Monday, 8 July 2013

Interview with Dr Keith Denkler

Today I have an interview with a specialist, this is the first time in about a year that I am doing one of these posts but hopefully there will be several more of them in the coming weeks as I try to branch out and discuss the treatment options with specialists from around the world. I am quite keen to talk to any specialists in the USA, particularly those doing radiotherapy, this is because I am often asked about them by people e-mailing me and it would be nice to give a good answer. So if you have been treated in the US then please get in touch and if you can let me know who you were treated by and if you have contact details (especially e-mail) please provide them. Thanks. 

Right onto today. I was browsing the web last week looking for a Dr or two to pester about these conditions, I thought it would be great to chat to someone who has done the surgery and I came across the following website with loads of information: 

There is a lot of good information on there so I thought that this person would likely be well informed and was worth contacting, I sent him an e-mail and although he was happy to help he did admit to not having done surgery on many Ledderhose patients but has seen a lot of patients, here are the answers I got. Some are not as detailed as I would like but the professionals are of course very busy so any response for a blog is a great result.

 Dr Keith Denkler  

Profile (from his website): (Information posted with permission from website listed above)

Dr. Denkler has been practising medicine since 1989 in Marin County, California. His practice includes both plastic (aesthetic-cosmetic) and reconstruction surgery. Dr. Denkler has achieved board certification in both plastic and hand surgery and teaches as a Clinical Professor of Surgery at UCSF Medical School. Dr. Denkler is one of the few doctors offering treatment for Dupuytren's contracture using the French needle technique called NA (needle aponeurotomy), a type of subcutaneous fasciotomy Dupuytren's in addition to XIAFLEX™. Dr Denkler is still based in California.

This page may be of interest for Dupuytren's patients:

Now on to the interview: 

1) How long having you been treating Dupuytren's and Ledderhose disease?  
I have been treating these conditions for almost 25 years.

2) Roughly how many Dupuytren's patients have you treated and how many Ledderhose patients have you treated?

I have treated thousands of patients with Dupuytren contracture and have seen hundreds with Ledderhose.

3) What treatments have you used for these conditions? Would you recommend the treatment and roughly how successful is the treatment for each condition?
My treatments are predominately needle and or Xiaflex/Xiapex. I only occasionally do surgery.  Ten years ago I did only surgery, using the wide awake technique which I developed.

For Ledderhose, I occasionally have excised, wide-awake, but scar tissue tends to replace the Ledderhose.  I have done this in about half-dozen patients. 

I have done a few dozen needle aponerutomies for Ledderhose, which can give some improvement in severe cases.
I also inject Kenalog(cortisone) which can soften nodules.
Xiaflex/Xiapex may have a role, but the it is very tender and sore for some weeks and my experience is limited to a few patients with small doses.  The extra enzyme from the hand can be legally used on the feet.  Otherwise the enzyme is not approved in the USA for Ledderhose.

Mostly I recommend starting with Kenalog injections, then needle, and then perhaps wide awake surgery or enzyme.
There is no optimal treatment.  Freezing (which I don't do) may be beneficial.

4) What would your recommendations be to Dupuytren's and Ledderhose patients and do you have any advice you would like to give?

These are chronic conditions and are managed, not cured.

Keep the treatments simple with needle, or enzyme, or both.  Save surgery (has highest complication rate) for severe cases not amenable to the other treatments.
Overall there are some very interesting points that he makes, in questions 4 he mentioned keeping the treatments simple but he does not mention radiotherapy, in fact it is not mentioned anywhere in his report. It is mentioned, although briefly, on his website that I linked to above. 
It is interesting that the technique of choice in the last 10 years, for Ledderhose at least, has shifted from " Ten years ago I did only surgery," to now "Save surgery for severe cases not amenable to the other treatments." whether this is just because he now does the other treatments or because the optimal treatment path has changed I don't know, of course Xiapex was not available.