今日の臨床サポート

デュピュイトラン拘縮

著者: 平田仁 名古屋大学 手の外科

著者: 岩月克之 名古屋大学 手の外科

監修: 落合直之 キッコーマン総合病院外科系センター

著者校正/監修レビュー済:2021/06/02
患者向け説明資料
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
平田仁 : 研究費・助成金など(三菱ガス化学株式会社,ニプロ株式会社)[2021年]
岩月克之 : 未申告[2021年]
監修:落合直之 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 酵素注射療法の薬剤(ザイヤフレックス注射用)の入手が困難になっている状況を追記した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. Dupuytren拘縮とは手掌腱膜の肥厚および線維性の硬結やコードが出現し、比較的ゆっくり進行するが、進行に伴い指の屈曲変形、拘縮を生じる疾患である。
  1. 40~60歳以上の男性(5:1~15:1)に多い。
  1. 好発部位は環指、小指、中指の順であり、約半数は両側罹患例である。
  1. 白人、特に北欧人に多いが、黄色人種にもみられる[1][2]
  1. 足底に足底線維腫症、陰茎にペイロニー病、指にknuckle padとよばれる病態を合併することがみられる。
 
足底線維腫症 knuckle pad

手以外の病変
a:両側の足底線維腫症
b:右母趾
c:PIP関節のknuckle pad

 
  1. 原因は不明であるが、家族性、外傷、糖尿病、てんかん、飲酒などがリスクファクターであるといわれている[3][4][5]
  1. 線維芽細胞の量によりproliferative phase, involutional phase, residual phaseに分けられ、それぞれfibroblast, myofibroblast, fibroblastが主な細胞成分である[6][7][8]
  1. Zf9遺伝子やWnt 経路の異常に関連があるという報告がある[9][10]
 
  1. 足底線維腫症合併例59歳 男性
  1. 現病歴
  1. 左手に結節を自覚し、皮膚科を受診。Dupuytren拘縮を疑われ、紹介受診。
  1. 初診時所見
  1. 両環指に結節を認めるが、指の拘縮は進行していない。握力:右40kg、左36kg。疼痛はない。Table top test 陰性。
  1. 両足裏にも腫瘤を触知。
  1. 飲酒なし、喫煙なし、家族歴なし。既往歴:糖尿病、高血圧。
  1. 主たる臨床検査結果とその解釈
  1. 血液検査で糖尿病。
  1. X線像その他画像の解釈と診断結果
  1. 手単純X線 2方向撮影で骨病変はない。
  1. 足部MRI:足底腱膜にT1強調像で低信号、T2強調像で低信号の充実性腫瘤を認め、足底線維腫症が考えられる。
  1. 上記から推定できる病態とその根拠
  1. 両手のDupuytren拘縮(Meyerding Grade 0)およびDupuytren拘縮に合併した足底線維腫症。
  1. 治療計画とインフォームドコンセント
  1. 手の拘縮はほとんど起きていないため、定期的な経過観察を行う。
  1. 治療経過と成績
  1. 初診から2年間の経過観察を行い、拘縮の進行はない。
  1. 追記:
  1. 両側のDupuytren拘縮<図表>
  1. 両足底線維腫症<図表>
  1. 単純X線写真 手と足<図表>
  1. 足底線維腫症のMRI検査所見<図表>
 
Grade0

両環指に結節を認める
a:右手
b:左手

出典

img1:  著者提供
 
 
 
足底線維腫症

両足に足底線維腫症を認める。
a:右足
b:左足

出典

img1:  著者提供
 
 
 
単純X線画像

特記すべき所見はない。
a:右手
b:右足

出典

img1:  著者提供
 
 
 
足底線維腫症MRI画像

T1強調像で低信号、T2強調像で低信号。腱との境界は明瞭である。
a:T1強調像 sagittal image
b:T2強調像 sagittal image
c:T1強調像 axial image
d:T2強調像 axial image

出典

img1:  著者提供
 
 
問診・診察のポイント  
問診:
  1. 発症時期を確認する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
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文献 

著者: Robert M McFarlane
雑誌名: J Hand Surg Am. 2002 May;27(3):385-90.
Abstract/Text The first author to suggest an origin and spread of Dupuytren's disease was Early who wrote in 1962, "If one postulates the condition as having arisen in one particular racial group (the Nordic for example) then the variable distribution in other parts of the world might be explained on the basis of migration from that group." Dupuytren's disease is currently called a Viking disease on the assumption that the disease was spread to Europe and the British Isles during the Viking Age of the 9th to the 13th centuries. From a literature search, it is proposed that Dupuytren's disease existed in Europe earlier than the Viking Age and originated much earlier in prehistory.

