XIAFLEX and Needle Aponeurotomy for Dupuytren's Contracture


 
 




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Keith Denkler, M.D.


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XIAFLEX for Distal Joint Dupuytren's Contracture


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AAPS Presentation on Needle Aponeurotomy for Severe Dupuytren's


Dupuytren's Boutonniere Deformity Treated with XIAFLEX


XIAFLEX Boutonniere Treatment


2011 ASSH Dupuytren's Needle Presentation


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Keith Denkler M.D.  
415-924-6010  
275 Magnolia Ave.  
www.PlasticSurgerySF.com  
Larkspur, CA 94939  


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Fat Grafting Before and After …

Seven Year Needle Follow-up.jp…

Xiaflex for Severe Dupuytren C…
Fat grafting can be performed after needle aponeurotomy.
The fat acts as a spacer and also introduces stem cells into the palmar fascia affected by the Dupuytren contracture.
Thin and tight palmar skin with Dupuytren contracture does very well with fat grafting.


Severe Dupuytren contracture in the left ring and little fingers. A single treatment with needle aponeurotomy has not recurred even after seven years. This is why needle or Xiaflex should be performed first. Excellent long term results can occur in some patients.


The upper left photo is before treatment.  The upper right shows the finger two weeks after the XIAFLEX injection, and before straightening.  Notice the delay allows for much less bruising and swelling.  The finger has become slightly straighter in this period.  The bottom left photo shows the finger immediately after the manipulation. The white color is from the use of lidocaine with epinephrine as an anesthetic.  This constricts the tissues temporarily and allows for less bruising with the straightening procedure.  The circulation is nice and pink to the tip.  The bottom right photo is the finger another two weeks later.  A small amount of the vial was placed into the ring finger and this finger improved also.



XIAFLEX (one vial) to Multiple…

XIAFLEX to PIP Joint

XIAFLEX to The Right Hand

This patient is seen before one treatment with XIAFLEX to multiple PIP joints.


One vial was used and spread to multiple PIP joints.  He is seen at straightening 10 days after the XIAFLEX injections with a small skin tear (occurs about 10-15% of the time).  The brusing at ten days should be noted.  The last pictures are two weeks after the straightening.  The skin tear has healed and he has excelllent improvement in finger extension.




This patient is one month after XIAFLEX treatments to the little finger PIP joint which had a 60 degree contracture.  A top hand surgeon at a fine teaching institution had stated XIAFLEX would not work for a sole, severe PIP contracture and he would need pinning, the Digit Widget™ application, and then excisional surgery (fasciectomy).  This patient chose the non-surgical alternative, XIAFLEX and had a very nice result.


The drug for these conditions is used in smaller doses, and more distal than the FDA recommends.  The drug is made slightly more dilute, and spread more widely to achieve this actual result for PIP joint Dupuytren's.




This patient is the palmar view of a hand three weeks after XIAFLEX.  Very nice improvements are seen in this early result.



Xiaflex to Middle (PIP) and Di…

XIAFLEX to PIP of Little and R…

Xiaflex to PIP
This finger had a -50 degree bend at the middle joint (PIP) and -15 degree bend at the last joint (DIP).  It took two session of XIAFLEX using two vials to correct this finger bend to normal.  The first session only corrected to about 15 degrees of improvement, but the second session got it all straight in this 32 year-old patient with Dupuytren's.


This patient had surgery to the other hand which gave him full extension, but he lost flexion due to stiffness and he has lost some ability to grip.
XIAFLEX, one entire vial was used to his left ring finger (.6 mg) to just proximal to the MCP joint for a -40 degree MCP and -90 degree PIP contracture.
The little finger was -30 at the MCP and -70 degrees at the PIP joint. This finger was treated with XIAFLEX (.2 mg) at the MCP joint and at the PIP joint (.1 mg).
The result two weeks after the treatment is seen in the bottom photos as this one office treatment has gained him excellent extension without loss of work due to recovery.


