DENERVATION

OF HAND JOINTS


Pulvertaft Hand Centre

Clinical Teaching for Fellows
September 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: 225230.

Lora PD. First carpometacarpal joint denervation: anatomy and surgical technique. Tech Hand Up
Extrem Surg. 2003;7:26-31.
Lora P, Dury M, Marin Braun F, Dekka 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