PMID 12015711  J Hand Surg Am. 2002 May;27(3):385-90.
著者: David Slattery
雑誌名: ANZ J Surg. 2010 Jul-Aug;80(7-8):495-9. doi: 10.1111/j.1445-2197.2010.05364.x.
Abstract/Text BACKGROUND: The presentation of a Chinese patient with unilateral Dupuytren's disease (DD) prompted a literature search and a review of the epidemiology of DD in the Asian population as it has never been cumulatively reported. The purpose of this paper is to review all the reported cases of DD in the literature and aetiological links to DD elsewhere.
METHODS: The literature was searched with a wide variety of terms, and subsequent references were analysed and further references investigated for other reported cases of DD in the Asian population.
RESULTS: This review found 595 cases and has shown that DD is present to a variable extent in China (96 cases), Thailand (19 cases), Vietnam (one case), India (15 cases) and Japan (474 cases). A total of 54% had bilateral disease. Risk factors (diabetes, trauma, epilepsy, alcoholism, manual labour) were reportedly present in 65% of the patients, and a positive family history was reported in 9%. The average patient age was 67 years.
CONCLUSION: This review shows that there is a low but significant incidence of DD across Asia, which supports the hypothesis of a widespread genetic susceptibility to the disease. Therefore, the prevalence of DD in this community is not likely due to sporadic genetic mutation as previously presumed but rather individual genetic susceptibility and that risk factors play a major role in the expression of DD in this population.

PMID 20795961  ANZ J Surg. 2010 Jul-Aug;80(7-8):495-9. doi: 10.1111/j.・・・
著者: I S Yi, G Johnson, M S Moneim
雑誌名: Hand Clin. 1999 Feb;15(1):43-51, vi.
Abstract/Text The etiology of Dupuytren's disease is still unknown in spite of significant recent advances in identifying the type of cell responsible for initiating the process. Associated factors such as alcoholism, smoking, work, diabetes, and epilepsy are discussed. The course of the disease in men as compared with women is also discussed. Recent evidence has shown that there may be genetic and immunologic factors involved. Superoxide free radicals and their effect on fibroblast proliferation may play a significant role in the disease process.

PMID 10050241  Hand Clin. 1999 Feb;15(1):43-51, vi.
著者: J M Geoghegan, J Forbes, D I Clark, C Smith, R Hubbard
雑誌名: J Hand Surg Br. 2004 Oct;29(5):423-6. doi: 10.1016/j.jhsb.2004.06.006.
Abstract/Text Dupuytren's is a common problem, but little is known about its aetiology. We have undertaken a large case-control study to assess and quantify the relative contributions of diabetes and epilepsy as risk factors for Dupuytren's in the community. Cases were patients with a diagnosis of Dupuytren's disease and, for each, two controls were individually matched by age, sex, and general practice. Our dataset included 821 cases and 1,642 controls. Five hundred and eighty-eight (72%) of the cases were men. The mean age at diagnosis was 62 (range 24-97) years. Diabetes was a significant risk factor for Dupuytren's disease (OR=1.75) and there was an increased risk for medicinally treated diabetes (metformin--OR=3.56; sulphonylureas--OR=1.75) and particularly insulin controlled (OR=4.38) rather than diet-controlled diabetes. Epilepsy (OR=1.12) and anti-epileptic medications were not associated with Dupuytren's disease. Ascertainment bias in previous studies may explain the reported association with epilepsy.

