Functional and patient-reported outcome of partial wrist denervation versus the Mannerfelt wrist arthrodesis in the rheumatoid wrist

Introduction

Wrist arthrodesis offers high success rates in patients with rheumatoid arthritis; however, loss of residual mobility may cause unnecessary disability. This makes wrist denervation an appealing alternative. However, there is a distinct lack of patient-reported outcome measure studies comparing these two procedures. The aim of this study was to report any change in function, pain and satisfaction following wrist arthrodesis compared to denervation in a single surgeon series of rheumatoid patients.

Patients and methods

The results of 16 wrist arthrodesis in 15 patients and 14 partial (PIN) wrist denervations in 13 patients were compared with a mean follow-up period of 39 and 22 months, respectively. The primary outcome measures were the same for both groups and included the validated patient-rated wrist evaluation questionnaire and a satisfaction questionnaire.

Results

Wrist arthrodesis significantly improved the mean total pain and functional outcome scores by 54 and 36 %, respectively, at the time of follow-up. Wrist denervation patients also reported significant improvements of 44 and 42 % in total pain and functional outcomes, respectively; 87 % reported being very satisfied with their wrist arthrodesis procedure compared to 78 % in the denervation group. No statistically significant difference in response between the groups was observed in this series of patients.

Conclusions

Both procedures enjoyed favourable results amongst patients with excellent satisfaction outcomes. PIN denervation is a simple procedure with low complication rates and we therefore consider it a valid alternative to more difficult treatment options, such as partial or total wrist arthrodesis.     

近排腕骨切除加骨间掌、背侧神经切断治疗退行性腕关节炎

目的评价近排腕骨切除加骨间掌、背侧神经切断术治疗退行性腕关节炎的疗效。方法1996年3月-2002年12月,对30例退行性腕关节炎行近排腕骨切除和腕部骨间掌、背侧神经切断术。术后测量腕关节的活动度、握力和疼痛程度,腕关节功能评定采用Krimmer评分法。术后拍摄腕关节X线正侧位片,了解腕关节骨性改变情况。结果术后随访8~66个月。腕关节屈伸活动度平均为70°(健侧为126°),尺桡偏平均为36°(健侧为66°);握力为25kg(健侧为46kg);疼痛值为32(术前为73);腕关节功能评分为70。腕关节X线片示,术后3例腕关节形成关节炎。结论近排腕骨切除加骨间掌侧及背侧神经切断可保留腕关节部分功能,减轻腕关节疼痛,是治疗退行性腕关节炎的有效手段。     

Innervation of the wrist joint and surgical perspectives of denervation

PURPOSE: Because our experience with the techniques used in denervation surgery of the wrist joint often has proven insufficient in treating chronic pain we conducted an anatomic study to clarify the exact contributions of the nerves supplying the wrist joint. Our goal was to reveal all periosteal and capsular nerve connections and if necessary adjust our technique used in denervation surgery. METHODS: Innervation of the wrist joint was investigated by microdissection and histologic examination of 18 human wrists. An acetylcholinesterase method was used to identify the nerves, both in whole-mount preparations and in sections. RESULTS: We found that the main innervation to the wrist capsule and periosteal nerve network came from the anterior interosseous nerve, lateral antebrachial cutaneous nerve, and posterior interosseous nerve. The palmar cutaneous branch of the median nerve, the deep branch of the ulnar nerve, the superficial branch of the radial nerve, and the dorsal branch of the ulnar nerve also were found to have connections with the capsule. The periosteal nerve branches did not appear to play a major role in the innervation of the capsule and ligaments; here the specific articular nerve branches proved more important. The posterior and medial antebrachial cutaneous nerves did not connect to the wrist capsule or periosteum but rather terminated in the extensor and flexor retinaculum. CONCLUSIONS: Based on our findings we propose to denervate the wrist by making 2 incisions. With one palmar and one dorsal incision it should be possible to disconnect the periosteum from the capsule and interrupt the majority of the capsular nerve branches.     

Partial dorsal wrist denervation: resection of the distal posterior interosseous nerve

Chronic dorsal wrist pain limits hand function. This article details preoperative diagnostic nerve block and patient selection criteria, operative technique for partial dorsal wrist denervation, and results of nonoperative as well as operative treatment for pain transmitted via the distal posterior interosseous nerve. More than 90% of the patients treated with the partial dorsal wrist denervation procedure achieved subjective relief of pain and objective improvement in wrist function, with 83% returning to work. Function did not improve in the group with fractures associated with reflex sympathetic dystrophy, and three of the four patients with rotary subluxation of the scaphoid subsequently required wrist fusion.     

Analgesic benefit,functional outcome,and patient satisfaction after partial wrist denervation

Partial wrist denervation is a useful palliative procedure for chronic wrist pain when reconstructive procedures are not feasible or desirable. We reviewed 19 patients who had 20 isolated anterior and posterior interosseous neurectomies with no previous or concurrent wrist surgery in a 5-year period at our institution. At an average of 2.5 years postoperatively, 80% of patients reported a decrease in pain, 45% reported normal or increased grip strength, and 73% of employed patients had returned to work. Three patients required additional procedures for pain relief (2 arthrodesis, 1 radial styloidectomies). Failure tended to occur in the first postoperative year. Poor preoperative range of motion and workers' compensation status were predictive of failure. Failure also occurred in the single patient with rheumatoid arthropathy. Two patients had subsequent arthrodeses. There were no complications related to the surgery. Overall, 85% of patients reported satisfaction with this procedure; 90% retrospectively would choose the same treatment for their chronic wrist pain. Partial denervation of the wrist via the anterior and posterior interosseous nerves is a technically easy procedure and may provide pain relief sufficient to markedly delay the need for more extensive salvage procedures in patients with wrist arthritis.     

Chronic wrist pain: indications for wrist arthroscopy

Although arthroscopy represents a new and dynamic diagnostic technique for evaluating the wrist, specific indications for arthroscopic intervention in the wrist are not defined. To place this technique in perspective, we review our experience with 54 consecutive arthroscopies of the radiocarpal and midcarpal joints in 53 patients with chronic wrist pain. On the basis of this review, we believe arthroscopy is indicated for the diagnosis of wrist pain of longer than 3 months' duration. Defects of the triangular fibrocartilage and lesions of the articular cartilage, including loose bodies, are detectable and easily treated with wrist arthroscopy.