Denervation of the wrist

Innervation of thumb carpometacarpal joint: implications for diagnostic block and denervation procedures

INTRODUCTION

Osteoarthritis (OA) of the thumb carpometacarpal (CMC) joint is a common disorder that negatively impacts hand function. Denervation of the thumb CMC joint has emerged as a viable treatment option. However, the innervation pattern of the thumb CMC joint is controversial. Therefore, the objective of this study was to identify the articular branches supplying the thumb CMC joint and to document their relationship to anatomical landmarks to provide the foundation for image-guided diagnostic block and denervation procedures.

METHODS

In 10 formalin-embalmed upper limb specimens articular branches supplying the thumb CMC joint were dissected from their origin to termination. A frequency map documenting the number of articular branches was generated. The frequency map enabled visualization and comparison of the relative area of innervation of the thumb CMC joint by each articular branch.

RESULTS

The thumb CMC joint received innervation from six nerves. These were the deep branch of ulnar nerve (DBUN), dorsal articular nerve (DAN) of the first interosseus space, thenar branch of median nerve (TBMN), palmar cutaneous branch of median nerve (PCBMN), lateral antebrachial cutaneous nerve (LACN) and superficial branch of the radial nerve (SBRN) and/or their branches. Each nerve was found to innervate different aspects of the joint. The DBUN and DAN were found to innervate the posteromedial aspect of the thumb CMC joint, the TBMN and PCBMN anterior/anteromedial aspects, LACN posterolateral/lateral/anterior aspects and SBRN posterolateral/anterolateral aspects.

CONCLUSIONS

The thumb CMC joint was innervated by articular branches originating from the SBRN, DAN, LACN, PCBMN, TBMN and DBUN. The documented anatomical relationships provide the foundation to inform selective diagnostic block and denervation of the thumb CMC joint. Further investigations are needed to assess the clinical implications of the current study.

Small Joint Denervation of the Hand and Thumb Base: History, Anatomy, Technique, and Outcomes

Painful arthritis of the small joints of the hand is a common condition affecting older adults, with distal interphalangeal joint and thumb carpometacarpal joint being the two most common locations. Younger adults may also develop painful arthritis after trauma and with inflammatory arthropathy. Traditional surgical approaches address the structure of the joints with either arthrodesis or arthroplasty with or without an implant. In recent decades, denervation has been reported as an alternative treatment for painful small joints that are mobile and stable. Publications on denervation often report faster surgery and recovery times than traditional surgeries that manipulate the small joint bony structures. This article reviews the history, anatomy, surgical techniques, and outcomes of denervation of the small joints of the hand.

Arthroscopic Resection Arthroplasty for Scapholunate Advanced Collapse Wrist

Purpose  Scapholunate advanced collapse (SLAC) wrist results from an untreated scapholunate dissociation and is the most common type of degenerative arthritis of the wrist. The most common surgical treatments for SLAC wrist are proximal row carpectomy and four-corner fusion with scaphoid excision. Arthroscopic surgical treatment for SLAC wrist has been reported; however, only limited data on functional outcomes are available. The purpose of this study is to report our 5-year follow-up clinical outcomes for arthroscopic treatment for SLAC wrist. Methods  Thirty-one consecutive cases of arthroscopic resection arthroplasty for SLAC wrist were reviewed. Preoperative and postoperative Disabilities of the Arm, Shoulder, and Hand (DASH) scores, range of motion, grip strength, and pain (on 0-10 scale) as well as postoperative satisfaction (0 = not satisfied, 5 = completely satisfied) were recorded. Grip and range of motion were measured by an occupational therapist. Results  The preoperative pain score was 7 and 0.18 postoperatively. The mean satisfaction at final follow-up was 4.8. Preoperative and final follow-up scores of the mean DASH was 48 and 3, respectively. The total arc of motion was 114 degrees preoperatively and 126.5 degrees postoperatively. Mean grip strength before surgery was 41 and 49 kg at final follow-up. Conclusion  Arthroscopic resection arthroplasty for SLAC wrist results in significant improvement in patient function as measured by DASH and pain scores. Type of Study/Level of Evidence  Therapeutic IV.

Partial Denervation of the Thumb Carpometacarpal Joint: A New Technique

BACKGROUND

To report the clinical outcomes of partial denervation for the treatment of basilar thumb joint arthritis.

METHODS

Patients who underwent partial denervation of the basilar thumb joint for osteoarthritis from a single center between 2019 and 2021 were recruited into the study. This involved a technique that involved cauterization of the joint capsule and its innervation through the branches of the superficial radial, palmar cutaneous branch of the median, lateral antebrachial, and ulnar nerves. Patients were followed up postoperatively to record clinical (grip strength, thumb apposition and opposition pinch grip strength, Kapandji score) and patient-reported outcomes (visual analogue scale [VAS], Quick Disabilities of the Arm, Shoulder and Hand [QuickDASH], Patient-reported Wrist Evaluation [PRWE]).

RESULTS

Twelve patients (15 carpometacarpal joints; 9 female and 3 male patients) underwent a partial denervation of the thumb (Eaton stage 3-4). The mean age at the time of surgery was 63 ± 5 years (range 56-72). The mean clinical follow-up duration was 23 ± 11 months (range 9-42 months), and functional score follow-up duration was 27 ± 7 months (range 14-42 months). At the latest clinical follow, VAS score, Kapandji score, grip strength, and thumb apposition/opposition pinch strength all improved significantly (P < .05). The mean QuickDASH score was 30 ± 16, and PRWE score was 32 ± 17. Patients who had unilateral partial thumb denervation demonstrated greater improvement in grip strength than patients who had bilateral partial thumb denervation procedures (P = .01).