PMID 15336742  J Hand Surg Br. 2004 Oct;29(5):423-6. doi: 10.1016/j.jh・・・
著者: Nina S Godtfredsen, Hasse Lucht, Eva Prescott, Thorkild I A Sørensen, Morten Grønbaek
雑誌名: J Clin Epidemiol. 2004 Aug;57(8):858-63. doi: 10.1016/j.jclinepi.2003.11.015.
Abstract/Text OBJECTIVE: To address the role of alcohol intake and tobacco smoking and the combination of the two on subsequent risk of Dupuytren's disease.
STUDY DESIGN AND SETTING: Cohort study of 7,254 subjects enrolled in the Copenhagen City Heart Study (1981-1983). Both self-reported information on lifestyle and objective measures at the baseline examination were linked to presence of Dupuytren's disease at a subsequent examination (1991-1994) using multivariate logistic regression analysis.
RESULTS: A total of 772 subjects had signs of Dupuytren's disease at follow-up. After adjustment for age, sex, educational level, diabetes, and either alcohol or tobacco consumption, respectively, odds ratios for having the disease increased in a dose-dependent manner with increasing levels of alcohol or tobacco intake; however, there was no statistical interaction between heavy smoking and heavy drinking.
CONCLUSION: Alcohol intake and tobacco smoking are independently associated with increased risk of Dupuytren's disease, and the combination of the two conveys a very large risk.

PMID 15485739  J Clin Epidemiol. 2004 Aug;57(8):858-63. doi: 10.1016/j・・・
著者: H F Chiu, R M McFarlane
雑誌名: J Hand Surg Am. 1978 Jan;3(1):1-10.
Abstract/Text The tissue from 38 patients with Dupuytren's contracture was submitted for light and electron microscopy. The clinical and pathological data were correlated so that three stages of disease were recognized: early, active, and advanced. The cell of early disease was the perivascular fibroblast; whereas, the cell of active disease was the myofibroblast. Because the myofibroblasts have cell-to-cell and cell-to-stroma attachments, the collagen not only becomes oriented as it is formed, but it also is subjected to a contractile force.

PMID 621363  J Hand Surg Am. 1978 Jan;3(1):1-10.
著者: J V LUCK
雑誌名: J Bone Joint Surg Am. 1959 Jun;41-A(4):635-64.
Abstract/Text
PMID 13664703  J Bone Joint Surg Am. 1959 Jun;41-A(4):635-64.
著者: Ardeshir Bayat, J Stewart Watson, John K Stanley, Mark W J Ferguson, William E R Ollier
雑誌名: Plast Reconstr Surg. 2003 Jun;111(7):2133-9. doi: 10.1097/01.PRS.0000060531.98180.32.
Abstract/Text Transforming growth factor beta 1 (TGF-beta 1) is a key fibrogenic cytokine that has been shown to stimulate fibroblast proliferation and extracellular matrix deposition and has been implicated in the pathogenesis of Dupuytren disease. Zf9 is a transcription factor that increases TGF-beta 1 expression in tissue. The authors previously demonstrated a lack of association between common TGF-beta 1 and TGF-beta 2 polymorphisms and Dupuytren disease. Therefore, Zf9 transcription factor represents an additional candidate susceptibility gene for investigating hereditary predisposition to Dupuytren disease. Dupuytren disease, or Dupuytren contracture, is a progressive and recurrent fibroproliferative disease of unknown etiology that affects the human hands. It is often a familial disorder affecting Northern European Caucasians. Genes implicated in the development of Dupuytren disease have not yet been found. Using a polymerase chain reaction-restriction fragment polymorphism method, the authors genotyped a novel single nucleotide polymorphism in the 3' untranslated region of the Zf9 gene. A case-control association study of 138 patients with Dupuytren disease versus 255 controls demonstrated a statistically significant difference in the genotype and allele frequencies between patients and controls for Zf9 gene polymorphism. Presence of the G allele versus the A allele is associated with an increased risk of developing Dupuytren disease (odds ratio, 1.9; 95 percent confidence interval, 1.2 to 2.9). The authors believe this to be the first report of a positive genetic association study in Dupuytren disease using single nucleotide polymorphisms.

