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Name:
Surgical Denervation of the Thumb Carpometacarpal Joint
Description:
Surgical Denervation of the Thumb Carpometacarpal Joint
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T00H13M01S
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https://cadmoreoriginalmedia.blob.core.windows.net/52728a28-b546-4311-be14-270182ea495f/v-005696.mp4?sv=2019-02-02&sr=c&sig=mcKSfREWOSDa04X3NTx6eC%2FIowPunD2sFAxxpMlLn2A%3D&st=2024-11-21T17%3A03%3A25Z&se=2024-11-21T19%3A08%3A25Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
KANU GOYAL: Hello, this is Kanu Goyal. I am a hand surgeon at the Ohio State University within the Department of Orthopedic Surgery. This is a surgical video on surgical denervation of the thumb CMC joint. I did this in conjunction with our current fellow Hussain Hamid and Parth Vaghani, who is a current medical student here.
KANU GOYAL: He helped edit and assemble this video for us. I have nothing to disclose that is relevant to this topic. So in brief, denervation of painful joints has become, I think, more popular recently. It's been done for several joints for several decades, such as the wrist but now I think in the past 10 years we've been discussing it more related to other joints in the body, not exclusive, not exclusive to the hand and upper extremity,
KANU GOYAL: but clearly that's what I'm going to be focusing on. So here in this video, I'm going to show what are the operative indications? While symptomatic CMC arthritis is the main indication and in most of these cases it hasn't improved to patient satisfaction with non operative management, such as with splinting,anti-inflammatories, topical agents or steroid injections.
KANU GOYAL: The advantages of this technique versus probably more standard of care approach to this procedure, which is a CMC arthroplasty, is that there is really a good difference in recovery period. That's probably the largest difference between the two procedures. And what I tell patients is, at least in my practice, when I do a CMC arthroplasty, realistically I tell them it's about a three month recovery where you have to be mindful of the operation you had done for the first three months, whereas with the CMC denervation, in theory at least what I tell them is it's a two week process. Probably in reality, and I do tell them this, it's probably closer to four weeks where you are being a little more careful with the thumb, but I lift restrictions at two weeks with a CMC denervation, whereas with an arthroplasty I ask them to maintain some precautions up until three months post-operatively.
KANU GOYAL: There's also a difference in anesthesia. CMC arthroplasty, I'm typically doing regional anesthesia or a nerve block with sedation, whereas with a denervation I'm doing sedation with local anesthesia. Finally, we're not ,we're not really addressing or operating on the joint itself. We're not changing the bony architecture, and therefore, the appearance of the thumb basal joint doesn't change which, which can be an advantage in some patients versus others, particularly if a patient who has a normal contour but painful thumb CMC joint, if they undergo a CMC arthroplasty, some of those patients will develop a kind of a classic adducted thumb metacarpal
KANU GOYAL: that may be not painful, but may not be the patient's idea of the best looking thumb. So this particular case is a 50-year-old woman, right hand dominant with pain at the base of the right thumb that's worse with gripping and pinching activities, non-smoker and non diabetic, had been going on for several years, has had several corticosteroid injections with diminishing relief.
KANU GOYAL: And so the patient after very thorough discussion with regards to the different treatment options elected for a CMC denervation. Here are some preoperative radiographs that show relatively early stage arthritic changes at the thumb CMC joint, probably a grade 2 changes. Some instability was present at the thumb CMC joint and pre hyperextension wasn't that bad in this patient.
KANU GOYAL: Some surgeons may consider doing a Eaton Littler ligament reconstruction, which I think would be reasonable if the main complaint is instability. Others may consider an NP or a metacarpal extension osteotomy, which I think is also reasonable, and I've done that in the past. But again, I think the main selling point, so to speak, of a CMC denervation is that the recovery period is short and it's a skin only, so to speak, procedure, whereas the Eaton Littler metacarpal extension osteotomies, CMC arthroplasty, all of those require a little bit more recovery time.
KANU GOYAL: All right, so here we have the patient in the operating room. And make that skin incision, as you see there. Usually it's along the volar medial aspect of the thumb metacarpal base and CMC joint. A blunt dissection down to the extensor tendons. Be mindful of dorsal radial sensory nerve branches, which can be dorsal and volar to our skin incision here, and we are progressively raising our thick skin flaps. There,
KANU GOYAL: I demonstrate a thumb extensor tendon EPL and I continue to raise tissue off of this extensor retinaculum extensor fascia, and as we do that, we are necessarily dividing branches, articular branches from the dorsal radial sensory nerve. So we continue to divide these articular branches, what we believe to be articular branches from the dorsal radial sensory nerve.
KANU GOYAL: As I'm dissecting further and further dorsal towards the index finger metacarpal base. Now I used to make a separate incision at the index finger radial aspect of the index finger CMC joint to divide these branches, but I found that through this incision here I can get quite easily ulnar enough to divide these branches. Now, I will on occasion do a D'écrivains release in these patients.
