Bruce
Stenman – Dupuytren’s Treatments (NA, XRT, and Xiaflex)
My Dupuyten’s treatment history began with a NA on both hands
by Dr. Denkler in March of 2007 in Larkspur,
The XRT was most
effective on my right hand which after the NA and XRT has no contracture
whatsoever now, which is 4 years after the treatments. My left hand was the one
that had progressed the most at the time of the XRT and that’s where I now
needed treatment again. This is why I believe that people should get XRT as
soon as they learn they have Dupuytren's and not wait for it to progress
further before taking action.
Several months
ago I decided to get either a second NA on my left and primary hand or a
Xiaflex treatment.
Left hand,
prior to collagenase injection. Purple ink
shows areas where Xiaflex is injected and blue circles show two of the areas
with impacting the contracture along with the area encircled in green. The
first doctor was planning to do the Xiaflex only in the green area while Dr.
Denkler injected the enzyme around all three areas.
There was
throbbing pain within 2 hours of injections and had to keep hand above head to
reduce blood pressure to the hand and in so doing alleviate the pain. Slept on
a sofa so my hand could be wedged between my body and the back of the couch and
so kept elevated. I used generic vicodin for first
two days to be able to sleep.
Hands became
very swollen, about 50% increase in size of fingers and the back of the hand
was so swollen that it was completely smooth. Could not put a
piece of paper all the way down between my fingers for the first 5 days.
Used ice packs and ice water bath for hand but neither had any affect on swelling.
Taking Ibuprophen for the swelling and discomfort for the first
6 days. Not intense pain just a throbbing kind of pain that persisted
for 6 days and was present whenever my hand was lower than my heart (and blood
pressure was increased in this area).
Shows the amount of swelling of the left hand the day after
the injections.
My swollen left hand
compared to my right hand after the injections
I had very
limited use of the treated hand until the final straightening by Dr. Denkler on
the 9th day after the injection. On the 6th day after the
injection the swelling was greatly reduced in my fingers and hand and I
attempted to straighten my hand on a granite countertop. I was able to get a
minor pop, then a major pop, and then another minor pop of my hand. The 40%
contracture (hand opening to about 140 degrees) was improved to a 20%
contracture (hand opening 160 degrees). After this partial straightening the
swelling returned to about 75% of what it had been the day after the injection.
On the 9th
day I made the trip to Dr. Denkler’s office and he injected a significant
amount of a local anesthetic into my hand. When my entire hand was completely
numb with no feeling at all he started manipulating it. In less than a minute
there was a large pop sound as he pressed against the bottom knuckle or joint
on the back of my ring finger while straightening my hand. This was a maneuver
that I never could have managed by myself. At this point my hand could open to
190 degrees and I could easily hold my hand open to 180 degrees. Had it been a
contracture of a single finger I probably could have straightened out myself
all the way on the seventh day.
It took four
hours for the local anesthetic to wear off completely and get all the feeling
back into my hand which is an indication of how much was used. At that point
there was very little pain at all in my hand, more of a mild soreness from the
physical workout it got. In my case it took someone using both hands to
straighten out my hand.
Day 9, after injection and manipulation: complete flattening
of the hand and no contractures remaining.
I am very glad I
traveled the extra distance three times to see Dr. Denkler. His initial consultation
convinced me that in my particular circumstance with the location of the
contracture that the risks with NA would be higher than average in terms of
possible nerve damage but at the same time safer for Xiaflex injections along
the sides of the area where he would not be hitting either nerves or tendons.
It became clear to me that the knowledge and experience of the practitioner are
both key to selecting the best treatment, doing the procedure, minimizing
potential side effects, and to getting the best possible results.
Waiting for 8
days instead of 24 hours after the straightening after the injections meant
much less risk of torn skin and the long recovery time that may entail along
with the increased risk of infection. Nothing was lost by waiting the additional
days after the injections in terms of the effectiveness of the treatment. I was
told that with some patients as long as three weeks might pass between their
getting the injections and having their hand straightened. After the
straightening by Dr. Denkler I saw that I had two small ¼’ long lateral tears
in a calloused area of my hand and nothing more.
Encircled in blue is the area that was most contracted and
where my Dupuytren’s first became evident, now completely flat. Area encircled
in green shows two small tears in a callous which was the only damage from the
straightening of the hand.
With NA my hands
were 100% ready for anything after 2 days. With Xiaflex that recovery time is
more like 10 days. Either is much shorter and much easier to deal with than
open hand surgery and physical therapy for months. Both treatments have their
place and which to use depends upon individual circumstances but I do recommend
getting a consultation with a doctor who has experience with both procedures
and is more likely to provide an accurate and unbiased assessment of the best
treatment for your condition. In my own experience with three different hand
surgeons I got three very different recommendations for treatment.
Dr. Denkler
believes that XRT is an effective co-treatment in conjunction with NA and or
Xiaflex. With XRT the aberrant healing process that creates the contractions
and nodules is damaged and as a result a NA or enzyme treatment should in
theory last longer. This is not all that different from cancer treatments where
XRT is used in conjunction with other treatments to get the best outcome.