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, California, followed by XRT on both hands in April of 2007 in Essen, Germany. My hope was that the XRT would postpone recurrence. Prof. Seegenschmiedt after examining my hands expressed the opinion that the Dupuytren's was far more advanced in my left hand than I had anticipated and he was somewhat doubtful as to the outcome. Nevertheless I had both of my palms radiated.

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.

March 7, 2011, after meeting the prior week and having my hand examined by Dr. Denkler I decided to get the Xiaflex injections. Dr. Denkler uses one vial but all 0.9mg instead of 0.58 as per Auxilium’s recommendation. He first injected local anesthetic in multiple locations and then was able to take his time making multiple injections of the Xiaflex at different locations around the contracted area. He covered with one vial what the first doctor I saw for the treatment was going to do with two vials, and the second vial would have been administered 30 or more days after the first 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.