Thèse ou mémoire avec insertion d'articles / Les déformations en flexion des doigts liées à la maladie de Dupuytren peuvent être réduites chirurgicalement afin de remédier aux difficultés fonctionnelles qu'elles occasionnent. Des études ont souligné la pertinence du suivi postopératoire en réadaptation sans être précises concernant le contenu et la forme qu'il doit prendre. L'objectif principal de ce mémoire était d'évaluer la faisabilité de conduire un essai clinique randomisé comparant les effets d'un suivi de réadaptation post-fasciectomie court à ceux d'un suivi intense sur les habiletés fonctionnelles et motrices des personnes ayant la maladie de Dupuytren. Puisque plusieurs questionnaires fonctionnels auto-rapportés peuvent être utilisés pour documenter les difficultés fonctionnelles liées à la maladie de Dupuytren, une première étude a été réalisée pour déterminer le ou les questionnaire(s) fonctionnel(s) possédant les meilleures propriétés métrologiques pour cette population. Cette première étude a adopté la méthodologie d'une revue systématique, et les résultats ont ciblé l'utilisation du Michigan Hand Questionnaire (MHQ) pour documenter les difficultés fonctionnelles liées à la maladie de Dupuytren dans l'étude principale. Ensuite, afin de répondre à l'objectif principal du mémoire, un essai pilote randomisé prenant la même forme que l'essai clinique randomisé projeté, mais à plus petite échelle, a été complété auprès de dix participants. Un taux de recrutement de 83.33% a été obtenu. Les taux d'adhérence aux traitements et aux évaluations étaient respectivement de 90% et 87.5%. Une seule complication post-opératoire est survenue. Les 2 groupes (suivi de faible intensité n = 6; suivi intense n=4) ont améliorés significativement dans le temps leurs habiletés fonctionnelles et leur fonction motrice. L'étude pilote a démontré que la réalisation d'un essai clinique randomisé comparant deux suivis de réadaptation post-fasciectomie est envisageable sans modification majeure à la méthodologie employée dans le cadre de l'étude pilote. Les résultats obtenus lors de l'essai pilote pourront ainsi être combinés à ceux de l'étude projetée. / Finger flexion contractures related to Dupuytren's disease (DD) can be surgically reduced to address the functional limitations they create. Studies have highlighted the relevance of postoperative hand therapy without being very specific about the content and form it should take. The main objective of this master's thesis is to assess the feasibility of conducting a randomized clinical trial comparing the effects of two post-fasciectomy hand therapy protocols on functional and sensorimotor outcomes of individuals with DD. Because several patient-reported outcome measures (PROMs) can be used to assess the functional limitations of DD, a first study, which aimed to identify which PROMs have the best psychometric properties to assess the functional abilities of individuals with DD, was conducted. The results of this first study, which was a systematic review, targeted the use of the Michigan Hand Questionnaire (MHQ) to assess functional limitations related to DD in the main study. To meet the main objective of this master's thesis, a pilot randomized trial taking the same form as the planned randomized clinical trial, but on a smaller size, was completed with ten participants. A recruitment rate of 83.33% was achieved. Adherence rates to proposed treatments and assessments were 90% and 87.5%, respectively. One postoperative complication occurred. The two groups (Low-Intensity group n=6; High-Intensity group n=4) improved significantly over time regarding functional ability and sensorimotor function. The pilot study showed that a randomized clinical trial comparing two post-fasciectomy hand therapy protocols is feasible without major changes to the methodology used in the pilot study. The results of the pilot study can thus be combined with those of the planned randomized clinical trial.