CONCLUSION

In this clinical case series, our method of basilar thumb joint partial denervation has been effective in improving clinical outcomes and reducing pain due to osteoarthritis.

LEVEL OF EVIDENCE

IV, case series.

Selective Thumb Carpometacarpal Joint Denervation Versus Trapeziectomy and Ligament Reconstruction With Tendon Interposition for Painful Arthritis: A Prospective Study With 2 Years of Follow-Up

PURPOSE

Thumb carpometacarpal (CMC) joint denervation is a relatively novel method for the management of osteoarthritis-associated pain by selective transection of articular nerve branches of the CMC joint. This study compared functional/patient-reported outcomes after CMC denervation with those after trapeziectomy and ligament reconstruction with tendon interposition (T + LRTI) over a 2-year follow-up period. We hypothesized that the outcomes of denervation and T + LRTI would be similar over the course of the study and at the final 2-year follow-up.

METHODS

Adults with Eaton stage 2-4 disease, no evidence of CMC subluxation, and no history of thumb injury/surgery were included. Pain scores, brief Michigan Hand Questionnaire (bMHQ), Kapandji score, 2-point discrimination, and grip/key/3-point pinch strength were measured at 3-, 6-, 12-, and 24-months after surgery. On average, T + LRTI patients underwent 7 weeks of splinting, with release to full activity at 3 months; denervation patients were placed in a soft postoperative dressing for 2 weeks, with release to full activity as tolerated at 3 weeks.

RESULTS

Thirty-three denervation and 20 T + LRTI patients were included. Preoperative characteristics were similar between both groups. Two denervation patients underwent secondary T + LRTI during the study period; one denervation patient underwent fat grafting to the CMC joint at an outside institution. Data prior to secondary surgeries were included in the analysis. The average tourniquet times (minutes) for denervation and T + LRTI were 43.5 ± 11.8 and 82.7 ± 14.2 minutes, respectively. For denervation and T + LRTI, the postoperative bMHQ scores were significantly higher than those at baseline at all time points. No significant differences were found between both groups for bMHQ, sensation, or strength measures.

CONCLUSIONS

Carpometacarpal denervation is well tolerated, with shorter tourniquet times and faster return to full activity than T + LRTI. For the study cohort, the conversion rate to T + LRTI at 2 years was 9%. Both procedures demonstrated durable improvement in bMHQ compared with the preoperative state with similar long-term outcomes over 2 years of follow-up.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Surgical denervation as a treatment strategy for pain in hand osteoarthritis: a systematic literature review

OBJECTIVE

Surgical denervation has been proposed as a treatment for pain in hand osteoarthritis (OA). This review aimed to summarise the available evidence and to propose a research agenda.

METHODS

A systematic literature search was performed up to September 2022. Two investigators independently identified studies that reported on denervation for OA of the proximal interphalangeal, distal interphalangeal, metacarpophalangeal or carpometacarpal joints. Quality of studies was assessed and study characteristics, patient characteristics, details of the surgical technique and outcomes of the surgery were extracted.

RESULTS

Of 169 references, 17 articles reporting on 384 denervations in 351 patients were selected. Sixteen case series reported positive outcomes with respect to pain, function and patient satisfaction. One non-randomised clinical trial reported no difference in outcome when comparing denervation of the first carpometacarpal (CMC I) joint to trapeziectomy. Adverse events were frequent, with sensory abnormalities occurring the most, followed by the need for revision surgery. All studies had significant risk of bias.

CONCLUSION

Surgical denervation for pain in hand OA shows some promise, but the available evidence does not allow any conclusions of efficacy and higher-quality research is needed. Techniques should be harmonised and more data regarding how denervation compares to current usual care, other denervation methods or placebo in terms of outcomes and adverse events are needed.

Ulnar Wrist Denervation: Articular Branching Pattern and Selective Blockade of the Dorsal Branch of the Ulnar Nerve

PURPOSE

Ulnar wrist denervation has been a successful treatment for patients with ulnar-sided wrist pain. The purpose of this study was to characterize the articular branches of the dorsal branch of the ulnar nerve (DBUN) and validate a technique for selective peripheral nerve blockade.

METHODS

In cadavers, we performed simulated local anesthetic injections using 0.5 mL of 0.5% methylene into the subcutaneous tissue at a point midway between the palpable borders of the pisiform and ulnar styloid. We then dissected the DBUN, characterized its articular branching pattern, and measured staining intensity of the DBUN and the ulnar nerve relative to a standard.

RESULTS

The DBUN branched from the ulnar nerve 7.0 ± 1.2 cm proximal to the ulnar styloid. Among 17 specimens, the DBUN provided an average of 1.2 (range, 0-2) ulnocarpal branches and 1.0 (range, 0-2) carpometacarpal articular branches. A simulated local anesthetic injection successfully stained 100% of the DBUN articular branches at or proximal to their takeoff. There was no staining of the proper ulnar nerves. In all specimens, the DBUN supplied at least one articular branch.

CONCLUSIONS

A point midway between the palpable border of the pisiform and ulnar styloid may be an effective location for selectively blocking the DBUN articular afferents.

CLINICAL RELEVANCE

In this study, we were able to identify a point halfway between the pisiform and ulnar styloid that has the potential to produce a selective peripheral nerve block of the portion of the DBUN that supplies articular fibers to the ulnocarpal joint and the fifth carpometacarpal joint. This technique may prove useful to surgeons treating ulnar-sided wrist pain.

