Factors Associated with the Development, Progression, and Outcome of Dupuytren Disease Treatment: A Systematic Review.

BACKGROUND: The factors typically considered to be associated with Dupuytren disease have been described, such as those in the "Dupuytren diathesis." However, the quality of studies describing them has not been appraised. This systematic review aimed to analyze the evidence for all factors investigated for potential association with the development, progression, outcome of treatment, or recurrence of Dupuytren disease. METHODS: A systematic review of the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and Cumulative Index to Nursing and Allied Health Literature databases was conducted using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant methodology up to September of 2019. Articles were screened in duplicate. Prognostic studies were quality assessed using the Quality in Prognosis Study tool. RESULTS: This study identified 2301 records; 51 met full inclusion criteria reporting data related to 54,491 patients with Dupuytren disease. In total, 46 candidate factors associated with the development of Dupuytren disease were identified. There was inconsistent evidence between the association of Dupuytren disease and the presence of "classic" diathesis factors. The quality of included studies varied, and the generalizability of studies was low. There was little evidence describing the factors associated with functional outcome. CONCLUSIONS: This systematic review challenges conventional notions of diathesis factors. Traditional diathesis factors are associated with disease development and recurrence, although they are not significantly associated with poor outcome following intervention based on the current evidence.

Surgical outcomes of the anterior versus posterior approach for advancement of the levator aponeurosis in Japanese patients.

PURPOSE: To compare the surgical outcomes of the anterior and posterior approaches for advancement of the levator aponeurosis for aponeurotic blepharoptosis in relation to levator function (LF). METHODS: This retrospective study included 223 eyelids from 125 patients with aponeurotic blepharoptosis. The anterior approach was used for 115 eyelids from 65 patients (anterior group), while the posterior approach was used in 108 eyelids from 60 patients (posterior group). Patients were subdivided into two groups in accordance with their LF (fair: 5-10 mm; good: > 10 mm). Functional success was defined as a margin reflex distance of 2-5 mm without serious complications at 3 months postoperatively. Cosmetic success was defined as the achievement of ≤ 1 mm laterality of the upper eyelid height, ≤ 2 mm laterality of the pretarsal show, and eyelid contour symmetry at 3 months postoperatively. RESULTS: The functional success rates of the anterior and posterior groups were comparable for patients with good LF (78.9% vs 87.7%, p = 0.228), whereas it was better in the posterior group (85.7%) than the anterior group (64.1%) in the total group (p = 0.022) and in patients with fair LF (p = 0.031). The posterior group achieved better cosmetic success than the anterior group regarding upper eyelid height symmetry (p = 0.042) and pretarsal show (p = 0.012). No serious complications occurred during follow-up. CONCLUSIONS: The posterior approach achieved better functional and cosmetic outcomes than the anterior approach, indicating that the posterior approach is more useful in patients with aponeurotic blepharoptosis, particularly for those with only fair LF.

Comparison of the therapeutic outcomes between open plantar fascia release and percutaneous radiofrequency ablation in the treatment of intractable plantar fasciitis.

BACKGROUND: Heel pain is one of the most common complaints in foot and ankle clinic, and one of the leading causes of heel pain is plantar fasciitis. METHODS: A retrospective analysis was carried out in 31 cases (39 feet) of patients with intractable plantar fasciitis. In the enrolled 26 cases, 16 patients (19 feet) received open plantar fascia release, and the other 15 patients (20 feet) received percutaneous radiofrequency ablation. The surgical results were assessed by visual analog scale (VAS) and American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS-AH) before and after surgery in all patients. RESULTS: All 31 patients were followed up successfully, with a mean follow-up time of 58.77 months. There were no differences of patient's demographics and characteristics information between the two groups. The average operative time of the feet in the open plantar fascia release is longer than that in the percutaneous radiofrequency ablation. Furthermore, the percutaneous radiofrequency ablation group had a shorter recovery time to normal activity than the open plantar fascia release group. There were no differences of postoperative VAS scores and the AOFAS-AH scores between the two groups. All patients reported satisfaction after either operation. CONCLUSION: The symptoms of pain and limb function were significantly improved in patients both of the partial plantar fascia release treated group and the percutaneous radiofrequency ablation treated group. The two types of surgical procedures shared the same long-term curative effects. However, percutaneous radiofrequency ablation was a better technique from the point of shorter operative time and postoperative recovery time. TRIAL REGISTRATION: Retrospectively registered.