El documento digital no refiere asesor / La enfermedad de Dupuytren es proceso de naturaleza proliferativa que afecta la fasciea palmar, el cual limita el movimiento adecuado de la mano. El objetivo principal del trabajo es conocer las características epidemiológicas y los principales tratamientos quirúrgicos en estos pacientes, para lo cual se revisaron 51 historias clínicas de pacientes con diagnostico de enfermedad de Dupuytren atendidos en la unidad de miembro superior del Hospital Nacional Edgardo Rebagliati Martins de enero del 2000 a diciembre del 2006. Se obtuvieron los siguientes resultados: el 90% de los pacientes eran de sexo masculino y 10% de sexo femenino. El rango de edad mas afectado en el sexo masculino fue el de 66 a 70 años y de 71 a 75 con un 20% de prevalencia en cada uno, en el grupo femenino fue el 61 a 65 años con un 6%. Entre las principales enfermedades asociadas se encontró a la diabetes mellitus (31%) y la hipertensión arterial (26%). No existe una relación directa entre la mano dominante y la afectada. En cuanto al compromiso de la mano se encontró un 34 % de afectación anular, 22% en el meñique y un 41% de la palma de la mano. Los tratamientos fueron de fasciotomía en 18% y fasciectomía en 82% las principales complicaciones fueron los hematomas (4%) y reoperaciones (6%). / Trabajo académico

INTRODUÇÃO: A Moléstia de Dupuytren (MD) é uma doença crônica progressiva fibroproliferativa caracterizada por contraturas em flexão dos dedos. A origem deste processo está na proliferação de miofibroblastos e na síntese de matriz extracelular. Diversas técnicas já foram descritas no tratamento da MD. A falta de uma técnica capaz de associar altas taxas de sucesso com baixos índices de complicações e recidivas estimulou a procura por novas técnicas. Acredita-se que a propriedade totipotente das células-tronco presentes no tecido adiposo seria capaz de atuar na proliferação e na diferenciação dos fibroblastos em miofibroblastos, interrompendo a formação da fibrose e consequentemente a progressão da deformidade dos dedos. OBJETIVO: O objetivo primário deste estudo foi avaliar o efeito do enxerto de gordura, rico em células-tronco, nos pacientes com MD, submetidos a fasciectomia parcial aberta, por meio de avaliação funcional e goniométrica, e comparar com a técnica convencional (sem adição de enxerto de gordura). MÉTODO: Dois grupos totalizando 45 pacientes (24 pacientes no Grupo Controle e 21 no Grupo com gordura) foram operados pela técnica da fasciectomia parcial aberta. No Grupo controle era realizada apenas a fasciectomia parcial aberta. No Grupo com gordura, era realizada a fasciectomia parcial aberta e injetado, no local da corda ressecada, o enxerto de gordura, após o processamento do lipoaspirado de adipócitos proposto por Coleman (2006). O estudo foi prospectivo, randomizado e terapêutico. Os desfechos foram avaliados pela medida goniométrica do Déficit de Extensão Passiva Total (DEPT) e pelo escore funcional Brief Michigan Hand Questionnaire (BMHQ). As avaliações eram feitas no pré-operatório, com 6 semanas, 6 meses, 1 ano e 2 anos de seguimento. RESULTADOS: Na comparação com 6 semanas de pós-operatório, houve um aumento significativo da dor no Grupo com Gordura [mediana 2 ± 2,82 versus 0 ± 1,86 no grupo Controle (p=0,045)]. Os resultados do DEPT, não mostraram diferença significativa entre os grupos. Observamos piores resultados do escore funcional BMHQ com 6 meses e 1 ano de pós-operatório no Grupo com gordura (p=0,040 e p=0,047, respectivamente). Observamos ainda 9 casos (43%) de complicações no Grupo com gordura e 2 (8%) no Grupo Controle (p=0,019). CONCLUSÃO: O uso do enxerto de gordura associado à fasciectomia parcial aberta promoveu piores resultados funcionais comparado com a fasciectomia parcial aberta convencional, no curto prazo (um ano de seguimento pós-operatório). No entanto, resta a dúvida de qual seriam os resultados a longo prazo e, se as células-tronco, presentes no enxerto de gordura, poderiam interferir na recidiva da doença futuramente / BACKGROUND: Dupuytren\'s disease (DD) is a progressive chronic fibroproliferative disease characterized by flexion contractures of the fingers. The origin of this process is the proliferation of myofibroblasts and extra-cellular matrix synthesis. Several techniques have been described to treat the DD. The lack