Background
Author | Iselin (1951) [13] | Shaw (1951) [57] | Steinberg (1951) [18] | Luck (1959) [8] | Early (1962) [12] | Chiu and McFarlane (1978) [10] | Tubiana (1968) [17] | Tubiana: Keilholz modification (1996) [14] | Tubiana: Seegenschmiedt modification (2001) [15] |
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Grade or Stage | 0: Small nodules, hand function not affected | 1: Hands with a nodule in the palmar fascia not yet involving the skin and causing no contracture of the fingers | 1: Fibrosis of palmar fascia without contractures | Proliferative stage: nodules in the palm and fingers | 0: Palmar nodules | Early disease: nodules in the palmar fascia without digital contracture | N: Palmar nodule without presence of contracture | As Tubiana | As Tubiana |
1: Nodules and cords in the palm and early contracture of MCPJ | 2: Nodule in the fascia involving the skin but not causing finger flexion deformity | 2: Contractures up to 135° toward the palm | Involutional stage: development of finger flexion contractures | 1 point: total digital deformity of ≤60° | Active disease: nodular thickening with associated digital contracture | 1: Total flexion deformity (TFD) between 0° and 45° | N/1: TFD 1–5 | N/1: TFD 1–10 | |
2: MCPJ contracture up to 30° and early PIPJ contracture | 3: Nodule in the palm invading skin plus flexion contracture of one or more fingers | 3: Contractures up to 90° toward the palm | Residual stage: cord development and finger contractures with joint changes | 2 points: 61 to 120° | Advanced disease: Progressive joint contracture for more than 3 years with diffuse palmar fibrotic thickening | 2: TFD between 45° and 90° | 1: TFD 6–45 | 1: TFD 11–45 | |
3: Contracture of IPJs more than 30° | 4: Includes all stage 3 cases in which the secondary changes have occurred in the tendons or joints of one or more fingers. | 4: Fibrosis of palmar fascia, with flexion deformities of the fingers beyond 90° toward the palm. | 3 points: >120 | 3: TFD between 90° and 135° |
As Tubiana
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As Tubiana
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4: Extreme digital flexion contracture. Sensory and circulatory disturbance | 4: TFD greater than 135° |
As Tubiana
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As Tubiana
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Methods
Inclusion and exclusion criteria
Search methods and identification of studies
Data collection and analysis
Results
Pharmacological therapy
Author (year) treatment | Total cohort of DD patients (hands) | Number of patients (hands) with early DD | Study type | Level of evidence (OCEBM) Prospective (P) Retrospective (R) Not stated (N) | Outcome measure | Results | Recurrence | Adverse events | ||
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Improved | No change | Deteriorated | ||||||||
Steroids | ||||||||||
Baxter (1952) [30], Intramuscular | 11 (16) | 1 (2) | Case study | 5 (N) | Clinical observation of nodules, extension deficit | 0 | 1 | 0 | Not reported | Not reported |
Oral | 1 (2) | Case study | 5 (N) | Clinical observation of palmar fascia | 0 | 1 | 0 | Not reported | Not reported | |
Ketchum (2000) [31], Injection | 63 (75) | 63 (75) | Case series | 4 (N) | Nodule easier to inject and flatter | 62 patients (73 hands) | 0 | 1 patient (2 hands) | 50 % of patients at 1 to 3 years | 50 % patients reported transient depigmentation or temporary subcutaneous atrophy at injection site. ‘Nearly all’ resolved at 6 months |
Clinically observed digital contracture | 0 | 62 patients (73 hands) | 1 patient (2 hands) | |||||||
Shelley (1993) [32], Topical | 2 | 1 | Case study | 5 (N) | Contracture shrinkage | 1 | 0 | 0 | None at 2 years | Not reported |
