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Delclaux, Stéphanie and Elia, Fanny and Bouvet, Cindy and Aprédoaei, Costel and Rongières,
Michel and Mansat, Pierre Denervation of the wrist with two surgical incisions. Is it
effective? A review of 33 patients with an average of 41 months’ follow-up. (2017) Hand Surgery
and Rehabilitation, 36 (4). 281-285. ISSN 2468-1229
OATAO
O
pen
A
rchive
T
ou
l
ouse
A
rchive
O
uverte
Denervation
of
the
wrist
with
two
surgical
incisions.
Is
it
effective?
A
review
of
33
patients
with
an
average
of
41
months’
follow-up
La
de´nervation
du
poignet
par
2
voies
d’abord
est-elle
efficace
?
A` propos
de
33
patients
revus
a` 41
mois
de
recul
moyen
S.
Delclaux,
F.
Elia,
C.
Bouvet,
C.
Apre´doaei,
M.
Rongie`res,
P.
Mansat
*
De´partement d’orthope´die et traumatologie–urgences mains hoˆpital Pierre-Paul-Riquet, hoˆpital universitaire de Toulouse, place du Dr-Baylac, 31059Toulousecedex,France
Keywords: Denervation Degenerativewrist SLAC SNAC Motscle´s: De´nervation Arthrosedupoignet SLAC SNAC ABSTRACT
Thegoalofwristdenervationistodecreasepainatthewrist,whethercausedbyanintra orextra articularproblemorevenwhenthereasonforthepainisunknown.Itisanalternativetopartialortotal arthrodesisandproximalrow carpectomy.Ourhypothesiswasthatwristdenervationwithatwo incisiontechniquewasareliableandefficientwaytotreatpainfuldegenerativewrists.Thirty three patients,48yearsoldonaverage,wereincludedinthisstudy.Indicationswerescapholunateadvanced collapse(SLAC)in18cases,scaphoidnonunionadvancedcollapse(SNAC)in10,distalradiusfracture sequelaewithadvancedradiocarpalosteoarthritisin4,andpost traumaticulnocarpalimpingementin 1case.At41months’follow up(12 161),therewasa75%reductioninpainlevels,decreasingfrom 7.1to1.8onavisualanalogscale(VAS).Therewerenomodificationsrelatedtowristrangeofmotionor gripstrength.TheQuickDASHaveraged23points(5to70).Radiographicevaluationshowedprogression ofintracarpaldegenerationin6patients.Allbut2patientsreturnedtotheirpreviouswork.Persistent dysesthesiawasobservedin7patients;itresolvedin3casesandpersistedin4.Onepatientdeveloped complexregionalpainsyndrome(CRPS).Amidcarpalarthrodesiswithscaphoidectomywasperformed inonepatientbecauseofdisablingpain5monthsaftersurgery.Wristdenervationwithatwo incision techniqueforpost traumaticosteoarthritisledtosatisfactoryresultsin75%ofcaseswithreductionin pain,preservationofrangeofmotionandgripstrength.However,thistechniquedoesnotstopthe progressionofosteoarthritis.Itcanbediscussedasatherapeuticalternativetoproximalrowcarpectomy orintracarpalarthrodesistotreatdegenerativepainfulwrists.
Typeofstudy/levelofevidence:TherapeuticIV.
R E´ SUM E´
Lebutd’unede´nervationdupoignetestdediminuerlasymptomatologiedouloureuse.Ils’agitd’une alternativea` l’arthrode`separtielleoutotale,oua` lare´sectiondelarange´eproximaleducarpe.Notre hypothe`see´taitquelade´nervationdupoignetre´alise´epar2voiesd’abordpermetd’obtenirdesre´sultats satisfaisantsetreproductiblesdansletraitementdespoignetsde´ge´ne´ratifs.Trente troispatients,d’aˆge moyen48ans,onte´te´ inclusdanscettee´tude.Lesindicationse´taientdesse´quellesdele´sionduligament scapho lunaire(SLACwrist)dans18cas,depseudarthroseduscaphoı¨de (SNACwrist)dans10cas,de fracturearticulairedel’extre´mite´ distaleduradiusdans4cas,etunearthroseparconflitulnocarpien dans1cas.A` 41moisdereculmoyen(12 161),l’ame´liorationdeladouleure´taitde75%,l’intensite´ passantde7,1a` 1,8surunee´chellevisuelleanalogique(EVA).Lamobilite´ dupoignetetlaforcedela poigne n’e´taient pas modifie´es. Le score QuickDASH e´tait de 23 points (5 a` 70). L’e´valuation
* Correspondingauthor.
