Xiaflex and Dupuytren Treatment

Xiaflex treats Dupuytren contracture by dissolving cords

Xiaflex is the brand name of the enzyme collagenase, produced by Auxilium Pharmaceuticals, Inc.,  that originates from clostridium histolyticum, the same bacterium that causes gas gangrene.  Actually, Xiaflex is a combination of two separate enzymes, called Aux-I and Aux-II that work together to break up the peptide bonds of the collagen protein. In early 2010 the FDA approved Xiaflex for treatment of Dupuytren contracture when a palpable cord is present; Xiaflex was not approved for Dupuytren treatment when only nodules or lumps on palms are found.

Dupuytren’s contracture is a slowly progressive condition that affects five times the number of men than women, affecting the deep soft tissue of the palm of the hand, called the palmar fascia.  The problem is characterized by excessive collagen deposition in the palmar fascia that leads to finger contracture caused by a nodule that can develop a rope-like cord. As Dupuytrens disease progresses, the cord can slowly cause the affected finger(s) to go into flexion contracture toward the palm of the hand.  With one or more fingers locked in a flexed contracture and unable to be straightened or extended, the individual with Dupuytren has significant problems with simple daily activities such as dressing, washing, toileting, and handling objects.

Xiaflex and Dupuytren treatment compared with surgery

The decision to use a surgical treatment for Dupuytren’s contracture depends on multiple factors:

1.    Stage and severity of the current condition
2.    History of prior hand surgery
3.    Status of the skin of the palm
4.    Age
5.    General health status
6.    Occupation
7.    Presence of complicating factors, such as the presence of bony deformity from joint disease or the like.

Surgery for Dupuytren’s contracture is typically considered a reasonable option only when the finger contracture causes a distortion of at least 30º of finger flexion.

Dupuytren surgical and drug options include:

1.   Fasciotomy – surgery in which only the offending cords are cut, without removal of any diseased fascia.  Needle aponeurotomy is a less invasive form of fasciotomy; it is a blind procedure in which the surgeon attempts to weaken the cords by tearing, puncturing and otherwise dividing the cords via a needle tip inserted through the skin, instead of a scalpel.

2.   Fasciectomy – surgery in which diseased, contracted and thickened tissue is cut and removed from the palm and fingers through incisions in the palm and affected finger(s).

a.    Partial fasciectomy – in which only mature and clearly deformed tissue is removed; it is often used in moderate to severe cases where 1 or 2 fingers are involved.

b.    Complete or radical fasciectomy – in which all bands of thickened and abnormal tissue that reduces joint movement and hand function are completely removed, sometimes requiring skin grafting if insufficient healthy skin is available due to the amount of tissue removed or when prior Dupuytren surgery has reduced the amount of available healthy tissue.

3.   Amputation of the affected finger(s) – surgery performed when hand pain and deformity is present to such a degree of impairment because past multiple Dupuytren surgeries have created so much scar tissue and removed so much tissue that no further surgery is possible.

4.  Xiaflex for Dupuytren treatment – used when cords, not nodules, are present.  Enables treatment to be done sooner when the MCP (metacarpophalangeal) or the PIP (proximal interphalangeal) joints are at 20º of finger flexion.   Thus, Xiaflex can be used 10º sooner into the finger flexion progression than surgery.

Xiaflex treatment of a Dupuytren cord requires a doctor to make multiple injections of Xiaflex into the palm of the hand into the Dupuytren’s cord at various points. Twenty four hours later the patient returns to the office for the doctor to forcefully break the cords that were enzymatically weakened the day before, by taking the fingers into extension

Xiaflex is injected into only one cord per treatment series, using a small quantity of Xiaflex solution that is divided between three injection sites selected by the treating doctor. If a first Xiaflex injection does not achieve the desired results then the procedure is repeated again one month later. A patient can only receive three series of Xiaflex treatments per Dupuytren cord.

In 70% of Xiaflex treatments the patient must return one month later for a second series of Xiaflex injections into the same finger cord to complete the procedure because of sufficient cord disruption did not occur at the first procedure.

Reasons to avoid Xiaflex as a Dupuytren treatment

Incorrectly performed injections of Xiaflex may cause damage of the local tendons, blood vessels, joints and nerves.   A mistake of injecting the Xiaflex by even 1mm can have terrible consequences in which permanent loss of finger movement or permanent injury to blood vessels and nerves can occur.    That is why the FDA requires that Xiaflex injections should be performed by a doctor who has been specially trained to make these collagenase injections.  However, this training consists of an online video that contains 20 minutes of training.

