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Dupuytren's contracture
LETTERS TO THE EDITOR Dupuytren's contracture To the Editor: Dr. Hoopes and his team! have presented a most interesting paper for all concerned with Dupuytren's contracture. That recurrence after surgical excision of Dupuytren's contracture is reduced or eliminated by replacing the local overlying skin with a skin graft from another area was suggested by Piulachs and Mir-Mir in 1952. Since 1973 we have been treating Dupuytren's disease, excising both the diseased palmar fascia and the overlying skin, leaving the cutaneous defects open to heal by second intention. 3 • 4 The results have been surprisingly good, not only as far as correction and final cosmesis, but also as we have had no recurrence over a series of 183 cases. This seems to prove Hoopes et al. 's thesis from a clinical point of view. However, it would be interesting to know if the dermis overlying a nodule is enzimatically more active than the skin overlying a band. J. E. Beltran, M.D., Ph.D ., F.R.C .S.(Engl.) Chief, Hand and Foot Division Department of Orthopaedic Surgery C. S. "Principes de Espana" Hospitalet Barcelona, Spain
REFERENCES I. Hoopes JE, Jabaley ME, Su CoT, et al: Enzymes of glucose metabolism in palmar fascia and Dupuytren's contracture. J HAND SURG 2:62-65, 1977 2. Piulachs P, Mir-Mir A: Consideraciones sobre la enfermedad de Dupuytren. Folia Clin Int (Bare) 2:8, 1952 3. Beltran JE, Jimeno F, Moreta D: The open palm and digit technique in the treatment of Dupuytren's contracture. Hand 8:73-77, 1976 4. Beltran JE: La fasciectomia digito-palmar abierta en el tratamiento de la enfermedad de Dupuytren. Rev Ortop TraumatoI21:187-196,1977
Reply To the Editor: The authors wish to thank Dr. Beltran for his comments concerning our paper and his clinical information correlating with our data. We have felt that a weak point of our paper was the lack of comparison of enzyme activities between nodules vs. bands of Dupuytren's contracture. Following Dr . Beltran's suggestion, we have assayed hexokinase and glucose 6-phosphate dehydrogenase activity in tissues obtained from a patient, 56 years of age, with a progressive contracture for I to 2 years. Small pieces (I mm in thickness) of palmar skin, involved and uninvolved, were obtained at operation,
Table I. Comparison of enzyme activities in the band and nodule of Dupu ytren' s contracture* Glucose 6phosphate dehydrogenase Tissues Fascia Uninvolved Band Nodule Dennis Uninvolved Band Nodule Epidennis Uninvolved Band Nodule
1
Hexokinase
1
%
No.
0.055 0.098 0.230
100 178 418
0.029 0.083 0.165
100 286 569
0.084 0.195 0.161
100 232 192
0.056 0.076 0.107
100 136 191
0.76 0.60 0.92
100 79 120
0.51 0.44 0.54
100 86 106
No.
%
• Enzyme activities are expressed as moles of substrate converted per hour per kilogram of dry weight. Each assay is in quintuplicate.
frozen in liquid nitrogen, sectioned 20 micron in thickness in a cryostat, and lyophilized. Microdissection separated the epidermis, dermis (reticular layer), and contracted fascia (2 to 5 f.Lg). Enzyme activities were measured fluorometrically in a volume of 10 f.LI of an appropriate reagent mixture. As demonstrated in the accompanying table (Table I), the dermis overlying nodules and bands of Dupuytren's contracture exhibited greater enzyme activities than dermis overlying uninvolved fascia. Hexokinase was more active in the dermis overlying nodules than in the dermis overlying bands, whereas glucose 6-phosphate dehydrogenase activity was less in the dermis overlying nodules than in the dermis overlying bands. Bands exhibited less enzyme activities than nodules. We look forward to adding more data to these preliminary results. Chi-Tsung Su, M.D . E. F. Shaw Wi/gis, M.D . John E. Hoopes, M.D. Division of Plastic Surgery The Johns Hopkins University School of Medicine Baltimore, MD 21205
Not in favor of standing to do hand surgery To the Editor: Kilgore and Newman,l in their recent article on standing to do hand surgery, made many good points regarding hand surgery-e.g., hand surgery is intricate THE JOURNAL OF HAND SURGERY
299
REFERENCES I. Hoopes JE, Jabaley ME, Su CoT, et al: Enzymes of glucose metabolism in palmar fascia and Dupuytren's contracture. J HAND SURG 2:62-65, 1977 2. Piulachs P, Mir-Mir A: Consideraciones sobre la enfermedad de Dupuytren. Folia Clin Int (Bare) 2:8, 1952 3. Beltran JE, Jimeno F, Moreta D: The open palm and digit technique in the treatment of Dupuytren's contracture. Hand 8:73-77, 1976 4. Beltran JE: La fasciectomia digito-palmar abierta en el tratamiento de la enfermedad de Dupuytren. Rev Ortop TraumatoI21:187-196,1977
Reply To the Editor: The authors wish to thank Dr. Beltran for his comments concerning our paper and his clinical information correlating with our data. We have felt that a weak point of our paper was the lack of comparison of enzyme activities between nodules vs. bands of Dupuytren's contracture. Following Dr . Beltran's suggestion, we have assayed hexokinase and glucose 6-phosphate dehydrogenase activity in tissues obtained from a patient, 56 years of age, with a progressive contracture for I to 2 years. Small pieces (I mm in thickness) of palmar skin, involved and uninvolved, were obtained at operation,
Table I. Comparison of enzyme activities in the band and nodule of Dupu ytren' s contracture* Glucose 6phosphate dehydrogenase Tissues Fascia Uninvolved Band Nodule Dennis Uninvolved Band Nodule Epidennis Uninvolved Band Nodule
1
Hexokinase
1
%
No.
0.055 0.098 0.230
100 178 418
0.029 0.083 0.165
100 286 569
0.084 0.195 0.161
100 232 192
0.056 0.076 0.107
100 136 191
0.76 0.60 0.92
100 79 120
0.51 0.44 0.54
100 86 106
No.
%
• Enzyme activities are expressed as moles of substrate converted per hour per kilogram of dry weight. Each assay is in quintuplicate.
frozen in liquid nitrogen, sectioned 20 micron in thickness in a cryostat, and lyophilized. Microdissection separated the epidermis, dermis (reticular layer), and contracted fascia (2 to 5 f.Lg). Enzyme activities were measured fluorometrically in a volume of 10 f.LI of an appropriate reagent mixture. As demonstrated in the accompanying table (Table I), the dermis overlying nodules and bands of Dupuytren's contracture exhibited greater enzyme activities than dermis overlying uninvolved fascia. Hexokinase was more active in the dermis overlying nodules than in the dermis overlying bands, whereas glucose 6-phosphate dehydrogenase activity was less in the dermis overlying nodules than in the dermis overlying bands. Bands exhibited less enzyme activities than nodules. We look forward to adding more data to these preliminary results. Chi-Tsung Su, M.D . E. F. Shaw Wi/gis, M.D . John E. Hoopes, M.D. Division of Plastic Surgery The Johns Hopkins University School of Medicine Baltimore, MD 21205
Not in favor of standing to do hand surgery To the Editor: Kilgore and Newman,l in their recent article on standing to do hand surgery, made many good points regarding hand surgery-e.g., hand surgery is intricate THE JOURNAL OF HAND SURGERY
299