Long-Term Outcome of Radiotherapy for Early Stage Dupuytren’s Disease: A Phase III Clinical Study

  • Michael Heinrich Seegenschmiedt
  • Ludwig Keilholz
  • Mark Wielpütz
  • Christine Schubert
  • Fabian Fehlauer

Abstract

Purpose: Several retrospective studies have shown that radiotherapy (RT) can prevent progression of Dupuytren’s disease (DD), but so far no dose-response relationship has been established. This chapter presents long-term results of our previously published prospective randomized trial comparing two different RT doses with a control group without RT. Methods: From January 1997 to December 2009 over 600 patients with DD were referred to our clinic for RT to prevent further disease progression. As of January 2011, 489 pts (291 males; 198 females) with at least five (range 5–13; mean 8.5) years follow-up (FU) were included in the analysis. Due to bilateral affliction, a total of 718 hands (sites) were evaluated. Overall 73% of all hands were affected, 230 (47%) on both hands; according to Tubiana’s classification, 470 (65.5%) hands had stage N (nodules/cords, no extension deficit), 124 (17%) had stage N/I (≤ 10° deficit), 106 (15%) had stage I (11–45° deficit), and 18 (2.5%) had stage II (46–90° deficit) or more. After clinical assessment and informed consent, patients could choose between observation only (83 patients with 122 affected hands) and RT (406 patients with 596 affected hands); all patients in the RT group were randomized into two different RT concepts: One group (207 patients with 303 affected hands) received 10 × 3 Gy (total 30 Gy) in 2 series of each 5 × 3 Gy separated by a break of 12 weeks; the other group (199 patients with 297 affected hands) received 7 × 3 Gy (total 21 Gy) in one series within 2 weeks. Orthovoltage RT (120 kV) was applied using standard cones and individual shielding of uninvolved areas of the palm. The relevant patient and disease parameters were equally distributed between control and both RT groups. The clinical evaluation (side effects, efficacy) was performed at 3 and 12 months after RT and at last follow-up (FU) in December 2010. Subjective (patient’s satisfaction) and objective parameters (palpation, measurements, and comparative photographs) were applied to assess the response. The primary endpoints were objective clinical progression and necessity of salvage surgery. Secondary endpoints were treatment of side effects and specific objective disease parameters (number and size of nodules, cords) and patient’s subjective satisfaction. Results: The acute radiogenic toxicity was low with 26.5% CTC grade 1 and 2.5% CTC grade 2; late effects, such as dry skin, were acceptable low with 14% LENT grade 1; no secondary cancer was observed in the long-term follow-up. After a minimum FU of >5 and a mean FU of 8.5 years, a total of 119 (16.5%) sites showed remission of nodules, cords or stage; 383 (53%) remained stable and 206 (29%) progressed and of those 97 (13.5%) required surgery. The progression rate in the control group (any progression 62%, surgery 30%) as compared to RT groups (21 Gy: 24%/surgery 12%; 30 Gy: 19.5%/surgery 8%) was significantly higher (p < 0.0001). Similarly, the overall and mean number of nodules, cords, and other changes decreased in the RT groups as compared to the progression in the control group (p < 0.01). Tubiana’s classification at last FU revealed a stage progression in the control group in 63 (52%) sites as compared to 64 (22%) and 49 (16%) in the 21 and 30 Gy RT group. There were 50 (8%) relapses inside and 114 (19%) outside the RT field in the RT group as compared to 52% and 28% potential relapses in the control group. Salvage surgery was possible without healing problems. Symptomatic relief was achieved in 4 (8%) sites of the control group as compared to 24 (21%) and 32 (26%) sites in the 21 and 30 Gy group, respectively. Uni- and multivariate prognostic factors for disease progression were smoking habit (trend), symptom duration prior to RT over 24 months, Dupuytren stage, extension deficit, and digital involvement (all p < 0.05). The most important independent factor was the implementation of RT as compared to the control without RT. Conclusions: RT is effective to prevent progression of Dupuytren’s disease; it reduces the necessity of hand surgery which is required due to disease progression at a minimum FU of 5 years. In addition, RT can reduce disease-related symptoms or helps to avoid their progression. Both RT protocols have been found to be effective and well tolerated, with slight advantage for the 30 Gy group as compared to 21 Gy group. Both acute and chronic side effects were well accepted and tolerated by the patients; so far no secondary malignancy was observed. From the radiobiologic background and rationale of radiotherapy, it appears possible not only to implement radiotherapy in the beginning of the disease process but also during active disease periods, e.g., for early relapses after surgical procedures.

