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Total Denervation of the Elbow: Cadaveric Feasibility Study

      Purpose

      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.

      Key words

      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.
      • Adla D.N.
      • Stanley D.
      Primary elbow osteoarthritis: an updated review.
      ,
      • Antuna S.A.
      • Morrey B.F.
      • Adams R.A.
      • O’Driscoll S.W.
      Ulnohumeral arthroplasty for primary degenerative arthritis of the elbow: long-term outcome and complications.
      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.
      • Sears B.W.
      • Puskas G.J.
      • Morrey M.E.
      • Sanchez-Sotelo J.
      • Morrey B.F.
      Posttraumatic elbow arthritis in the young adult: evaluation and management.
      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.
      • Sears B.W.
      • Puskas G.J.
      • Morrey M.E.
      • Sanchez-Sotelo J.
      • Morrey B.F.
      Posttraumatic elbow arthritis in the young adult: evaluation and management.
      Open and arthroscopic procedures provide good short- to midterm outcomes in younger patients with moderate OA.
      • Sears B.W.
      • Puskas G.J.
      • Morrey M.E.
      • Sanchez-Sotelo J.
      • Morrey B.F.
      Posttraumatic elbow arthritis in the young adult: evaluation and management.
      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%.
      • Sears B.W.
      • Puskas G.J.
      • Morrey M.E.
      • Sanchez-Sotelo J.
      • Morrey B.F.
      Posttraumatic elbow arthritis in the young adult: evaluation and management.
      ,
      • Siala M.
      • Laumonerie P.
      • Hedjoudje A.
      • Delclaux S.
      • Bonnevialle N.
      • Mansat P.
      Outcomes of semiconstrained total elbow arthroplasty performed for arthritis in patients under 55 years old.
      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.
      • Bateman J.E.
      Denervation of the elbow for the relief of pain; a preliminary report.
      Some authors feel that total elbow denervation (TED) is impossible.
      • Cheung E.V.
      • Steinmann S.P.
      Surgical approaches to the elbow.
      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.
      • Laumonerie P.
      • Tiercelin J.
      • Tibbo M.E.
      • et al.
      Sensory innervation of the human elbow joint and surgical considerations: a systematic review.
      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.
      • De Kesel R.
      • Van Glabbeek F.
      • Mugenzi D.
      • et al.
      Innervation of the elbow joint: Is total denervation possible? A cadaveric anatomic study.
      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.
      • Laumonerie P.
      • Tiercelin J.
      • Tibbo M.E.
      • et al.
      Sensory innervation of the human elbow joint and surgical considerations: a systematic review.
      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.
      • Laumonerie P.
      • Tiercelin J.
      • Tibbo M.E.
      • et al.
      Sensory innervation of the human elbow joint and surgical considerations: a systematic review.
      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,
      • Laumonerie P.
      • Tiercelin J.
      • Tibbo M.E.
      • et al.
      Sensory innervation of the human elbow joint and surgical considerations: a systematic review.
      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 thumbnail gr1
      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.
      • Laumonerie P.
      • Tiercelin J.
      • Tibbo M.E.
      • et al.
      Sensory innervation of the human elbow joint and surgical considerations: a systematic review.
      Table 1The 10 Key Steps of Selective TED
      1Anterolateral approach
      2Identification/resection of the posterior branch of the PCNF
      3Identification/resection of AB of the musculocutaneous nerve
      4Identification/resection of the ABs of the radial nerve
      5Anteromedial approach
      6Blind resection of the AB of the MABC nerve
      7Identification of the muscle (conservation) and articular (resection) branches of the median nerve
      8Wide neurolysis of the ulnar nerve with the resection of its ABs
      9Anterior transposition of the ulnar nerve
      10Identification/resection of the ABs of the ulnar nerve
      Figure thumbnail gr2
      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.

      Anterolateral approach

      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,
      • Wilhelm A.
      Tennis elbow: treatment of resistant cases by denervation.
      ,
      • Wilhelm A.
      The treatment of therapy-resistant lateral epicondylitis denervation.
      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 thumbnail gr3
      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.

      Anteromedial approach

      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 thumbnail gr4
      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.