PMID 12794452  Plast Reconstr Surg. 2003 Jun;111(7):2133-9. doi: 10.10・・・
著者: Guido H Dolmans, Paul M Werker, Hans C Hennies, Dominic Furniss, Eleonora A Festen, Lude Franke, Kerstin Becker, Pieter van der Vlies, Bruce H Wolffenbuttel, Sigrid Tinschert, Mohammad R Toliat, Michael Nothnagel, Andre Franke, Norman Klopp, H-Erich Wichmann, Peter Nürnberg, Henk Giele, Roel A Ophoff, Cisca Wijmenga, Dutch Dupuytren Study Group, German Dupuytren Study Group, LifeLines Cohort Study, BSSH-GODD Consortium
雑誌名: N Engl J Med. 2011 Jul 28;365(4):307-17. doi: 10.1056/NEJMoa1101029. Epub 2011 Jul 6.
Abstract/Text BACKGROUND: Dupuytren's disease is a benign fibromatosis of the hands and fingers that leads to flexion contractures. We hypothesized that multiple genetic and environmental factors influence susceptibility to this disease and sought to identify susceptibility genes to better understand its pathogenesis.
METHODS: We conducted a genomewide association study of 960 Dutch persons with Dupuytren's disease and 3117 controls (the discovery set) to test for association between the disease and genetic markers. We tested the 35 single-nucleotide polymorphisms (SNPs) most strongly associated with Dupuytren's disease (P<1×10(-4)) in the discovery set in three additional, independent case series comprising a total of 1365 affected persons and 8445 controls from Germany, the United Kingdom, and The Netherlands.
RESULTS: Initially, we observed a significant genomewide association between Dupuytren's disease and 8 SNPs at three loci. Tests of replication and joint analysis of all data from 2325 patients with Dupuytren's disease and 11,562 controls yielded an association with 11 SNPs from nine different loci (P<5.0×10(-8)). Six of these loci contain genes known to be involved in the Wnt-signaling pathway: WNT4 (rs7524102) (P=2.8×10(-9); odds ratio, 1.28), SFRP4 (rs16879765) (P=5.6×10(-39); odds ratio, 1.98), WNT2 (rs4730775) (P=3.0×10(-8); odds ratio, 0.83), RSPO2 (rs611744) (P=7.9×10(-15); odds ratio, 0.75), SULF1 (rs2912522) (P=2.0×10(-13); odds ratio, 0.72), and WNT7B (rs6519955) (P=3.2×10(-33); odds ratio, 1.54).
CONCLUSIONS: This study implicates nine different loci involved in genetic susceptibility to Dupuytren's disease. The fact that six of these nine loci harbor genes encoding proteins in the Wnt-signaling pathway suggests that aberrations in this pathway are key to the process of fibromatosis in Dupuytren's disease.

PMID 21732829  N Engl J Med. 2011 Jul 28;365(4):307-17. doi: 10.1056/N・・・
著者: J T Hueston
雑誌名: Hand. 1982 Feb;14(1):100-3.
Abstract/Text
PMID 7060997  Hand. 1982 Feb;14(1):100-3.
著者: M E Yacoe, A G Bergman, A L Ladd, B H Hellman
雑誌名: AJR Am J Roentgenol. 1993 Apr;160(4):813-7. doi: 10.2214/ajr.160.4.8456670.
Abstract/Text OBJECTIVE: Dupuytren's contracture is a common fibrosing disorder of the hand which often results in progressive and debilitating flexion contractures of the fingers. Recurrence after surgical release is common and may be related, in part, to the cellularity of the lesion. We describe the MR appearance of Dupuytren's contracture and correlate signal characteristics with the degree of cellularity of the lesion.
SUBJECTS AND METHODS: A total of 11 hands in 10 patients were studied. All patients had surgical resection after MR imaging (median interval, 3 days). The surgical and pathologic findings were correlated with the MR findings. The signal characteristics of the lesions were correlated with the histologic findings.
RESULTS: We found that MR imaging was accurate for detecting Dupuytren's contracture and depicting its extent. The lesions include subcutaneous nodules, usually at the level of the distal palmar crease, and cords that lie parallel and superficial to the flexor tendons. The cords had a uniformly low signal intensity (similar to the signal intensity of tendon) on both T1- and T2-weighted images in 18 of 22 cases, whereas the remaining four cases had a low to intermediate signal intensity on T1-weighted images (a slightly higher signal intensity than that of tendon) and a low signal intensity on T2-weighted images. Histologically, the cords were hypocellular and composed of dense collagen. Most nodules had an intermediate signal intensity (similar to that of muscle) on both T1- and T2-weighted images (10 of 13 cases), usually stippled with focal areas of lower signal intensity. Histologically, these nodules were mostly cellular. Three of the nodules had a low signal intensity on both T1- and T2-weighted images and were hypocellular histologically.
CONCLUSION: We conclude that MR imaging can be used to define palmar involvement in Dupuytren's contracture. The signal characteristics of the lesions correlate with the degree of cellularity of the lesions as seen histologically. The ability to assess preoperatively the cellularity of lesions of Dupuytren's contractures may be of prognostic significance, because highly cellular lesions tend to have higher rates of recurrence after surgery than do hypocellular lesions.