Keywords

Radiation therapy Radiotherapy Palmar fibromatosis Controlled clinical trial Prognostic factors Long-term outcome Non-malignant disorders Benign disease 

References

  1. Adamietz B, Keilholz L, Grünert J, Sauer R (2001) Radiotherapy of early stage Dupuytren disease. Long-term results after a median follow-up period of 10 years. Strahlenther Onkol 177(11):604–610, in GermanPubMedCrossRefGoogle Scholar
  2. Allen PW (1977) The fibromatoses: a clinicpathologic classification based on 140 cases. Am J Surg Pathol 1:255–270PubMedCrossRefGoogle Scholar
  3. Al-Qattan MM (2006) Factors in the pathogenesis of Dupuytren’s contracture. J Hand Surg [Am] 31(9):1527–1534CrossRefGoogle Scholar
  4. Andrew JG, Andrew SM, Ash A, Turner B (1991) An investigation into the role of inflammatory cells in Dupuytren’s disease. J Hand Surg [Br] 16:267–271CrossRefGoogle Scholar
  5. Au-Yong IT, Wildin CJ, Dias JJ, Page RE (2005) A review of common practice in Dupuytren’s surgery. Tech Hand Up Extrem Surg 9:178–187PubMedCrossRefGoogle Scholar
  6. Badalamente MA, Hurst LC (2012) Injectable collagenase (clostridium histolyticum) for Dupuytren’s contracture: results of the CORD I study. In: Dupuytren’s disease and related hyperproliferative disorders, pp 343–347Google Scholar
  7. Badois FJ, Lermusiaux JL, Masse C, Kuntz D (1993) Traitement non chirurgical de la maladie de Dupuytren par aponévrotomie à l’aiguille. Rev Rhum 60:808–813Google Scholar
  8. Baird KS, Crossan JF, Ralston SH (1993) Abnormal growth factor and cytokine expression in Dupuytren’s contracture. J Clin Pathol 46:425–428PubMedCrossRefGoogle Scholar
  9. Becker GW, Davis TR (2010) The outcome of surgical treatments for primary Dupuytren’s disease – a systematic review. J Hand Surg Eur Vol 35(8):623–626PubMedCrossRefGoogle Scholar
  10. Berndt A, Kosmehl H, Katenkamp D, Tauchmann V (1994) Appearance of the myofibroblastic phenotype in Dupuytren’s disease is associated with a fibronectin, laminin, collagen type I and tenascin extracellular matrix. Pathobiology 62:55–58PubMedCrossRefGoogle Scholar
  11. Betz N, Ott OJ, Adamietz B, Sauer R, Fietkau R, Keilholz L (2010) Radiotherapy in early-stage Dupuytren’s contracture. Long-term results after 13 years. Strahlenther Onkol 186(2):82–90PubMedCrossRefGoogle Scholar
  12. Braun-Falco O, Lukacs S, Goldschmidt H (1976) Dermatologic radiotherapy, 1st edn. Springer, Berlin/Heidelberg/New YorkCrossRefGoogle Scholar
  13. Brenner P, Mailänder P, Berger A (1994) Epidemiology of Dupuytren’s disease. In: Berger A, Delbrück A, Brenner P, Hinzmann R (eds) Dupuytren’s disease – Patho-biochemistry and clinical management. Springer, Berlin/Heidelberg, pp 244–254Google Scholar
  14. Brenner P, Sachse C, Reichert B, Berger A (1996) Expression of monoclonal antibodies in nodules and band stage in Dupuytren’s disease. Handchir Mikrochir Plast Chir 28:322–327PubMedGoogle Scholar
  15. Brouet JP (1986) Etude de 1000 dossiers de maladie de Dupuytren. In: Tubiana R, Hueston JT (eds) La maladie de Dupuytren. Expansion Scientifique Française, Paris, pp 98–105Google Scholar
