A pratitioner by definitiion is someone engaged in a practice and yet the amount of actual hands on practice by the doctor performing the Xiaflex and NA procedures is not adequaltly appreciated. Twice I have had an experienced doctor perform a combination of Xiaflex and NA with the use depending upon the location to be treated and the pressence of nerves and other factors. My, doctor, Kevin Denkler in Larkspur, CA has as much experience in performing various treatments including open surgery, as anyone in the world, and I trust his judgment as to what will best work where with the Dupuytren's in my hands.

I have had NA done 4 times and Xiaflex done three times and have learned along the way. I found that having the release work performed 20 hours after the Xiaflex injections made a huge difference in the next day symptoms and pain levels as compared to the procedures performed previously with the large gap between injection and manipulation. My prior experince has been to have a great deal of throbbing and pain as the post-injection swelling in combination with the Dupytren's created pressure points against the nerves in my hand. I had to keep my hand at the same vertical height as my heart to avoid throbbing pain with the impinged blood flow in my hand.

Having the release work performed 20 hours later has made a dramatic difference with zero pain and no discomfort by the end of the following day. This makes normal activities much less of a problem and greatly improved my sleep. Before it was two weeks before I could get a full night's sleep but this was now true last night only 30 hours after the manipulation work done on Wednesday morning.

It is important to note that Dr. Denkler treated some 10 distinct sections of my hands using 8 Xiaflex injections on the afternoon of one day and with manipulation ann NA the following afternoon. Xiaflex is supposed to work for 12 hours so the 20 hour gap was more than enough and the next day my wrist was injected with lidocaine and so with my entire hand numbed the doctor could do the necessay manipulation and incisions do both correct the cords and to also release the skin laying on top of the Dupuytrn's tissue. The trick in part is his generous use of the local anesthtic.

The 20 hour interval between the injections and the manipulation with the NA worked perfectly in my case. I believe I also benefited from having the bandages redone after the NA as they were done with my hands already swollen and so not nearly as tight or constrictive. The swelling retards healing by restricting the removal of waste product and I would expect that anything that reduces swelling or minimizes its effects would improve the body's ability to heal itself as with any injury.

The one day injections followed by the next day manipulation and NA meant only one night's stay at a local hotel. This would work very well for someone flying into San Francisco or Oakland to see Dr. Denkler. What I love about Dr. Denkler is that he is continually refining the process so as to get better outcomes for his patients and this is exceedingly rare with any professional.

Edited 11/22/13 19:47

Everyone is different but my experience has been as follows:

2007 - XRT and NA
2011 - Xiaflex and limited NA
2013 July - Xialex and limited NA
2013 November - Xiaflex and extensive NA

The .58mg amount of Xiaflex was not enough to cover the area of my contracture which is primarily between my second and third fingers and extends down into the palm area. Dr. Denkler did as much as he could with the one vial of Xiaflex and NA.

I waited for my hand to recover as much as possible from the July injections and the damage done by the Xiaflex and the swelling, and then scheduled the second treatment for November. This kept both procedures within the same year so I did not have to re-qualify in terms of the level of contracture from the Dupuytren's. The November procedure was in effect a continuation of the July procedure.

Dr. Denkler is an out of network provider for my insurance but I did not mind paying out of pocket to get the best doctor available. The insurance covered the two vials of Xiaflex which otherwise would have cost me $6800.

Overall this strategy worked for my treatment and for the even more difficult aspects of dealing with insurance companies in the USA who are happy to take your payments for the policy and happy to deny you coverage when you find you need it.

Dr. Denkler did extensive NA work after straightening my hand and digits as much as possible after the Xiaflex had time to do its work. He use NA to attack areas where the Xiaflex had not been needed and where no nerves were located and also to lift the skin away from the Dupuytrens where the Xiaflex had been injected. The cost was no more than had he only done the NA or only done the Xiaflex and not done the NA.

He is an exceptional doctor and regardless of where I lived in the USA he would be my top choice. The afternoon when I arrived for my injections a patient was leaving his office that had spent two days driving down from Washington to have Dr. Denkler work on his hand. The patient was delighted he had made the drive and with the outcome from the procedure.

It was 3 years after the first NA that I needed the second procedure and waited for the Xiaflex to become available. First Xiaflex vial injected in 2011 was not enough to treat the area that needed to be treated and so the treatment was only 50%. This time I had two procedures done using 2 vials and much more extensive NA that treated 100% of the area with Dupuytrens. This wlll be the true test.

As I stated previously, everyone is differnt. If I had a simple PIP in one finger it would be relatively trivial compared to my hand where about 10x as much tissue was involved. That is why there is little value in asking which treatment is better as it depends upon the individual. Same is true in terms of complications and recurrence of the Dupuytren's.

Recurrence is going to happen so best to use treatments that are low risk and use the best qualified doctor tht you can find as the odds of having a complication doubles with each additional procedure.

Dr. Denkler presented a paper to the international symposium for hand surgeons in 2007 regarding alternatives to tourniquets during open hand surgery with the results of 4000 operations using an arterial clamp instead. 5 years later the "profession" is still doing tourniquets.

I would guess that the people who learned NA are the early adopters who are more open to learning new ways to deal with medical problems. Problem at least in my part of the USA is that the people at Xiaflex licensed virtually any physician to do the treatments and most had no experience with NA and often were not even certified hand surgeons. No way could these doctors have good jugdment as to the best course of action for a particular patient.

American medical practice largely involves looking for a larger hammer and seldom is any thought given to an integrated approach. That is why someone like Dr. Denkler is so very rare in this country.