Radical Wrist Denervation and Preliminary Results

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.

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.

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.

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.

Superselective angiography of the wrist in patients with Kienböck's disease

BACKGROUND

Microvascular problems like increased intraosseous pressure or venous congestion may influence the development of Kienböck's disease. We examined if wrist position modifies the blood flow in the nutrient vessels.

METHODS

Retrospective analysis of 17 patients with Kienböck's disease who had a superselective microangiography of the radial, ulnar and interosseous artery in different wrist positions under general anaesthesia. We analysed the data with Fisher's exact and Wilcoxon-test.

RESULTS

We found vessels that entered the bone, that ended at the bone edge, and that supplied a vascular plexus. The origins were the anterior interosseous artery in 10 of 17 cases, the radial artery in seven cases, and the ulnar artery in five cases. Movement of the wrist could reduce or stop the blood flow. Type of lunate configuration showed no significant influence on the blood supply in neutral position.

CONCLUSION

The radial, ulnar, and anterior interosseous artery contribute to the vascular supply of the lunate bone in different combinations. Wrist movement can reduce blood flow to the lunate bone.

Outcomes Following Isolated Posterior Interosseous Nerve Neurectomy: A Systematic Review

BACKGROUND

Posterior interosseous nerve neurectomies (PINN) are an option in the treatment of chronic dorsal wrist pain. However, the literature describing PINN consists primarily of small case series, and the procedure is typically done as an adjunct treatment; therefore, the outcomes of the PINN itself are not well known. We performed a systematic review of the literature to provide characteristics of patients following a PINN.

METHODS

A systematic review of the literature was performed. Papers published in the PubMed database in English on isolated PINN were included. Articles in which a PINN was performed as an adjunct were excluded. Primary outcomes were return to work, patient satisfaction, pain/function scores, wrist range of motion, complications, and pain recurrence. Weighted averages were used to calculate continuous data, whereas categorical data were noted in percentages.

RESULTS

The search yielded 427 articles including 6 studies and 135 patients (136 cases). The average age was 43.6 years (range, 17-75), and most patients were female (54.1%). At an average final follow-up of 51 months, 88.9% of patients were able to return to work. After initial improvement, a recurrence of pain occurred in 25.5% of patients at an average of 12.3 months. Excluding recurrence of pain, the complication rate was 0.9%, including 1 reflex sympathetic dystrophy. Overall, 88.4% of patients experienced a subjective improvement and were satisfied with the procedure.

CONCLUSIONS

Isolated PINN have shown excellent clinical outcomes, with few patients experiencing recurrent pain at long-term follow-up. PINN can provide relief in patient's chronic wrist pain.

Patient-rated long-term results after complete denervation of the wrist

The aim of this study was to examine the long-term results after the denervation of the wrist. Between 1977 and 2001, we treated 375 patients in our clinic. The mean age was 43.5 years; 81% were male and 19% female. The long-term results were assessed by a questionnaire assessing pain on a visual analog scale and patient satisfaction and by the DASH questionnaire. After a mean follow-up of 12.23 years, we found an overall pain reduction of 52.1%. In 67.7% of the patients, we found a relief of pain: of these, 44% are free of pain until today and 56% were temporarily asymptomatic. Patients with a painful osteoarthritic condition without dynamic instability and good range of motion are ideal candidates to benefit from the denervation. The complete denervation of the wrist is an effective treatment option in patients with painful wrist conditions to reduce pain and improve the overall function.