In the multivariate analysis, multivariate logistic regression with Firth logistic regression demonstrated an association between age and Dupuytren’s contracture [OR 1.045 (95% CI, 1.015–1.077)], as well as trigger finger and Dupuytren’s contracture [OR 308.055 (95% CI, 18.343, >999.999)]. Association with sex was not found to be significant with multivariable logistic regression (Table 4). Trigger finger as a covariate in multivariate analysis initially resulted in a quasi-complete separation and thus firth logistic regression was used to correct for it.
Both Dupuytren’s contracture and stenosing tenosynovitis or trigger finger are frequently encountered by practicing hand surgeons. It is not uncommon in practice to identify patients with clear stenosing flexor tenosynovitis with overlying subtle nodules or cords associated with early Dupuytren’s contracture. As stressed by Burgess, if the surgeon simply opens the A1 pulley without addressing the overlying subtle cord/nodule, he or she may see early progression of Dupuytren’s contracture, which may be of further burden/morbidity for the patient.24 Yet, a myriad of publications exist in the literature regarding both subjects, but the exact pathogenesis of the 2 remains to be elucidated.
Concerning Dupuytren’s contracture, progressive formation of nodules and cords in the palmar fascia leads to flexion contracture of d digits.1 , 2 Histologic studies have shown increased production of type III collagen especially in the early phase as well as imbalance in cellular signal proteins such as transforming growth factor-β, mitogen activated protein kinase, Wnt/β-catenin, etc.25–27 The current accepted model of Dupuytren’s contracture is similar to that of scar formation and maturation.28 In primary idiopathic trigger finger or thumb, a proposed mechanism consists of pathologic inflammatory changes secondary to repetitive friction between the flexor tendon and its enclosing sheath.29 Histologically, fibrocartilaginous metaplasia occurs in the diseased flexor tendon and A1 pulley, which can cause the pulley to triple in thickness.30
Although treatment of trigger finger commonly targets the pathological inflammation with splinting, steroid injection, and percutaneous or open A1 pulley release, treatment of Dupuytren’s contracture focuses on disruption of the pathological fascial nodule and cords with splinting, collagenase injection, needle aponeurotomy, and open palmar fasciectomy.15 , 28 , 31–39 We do not generally offer steroid injections for Dupuytren’s contracture. Although the 2 disease processes seem to be separate and distinct entities, they do share some common risk factors that have been reported in literature including, age, manual labor, diabetes.4 , 7 , 8 , 22 , 23 , 28 , 40 , 41 The validity of these secondary risk factors remains a subject of debate. In our study, age is the only significant risk factor for both Dupuytren’s contracture in both univariate and multivariate analysis. Sex was only significant in univariate analysis. Other factors such as manual labor, diabetes, alcohol, and smoking are not found to be significant, although diabetes was close to reach statistical significance for trigger fingers (Tables 3, 4). This may be due to a lack of power, as a larger sample size may be needed to reach significance. In addition, due to the retrospective nature of the study, we were not able to accurately assess certain variables such as amount of alcohol consumed, degree and length of manual labor performed, etc.
Interestingly, only a few articles have mentioned the possible association between Dupuytren’s contracture and trigger finger in the past. In 1979, Parker42 first reported 5 cases of Dupuytren’s as a plausible cause of trigger finger in 1987, Burgess and Watson24 reported a series of 47 patients with concomitant Dupuytren’s contracture and trigger fingers, and noted a category of patients with Dupuytren’s contracture with involvement of the vertical septa as a cause of tendon constriction. Furthermore, he stressed that operating through Dupuytren’s-involved fascia for stenosing tenosynovitis causes marked postoperative reaction and fibrosis, and thus a concurrent local fasciectomy is warranted.24
In our study, we also noticed a large number of patients suffering from both pathologies (Fig. 1). Comparable to Burgess’ study, we identified 43 patients with Dupuytren’s contracture and stenosing tenosynovitis. A significant association was identified in our univariate and multivariate analyses. In addition to tendon constriction caused by involvement of the vertical septa in Dupuytren’s contracture as pointed out by Burgess, we believe that stenosing tenosynovitis may possibly elicit or worsen Dupuytren’s contracture through the process of inflammation in the neighboring tissue. This inflammation can occur as part of the trigger digit pathology as well as postoperative healing after surgical A1 pulley release. As type III collagen deposition in Dupuytren’s contracture resembles that of scar formation, inflammation involving the tenosynovium may lead to processes of accelerated collagen deposition. And in individuals predisposed to Dupuytren’s contracture whether genetically or simply by carrying a mild subclinical form of the disease, stenosing tenosynovitis may ultimately hasten the clinical presentation of Dupuytren’s contracture.
Although we identified a significant association between the 2 entities in our patient cohort, further studies are needed to identify any direct causation that may exist. Nonetheless, practicing hand surgeons should be aware of the association between these 2 commonly encountered pathologies. It is worthwhile to examine and look for mild or early Dupuytren’s contracture when patients present with trigger digits and vice versa. Patients should be educated preoperatively and a concurrent A1 pulley release and limited local fasciectomy should be considered in select patients. For those patients, an A1 pulley release could be done via individual surgeon’s preferred incisions for limited fasciectomy.
The authors are grateful to Beth Kaczmarek at The Medical Wordsmith for her assistance in the preparation of this article and Dr. Christopher Dodgion for assistance in the statistical analysis.
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