Each patient undergoing these injections must know that the recurrence rate of Dupuytren contracture after Xiaflex treatment is for 19.3% recurrence after two years.  This is a lower recurrence rate compared to fasciectomy (34% recurrence) and needle aponeurotomy (85%,recurrence), but still recurrence of the problem.  At this time no one knows if this recurrence rate increases with each subsequent series of injections, or if the degree of Dupuytren thickening worsens each time recurrence occurs..  Also, at this time, no one knows if the long term effects of repeated injections of Xiaflex on healthy tendons, ligaments, arteries, veins and blood vessels.

To avoid the possible side effects and adverse reactions of Xiaflex for Dupuytren treatment, it is worthwhile to consider first using more conservative Alternative Medicine methods before more radical methods like surgery or Xiaflex injections .

>>  Click here for FAQ about Dupuytrens.
>>  Click here for ideas how to treat Dupuytren contracture naturally.

6 thoughts on “Xiaflex and Dupuytren Treatment

  1. John Loebel says:

    I have a Dupuytren’s contracture nodule at the 2nd PCP joint and a cord extending into the palm causing a 30 degree bend. Since Ziaflex is not used on nodules, is it reasonable to excise the nodule after Ziaflex treatment of the cord?

  2. Dr.Herazy says:

    Greetings John,

    I doubt you would find a surgeon who would consider removing the palm nodule of Dupuytren’s contracture after Xiaflex injection.

    Theoretically, once the cord no longer limits movement or interferes with normal daily activities, there is no reason to remove the palm nodule; the palm nodule is considered more so a cosmetic issue if it does not adversely affect your life. Too many palm surgeries result in bad reactions or worsen the basic Dupuytren’s contracture that additional surgery is considered to be not worth the risk.

    In actual practice, many times after Xiaflex injection for Dupuytren’s contracture the problem does not change, or new problems arise or old problems intensify, that removal of the palm lump is not all that important.

    People would like to think that all surgeries are wildly successful and that after a Xiaflex injection all traces of the original problem are permanently gone. From my perspective based on the information I get from around the world communicating with people you, a perfect Xiaflex outcome is rare. For this reason I suggest that you be very careful about who hire to do this work because when it goes bad it can be very bad. I believe the best approach is to try to avoid any type of direct physical intervention with Dupuytren’s contracture by trying to increase your natural ability to heal DC.

    Please let me know if you have any more questions about Dupuytren’s contracture. TRH

  3. Barbara says:

    I’m a 84 year old woman diagnosed two years ago with dupuytren contracture on three fingers of each hand. Quality of life reduced significantly. Would xiaflex injections be recommended

  4. Dr.Herazy says:

    Greetings Barbara,

    You ask a simple question that requires a long and complex answer about Dupuytren’s contracture treatment. I will only be able to quickly skim the surface of an answer for you; the rest you should do with independent study into this subject.

    While there are many doctors who favor Xiaflex injections as a way to break the Dupuytren’s contracture cord, there are just as many who do not. The primary reasons are:
    1. Faster recurrence of DC after surgery than other medical methods of treatment.
    2. Difficulty to control the migration of Xiaflex into normal and healthy tissue, sometimes as far away as the shoulder joint, resulting in serious side effects.
    3. Great pain during the cord breaking procedure.
    4. Cost factors along with a questionable risk to reward ratio.

    I suggest you consider the natural self-treatment concepts found on this website. Please read what others have said about Xiaflex injections for Dupuytren’s contracture when it goes bad. Our natural Alt Med methods do not cause side effects and no recurrence has been reported after treatment. After many years of doing htis work we get 8-10 people report moderate to marked success with DCI treatment, for every one report of failure.

    Good luck with your Dupuytren’s contracture treatment. TRH

  5. joyce pinto says:

    Hello- I had Xiaflex injections 3 days ago and I could not return for the breakage of the Peyronie’s disease tendon. I was terrified from the pain I had felt during the injections and some pain from just moving my hand. I just could not go back for the manipulation of the finger…now not too sure what will happen-but there is no way my Dr. that I really like and trust is going to break my tendon… I would rather have had the surgery.

  6. Dr. Herazy says:

    Greetings Joyce,

    Yes, the entire Xiaflex injection process can be an extremely painful experience. This is true, especially if the doctor doing it has minimal experience. Even in the hands of an experienced and talented doctor there is a lot that can go wrong during a Xiaflex procedure.

    It is nice that you like your doctor, but those things are usually more based on the personality of the individual, which has nothing to do with professional skill and competence.

    Considering the extreme amount of pain you report, it is certainly possible some type of mistake was made when the collagenase was injected into your hand. I suggest that you immediately find the best hand surgeon you can find to determine what your next step should be. Besides the obvious consideration of what has been done to your hand, you also have to consider what will be done next for your hand. Perhaps you can discuss with this next doctor non-surgical options, such as the PDI Alt Med program. You can tell him/her that we get 8-10 reports of moderate to marked reduction of the DC nodule for every one report of failure. That is obviously a good outcome by surgical standards, and there has never been a report of any side effects.

    Best of luck to you. TRH

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