Outcomes Following Isolated Posterior Interosseous Nerve Neurectomy: A Systematic Review

Does anterior plus posterior interosseus neurectomy lead to better outcomes than isolated posterior interosseus denervation in the treatment of chronic wrist pain? A systematic review of the literature and meta-analysis

Purpose

Partial wrist denervation can be performed by isolated posterior interosseous nerve (PIN) or combined PIN plus (+) anterior interosseous nerve (AIN) neurectomy procedures. The purpose of the current systematic review is to investigate any differences in clinical outcomes and failures in patients undergoing AIN + PIN vs isolated PIN neurectomy.

Methods

A review of the English Literature was performed on Medline, WOS and Scopus according to PRISMA protocol combining 'wrist denervation', 'PIN neurectomy', 'AIN neurectomy', anterior interosseous nerve neurectomy' and 'posterior interosseous nerve neurectomy'. Studies were assessed with a modified Coleman Methodology Score (CMS). The primary outcome for meta-analysis was 'Failures', including all patients who have required a second surgery or those who are left with pain (defined as 'bad').

Results

Overall, 10 studies totalling 347 wrists were included in this systematic review, with a 'moderate' CMS. The isolated PIN neurectomy technique showed a 15.1% pooled failure rate at a median follow-up of 22 months, while the combined AIN+PIN denervation had a pooled failure rate of 23.6% at a follow-up with a median of 29 months. The combined analysis of both procedures did not show significantly better results in favour of either technique, with a general failure rate of 21.6% (P = 0.0501).

Conclusion

Partial denervation for chronic wrist pain is a salvage procedure that leads to an overall success of 78.4% for pain relief, with no substantial complications. Apparently, performing the neurectomy also of the AIN does not offer greater advantages compared to the isolated PIN neurectomy.

Long-Term Oral Steroid Use: A Unique Risk Factor in 4-Corner Fusion Compared With Other Wrist Salvage Operations

INTRODUCTION

Salvage procedures such as proximal row carpectomy, 4-corner fusion, total wrist arthroplasty, and total wrist arthrodesis are commonly used at the end stages of wrist arthritis. These operations have high complication rates, and significant controversy exists regarding the selection of procedure. Long-term oral glucocorticoid therapy has previously been identified as a risk factor for complications in multiple orthopedic procedures. The purpose of this study is to investigate the effect long-term oral preoperative corticosteroid use has on complications after different salvage operations for wrist arthritis.

METHODS

The National Surgical Quality Improvement Program database was queried to identify patients who underwent proximal row carpectomy, 4-corner fusion, total wrist arthroplasty, or total wrist fusion between 2005 and 2020. Patients were classified by steroid use. Univariate analysis and multivariate logistic regression were used to assess the risk of complications.

RESULTS

A total of 1298 patients were identified. Overall, steroid use was found to be independently associated with a higher complication rate. On multivariate analysis of patients who underwent 4-corner fusion, steroid use was found to be associated with higher complication rate and surgical site infection rate. Steroid use was not associated with increased complications in patients who underwent proximal row carpectomy, total wrist arthroplasty, or total wrist fusion when examined individually.

CONCLUSION

Long-term oral corticosteroid therapy was associated with an increased risk of postoperative infections in patients who underwent 4-corner fusion, which was not found in other wrist salvage operations.

Risk of Total Wrist Arthrodesis Following Proximal Row Carpectomy: An Analysis of 1,070 Patients

PURPOSE

Proximal row carpectomy (PRC) is a motion-sparing procedure with good patient-reported and clinical outcomes. Although some studies have investigated the risk of conversion to total wrist arthrodesis (TWA) after PRC, additional larger studies evaluating the specific risk factors that lead to failure are required. This study aimed to investigate the patient and procedure factors that are associated with increased risk for conversion to TWA in a large cohort of patients who underwent PRC.

METHODS

The current procedural technology codes identified patients in a National Veteran's Health database undergoing a PRC over a 26-year period. Risk factors of interest comprised age, posterior interosseous nerve neurectomy, wrist arthritis pattern, bilateral surgery, smoking, comorbidities, and preoperative opioid use. The primary outcome was the rate of conversion to TWA. Cox proportional hazard regression was used to create hazard ratios of selected factors for reoperation.

RESULTS

There were 1,070 PRCs performed, with a mean follow-up of 79.8 ± 59.6 months. A total of 5.3% (57/1,070) wrists underwent conversion to TWA. Younger age at the time of PRC (<50 years) significantly increased the risk of TWA (hazard ratio, 3.8; 95% confidence interval, 2.2-6.6). With every 1-year increase in age, there was a reduction of 4% (hazard ratio, 0.96; 95% confidence interval: 0.94-0.98) in the hazard of conversion to TWA. No other factors, including concomitant posterior interosseous nerve neurectomy or bilateral PRC, increased the risk of conversion to TWA.