  16. Cooper AP (1822) On dislocation of the fingers and toes - dislocation from contracture of the tendons. A treatise on dislocations and fractures of the joints. Longman and Co.:524–525Google Scholar
  17. Crocker I (1999) Radiation therapy to prevent coronary artery restenosis. Semin Radiat Oncol 9:134–143PubMedCrossRefGoogle Scholar
  18. Dave SA, Banducci DR, Graham WP 3rd et al (2001) Differences in alpha smooth muscle actin expression between fibroblasts derived from Dupuytren’s nodules or cords. Exp Mol Pathol 71:147–155PubMedCrossRefGoogle Scholar
  19. Degreef I, de Smet L (2010) A high prevalence of Dupuytren’s disease in Flanders. Acta Orthop Belg 76(3):316–320PubMedGoogle Scholar
  20. Denkler K (2010) Surgical complications associated with fasciectomy for Dupuytren’s disease: a 20-year review of the English literature. EPlasty 10:e15PubMedGoogle Scholar
  21. Descatha A (2012) Dupuytren’s disease and occupation. In: Dupuytren’s disease and related hyperproliferative disorders, pp 45–49Google Scholar
  22. Dewing SB (1965) Disorders of function and overgrowth. In: Dewing SB (ed) Radiotherapy of benign disease. Thomas, Springfield, pp 78–171Google Scholar
  23. Dupuytren G (1832) Leçons orales de clinique chirurgicale, faites à l’Hôtel-Dieu de Paris. Bd. I. Germer Baillière, ParisGoogle Scholar
  24. Dupuytren G (1834) Permanent retraction of the fingers, produced by an affection of the palmar fascia. Lancet 2:222–225Google Scholar
  25. Dupuytren Society (2011) Listing of clinics offering radiotherapy for Dupuytren’s disease. http://www.dupuytren-online.info/radiotherapy_clinics.html. Accessed Jan 2011
  26. Early PF (1962) Population studies in Dupuytren’s contracture. J Bone Joint Surg Br 44:602–613Google Scholar
  27. Falter E, Herndl E, Muhlbauer W (1991) Dupuytren’s contracture. When operate? Conservative preliminary treatment? Fortschr Med 109:223–226PubMedGoogle Scholar
  28. Finck KW (1955) Zur Frage der Dupuytrenschen Fingerkontaktur und ihrer Behandlung mit Radium. Strahlentherapie 97:608–612Google Scholar
  29. Finney R (1955) Dupuytren’s contracture. Br J Radiol 28:610–613PubMedCrossRefGoogle Scholar
  30. Flint M (1990a) Connective tissue biology. In: McFarlane RM, McGrouther DA, Flint M (eds) Dupuytren’s disease. Biology and treatment, vol 5, The hand and upper limb series. Churchill Livingstone, Edinburgh, pp 13–24Google Scholar
  31. Flint M (1990b) The genesis of the palmar lesion. In: McFarlane RM, McGrouther DA, Flint M (eds) Dupuytren’s disease. Biology and treatment, vol 5, The hand and upper limb series. Churchill Livingstone, Edinburgh, pp 136–154Google Scholar
  32. Gabbiani G, Ryan GB, Majno G (1971) Presence of modified fibroblasts in granulation tissue and their possible role in wound contraction. Experimentia 27:549–550CrossRefGoogle Scholar
  33. Geldmacher J (1994) Limited fasciectomy. In: Berger A, Delbrück A, Brenner P, Hinzmann R (eds) Dupuytren’s disease. Springer, Berlin/Heidelberg, pp 257–263CrossRefGoogle Scholar
