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Results of denervation of the wrist and wrist joint by Wilhelm's method
Results of Denervation of the Wrist and Wrist Joint by WilheIm's M e t h o d - J. Geldmacher, H. R. Legal and E. Brug
RESULTS
OF D E N E R V A T I O N OF T H E W R I S T A N D B Y WILHELM'S M E T H O D
WRIST JOINT
J. G E L D M A C H E R , H. R. L E G A L and E. BRUG, Erlangen, Germany The most common causes of painful and disabling arthrosis of the wrist joint are pseudarthrosis of the scaphoid bone following an unrecognised or mistreated fracture and Kienb6ck's disease of the lunate. These lead progressively in many cases to loss of work due to pain. Bradford and Dolphin (1966) write in Flynn's " H a n d Surgery . . . . Such cases deserve surgical interference if the pain is severe enough to provide a major handicap. The operation of choice is that of wrist fusion, which may be carried out by any method the surgeon elects". More effective and elegant, because it has proved less disabling is Wilhelm's (1966) method which eliminates the painful loss of function by selective denervation of the wrist joint. ANATOMY Necessary for the development of this surgical procedure was an intensive anatomical research, which was published by Wilhelm (1958). To ensure complete freedom from pain all the nerve branches which lead to the wrist, the wrist joint and the periosteum in the proximity of the joints, have to be severed. These are at the dorsal aspect of the distal forearm, the wrist and the hand, the dorsal interosseous nerve, the articular branches of the cutaneous antebrachial branch of the radial nerve, the articular branch of the first proper dorsal digital nerve from the radial nerve, and the articular branch in the first interosseous space. It is not absolutely necessary to sever the perforating branches of the ulnar nerve which lead to the carpo-metacarpal joints, in arthrosis confined to the wrist joint. On the volar aspect the articular branches of the radial antebrachial cutaneous nerve and the ulnar antebrachial cutaneous nerve have to be severed, but not necessarily the articular branches of the palmar branches of the median nerve and the articular branches of the median nerve itself. METHOD After an exact analysis of the joints in detail, it is advisable to interrupt the nerve conduction with 1% Novocain as a test to eliminate diffuse pain due to inflammation of the soft tissues. This type of pain is not influenced by the operation. The procedure is done under brachial plexus anaesthesia and in a bloodless field. The dorsal interosseous nerve, the posterior interosseous nerve of the forearm is easily displayed by a three centimetre long dorso-median transverse incision about three centimetres proximal to the wrist joint. The tendons of the extensor digitorum communis muscle and the extensor pollicis longus muscle are drawn to the ulnar side, the tendons of the extensor carpi radialis longus and brevis and the abductor poflicis longus muscles are drawn to the radial side. The nerve is easily seen on the interosseou,s membrane and must be resected as far proximal as possible to include the branch which leads to the distal radio-ulnar joint. The articular branch of the first intermetacarpal space is found easily through a longitudinal incision over the first carpo-metacarpal joint. From small incisions over the bases of the metacarpal bones the first, second and third perforating branches of the ulnar nerve can be interrupted. Vol. 4
No. 1
1972
57
Results of Denervation of the Wrist and Wrist Joint by Wilhelrn's Method-J. GeIdrnaeher, H. R. Legal and E. Brug
The branches, which lead from the dorsal branch of the ulnar nerve to the joint and the ulnar antebrachial cutaneous nerve are broken by a curved dorsoulnar incision and epifascial lifting of the skin and subcutaneous tissues. On the volar aspect a curved incision is placed over the distal end of the radius. The branches of the radial antebrachial cutaneous nerve are broken by resection of the soft tissue around the radial artery in whole extent of the snuffbox. Finally we can sever the volar interosseous nerve by enlargement of this incision at the border of the pronator quadratus, the branches of the palmar branches of the median nerve and the radial antebrachial cutaneous nerve a little bit more proximal. RESULTS Table i
Number of Patients Number of Denervations Follow-up Studies
35 36 32
During the last four years we carried out a denervation of the wrist and the wrist joint thirty-six times in thirty-five patients. Follow-up studies were possible in thirty-two patients. Table 2
Aetiology ,ot Wrist Joint Arthrosls Ununited Fracture of the Scaphoid Bone Kienb6ck's Disease Miscellaneous TOTAL
24 8 3 35
Twenty-four times the cause of the wrist joint arthrosis was a non-union of the scaphoid bone, eight times a Kienb6ck's disease, twice joint deformation after Colles' fracture and once rheumatoid arthritis. Table 3