Wrist Salvage Procedures for the Treatment of Kienbock's Disease

Kienbock's disease is a progressive condition characterized by lunate collapse, carpal instability, and eventually perilunate arthritis. Etiology is likely multifactorial, including vascular and anatomic or osseus causes. In cases of advanced disease, disabling pain, limited motion, and decreased grip strength may be present. The preferred treatment options for the nonreconstructable wrist are proximal row carpectomy (PRC), total wrist arthrodesis, and total wrist arthroplasty (TWA). In the following chapter, we will discuss various surgical options for patients with advanced Kienbock's disease.

Anatomical Study of the Innervation of Triangular Fibrocartilage Complex and Distal Radioulnar and Radiocarpal Joints: Implications for Denervation

PURPOSE

Open and percutaneous denervation is an emerging technique for joint pain. This study investigated the course and distribution of the articular branches innervating the triangular fibrocartilage complex (TFCC), distal radioulnar joint (DRUJ), and radiocarpal joint (RCJ) relative to bony and soft tissue landmarks to guide wrist denervation procedures.

METHODS

Fourteen formalin-embalmed specimens were serially dissected to expose the origin, course, and distribution of articular branches innervating the TFCC, DRUJ, and RCJ. Bony and soft tissue landmarks to localize each articular branch were documented and visualized on a 3-dimensional reconstruction of the bones of the distal forearm and hand.

RESULTS

The TFCC was innervated by articular branches from the posterior interosseus nerve (10 of 14 specimens), dorsal cutaneous branch of the ulnar nerve (14 of 14 specimens), palmar cutaneous branch of the ulnar nerve (12 of 14 specimens), and medial antebrachial cutaneous nerve (9 of 14 specimens). The DRUJ was innervated by the posterior interosseus nerve (9 of 14 specimens) and anterior interosseus nerve (14 of 14 specimens). The RCJ was innervated by the posterior interosseus nerve (14 of 14 specimens), superficial branch of the radial nerve (5 of 14 specimens), lateral antebrachial cutaneous nerve (14 of 14 specimens), and palmar cutaneous branch of the median nerve (10 of 14 specimens).

CONCLUSIONS

Multiple nerves were found to innervate the TFCC, DRUJ, and RCJ. The relationship of anatomical landmarks to specific articular branches supplying the TFCC, DRUJ, and RCJ can inform selective denervation procedures based on the structural origin of pain.

CLINICAL RELEVANCE

The detailed documentation of the spatial relationship of the nerve supply to the wrist provides clinicians with the anatomical basis to optimize current, and develop new denervation protocols to manage chronic wrist pain.

First Carpometacarpal Joint Denervation: A Systematic Review

PURPOSE

The first carpometacarpal (CMC) joint is a frequent location of osteoarthritis in the hand. The denervation of the first CMC joint has gained traction as a viable treatment for CMC arthritis. This study reviewed literature on CMC denervation for first CMC arthritis.

METHODS

A systematic review of papers and abstracts was conducted. The preferred reporting items for systematic reviews and meta-analyses guidelines were followed. Articles including the results of CMC denervation were included. We compiled data on patient demographics, preoperative testing, intraoperative technique, and postoperative outcomes. Anatomic literature was also reviewed to assess agreement on the innervation of the first CMC joint.

RESULTS

Six anatomic studies and 9 clinical studies were included in this systematic review. Pinch strength, grip strength, and Kapandji scores increased on average in patients. Pain relief was noted on average in patients in 5 studies that reported pain outcomes. In studies that reported postoperative complications, the most frequent complications were radial paresthesias, hypoesthesia dorsal and/or distal to the surgical site, and wound infection.

CONCLUSIONS

The innervation of the CMC joint is controversial. This is reflected in clinical practice, wherein varied surgical approaches are used. Carpometacarpal denervation shows promise as an option to treat patients with CMC arthritis without joint instability, but its results vary. Additional clinical studies with longer-term follow-up and control groups are necessary to better determine its longevity and efficacy.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Selective Thumb Carpometacarpal Joint Denervation for Painful Arthritis: Follow-Up of Long-Term Clinical Outcomes

Purpose

Thumb carpometacarpal (CMC) joint osteoarthritis is a common problem affecting up to 85% of patients over the age of 70. The most common presenting symptom for patients with CMC arthritis is pain with joint loading. Loss of function due to subluxation or joint destruction is comparatively rare. Carpometacarpal joint denervation is a relatively novel method for managing CMC arthritis, treating the most impactful symptom: pain.

Methods

In this paper, we present a 4- to 6-year follow-up case series on patients who underwent CMC denervation between 2015 and 2017.

Results

Denervation was safe, with less downtime than trapeziectomy with ligament reconstruction with tendon interposition and provided durable complete or partial relief of pain after 5 years in 5 of 9 patients. Four of 9 patients had recurrence of pain by 5 years. Of those with recurrent pain, 3 of 5 eventually underwent trapeziectomy with ligament reconstruction and tendon interposition; the secondary surgery occurred between 17 and 66 months after denervation.

Conclusion

Thumb CMC denervation provides effective relief of arthritis pain that was durable at 5+ years after surgery in more than half of our initial cohort of patients treated. Prospective studies with validated patient-reported and objective outcome measures between distinct treatment arms, such as denervation versus ligament reconstruction with tendon interposition, are needed to firmly establish the role of CMC denervation for patients with symptomatic thumb CMC osteoarthritis.

Type of study/level of evidence

Therapeutic/Level IV.

Denervation of the Joints of the Hand and Wrist: Surgical Techniques and a Systematic Review with Meta-Analysis

BACKGROUND

Joint denervation of the wrist, basal joint of the thumb, and the finger is an option for patients with chronic pain. Compared with other surgical treatment options, function is preserved and the rehabilitation time is limited. A systematic review and meta-analysis were performed for each joint to determine whether the choice of technique and choice of denervation of specific articular sensory branches lead to a different outcome.