Zachariae (1955) [33], Injection | 11 (11) | 9 (9) | Case series | 4 (N) | Fibrosis diminished or softer | 9 | 0 | 0 | 1 at 14 months | Not reported |
Coste (1953) [34], Injection | 9 (13) | 2 (2) | Case series | 4 (N) | Clinical observation of nodules, extension deficit | 2 | 0 | 0 | Not reported | Not reported |
Vitamin E (oral) | ||||||||||
Reilly (1974) [35] | 1 (2 hands) | 1 (2 hands) | Case study | 5 (N) | Clinical observation | 0 | 0 | 1 patient (2 hands) | Eventually required surgery in both hands | Not reported |
Richards (1952) [36] | 70 hands | 63 hands | Case series | 4 (N) | Observation, deformity monitored using plaster cast moulds | 0 | 60 | 3 | Not reported | No toxic effects |
Steinberg (1951) [18] | 22 | 6 | Case series | 4 (N) | Clinical observation | 6 | 0 | 0 | Not reported | Not reported |
Other | ||||||||||
Skliarenko (1982) [37], furazolidone injection | 98 | 74 | Case series | 4 (N) | Clinically observed digital contracture | 74 | 0 | 0 | 9 patients in total cohort (4 at 1 year, 3 at 2 years, 2 after 3 years) | 18 of total cohort of 98 reported minor hand swelling, raised temperature after 1st injection. No systemic side effects. |
Gatev (1997) [38], Topical aminosyn and ultrasound | 63 | 22 | Cohort study | 4 (N) | Clinical observation of palm thickening, tension and trembling | 21 | 1 | 0 | Not reported | Not reported |
Topical aminosyn | 4 | 4 | 0 | 0 | ||||||
Ultrasound | 6 | 4 | 2 | 0 | ||||||
Yildiz (2004) [39], Hyperbaric oxygen | 1 | 1 | Case study | 5 (N) | Extension deficit, clinical observation | 1 | 0 | 0 | None at 1 year | No adverse effects. |
Steroids
Intralesional steroid injection
Topical steroids
Oral steroids
Intramuscular steroids
Vitamin E
Other
Physical therapy
Author (year) treatment | Total cohort of DD patients (hands) | Number of patients (hands) with early DD | Study type | Level of evidence (OCEBM) Prospective (P) Retrospective (R) Not stated (N) | Outcome measure | Results | Recurrence | Adverse events | ||
---|---|---|---|---|---|---|---|---|---|---|
Improved | No change | Deteriorated | ||||||||
Markham (1980) [40], Ultrasound | 8 (9 hands) | 3 (4 hands) | Case series | 4 (P) | Digital joint extension in degrees (n = 4) | 2 | (2 had no extension deficit at baseline) | 0 | None | Not reported |
Clinical observation (n = 2) | 1 patient (2 hands) | |||||||||
Hand span (n = 4) | 2 | 2 | ||||||||
Grip strength (n = 4) | 4 | |||||||||
Ball (2002) [41], Splinting | 6 (7 hands) | 5 (6 hands) | Case series | 4 (P) | Active digital joint extension in degrees | 4 patients (5 hands) | 1 patient (1 hand) | 0 | None at 2 years | Not reported |
Larocerie-Salgado, (2012) [42], Splinting | 13 (13 hands) | 2 | Case series | 4 (P) | Digital joint extension in degrees | 2 patients | 0 | 0 | Not reported | Not reported |
Christie (2012) [43], Frictional massage, (Treatment hand) | 1 (2 hands) | 1 (2 hands) | Case study | 5 (P) | Active digital joint extension in degrees | 1 hand (2 digits) | 0 | 0 | Not reported | Not reported |
(Control hand) | 0 | 0 | 1 hand (2 digits) | |||||||
Onat (2013) [44], Heat, splinting, stretching | 3 | 2 | Case series | 5 (N) | Degrees of digital motion | 2 | 0 | 0 | Not reported | Not reported |
Radiotherapy
Author (year) Treatment | Total cohort of DD patients (hands) | Number of patients (hands) with early DD | Study type | Level of evidence (OCEBM) Prospective (P) Retrospective (R) Not stated (N) | Outcome measure | Results | Recurrence | Adverse events | ||
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Improved | No change | Deteriorated | ||||||||
Keilholz (1996) [14] Radiotherapy | (142 hands) | (129 hands) | Case series | 4 (R) | Clinical assessment of consistency and size of nodule | 102 | 25 | 2 | Not reported | EORTCa Grade 1 and 2 toxicity for total cohort. |