Xiaflex to PIP joint and five days later.
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Xiaflex to PIP Joint

Xiaflex and Needle Aponeurotom…

Severe Stage IV Dupuytren's C…
Xiaflex to PIP joint of index finger and result at the time of numbing and straightening under local anesthesia.


This patients photos are the next day after XIAFLEX injection equally into five dotted areas.  The thick cords were not weakened enough for rupture with manipulation under local anesthesia since the XIAFLEX was diluted into five aliquots.  Judicious needle fasciotomy in two areas (bloody) completed the straightening.  Needle and XIAFLEX can be combined, however it is more optimal to do this after much of the swelling has gone down.  In this case traveling from another state, the needle was safely done the next day to allow straightening of the finger and saving another visit.  An alternative would be to re-inject XIAFLEX in one month.




Two treatments of XIAFLEX were needed to treat this severe Dupuytren's contracture.


The PIP (middle) joint has residiual bend, but the overall function is highly improved.





Aponeurotomy Stage IV Dupuyten…

Aponeurotomy for Stage IV Long…

Successful XIAFLEX Injection

This patient is five years after needle aponeurotomy to his little and ring fingers.  Both were severe stage IV contractures and have remained much improved more than five years later.  This example shows why it is important to start with less invasive techniques such as needle or XIAFLEX first, since long-term improvement can occur with these techniques alone.




This patient is 4.5 years after a needle aponeurotmy and skin graft to the right ring finger.  New disease had developed in the middle finger but the ring finger has remained a lot straighter.


Two month followup of XIAFLEX injection to the right little finger, one treatment only.



XIAFLEX Injection for Dupuytre…

5 year Needle Before and After…

Needle Aponeurotomy Then Xiafl…

The upper left photo shows the finger before XIAFLEX injection for Dupuytren's The photo on the upper right shows the bruising seen the following day. The lower photographs are the finger at two-week followup exam, also showing great improvement after one treatment cycle.


Dupuytren's will continue to grow and develop after any treatment. However, all options for future treatment are available such as repeat XIAFLEX injections, needle aponeurotomy, or surgical excision depending on how fast the disease re-develops.




Needle can be successful long-term in some cases and is an excellent way to start. Recurrent disease may be treated with repeat needle or with XIAFLEX.


This patient with severe disease after previous surgery had a needle aponeurotomy first with the results seen months later in the middle pictures at the time of his Xiaflex treatment.  The lower  pictures are his results one month later after Xiaflex treatment.  The middle photos show his Xiaflex treatment of small doses to the residual Dupuytren's cord of his PIP and DIP (middle and last) joints.



XIAFLEX Injection and Two Week…

Twenty Months After NA for Dup…

XIAFLEX Before and After
Upper left photos shows the finger before XIAFLEX injection.  Upper right shows the injection.  Lower photos are the hand two weeks after the injection with significant improvement after one treatment cycle.


This patient with severe Dupuytren's is seen before and twenty months after needle aponeurotomy (needle fasciotomy) of Dupuytern's contracture.


This patient had previous surgery five years ago to the middle (PIP) joint and his photos of the surgery are seen in the adjacent photo with the sutures in place. The surgery was successful at keeping his middle joint straight, however his disease progressed and now his first joint (MCP) was contracting in an area that had not had surgery. The photos on the right show successful release of the first joint. The previous surgery scars can be seen in the photos on the right.



Severe Dupuytren's Contracture…

Surgery and Xiaflex

XIAFLEX PIP Joint of Little Fi…
These before and after pictures of Dupuytren's contracture show results three weeks after a needle fasciotomy.


This patient had surgery seven years ago to the the PIP joint of the little finger.  The surgery (fasceictomy) was successful, however new disease developed just proximal to the MCP (first joint).  This disease was treated successfully with three XIAFLEX injections (blue marks).  The fingers at the bottom are two month follow-up showing excellent extension.