PMID 8456670  AJR Am J Roentgenol. 1993 Apr;160(4):813-7. doi: 10.221・・・
著者: A von Campe, K Mende, H Omaren, C Meuli-Simmen
雑誌名: J Hand Surg Am. 2012 Jul;37(7):1313-8. doi: 10.1016/j.jhsa.2012.03.014. Epub 2012 May 4.
Abstract/Text PURPOSE: The etiology of Dupuytren disease is unclear. Pain is seldom described in the literature. Patients are more often disturbed by impaired extension of the fingers. We recently treated a series of patients who had had painful nodules for more than 1 year, and we therefore decided to investigate them for a possible anatomical correlate.
METHODS: Biopsies were taken during surgery from patients with Dupuytren disease and stained to enable detection of neuronal tissue.
RESULTS: We treated 17 fingers in 10 patients. Intraoperatively, 10 showed tiny nerve branches passing into or crossing the fibrous bands or nodules. Of 13 biopsies, 6 showed nerve fibers embedded in fibrous tissue, 3 showed perineural or intraneural fibrosis or both, and 3 showed true neuromas. Enlarged Pacinian corpuscles were isolated from 1 sample. All patients were pain free after surgery.
CONCLUSIONS: Although Dupuytren disease is generally considered painless, we treated a series of early stage patients with painful disease. Intraoperative inspection and histological examination of tissue samples showed that nerve tissue was involved in all cases. The pain might have been due to local nerve compression by the fibromatosis or the Dupuytren disease itself. We, therefore, suggest that the indication for surgery in Dupuytren disease be extended to painful nodules for more than 1 year, even in the early stages of the disease in the absence of functional deficits, with assessment of tissue samples for histological changes in nerves.

Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
PMID 22560560  J Hand Surg Am. 2012 Jul;37(7):1313-8. doi: 10.1016/j.j・・・
著者: Ilse Degreef, Luc De Smet
雑誌名: Acta Orthop Belg. 2011 Feb;77(1):27-32.
Abstract/Text In order to investigate the prognostic value of possible risk factors for Dupuytren's diathesis, clinical parameters on disease presentation in an operated group of patients were compared with self-reported recurrence after a minimum 2 years follow-up. In order of significance, the following factors were found to be significantly correlated with disease recurrence : age of onset under 50 years (p = 0.01), bilateral disease (p = 0.01), Ledderhose disease (p = 0.01), first ray involvement (p = 0.02), multiple ray involvement (more than 2 digits, p = 0.02), ectopic fibromatosis (p = 0.02), family occurrence (p = 0.04) and male gender (p = 0.05). No correlation of self-reported disease recurrence was seen with diabetes, frozen shoulder syndrome or epilepsy. An insight in the significance of the influence of specific risk factors on recurrence rates, helps in creating a clearer representation of Dupuytren's diathesis. This will help the surgeon to more accurately inform the patient and possibly to reconsider and adjust the choice in treatment options.

PMID 21473442  Acta Orthop Belg. 2011 Feb;77(1):27-32.
著者: A C Smith
雑誌名: Hand Clin. 1991 Nov;7(4):635-42; discussion 643.
Abstract/Text Dupuytren's disease is a common problem in most hand surgery practices. It is usually easily diagnosed by the presence of its primary palmar manifestations: the nodule, the cord, and the digital flexion contracture. The isolated nodule may occasionally require biopsy to rule out the possibility of malignancy, but this is unusual. The nodule is typically the first lesion to appear and is the site of active biologic activity. The cord is the pathologically thickened and shortened normal longitudinal fascial structure of the palm and digit. Its insertion distal to the MPJ or PIP accounts for the progressive flexion contracture of these joints. Secondary findings include knuckle pads, plantar fascial nodules, and penile fascial contracture, which may signal the presence of Dupuytren's diathesis, a particularly aggressive form of the disease. The need and advisability of surgical intervention should be determined in close consultation with the patient after becoming thoroughly familiar with functional deficits and specific functional goals. A flexion contracture of more than 30 degrees at the MPJ or any contracture at the PIP is generally thought to be an indication for palmar fasciectomy. Patients should be aware of potential complications, those in higher risk categories should be identified preoperatively. Details of the operative procedure and variations in technique are discussed in subsequent articles in this issue.