Operative Procedures ill Tre,atme~t of Wrist Joint Arthrosis Complete Denervation Only Incomplete Denervation Only 11 1 4 Combined with Reconstruction of the Scaphoid Bone (Screwing, Bone 0 Pegging, etc.) 4 Combined with Palliative Surgical Procedures (Styloidectomy, Resec5 tion of Arthrotic Exostoses) 7 Combined with Reconstructive and Palliative Surgical Procedures 4 26 58
TOTAL
36
10 Vol. 4
No. 1
1972
Results of Denervation of the Wrist and Wrist Joint by Wilhelrn's Method-Y. Geldmaeher, H. R. Legal and E. Brug
In twenty-six cases a complete denervation was done: of these in eleven cases the denervation alone was done, in four cases comNned with reconstruction of the scaphoid bone and in four cases combined with palliative surgical procedures. In seven cases the complete denervation was combined with reconstructive and palliative procedures. Ten times an incomplete denervation was done: of these once as the only operation, five times combined with palliative surgical procedures and four times combined with reconstructive and palliative surgical procedures. Table 4
Results of Denervafion ot the Wrist Relative to Pain and Funct~o~ Excellent Good Satisfactory Poor
20 3 4 5
= 62.5% = 9.4% = 12.5% = t5.6°/o
TOTAL
32 = 100%
Positive Results 27 --- 84.4% Negative Results 5 = 15.6% 32 =
100%
In twenty-three cases the results were excellent or good. The patients have been totally symptom free, with some increased mobility of the wrist joint. Four cases had a satisfactory result. In five cases the result was poor. The main reason for the poor results has been failure in operative technique, nearly all occurring after incomplete denervation. We are astonished that this method, which already was published five years ago, is not better known. Our results show, that this procedure is a valuable addition to operative treatment in hand surgery. In many cases an arthrodesis is avoidable and we can obtain a painfree joint with preservation or even increase of mobility. Meanwhile, we have performed this procedure on other cases of painful and destructive rheumatoid arthritis with good results. If instability of the wrist joint occurs arthrodesis later is still possible.
REFERENCES BRADFORD, C. H., and DOLPHIN, J. A. (1966) Fractures of the Hand and Wrist in Hand Surgery, Ed. J. E. Flynn. Baltimore, Williams and Wilkins Company. p. 154. WILHELM, A. (1958) Zur Innervation der Gelenke der oberen Extremifftt. Zeitschrift far Anatomie und Entwicklungsgeschichte. 120: 331-371. WILHELM, A. (1966) Die Gelenkdenervation und ihre anatomischen Grundlagen. Ein neues Behandlungsprinzip in der Handchirurgie zur Behandlung der Lunatummalazie and Navicularepseudarthrose. Hefte z. Unfallheilk., Heft 86. Berlin--Heidelberg--New York. Springer Verlag. Vol. 4
No. 1
1972
59
RESULTS
OF D E N E R V A T I O N OF T H E W R I S T A N D B Y WILHELM'S M E T H O D
WRIST JOINT
J. G E L D M A C H E R , H. R. L E G A L and E. BRUG, Erlangen, Germany The most common causes of painful and disabling arthrosis of the wrist joint are pseudarthrosis of the scaphoid bone following an unrecognised or mistreated fracture and Kienb6ck's disease of the lunate. These lead progressively in many cases to loss of work due to pain. Bradford and Dolphin (1966) write in Flynn's " H a n d Surgery . . . . Such cases deserve surgical interference if the pain is severe enough to provide a major handicap. The operation of choice is that of wrist fusion, which may be carried out by any method the surgeon elects". More effective and elegant, because it has proved less disabling is Wilhelm's (1966) method which eliminates the painful loss of function by selective denervation of the wrist joint. ANATOMY Necessary for the development of this surgical procedure was an intensive anatomical research, which was published by Wilhelm (1958). To ensure complete freedom from pain all the nerve branches which lead to the wrist, the wrist joint and the periosteum in the proximity of the joints, have to be severed. These are at the dorsal aspect of the distal forearm, the wrist and the hand, the dorsal interosseous nerve, the articular branches of the cutaneous antebrachial branch of the radial nerve, the articular branch of the first proper dorsal digital nerve from the radial nerve, and the articular branch in the first interosseous space. It is not absolutely necessary to sever the perforating branches of the ulnar nerve which lead to the carpo-metacarpal joints, in arthrosis confined to the wrist joint. On the volar aspect the articular branches of the radial antebrachial cutaneous nerve and the ulnar antebrachial cutaneous nerve have to be severed, but not necessarily the articular branches of the palmar branches of the median nerve and the articular branches of the median nerve itself. METHOD After an exact analysis of the joints in detail, it is advisable to interrupt the nerve conduction with 1% Novocain as a test to eliminate diffuse pain due to inflammation of the soft tissues. This type of pain is not influenced by the operation. The procedure is done under brachial plexus anaesthesia and in a bloodless field. The dorsal interosseous nerve, the posterior interosseous nerve of the forearm is