Xiaflex: Non-Surgical Treatment for Dupuytren’s Contracture?

Xiaflex: Non-surgical treatment for Dupuytren’s contracture?

Xiaflex surgery is not a non-surgical treatment for Dupuytren's contracture.TV and radio ads say a Xiaflex injection is a non-surgical treatment for Dupuytren’s contracture.  Doctors tell Dupuytren’s contracture patients a Xiaflex procedure is no big deal; “like getting a shot.”  For this reason, patients are shocked after getting a Xiaflex “shot.”  Real life is much different.

Putting Xiaflex enzymes into the body is a big deal.  After all, Xiaflex dissolves collagen in any nerve, muscle, tendon, ligament etc. it touches, as well as the DC finger cord.  Talk about needing surgical precision!  It is difficult to do well, and risky if things go wrong – just like all surgeries.

Obviously, a Xiaflex injection is not major hand surgery.  On day one, a surgeon guides a hypodermic needle under the skin to put enzymes in three parts of the finger cord.  Remember, the goal is to make a precise injection – without being able to see the needle tip or cord.  Xiaflex enzymes then attack the cord to dissolve it.  On day two, the doctor forces the finger straight until the cord breaks.  These two acts are surgery, as described below. The Xiaflex procedure requires no cutting, results in little blood loss, although pain can be intense.  Even so, side effects can arise as in any surgery.  Still, no scalpel cuts the skin.  This makes it easier to say Xiaflex is a non-surgical treatment for Dupuytren’s contracture.

In fact, scalpels and blood loss are a part of  surgery, but not all.  As noted below, the Xiaflex procedure is minimally invasive surgery for the treatment of a disorder through any size opening made with a sharp tool.  Because it is surgery, it has side effects and complications.  Like any surgery.

Only trying to avoid hand surgery

Naturally, most people want to avoid surgery.  By calling Xiaflex a non-surgical treatment for Dupuytren’s contracture, it is easier for patients to agree to it.  Patients have the Xiaflex procedure to avoid surgery.  Soon, they discover it is minimally invasive closed hand surgery.

Xiaflex injections are clearly a surgical treatment for Dupuytren’s contracture, not a simple thing like “getting a shot.”  Proof:

  • American College of Surgery statement
  • Dictionary and common sense
  • Side-by-side comparison to “getting a shot”

American College of Surgeons’ statement

The ACS definition of surgery:  “Surgery is the diagnostic or therapeutic treatment of conditions or disease processes by any instrumentswhich include lasers, ultrasound, ionizing radiation, scalpels, probes, and needles.   Injection of diagnostic or therapeutic substances…is also considered to be surgery…”   Emphasis added.

With no large incision on the palm, the real work takes place under the skin by the action of Xiaflex enzymes.  It is like putting acid down a clogged drain. Like all surgeries, this creates the potential for positive and negative consequences.

Dictionary and common sense

Dictionaries do not agree that the Xiaflex injection is a non-surgical treatment for Dupuytren’s contracture.

  • Surgery – “treatment of injuries or disorders of the body by incision or manipulation, especially with instruments.” (Oxford dictionary)
  • Manipulation – “medical procedure to mobilize, stretch, traction, or physically break up fibrous and scar tissue to relieve pain and improve range of motion.” (Wellmark)
  • Incision – “opening that is made in something with a sharp tool, especially in someone’s body during an operation (surgery).” (Cambridge dictionary).

During Xiaflex closed surgery, destruction of cord tissue occurs after a needle delivers the therapeutic substance Xiaflex into the DC cord.  Later, manipulation of the weakened cord breaks it.  This is the dictionary definition of surgery.

Comparison of “getting a shot” to Xiaflex

A trained layperson can give a flu shot.  It is easy to learn and simple to do.

