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Why waste time with Xiaflex?
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02/15/11 23:46
flojo 
02/15/11 23:46
flojo 
Re: Why waste time with Xiaflex?

Moondanc,

My understanding is that Dr. Denkler uses the vial at one time, but does multiple injections of small amounts. He did say the if a whole vial were put in one spot and a tendon was too close, it potentially could compromise the tendon. He sees small amounts in several places along the cord minimizing the likelihood of messing up a tendon and also breaking the cord at several places will likely keep the cords severed. When he did NA for me, he did more than one snap of a cord. (I really didn't want to know everything he was doing at the time)

I know Dr. Denkler knows hands. I also know he prefers to do NA and now Xiaflex when possible, but if not, he still does surgery for on hands that NA or Xiaflex isn't a viable treatment.

02/15/11 23:54
bstenman 
02/15/11 23:54
bstenman 
Re: Why waste time with Xiaflex?

Thanks for the information Flora. On the surface it seems to confirm my thinking that an experienced hand surgeon who has performed treatments using NA and Xiaflex is going to be in a better position to judge which treatment will be safest and is likely to produce the best results for a particular patient.

Information about status 8 months after injection is not particularly helpful given the usual rate of progression. My own NA was great for the first 18 months and the contracture gradually returned over the past 48 months years to the point where I am seeking additional treatment.

It is not true that Xiaflex is just like NA. With NA the incisions go along the chord and with Xiaflex there is a single point of injection of a substance that does not travel much through the tissue. The Xiaflex dissolves tissue and this can include tendons and ligaments which is not the case with NA.

Lidocaine was viewed initially as a panacea and injected into many people's hands to relieve a variety of conditions including trigger finger. It was discovered to lead frequently to ruptured tendons and sometimes the permanent crippling of individuals. I see a parallel to Xiaflex as a treatment for Dupuytren's and only time, a lot of time, will tell.

02/16/11 00:14
flojo 
02/16/11 00:14
flojo 
Re: Why waste time with Xiaflex?

Bstenman,
I agree that a surgeon who is open minded would have full knowledge of the anatomy of the hand and able to give an educated opinion about what treatment or combination of treatments would be best for any particular hand. The reason Dr. Denkler started doing NA in the first place was because it is less invasive, not having the scar tissue of surgery and less recovery time. If a hand can be corrected with NA, he will do that rather than surgery. Now he finds Xiaflex offers another alternative to surgery.

He does inject the enzyme in several spots along a cord, not just one spot. I guess it depends how long the cord is. He also said that in my hand, I could consider a little xiaflex between my little finger and ring finger. There is tightness there and it's like a cord dead ends right at that point.

I agree with your analysis of our options.

Edited 02/16/11 00:18

02/16/11 02:11
moondanc 
02/16/11 02:11
moondanc 
Re: Why waste time with Xiaflex?

flojo:
Moondanc,

My understanding is that Dr. Denkler uses the vial at one time, but does multiple injections of small amounts. He did say the if a whole vial were put in one spot and a tendon was too close, it potentially could compromise the tendon. He sees small amounts in several places along the cord minimizing the likelihood of messing up a tendon and also breaking the cord at several places will likely keep the cords severed. When he did NA for me, he did more than one snap of a cord. (I really didn't want to know everything he was doing at the time)

I know Dr. Denkler knows hands. I also know he prefers to do NA and now Xiaflex when possible, but if not, he still does surgery for on hands that NA or Xiaflex isn't a viable treatment.

Hi Flojo,
When I did my original post I couldn't think of the proper term to use-- vial--and so my explanation was a bit awkward. That's what I was referring to, only one vial every 30 days. In the trials it was divided into 3 injections into the cord. There's a case study on Dr. Denkler's website where he'd divided a vial into 5 separate injections and it was not successful. "The thick cords were not weakened enough for rupture with manipulation under local anesthesia since the XIAFLEX was diluted into five aliquots."

http://www.plasticsurgerysf.com/scrapboo...k&UID=10062

Lots of other good info -- interesting to mix Xiaflex and NA.
http://www.plasticsurgerysf.com/scrapbook/

More good information on Dr. Eaton's website comparing NA to Xiaflex, doesn't make Xiaflex look all that favorable:

http://www.handcenter.org/newfile20.htm

Moondanc

Edited 02/16/11 02:12

02/16/11 06:08
flojo 
02/16/11 06:08
flojo 
Re: Why waste time with Xiaflex?

Moondanc,

Definitely something to keep tabs on. It will be interesting to see what this all looks like in 3-4 years when the data will show long term effects of Xiaflex. Those of us who have aggressive Dups may have to have repeat or different treatments before all of the data comes in.