KANU GOYAL: I don't do it routinely, but it's not unreasonable to. It depends a little bit on the patient's preoperative symptoms on whether or not I do it. So here we are exposing the EPL, I'm sorry, EPB and EPL tendons, and I like to dissect between the two to get to the floor of the snuffbox. So here we are identifying the radial artery
KANU GOYAL: within the snuff box. And as we dissect down to the radial artery, we are going to, as we would typically do if you're doing a dorsal approach for a thumb CMC arthroplasty retracted dorsally. And as we're doing the dissection of the radial artery and we're retracting it dorsally, we are denervating the thumb CMC joint. More specifically, we're dividing the articular branches from the LEBC nerve.
KANU GOYAL: Now when I'm doing a CMC arthroplasty, I only dissect the radial artery enough for me to do the operation. However, when I'm doing a denervation, I'm a little more aggressive with dissecting the radial artery off of the dorsal capsule of the thumb CMC joint and the STT joint. Once I have it retracted safely, I cauterize the floor there with my bipolar cautery.
KANU GOYAL: And I make sure to take the radial artery as far dorsal as possible so I can get a very thorough cauterization of the dorsal capsule, as you see there. And I go as volar as possible and as dorsal as possible. So now I'm raising a volar flap, and here, you may see another branch of the dorsal radial sensory nerve that provides, on occasion articular branch volarly, in which case you can divide that as well.
KANU GOYAL: Now here I'm raising the thenar musculature off of the APL tendon insertion, which is, which attaches at the thumb metacarpal base. And I'm lifting this off volarly in the classic volar approach or Wagner approach to the thumb CMC joint. And I take it fairly volar so that I can get really as close to the volar beak ligament as possible and close to the FCR tendon sheath. So those Ragnell retractors are retracting the musculature and I'm as volar as I can get.
KANU GOYAL: And then I will not infrequently make a mini arthrotomy into the thumb CMC joint, apply traction and do a synovectomy. Some of these patients will have a joint diffusion and some synovitis and just evacuating and removing that inflammation can help the patient's short term pain. After I've done that, I cauterize a volar capsule pretty aggressively and to make sure I've divided any articular branches from the thenar branch of the median nerve and the palmar cutaneous branch of the median nerve.
KANU GOYAL: And then I repair the thenar muscle, as you see there, with a couple of stitches. And then we come down and tourniquet and repair skin. I used to make a separate volar incision at the wrist flexion crease right at where palmaris is identified, the palmar cutaneous nerve and dissect that out distally and find a articular branch and divide it there. But I find that that dissection wasn't always reliable in terms of finding a articular branch, and it was maybe a little bit more painful for patients to have that skin incision than the volar radial incision that I showed here.
KANU GOYAL: So post operatively, I put them in a soft dressing for five days and then we see them back in two weeks to have stitches removed. And then at the two week mark, I really lift activity restrictions, although I tell them that if they do too much too early, they may prolong their surgical recovery. So some pearls. I think it's a very reasonable treatment option to offer to any patient who is considering surgery for basal thumb arthritis,
KANU GOYAL: that's number one. Number two, I think being aggressive with your capsular exposure, aids in a more complete denervation and that's both dorsal, ulnar, dorsal and volar aspects of the thumb CMC joint. Pitfalls; you've got to set patient's expectations appropriately. And in my experience, there is some variability in the degree of pain relief and the timing of symptom relief.
KANU GOYAL: I've had patients who have noticed significant pain relief at the two week visit and I've had others where they tell me they're not able to tell until the six week or three month visit. I've also had patients tell me they've had 40% pain relief and I've had patients tell me that they have 100% pain relief and it's not common but on occasion I'll have a patient, maybe one out of every 20 patients who did not notice any pain relief.
KANU GOYAL: So there is some literature to support this operation and a prospective study of 30 patients. In this study, they found a reduction in pain and significant improvement, improvements in the Kapandji score and keeping strength in all cases, with 75% of patients satisfied with the procedure at one year, post op. In a case series with a single incision dorsal approach, 11 out of 12 patients had complete or near-complete resolution of pain, and I believe that was at the one to two year mark
KANU GOYAL: and a similar study, 92% patient satisfaction in a retrospective review of 60 patients. Thank you for watching our surgical video on surgical denervation of the thumb CMC joint.
Segment:0 .
KANU GOYAL: Hello, this is Kanu Goyal. I am a hand surgeon at the Ohio State University within the Department of Orthopedic Surgery. This is a surgical video on surgical denervation of the thumb CMC joint. I did this in conjunction with our current fellow Hussain Hamid and Parth Vaghani, who is a current medical student here.
KANU GOYAL: He helped edit and assemble this video for us. I have nothing to disclose that is relevant to this topic. So in brief, denervation of painful joints has become, I think, more popular recently. It's been done for several joints for several decades, such as the wrist but now I think in the past 10 years we've been discussing it more related to other joints in the body, not exclusive, not exclusive to the hand and upper extremity,
KANU GOYAL: but clearly that's what I'm going to be focusing on. So here in this video, I'm going to show what are the operative indications? While symptomatic CMC arthritis is the main indication and in most of these cases it hasn't improved to patient satisfaction with non operative management, such as with splinting,anti-inflammatories, topical agents or steroid injections.
