In February 2010, Xiaflex was approved by the FDA; however, insurance companies in the USA still considered it experimental and were not routinely covering the treatment of Dupuytren contracture with Xiaflex. Finally, in the summer and fall of 2010, medical insurance coverage for Xiaflex became available for most patients. Once this payment bearer was overcome, there were 852 patients on the waiting list at the University Hand Center at Stony Brook who were requesting treatment for their Dupuytren contractures with Xiaflex. It took two years to treat the backlog of 852 patients.

In January 2011 the public media became involved in the Dupuytren Disease and the Xiaflex story. Xiaflex was used in the TV show “Royal Pains,” where a concierge physician in the episode called “Muligan” injected a Xiaflex to his friend’s hands over lunch and manipulated his fingers during the golf outing the next day. Obviously this was a TV dramatization which took considerable literary license with the FDA’s labeling recommendations. However, this single TV show did increase the US public’s awareness of Dupuytren Disease and Xiaflex treatment.

After Xiaflex became available for clinical use in the USA, other international pharmaceutical companies made partnership arrangements with Auxilium. These included Pfizer in 2008 and SOBI in 2014 to provide Xiapex (Xiaflex’s European name) in the European Union, Actelion provided it in Canada and Australia in 2011, Asahi Kasei Pharmaceutical Corporation in Japan in 2012 with release in 2016, and lastly Auxilium which was bought by Endo Pharmaceuticals in 2015.

Xiaflex (Xiapex in Europe) is recommended for patients with a palpable cord causing MP joint contractures of 20–30° or more as well as PIP joint contractures of 20° or more that are getting progressively worse over time and a positive tabletop test. For the actual injection of Xiaflex, Dr. Hurst prefers to use a 1 mL hubless syringe with a fixed 27 gauge needle. 0.25 mL is injected for the MP joint and 0.20 mL for the PIP joint; each injection contains 0.58 mg of collagenase (Xiaflex). Aliquots of the 0.58 mg dose are placed in 3–5 separate locations in the Dupuytren cord. For the manipulations, approximately 9 cc of 1 % lidocaine is used with 1 cc of bicarbonate buffer to give a per manipulation local field block. The finger manipulation or finger extension procedure is always done in a four-step manner: (1) extend the MP joint with PIP flexed, (2) extend the PIP joint with the MP flexed, (3) extend the MP and PIP joints simultaneously, and (4) with the MP and PIP extended, push on any areas with residual cord with the surgeon’s opposite thumb or index finger. During the manipulation, it is important to be as gentle as possible to avoid skin tears. Skin tears often start through areas of skin with blood blisters so extra caution is warranted when blisters are present after injection.

The use of Xiaflex is currently approved for use in MP and PIP joints; however, Dr. Hurst has successfully used it in DIP joints and thumb contractures and first web contractures as well. Although these treatments are “off-label” uses of Xiaflex, Xiaflex has proved to be beneficial in Dr. Hurst’s patients for DIP flexion contractures, web contractures, and thumb contractures. Xiaflex has also been used successfully in the treatment of cord combinations such as the “Y” cord which is a combination of a central cord and a natatory cord. By dividing a single Xiaflex dose and by using two concurrent doses in the same hand, which has now been FDA approved, multiple complex cord combinations can now be treated in a single sitting. Recent studies have also allowed the FDA labeling to include delayed finger extension timings at 48 and 72 h after injection. Concurrent double-dose treatment has proven to be both efficacious and safe to administer for contractures of two joints in the same finger or for fixed MP or PIP flexion contractures in different fingers in the same hand (Gaston et al. 2015).