Clinics in diagnostic imaging (195). Plantar fibromatosis.

A 46-year-old man presented with a six-month history of lumps in the sole of his left foot. Physical examination revealed two nodules, one tender and one firm, at the plantar left foot with no overlying skin changes. Although the initial radiographs were normal, magnetic resonance imaging of the left foot demonstrated two nodules along the medial band of the plantar fascia, characteristic of plantar fibromas. The patient opted for surgical excision. There was no further recurrence of symptoms after surgery. We describe the clinical and radiological features of plantar fibromatosis and briefly discuss other causes of lumps and pain in the sole of the foot.

Percutaneous Plantar Fascia Release With Needle: Anatomic Evaluation with Cadaveric Specimens.

Percutaneous plantar fascia release with needle is a novel procedure for the treatment of plantar fasciitis. The objective of this cadaveric study is to perform an anatomic evaluation of the percutaneous plantar fascia release method using a conventional hypodermic needle. In this study, we used 14 fresh-frozen cadaveric trans-tibial amputation specimens. Percutaneous plantar fasciotomy with a conventional hypodermic needle was performed. After a proper dissection, the width of the plantar fascia, the thickness of the medial border, and the width of the cut segment were measured and recorded. Any muscle damage on the flexor digitorum brevis and damaged area depth were recorded. Any damage on the lateral plantar nerve and the first branch of the lateral plantar nerve, also known as Baxter's nerve, and their distance to fasciotomy were also recorded. Mean width (± standard deviation) of the plantar fascia was measured as 20.34 ± 4.25 mm. The mean thickness of the medial border of the plantar fascia was 3.04 ± 0.54 mm. Partial fasciotomy was performed in all cadavers with 49.47% ± 7.25% relative width of the plantar fascia. No lateral plantar nerve, or its first branch Baxter's nerve, was damaged, and the mean distance from the deepest point of the fasciotomy up to the Baxter's nerve was 8.62 ± 2.62 mm. This cadaveric study demonstrated that partial plantar fasciotomy can be achieved via percutaneous plantar fascia release with a conventional hypodermic needle without any nerve damage.

Possible association of oestrogen and Cryba4 with masticatory muscle tendon-aponeurosis hyperplasia.

OBJECTIVE: Masticatory muscle tendon-aponeurosis hyperplasia, which is associated with limited mouth opening, progresses very slowly from adolescence. The prevalence rates of this disease are higher among women than among men, suggesting oestrogen involvement. As parafunctional habits are frequently observed, mechanical stress is likely involved in the pathogenesis and advancement of this disease. To elucidate the pathological condition, we examined the effect of oestrogen on tenocyte function and the relationship between mechanical stress and crystallin beta A4 (Cryba4), using murine TT-D6 tenocytes. MATERIALS AND METHODS: Cell proliferation assays, RT-PCR, real-time RT-PCR, Western blot analysis and mechanical loading experiments were performed. RESULTS: The physiological dose of oestrogen increased the levels of scleraxis and tenomodulin in TT-D6 tenocytes. In contrast, forced expression of Cryba4 inhibited scleraxis expression in these cells. Surprisingly, oestrogen significantly promoted cell differentiation in the Cryba4-overexpressing TT-D6 tenocytes. Moreover, tensile force induced Cryba4 expression in these tendon cells. CONCLUSION: Oestrogen and Cryba4 may be associated with the progression of masticatory muscle tendon-aponeurosis hyperplasia.

[Variants of clinical course of Dupuytren's contracture and palmar aponeurosis tissue composition in patients of different age groups.]

For the purpose of comparative analysis of the clinical course of fascial fibromatosis and tissue composition of the palmar aponeurosis in patients of different age groups сase reports and histological surgical material from 179 Dupuytren's contracture patients treated in 2014-2018 were analyzed. Patients were distributed in age groups: the 1st - younger than 50 years, the 2nd - 50-65 years, the 3rd - over 65 years old. In all groups four variants of Dupuytren's contracture clinical course were noted: swift, fast, benign and deffered. The rates of third-fourth levels of contracture in age groups were 50, 54 and 76% respectively. In groups 2 and 3 the volume per cents of hyperplastic connective tissue and adipocytes in palmar aponeurosis were decreased though body mass indexes were increased in comparison with group 1 (p<0,005). The signs of fat tissue vascularity and perivascular inflammatory infiltration were most pronounced in group 1, in group 3 per cent of vessels with adventitial fibrosis was significantly increased. The obtained data may be used for age-oriented treatment protocols and individual prognosis of fascial fibromatosis recurrence and spread.