A surgeon must do the Xiaflex procedure.  Since the skin is not open, the doctor cannot see the cord or tip of the needle. For this reason, it is complex and difficult to do.  The surgeon must rely on keen skill and long experience to put the Xiaflex only into the cord.  The goal is to not allow even the smallest amount of Xiaflex in or on muscles, tendons, ligaments and nerves near or next to the DC cord.  Xiaflex surgery can be difficult to do well.  This is why some Xiaflex procedures go badly wrong.

Why Xiaflex is not a non-surgical treatment for Dupuytren’s contracture                                     

                                                                   Comparison of Xiaflex procedure to a common injection

 Compare  Xiaflex procedure for Dupuytren’s contracture  Simple injection – like a flu shot
 1. Performed by  Must be MD; usually orthopedic, hand, or plastic surgeon;   seldom general practice doctor  MD, RN, LPN, trained layperson or patient, etc.
 2. Selection of area  Specific and precise, down to a millimeter of DC cord     thickness and location based on palpation and   measurements  Thick muscle of shoulder or thigh; visual   determination
 3. Examination of area  Critical for success; detailed and precise  None required
 4. Local anesthesia  Required; extensive and deep to entire hand  None required
 5. Preparation  20-30 minutes  One second for alcohol swab application
 6. Needle penetration  Critical for success; three injections exactly placed in DC
cord only – done while not able to see cord or tip of needle
 7. Time needed  20-60 minutes  30 seconds or less
 8. Sterile technique  Strict sterile technique, as used in all surgeries  No mask, no gloves, just quick swipe with   alcohol   swab and injection is made
 9. Purpose  Dissolve and break Dupuytren’s contracture cord  Deliver drug into general circulation
 10. Side effect and   complications  Complex problems if Xiaflex leaks out to contact nerves,   tendons, ligaments etc.; sometime requires remedial   plastic  surgery; poor outcome in up to 30% of   procedures  Rare to none
 11. Skill level required  Extreme; critical for success*  Basic
 12. Insurance code  # 20527  –  Day 1.  Injection of an enzyme in three areas    of DC cord, no more than 2-3mm deep, 1-3mm apart
# 26341  –  Day 2.  Manipulation by surgeon to forcefully   break cord
 # 96372 – injection of medication,
intramuscular or subcutaneous
 13. Total cost  $6,000-$12,000 range: average $7,657.00**  $40.00 at Walgreens and CVS drug stores

Further discussion of results and costs of Xiaflex procedure

* 70% of patients need a second Xiaflex series because the cord does not break after the first Xiaflex series.  No data is found telling how many patients must receive a third Xiaflex series, if the second series fails.  Additional Xiaflex injections not allowed if the third Xiaflex series does not break the DC cord.

No data is available telling how many patients never have the cord snapped.

** Average cost of $7657.00 based on DC cord breaking at the end of the first Xiaflex injection series.  If it takes one or two more Xiaflex series to  to break the DC cord, the total cost increases with each one.

Bottom line for non-surgical treatment for Dupuytren’s contracture

  • American College of Surgeons says not all surgeries need a scalpel, or a lot of blood loss.
  • Dictionaries explain, surgery occurs when a doctor uses a sharp instrument (needle) to make an opening (needle hole) to treat a disease (Dupuytren’s contracture) or manipulate tissue (break DC cord).  No scalpels or blood loss.
  • Insurance companies pay $6,000.00 to $12,000.00 for the Xiaflex procedure. Why is that?  They do not pay anyone that much money for giving a shot.  Simply, it costs that much because it is surgery.

The Xiaflex procedure is demanding and can be difficult.  It requires high surgical skill and effort. Remember, the surgeon cannot actually see the cord or needle tip while making Xiaflex injections. Therefore, great risk is involved – much more than getting a shot.   Many doctors do not get it right the first time.  For this reason, many patients need two or three Xiaflex procedures to break the cord.  For some people it is never broken.  If this is not surgery, what is?

The Xiaflex procedure helps many Dupuytren’s contracture patients.  However, saying it is non-surgery downplays the difficulty and surgical risk involved.

It is not correct to say the Xiaflex procedure is a non-surgical treatment for Dupuytren’s contracture.