METHODS

Embase, MEDLINE (OvidSP), Web of Science, Scopus, PubMed publisher, Cochrane, and Google Scholar database searches yielded 17 studies with reported outcome on denervation of the wrist, eight on the basal joint of the thumb, and five on finger joints.

RESULTS

Overall, the level of evidence was low; only two studies included a control group, and none was randomized. Meta-analysis for pain showed a 3.3 decrease in visual analogue scale score for wrist pain. No difference was found between techniques (total versus partial denervation), nor did different approaches influence outcome. The first carpometacarpal joint showed a decrease for visual analogue scale score for pain of 5.4. Patient satisfaction with the treatment result was 83 percent and 82 percent, respectively. Reported pain in finger joints decreased 96 percent in the metacarpophalangeal joints, 81 percent in the proximal interphalangeal joint, and 100 percent in the distal interphalangeal joint. The only reported case in the metacarpophalangeal joint of the thumb reported an increase of 37 percent.

CONCLUSIONS

Only denervation of the metacarpophalangeal joint of the thumb reported an increase in pain; however, this was a single patient. Wrist and first carpometacarpal joint and finger joint denervation have a high satisfaction rate and decrease the pain. There was no difference between techniques.

A New "Denervation" Technique for Painful Arthritic Wrist

Wrist denervation is, by the way, one of the most performed and long-lasting surgical technique for wrist arthritis. Despite many progresses in upper extremity joint arthroplasty, wrist arthritis remains difficult to treat specially in young patients and heavy manual workers. The aim of this technical article is to describe a new outpatient's procedure in which applying pulsed radio frequency on nerve structure of the wrist could achieve similar clinical results of a wrist denervation without surgical incision.

Innervation of the wrist joint: Literature review and clinical implications

The aim of this study was to review the literature on the innervation of the wrist with an emphasis on pathological and therapeutic aspects. The nerves involved in wrist innervation and their mechanoreceptor endings are described. The literature over the past 30 years includes several topics that are still subjects of discussion and debate and require further research.

Cadaveric evaluation of the feasibility of glenohumeral joint denervation

Purpose

To assess the feasibility of total shoulder denervation through two proposed incisions.

Methods

Total shoulder denervation was performed through an extended delta-pectoral approach and a transverse dorsal approach at the spine of the scapula. The study involved six cadavers. Course and number of articular branches from the lateral pectoral, axillary and supra-scapular nerve were documented.

Results

All shoulder joint articular branches were accessible through the proposed anterior and posterior approaches. The articular branch of the lateral pectoral nerve and supra scapular nerve were present in all the specimen. Axillary nerve articular branches were variable in number but when present anteriorly were proximal to the deltoid muscular branches and posteriorly proximal to the muscular branches to the teres minor.

Conclusion

Total glenohumeral denervation was feasible through our proposed anterior and posterior approaches. Enhanced knowledge of articular nerve branches could provide interventional targets for joint and ligament pain, with low risk of muscle weakness.

Anatomic surface landmarks to guide injection for posterior interosseous nerve block

Proper injection of the posterior interosseous nerve (PIN) is important for both the therapeutic and diagnostic management of wrist pain. However, no anatomical study exists describing the site of injection based on individual wrist width. We sought to develop a reproducible anthropometric ratio utilizing external wrist surface anatomy to predict a safe and accurate injection site for the PIN. Fresh frozen cadaver forearms were dissected at the University of Louisville tissue lab. Several anthropometric measurements were obtained in order to develop a reproducible ratio to calculate location of injection. A total of 16 cadaver forearms of equal male to female ratio were obtained. On average, the male forearm had a greater mean wrist circumference obtained at the level of Lister's tubercle compared to female forearms, 17.1 cm vs. 13.5 cm. An injection given ulnar to proximal edge of Lister's tubercle at a length of one-fourth the distance between Lister's tubercle and radial aspect of ulnar styloid resulted in 100% accurate perineural injection without intraneural injection. An anthropometric ratio of one-fourth the distance from Lister's tubercle to the ulnar styloid was able to predict accurate injection sites for the distal PIN in cadaveric specimens of varying anatomical proportions.

Salvage procedure after malunited distal radius fractures and management of pain and stiffness

Indications for surgical treatment of distal radius fractures (DRF) remain controversial in the literature, especially in elderly patients. Complication rates after operatively treated DRF are low and well documented. These include malunion, degenerative osteoarthritis in the radiocarpal joint and subsequently pain and impaired hand function. If conservative treatment fails then salvage procedures are necessary. This review summarizes the therapeutic options available to treat degenerative osteoarthritis after malunited distal radius fractures, regardless of the initial operative or conservative treatment.

Evaluation of proprioception in denervated and healthy wrist joints

We recruited 25 patients after complete wrist denervation and 60 healthy adults to investigate conscious and unconscious proprioception of the wrist. Ipsi- and contralateral joint-position sense, force sense, and wrist reflexes were measured. The latter were triggered by a trapdoor, recording electromyographic signals from the extensor carpi radialis brevis, extensor carpi ulnaris, flexor carpi radialis, and flexor carpi ulnaris muscles. No significant differences were found for joint position sense, force sense, and wrist reflexes between both groups, except for reflex time of the flexor carpi ulnaris after denervation of the left wrist as compared with the left flexor carpi ulnaris in controls or in right operated wrists. At a mean follow-up of 32 months (range 8 to 133), we found no proprioceptive deficit of the conscious proprioceptive qualities of joint position sense, force sense, and the unconscious proprioceptive neuromuscular control of wrist reflex time for most muscles after complete wrist denervation. We conclude from this study that complete wrist denervation does not affect the proprioceptive senses of joint position, force sense, and reflex time of the wrist.