of a technique capable to associate high success rates with low rates of complications and recurrence stimulated the search for new techniques. It is believed that the totipotent property of the adipose-derived stem cells present in the processed lipoaspirate tissue would be able to inhibit the proliferation and differentiation of fibroblasts in myofibroblasts, interrupting the formation of fibrosis and consequently the progression of finger deformity. The primary objective of this study was to evaluate the effect of adipose-derived stem cells in patients with DD who underwent to open limited fasciectomy and compare with the conventional technique of limited fasciectomy. METHODS: A total of 45 patients were assigned in two groups in a single blind, prospective, randomized, controlled trial. All the patients were treated by the limited fasciectomy technique. In the control group (24 patients), only limited fasciectomy was performed. In the study group (21 patients), after the limited fasciectomy procedure, autologous lipoaspirate was injected at the site of the resected cord. Outcomes were assessed by the Total Passive Extension Deficit (TPED) and by the Brief Michigan Hand Questionnaire (BMHQ) functional score. The evaluations were performed by occupational therapists in the preoperative and at 6 weeks, 6 months, 1 year and 2 years. RESULTS: The study group presented higher rates of pain at 6 weeks postoperative (median 2 ± 2,82 versus 0 ± 1,86 on control group, p=0,045). TPED showed no significant differences between groups. BMHQ score, at 6 months and 1 year after surgery, were significantly inferior in the study group (p=0,040 e p=0,047, respectively). Patients in the study group had higher incidence of complications (9 patients, 43% versus 2, 8% in the control group, p=0,019). CONCLUSIONS: The autologous lipoaspirate associated to limited fasciectomy demonstrates inferior results regarding to functional score and pain compared to conventional limited fasciectomy, in short-term. Further long-term analysis is required to observe the effect of adipose-derived stem cells in the recurrences rates

Dupuytren's contracture (DC) is a fibromatous disease of the palmar fascia of unknown etiology. The present study was undertaken in order to assess pathophysiological mechanisms and consequences. In a cohort study of 2,375 patients operated for DC at the Department of Hand Surgery, Uppsala there was a male: female ratio of 5.9:1. Women had a higher mean age at first operation than men. One-third of the men and one-quarter of the women required repeated surgery. Early age at first operation was associated with recurrent disease. The risk of cancer was determined in 15,212 patients operated on for DC in Sweden. The overall relative risk was increased by 24%. There was a significantly increased risk for buccal, oesophageal, gastric, lung and pancreatic cancers, which indicates that smoking and alcohol abuse are probable risk factors for DC. Furthermore, there was an increased frequency of fibrosarcoma and malignant fibrous histiocytoma, the cause of which is unexplained The causes of death were evaluated in a national cohort of 16,517 patients operated for DC. There was an overall increased mortality (SMR=1.06), inversely related to age and significant for both sexes, in patients under 70 years. The risk estimate was highest for endocrine-, gastrointestinal-, and respiratory diseases, and accidents. There was also an increased SMR for cardiovascular diseases in younger patients more than 10 years after surgery. The most probable mechanism is related to smoking and other lifestyle factors. Outcome after surgery was not related to the immunohistochemical expression of connective tissue activation markers, such as collagen type IV, integrin α5, laminin, smooth muscle α-actin, procollagen type I, and desmin, in surgical specimens in a prospectively investigated group of patients. Furthermore, there were no associations between gender, age at onset of DC, number of operations, heredity, diabetes mellitus, or medication for cardiovascular disease, and the expression of the different markers. The individual characteristics that place a person at high risk are, thus, not obviously related to ongoing connective tissue production at time of surgery or to connective tissue activity in its conventionally used sense.

