Advanced Derby Hand Course 23rd and 24th May 2013 DERBY

DENERVATION OF THE TRAPEZIOMETACARPAL JOINT

Joan M. Arenas-Prat Pulvertaft Hand Centre, Derby Serveis Medics Penedes, Barcelona

WHAT IS JOINT

DENERVATION?
Surgical technique to isolate a joint from its sensitive branches in order to treat osteoarthritic pain

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HISTORICAL PERSPECTIVE

TMCJ denervation was first described by Lora in 2002 following the same principles of Wilhelm's wrist denervation in 1966

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;21:209-17. Wilhelm A. Die Gelenkdenervation und hire anatomischen Grundlagen. Hefte zur Unfallheilk. 1966;86:1-109.
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WHY DENERVATION ?
Simple technique Does not interfere with biomechanics of joint Faster recovery time Does not preclude further surgery Because it works

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DENERVATION FACTS
All or nothing technique. Avoid partial or shy denervations

Pain relief

Pain relief

amount of divided articular rami

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amount of divided articular rami

DENERVATION FACTS (2)

Most orthopaedic operations imply a degree of involuntary denervation Pre-operative tests with local anaesthetic might exclude patients that otherwise would benefit from denervation

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DENERVATION MYTHS
DENERVATION AND PROPRIOCEPTION : A LONGSTANDING CONTROVERSY
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
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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

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CONTRAINDICATIONS

Grossly unstable joints Joint deformities that impair function

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TECHNIQUE

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 +/- deep branch of ulnar nerve
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. Miki RA et al. Ulnar nerve component to innervation of thumb carpometacarpal joint. Iowa Orthop J. 2011; 31: 225230.
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arenasprat@hotmail.com

arenasprat@hotmail.com

arenasprat@hotmail.com

arenasprat@hotmail.com

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

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It's only denervation. But I like it.

The Rolling Stones . 1974

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Thank you