1. Introduction
Thegoalofwristdenervationistodecreasepainatthewrist, whethercausedbyanintra orextra articularproblem oreven whenthereasonforthepainisunknown[1].Itisanalternative therapeuticoptiontointracarpalproceduressuchaspartialortotal arthrodesis [2] and proximal row carpectomy (PRC) [3]. The original surgical technique used eight approaches to resect all 10 articular nerve branches responsible for pain transmission
[1].AnanatomicstudyperformedbyDubertetal.[4]showedthat wristdenervationcouldbeperformedthroughonlythreesurgical approaches.Bergeretal.[5]proposedasingleposteriorapproach to resect the posterior interosseous nerve (PIN) and anterior interosseousnerve(AIN). However, this techniquehasarisk of pronatorquadratusmuscledenervation[6].
Wristdenervationthroughtwoapproacheshasbeenusedin ourdepartment for many years. Our hypothesis was that this surgicaltechniquewasareliableandefficientwaytotreatpainful degenerativewrists.
2. Materialandmethods 2.1. Patients
A retrospective study wasconductedin ourOrthopedic and TraumatologyDepartmentata UniversityHospital.Institutional reviewboardapprovalwasnotrequiredforthisstudy.Allpatients wereinformedabouttheuseoftheirpersonaldataforthisstudy. Included were all patients who underwent isolated wrist denervation through two approaches between 1995 and 2010, withatleast1yearoffollow up.Excludedwereallpatientswho underwentwristdenervationwithassociatedprocedures,orwith adifferentsurgicaltechnique,orwithlessthan1yearoffollow up. BetweenJanuary1995and May2010,33patients whowere 48years old on average (range 23 to 68 years) fulfilled the inclusioncriteriaandwereincludedinthisstudy.Thedominant sidewasinvolved in 17patients. Fifteen patients weremanual laborers.
Indicationsforwristdenervationwerescapholunateadvanced collapse (SLAC) in 18 cases and scaphoid nonunion advanced collapse(SNAC)in10.In4cases,wristdenervationwasperformed for distal radius fracture sequelae with advanced radiocarpal osteoarthritis. Finally, wristdenervation was performed in one caseforpost traumaticulnocarpalimpingement.
3. Methods
Preoperativepainassessedwithavisualanalogscale(VAS)was 7.1onaverage (4to10).Preoperative rangeofmotionassessed
witha goniometerfoundwristflexionof51.68(308to708)and wristextensionof50.88(208to708).Preoperativewriststrength measuredwithaJamar1
dynamometerwas33kg(13to50kg). Preoperativeposteroanteriorandlateralviewsofthewristwith CT examwasavailableforallpatients.Degenerativechangesofthe carpuswereclassifiedaccordingtoWatsonandBallet[7]andAlnot
[8](Table1).
3.1. Surgicaltechnique
Twodifferenthandsurgeonsperformedallproceduresunder regionalanesthesia.Atourniquetatthearmwasusedinallcases. Adorsalskinincisionwasperformedbetweenthe3rdand4th extensorcompartments.Subcutaneousdissectionwasperformed totheradialstyloidtoresectallarticularnervesbranchesofthe superficialbranchoftheradialnerve andthelateralcutaneous nerveoftheforearm.Thendissectionwasdirectedtotheulnar headtoresectallarticularnervesbranchesofthedorsalbranchof the ulnar nerve and posterior cutaneousnerve of the forearm. Depthofsofttissuedissectionwasthenlimited attheextensor retinaculum level dorsally. The extensorretinaculum wasthen transected between the3rd and 4th extensor compartment to locatetheterminalbranchofthePINandtoresectiton3cm.The extensorretinaculumwasthenrepaired.
