Echogenicity of Dupuytren's nodules is correlated to myofibroblast load and nodule hardness.

This study aimed to determine the association between the echogenicity of Dupuytren's disease nodules and myofibroblast load, and between echogenicity and nodule hardness. Thirty-eight nodules were assessed sonographically. The echogenicity of nodules was measured objectively with Image J (grey-value) and subjectively by visual inspection (hypo-, mixed and hyper-echogenicity). These findings were compared with myofibroblast load measured by histopathological analysis. In a different cohort, 97 nodules were assessed for grey-value and nodule hardness using a tonometer. There was a moderate, significant, negative association between grey-value and myofibroblast load and the subjective visual measurements corresponded to this finding. There was also a moderate, significant, negative association between grey-value and nodule hardness. Ultrasound and tonometry may be useful in the selection of patients for possible future preventive treatments.

Reliability and Interpretability of Sonographic Measurements of Palmar Dupuytren Nodules.

PURPOSE: In the future, it is expected that treatment of Dupuytren disease (DD) may shift toward control of early disease. Ultrasound might be an accurate method to measure the outcome of such treatment. The aim of this study was to assess the reliability of sonographic measurement of palmar nodules. METHODS: Fifty patients with nodules characteristic for early disease were assessed with ultrasound by 2 observers. Four different aspects of DD nodules were measured in the transversal and sagittal planes, width, depth, circumference, and area. The intra- and interobserver reliabilities were calculated using the intraclass correlation coefficient (ICC). The standard error of measurement (SEM) and the smallest detectable change (SDC) were also calculated for each aspect. RESULTS: The intraobserver reliability was good (ICC, 0.724 [0.562-0.833] to 0.886 [0.808-0.934]), except for width in the sagittal direction (ICC, 0.671 [0.484-0.799]). The interobserver reliability was moderate (ICC, 0.385 [0.126-0.596] to 0.757 [0.538-0.869]). The intraobserver ICCs of area were highest (transverse, 0.847 [0.744-0.893]; sagittal, 0.886 [0.808-0.934]). The SEM and SDC of area were 6.1 and 16.9 mm2 in the transverse and 8.0 and 22.2 mm2 in the sagittal plane. CONCLUSIONS: The intraobserver reliability of sonographic assessment of DD nodules is good. The measurement of area is the most reliable and is, therefore, recommended for future studies. However, even single-observer measurements have a clear dispersion, and a change beyond 16.9 (61%) and 22.2 mm2 (79%) has to be observed in the transverse and sagittal planes, respectively, before it can be considered as regression or progression. CLINICAL RELEVANCE: Repeated ultrasonographic measurements in DD should ideally be done by a single observer, using area of the nodule in the sagittal plane. Change beyond 16.9 (transverse) and 22.2 (sagittal) mm2 can be considered as a real change in nodule size.

Imaging for Dupuytren disease: a systematic review of the literature.

BACKGROUND: As treatment of Dupuytren disease (DD) is expected to shift towards prevention of progression, the use of imaging in patients with DD becomes more important. In this systematic review an overview is given of the different methods for and applications of imaging for DD that have been described. METHODS: The MEDLINE and EMBASE databases were searched for articles reporting the use of imaging in patients with DD, published before May 17, 2018. Studies were systematically examined in two rounds by two observers according to the PRISMA systematic. All studies containing original data on imaging for DD were considered for inclusion. RESULTS: Three hundred and seven unique studies were identified, of which 23 were included in the study. Only studies on the use of ultrasound (US) and magnetic resonance imaging (MRI) were identified. Broadly, articles could be divided into 5 categories. Seven studies were found on diagnosis, two on measurement of disease extent, four on measurement of disease activity, seven on guidance of minimally invasive procedures and five studies on evaluation of treatment. According to the Oxford CEBM, the levels of evidence were low, ranging from level 3 to 5. CONCLUSIONS: A variety of applications for US and MRI for patients with DD has been described. Based on the results of this review, the largest value for imaging lies in the measurement of disease activity and the follow-up of treatment of patients with early stage disease. Unfortunately, the overall level of evidence of the available literature was low. Future research is necessary to define the exact value of US and MRI in the management of patients with DD.

Echogenicity of Palmar Dupuytren's Nodules Is Not a Predictor of Disease Progression in Terms of Increase in Nodule Size.

BACKGROUND: Ultrasound might enable us to measure Dupuytren's disease activity and predict disease progression. The aim of this study was to analyze whether echogenicity of Dupuytren's nodules can be used to predict progression in terms of increase in nodule size. METHODS: Ultrasonographic assessment of a Dupuytren's nodule was performed in 91 patients participating in an existing longitudinal cohort study. Images were scored for echogenicity by two observers. Echogenicity of 89 nodules was matched to growth 1 year later using linear regression analysis. Sensitivity analysis was performed using data obtained 1 year before ultrasound. The interobserver and intraobserver reliability was calculated using the intraclass correlation coefficient. RESULTS: Hypoechogenicity was not a predictor of growth 1 year later (beta = -0.019, p = 0.748). Sensitivity analysis looking at the year before ultrasonographic measurement showed that hypoechogenic nodules were more likely to have grown in the past year (beta = 0.173, p = 0.011). However, these data were influenced by nodules that developed in the year before ultrasound. The intraobserver reliability of echogenicity of Dupuytren's nodules was excellent (intraclass correlation coefficient, 0.996; 95 percent CI, 0.993 to 0.998) and the interobserver reliability was fairly good but imprecise (intraclass correlation coefficient, 0.688; 95 percent CI, 0.329 to 0.977). CONCLUSIONS: Hypoechogenicity is not a predictor of progression in terms of increase in nodule size measured by physical examination 1 year later. When using ultrasound to assess echogenicity of Dupuytren's nodules, the use of a single observer leads to more consistent results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk III.

