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.

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.

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.

Surgical denervation of the thumb CMC joint: anatomy, technique.

Surgical denervation of the thumb carpometacarpal (CMC) joint is a theoretical surgical option for thumb CMC arthritis. Some authors have described the nerve branches of thumb CMC joint. We present the innervation of the thumb CMC joint (thenar - recurrent - branch of median nerve, palmar branch of median nerve, superficial branch of radial nerve, lateral cutaneous nerve of forearm, deep branch of ulnar nerve) and the surgical techniques to achieve optimal denervation of this joint. While the results have been disappointing, this technique may be combined with conservative surgical procedures (synovectomy, ligament reconstruction) and it allows more invasive surgery in the future if necessary.

Selective Thumb Carpometacarpal Joint Denervation for Painful Arthritis: Clinical Outcomes and Cadaveric Study.

PURPOSE: To determine the innervation pattern to the thumb carpometacarpal (CMC) joint and assess the safety and efficacy of selective joint denervation for the treatment of pain and impairment associated with thumb CMC arthritis. METHODS: Cadaveric dissections were performed in 10 fresh upper extremities to better define the innervation patterns to the CMC joint and guide the surgical approach for CMC joint denervation. Histologic confirmation of candidate nerves was performed with hematoxylin and eosin staining. Results from a series of 12 patients with symptomatic thumb CMC arthritis who underwent selective denervation were retrospectively evaluated to determine the safety and efficacy of this treatment approach. Differences in preoperative and postoperative measurements of grip and key-pinch strength as well as subjective reporting of symptoms were compared. RESULTS: Nerve branches to the thumb CMC joint were found to arise from the lateral antebrachial cutaneous nerve (10 of 10 specimens), the palmar cutaneous branch of the median nerve (7 of 10 specimens), and the radial sensory nerve (4 of 10 specimens). With an average follow-up time of 15 months, 11 of 12 patients (92%) reported complete or near-complete relief of pain. Average improvements in grip and lateral key-pinch strength were 4.1 ± 3.0 kg (18% ± 12% from baseline) and 1.7 ± 0.5 kg (37% ± 11% from baseline), respectively. One patient experienced the onset of new pain consistent with a neuroma that resolved with steroid injection. All patients were released to light activity at 1 week after surgery, and all activity restrictions were lifted by 6 weeks after surgery. CONCLUSIONS: Selective denervation of the CMC joint is an effective approach to treat pain and alleviate impairment associated with CMC arthritis. The procedure is well tolerated, with faster recovery as compared with trapeziectomy. Branches arising from the lateral antebrachial cutaneous nerve, palmar cutaneous branch of the median nerve, and radial sensory nerve can be identified and resected with a single-incision Wagner approach. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Emerging Technologies in Upper Extremity Surgery: Polyvinyl Alcohol Hydrogel Implant for Thumb Carpometacarpal Arthroplasty and Processed Nerve Allograft and Nerve Conduit for Digital Nerve Repairs.

In the field of upper extremity surgery there are myriad new and developing technologies. The purpose of this article is to highlight a few of the most compelling new technologies and review their background, indications for use, and most recently reported outcomes in clinical practice.

First Carpometacarpal Joint Denervation for Primary Osteoarthritis: Technique and Outcomes.

BACKGROUND: First carpometacarpal (CMC) joint osteoarthritis (OA) is commonly encountered in clinical practice. The preferred surgical option when conservative therapy fails varies with the stage and nature of the disease. Denervation of the first CMC joint is a relatively new procedure for managing stable thumb CMC joint OA. Our objective was to review our experience and surgical technique with first CMC joint denervation surgery. METHODS: All patients who underwent first CMC joint denervation surgery from January 2015 through September 2017 were retrospectively identified. Before undergoing surgical CMC denervation, patients received a joint block at the first CMC joint with 0.25% bupivacaine. Only patients with a good response to injection were selected for surgical denervation. Patient demographics, preoperative and postoperative pain scores using a numeric rating scale, and grip strength using the Jamar Hydraulic Hand Dynamometer were analyzed. RESULTS: Of 10 patients (13 hands) with CMC joint OA, 8 patients (11 hands) met the inclusion criteria. Patients' average grip strength improved significantly after the procedure (from 38.4 ± 26.7 foot/lb to 50.2 ± 27.6 foot/lb; P = 0.007). The numeric rating scale pain score improved significantly from 7.8 ± 2.4 to 2.4 ± 1.8 (P < 0.001). Seven of 8 patients reported satisfaction with surgery. There were 2 complications. CONCLUSIONS: First CMC joint denervation provided good pain relief and improvement in grip strength in patients with thumb CMC joint OA. This minimally invasive technique proved to be a good option for providing optimal pain control and improvement in strength with minimal and mild complications.