A volar arcuateincisionwas then performed parallel tothe radial artery and parallel to thedistal radius articular surface. Dissectionaroundtheradialarterywasthenperformedtoidentify thepairofvenæcomitantes,whichwerecoagulatedandresected 3to4cm.Thedistalpartofthepronatorquadratusmusclewas thenidentified.Itwasincisedtransverselydistallyandaperiosteal elevatorwasusedtoremovetheundersurfaceofthemusclefrom thebone,blindlytransectingtheterminalarticularbranchesofthe AIN.Thisvolarapproachdidnotincludedeflectionofthepalmar branchofmediannerve.
Patientswereimmobilized in a splintfor2weeks,andthen wereallowedtomovetheirwrist.Notherapywasprescribed. 3.2. Evaluationmethods
All patient records were review retrospectively. The mean follow up was 41months (range, 12 to 161months). Clinical evaluation was basedon theVAS pain rating.Pain at restand during exercise was also specified. Wrist range of motion in flexion/extensionwasmeasuredwithagoniometer.Gripstrength wasmeasuredwithaJamar1
dynamometer.Functionalevaluation oftheupperlimbwasperformedusingtheQuickDASHquestion naire[9].Atthelastfollow up,posteroanteriorandlateralviewsof the wrist were taken to look for progression of intracarpal degenerativelesions.
radiographiquemontraituneprogressiondesle´sionsde´ge´ne´rativesintracarpiennedans6cas.Tousles patients, sauf2, ont pu reprendreleur activite´ professionnelle. Des dysesthe´siespersistaientchez 7patients;3e´taienttransitoireset4ontpersiste´.Unpatientade´veloppe´ unsyndromedouloureux re´gionalcomplexe.Unearthrode`seme´diocarpienneavecscaphoı¨dectomie ae´te´ ne´cessairechezun patientpourpersistancedesdouleurs5moisapre`slade´nervation.Danslecadredepoignetde´ge´ne´ratif, lade´nervationdupoignetre´alise´epar2voiesd’abordpermetd’obtenirdesre´sultatssatisfaisantsdans 75%descas,avecdiminutiondel’intensite´ desdouleursetconservationdesamplitudesarticulairesetde laforcedelapoigne.Cependantellenestoppepasl’e´volutiondel’arthrose.Cettetechniquepeuteˆtre discute´eparrapportauxautresoptionsthe´rapeutiquesclassiques:re´sectiondelarange´eproximaledu carpe,etarthrode`separtielleoutotaleducarpe.
4. Results
4.1. Complicationsandrevisions
In the immediate postoperative period, dysesthesia was observedin 7 patients:3 in theulnar nerve territoryand 4 in the radial nerve territory. Three cases were self limiting and 4persisted(1intheulnarnerveterritoryand3intheradialnerve territory).Onepatientdevelopedcomplexregionalpainsyndrome (CRPS).
Onepatientcontinuedtohavedisablingpain 4monthsafter surgery. This patient had a stage 3 SLAC wrist. Midcarpal arthrodesiswithscaphoidectomywasperformed5monthsafter thedenervationprocedure.Anotherpatientwithstage2SLAChad notimprovedatthe2 yearfollow upwithVASof5.Norevision wasperformed butmidcarpalarthrodesis wasdiscussed.Radio lunate osteoarthritis appeared in a third patient with post traumaticulnocarpalimpingement;radiolunatearthrodesis was performedincombinationwithdistalulnaresection.
4.2. Clinicalresults
Forthe33patientsreviewed,themeanVASwas1.8(0to8)with ameanVASof1.1(0to4)atrestand2.6(0to10)duringexercise. Thepain level was reduced 75% compared tothe preoperative level.Postoperativerangeofmotionwas448(208to708)inflexion and498(308to708)inextension.Gripstrengthwas35.4kg(26to 55kg).TheQuickDASHaveraged23points(5to70).Therewasno significant difference in the clinical outcome related to the indications.