  34. Görlich W (1981) Die Dupuytrensche Kontraktur. Chir Praxis 28:91–98Google Scholar
  35. Haase W (1982) Strahlentherapie hypertrophischer Prozesse des Bindegewebes. Therapiewoche 32:4856–4864Google Scholar
  36. Herbst M, Regler G (1986) Dupuytrensche Kontraktur. Radiotherapie der Frühstadien. Strahlentherapie 161:143–147Google Scholar
  37. Heyd R et al. “Strahlentherapie bei frühen Stadien des Morbus Ledderhose” Strahlentherapie und Onkologie 186 (2010) p 24–29Google Scholar
  38. Hesselkamp J, Schulmeyer M, Wiskemann A (1981) Röntgen­therapie der Dupuytrenschen Kontraktur im Stadium I. Therapiewoche 31:6337–6338Google Scholar
  39. Hueston JT (1987) Dupuytren’s contracture and occupation. J Hand Surg [Am] 12:657–658Google Scholar
  40. Igarashi A, Nashiro K, Kikuchi K, Sato S, Ihn H, Fujimoto M, Grotendorst GR, Takehara K (1996) Connective tissue growth factor gene expression in tissue sections from localized scleroderma, keloid, and other fibrotic skin disorders. J Invest Dermatol 106:729–733PubMedCrossRefGoogle Scholar
  41. Incrocci L, Hop WC, Seegenschmiedt MH (2008) Radiotherapy for Peyronie’s disease: a European survey. Acta Oncol 47:1110–1112PubMedCrossRefGoogle Scholar
  42. Jansen JT, Broerse JJ, Zoetelief J, Klein C, Seegenschmiedt HM (2005) Estimation of the carcinogenic risk of radiotherapy of benign diseases from shoulder to heel. Radiother Oncol 76(3):270–277PubMedCrossRefGoogle Scholar
  43. Jerosch-Herold C, Shepstone L, Chojnowski AJ, Larson D (2012) Night-time splinting after fasciectomy or dermofasciectomy for Dupuytren’s Contracture: a pragmatic, multi-centre, randomized controlled trial. In: Dupuytren’s disease and related hyperproliferative disorders, pp 323–332Google Scholar
  44. Kampinga HH, van Waarde-Verhagen MA, van Assen-Bolt AJ et al (2004) Reconstitution of active telomerase in primary human foreskin fibroblasts: effects on proliferative characteristics and response to ionizing radiation. Int J Radiat Biol 80:377–388PubMedCrossRefGoogle Scholar
  45. Kaplan II (1949) Clinical radiation therapy, 2nd edn. Hoeber, New YorkGoogle Scholar
  46. Keilholz L, Seegenschmiedt MH, Sauer R (1996) Radiotherapy for prevention of disease progression in early-stage Dupuytren’s contracture: initial and long-term results. Int J Radiat Oncol Biol Phys 36:891–897PubMedCrossRefGoogle Scholar
  47. Keilholz L, Seegenschmiedt MH, Born AD, Sauer R (1997) Radiotherapy in the early stages of Dupuytren’s disease: indication, technique, long-term results. Strahlenther Onkol 173:27–35PubMedCrossRefGoogle Scholar
  48. Ketchum LD, Donahue TK (2000) The injection of nodules of Dupuytren’s disease with triamcinolone acetonide. J Hand Surg 25:1157–1162Google Scholar
  49. Kischer CW, Speer DW (1986) Microvascular changes in Dupuytren’s contracture. J Hand Surg 9A:58–62Google Scholar
  50. Köhler AH (1984) Die Strahlentherapie der Dupuytrenschen Kontraktur. Radiobiol Radiother 25:851–853Google Scholar