[Pathological features of levator aponeurosis in patients with involutional blepharoptosis].

Objective: To observe pathological features of levator aponeurosis in patients with involutional ptosis. Methods: A prospective study. Twenty-nine consecutive patients with involutional blepharoptosis who underwent levator aponeurosis advancement surgery for blepharoptosis correction were enrolled at Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University from 2007 to 2013. Twenty-nine specimens of the levator aponeurosis were obtained during surgery. Hematoxylin-eosin staining, Van Gieson staining, Masson staining, immunohistochemistry and transmission electron microscope observations were performed to observe the features of levator aponeurosis. Twelve normal specimens of fresh levator aponeurosis were obtained from Beijign Tongren Eyebank as control group. Mann-Whitney's U-test and multiple linear regression were used for statistical analysis. Results: Among the enrolled cases, there were 19 males and 10 females;14 cases were diagnosed with moderate ptosis and 15 cases with severe ptosis;9 cases involved with both eyes, 9 cases with right eyes, and 11 cases with left eyes. The mean age was 59 years. Among the 12 normal cases, there were 5 males and 7 females. The mean age was 56 years. Histopathological observation showed fascicle disruption(+++, ++, + 24, 2, 3 vs. 0, Z=-5.666, P<0.001), scarcity of cross-striations(+++, ++, + 23, 2, 4 vs. 0, Z=-5.582,P<0.001), collagen fibers hyperplasia(+++, ++, + 15, 10, 4 vs. 0, Z=-5.223,P<0.001), fatty infiltration(+++, ++, + 24, 5, 0 vs. 0, Z=-5.671,P<0.001), and a decrease of myoglobin expression(+++,++,+,- 9, 1, 1, 15 vs. 8, 1, 0, 0, Z=-3.004, P=0.005) in levator aponeurosis. Transmission electron microscope recorded presence of collagen fiber hyperplasia and cellular degeneration including mitochondria swelling and hyperplasia, vacuoles, lipid droplets, nucleus pycnosis, chromosome condensation, disintegrated organelles, myeloid body and autophagy. Multivariate linear regression showed a correlation between fat infiltration and age(ß=0.425, P=0.043) while suspicious related clinical features as independent variables and observed histopathological features as dependent variables. Conclusion: The levator aponeurosis appears to be involved with muscle fiber degeneration, collagen fiber hyperplasia and cellular degeneration in patients with involutional blepharoptosis. (Chin J Ophthalmol, 2018, 54: 671-677).

Hand fasciae innervation: The palmar aponeurosis.

There are few data in the scientific literature about the innervation of fasciae of the hand. The present study first elucidates the density and location of nervous structures in the palmar aponeurosis and, for comparison, in the flexor retinaculum (both can be considered specializations of the deep fascia of the upper limbs). Second, it compares nonpathological with pathological palmar aponeurosis. Samples of nonpathological fascia were taken from the flexor retinaculum and palmar aponeurosis of 16 upper limbs of unembalmed cadavers. Samples of pathological palmar aponeurosis were taken from seven patients with Dupuytren's disease. All samples were stained immunohistochemically with anti-S100 and anti-tubulin antibodies, and analyzed quantitatively and qualitatively by microscopy. The palmar aponeurosis showed higher median density than the retinacula of free nerve endings (22 and 20 elements/cm2 , respectively), Pacinian corpuscles (2 and 0 elements/cm2 ) and Golgi-Mazzoni corpuscles (1.0 and 0.5 element/cm2 ). Some corpuscles were located at the intersections of the fibers in the three directions. Free nerve endings were denser in pathological palmar aponeurosis (38 elements/cm2 ). The results indicate that the palmar aponeurosis is central to proprioception of the hand and that surgery should therefore avoid injuring it. The higher density of free nerve endings in pathological samples indicates that the nervous structures are implicated in the amplified fibrosis of Dupuytren's disease. Clin. Anat. 31:677-683, 2018. © 2018 Wiley Periodicals, Inc.

[Collagen types ratio in prediction of postoperative ventral hernias]. / Sootnoshenie tipov kollagena v prognozirovanii posleoperatsionnykh ventral'nykh gryzh.