      Results

      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
      • Sears B.W.
      • Puskas G.J.
      • Morrey M.E.
      • Sanchez-Sotelo J.
      • Morrey B.F.
      Posttraumatic elbow arthritis in the young adult: evaluation and management.
      ; 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).
      • Laumonerie P.
      • Tiercelin J.
      • Tibbo M.E.
      • et al.
      Sensory innervation of the human elbow joint and surgical considerations: a systematic review.
      ,
      • Kholinne E.
      • Lee H.J.
      • Lee Y.M.
      • et al.
      Mechanoreceptor profile of the lateral collateral ligament complex in the human elbow.
      ,
      • Phillips D.
      • Petrie S.
      • Solomonow M.
      • Zhou B.H.
      • Guanche C.
      • D’Ambrosia R.
      Ligamentomuscular protective reflex in the elbow.
      We speculated that the loss of mechanoreceptors induces accelerated arthropathy and/or recurrent elbow instability via the abolition of musculoligamentous protective reflex.
      • Siala M.
      • Laumonerie P.
      • Hedjoudje A.
      • Delclaux S.
      • Bonnevialle N.
      • Mansat P.
      Outcomes of semiconstrained total elbow arthroplasty performed for arthritis in patients under 55 years old.
      ,
      • Laumonerie P.
      • Tiercelin J.
      • Tibbo M.E.
      • et al.
      Sensory innervation of the human elbow joint and surgical considerations: a systematic review.
      ,
      • Kholinne E.
      • Lee H.J.
      • Lee Y.M.
      • et al.
      Mechanoreceptor profile of the lateral collateral ligament complex in the human elbow.
      This only adds to the clinical complexity because total elbow arthroplasty is typically reserved for older, less active patients.
      • Siala M.
      • Laumonerie P.
      • Hedjoudje A.
      • Delclaux S.
      • Bonnevialle N.
      • Mansat P.
      Outcomes of semiconstrained total elbow arthroplasty performed for arthritis in patients under 55 years old.
      Total elbow denervation was first described in 1948 by Bateman
      • Bateman J.E.
      Denervation of the elbow for the relief of pain; a preliminary report.
      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.
      • Bateman J.E.
      Denervation of the elbow for the relief of pain; a preliminary report.
      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).
      • Cheung E.V.
      • Steinmann S.P.
      Surgical approaches to the elbow.
      ,
      • Howard J.L.
      • Agel J.
      • Barei D.P.
      • Benirschke S.K.
      • Nork S.E.
      A prospective study evaluating incision placement and wound healing for tibial plafond fractures.
      ,
      • Jeon I.H.
      • Morrey B.F.
      • Anakwenze O.A.
      • Tran N.V.
      Incidence and implications of early postoperative wound complications after total elbow arthroplasty.
      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).
      • Jeon I.H.
      • Morrey B.F.
      • Anakwenze O.A.
      • Tran N.V.
      Incidence and implications of early postoperative wound complications after total elbow arthroplasty.
      Blind transection poses risk to the proprioceptive nerve branches that may provide stability to the posterolateral elbow.
      • Laumonerie P.
      • Tiercelin J.
      • Tibbo M.E.
      • et al.
      Sensory innervation of the human elbow joint and surgical considerations: a systematic review.
      ,
      • Kholinne E.
      • Lee H.J.
      • Lee Y.M.
      • et al.
      Mechanoreceptor profile of the lateral collateral ligament complex in the human elbow.
      ,
      • Phillips D.
      • Petrie S.
      • Solomonow M.
      • Zhou B.H.
      • Guanche C.
      • D’Ambrosia R.
      Ligamentomuscular protective reflex in the elbow.
      ,
      • Kholinne E.
      • Lee H.J.
      • Kim G.Y.
      • et al.
      Mechanoreceptors distribution in the human medial collateral ligament of the elbow.
      ,
      • Sasaki K.
      • Ohki G.
      • Iba K.
      • Yamashita T.
      • Wada T.
      • Kokai Y.
      Innervation pattern at the undersurface of the extensor carpi radialis brevis tendon in recalcitrant tennis elbow.
      Previous anatomic descriptions of elbow capsular innervation have posited that the lateral epicondylar region is exclusively supplied by the radial nerve and its branches.
      • Wilhelm A.
      Tennis elbow: treatment of resistant cases by denervation.
      ,
      • Wilhelm A.
      The treatment of therapy-resistant lateral epicondylitis denervation.
      Wilhelm
      • Wilhelm A.
      Tennis elbow: treatment of resistant cases by denervation.
      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.
      • Wilhelm A.
      • Gieseler H.
      Die behandlung der epicondylitis humeri radialis durch denervation.
      In a retrospective, comparative study, Wilhelm
      • Wilhelm A.
      Tennis elbow: treatment of resistant cases by denervation.
      found that the original method led to the best results.
      • Wilhelm A.
      • Gieseler H.
      Die behandlung der epicondylitis humeri radialis durch denervation.
      Simultaneous direct and indirect decompressions of the posterior interosseous and radial nerves led to a higher rate of poor outcomes.
      • Wilhelm A.
      Tennis elbow: treatment of resistant cases by denervation.
      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.
      • Laumonerie P.
      • Tiercelin J.
      • Tibbo M.E.
      • et al.
      Sensory innervation of the human elbow joint and surgical considerations: a systematic review.
       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.
      • Laumonerie P.
      • Tiercelin J.
      • Tibbo M.E.
      • et al.
      Sensory innervation of the human elbow joint and surgical considerations: a systematic review.
      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).
      • Laumonerie P.
      • Tiercelin J.
      • Tibbo M.E.
      • et al.
      Sensory innervation of the human elbow joint and surgical considerations: a systematic review.
      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.
      • Adla D.N.
      • Stanley D.
      Primary elbow osteoarthritis: an updated review.
      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.
      • Wilhelm A.
      Tennis elbow: treatment of resistant cases by denervation.
      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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