PMID 1769986  Hand Clin. 1991 Nov;7(4):635-42; discussion 643.
著者: L C Hurst, M A Badalamente
雑誌名: Hand Clin. 1999 Feb;15(1):97-107, vii.
Abstract/Text Many nonoperative therapies have been investigated for the treatment of Dupuytren's disease. These include needle fasciotomy, continuous slow skeletal traction, radiation, dimethyl sulfoxide, vitamin E, allopurinol, physical therapy, ultrasound therapy, steroid injections, radiation, interferon, splinting, and enzymatic fasciotomy. Most of these therapies have not proven to be clinically useful. However, recent investigation of enzymatic fasciotomy using collagenase injection has shown encouraging results.

PMID 10050246  Hand Clin. 1999 Feb;15(1):97-107, vii.
著者: Lawrence C Hurst, Marie A Badalamente, Vincent R Hentz, Robert N Hotchkiss, F Thomas D Kaplan, Roy A Meals, Theodore M Smith, John Rodzvilla, CORD I Study Group
雑誌名: N Engl J Med. 2009 Sep 3;361(10):968-79. doi: 10.1056/NEJMoa0810866.
Abstract/Text BACKGROUND: Dupuytren's disease limits hand function, diminishes the quality of life, and may ultimately disable the hand. Surgery followed by hand therapy is standard treatment, but it is associated with serious potential complications. Injection of collagenase clostridium histolyticum, an office-based, nonsurgical option, may reduce joint contractures caused by Dupuytren's disease.
METHODS: We enrolled 308 patients with joint contractures of 20 degrees or more in this prospective, randomized, double-blind, placebo-controlled, multicenter trial. The primary metacarpophalangeal or proximal interphalangeal joints of these patients were randomly assigned to receive up to three injections of collagenase clostridium histolyticum (at a dose of 0.58 mg per injection) or placebo in the contracted collagen cord at 30-day intervals. One day after injection, the joints were manipulated. The primary end point was a reduction in contracture to 0 to 5 degrees of full extension 30 days after the last injection. Twenty-six secondary end points were evaluated, and data on adverse events were collected.
RESULTS: Collagenase treatment significantly improved outcomes. More cords that were injected with collagenase than cords injected with placebo met the primary end point (64.0% vs. 6.8%, P < 0.001), as well as all secondary end points (P < or = 0.002). Overall, the range of motion in the joints was significantly improved after injection with collagenase as compared with placebo (from 43.9 to 80.7 degrees vs. from 45.3 to 49.5 degrees, P < 0.001). The most commonly reported adverse events were localized swelling, pain, bruising, pruritus, and transient regional lymph-node enlargement and tenderness. Three treatment-related serious adverse events were reported: two tendon ruptures and one case of complex regional pain syndrome. No significant changes in flexion or grip strength, no systemic allergic reactions, and no nerve injuries were observed.
CONCLUSIONS: Collagenase clostridium histolyticum significantly reduced contractures and improved the range of motion in joints affected by advanced Dupuytren's disease. (ClinicalTrials.gov number, NCT00528606.)

2009 Massachusetts Medical Society
PMID 19726771  N Engl J Med. 2009 Sep 3;361(10):968-79. doi: 10.1056/N・・・
著者: S M Crean, R A Gerber, M P Hellio Le Graverand, D M Boyd, J C Cappelleri
雑誌名: J Hand Surg Eur Vol. 2011 Jun;36(5):396-407. doi: 10.1177/1753193410397971. Epub 2011 Mar 7.
Abstract/Text A structured review of published papers was done to assess the efficacy and safety of fasciectomy and fasciotomy in European patients with Dupuytren's contracture. The outcomes varied across 48 studies. For fasciectomy, outcomes and results were as follows: the proportions of patients with a 100% correction in contracture angle ranged from 61 to 97%, the mean improvement in contracture angle ranged from 58 to 79%, and cases judged excellent/good ranged from 63 to 90%. Fasciotomy had similar outcomes, with a mean improvement in contracture angle ranging from 46 to 88%. Immediate failures upon recovery were reported for both procedures. The average recurrence rates were 39% after a fasciectomy and 62% after a fasciotomy at a median time of about 4 years. Overall, about 20% of fasciectomy and fasciotomy patients experienced an adverse event. In summary, postoperative outcomes were successful, but surgical complications were common and recurrence of a contracture was likely within a few years.