INTRODUÇÃO: A Moléstia de Dupuytren (MD) é uma doença crônica progressiva fibroproliferativa caracterizada por contraturas em flexão dos dedos. A origem deste processo está na proliferação de miofibroblastos e na síntese de matriz extracelular. Diversas técnicas já foram descritas no tratamento da MD. A falta de uma técnica capaz de associar altas taxas de sucesso com baixos índices de complicações e recidivas estimulou a procura por novas técnicas. Acredita-se que a propriedade totipotente das células-tronco presentes no tecido adiposo seria capaz de atuar na proliferação e na diferenciação dos fibroblastos em miofibroblastos, interrompendo a formação da fibrose e consequentemente a progressão da deformidade dos dedos. OBJETIVO: O objetivo primário deste estudo foi avaliar o efeito do enxerto de gordura, rico em células-tronco, nos pacientes com MD, submetidos a fasciectomia parcial aberta, por meio de avaliação funcional e goniométrica, e comparar com a técnica convencional (sem adição de enxerto de gordura). MÉTODO: Dois grupos totalizando 45 pacientes (24 pacientes no Grupo Controle e 21 no Grupo com gordura) foram operados pela técnica da fasciectomia parcial aberta. No Grupo controle era realizada apenas a fasciectomia parcial aberta. No Grupo com gordura, era realizada a fasciectomia parcial aberta e injetado, no local da corda ressecada, o enxerto de gordura, após o processamento do lipoaspirado de adipócitos proposto por Coleman (2006). O estudo foi prospectivo, randomizado e terapêutico. Os desfechos foram avaliados pela medida goniométrica do Déficit de Extensão Passiva Total (DEPT) e pelo escore funcional Brief Michigan Hand Questionnaire (BMHQ). As avaliações eram feitas no pré-operatório, com 6 semanas, 6 meses, 1 ano e 2 anos de seguimento. RESULTADOS: Na comparação com 6 semanas de pós-operatório, houve um aumento significativo da dor no Grupo com Gordura [mediana 2 ± 2,82 versus 0 ± 1,86 no grupo Controle (p=0,045)]. Os resultados do DEPT, não mostraram diferença significativa entre os grupos. Observamos piores resultados do escore funcional BMHQ com 6 meses e 1 ano de pós-operatório no Grupo com gordura (p=0,040 e p=0,047, respectivamente). Observamos ainda 9 casos (43%) de complicações no Grupo com gordura e 2 (8%) no Grupo Controle (p=0,019). CONCLUSÃO: O uso do enxerto de gordura associado à fasciectomia parcial aberta promoveu piores resultados funcionais comparado com a fasciectomia parcial aberta convencional, no curto prazo (um ano de seguimento pós-operatório). No entanto, resta a dúvida de qual seriam os resultados a longo prazo e, se as células-tronco, presentes no enxerto de gordura, poderiam interferir na recidiva da doença futuramente / BACKGROUND: Dupuytren\'s disease (DD) is a progressive chronic fibroproliferative disease characterized by flexion contractures of the fingers. The origin of this process is the proliferation of myofibroblasts and extra-cellular matrix synthesis. Several techniques have been described to treat the DD. The lack of a technique capable to associate high success rates with low rates of complications and recurrence stimulated the search for new techniques. It is believed that the totipotent property of the adipose-derived stem cells present in the processed lipoaspirate tissue would be able to inhibit the proliferation and differentiation of fibroblasts in myofibroblasts, interrupting the formation of fibrosis and consequently the progression of finger deformity. The primary objective of this study was to evaluate the effect of adipose-derived stem cells in patients with DD who underwent to open limited fasciectomy and compare with the conventional technique of limited fasciectomy. METHODS: A total of 45 patients were assigned in two groups in a single blind, prospective, randomized, controlled trial. All the patients were treated by the limited fasciectomy technique. In the control group (24 patients), only limited fasciectomy was performed. In the study group (21 patients), after the limited fasciectomy procedure, autologous lipoaspirate was injected at the site of the resected cord. Outcomes were assessed by the Total Passive Extension Deficit (TPED) and by the