Selective denervation of the wrist for chronic pain: a systematic literature review

Selective denervation of sensory nerve branches to the wrist is a palliative surgical treatment option for patients with chronic wrist pain when preserving the range of motion and function is preferred. Treatment varies from partial isolated denervation of the posterior interosseous nerve to extensive 'complete' denervations. This study aimed to provide an overview of the literature regarding treatment outcomes in the domains of pain, grip strength, patient satisfaction and return to work. MEDLINE (PubMed), EMBASE and Cochrane databases were systematically searched and identified 993 studies, of which 12 were eligible for analysis. Denervation resulted in high 'return to work' rates (up to 94%), patient satisfaction (up to 92%), increased grip strength (7%-64%) and improved average pain scores (36%-92%). Treatment outcomes of both partial and complete denervations were favourable; however, variations in outcomes suggest the need for improving evidence regarding surgical technique and nerve identification.

Total wrist denervation: Retrospective study of 39 wrists with 56 months' follow-up

INTRODUCTION

The objective of this study was to analyze patient satisfaction after total wrist denervation.

HYPOTHESIS

Total wrist denervation provides reliable and durable results.

MATERIAL AND METHOD

A single-center multi-surgeon retrospective study included a cohort of 39 wrists. Mean age was 58 years. The dominant side was operated on in two-thirds of cases. SLAC wrist and SNAC wrist accounted for 41% of etiologies. All patients were seen again in consultation and were evaluated for pain, strength, mobility and limb function. Failure was defined as any reoperation.

RESULTS

Mean follow-up was 56 months, with no loss to follow-up. Pain improved in 79.5% of cases. Median DASH score was 27.27. Strength on Jamar® dynamometer improved from 60% to 75% compared to the contralateral side (p=0.012). Range of motion improved by 5° (p=0.052). At last follow-up, 31% of patients showed aggravation of radiological osteoarthritis. There were 4 revision procedures (total wrist fusion), and 4 complications.

DISCUSSION

The present results were comparable to those in the literature in terms of satisfaction, functional scores and number of complications and revision procedures. Total wrist denervation is a reliable and reproducible surgical technique in terms of pain relief preservation of function in painful osteoarthritic wrists. It thus has an essential place in the therapeutic algorithm of patients presenting with chronic pain in a wrist that is still mobile, whatever the initial etiology.

LEVEL OF EVIDENCE

IV, Retrospective cohort.

An Anatomical Study to the Branching Pattern of the Posterior Interosseous Nerve on the Dorsal Side of the Hand

Partial denervation of the wrist can benefit patients with chronic wrist pain. A complication of partial denervation is loss of proprioception and hypesthesia on the dorsal side of the hand. Our aim is to evaluate whether the sensory branches of the posterior interosseous nerve could contribute to the loss of proprioception and sensation. The branching pattern of the posterior interosseous nerve was studied in 20 cadaveric hands. The terminal branches of the posterior interosseous nerve reached the metacarpophalangeal joints in three specimens (15%), the midshaft of the metacarpals in three specimens (15%), carpometacarpal joints in 11 specimens (55%), and the scapholunate joint in three specimens (15%). The finding that terminal branches of the posterior interosseous nerve can reach the metacarpals and the metacarpophalangeal joints indicates that the posterior nerve may contribute to the proprioception and sensation of the dorsal side of the hand. Clin. Anat., 33:678-682, 2020. © 2019 Wiley Periodicals, Inc.

Wrist Denervation: Techniques and Outcomes

Wrist denervation is a safe and effective procedure for the treatment of chronic wrist pain that can delay or eliminate the need for salvage or anatomically distorting procedure, such as proximal row carpectomy. The traditionally more extensive wrist denervation has evolved to procedures requiring fewer incisions. Efficacy of this procedure is corroborated by multiple publications either as a stand-alone procedure or as an adjunct to other procedures. This review provides an update on the status of wrist denervation.

No Benefits of Combining Proximal Row Carpectomy With PIN Neurectomy for Wrist Disorders-A Comparative Study With Systematic Review of the Literature

Background

Posterior interosseous nerve (PIN) resection in combination with proximal row carpectomy (PRC), is a preferred method in order to obtain rapid recovery. However, the contribution of such combination to results isn't known well.

Objectives

We performed a comparative study to evaluate the effects of PIN neurectomy for PRC and a systematic review of the literature was performed to identify whether such combination has an advantage.

Methods

Patients with wrist diseases who underwent PRC were evaluated retrospectively. Patients without PIN neurectomy (group 1, n = 7) and with PIN neurectomy (group 2, n = 8) were compared in respect of mean age, follow-up, gender, Q-DASH, VAS, MAYO wrist scores, flexion-extension/radial-ulnar deviation range of motion at final follow-up. The MEDLINE database was searched for studies published between 2005 and 2015, as the second part of the study. The following keywords were used: "proximal," "row," "carpectomy." Studies, which met the inclusion criteria, were evaluated in terms of such combination.

Results

There were no significant difference between the groups in regard with age (P = .463), follow-up period (P = .728), the ranges of flexion-extension (P = .431) and radio-ulnar deviation (P = .689), Q-DASH (P = .452), and MAYO scores (P = .728). In the second part of the study, 12 studies met the inclusion criteria and none of them was specifically evaluating such combination. Only one study had specific comments on PRC with PIN neurectomy.

