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To analyze patient-reported outcomes and range of motion in a cohort of patients who underwent wrist denervation for advanced wrist osteoarthritis. We hypothesized that improvements in pain and function would be seen with preserved range of motion.
Methods
Thirty patients underwent wrist denervation for symptomatic stage 1–4 scapholunate advanced collapse (SLAC) arthritis. Patient-Rated Wrist Evaluation, Quick Disabilities of the Arm, Shoulder, and Hand score, and range of motion measurements were assessed preoperatively and at final follow-up.
Results
The mean follow-up duration was 47 months (range, 24–92 months). The mean age at surgery was 65 years, and 96% of the patients were men. The dominant hand was involved in 66% of cases. The SLAC grades of patients involved were as follows: 10% (n = 3) grade 1, 27% (n = 8) grade 2, 60% (n = 18) grade 3, and 3% (n = 1) grade 4. Two patients required conversion to a wrist fusion and were considered failures. In the remaining 28 patients, the mean Patient-Rated Wrist Evaluation total score decreased 22 points (82.4 to 60.9) and the mean Quick Disabilities of the Arm, Shoulder, and Hand score decreased 8 points (32.4 to 24.8). Total arc of wrist flexion-extension showed an average 5° improvement.
Conclusions
This method of wrist denervation was a viable salvage option for patients with symptomatic SLAC wrist osteoarthritis to preserve motion, decrease pain, and increase function with a low absolute failure rate at mid- to long-term follow-up.
Post-traumatic wrist osteoarthritis from scapholunate advanced collapse (SLAC) is a painful pathological condition often encountered by hand surgeons. Patients can be asymptomatic early in the disease process and present with more advanced radiographic and clinical disease at a later stage.
Treatment outcomes of 4-corner arthrodesis for patients with advanced carpal collapse: an average of 4 years’ follow-up comparing 2 different plate types.
Patients who develop persistent pain and functional limitation unrelieved by nonoperative measures are often treated with denervation, partial or total wrist arthrodesis, or implant arthroplasty.
Motion-preserving options are often preferable in younger, active patients with well-maintained wrist motion, particularly involving their dominant hand.
Denervation, as originally described by Wilhelm in 1966, was intended as a motion-sparing procedure focused primarily on alleviating pain and secondarily on improving function.
Articular denervation and its anatomical foundation. A new therapeutic principle in hand surgery. On the treatment of the later stages of lunatomalacia and navicular pseudarthrosis. Article in German.
Subsequent anatomical studies have described the capsular afferent pain fiber innervation of the wrist, leading investigators to try and improve upon this initial description.
Proponents of denervation emphasize the minimal morbidity associated with the surgical procedure itself, a rapid return to activity, preservation of additional salvage options in the future, and a reported improvement of pain in roughly 75% of patients.
While the success of this operation has been difficult to demonstrate secondary to variation in techniques and individual nerves managed, clinical studies have traditionally focused on pain relief, satisfaction, and range of motion measurements. Formal use of widely accepted patient-reported outcome scores has been scarce. While literature exists demonstrating the pain improvement and satisfaction with “partial” and “complete” wrist neurectomies, data are lacking on prospectively evaluated patients with preoperative baseline patient-reported outcomes measures (PROMs) such as the Patient-Rated Wrist Evaluation (PRWE) and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH).
The purpose of this study was to assess the changes in the range of motion and 2 widely used PROMs (PRWE and QuickDASH) at midterm follow-up for patients with symptomatic SLAC wrist arthritis who underwent wrist denervation. We hypothesized that there would be notable improvements in both PROMs.
Methods
A single hand surgeon at a large academic tertiary center retrospectively reviewed 30 patients who underwent wrist denervation. Patients were included in this study if they had symptomatic wrist arthritis (SLAC 1–4, see Table 1) and had failed a course of nonoperative therapy including physical therapy, bracing, and injections.
Treatment outcomes of 4-corner arthrodesis for patients with advanced carpal collapse: an average of 4 years’ follow-up comparing 2 different plate types.