Eight patients had at least 5 years’ follow up 8years on average(5to14years).Allthesepatientswereverysatisfiedwith thesurgery.MeanVASwas1.6atrestand2.4duringeffort.The QuickDASHaveraged19.8points(7to45).
4.3. Functionalresults
Fifteenpatientsworkedinheavymanuallaborjobsatthetime ofthedenervationprocedure.Forthesepatients,averagepainwas 2.5on VASduringeffort. Allbut twopatients returnedtotheir previouswork.
4.4. Radiologicalresults
Of the 33 patients reviewed, 6 had progression of the intracarpaldegenerativelesions,withoutrecurrenceorincreased pain (Fig. 1, Table 1). In the group of patients with 5years’ minimum follow up, no patients had increased signs of radio graphicosteoarthritis.
5. Discussion
Degenerativelesionsofthewristareoftenpost traumaticand affectyoungpatients.Therapeuticoptionsforadvancedosteoar thritis are partial or total wrist fusion [2], PRC [3] or wrist denervation[1,4,5].Theadvantageofwristdenervationisitseffect onpainsymptomswithoutimpairmentofwristmotion.Strength is often preserved or increased. The disadvantage is that the underlyingosteoarthritisisnottreatedandtendstoprogressover time.
Insimilarpublishedstudies,thereductionofpainsymptoms averaged 72% (range,62 to 81%)(Table 2). Usually, resultsare gradualandreachaplateauattheendofthefirstyear[14].Range ofmotionisunchangedorslightlyimproved.Wriststrengthtends toincreaseafterdenervationofthewrist,whileremaininglower than the healthy contralateral side. However, follow up with radiographsrevealedworseningofosteoarthriticlesionsinmost
Fig.1.Exampleofapatientwithstage1SLACpreoperatively(A)andstage2at3yearsafterwristdenervation(B). Table1
ChangeintheradiologicalclassificationofSLAC/SNACwristspreoperativelyandat thelastfollow-up.
Preoperative Lastfollow-up Worseningofdegenerativelesions SNAC(10patients)
1stage1 0stage1 2patients 3stage2A 3stage2A
4stage2B 5stage2B 2stage4 2stage4 SLAC(18patients)
4stage1 2stage1 4patients 8stage2 8stage2
cases[14,17],withrecurrenceofpaininsomecases[11,13].Based ontheliterature,itseemsthatbetterresultscanbeobtainedfor SLAClesions,distalradiusfracturesequelae[12,13]orKienbo¨ck disease[19]intermsofgripstrength,rangeofmotion,andpain relief. However, like Simon et al. [17], we could not find any differencesinoutcomesbytheindicationsinourstudy.Ourstudy confirmed previous studies showing 75% reduction in pain. Worseningof degenerative intracarpallesions wasobserved in 6out of 33patients inour studywithout clinicalchanges at follow up.
TotalwristdenervationwasinitiallydescribedbyWilhelmetal.
[1].Theydescribed10nervebranchesresponsibleforjointpain transmission.Fiveincisionswererecommendedtodivideallthese branches.The surgical procedure wastechnically difficult with unreliableresults.Sideeffectswerereportedsuchaslossofskin sensibilityandwristproprioception[20].However,inacadaveric study,Dubertetal. [4]foundthat somebranchesdescribed by Wilhelmappearinaccessiblebecausetheywerecloselylocatedto other motor branches (deep branches of the ulnar nerve). Furthermore,somebrancheswerenotfoundintheirdissections: branchletsfromthepalmarbranchofthemediannerveanddirect branchesoftheulnarnerve.Theyrecommendedusingonlythree incisionstoperformcompletewristdenervation:dorsal,palmar andatthefirstwebspacetoresectthearticularnervesofthefirst interosseousspace.LaterBergeretal.[5]describedthepossibility ofdoingpartialdenervationofthewristbyresectingtheAINand PINthroughasingleposteriorapproach.Atanaverageof2.5years postoperatively,theyreportedthat80%ofpatientshadadecrease in pain, 45% normal or increased grip strength, and 73% of employedpatientshadreturnedtowork[21].However,Grafeetal.
