Dupuytren's contracture

Sir,

I read with interest the review article, by Thurston1 in the May 2003 issue entitled 'Dupuytren's disease'.

In his comprehensive review Professor Thurston supports an association with exposure to hand-held vibrating tools. This view has implications in the medicolegal field and deserves closer analysis.

The classic study of 286 pneumatic tool workers in British factories found vibration white finger (VWF) in 152 individuals.2 The hands of all 286 workers exposed to vibration were examined but although 55 of the workers were aged 50 or over, only one had Dupuytren's contracture.

In a study of VWF in quarry drillers and stone carvers in Italy by Bovenzi,' 3.5% of 258 workers not using vibrating tools and 10% of 570 workers using vibrating tools had Dupuytren's disease. The analysis was adjusted for age. However, 40% of the workers exposed to vibration and only 27% of controls were aged 45 or over. Adjustment for the confounding effect of age which assumes a linear effect on risk is likely to underestimate the true confounding effect, bearing in mind the steep rise in the prevalence of Dupuytren's disease after the age of 45 years. In a subsequent comprehensive review of vibration exposure and upper limb disorders,'4 the same author makes no mention of Dupuytren's disease, suggesting to me that the data do not support the interpretation in the earlier paper.

Other studies have shown no significant association. A case control study of lumberjacks gave an odds ratio (OR) of 0.9 (95% confidence interval (CI) 0.5 to 1.8).Λ A comparison of 807 workers exposed to vibration with 444 maintenance and clerical workers in Czechoslovakia,6 quoted by Liss and Stock,7 gave an OR =1.2 (95% CI 0.8 to 2.0).

Of 500 claimants considered to have VWF, 20% of those aged 50 to 85 had Dupuytren's disease compared with 10.7% of controls.s However, 45% (20 of 46) of the claimants over the age of 45 in the earliest stage of VWF had Dupuytren's disease, whereas the prevalence in the more severe stages (stages 2 to 4) mirrored the controls at 10.7%. Selection bias (the disease itself contributing to presentation as a claimant) is the probable explanation, as the authors acknowledged. The methodological flaws in this and other studies were not fully considered in the review' quoted by Professor Thurston.

Data from examination of over 100 000 British coal miners claiming compensation for VWF (see http://www.dti.gov.uk/coalhealth) may eventually throw light on this interesting question.

C. P. BURGE, FRCS

Nuffield Orthopaedic Centre,

Oxford, UK.

1. Thurston AJ. Dupuytren's disease. J Bone Joint Surg IBr]2003:85-8:469-77.

2. Hunter D, McLaughlin AIG, Perry KMA. Clinical effects of the use of pneumatic tools. Br J Indust Med1945:2:10-16.

3. Bovenzi M. Hand-arm vibration syndrome and dose-response relation for vibration induced white finger among quarry driller and stonecarvers. Italian study group on physical hazards in the stone industry. Occup Environ Med 1994:51:603-11.

4. Bovenzi M. Exposure-response relationship in the hand-arm vibration syndrome: an overview of current epidemiology research, lnt Arch Occup Environ Health 1998:71: 509-19.

5. Patri B, Vayssairat M, Guilmot JL, et al. Epidemiology and clinical studies of the lumberiack's white finger syndrome. Arch Mal Prof 1982:43:253-9.

6. Landgrot B, Huzi F, Koudela K, Potmesil J, Sykora J. The incidence of Dupuytren's contracture in workers in hazards of vibration. Pracov Lek 1975:27:331-5.

7. Liss GM, Stock SR. Can Dupuytren's contracture be work-related?: review of the evidence. Am J lnd Med 1996:29:521-32.

8. Thomas PR, Clarke D. Vibration white finger and Dupuytren's contracture: are they related? Occup Med fLondl 1992:42:155-8.

Author's reply:

I thank Mr Burge for his letter and interest in my review article.

In his comments, Mr Bürge has highlighted the lack of good scientific studies on the effects of vibration on the hands and the relationship with Dupuytren's disease. The literature was reviewed by Liss and Stock.1 Only three studies met their reasonably stringent criteria for inclusion. Dupuytren's disease was observed more frequently among vibration white finger claimants than controls by Thomas and Clarke2 (odds ratio (OR), 2.1; 95% confidence interval (CI), I.I to 3.9), and more frequently among vibration-exposed workers than controls by Bovenzi '(OR, 2.6; 95% CI, 1.2 to 5.5). Cocco et al4 found that a history of exposure to vibration was more frequent among cases of Dupuytren's disease than among controls (OR, 2.3; 95% CI, 1.5 to 4.4). Liss and Stock1 concluded that the latter two studies presented some evidence of a dose-response relationship and that there is good evidence of an association between exposure to vibration and Dupuytren's disease. It is inappropriate and unscientific for Mr Burge to assume that Bovenzi,5 by not including information about Dupuytren's disease in his 1998 paper, suggests that his data did not support an association between Dupuytren's disease and vibration.

The studies cited by Mr Burge as showing no significant association included that by Landgrot et al;6 this paper was excluded from the analysis of Liss and Stock because it did not meet their selection criteria in that the control group was comprised largely of manual workers. The other paper, by Patri et al,' was also excluded because it was not scientifically rigorous.

The evidence so far, albeit limited, supports an association between Dupuytren's disease and vibration. I suspect that Mr Burge may have unpublished data that contradicts this.

A. J. THURSTON, ED, MB, ChB, MSc (Oxon), FRACS, FNZOA

University of Otago

Wellington, New Zealand.

1. Liss G, Stock S. Can Dupuytren's contracture be work-related?: review of the evidence. Am J Ind Med1996;29:521-32.

2. Thomas P, Clarke D. Vibration white finger and Dupuytren's contracture: are they related' Occup Med1992;42:155-8.

3. Bovenzi M. Hand-arm vibration syndrome and dose-response relation for vibration induced white finger among quarry drillers and stonecarvers: Italian study group on physical hazards in the stone industry. Occup Environ Med 1994;51:603-11.

4. Cocco P, Frau P, Rapallo M, et al. Esposizione professionale a vibrazioni e malattia di Dupuytren: un approccio caso-controllo. Med Lav 1987:78:386-92.

5. Bovenzi M. Exposure-response relationship in the hand-arm vibration syndrome: an overview of current epidemiology research. ImI Arch Occup Environ Health 1998;71:509-19.

6. Landgrot B, Huszl F, Koudela K, et al. The incidence of Dupuytren's contracture in workers in hazards of vibration. PracovLek 1975:27:331 -5.

7. Patri V, Vayssairat M, Guilmot J, et al. Epidemiology and clinical studies of the lumberkack's white finger syndrome. Arch Mal Prof 1982:43:253-9.

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