AIM: To analyze collagen types ratio in skin and aponeurosis in order to predict postoperative ventral hernias. MATERIAL AND METHODS: The trial included 141 patients for the period 2012-2015. Group I (n=65) of patients without ventral hernias was divided into subgroup AI (primary operation, n=41) and BI (re-operation, n=24). Group II consisted of 76 patients with ventral hernias. We performed histological examination of skin and aponeurosis to define the collagen structure of connective tissue. RESULTS: There were significant differences between collagen type I/III ratio in skin (2.81±0.52 in group I vs. 1.13±0.48 in group II) and aponeurosis (2.69±0.41 vs. 1.09±0.21, respectively, p≤0.05). We revealed strong direct correlation (r=+0.92) between aponeurosis and skin specimens in one group. Collagen type I level was 73.81±2.74% in subgroup AI and 72.03±2.47% in subgroup BI. Collagen type I was predominant (p≤0.05). CONCLUSION: In patients with ventral hernias collagen type I/III ratio in skin is 2.54 times lower than in patients without hernias. Significant correlation of collagen types in skin and aponeurosis (r= +0.92) allows to predict the risk of postoperative ventral hernias on basis of skin fragment.

[The fibrous skeleton of the hand : Changes with Dupuytren's contracture]. / Das fibröse Skelett der Hand : Veränderungen bei der Dupuytren-Kontraktur.

The exact knowledge of the anatomy of the fibrous skeleton of the hand is an absolute prerequisite for any treatment of Dupuytren's disease. The fibrous skeleton does not only include the palmar aponeurosis, but also numerous retinacula cutis, which are not found in current anatomy books. Here, eponyms facilitate the otherwise difficult and over-pronounced names of the fiber systems. Skoog, Legueu and Juvara, Gosset, Grapow, Grayson, Cleland, Thomine, and Barton are the most important. This systematic review of the fibers and strands is designed to help reduce iatrogenic complications.

Plicatura e reinserção da aponeurose do músculo levantador da pálpebra superior com sutura contínua na correção cirúrgica da ptose palpebral leve e moderada-experiência pessoal / Plication and reinsertion of the aponeurosis of the lifting muscle of the upper eyelid with continuous suture in the surgical correction of light and moderate eyelid ptosis - personal experience

Introdução: A blefaroptose ou ptose palpebral caracteriza-se pelo posicionamento anômalo da pálpebra superior em relação à sua posição normal, que é de 1 a 2 mm abaixo do limbo superior da íris; pode variar, apresentando desde uma queda discreta, até a oclusão total da fenda palpebral. Em geral, trata-se de deficiência muscular ou nervosa, de etiologia congênita ou adquirida, que resulta na impossibilidade de elevação completa da pálpebra superior, podendo também ocorrer por desinserção aponeurótica. Apresenta-se neste trabalho a tática da sutura contínua da aponeurose do músculo levantador ao tarso, ou mesmo na sua plicatura, para o tratamento da ptose leve ou moderada. Métodos: No período de 2006 a 2012, foram realizadas 26 cirurgias, abordando a aponeurose do músculo levantador com encurtamento na relação 4:1, usando sutura contínua em duplo sentido, finalizando-a com ponto em formato de oito. Resultados: Em 88,32% dos casos, os resultados foram bons e, em 11,68%, regulares. Apenas um caso evoluiu com retração na pálpebra superior, elevando o sulco palpebral. Observou-se correção incompleta, com ptose residual de 2 a 4 mm em 2 casos, os quais foram submetidos a revisão cirúrgica após 6 meses.

Introduction: Blefaroptose or eyelid ptosis is characterized by the anomalous positioning of the upper eyelid in relation to its normal position, which is 1 to 2 mm below the upper margin of the iris. It can vary from a slight descent to a total occlusion of the eyelid slit. In general, whether caused by a muscular or nerve deficiency, congenital or acquired, it results in the impossibility to use the muscle to raise the eyelid. It can also occur due to the detachment of the aponeurosis. Presented in this study is the tactic of continuous suture of the aponeurosis of the lifting muscle at the tarsus or at its foldings, for the treatment of light or moderate ptosis. Methods: In the period from 2006 to 2012, we analyzed 26 eyelids submitted to surgical treatment. 24 were operated upon, addressing the aponeurosis of the raising muscle with a shortening in the relation of 4:1 and, in 2 cases, with the reinsertion of the aponeurosis in the raising muscle of the eyelid, using continuous two-way suture completing the same with a stitch in a figure eight. Results: In 88.32% of the cases, the results were considered good, and in 11.68% satisfactory.