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Corresponding author: Pierre Laumonerie, MD, MSc, Department of Orthopaedic Surgery, Hôpital Pierre-Paul Riquet, Place du Docteur Baylac, Toulouse, 31059, France.
Total elbow arthroplasty for the treatment of patients with severe elbow osteoarthritis is associated with postoperative activity limitations and risk of midterm complications. Elbow denervation could be an attractive therapeutic option for young, active patients. The aim of our study was to assess the feasibility of selective total elbow denervation via 2 anteriorly based approaches.
Methods
Selective total elbow denervation was performed in 14 cadaver elbows by 2 fellowship-trained elbow surgeons. Lateral and medial approaches to the elbow were used. The length of skin incisions and the minimum distance between them were noted. The number of articular branches identified and their respective distances from the lateral or medial epicondyle of the humerus were recorded.
Results
The anterolateral and anteromedial approaches allowed for the identification of all mixed and sensory nerves in all 14 cases. The mean number of resultant articular branches per cadaver was 1 for the musculocutaneous nerve, 2 (range, 1–3) for the radial nerve, 1 (range, 1–3) for the posterior cutaneous nerve of the forearm, 2 (range, 1–3) for the ulnar nerve, and 2 (range, 1–3) for the medial antebrachial cutaneous nerve; the collateral ulnar nerve was connected directly to the capsule. The length of the medial and lateral incisions was 15 cm (range, 12–18 cm) and 12 cm (range, 10–16 cm), respectively. The mean minimum distance between the incisions was 7.5 cm (range, 6.7–8.5 cm).
Conclusions
The findings suggest that selective elbow denervation via 2 approaches is feasible.
Clinical relevance
Selective elbow denervation via 2 approaches is feasible. Surgeons should target the articular branches of the musculocutaneous, radial, ulnar, and collateral ulnar nerves, posterior cutaneous nerve of the forearm, as well as medial antebrachial cutaneous nerves when carrying out this procedure.
Symptomatic osteoarthritis (OA) of the elbow is a debilitating disease, affecting up to 3.5% of men over the age of 40 years in the United States alone.
Young patients with primary or post-traumatic OA have a high level of demand on their elbows and, therefore, pose a significant challenge for elbow surgeons.
The primary goals of treatment in these patients are pain relief and restoration of function while preserving the potential for future salvage surgical options. Patients with mild OA who experience pain and stiffness during extreme motion due to impingement may benefit from open or arthroscopic osteocapsular debridement.
For patients with advanced degenerative disease, it may be appropriate to consider arthroplasty options; however, these must be considered salvage options because they are associated with postoperative activity limitations and risk of midterm complications as high as 42%.
Elbow denervation could be an attractive therapeutic option for active patients with severe OA.
Elbow denervation was first described in the late 1940s, and although this procedure provides good outcomes and pain relief, it has not been widely adopted.
We previously published a literature review in an effort to establish the anatomic features of the articular branches (ABs) innervating the elbow joint and the distribution of sensory receptors about its capsule.
The anterior capsule is innervated by a fine plexus of muscular nerve branches, which makes their dissection complex. The transection of these branches may lead to an iatrogenic motor deficit.
Conversely, nociceptive branches arising directly from mixed (radial, ulnar, median, and musculocutaneous nerves) and sensory (medial antebrachial cutaneous nerve [MABC]) nerves have a well-established course about the posterior capsule.
We assumed that denervation techniques (ie, selective nociceptive branches of the nerves) should focus on the posterior capsule but also include nociceptive fibers supplying the anterior capsule.
The aim of our study was to assess the feasibility of TED via 2 approaches: lateral and medial approaches.
Materials and Methods
Cadaveric dissection
Specimens
A convenience sample of 14 fresh cadaveric upper extremities (7 left and 7 right) from 2 men and 7 women, with a median age of 83.7 years (range, 70–104 years), was included. The exclusion criteria were antecedent trauma or a surgical intervention at the level of the arm, elbow, and forearm. Four cadaveric elbows were excluded because of previous surgery or a history of trauma.
Surgical technique
A frequency map of the ABs and sensory receptors innervating the capsuloligamentous structures of the elbow, reported by Laumonerie et al,
provided an anatomic basis for the surgical technique described herein (Fig. 1). Lateral and medial approaches to the elbow were used by 2 specialty-trained elbow surgeons (P.L. and S.R.). The 10 critical steps of the surgical technique for TED are summarized in Table 1. Surgical loops (magnification × 4) and fine microsurgical instruments were used for the dissection of the ABs. The length of skin incisions and the minimum distance between them were noted (Fig. 2). The number of identified nociceptive ABs and their respective distances from the lateral or medial epicondyle of the humerus were recorded. All measurements were recorded by a single observer using calipers (S.R.).