  51. Leer JW, van Houtte P, Seegenschmiedt MH (2007) Radiotherapy of non-malignant disorders: where do we stand? Radiother Oncol 83:175–177PubMedCrossRefGoogle Scholar
  52. Ling RSM (1963) The genetic factor in Dupuytren’s disease. J Bone Joint Surg Br 45:709–718PubMedGoogle Scholar
  53. Loos B, Puschkin V, Horch RE (2007) 50 years experience with Dupuytren’s contracture in the Erlangen University Hospital - a retrospective analysis of 2919 operated hands from 1956–2006. BMC Musculoskelet Disord 8:60–69PubMedCrossRefGoogle Scholar
  54. Lubahn JO, Lister GD, Wolfe T (1984) Fasciectomy of Dupuytren’s disease, comparison between the open-palm technique and wound closure. J Hand Surg 9A:53–58Google Scholar
  55. Luck JV (1959) Dupuytren’s contracture. J Bone Joint Surg [Am] 41:635–664Google Scholar
  56. Lukacs S, Braun Falco O, Goldschmidt H (1978) Radiotherapy of benign dermatoses: indications, practice, and results. J Dermatol Surg Oncol 4:620–625PubMedGoogle Scholar
  57. McFarlane RM, McGrouther DA, Flint MH (1990) Dupuytren’s disease. Biology and treatment, vol 5, The hand and upper limb series. Churchill Livingstone, EdinburghGoogle Scholar
  58. McGrouther DA (1982) The microanatomy of Dupuytren’s contracture. Hand 13:215–236Google Scholar
  59. Millesi H (1981) Dupuytren-Kontraktur. In: Nigst H, Buck-Gramcko D, Millesi H (eds) Handchirurgie, Band I. Thieme, Stuttgart/New York, pp 1500–1557Google Scholar
  60. Mohr W, Wessinghage D (1994) Morphology of Dupuytren’s disease. In: Berger A, Dellbrück A, Brenner P, Hinzmann R (eds) Dupuytren’s disease. Springer, Berlin/Heidelberg, pp 3–15CrossRefGoogle Scholar
  61. Moorhead JJ (1956) Dupuytren’s contracture. Review of the disputed etiology 1831–1956. NY J Med 56:3686–3703Google Scholar
  62. Moyer KE, Banducci DR, Graham WP 3rd et al (2002) Dupuytren’s disease: physiologic changes in nodule and cord fibroblasts through aging in vitro. Plast Reconstr Surg 110:187–193PubMedCrossRefGoogle Scholar
  63. Murrell GAC, Francis MJO (1994) Oxygen free radicals and Dupuytren’s disease. In: Berger A, Delbrück A, Brenner P, Hinzmann R (eds) Dupuytren’s disease. Springer, Berlin/Heidelberg, pp 227–234CrossRefGoogle Scholar
  64. Murrell GAC, Francis MJO, Howlett CR (1989) Dupuytren’s contracture. Fine structure in relation to aetiology. J Bone Joint Surg Br 71:367–372PubMedGoogle Scholar
  65. Murrell GAC, Francis MJO, Bromley L (1990) Modulation of fibroblast proliferation by oxygen free radicals. Biochem J 165:659–665Google Scholar
  66. Mutsaers SE, Bishop JE, McGrouther G, Laurent GJ (1997) Mechanisms of tissue repair: from wound healing to fibrosis. Int J Biochem Cell Biol 29:5–17PubMedCrossRefGoogle Scholar
  67. National Institute for Health and Clinical Excellence (NICE) (2010) Radiation therapy for early Dupuytren’s disease: guidance. http://guidance.nice.org.uk/IPG368. Accessed Jan 2011
  68. Order SE, Donaldson SS (1990) Radiation therapy of benign diseases – A clinical guide. Springer, Berlin/Heidelberg/New YorkGoogle Scholar
