DENERVATIONOF HAND JOINTS

Pulvertaft Hand Centre

Clinical Teaching for FellowsSeptember 2014

Mr J Arenas-Prat

WHAT IS JOINT

DENERVATION?

Surgical technique to isolate a joint from its sensory

branches in order to treat osteoarthritic pain

HISTORICAL PERSPECTIVE

Denervation of a hand joint was first described by

Wilhelm at wrist level in 1966 and based

on the same principles proposed by Camitz in 1933 for

osteoarthritis of the hip join

Wilhelm A. Die Gelenkdenervation und hire anatomischen Grundlagen. Hefte zur Unfallheilk. 1966;86:1-109.

Camitz H. Die deformierende Huftgelenksarthritis und speziell ihre behandlung. Acta Orhop Scand 1933;4:193-213

WHY DENERVATION ?

• “Less is more” in Hand Surgery

• Simple technique

• Does not interfere with biomechanics of joint

• Faster recovery time

• Does not preclude further surgery

• It is ideal for non weight-bearing joints

• Because it works

DENERVATION FACTS “All or nothing“ technique. Avoid partial or “shy“

denervations. Denervation is based on NEURECTOMY, NOT NEURAPRAXIA, otherwise

pain will reoccur within the following two years

amount of divided articular rami amount of divided articular rami

Pain

relief

Pain

relief

DENERVATION FACTS (2)

Be radical with your technique but at the same

time, extremely gentle with nerve tissue

handling during the operation

DENERVATION FACTS (3)

• Most orthopaedic operations imply a degree of

involuntary denervation

• Pre-operative tests with local anaesthetic might exclude patients that otherwise would benefit from denervation

DENERVATION ”MYTHS”

• J Hand Surg Am. 2011 Nov;36(11):1774-9. Effect of partial wrist denervation on wrist kinesthesia: wrist denervation does not impair proprioception. Gay A et al

• J Hand Surg Am. 2010 Jul;35(7):1059-66. Desensitizing the posterior interosseous nerve alters wrist proprioceptive reflexes Hagert E. Persson JK.

• J Hand Surg Am. 2010 Jul;35(7):1067-9. : Desensitizing the posterior interosseous nerve alters wrist proprioceptive reflexes: it is ok to lose your nerve . Dellon AL

DENERVATION AND PROPRIOCEPTION :

A LONGSTANDING CONTROVERSY

DENERVATION “MYTHS“(2)

END OF CONTROVERSY ?

● There is no clinical evidence that denervation affects proprioception (longstanding controversy)

● Pain affects proprioception more than denervation: “It is ok to lose your nerve when the nerve you lose impairs function“ AL. Dellon

● Apart from capsular and ligamentous receptors proprioception is regulated by skin and musculotendinous receptors

CONTRAINDICATIONS

• Grossly unstable joints

• Joint deformities that impair function

DISTAL INTERPHALANGEAL JOINT DENERVATION

Arenas-Prat JM. Denervation of the distal interphalangeal joint. Tech Hand Up Extrem Surg. 2012 Mar;16(1):12-3

Innervation of the DIPJ

● Articular branchletts from the ulnar and radial digital nerves, either directly from the main trunk of the digital nerve or from twigs arising from a dorsal branch of the palmar digital nerve

● These branchletts enter the joint at volar,lateral and dorsal aspects

PROXIMAL INTERPHALANGEAL

JOINT DENERVATION

Lorea P, Ezzedine R, Marchesi S. Denervation of the proximal interphalangeal joint: a realistic amb simple procedure Tech Hand Up Extrem Surg. 2004 Dec;8(4):262-5

Innervation of the PIPJ

● Articular sensory branchletts arising from the volar digital nerves

● Some authors (Chen et al) have demostrated that the dorsal aspect of the joint is innervated by sensory branchletts from the dorsal digital nerve

METACARPOPHALANGEAL JOINT DENERVATION

Arenas-Prat J. Denervation of the metacarpophalangeal joint. Tech Hand Up Extrem Surg. 2014 Jul 25. [Epub ahead of print)

Innervation of the metacarpophalangeal joint

● Articular branches from dorsal and palmar digital nerves

● One articular branch from the deep branch of the ulnar nerve. It is located deep and radial to the flexor tendon and superficial to the interosseus muscle. This only aplies for the second to fifth metacarpophalangeal joints

EXTENSIVE WRIST DENERVATION

Ferreres A, Foucher G, Suso S. Extensive denervation of the wrist. Tech Hand Up Extrem Surg. 2002 Mar;6(1):36-41

Innervation of wrist joints

1-Dorsal branch of the ulnar nerve innervates the ulno-dorsal aspect of the wrist

2-Superficial branch of the radial nerve takes part in the innervation of the radio-dorsal aspect of the joint

3-Posterior interosseus nerve (branch from the radial nerve) innervates the dorsal aspect of the radiocarpal joint and distal radioulnar joint

4-Lateral antebrachial nerve innervates the radial aspect

5-Medial antebrachial nerve participates in the innervation of the ulnar aspect of the joint

6-Anterior interosseus nerve (branch from the median nerve) innervates the volar aspect of the radiocarpal, ulnocarpal and distal radioulnar joints

7-Palmar cutaneous branch of median nerve contributes to innervate the radio-volar aspect of the wrist

8-Sensitive branches from the deep branch of ulnar nerve innervate the carpometacarpal joints however some authors (1) believe that they also participate in the innervation of the midcarpal joint

FIRST CMC JOINT DENERVATION

Arenas-Prat JM. Wagner approach for first carpometacarpal denervationTech Hand Up Extrem Surg. 2012 Jun;16(2):107-9

Innervation of the 1st CMCJ

● Articular rami from the superficial branch of the radial nerve innervate the dorsolateral area of the joint

● Articular rami from the palmar branch of the median nerve carry out the innervation of the radiovolar segment

● Sensory articular rami from the thenar branch of the median nerve innervate the volar and ulnar regions of the joint

● Sensory branchletts from deep branch of ulnar nerve

● The Cruveilhier branch from the lateral antebrachial cutaneous nerve innervates the radial and radiovolar aspect of the joint

1st CMCJ denervation●Traditional techniques involve a single dorsal incision or two smaller dorsal and volar incisions

●Wagner approach, apart from the three main sensitive articular branches, also addresses the sensitive rami from the thenar branch of the median nerve and from deep branch of ulnar Nerve

Miki R, Kam C, Gennis E, Barkin J Riel R, Robinson P Owens P. Ulnar nerve component to innervation of thumb carpometacarpal joint; Iowa Orthop J. 2011; 31: 225–230.

Loréa PD. First carpometacarpal joint denervation: anatomy and surgical technique. Tech Hand UpExtrem Surg. 2003;7:26-31.

Loréa P, Dury M, Marin Braun F, Dekkaï T, De Mey A, Foucher G. Trapeziometacarpal denervation.Description of surgical technique and preliminary results from a prospective series of fourteen cases.Chir Main. 2002;21:209-172

Arenas-Prat, JM. Wagner approach for first carpometacarpal denervation. Tech Hand Up Extrem Surg. 2012

Jun;16(2):107-9.

STT JOINT DENERVATION

● Same innervation and technique than first CMC joint applies

● Thenar deflection is extended proximally to the STT joint which is identified using a hypodermic needle

POST OPERATIVE CARE

●Early mobilization as pain allows

●Assess results 3 months after surgery, when most post-operative pain will have subsided

●Inform patient that residual pain can be beneficial because protects the joint from excessive strain

It's only denervation. But I like it.The Rolling Stones . 1974

Thank you