Exclusion criteria included age <18 years, prior ipsilateral wrist surgery, simultaneous cointerventions such as carpal tunnel release, and a total arc of wrist motion less than 40°. In this last group, a wrist arthrodesis was performed. The period of study was March 8, 2012, to March 24, 2017. During this period, there were approximately 10 other patients surgically treated for symptomatic SLAC wrist arthritis. Five patients who had simultaneous cointerventions (carpal tunnel release [n = 2], first dorsal compartment release, extensor tenosynovectomy, and volar ganglion excision) were excluded. Three patients chose a different option based on preoperative counseling and a lack of long-term data on the proposed denervation procedure; choosing to undergo a proximal row carpectomy. One patient had marked stiffness and underwent a total wrist arthrodesis. One patient who had a denervation was lost to follow-up. The study was approved by the institutional review board.
Patient-reported outcomes measures, including the PRWE and QuickDASH, as well as the range of motion measurements (wrist flexion, extension), were preoperatively obtained for all patients and repeated at the final follow-up (minimum of 2 years for outcome scores; 1–72 months, average 15.2 months, for range of motion). Patient-reported outcomes measures not obtained in the clinic at the last follow-up were obtained by mail. A goniometer with 5° intervals was used to measure motion. Descriptive statistics and t tests for continuous variables were performed with an α value of 0.05 set as significant.
Surgical technique
Our denervation procedure was a slight modification of the technique described by Braga-Silva et al.
The radial artery was exposed through a 4-cm longitudinal incision over the volar radial aspect of the distal forearm, just proximal to the wrist flexion crease (Fig. 1). The venae comitantes were ligated, and then 1 cm of adventitia was stripped from around the radial artery. As described by Braga-Silva et al,
this was necessary to cut the 2 terminal branches of the lateral antebrachial nerve and radial nerve, which accompanied the radial artery and reached the radial side of the wrist. Through this incision, a gloved finger was used to sweep deep to the radial sensory and lateral brachial cutaneous nerves laterally to avulse any afferent branches that were communicating with the wrist joint. The palmar cutaneous branch of the median nerve was then isolated, and a thorough neurolysis was completed to a point about 2 cm distal to the wrist joint, transecting all branches communicating with the wrist joint (Fig. 2).
Figure 1Volar surgical incisions over the radial and ulnar aspects of the wrist.
A second, similar incision was made over the volar ulnar aspect of the wrist, and the venae comitantes were ligated, followed by 1 cm of adventitial stripping of the ulnar artery (Fig. 1). Next, a 5-cm dorsal incision was made directly over the fourth extensor compartment (Fig. 3), and a 1-cm section of the posterior interosseous nerve (PIN) and anterior interosseous nerve (AIN) were both excised. Their accompanying vessels were ligated, as described by Berger.
The AIN was transected through a dorsal wound, as it lay close to the PIN on the opposite side of the interosseous membrane. It was transected before it penetrated the pronator quadratus to innervate the anterior joint capsule.
Again, sweeping under the radial sensory nerve branches with a gloved finger was performed, disrupting any small branches to the wrist joint (Fig. 4). A subcutaneous flap was developed ulnarly, and branches of the dorsal sensory portion of the ulnar nerve were identified. These branches were retracted bluntly, and afferent branches from the wrist joint, including the distal radioulnar joint branch contributions, were transected (Fig. 5).
Figure 4Gloved finger sweeping between radial superficial sensory nerve (black arrow) and branches to the wrist capsule.
After wound closure, a bulky soft dressing was applied, incorporating a volar plaster slab. This dressing was removed at 3 days, and the patient began unrestricted motion and light activities. Sutures were removed at a 2-week postoperative visit, and the patient was released to unrestricted activity as tolerated. No formal hand therapy was prescribed or used.