The little finger PIP joint is the toughest to treat with any method. This thirty-two year old male is seen after two XIAFLEX injections to his little finger.
Two years previously he had needle aponeurotomy to this joint and improved from -70 degrees to -50 degrees as seen in the upper left photo. The photo on the right is at the "straightening" procedure. One month later he is improved after one injection as seen in the left lower photo. More XIAFLEX was added and the photo on the lower right is at the straightening procedure and he has his own full extension back.



Dupuytren's of First Joint (MC…

Needle Aponeurotomy Two Years …

NA for Severe Dupuytren's
This seventy degree contracture improved markedly as seen in follow-up photo three months after NA (needle aponeurotomy, needle aponevrotomy).


Needle aponeurotomy is criticized by surgeons for "rapid recurrence" since no diseased fascia is removed. However, many people do very well after needle aponeurotomy as evidenced by this patient with severe Dupuytren's. The photo is before and after results at two years after needle aponeurotomy.
Needle aponeurotomy is an excellent first choice for Dupuytren's even for patients with severe disease.


Another hand surgeon recommended amputation for this severe stage of disease. The patient came to me for a second opinion. The Dupuytren's contracture had pre-op loss of extension of 195 degrees. The photos on the right are at one year follow-up after needle aponeurotomy.



Needle Aponeurotomy

NA Needle Aponeurotomy

Seventeen Month Follow-up
Ten month follow-up after needle release (needle aponeurotomy) of Dupuytren's contracture.
This patient with stage four disease and 175 degrees of bend had more than 120 degrees of improvement in finger extension. This required one treatment under local anesthesia.
The other fingers showed significant gains in extension also.


Immediate before and after photos of multiple finger NA procedure for Dupuytren's contracture


This Mexican male with Dupuytren's had been told by two doctors he needed open surgery, fasciectomy for his Dupuytren's contracture. The photo above is his result seventeen months after needle aponeurotomy (fasciotomy).
Dupuytren's is unusual in Hispanics and persons from Latin descent. The highest incidence of Dupuytren's is in the Nordic countries.



Multiple Finger NA for Dupuytr…

Needle Aponerutomy Results at …

Needle Aponeurotmy at Time of …
This shows the before and after treatment of Dupuyten's contracture with Boutonniere of the little finger.  This requires release of not only the fibrous Dupuytren's, but also the contracted joints and tendons


This hand had needle aponeurotomy for Dupuytren's contracture in 2005. The short term result was excellent as seen in the middle photos. After six years the little finger may be retreated with needle aponeurotomy or he would be a candidate for XIAFLEX to dissolve the cord. The other fingers remain stable.


The result at the first joint was excellent four years later, but the PIP (middle) joint will most likely be treated with supplemental Xiaflex.



Needle Aponeurotmy for Severe …

Needle Aponeurotomy for Stage …

Lariboisière Hospital
Three months after needle aponeurotomy


This patient had a loss of 70 degrees of straightening at his first joint (MCP) and a loss of 65 degrees at the middle joint (PIP). The total loss of extension was 135 degrees or stage IV. The bottom pictures show the significant improvement eight months later. There is a residual bend of 35 degrees at the PIP joint, but the first joint has maintained extension.


Hospital in France where Dr. Denkler learned the French needle technique for release of Dupuytren's contracture.


What your hands look like under the skin, both front and back

Anatomy of Dupuytren's Contrac…

Fasciectomy for Dupuytren's

Dupuytren's Knuckle Pad
On the back of the hand, after skin removal, the tendons are seen. On the palm of the hand, after skin removal, a sheet of fibrous gristle or fascia is seen. This fascia is tightly adherent to the skin of the palm and aids in grabbing things (try to grab something with the skin on the back of the hand: it rolls). In the disease of Dupuytren this fibrous gristle or fascia grow and tightens pullling the fingers into a contraction and limiting ability to straighten out the fingers. Underneath this sheet of fibrous tissue on the palm of the hand are the flexor tendons.