PMID 21382860  J Hand Surg Eur Vol. 2011 Jun;36(5):396-407. doi: 10.11・・・
著者: Barbara Shih, Ardeshir Bayat
雑誌名: Nat Rev Rheumatol. 2010 Dec;6(12):715-26. doi: 10.1038/nrrheum.2010.180. Epub 2010 Nov 9.
Abstract/Text Dupuytren disease (DD) is a fibroproliferative disorder of unknown etiology that often results in shortening and thickening of the palmar fascia, leading to permanent and irreversible flexion contracture of the digits. This Review provides a detailed update of the scientific understanding of DD and its clinical management, with perspectives on emerging research and therapy. Established risk factors include genetic predisposition and ethnicity, as well as sex and age. Several environmental risk factors (some considered controversial) include smoking, alcohol intake, trauma, diabetes, epilepsy and use of anticonvulsant drugs, and exposure to vibration. DD has been variously attributed to the presence of oxygen free radicals, trauma to the palmar fascia, or aberrant immune responses with altered antigen presentation, or to interactions between these proposed mechanisms. The presence of immune cells and related phenomena in DD-affected tissue suggests that DD is possibly immune-related. Mechanically, digital contracture is caused by myofibroblasts in the DD palmar fascia; however, the exact origin of this cell type remains unknown. The mainstay of treatment is surgical release or excision of the affected palmodigital tissue, but symptoms often recur. Nonsurgical correction of DD contractures can be achieved by Clostridium histolyticum collagenase injection, although the long-term safety and recurrence rate of this procedure requires further assessment.

PMID 21060335  Nat Rev Rheumatol. 2010 Dec;6(12):715-26. doi: 10.1038/・・・
著者: C R MCCASH
雑誌名: Br J Plast Surg. 1964 Jul;17:271-80.
Abstract/Text
PMID 14191131  Br J Plast Surg. 1964 Jul;17:271-80.
著者: R Prosser, W B Conolly
雑誌名: J Hand Ther. 1996 Oct-Dec;9(4):344-8.
Abstract/Text Dupuytren's disease is a proliferative fibroplasia that can lead to a significant contracture of the metacarpophalangeal (MCP) and interphalangeal (IP) joints, causing a functional disability. Surgical excision of the Dupuytren's tissue and release of the contracted joints may be necessary to restore function. Most patients require hand therapy postoperatively. Postoperative complications have been reported at 17%. These include excessive inflammation, hematoma, ischemic skin necrosis, infection, granuloma formation, transient paresthesia, scar contracture, persistent proximal interphalangeal (PIP) flexion contracture, distal interphalangeal (DIP) hyperextension deformity, joint stiffness, poor flexion and grip strength, pain, and reflex sympathetic dystrophy (RSD). The hand therapist plays a vital role in the early detection and treatment of many of these complications.

PMID 8994009  J Hand Ther. 1996 Oct-Dec;9(4):344-8.
著者: R TUBIANA
雑誌名: J Bone Joint Surg Am. 1955 Dec;37-A(6):1155-68.
Abstract/Text
PMID 13271462  J Bone Joint Surg Am. 1955 Dec;37-A(6):1155-68.
著者: P A Mullins
雑誌名: Hand Clin. 1999 Feb;15(1):167-74, viii.
Abstract/Text Postoperative rehabilitation is an important component in the management of Dupuytren's disease patients. Through an effective splinting and exercise program, the surgical outcome can be enhanced. Treatment should be directed toward restoring hand function and monitoring development of complications that could compromise the outcome.