Figure 1Schematic diagram of sensory innervation of the human elbow joint. A Anterior view and B posterior view. Articular ramifications originating from muscular branches were not included. Reprinted with permission from Laumonerie et al.
Figure 2Anterolateral and anteromedial approaches to elbow denervation. A The minimum length (dotted white arrow) between the incisions on the lateral and medial aspects of the elbow was >6.7 cm. B The posterior aspect of the elbow was kept intact.
With the specimen in the supine position, the arm was positioned in abduction and forearm in supination (Fig. 3). An incision with a mean length of 12 cm (range, 9–16 cm) was made along the anterior border of the brachioradialis muscle. The lateral aspect of the biceps brachii was then identified and retracted medially, uncovering the interval between the biceps brachii and brachialis. The musculocutaneous nerve was identified in that interval, and its AB was transected at a mean distance of 2.5 cm (range, 2–3 cm) proximal to the lateral epicondyle. The posterior cutaneous nerve of the forearm (PCNF) was identified at a mean distance of 6 cm (range, 5–7 cm) proximal to the lateral epicondyle in the subcutaneous fat; its posterior branch was resected. The radial nerve was also identified between the brachioradialis laterally and between the biceps brachii and brachialis medially. Dissection of the radial nerve was performed in a proximal-to-distal direction until the aponeurotic edge of the supinator (arcade of Fröhse) was reached; the latter was not incised. The muscular branches of the brachioradialis, extensor carpi radialis brevis and longus, and anconeus muscles arising from the lateral edge of the radial nerve were preserved. The collateral branch(es) of the radial nerves, as named by Wilhelm,
was identified beneath the superficial fascia, running together with the lateral collateral vessels along the dorsal rim of the intermuscular septum. These branches were resected at a mean distance of 7 cm (range, 4–10 cm) from the lateral epicondyle.
Figure 3Anterolateral approach to elbow denervation. A The posterior cutaneous nerve of the forearm (1) was identified with its posterior ABs (2) in the subcutanenous layer. B The musculocutaneous nerve (3) was identified with its cutaneous sensory (4) and articular branches (5); the latter (5) were subsequently resected. C The collateral branch (6) of the radial nerve (7) was identified to be running with the lateral collateral vessels along the dorsal rim of the intermuscular septum. The collateral branch of the radial nerve (6) and a second articular branch (8) were subsequently resected.
In the same position, a 15-cm (range, 12–18 cm) incision was made along the anterior border of the extensor carpi ulnaris muscle, extending proximally and distally along the medial border of the biceps (Fig. 4). The MABC nerve was identified at a mean distance of 7 cm (range, 5–8 cm) from the medial epicondyle of the humerus and dissected in a proximal-to-distal direction. The nerve was elevated from the surrounding subcutaneous fat from a deep level to a superficial level, thereby resecting all ABs and preserving branches innervating the subcutaneous tissue. The median nerve was then dissected at the interval between the biceps brachii and brachialis based on the identification and lateral retraction of the medial border of the bicep brachii. The proximal articular branch was transected at a mean of 1.5 cm (range, 1–2 cm) from the medial epicondyle, whereas other muscular branches were preserved. The ulnar nerve was also dissected and unroofed in a proximal-to-distal direction, with the cutting of all ABs. The ulnar collateral nerve was identified deep to the medial intermuscular septum and superficial to the ulnar nerve; it was then resected at a mean distance of 5 cm (range, 3–7 cm) from the medial epicondyle. The ulnar nerve was then transposed anteriorly, in a subcutaneous fashion, in an effort to avoid complications associated with iatrogenic ulnar nerve instability induced at the time of a surgical intervention.
Figure 4Anteromedial approach to elbow denervation. A The MABC nerve and its ABs (1) were identified on the posteromedial aspect of the basilic vein (2) before resecting the ABs via elevation of the deep portion of the subcutaneous fat layer (star). B The median nerve (3) was dissected as it coursed with the brachial artery (4); only 1 muscular branch (5) destined to the pronator teres was identified. C Wide neurolysis of the ulnar collateral (6) and ulnar nerves (7) was performed before subcutaneous transposition of the ulnar nerve and resection of the ulnar collateral nerve.
The anterolateral and anteromedial approaches allowed for the identification of all mixed and sensory nerves (ie, radial, ulnar, median, musculocutaneous, PCNF, and MABC nerves) in all 14 cases. The mean number of resultant ABs per cadaver was 1 for the musculocutaneous nerve, 2 (range, 1–3) for the radial nerve, 1 (range, 1–3) for the PCNF, 2 (range, 1–3) for the ulnar nerve, and 2 (range, 1–3) for the MABC nerve; the collateral ulnar nerve was connected directly to the capsule. The mean length of the medial and lateral incisions was 15 cm (range, 12–18 cm) and 12 cm (range, 10–16 cm), respectively. The mean minimum length between these latter approaches on the lateral and medial aspects of the elbow was 7.5 cm (range, 6.7–8.5 cm; Fig. 2). In all 14 cadavers, the minimum distance was located at the distal-most aspect of the 2 approaches (at the proximal aspect of the forearm).