CONCLUSIONS

Proximal row carpectomy is a motion-preserving salvage procedure with a low rate of conversion to wrist arthrodesis. Younger patient age increases the risk of conversion to arthrodesis, whereas posterior interosseous nerve neurectomy, bilateral PRCs, and comorbidity status do not appear to have an impact on the risk of arthrodesis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Combined Treatment of Trapeziometacarpal Joint Arthritis and Scapholunate Advanced Collapse Wrist

PURPOSE

The combined treatment of trapeziometacarpal joint arthritis and scapholunate advanced collapse (SLAC) wrist presents unique challenges. The consequences of the loss of radial column support caused by scaphoidectomy and trapeziectomy are not well known. The purpose of this study was to evaluate the outcomes of the simultaneous and staged treatment of trapeziometacarpal joint arthritis and SLAC wrist.

METHODS

A retrospective review of patients who underwent surgery for both trapeziometacarpal joint arthritis and SLAC wrist was performed. The wrist and thumb range of motion; grip and pinch strength; pain; quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; and radiographs were analyzed.

RESULTS

Twenty-four patients who underwent both trapeziectomy and 1 of 3 procedures for SLAC wrist (4-corner fusion [n = 10]), proximal row carpectomy [n = 9], and total wrist arthroplasty [n = 5]) in a single stage (n = 10) or in 2 stages (n = 14) were included. The median age was 63 years. The median follow-up period was 35 months. Twelve (50%) patients underwent complete scaphoidectomy, and 12 (50%) patients underwent partial scaphoidectomy. All 3 procedures resulted in an improvement in pain at rest, pain during activity, and quick Disabilities of the Arm, Shoulder and Hand scores. The final range of motion, grip and pinch strength, and complication rates were consistent with those reported in the literature for isolated procedures.

CONCLUSIONS

Trapeziometacarpal joint arthritis and SLAC wrist may be treated either simultaneously or in stages.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

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.

Hemiresection Interposition Arthroplasty of the Distal Radioulnar Joint: A Long-term Outcome Study

Background: The aim of this study was to assess factors associated with long-term patient-reported functional, pain, and satisfaction scores in patients who underwent (Bowers) hemiresection interposition technique (HIT) arthroplasty of the distal radioulnar joint (DRUJ). The secondary aims were to determine the complication and reoperation rates. Methods: A retrospective study with long-term follow-up of patients undergoing HIT arthroplasty was performed. Demographic, disease, and treatment characteristics were collected for the 66 included patients. Thirty-one patients completed all surveys, which were the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), our custom-made HIT arthroplasty questionnaire, Numeric Rating Scale (NRS) for pain, and NRS for satisfaction. The mean interval between surgery and follow-up by means of questionnaires was 8.6 ± 3.4 years. Results: The mean QuickDASH score was 31.0 ± 20.2. The mean score of the HIT arthroplasty questionnaire was 2 ± 2. The median NRS for pain was 1 (interquartile range [IQR], 0-3), and the median NRS for satisfaction was 9 (IQR, 8-10). The complication rate and reoperation rate were 14% and 8%, respectively. Conclusion: Overall, patients expressed satisfaction with HIT arthroplasty, despite a mean QuickDASH score of 31.0. In our cohort, patients with inflammatory arthritis had higher satisfaction and lower pain scores. Patients who had prior trauma, prior surgery, or DRUJ subluxation are generally less satisfied. Men, older patients, and posttraumatic patients had higher long-term pain scores; however, posterior interosseous nerve neurectomy is associated with improved pain scores. Our findings support the use of HIT arthroplasty in patients with inflammatory arthritis.

Factors Associated With Reoperation and Conversion to Wrist Fusion After Proximal Row Carpectomy or 4-Corner Arthrodesis

PURPOSE

Proximal row carpectomy (PRC) and 4-corner arthrodesis (FCA) are common salvage procedures for the treatment of scapholunate advanced collapse and scaphoid nonunion advanced collapse. This study aimed to assess rates of reoperation and conversion to wrist fusion and to assess the factors associated with reoperation and conversion to wrist fusion for patients treated with PRC and FCA.

METHODS

A retrospective chart review was performed evaluating 266 adult patients undergoing PRC or FCA at a single institutional system from 2002 to 2016. Demographic data, patient- and injury-specific data, reoperation and conversion rates, and complications were collected. Potential factors associated with reoperation or wrist fusion were evaluated using a bivariate, followed by a multivariable, analysis.

RESULTS

Reoperation was more commonly performed in FCA (34%) than in PRC (11%) (odds ratio [OR], 3.4; 95% confidence interval [95% CI], 1.7-6.8) and occurred at a shorter postoperative interval. In a multivariable analysis for reoperation, manual labor was associated with reoperation in patients undergoing FCA (OR, 5.4; 95% CI, 1.5-19.1). In those undergoing PRC, anterior interosseous nerve (AIN) and/or posterior interosseous nerve (PIN) neurectomy was associated with a lower rate of reoperation (OR, 0.18; 95% CI, 0.06-0.57). In a multivariable analysis for conversion to wrist arthrodesis, intraoperative AIN and/or PIN neurectomy (OR, 0.18; 95% CI, 0.06-0.57) was associated with a lower rate of conversion to wrist fusion, and smoking (OR, 4.9; 95% CI, 1.8-13.5) was associated with a higher rate of conversion to wrist fusion. In the subanalysis of patients who underwent PRC, only AIN and/or PIN neurectomy was associated with lower rates of conversion to wrist arthrodesis (OR, 0.15; 95% CI, 0.04-0.56).