[22] and Lin et al. [6] described a serious risk of completely denervating the pronator quadratus muscle when using this surgicaltechnique.Therefore,AINresectionshouldbeperformed closetothedistalmarginofthepronatorquadratusmuscle.More recently,VandePoletal.[23]foundthatthemaininnervationto thewristcapsuleandperiostealnervenetworkcamefromtheAIN, lateralantebrachialcutaneousnerve,andPIN.Thepalmarbranch of the median nerve, thedeep branch of the ulnar nerve, the superficialbranchoftheradialnerve,andthedorsalbranchofthe ulnarnervealsowerefoundtohaveconnectionswiththecapsule. Basedonthesefindingstheyproposeddenervatingthewristby making only two incisions one palmar and one dorsal to disconnectthe periosteum from thecapsule and interrupt the majorityofthecapsularnerve branches.In ourstudy,onlytwo incisions were made and this ledto reliable results likeother studieswithdifferentsurgicaltechniques.
Fewcomplicationshavebeenreportedafterwristdenervation. Braga Silvaetal.[14]reviewed49patientstreatedwithWilhelm’s techniqueandfoundneuromasassociatedwiththeradialdorsal digitalnerveoftheindexfinger;mostpatientsreportedtransient
hypoesthesiaintheterritoryofthesuperficialbranchoftheradial nerve.Simonetal.[17],usingathree incisionprocedure,reported 4casesoftransienthypoesthesiaintheterritoryofthesuperficial branch of theradial nerve out of 29 patients. One required a revisionprocedurewithresectionoftheneuroma.Sevencasesof dysesthesiawereobservedinourstudyoutof33patients:3were self limitingand4persisted.
Neurotrophic degeneration of the wrist joint has been theoretically described as a possible complication of wrist denervation. However, radiographic changes that could be attributedtoneurotrophicdegenerationhavenotbeenreported in any publishedstudies, with all changes being attributed to progressionoftheosteoarthritis.
6. Conclusion
Atanaverageof41months’follow up,wristdenervationwitha two incision technique for post traumatic osteoarthritis led to satisfactoryresultsin75%ofcaseswithreductionofpainlevels, preservation of range of motion and wrist strength. The complication rate was low and mainly related to persistent dysesthesia.However,thistechniquedoesnotstoptheprogression ofradiologicalsignsofosteoarthritis.
Funding
Nofundingwasreceivedrelatedtothisstudy. Disclosureofinterest
Theauthorsdeclarethattheyhavenocompetinginterest. References
[1]WilhemA.Denervationofthewrist.TechHandUpExtremSurg2001;5:14–30.
[2]DelclauxS,MansatP,Rongie`resM,Apre´doaeiC,BonnevialleP.Re´sultats
cliniquesetradiologiquesa` 10ansdemoyennedel’arthrode`secapito-lunaire.
Se´riemonocentriquede12patients.ChirMain2013;32:310–6.
[3]DelclauxS, IsraelD, Apre´doaei C, Rongie`resM,Mansat P.Proximalrow
carpectomyonmanualworkers:17patientsfollowedforanaverageof6years.
HandSurgRehabil2016;35:401–6.
[4]DubertT,OberlinC,AlnotJY.Articularnervesofthewrist.Implicationson
wristdenervationtechnique.AnnChirMainMembSuper1990;9:15–21.
[5]BergerR.Partialdenervationofthewrist:anewapproach.TechHandUpExt
Surg1998;2:25–35.
[6]LinDL,LenhartMK,FarberGL.Anatomyoftheanteriorinterosseous
innerva-tionofthepronatorquadratus:evaluationofstructuresatriskinthesingle
dorsalincisionwristdenervationtechnique.JHandSurgAm2006;31:904–7.
[7]WatsonHK,BalletFL.TheSLACwrist:scapholunateadvancedcollapsepattern
ofdegenerativearthritis.JHandSurgAm1984;9:358–65.