  69. Pavy JJ, Denekamp J, Letschert J, Littbrand B, Mornex F, Bernier J, Gonzales-Gonzales D, Horiot JC, Bolla M, Bartelink H (1995) EORTC Late Effects Working Group. Late Effects toxicity scoring: the SOMA scale. Int J Radiat Oncol Biol Phys 31(5):1043–1047PubMedCrossRefGoogle Scholar
  70. Platter F (1614) Observationum un Hominis Affectibus. Libri tres. Basel, L. König: 140–146Google Scholar
  71. Rafter D, Kenny R, Gilmore M, Walsh CH (1980) Dupuytren’s contracture – a survey of a hospital population. Ir Med J 73:227–228PubMedGoogle Scholar
  72. Rayan GM, Parizi M, Tomasek JJ (1996) Pharmacological regulation of Dupuytren’s fibroblast contraction in vitro. J Hand Surg [Am] 21:1065–1070CrossRefGoogle Scholar
  73. Rodemann HP, Bamberg M (1995) Cellular basis of radiation induced fibrosis. Radiother Oncol 35:83–90PubMedCrossRefGoogle Scholar
  74. Rubin P, Constine LS, Fajardo LF, Phillips TL, Wasserman TH (1995) RTOG Late Effects Working Group. Overview. Late Effects of Normal Tissues (LENT) scoring system. Int J Radiat Oncol Biol Phys 31(5):1041–1042PubMedCrossRefGoogle Scholar
  75. Rubin P, Soni A, Williams JP (1999) The molecular and cellular biologic basis for radiation treatment of benign proliferative diseases. Semin Radiat Oncol 9:203–214PubMedCrossRefGoogle Scholar
  76. Rudolph R, Vande Berg J (1991) The myofibroblast in Dupuytren’s contracture. Hand Clin 7:683–692PubMedGoogle Scholar
  77. Schink W (1978) Die Dupuytrensche Kontraktur. Med Klin 73:1371–1379PubMedGoogle Scholar
  78. Seegenschmiedt MH (1998) Interdisciplinary documentation of treatment side effects in oncology. Present status and perspectives. Strahlenther Onkol 174(Suppl 3):25–29PubMedGoogle Scholar
  79. Seegenschmiedt MH, Attassi M (2003) Strahlentherapie beim Morbus Ledderhose – Indikation, und klinische Ergebnisse. Strahlenther Onkol 179:847–853PubMedCrossRefGoogle Scholar
  80. Seegenschmiedt MH, Olschewski T, Guntrum F (2001) Optimierung der Radiotherapie beim Morbus Dupuytren: erste Ergebnisse einer kontrollierten Studie. Strahlenther Onkol 177:74–81PubMedCrossRefGoogle Scholar
  81. Seegenschmiedt MH (2008) Morbus Dupuytren/Morbus Ledderhose (Chapter 9) In Seegenschmiedt MH, Makoski H-B, Trott KR, Brady L (Eds) Radiotherapy for Non-Malignant Disorders, ISBN 978-3-540-62550-6. Springer (Berlin, New York, 2008) pp 161 – 191PubMedCrossRefGoogle Scholar
  82. Skoog T (1948) Dupuytren’s contraction with special reference to aetiology and improved surgical treatment, its occurence in epileptics. Acta Chir Scand 96(Suppl):139Google Scholar
  83. Smitt MC, Donaldson SS (1999) Radiation therapy for benign disease of the orbit. Semin Radiat Oncol 9:179–189PubMedCrossRefGoogle Scholar
  84. Strickland JW, Idler RS, Creighton JC (1990) Dupuytren’s disease. Indiana Med 83:408–409PubMedGoogle Scholar
  85. Suit H, Spiro I (1999) Radiation treatment of benign mesenchymal disease. Semin Radiat Oncol 9:171–178PubMedCrossRefGoogle Scholar