Results
Thirty patients participated in this study over 6 years. The mean age was 65 years (range, 49–75 years). Twenty-nine of the 30 patients were men (97%), and the dominant wrist was involved in 20 of the 30 cases (67%). All patients included in the study had radiographic SLAC wrist arthritis grade 1–4 (Table 1). Mean follow-up was 47 months (range, 24–92 months).
Preoperatively, patients reported a mean PRWE pain score of 32.9 (range, 21–47; SD, 7.4), which significantly decreased to 24.4 (range, 0–50; SD, 13.5) postoperatively (P < .05). Mean PRWE functional scores also improved from 49.5 (range, 8–83; SD, 17.1) to 36.6 (range, 0–100; SD, 30.4) (P < .05). Mean total PRWE score significantly improved from 82.4 (range, 40–130; SD, 22.4) to 60.9 (range, 0–150; SD, 42.7) (P < .05). Mean QuickDASH scores also significantly improved from 32.4 (range, 20–46; SD, 6.7) preoperatively to 24.8 (range, 11–44; SD, 8.3) postoperatively (P < .05) (Table 2). Range of motion was similar between the 2 time points, with a preoperative average total arc of motion of 90° (range, 50–130; SD, 22) that improved to 95° postoperatively (range, 50–130; SD, 19; P = .35).
Table 2Average Patient-Reported Outcome Scores and Arc of Motion for Patients Undergoing Modified Wilhelm Wrist Denervation
Outcomes
Preoperative
Postoperative
Delta
P value
PRWE pain
32.9
24.4
8.5
<.05
PRWE function
49.5
36.6
13
<.05
PRWE total (combined)
82.4
60.9
21.5
<.05
QuickDASH
32.4
24.8
7.6
<.05
Total arc of motion (degrees)
90
95
-5
.35
PRWE, Patient-Rated Wrist Evaluation; QuickDASH, Quick Disabilities of the Arm, Shoulder, and Hand Score.
Of the 30 patients, 2 patients underwent subsequent revision surgery to a total wrist arthrodesis at an average of 12 months after surgery (Stage 4 and Stage 3 SLAC arthritis). Wrist, rather than 4-corner, arthrodesis was chosen in the patient with Stage 3 SLAC wrist because of the patient’s desire for a definitive procedure and surgeon preference. One of these failures developed a nonunion and was scheduled to undergo revision wrist arthrodesis. Two patients experienced hypersensitivity over the dorsum of their hand that spontaneously resolved over 2 and 3 months, respectively, without further intervention. No infection, wound, or other complications were seen.
Discussion
Wrist osteoarthritis can manifest with pain, instability, and/or stiffness. In patients with symptomatic arthritis and preserved range of motion, denervation has been favored by some authors.
Our study demonstrates objective improvement from preoperatively assessed PROMs (PRWE, QuickDASH). Both instruments have been shown to be responsive, reliable, and valid instruments to assess pain and function involving wrist disorders.
Construct validity, reliability, response rate, and association with disease activity of the quick disabilities of the arm, shoulder and hand questionnaire in the assessment of rheumatoid arthritis.
At mid- to long-term follow-up, additional surgical intervention was uncommon. Of course, the infrequency of later surgery could reflect other socioeconomic factors, or patient reluctance to undergo additional surgery, rather than a measure of successful outcomes in the remaining patients. Of importance, motion across this cohort was also preserved.
Prior literature focusing on PROMs has primarily been retrospective and has focused on self-reported pain improvement following denervation.
published a prospective series of 37 patients who underwent partial (AIN and PIN) denervation. Patients demonstrated a significant decrease in median pain scores and improved activity at a mean follow-up of 18 months. Riches et al
prospectively compared PIN partial denervation to wrist arthrodesis in 22 patients with rheumatoid arthritis and demonstrated similar rates of pain relief with decreased complications and decreased rates of functional impairment.
Although our study focuses on patients with symptomatic SLAC arthritis and uses a more complete denervation technique, our results confirm a significant reduction in pain and significant improvement in function while preserving motion. Prior literature has also suggested a minimal clinically reported difference of approximately 7–14 points for the QuickDASH and 14–24 points for the PRWE among atraumatic upper extremity conditions.