PMID 10050252  Hand Clin. 1999 Feb;15(1):167-74, viii.
著者: N Weinzweig, J E Culver, E J Fleegler
雑誌名: Plast Reconstr Surg. 1996 Mar;97(3):560-6; discussion 567.
Abstract/Text Severe proximal interphalangeal joint contracture in Dupuytren's disease presents a frustrating problem for hand surgeon. Some surgeons argue for fasciectomy alone, avoiding violation of the proximal interphalangeal joint, which may prolong morbidity and result in permanent limitation of flexion; this loss of flexion can be more disabling than a mild flexion contracture. Others favor capsulotomy in addition to fasciectomy, especially for severe contractures, to obtain additional release, arguing that one cannot completely correct secondary contracture by fasciectomy alone. We performed a retrospective review of severe flexion contractures (60 degrees or greater) involving 42 proximal interphalangeal joints in 28 patients with Dupuytren's disease. Twenty-seven joints in 18 patients underwent fasciectomy alone, and 15 joints in 10 demographically similar patients underwent capsulotomy in addition to fasciectomy. In the noncapsulotomy group, preoperative contracture averaged 78.4 degrees. Postoperative contracture averaged 36.6 degrees, with a 53 percent improvement. In the capsulotomy group, preoperative joint contracture averaged 82.5 degrees. Postoperative contracture averaged 36.8 degrees, with a 55 percent improvement. Intraoperative residual contracture for 21 of the 27 joints in the noncapsulotomy group averaged 7 degrees compared with 8 degrees for 9 of the 15 joints in the capsulotomy group. Preoperative proximal interphalangeal joint flexion averaged 100.6 degrees in the noncapsulotomy group and 98.6 degrees in the capsulotomy group. Postoperative flexion averaged 92.2 degrees in the noncapsulotomy group, which was 91.7 percent of preoperative flexion, and 82.7 degrees, which was 83.9 percent of preoperative flexion, in the capsulotomy group. No statistically significant difference was seen in the percentage of contracture correction in the capsulotomy group compared with the noncapsulotomy group at follow-up. The degree of correction initially obtained at surgery using either method was not maintained during the short follow-up period. There was a significant decrease in postoperative proximal interphalangeal joint flexion compared with preoperative flexion following either surgical approach; however, there was no significant difference between the two groups with respect to the percentage of flexion lost. Complications developed in both groups but tended to occur more commonly in the capsulotomy group. This study failed to show any advantage to capsuloligamentous release in addition to fasciectomy in treating severe proximal interphalangeal joint contracture due to Dupuytren's disease.

PMID 8596787  Plast Reconstr Surg. 1996 Mar;97(3):560-6; discussion 5・・・
著者: Debbie Larson, Christina Jerosch-Herold
雑誌名: BMC Musculoskelet Disord. 2008 Jul 21;9:104. doi: 10.1186/1471-2474-9-104. Epub 2008 Jul 21.
Abstract/Text BACKGROUND: Splinting after contracture release for Dupuytren's disease of the hand is widely advocated. The purpose of this systematic review was to evaluate the quantity and quality of evidence regarding the effectiveness of splinting in the post-surgical management of Dupuytren's contractures.
METHODS: Studies were identified by searching the electronic databases Medline, AMED, CINAHL and EMBASE. Studies were included if they met the following inclusion criteria: prospective or retrospective, experimental, quasi-experimental or observational studies investigating the effectiveness of static or dynamic splints worn day and/or night-time for at least 6 weeks after surgery and reporting either individual joint or composite finger range of motion and/or hand function. The methodological quality of the selected articles was independently assessed by the two authors using the guidelines for evaluating the quality of intervention studies developed by McDermid.
RESULTS: Four studies, with sample sizes ranging from 23 to 268, met the inclusion criteria for the systematic review. Designs included retrospective case review, prospective observational and one controlled trial without randomisation. Interventions included dynamic and static splinting with a mean follow-up ranging from 9 weeks to 2 years. Pooling of results was not possible due to the heterogeneity of interventions (splint type, duration and wearing regimen) and the way outcomes were reported.
CONCLUSION: There is empirical evidence to support the use of low load prolonged stretch through splinting after hand surgery and trauma, however only a few studies have investigated this specifically in Dupuytren's contracture. The low level evidence regarding the effect of post-operative static and dynamic splints on final extension deficit in severe PIP joint contracture (>40 degrees ) is equivocal, as is the effect of patient adherence on outcome. Whilst total active extension deficit improved in some patients wearing a splint there were also deficits in composite finger flexion and hand function. The lack of data on the magnitude of this effect makes it difficult to interpret whether this is of clinical significance. There is a need for well designed controlled trials with proper randomisation to evaluate the short-term and long-term effectiveness of splinting following Dupuytren's surgery.

PMID 18644117  BMC Musculoskelet Disord. 2008 Jul 21;9:104. doi: 10.11・・・

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