Surgical removal of diseased fascia in Dupuytren's is a traditional surgical approach.  It removes the diseased fascia entirely and may help prevent recurrence.  It may be performed as an office surgery using local anesthetia with epinephrine and no constricting tourniquet.  It's safety and efficacy has been published in the Journal of Plastic and Reconstructive Surgery in March of 2005.


 




Dupuytren's can deposit collagen to the back of the knuckles and are called knuckle pads. The Dupuytren's knuckle pads can be irritating but rarely affect function. They can sometimes limit flexion if they are large. Cortisone injections are the first treatment. Direct excision under local anesthesia can remove the offending collagen deposits. This little finger is seen six months after excision of the knuckle pad.



Dupuytren's cord contracture

Needle Release Problem

Recurrent Dupuytren's
Notice the pulling of the Dupuytren's cord brings the digital nerve into a dangerous postion for injury with needle release or traditional surgery.
In the area of the PIP joint, the lateral contracted tissues may prevent full needle releases of the Dupuytren's cords. In this situation, gentle superficial sectioning, plus firm traction into extension is necessary to ruputure the cord with less risk to the digital nerve.


This before after needle release of Dupuytrens shows the problem of weak and contracted intrinsic muscles that limit post-operative ability to regain extension.  Notice on the preoperative photo upper Dupuytrens contracture the little finger.  There is MCP and PIP joint disease that limits extension of the little finger.  Plus MCP joint disease of the ring and middle fingers that prevent full extension.  After NA, the MCP joint disease is corrected on all three fingers in the bottom left picture.  In the upper right picture the intrinsic muscles are relaxed via MCP joint forced flexion and there is improvement in PIP extension over the bottom left view.  In the final bottom right photo one can see that the dupuytrens contracture is all released and there is full PIP extension with passive extension by the physician.


These photos demonstrate the need for postoperative exercises to improve intrinsic muscle strength as these muscles have atrophied due to non-use.


On a positive note, it notice the immediate, excellent improvement of MCP extension of the little, ring, and middle fingers




This patient had two previous open surgeries by a top local hand surgeon.  With residiual contracture of 65 degrees after two surgeries, the patient was told  that nothing more could be done. 


NA after previous open surgery has higher complications and poorer results, but this before and immediate after photo shows a very good immediate result.  If recurrence is rapid due to scar tissue from the previous open surgeries, then a repeat NA with skin grafting would be the next option.





Hand Plastic Surgery

Office in Larkspur

Needle Aponeurotomy on Multipl…
This patient disliked the large veins and shrunken tissues on the back of the hand. The photo is a 3 month before and after photo of Radiesse injections into the back of her hand.
Radiesse is a filler that helps bulk up tissues such as the nasolabial folds in the face or wrinkles of the face and hands.





This hand is seen 18 months after needle aponeurotomy for three bent fingers from Dupuytren's contracture

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Keith Denkler, M.D.  |  Contact Info  |  Kybella  |  Common Procedures  |  BOTOX® for Wrinkles  |  Dupuytren's and XIAFLEX Pictures  |  Dupuytren's Contracture (Maladie de Dupuytren)  |  Dupuytren's for Patients  |  FAQ/Needle Aponeurotomy  |  XIAFLEX for Distal Joint Dupuytren's Contracture  |  ASSH Hand Society Presentation of NA  |  AAPS Presentation on Needle Aponeurotomy for Severe Dupuytren's  |  Dupuytren's Boutonniere Deformity Treated with XIAFLEX  |  XIAFLEX Boutonniere Treatment  |  2011 ASSH Dupuytren's Needle Presentation  |  Credentials  |  Curriculum Vitae  |  Directions/Office Hours  |  Links  |  News Articles  |  Needle Release for Beauty

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