[8]AlnotJY.Lesdiffe´rentsstadesdepseudarthrose.In:«Symposium:fractureet
pseudarthroseduscaphoı¨de carpien».RevChirOrthopReparatriceApparMot
1988;74:114–7.
[9]DubertT,VocheP,DumontierC,DinhA.TheDASHquestionnaire.French
translationofatrans-culturaladaptation.ChirMain2001;20:294–302.
Table2
Reviewofthemostrecentliteratureontheresultsobtainedafterwristdenervation.
Authors N Numberof incisions Follow-up (month) Results(%with painreduction) Hofmeister(2006)[10] 50 1 28 51% Rotheetal.(2006)[11] 32 – 76 62.5% Schweizeretal.(2006)[12] 71 5 113 67% Raduetal.(2010)[13] 29 – 51 70% Braga-Silva(2011)[14] 49 4 72 794% Storey(2011)[15] 37 1 18 60% Hohendorff(2012)[16] 30 5 120 73% Simonetal.(2012)[17] 27 3 77 81% Richesetal.(2014)[18] 14 1 22 42% Ourstudy(2016) 33 2 41 75%
[10]HofmeisterEP,MoranSL,ShinAY.Anteriorandposteriorinterosseous
neu-rectomyforthetreatmentofchronicdynamicinstabilityofthewrist.Hand
2006;1:63–70.
[11]RotheM,RudolfKD,ParteckeBD.Longtermresultsfollowingdenervationof
thewristinpatientswithstagesIIandIIISLAC/SNACwrist.Handchir
Mikro-chirPlastChir2006;38:261–6.
[12]SchweizerA,vonKa¨nelO,KammerE,Meuli-SimmenC.Longtermfollow-up
evaluationofdenervationofthewrist.JHandSurgAm2006;31:559–64.
[13]RaduCA,SchachnerM,Tra¨nkleM,GermannG,SauerbierM.Functionalresults
afterwristdenervation.HandchirMikrochirPlastChir2010;42:279–86.
[14]Braga-SilvaJ,Roma´nJA,PadoinAV.Wristdenervationforpainfulconditionsof
thewrist.JHandSurgAm2011;36:961–6.
[15]StoreyPA,LindauT,JansenV,WoodbridgeS,BainbridgeLC,BurkeFD.Wrist
denervationinisolation:aprospectiveoutcomestudywithpatientselection
bywristblockade.HandSurg2011;16:251–7.
[16]HohendorffB,Mu?hldorfer-FodorM,KalbK,vonSchoonhovenJ,
Prommers-bergerKJ.Long-termresultsfollowingdenervationofthewrist.Unfallchirurg 2012;115:343–52.
[17]SimonE,ZemirlineA,RichouJ,HuW,LeNenD.Lade´nervationtotaledu
poignet:unee´tudere´trospectivede27casaureculmoyende77mois.Chir
Main2012;31:306–10.
[18]RichesPL,ElherikFK,BreuschSJ.Functionalandpatient-reportedoutcomeof
partial wristdenervationversus the Mannerfeltwristarthrodesisin the
rheumatoidwrist.ArchOrthopTraumaSurg2014;134:1037–44.
[19]Buck-GramckoD.Wristdenervationproceduresinthetreatmentof
Kien-bock’sdisease.HandClin1993;9:517–20.
[20]FerreresA,SusoS,FoucherG,OrdiJ,LlusaM,RuanoD.Wristdenervation.
Surgicalconsiderations.JHandSurgBr1995;20:769–72.
[21]WeinsteinLP,BergerRA.Analgesicbenefit,functionaloutcome,andpatient
satisfactionafterpartialwristdenervation.JHandSurgAm2002;27:833–9.
[22]GrafeMW,KimPD,RosenwasserMP,StrauchRJ.Wristdenervationandthe
anterior interosseous nerve: anatomic consideration. J Hand Surg Am
2005;30:1221–5.
[23]VandePolGJ,KoudstaalMJ,SchuurmanAH,BleysRL.Innervationofthewrist
jointandsurgicalperspectivesofdenervation.J HandSurgAm2006;31:
