contrast, such data on plantar fibromatosis are quite scarce. A histochemical, immunohistochemical, and ultrastructural study was performed on nodule tissue from six patients who were subjected to total fasciectomy for plantar fibromatosis. The study of myofibroblasts revealed features suggestive of their fibroblastic origin and evidenced a cytoskeleton and an extracellular filamentous system that could enable myofibroblasts to generate and exert the intracellular forces that contribute to the contraction of the aponeurosis. These aspects are similar to those observed in Dupuytren's disease and seem to lend support to the theory that the two diseases are expressions of the same disorder.     

Osteoclastogenesis is repressed by mechanical strain in an in vitro model.

Functional loading provides a site-specific signal for the regulation of bone mass and morphology. To determine if strain can inhibit the resorptive component of bone remodeling, osteoclast formation was assessed in marrow cultures plated on flexible membranes subjected to 5% strain for 10 cycles/minute, 24 hours per day. Cultures strained during days 2 through 7 inhibited osteoclast formation to 61+/-7% of control cultures (p < 0.05), a degree of inhibition similar to that observed when the cultures were subjected to strains during only days 2 through 4 but also evaluated on day 7 (67+/-4% of control; p < 0.05). In contrast, straining of cultures during days 5 through 7 had little influence on inhibiting the formation of osteoclasts (94+/-5% of control; no significant difference). The nonuniformly strained substrate was subdivided into three concentric rings. and cultures were used to examine the site-specificity of the inhibition caused by strain. Osteoclast formation in the outermost boundary, which was distended from 3.6 to 5%, was 41+/-7% of that observed in outer regions of control wells. The inhibitory potential of mechanical strain was reduced within the middle ring (73+/-6% of control osteoclasts: p < 0.01), where the strain ranged from 0.2 to 3.6%. The central region, which experienced strains equivalent to those in the middle ring (0.2 to -4% strain), showed inhibition of osteoclast formation to a similar degree (75+/-6% of control). Media harvested from strained cultures failed to inhibit osteoclast formation in unstrained cultures; this implies that the inhibitory effect of strain depended on the direct interaction of the cell with the substrate rather than by a humoral factor. A second device, where a uniform strain was delivered at 1.8% throughout the entire plate, inhibited osteoclast recruitment to 48+/-3.6%, emphasizing that uniform strain in the absence of shear stress constrains osteoclast recruitment. These in vitro experiments can but model the complex environment generated by in vivo mechanical strains: however, they provide the first direct evidence that strain must be considered as inhibitory to osteoclast recruitment.