CONCLUSIONS

In our cohort, we observed that AIN and/or PIN neurectomy reduced the risk of reoperation and conversion to wrist arthrodesis after PRC. Smoking increased the odds of conversion to wrist arthrodesis in the combined PRC/FCA cohort; however, it is unclear whether this was due to smoking itself or whether the indications for PRC or FCA were affected, leading to this result.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Functional outcomes after salvage procedures for the destroyed wrist: an overview

The most widely used procedures for salvaging a destroyed wrist are four-corner arthrodesis, radiocarpal arthrodesis, proximal row carpectomy, total wrist arthrodesis, and total wrist replacement or resurfacing. The purpose of this article is to give an overview of the functional results obtained with the various salvage procedures and of the common methods for assessing the surgical outcomes. The outcomes are assessed by clinical measurements and scoring methods, but the actual functional status and well-being of the patients should be presented together with patient-reported outcomes. No salvage procedure can restore entirely full wrist function. Understanding indications, risks, and the outcomes of these procedures would favour a better decision for surgery and help choose the proper treatment from among the surgical options discussed with patients.

Patient satisfaction and outcomes of partial wrist denervation in inflammatory arthritis

INTRODUCTION

Inflammatory arthritis frequently affects the wrist, resulting in pain and disability. This study aims to investigate the long-term outcome of patients who underwent posterior interosseous nerve (PIN) denervation for inflammatory arthritis of the wrist.

METHOD

xForty consecutive wrists (36 patients) treated with PIN denervation were identified (mean follow-up 47 months; mean age 62.6 years, 77.5% female). Pain and function scores were objectively measured using the patient-rated wrist-evaluation (PRWE) questionnaires. Data was compared for pre-operation and post-operation (early and long term). The Student's t test was used to compare differences between groups for continuous data, whilst the sign test was utilised for pairwise comparisons. The p value was set at 0.05 for all comparisons.

RESULTS

Three patients died during the course of this study from causes unrelated to wrist surgery, resulting in 93% follow-up. PRWE questionnaires demonstrated a significant improvement following PIN denervation (median pain pre-op 42 vs post-op 16 (p < 0.001); median function pre-op 82 vs post-op 41 (p < 0.001), respectively). There were no differences identified between early and long-term post-operative scores. Four cases (10%) had persistent, ulnar-based pain and required secondary salvage wrist arthrodesis. However, 95% of patients remained "very satisfied" or "satisfied" after surgery.

CONCLUSIONS

This study highlights the effectiveness of PIN denervation as a simple alternative to wrist arthrodesis due to long-term improvement in pain and preservation of function. We recommend this procedure in the presence of a positive diagnostic PIN infiltration test to avoid wrist arthrodesis for as long as possible. In patients with predominantly ulnar-based wrist pain, the outcome is less predictable and this subgroup of patients should be counselled about the possibility of subsequent salvage wrist fusion. Key Points • One of the largest study cohorts which report on the outcome of the wrist PIN denervation procedure with over 2-year follow-up • Clinical outcomes of success are enhanced with the use of validated, objective patient-reported outcome measures relating to overall satisfaction, pain relief and function. • Long-term outcomes are compared to pre-operative and immediate post-operative outcome scores, demonstrating the benefits of PIN denervation and the longevity it provides.

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.

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.

Ulnar head arthroplasty with posterior interosseous nerve neurectomy: A case report

BACKGROUND

Distal Radioulnar joint (DRUJ) arthropathy can occur as a consequence of multiple mechanisms, including trauma, inflammatory or degenerative arthritis or even congenital anomalies. Ulnar head arthroplasty has been proposed as a viable therapeutic option, potentially restoring wrist function and improving pain control. This can also be achieved by complete wrist neurectomy but it has several risks associated with the procedure. A selective neurectomy may be more effective.

CASE PRESENTATION

We report the case of a 51-year-old man, Tool-Colector, who suffered from constant diffuse left wrist pain aggravated with activities and had a swollen and tender wrist at physical examination with limited range of motion on prono-supination. Radiographic and magnetic resonance imaging showed degenerative changes in the radiocarpal joint and distal radioulnar joint. In order to preserve the remaining mobility and reduce the wrist pain we proceeded with an ulnar head arthroplasty and a posterior interosseous nerve neurectomy, through a single skin incision in the dorso-ulnar side of the wrist. Afterwards, the patient followed a strict rehabilitation program with a hand therapist. Six months later he returned to his previous job with no limitations.

CONCLUSIONS

Ulnar head arthroplasty seems to be a very good option in the treatment of severe DRUJ arthrosis. It significantly improves pain control while maintains or even improves range of motion. Posterior interosseous nerve neurectomy is a simple technique and highly effective.