Psychometric properties of the shortened disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and Numeric Pain Rating Scale in patients with shoulder pain.
The difference in preoperative and postoperative PRWE and QuickDASH scores in our study was 21.5 and 7.6 points, respectively. So, while statistically significant improvement was noted in both measures, clear clinically relevant improvement may not have occurred. Of importance, limitations in QuickDASH sensitivity may lead to overestimation of clinical significance at the lower bounds of the previously cited minimal clinically important difference range of 7–14.
It is possible that both QuickDASH and PRWE may be insensitive to the changes induced by denervation. In other words, neither of these outcome measures may be the correct instruments for measuring outcomes for this particular procedure. Therefore, it is quite possible that this denervation procedure did not result in a clinically relevant improvement or, if it did, that improvement was only incrementally above what had been established as the minimum. Given that there is a fair amount of heterogeneity with respect to reported denervation procedures, we cannot claim the superiority of this particular technique. Patients clearly had some residual disability.
Comparison to another popular, effective intervention, such as a 4-corner arthrodesis, would likely give more valuable information about the true clinical value of denervation with respect to clinically relevant improvement in pain, function, and range of motion. In fact, it is quite possible that some portions of the procedure advocated by Braga-Silva et al,
such as adventitial stripping of the radial and/or ulnar arteries, are likely unnecessary to achieve objective improvements in pain and function. A more limited denervation approach has been shown to yield successful results.
As the transection of this branch has not been described in the literature, we did not include it as part of the procedure we performed based on the published description by Braga-Silva et al.
Perhaps transection of this branch may produce better pain relief. Nonetheless, we feel that this study provides objective improved results with validated PROMs, to which other denervation techniques may now be compared.
Limitations to this study exist. The primary limitation is the lack of a control group and the fact that the study cohort itself is small despite a 6-year collection period (2012–2017). Second, a single-surgeon study may limit generalizability, even though a single surgeon with a consistent technique can help limit confounding by other variables. Additionally, interpretation of clinical relevance is limited by the potential lack of responsiveness of the PRWE and QuickDASH for denervation, despite statistical significance. In many patients, PROMs were obtained by mail after the range of motion measurements were obtained in the clinic. In 5 patients, however, digital photographs of maximal wrist motion were returned by email at the same time as the PROMs. Although we recognize that this is suboptimal from a consistency perspective and the range of motion may have changed slightly in the interim, the primary objective of the study was to evaluate pain and function.
In summary, our results demonstrate that a modified Wilhelm wrist denervation is a good procedure for patients with symptomatic SLAC wrist who have failed nonoperative treatment. Preserved motion, no postoperative immobilization or supervised therapy, and the ability to preserve salvage procedure options in the future make it appealing.
Improvements in total PRWE and QuickDASH scores were observed, although it is unclear whether these improvements were truly clinically relevant. The average range of motion was preserved, and additional surgery was seen in only 2 patients, despite the latter finding being an unreliable indicator of success. Although our cohort was limited to patients with SLAC arthritis, we feel that it may also be appropriate in patients with wrist arthritis from other causes and is worthy of being studied further.
References
Smet L.D.
Degreef I.
Robijns F.
Truyen J.
Deprez P.
Salvage procedures for degenerative osteoarthritis of the wrist due to advanced carpal collapse.
Treatment outcomes of 4-corner arthrodesis for patients with advanced carpal collapse: an average of 4 years’ follow-up comparing 2 different plate types.
Articular denervation and its anatomical foundation. A new therapeutic principle in hand surgery. On the treatment of the later stages of lunatomalacia and navicular pseudarthrosis. Article in German.
Construct validity, reliability, response rate, and association with disease activity of the quick disabilities of the arm, shoulder and hand questionnaire in the assessment of rheumatoid arthritis.
Psychometric properties of the shortened disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and Numeric Pain Rating Scale in patients with shoulder pain.
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