Thumb carpometacarpal joint denervation for primary osteoarthritis: A prospective study of 31 thumbs.

We present the results of a prospective study of 31 thumbs in 30 patients affected by primary osteoarthritis at the thumb carpometacarpal (CMC1) joint who were treated with denervation of the involved joint. For every operated hand, the Kapandji score, key-pinch strength, grip strength and pain on a visual analogue scale were evaluated preoperatively and postoperatively at 2 weeks, 6 weeks, 3 months, 6 months and 1 year. The patients' satisfaction was determined. The Kapandji score and key-pinch strength improved significantly in all patients. Grip strength improved significantly in 10 hands. Pain was reduced in all cases. Nevertheless, 6 patients were dissatisfied with the operation. Of these 6 patients, 4 had stage IV arthritis in the TMC and scaphotrapeziotrapezoid joints of the thumb. Thumb CMC denervation appears to reduce pain at 1 year with an overall improvement in key-pinch strength. However, patients with stage IV CMC arthritis were not satisfied with the outcome of the procedure.

Ultrastructure and innervation of thumb carpometacarpal ligaments in surgical patients with osteoarthritis.

BACKGROUND: The complex configuration of the thumb carpometacarpal (CMC-1) joint relies on musculotendinous and ligamentous support for precise circumduction. Ligament innervation contributes to joint stability and proprioception. Evidence suggests abnormal ligament innervation is associated with osteoarthritis (OA) in large joints; however, little is known about CMC-1 ligament innervation characteristics in patients with OA. We studied the dorsal radial ligament (DRL) and the anterior oblique ligament (AOL), ligaments with a reported divergent presence of mechanoreceptors in nonosteoarthritic joints. QUESTIONS/PURPOSES: This study's purposes were (1) to examine the ultrastructural architecture of CMC-1 ligaments in surgical patients with OA; (2) to describe innervation, specifically looking at mechanoreceptors, of these ligaments using immunohistochemical techniques and compare the AOL and DRL in terms of innervation; and (3) to determine whether there is a correlation between age and mechanoreceptor density. METHODS: The AOL and DRL were harvested from 11 patients with OA during trapeziectomy (10 women, one man; mean age, 67 years). The 22 ligaments were sectioned in paraffin and analyzed using immunoflourescent triple staining microscopy. RESULTS: In contrast to the organized collagen bundles of the DRL, the AOL appeared to be composed of disorganized connective tissue with few collagen fibers and little innervation. Mechanoreceptors were identified in CMC-1 ligaments of all patients with OA. The DRL was significantly more innervated than the AOL. There was no significant correlation between innervation of the DRL and AOL and patient age. CONCLUSIONS: The dense collagen structure and rich innervation of the DRL in patients with OA suggest that the DRL has an important proprioceptive and stabilizing role. CLINICAL RELEVANCE: Ligament innervation may correlate with proprioceptive and neuromuscular changes in OA pathophysiology and consequently support further investigation of innervation in disease prevention and treatment strategies.

Wagner approach for first carpometacarpal joint denervation.

First carpometacarpal joint osteoarthritis is one of the most common conditions hand surgeons have to deal with. In this article, a more radical technique for joint denervation is presented as a treatment for painful degenerative or posttraumatic osteoarthritis. Moreover, a preliminary report of 18 cases treated with this technique is presented to support its benefits.