A Systematic Review and Meta-Analysis on the Strength and Consistency of the Associations between Dupuytren Disease and Diabetes Mellitus, Liver Disease, and Epilepsy.

BACKGROUND: The role of diabetes mellitus, liver disease, and epilepsy as risk factors for Dupuytren disease remains unclear. In this systematic review and meta-analysis, the strength and consistency of these associations were examined. METHODS: The MEDLINE, EMBASE, and Web of Science databases were searched for articles reporting an association between Dupuytren disease and diabetes mellitus, liver disease, and epilepsy published before September 26, 2016. The frequencies of Dupuytren disease and diabetes mellitus, liver disease, and epilepsy were extracted, as was information on potential confounders. Generalized linear mixed models were applied to estimate pooled odds ratios, adjusted for confounders. Heterogeneity between studies was quantified using an intraclass correlation coefficient and was accounted for by a random effect for study. RESULTS: One thousand two hundred sixty unique studies were identified, of which 32 were used in the meta-analyses. An association between Dupuytren disease and diabetes mellitus was observed (OR, 3.06; 95 percent CI, 2.69 to 3.48, adjusted for age), which was stronger for type 1 diabetes mellitus than for type 2 diabetes mellitus but was not statistically significant (p = 0.24). An association between Dupuytren disease and liver disease was observed (OR, 2.92; 95 percent CI, 2.08 to 4.12, adjusted for sex). Dupuytren disease and epilepsy were associated, yielding an OR of 2.80 (95 percent CI, 2.49 to 3.15). Heterogeneity between studies was moderate to low. CONCLUSIONS: These findings demonstrate an association between Dupuytren disease and diabetes mellitus, liver disease, and epilepsy. Prospective, longitudinal studies are needed to elucidate the pathways causing these associations.

Early Postoperative Results of Percutaneous Needle Fasciotomy in 451 Patients with Dupuytren Disease.

BACKGROUND: Percutaneous needle fasciotomy is a minimally invasive treatment modality for Dupuytren disease. In this study, the authors analyzed the efficacy and complication rate of percutaneous needle fasciotomy using a statistical method that takes the multilevel structure of data, regarding multiple measurements from the same patient, into account. METHODS: The data of 470 treated rays from 451 patients with Dupuytren disease that underwent percutaneous needle fasciotomy were analyzed retrospectively. The authors described the early postoperative results of percutaneous needle fasciotomy and applied linear mixed models to compare mean correction of passive extension deficit between joints and efficacy of primary versus secondary percutaneous needle fasciotomy. RESULTS: Mean preoperative passive extension deficits at the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints were 37, 40, and 31 degrees, respectively. Mean preoperative total passive extension deficit was 54 degrees. Results were excellent, with a mean total passive extension deficit correction of 85 percent. Percutaneous needle fasciotomy was most effective for metacarpophalangeal joints and less effective for proximal interphalangeal and distal interphalangeal joints. Secondary percutaneous needle fasciotomy was as effective as primary percutaneous needle fasciotomy. Complications were rare and mostly minor. CONCLUSION: The results of this study confirm that percutaneous needle fasciotomy is an effective and safe treatment modality for patients with mild to moderate disease who prefer a minimally invasive procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Predictors of Complications After Pectoralis Major Transposition for Sternum Dehiscence.

OBJECTIVES: Mediastinitis and sternum dehiscence are serious complications after open heart surgery, causing an increase in hospital stay, utilization of health care resources, and mortality. The defect that results after sternal wound debridement frequently necessitates tissue-flap coverage, for which pectoralis major transposition currently is the preferred method. In this study, the postoperative outcome and individual characteristics of patients undergoing pectoralis major transposition were analyzed to identify predictors of complications after wound closure. METHODS: A retrospective chart review was conducted, covering a 7-year period, focusing on patient and operation characteristics. All patients with sternum dehiscence, who underwent pectoralis major transposition, were included. All postoperative wound complications were graded according to the Clavien-Dindo classification of surgical complications. Complications were further divided in major and minor. Mortality was defined as death within 30 days after sternal wound repair or during hospital stay. RESULTS: In total, 77 patients underwent a pectoralis major transposition repair of the sternum. Thirty-eight patients (49%) developed a wound complication of which 21 (27%) had a major wound complication. Mortality was 9%. Further analyses of our data showed that smoking and length of operation time were predictors of wound complications (P = 0.018 and P = 0.01). Female sex showed a relation with wound redehiscence (P = 0.014). Postoperative bleeding, for which reoperation was necessary, occurred more often when the humeral insertion of the pectoralis major flap was divided (P = 0.004). CONCLUSIONS: Tissue-flap coverage of the sternum using pectoralis major advancement flaps is a procedure that is still hampered by a high postoperative complication incidence. Female sex, smoking, detachment of the humeral insertion and operation time are associated with postoperative wound complications. These results may contribute in improving operative strategy. Also the use of the Clavien-Dindo classification makes underestimation of the complication rate unlikely in this study. The classification can easily be used in future studies, which will enhance comparability of results.