  86. Terek RM, Jiranek WA, Goldberg MJ, Wolfe HJ, Alman BA (1995) The expression of platelet-derived growth-factor gene in Dupuytren contracture. J Bone Joint Surg Am 77:1–9PubMedGoogle Scholar
  87. Tomasek J, Rayan GM (1995) Correlation of alpha-smooth muscle actin expression and contraction in Dupuytren’s disease fibroblasts. J Hand Surg [Am] 20:450–455CrossRefGoogle Scholar
  88. Tomasek JJ, Schultz RJ, Haaksma CJ (1987) Extracellular matrix-cytoskeletal connections at the surface of the specialized contractile fibroblast (myofibroblast) in Dupuytren disease. J Bone Joint Surg Am 68:1400–1407Google Scholar
  89. Tripuraneni P, Giap H, Jani S (1999) Endovascular brachytherapy for peripheral vascular disease. Semin Radiat Oncol 9:190–202PubMedCrossRefGoogle Scholar
  90. Trott KR, Kamprad F (2006) Estimation of cancer risk from radiotherapy of benign diseases. Strahlenth Onkol 182:431–436CrossRefGoogle Scholar
  91. Trotti A, Byhardt R, Stetz J, Gwede C, Corn B, Fu K, Gunderson L, McCormick B, Morrisintegral M, Rich T, Shipley W, Curran W (2000) Common toxicity criteria: version 2.0. an improved reference for grading the acute effects of cancer treatment: impact on radiotherapy. Int J Radiat Oncol Biol Phys 47(1):13–47PubMedCrossRefGoogle Scholar
  92. Trotti A, Colevas AD, Setser A, Rusch V, Jaques D, Budach V, Langer C, Murphy B, Cumberlin R, Coleman CN, Rubin P (2003) CTCAE v3.0: development of a comprehensive grading system for the adverse effects of cancer treatment. Semin Radiat Oncol 13(3):176–181PubMedCrossRefGoogle Scholar
  93. Tubiana R, Michon J, Thomine JM (1966) Evaluation chiffree des deformations dans la maladie de Dupuytren. In: Maladie du Dupuytren, monographies du G.E.M. Expansion Scien­tifique Francaise, ParisGoogle Scholar
  94. Viljanto JA (1973) Dupuytren’s contracture: A review. Semin Arthritis Rheum 3A:155–176CrossRefGoogle Scholar
  95. Vogt HJ, Hochschau L (1980) Behandlung der Dupuytrenschen Kontraktur. Münch Med Wschr 122:125–130Google Scholar
  96. Wasserburger K (1956) Therapie der Dupuytrenschen Kontraktur. Strahlenther 100:546–560Google Scholar
  97. Weinzierl G, Flügel M, Geldmacher J (1993) Fehlen der Effektivität der alternativ nicht-chirurgischen Behandlungs­verfahren beim Morbus Dupuytren. Chirurg 64:492–494PubMedGoogle Scholar
  98. Yost J, Winter T, Fett H (1955) Dupuytren’s contracture. A statistical study. Am J Surg 90:568–571PubMedCrossRefGoogle Scholar
  99. Zerajic D, Finsen V (2012) The epidemiology of Dupuytren’s disease in Bosnia. In: Dupuytren’s disease and related hyperproliferative disorders, pp 123–127Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • Michael Heinrich Seegenschmiedt
    • 1
    • 2
  • Ludwig Keilholz
    • 3
  • Mark Wielpütz
    • 2
  • Christine Schubert
    • 2
  • Fabian Fehlauer
    • 1
  1. 1.Strahlenzentrum HamburgStrahlentherapie & RadioonkologieHamburgGermany
  2. 2.Klinik für Strahlentherapie und RadioonkologieAlfried Krupp KrankenhausEssenGermany
  3. 3.Klinik für StrahlentherapieKlinikum BayreuthBayreuthGermany

Personalised recommendations