First carpometacarpal joint denervation for primary osteoarthritis: technique and outcomes
Daniel P. Donato, M.D.1; James Willcockson, M.D.1; Leah Frazer, PA-C2; Mark A. Mahan, MD3; (1)University of Utah, Division of Plastic Surgery, Salt Lake City, UT, (2)University of Utah, Department of Neurosurgery, Salt Lake City, UT, (3)Department of Neurosurgery, University of Utah, Salt Lake City, UT
Introduction: Pain at the thumb carpometacarpal (CMC) joint is one of the most common complaints in patients with osteoarthritis. The innervation of the first CMC joint is believed to arise from branches of the four principle nerves that surround it: the superficial branch of the radial nerve, palmar cutaneous branch of the median nerve, recurrent branch of the median nerve, and the lateral antebrachial cutaneous nerve. Using 2 small incisions, all the articular branches are able to be severed effectively relieving joint pain. There are small case series in Europe showing success of this procedure as the primary treatment modality, but the available studies are relatively small, and there are no published studies from North America. We sought to show efficacy of the procedure and increase the available body of literature for this procedure.
Material and Methods: We reviewed all patients who underwent first carpometacarpal (CMC) joint denervation at our institution between January 1, 2015 and May 1, 2017. These patients were prospectively assessed with preoperative pain scores and grip strength measurements using a Jamar Dynamometer. Patients were offered the surgery if they 1) had a positive response in grip strength after diagnostic injection; 2) had no evidence of CMC joint instability on exam. All patients underwent the same CMC denervation procedure through incisions at the volar wrist crease and dorsal first web space.
Results: A total of 9 patients and 11 first CMC joints underwent this operation. Prior to surgery, all patients reported poor function and significant levels of pain, with an average VAS of 7.1. All patients demonstrated improved grip strength at diagnostic injection. Post-operative VAS decreased to an average of 3.1 out of 10. All but one patient reported improvement in pain, and no patient reporting worsened pain. Grip strength increased from 36.9 foot/pounds preoperatively to 50.1 foot/pounds post-operatively. 8 of 9 patients reported satisfaction with the procedure and 1 was unsure. Complications were relatively low. One patient developed a post-operative wound infection requiring antibiotics, one develop a C6 radiculopathy, and on patient had persistent focal pain at the dorsal CMC joint, likely secondary to a missed dorsal branched during the denervation.
Conclusion: Thumb CMC denervation provides good pain relief and improvement in grip patients with osteoarthritis. This provides a good alternative for patients unable or unwilling to undergo more invasive procedures.
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