Discussion
This study confirmed that selective TED via 2 approaches is a feasible means to selectively denervate the anterior and posterior aspects of the elbow capsule.
Young patients, even those with arthritis, have high expectations when it comes to the function of their upper extremities
; therefore, they pose a challenge for elbow surgeons. Open or arthroscopic osteocapsular debridement is indicated in patients with early OA in whom nonsurgical management has failed. Multiple prior studies have found that open or arthroscopic osteocapsular debridement destroys a large number of mechanoreceptors about the proximal anterior capsule and its associated ligaments (Fig. 1).
We speculated that the loss of mechanoreceptors induces accelerated arthropathy and/or recurrent elbow instability via the abolition of musculoligamentous protective reflex.
for use in cases of post-traumatic osteoarthritis or osteonecrosis in young patients with severe pain. Despite promising midterm results, no other series on TED have been published.
In accordance with Bateman’s TED procedure, we used 2 anterior approaches with a minimum 7.5-cm (range, 6.7–8.5 cm) skin bridge between them to reduce the potential risk of cutaneous necrosis (Fig. 2).
Bateman’s approach also included a third, posterior incision behind the lateral epicondyle to allow the stripping of the undersurface of the anconeus and its neurovascular bundle. We recommend maintaining the integrity of the posterior aspect of the elbow to avoid hindering future posterior approaches necessary for total elbow arthroplasty in cases of TED failure (Fig. 2).
Previous anatomic descriptions of elbow capsular innervation have posited that the lateral epicondylar region is exclusively supplied by the radial nerve and its branches.
pioneered the partial denervation of the lateral humeral epicondyle via 3 successive surgical procedures focused on the radial nerve. The original methodology consisted of neurotomy of the PCNF, lateral collateral branch of the radial nerve, and muscular branch of the anconeus muscle.
Based on our prior investigation, we did not resect branch(es) leading to the anconeus muscle because we consider them as having a proprioceptive function.
To complete the denervation of the anterolateral capsule, we also resected the AB of the musculocutaneous nerve in accordance with Bateman’s original approach. Although this branch is rare (we only identified it in 2 [14%] specimens compared with Bateman’s report of 22%), it did not lead to a longer surgical incision (Fig. 3).
Denervation of the medial epicondylar region was performed via the resection of ABs arising from the ulnar, collateral ulnar, median, and MABC nerves identified.
Bateman’s technique involves the interruption of the ABs of the ulnar and median nerves using an anteromedial approach. One anatomic description also highlighted the contribution of the ulnar, MABC, and median nerves to the medial epicondylar region (Fig. 1).
Bateman identified ABs arising from the median nerve in 11 of 28 cases; this number was higher than the 2 ABs of the median nerve identified among our 14 specimens. We hypothesized that this difference was due to the fact that we only included nociceptive branches and not muscular branches. Given the risk of injury to the brachial artery, we felt that the exposure and subsequent sectioning of the ABs of the median nerve was not justified. We hypothesized that the sectioning of all ABs of the MABC nerve in contact with the superficial edge of the common extensor tendon allows for the preservation of the integrity of cutaneous branches (Fig. 2). However, this study could not assess the potential neurologic deficit that may be associated with this technique. Importantly, transient nerve palsy is the most common complication following arthroscopic debridement, which has been shown to occur in up to 14% of reported series.
This study was subject to the inherent biases associated with cadaveric studies. Total elbow denervation is indicated for patients with a painful degenerative elbow; however, this study did not allow us to predict the clinical outcomes or complications that may occur after the surgery. A diagnostic nerve blockade may be useful to predict the effectiveness of TED with respect to pain relief.
Intraoperative nerve stimulation allows for the guided resection of ABs arising from mixed nerves. Knowledge of the anatomic location—and the related landmarks—of the ABs is essential to avoid postoperative neurologic deficits. Our study consisted of a limited number of specimens, thereby potentially decreasing the reliability of descriptive statistics related to the landmarks used for the identification of the ABs. Furthermore, the dissection may have modified the anatomy, leading to a distortion of the study’s findings.
The data suggest that nociceptive denervation of the elbow via 2 approaches is feasible. Denervation of the elbow joint might be an attractive alternative to total elbow arthroplasty for young patients with advanced OA. Additional studies are needed to determine the safety and effectiveness of this method in terms of pain relief.
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