Conclusion

According to our study (which, to our knowledge, was the first comparative study in the literature), we advocate not to combine PRC with PIN neurectomy for such an approach has no advantage.

Partial Wrist Denervation for Idiopathic Dorsal Wrist Pain in an Active Duty Military Population

PURPOSE

Treating dorsal wrist pain of unknown etiology provides a challenge to the most experienced hand surgeon. Therefore, we conducted a study aimed to determine outcomes of patients undergoing a posterior interosseous nerve (PIN) or anterior/posterior interosseous nerve (AIN/PIN) neurectomy for wrist pain without a known cause, in patients who responded to preoperative injection.

METHODS

A retrospective chart review was performed of all active duty patients undergoing isolated PIN or AIN/PIN neurectomy for idiopathic dorsal wrist pain with a documented response to preoperative injection between December 2011 and April 2017. Demographic data, return to duty status, pain scores, and range of motion were among the data collected and reviewed.

RESULTS

The initial search yielded 108 patients of whom 13 met inclusion criteria for our study. Overall, only 2 of 13 patients were able to return to full duty without restrictions, 5 went on to medical discharge, and 6 were placed on permanent duty restrictions. No patients within our study were deployed. Patients had improvement in their pain scores from 4.0 to 2.2. Range of motion was similar before and after surgery.

CONCLUSIONS

A PIN or AIN/PIN neurectomy resulted in improvement in pain scores in patients, but was not successful in returning the majority of patient to full active duty status without restrictions.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Concepts and Artistry in the Treatment of Scapholunate Ligament Injuries

BACKGROUND

Scapholunate ligament injuries are highly challenging injuries to treat. Great uncertainly remains in determining which operative procedures are most effective. Furthermore, there is no consensus on whether surgical intervention changes the natural course of scapholunate injuries.

METHODS

The authors present their assessment of scapholunate injuries and the senior author's preferred surgical techniques. Surgical videos are included. The authors' postoperative management is described.

RESULTS

Operative procedures are selected based on the patient's timing and pattern of injury, degree of associated carpal changes and arthritis, and goals.

CONCLUSION

Over the past 20 years, the senior author has had good success with these techniques, but prospective, longterm outcome studies are needed to critically assess whether these surgical techniques improve patients' long-term function and pain.

Partial Wrist Denervation: The Evidence Behind a Small Fix for Big Problems

Wrist denervation addresses symptomatic wrist pain without the morbidity and complication profile of more extensive surgical procedures aimed to correct the underlying pathology. The concept of wrist denervation is not new, but its practical application has been modified over the past 50 years. A variety of techniques have been described for various indications, with generally good results. In the United States, a simple, single incision partial denervation consisting of neurectomies of the anterior and posterior interosseous nerves is most commonly performed. Although data on this procedure are limited, most patients are satisfied with pain relief in the short term. There is no evidence that partial denervation procedures alter proprioception of the wrist, and this procedure shows promise as a good option for palliating pain without prolonged postoperative immobilization or leave from work. Preoperative injections do not seem to correlate well with postoperative results. Future studies are needed to assess the duration of relief and possible acceleration of underlying pathology.

Sensory nerve supply of the distal radio-ulnar joint with regard to wrist denervation

The objective of this study was to determine the precise departure points of the articular branches innervating the distal radio-ulnar joint from the anterior and posterior interosseous nerves. The study sample consisted of 116 upper limbs from adult human cadavers. The articular branches were prepared under the dissection microscope to take measurements using the radial styloid process as point of reference. The articular branch departed from the anterior interosseous nerve at a mean distance of 2.9 cm proximal to the styloid for a radius length of 20.5 cm, and 3.7 cm for a radius length of 26.5 cm, respectively. For the posterior interosseous nerve, the departure point was at a mean distance of 3.1 cm (radius length of 20.5 cm) and at 4.0 cm (radius length of 26.5 cm). Apart from a single branch from the posterior interosseous nerve, all articular branches were located distal to the proximal border of the pronator quadratus. Results indicate that wrist denervation from the volar approach, if performed at the proximal border of the pronator quadratus, or from the dorsal approach at a distance of 4.8 cm (for a radius length of 20.5 cm) or 6.2 cm (for a radius length of 26.5 cm) proximal to the radial styloid process, will eliminate the nerve supply to the distal radio-ulnar joint in the majority of cases.

Denervation of the Wrist Joint for the Management of Chronic Pain

Wrist denervation for the management of chronic wrist pain is a safe and effective procedure that can delay or eliminate the need for more invasive and kinematically compromising salvage procedures. Wrist denervation has become increasingly popular since it was first described in 1959, and the technique has evolved from more extensive denervations to limited single-incision approaches. Many physicians have performed this procedure as a palliative approach to managing chronic wrist pain and as an adjunct to other procedures.

Denervation of the wrist with two surgical incisions. Is it effective? A review of 33 patients with an average of 41months' follow-up