easily displayed by a three centimetre long dorso-median transverse incision about three centimetres proximal to the wrist joint. The tendons of the extensor digitorum communis muscle and the extensor pollicis longus muscle are drawn to the ulnar side, the tendons of the extensor carpi radialis longus and brevis and the abductor poflicis longus muscles are drawn to the radial side. The nerve is easily seen on the interosseou,s membrane and must be resected as far proximal as possible to include the branch which leads to the distal radio-ulnar joint. The articular branch of the first intermetacarpal space is found easily through a longitudinal incision over the first carpo-metacarpal joint. From small incisions over the bases of the metacarpal bones the first, second and third perforating branches of the ulnar nerve can be interrupted. Vol. 4
No. 1
1972
57
Results of Denervation of the Wrist and Wrist Joint by Wilhelrn's Method-J. GeIdrnaeher, H. R. Legal and E. Brug
The branches, which lead from the dorsal branch of the ulnar nerve to the joint and the ulnar antebrachial cutaneous nerve are broken by a curved dorsoulnar incision and epifascial lifting of the skin and subcutaneous tissues. On the volar aspect a curved incision is placed over the distal end of the radius. The branches of the radial antebrachial cutaneous nerve are broken by resection of the soft tissue around the radial artery in whole extent of the snuffbox. Finally we can sever the volar interosseous nerve by enlargement of this incision at the border of the pronator quadratus, the branches of the palmar branches of the median nerve and the radial antebrachial cutaneous nerve a little bit more proximal. RESULTS Table i
Number of Patients Number of Denervations Follow-up Studies
35 36 32
During the last four years we carried out a denervation of the wrist and the wrist joint thirty-six times in thirty-five patients. Follow-up studies were possible in thirty-two patients. Table 2
Aetiology ,ot Wrist Joint Arthrosls Ununited Fracture of the Scaphoid Bone Kienb6ck's Disease Miscellaneous TOTAL
24 8 3 35
Twenty-four times the cause of the wrist joint arthrosis was a non-union of the scaphoid bone, eight times a Kienb6ck's disease, twice joint deformation after Colles' fracture and once rheumatoid arthritis. Table 3
Operative Procedures ill Tre,atme~t of Wrist Joint Arthrosis Complete Denervation Only Incomplete Denervation Only 11 1 4 Combined with Reconstruction of the Scaphoid Bone (Screwing, Bone 0 Pegging, etc.) 4 Combined with Palliative Surgical Procedures (Styloidectomy, Resec5 tion of Arthrotic Exostoses) 7 Combined with Reconstructive and Palliative Surgical Procedures 4 26 58
TOTAL
36
10 Vol. 4
No. 1
1972
Results of Denervation of the Wrist and Wrist Joint by Wilhelrn's Method-Y. Geldmaeher, H. R. Legal and E. Brug
In twenty-six cases a complete denervation was done: of these in eleven cases the denervation alone was done, in four cases comNned with reconstruction of the scaphoid bone and in four cases combined with palliative surgical procedures. In seven cases the complete denervation was combined with reconstructive and palliative procedures. Ten times an incomplete denervation was done: of these once as the only operation, five times combined with palliative surgical procedures and four times combined with reconstructive and palliative surgical procedures. Table 4
Results of Denervafion ot the Wrist Relative to Pain and Funct~o~ Excellent Good Satisfactory Poor
20 3 4 5
= 62.5% = 9.4% = 12.5% = t5.6°/o
TOTAL
32 = 100%
Positive Results 27 --- 84.4% Negative Results 5 = 15.6% 32 =
100%
In twenty-three cases the results were excellent or good. The patients have been totally symptom free, with some increased mobility of the wrist joint. Four cases had a satisfactory result. In five cases the result was poor. The main reason for the poor results has been failure in operative technique, nearly all occurring after incomplete denervation. We are astonished that this method, which already was published five years ago, is not better known. Our results show, that this procedure is a valuable addition to operative treatment in hand surgery. In many cases an arthrodesis is avoidable and we can obtain a painfree joint with preservation or even increase of mobility. Meanwhile, we have performed this procedure on other cases of painful and destructive rheumatoid arthritis with good results. If instability of the wrist joint occurs arthrodesis later is still possible.
REFERENCES BRADFORD, C. H., and DOLPHIN, J. A. (1966) Fractures of the Hand and Wrist in Hand Surgery, Ed. J. E. Flynn. Baltimore, Williams and Wilkins Company. p. 154. WILHELM, A. (1958) Zur Innervation der Gelenke der oberen Extremifftt. Zeitschrift far Anatomie und Entwicklungsgeschichte. 120: 331-371. WILHELM, A. (1966) Die Gelenkdenervation und ihre anatomischen Grundlagen. Ein neues Behandlungsprinzip in der Handchirurgie zur Behandlung der Lunatummalazie and Navicularepseudarthrose. Hefte z. Unfallheilk., Heft 86. Berlin--Heidelberg--New York. Springer Verlag. Vol. 4
No. 1
1972
59