We have such a great place to store the results of our various treatments. Thank you, Wolfgang, and all who contribute to this ongoing saga.

02/16/11 16:08
sbid

not registered

02/16/11 16:08
sbid

not registered

Re: Why waste time with Xiaflex?

bstenman:

The Xiaflex dissolves tissue and this can include tendons and ligaments which is not the case with NA.


This is news to me: specifically that the dissolved tissue can include tendons and ligaments. Can you provide a reference for that?

02/17/11 08:07
moondanc 
02/17/11 08:07
moondanc 
Re: Why waste time with Xiaflex?

@sbid:
bstenman:

The Xiaflex dissolves tissue and this can include tendons and ligaments which is not the case with NA.


This is news to me: specifically that the dissolved tissue can include tendons and ligaments. Can you provide a reference for that?

Xiaflex (collagenase) dissolves collagen. Collagen is found in tendons. If not injected in the proper place, at the proper depth, tendon damage can occur. The FDA studies on Xiaflex are not complete and AFAIK, nothing has been published on how long Xiaflex stays in the system, how long the antibodies remain, etc. There's a reason the FDA restricts injections to once every 30 days ...

Here are some references:
#1-from Dr. Eaton's website which I posted previously comparing NA to Xiaflex- halfway down the page under Xiaflex, possible complications:
http://www.handcenter.org/newfile20.htm
"Tendon Dissolved Nerve Injury
Infection
Ligament Injury
Tendon Pulley Rupture
Allergic Reaction"

#2-http://orthopedics.about.com/b/2010/02/22/new-treatment-option-for-dupuytrens.htm
"That said, there are some concerns about Xiaflex. One rare complication can occur if Xiaflex is injected too close to a tendon. If this occurs, the tendon can rupture (the collagenase dissolves the tendon tissue) requiring a surgery to fix the problem"

#3 http://www.ft.com/cms/s/2/aba2b8f0-7aee-...l#axzz1ECA30Zhg

Multiple references in the article including this one, "Dr Srinath Kamineni, a consultant orthopedic surgeon and elbow, shoulder, hand and wrist specialist in London, said that extensive training is needed - citing the potential risks of tendon rupture and nerve damage with injections. Tendon rupture is a huge concern because if Xiaflex is injected in the wrong place, it could lead to tendon breakdown, he said"

#4- http://www.recordonline.com/apps/pbcs.dl...HEALTH/10130325
"Complications with the new treatment are rare, says Del Savio. "Collagen is found in tendons as well as in the cord, and there have been rare instances of tendon rupture. This is why the procedure should only be done by someone who is very familiar with the anatomy of the hand and the treatment of this disease." There may also be some temporary discoloration around the injection site."

Moondanc

02/17/11 18:47
David26

not registered

02/17/11 18:47
David26

not registered

Re: Why waste time with Xiaflex?

Quote: The Xiaflex dissolves tissue and this can include tendons and ligaments which is not the case with NA.

To be fair, there are similar risks and complications with NA. Tendons and nerves can be cut with NA. The actual risk of severe complications with either NA or Xiaflex is low. With an experience doctor doing NA or injecting Xiaflex your risk of serious complications should be very low.

The most important issue in my opinion is what best in your situation. What is best for your hands, your disease progress, your financial/insurance situation, your proximity to medical care, etc.

As far as effectiveness I think they are similar in regard to correction of bent fingers and recurrence.

02/17/11 20:02
sbid

not registered

02/17/11 20:02
sbid

not registered

Re: Why waste time with Xiaflex?

moondanc:

<snip>

Moondanc

Thank you for the information and references.

02/17/11 21:44
guest

not registered

02/17/11 21:44
guest

not registered

Re: Why waste time with Xiaflex?

David26:
To be fair, there are similar risks and complications with NA. Tendons and nerves can be cut with NA. The actual risk of severe complications with either NA or Xiaflex is low. With an experience doctor doing NA or injecting Xiaflex your risk of serious complications should be very low.

As far as effectiveness I think they are similar in regard to correction of bent fingers and recurrence.

There is NO long term documentation of the effectiveness of Xiaflex. In fact, check out the Xiaflex website and you will see that in some cases the *short-term* effectiveness is only 44%. Range of motion increases
https://www.xiaflex.com/treatment_outcomes.jsp

"In clinical studies, XIAFLEX reduced contracture to straight or near-straight in 44%-64% of patients 30 days after up to 3 injections, compared with 5%-7% of patients who received injection with placebo (an inactive substance)."

*http://abclocal.go.com/kgo/story?section...&id=7745352
Check out this video of a Xiaflex injection. Notice at approximately 1:04-- the bent needle.

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