The goal of wrist denervation is to decrease pain at the wrist, whether caused by an intra- or extra-articular problem or even when the reason for the pain is unknown. It is an alternative to partial or total arthrodesis and proximal row carpectomy. Our hypothesis was that wrist denervation with a two-incision technique was a reliable and efficient way to treat painful degenerative wrists. Thirty-three patients, 48years old on average, were included in this study. Indications were scapholunate advanced collapse (SLAC) in 18 cases, scaphoid nonunion advanced collapse (SNAC) in 10, distal radius fracture sequelae with advanced radiocarpal osteoarthritis in 4, and post-traumatic ulnocarpal impingement in 1 case. At 41 months' follow-up (12-161), there was a 75% reduction in pain levels, decreasing from 7.1 to 1.8 on a visual analog scale (VAS). There were no modifications related to wrist range of motion or grip strength. The QuickDASH averaged 23 points (5 to 70). Radiographic evaluation showed progression of intracarpal degeneration in 6 patients. All but 2 patients returned to their previous work. Persistent dysesthesia was observed in 7 patients; it resolved in 3 cases and persisted in 4. One patient developed complex regional pain syndrome (CRPS). A midcarpal arthrodesis with scaphoidectomy was performed in one patient because of disabling pain 5months after surgery. Wrist denervation with a two-incision technique for post-traumatic osteoarthritis led to satisfactory results in 75% of cases with reduction in pain, preservation of range of motion and grip strength. However, this technique does not stop the progression of osteoarthritis. It can be discussed as a therapeutic alternative to proximal row carpectomy or intracarpal arthrodesis to treat degenerative painful wrists.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Volar denervation and osteophyte resection to relieve volar CMC joint pain

At mean 125.6 months, pain was reduced from mean of 8.7 to 0.67, p < .001. Each of three patients, two of whom were musicians, returned to full professional ability. It is concluded that volar CMC joint denervation is a useful procedure, preserving joint function and relieving pain long-term.

Long-Term Outcome of Arthroscopic Resection Arthroplasty With or Without Interposition for Thumb Basal Joint Arthritis

PURPOSE

To report results on 144 cases following arthroscopic resection arthroplasty (ARA) with or without interposition for basal joint arthritis.

METHODS

Cases undergoing ARA for thumb carpometacarpal osteoarthritis between 2004 and 2011 were prospectively enrolled (n = 178). Data were collected before surgery and after surgery at 1, 3, 6, and 12 months and annually thereafter. Patients were excluded for less than 1-year follow-up or concomitant procedures that interfered with evaluation of the variable of interest (interposition). Human acellular dermal matrix (GRAFTJACKET) was the most commonly used interposition. Outcomes on 19 cases of interposition using collagen bioimplant (OrthADAPT) and porous polyurethaneurea (Artelon) scaffolds were also reported. Comparative analyses were performed on 52 patients with GRAFTJACKET interposition and on 73 without. Mean follow-up was 7.4 and 5.6 years with and without interposition, respectively. Descriptive statistics were evaluated on all baseline variables. Raw change scores of grip, pinch, and pain outcomes were evaluated. Confounding variables at a significance level of P less than .05 were adjusted for in linear mixed models, and an analysis of covariance was employed through an unstructured type of variance-covariance matrix.

RESULTS

Change scores from baseline to 1 year for the interposition group for pain (numerical rating scale, 0-10), pinch, and grip was -5.8, 3.3, and 7, respectively, and -5.1, 2.1, and 9 for the noninterposition group. Postoperative mean satisfaction was 4.7 and 4.4 for the with- and without-interposition groups, respectively. There were 4 failures with and 2 without interposition. Artelon and OrthADAPT did poorly with unacceptably high failure rates.

CONCLUSIONS

This study suggested that interposition is not necessary following ARA for thumb basal joint arthritis. Because arthroscopic interposition of material contributes to health care costs in terms of patient and facility costs without clear benefit to the patient, routine use of expensive interposition products should be abandoned or carefully evaluated with a prospective randomized controlled trial.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A service evaluation of the therapy assessments used for preoperative wrist surgery assessments within a single National Health Service Trust

Introduction

Chronic wrist joint pain is complex and often managed surgically. Where pain predominates, but function and movement are good, conservative or less invasive procedures may be preferable, such as denervation. To aid surgical selection denervation effectiveness can be predicted by a wrist assessment including nerve blocks. While much literature exists for denervation surgery no research to date has explored nerve blocks from a therapy assessment perspective. The purpose of this service evaluation was to establish current assessment practice, provide an important starting point to discuss why assessments may be selected and aid understanding of the assessment service provided.

Methods

A service evaluation was undertaken. The assessments selected by three therapists for cases referred for a preoperative wrist assessment were recorded and analysed.

Results

Fourteen participants were recruited during a five-month period. The mean age was 57.43 years (range 21–79). Two assessments were terminated to address conservative management. Of the remaining 12 participants, assessments included range of motion, cumulative and resting pain 100% (n = 12), grip and pinch strength 92% (n = 11), function 17% (n = 2) and Baltimore Therapeutic Equipment static and dynamic movements 92% (n = 11).

Conclusion

This time-limited evaluation provides insight into the varied assessments used, by therapists within a single NHS Trust, to simulate activity and/or wrist structures under stress. The assessment is a global patient-centred process which aids identification of strategies for conservative and surgical procedures including denervation surgery. Despite the small sample, trends were noted in the practices of experienced hand therapists.