Ulnar nerve component to innervation of thumb carpometacarpal joint.

PURPOSE: Thumb carpometacarpal (CMC) joint arthritis is one of the most common problems addressed by hand surgeons. The gold standard of treatment for thumb CMC joint arthritis is trapeziectomy, ligament reconstruction and tendon interposition. Denervation of the thumb CMC joint is not currently used to treat arthritis in this joint due to the failure of the procedure to yield significant symptomatic relief. The failure of denervation is puzzling, given that past anatomic studies show the radial nerve is the major innervation of the thumb CMC joint with the lateral antebrachial nerve and the median nerve also innervating this joint. Although no anatomic study has ever shown that the ulnar nerve innervates the CMC joint, due to both the failure of denervation and the success of arthroscopic thermal ablation, we suspect that previous anatomic studies may have overlooked innervation of the thumb CMC joint via the ulnar nerve. METHODS: We dissected 19 formalin-preserved cadaveric hand-to-mid-forearm specimens. The radial, median and ulnar nerves were identified in the proximal forearm and then followed distally. Any branch heading toward the radial side of the hand were followed to see if they innervated the thumb CMC joint. RESULTS: Eleven specimens (58%) had superficial radial nerve innervation to the thumb CMC joint. Nine specimens (47%) had median nerve innervation from the motor branch. Nine specimens (47%) had ulnar nerve innervation from the motor branch. CONCLUSIONS: We believe this is the first study to demonstrate that the ulnar nerve innervates the thumb CMC joint This finding may explain the poor results seen in earlier attempts at denervation of the thumb CMC, but the more favorable results with techniques such as arthroscopy with thermal ablation.

Preserving the superficial branch of the radial nerve during carpometacarpal and metacarpophalangeal joint arthroscopy: an anatomical study.

BACKGROUND: The superficial branch of the radial nerve (SBRN) is potentially at risk during thumb carpometacarpal (TCM) or thumb metacarpophalangeal (TMP) joint arthroscopy. The aim of this anatomical study was to describe the different branching patterns of the SBRN and to optimize positioning of portals during TCM and TMP arthroscopy. METHODS: The SBRN was dissected in 30 forearms. Three branches of the nerve (SR1, SR2, and SR3) were recorded and distances between SBRN branches and portals used for carpometacarpal (TCM) and metacarpophalangeal (TMP) joints of the thumb arthroscopy were measured. Three main portals were used for TCM joint arthroscopy. These portals were an ulnar portal (1-U), a radial portal (1-R), and an accessory portal (D-2). A radial metacarpophalangeal (MCP-rad) and an ulnar metacarpophalangeal (MCP-uln) portal were used for TMP joint arthroscopy. RESULTS: In 24 cases (80%), the 1-R portal was inserted radially (volar) to SR3 at a mean distance of 4.8 mm (0-8). In the remaining six cases (20%) when 1-R portal was inserted ulnar (dorsal) to SR3, the distance was less than 2 mm in all cases. SR3 was always far from the 1-U portal at a mean 13 mm (7-22). The D-2 portal was always close to SR2-D1 at a mean distance of 1.7 mm (0-6). The distance from SR2-D2 and D-2 portal was also inferior by 5 mm. At the level of the metacarphalangeal joint of the thumb, the MCP-rad portal was always situated dorsally and very close to SR3, at a mean distance of 1 mm (0-5). The MCP-uln portal was also situated dorsal to SR2-D1 at a mean distance of 3.7 mm (1.5-6.5). CONCLUSION: The results of this anatomical study confirm actual reported findings about the SR2 and SR3 branches. These two branches of the SBRN are the most at risk of injury during TCM and TMP joint arthroscopy. According to our measurements, the 1-U portal is a safer portal than 1-R and D-2 portal for TCM arthroscopy and should be preferred for surgery necessitating only one portal. Concerning TMP arthroscopy, the SBRN appears less at risk of injury when using a MCP-uln portal and safer than MCP-rad which is at risk at less than 5 mm from the extensor pollicis longus tendon.