Brief Michigan Hand Questionnaire (BMHQ) functional score. The evaluations were performed by occupational therapists in the preoperative and at 6 weeks, 6 months, 1 year and 2 years. RESULTS: The study group presented higher rates of pain at 6 weeks postoperative (median 2 ± 2,82 versus 0 ± 1,86 on control group, p=0,045). TPED showed no significant differences between groups. BMHQ score, at 6 months and 1 year after surgery, were significantly inferior in the study group (p=0,040 e p=0,047, respectively). Patients in the study group had higher incidence of complications (9 patients, 43% versus 2, 8% in the control group, p=0,019). CONCLUSIONS: The autologous lipoaspirate associated to limited fasciectomy demonstrates inferior results regarding to functional score and pain compared to conventional limited fasciectomy, in short-term. Further long-term analysis is required to observe the effect of adipose-derived stem cells in the recurrences rates

Introduktion: Uppsatsen är en systematisk litteraturstudie där författaren kritiskt granskar adekvata artiklar och annan aktuell litteratur, vilka beskriver Dupuytren´s kontraktur. Dupuytrens kontraktur är en fibroproliferativ sjukdom i palmar fascia och kännetecknas av en överdriven kollageninlagring. Syfte: Syftet med studien var att undersöka situationen för det kliniska arbetet samt forskning, hur man med den samlade kunskapen kan behandla Dupuytren´s kontraktur, vilka behandlings-metoder som har evidens idag samt vilken praxis som tillämpas inom området. Metod: En litteratursökning genomfördes i PubMed med sökord och kombination med Booleska sökoperationer för framtagning av relevanta artiklar, vilka faller inom ramen för uppsatta inklusionskriterier samt matchar syftet för uppsatsen. Resultat: Ingen behandling är överlägsen någon annan behandling och det finns en betydande och delad uppfattning om respektive metoder. Mindre invasiva tekniker, såsom perkutan nålfasciotomi samt injektionsbehandling med enzymet Kollagenas, är många gånger ett alternativ till kirurgi Slutsats: Hanteringen av en handkontraktur hos patienter med Dupuytrens sjukdom innebär fortfarande många utmaningar för handkirurger, trots framsteg inom medicinsk vetenskap och kirurgiska tekniker.

Based upon a servey of the Université libre de Bruxelles medecine museum anatomical waxes collection, my Phd aims to study in an historical context the anatomical waxes fron the 18th Century to the 20th Century. We demonstrated who the didactical items created by sculpture ways appeared throw their successif uses from medical teaching to the prevention of the diseases of the time in the anatomical fairground attractions. Sur base d'une étude de la collection des cires anatomiques du musée de la médecine d'Erasme, ma thèse de doctorat vise à l'étude contextuelle de la production de cires anatomiques depuis la fin du 18e siècle jusqu'au 20e siècle. Nous avons montré comment ses objets didactiques, produits par des moyens sculpturaux, ont été perçu à travers leurs usages successifs depuis l'enseignement médicale jusqu'à la prévention sociale des maladies d'époque, au sein des musées anatomiques forains.

Based upon a servey of the Université libre de Bruxelles medecine museum anatomical waxes collection, my Phd aims to study in an historical context the anatomical waxes fron the 18th Century to the 20th Century. We demonstrated who the didactical items created by sculpture ways appeared throw their successif uses from medical teaching to the prevention of the diseases of the time in the anatomical fairground attractions.<p><p>Sur base d'une étude de la collection des cires anatomiques du musée de la médecine d'Erasme, ma thèse de doctorat vise à l'étude contextuelle de la production de cires anatomiques depuis la fin du 18e siècle jusqu'au 20e siècle. Nous avons montré comment ses objets didactiques, produits par des moyens sculpturaux, ont été perçu à travers leurs usages successifs depuis l'enseignement médicale jusqu'à la prévention sociale des maladies d'époque, au sein des musées anatomiques forains.<p> / Doctorat en philosophie et lettres, Orientation histoire de l'art et archéologie / info:eu-repo/semantics/nonPublished