Arthroscopic Resection Arthroplasty of the Radial Column for SLAC Wrist

Background Symptomatic advanced scapholunate advanced collapse (SLAC) wrists are typically treated with extensive open procedures, including but not limited to scaphoidectomy plus four-corner fusion (4CF) and proximal row carpectomy (PRC). Although a minimally invasive arthroscopic option would be desirable, no convincing reports exist in the literature. The purpose of this paper is to describe a new surgical technique and outcomes on 14 patients who underwent arthroscopic resection arthroplasty of the radial column (ARARC) for arthroscopic stage II through stage IIIB SLAC wrists and to describe an arthroscopic staging classification of the radiocarpal joint for patients with SLAC wrist. Patients and Methods Data were collected prospectively on 17 patients presenting with radiographic stage I through III SLAC wrist who underwent ARARC in lieu of scaphoidectomy and 4CF or PRC. Fourteen patients (12 men and 2 women) subject to 1-year follow-up were included. The average age was 57 years (range 41 to 78). The mean follow-up was 24 months (range 12 to 61). Arthroscopic resection arthroplasty of the radial column is described for varying stages of arthritic changes of the radioscaphoid joint. Midcarpal resection was not performed. Results The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 66 preoperatively and 28 at final follow-up. The mean satisfaction (0 = not satisfied, 5 = completely satisfied) at final follow-up was 4.5 (range 3 to 5). The pain level (on 0-10 scale) improved from 6.6 to 1.3. The total arc of motion changed from 124° preoperatively to 142° postoperatively following an ARARC. Grip was 16 kg preoperatively and 18 kg postoperatively. Radiographic stages typically underestimated arthroscopic staging. Although four of our patients appeared to be radiographic stage I, all were found to have arthritis involving some or all of the radioscaphoid articulation at the time of arthroscopy. Clinical Relevance Pain relief is rapid and remains consistent over time following ARARC. ARARC may be a viable surgical option for patients with SLAC wrist who desire a minimally invasive procedure. Radiographic stages underestimate the degree of arthritic change. Accurate staging requires arthroscopy. The indications and long-term outcome are not well defined; continued surveillance is warranted. Level of Evidence Level IV, Therapeutic study.

Joint denervation and neuroma surgery as joint-preserving therapy for ankle pain

Partial joint denervation or surgical neuroma therapy are alternative concepts to treat pain around the ankle joint that preserve joint function and relieve pain by interrupting neural pathways that transmit pain impulses from the joint to the brain. This review article summarizes the indication, anatomic background, operative techniques, and clinical results of joint denervation or neuroma surgery, which, although rarely reported and used, may provide a valuable alternative treatment in selected patients with neurogenous problems around the ankle.

WRIST DENERVATION IN ISOLATION: A PROSPECTIVE OUTCOME STUDY WITH PATIENT SELECTION BY WRIST BLOCKADE

Surgical wrist denervation involves division of the anterior and posterior interosseous nerves and articular branches of the superficial radial nerve. In this outcome study, 37 patients were individually assessed and deemed suitable for denervation surgery due to appreciable symptom resolution following a local anesthetic wrist block. At a mean of 18 months following denervation surgery, median activity pain scores had decreased by 60% (p < 0.001) from initial assessment levels, and more than three quarters (30/37) of patients reported continued improvement in their activity pain (p < 0.001). More than two thirds of patients had a satisfaction VAS of greater than 50, with less postoperative resting pain and a greater reduction in postoperative activity pain as the important predictors of patient satisfaction. Thirty-one out of the 37 patients had not represented to our department for revision wrist surgery by a mean of 10.3 years follow-up. We have found this procedure useful in ameliorating symptoms for some patients who would conventionally have required partial or total wrist fusions with greater residual functional limitation.

Dorsal intercarpal ligament capsulodesis for predynamic and dynamic scapholunate instability

We treated a prospective series of 18 patients (nine men and nine women) with a mean age of 35 years (range 15 to 57), with chronic predynamic or dynamic scapholunate instability by a dorsal intercarpal ligament capsulodesis using the modified Mayo technique. All the patients were assessed by the modified Mayo wrist score and DASH questionnaire. Wrist arthroscopy was done in all patients before open surgery in order to grade the scapholunate instability and correlate the findings with the radiographic and MRI results. At an average follow-up of 45 months (range 34 to 60) pain significantly diminished (P < 0.05) with improvement in the grip strength (P < 0.005) in all 18 cases. Wrist motion remained almost the same. The mean Mayo wrist score improved from 62 to 84 (P < 0.005).We recommend dorsal capsulodesis by using the dorsal intercarpal ligament flap for the treatment of scapholunate dissociation, when the ligament is still repairable.

Dénervations articulaires en chirurgie de la main : un plaidoyer

Since the original description of wrist denervation, the principle of joint denervation in hand surgery has been extended to other joints like the first carpometacarpal, interphalangeal and metacarpophalangeal joints. At the wrist level as at the digital level, the results are comparable to those obtained with other surgical alternatives. In case of unsatisfactory results, a more traditional intervention remains always possible.

First carpometacarpal joint denervation: anatomy and surgical technique

The main goal of first carpometacarpal arthritis surgery is to relieve pain. The main disadvantage of the classic techniques (trapeziectomy, implant arthroplasty) is that they are extensive surgeries with potential complications, such as radial nerve paresthesia and synovitis. In the author's opinion, denervation of the first carpometacarpal joint is a viable option in selected cases. He describes the technique of denervation based on his previous anatomic investigations. Two incisions are needed to sever all the articular branches derived from the superficial branch of the radial nerve, the palmar cutaneous branch of the median nerve, the thenar branch of the median nerve, and the lateral antebrachial cutaneous nerve. Results comparable with trapeziectomy or first carpometacarpal joint fusion are obtained concerning pain. Complications are uncommon, except for temporary paresthesia of the radial nerve sensory branch.

The nerve supply of the trapeziometacarpal joint

Ten forearm and hand specimens from fresh cadavers were dissected and examined under magnification for articular branches to the trapeziometacarpal joint arising from the thenar and palmar cutaneous branches of the median nerve, the superficial branch of the radial nerve and the lateral cutaneous nerve of forearm. In all but one specimen the thenar branch of the median nerve sent an articular branch to the trapeziometacarpal joint. Multiple branches from the palmar cutaneous branch of the median nerve, the superficial branch of the radial nerve and the lateral cutaneous nerve of forearm were also found. All these branches need to be divided during a "complete" denervation of the trapeziometacarpal joint.