Lukacs (1978) [45] Radiotherapy | 36 | 32 | Case series | 4 (N) | Clinical assessment of softening of nodules, contracture improvement | 26 | 6 | 0 | Not reported | Not reported |
Hesselkamp (1981) [46] Radiotherapy | 46 | 46 | Case series | 4 (N) | Clinical assessment of softening of nodules and cords | 24 | 19 | 3 | Not reported | 63 % dry skin with desquamation, 24 % skin atrophy, pigmentation and telangiectasia. |
Adamietz (2001) [47] Radiotherapy | 99 (176 hands) | (156 hands) | Case series | 4 (R) | Tubiana grade | 18 | 79 | 59, (27 within and 32 outside RT field) | At 10 years >20 % N (n = 13), >20 % N/1 (n = 13), 65 % stage 1 (n = 30. | For total cohort of 176 hands at median 10 years, 44 reported strong desquamation and 15 cutaneous telangiectasia with subcutaneous atrophy. |
Kohler (1984) [48] Radiotherapy | 29 (33 hands) | 29 (33 hands) | Case series | 4 (N) | Clinical assessment of softening of DD tissue | 7 | 20 | 6 | 1 outside the radiotherapy area. | Not reported |
Weinzierl 1993) [49] Radiotherapy n = 34 | 39 (56 hands) | 39 (56 hands) | 2 Case series | 4 (N) | Clinical assessment of consistency and size of nodules | 3 | 14 | 17 | Not reported | 32 % had small but ongoing skin change (dry skin). |
Injection Superoxide dismutase n = 22 | 7 | 9 | 6 | Not reported | No local or systemic adverse effects. | |||||
Corsi (1966) [50] Radiotherapy, plesiotherapy plus vitamin E | 11 (13 hands) | 10 (11 hands) | Case series | 4 (N) | Clinical assessment of skin consistency, nodule size and digital extension. | 8 | 3 | 0 | Not reported | Temporary skin rash and epidermolysis noted at end of treatment (number affected not given). |
Grenfell (2014) [51] Radiotherapy | 6 (4 hands) | 3 (4 hands) | Case series | 4 (N) | Clinical assessment whether nodule size and hardness | 4 | 0 | 0 | None at 34–42 months | Acute side effects: minimal fatigue, mild local oedema and erythema for total cohort. Number affected and duration not given. |
Finney (1953) [52] Radiotherapy | 25 | 7 | Case series | 4 (N) | Clinical assessment of functional improvement | 6 | 1 | 0 | None at 2–10 years | 1st degree reaction: skin dryness, slight erythema for total cohort. Number affected not given. |
Finney (1955) [53] Radiotherapy | 18 | 3 | Case series | 4 (N) | Clinical assessment of functional improvement | 3 | 0 | 0 | Not reported | 2nd degree reaction: skin dryness, persistent paraesthesia for total cohort. Number affected not given. Paraesthesia persisting up to 12 months in 2 cases. |
Discussion
Pharmacological therapy
Physical therapy
Radiotherapy
Collagenase
Limitations of the review
Conclusions
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A clear definition of early DD and a consensus on a definition of disease recurrence is also essential to allow comparison between studies.
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All treatment outcomes should be measured using objective, reproducible methods, including:1.Goniometric measurement of extension and flexion of individual joints.2.A reliable and validated measure of nodule consistency and the role of tonometry, which has been used to assess Dupuytren’s pre-and post-surgery [72], should be investigated.3.The use of ultrasound imaging to monitor change in nodule size.4.New disease specific Patient reported outcome measures (PROMs). These need to be developed to gain the patient’s perspective in early disease and to monitor disease progression. PROMS have been developed and validated in advanced disease but these are unlikely to reflect the problems of patients with nodules with little or no contracture.
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Studies should be well designed and adequately powered.
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Safety should be reported and described in all studies.