KANU GOYAL: The advantages of this technique versus probably more standard of care approach to this procedure, which is a CMC arthroplasty, is that there is really a good difference in recovery period. That's probably the largest difference between the two procedures. And what I tell patients is, at least in my practice, when I do a CMC arthroplasty, realistically I tell them it's about a three month recovery where you have to be mindful of the operation you had done for the first three months, whereas with the CMC denervation, in theory at least what I tell them is it's a two week process. Probably in reality, and I do tell them this, it's probably closer to four weeks where you are being a little more careful with the thumb, but I lift restrictions at two weeks with a CMC denervation, whereas with an arthroplasty I ask them to maintain some precautions up until three months post-operatively.
KANU GOYAL: There's also a difference in anesthesia. CMC arthroplasty, I'm typically doing regional anesthesia or a nerve block with sedation, whereas with a denervation I'm doing sedation with local anesthesia. Finally, we're not ,we're not really addressing or operating on the joint itself. We're not changing the bony architecture, and therefore, the appearance of the thumb basal joint doesn't change which, which can be an advantage in some patients versus others, particularly if a patient who has a normal contour but painful thumb CMC joint, if they undergo a CMC arthroplasty, some of those patients will develop a kind of a classic adducted thumb metacarpal
KANU GOYAL: that may be not painful, but may not be the patient's idea of the best looking thumb. So this particular case is a 50-year-old woman, right hand dominant with pain at the base of the right thumb that's worse with gripping and pinching activities, non-smoker and non diabetic, had been going on for several years, has had several corticosteroid injections with diminishing relief.
KANU GOYAL: And so the patient after very thorough discussion with regards to the different treatment options elected for a CMC denervation. Here are some preoperative radiographs that show relatively early stage arthritic changes at the thumb CMC joint, probably a grade 2 changes. Some instability was present at the thumb CMC joint and pre hyperextension wasn't that bad in this patient.
KANU GOYAL: Some surgeons may consider doing a Eaton Littler ligament reconstruction, which I think would be reasonable if the main complaint is instability. Others may consider an NP or a metacarpal extension osteotomy, which I think is also reasonable, and I've done that in the past. But again, I think the main selling point, so to speak, of a CMC denervation is that the recovery period is short and it's a skin only, so to speak, procedure, whereas the Eaton Littler metacarpal extension osteotomies, CMC arthroplasty, all of those require a little bit more recovery time.
KANU GOYAL: All right, so here we have the patient in the operating room. And make that skin incision, as you see there. Usually it's along the volar medial aspect of the thumb metacarpal base and CMC joint. A blunt dissection down to the extensor tendons. Be mindful of dorsal radial sensory nerve branches, which can be dorsal and volar to our skin incision here, and we are progressively raising our thick skin flaps. There,
KANU GOYAL: I demonstrate a thumb extensor tendon EPL and I continue to raise tissue off of this extensor retinaculum extensor fascia, and as we do that, we are necessarily dividing branches, articular branches from the dorsal radial sensory nerve. So we continue to divide these articular branches, what we believe to be articular branches from the dorsal radial sensory nerve.
KANU GOYAL: As I'm dissecting further and further dorsal towards the index finger metacarpal base. Now I used to make a separate incision at the index finger radial aspect of the index finger CMC joint to divide these branches, but I found that through this incision here I can get quite easily ulnar enough to divide these branches. Now, I will on occasion do a D'écrivains release in these patients.
KANU GOYAL: I don't do it routinely, but it's not unreasonable to. It depends a little bit on the patient's preoperative symptoms on whether or not I do it. So here we are exposing the EPL, I'm sorry, EPB and EPL tendons, and I like to dissect between the two to get to the floor of the snuffbox. So here we are identifying the radial artery
KANU GOYAL: within the snuff box. And as we dissect down to the radial artery, we are going to, as we would typically do if you're doing a dorsal approach for a thumb CMC arthroplasty retracted dorsally. And as we're doing the dissection of the radial artery and we're retracting it dorsally, we are denervating the thumb CMC joint. More specifically, we're dividing the articular branches from the LEBC nerve.
KANU GOYAL: Now when I'm doing a CMC arthroplasty, I only dissect the radial artery enough for me to do the operation. However, when I'm doing a denervation, I'm a little more aggressive with dissecting the radial artery off of the dorsal capsule of the thumb CMC joint and the STT joint. Once I have it retracted safely, I cauterize the floor there with my bipolar cautery.
KANU GOYAL: And I make sure to take the radial artery as far dorsal as possible so I can get a very thorough cauterization of the dorsal capsule, as you see there. And I go as volar as possible and as dorsal as possible. So now I'm raising a volar flap, and here, you may see another branch of the dorsal radial sensory nerve that provides, on occasion articular branch volarly, in which case you can divide that as well.
KANU GOYAL: Now here I'm raising the thenar musculature off of the APL tendon insertion, which is, which attaches at the thumb metacarpal base. And I'm lifting this off volarly in the classic volar approach or Wagner approach to the thumb CMC joint. And I take it fairly volar so that I can get really as close to the volar beak ligament as possible and close to the FCR tendon sheath. So those Ragnell retractors are retracting the musculature and I'm as volar as I can get.
KANU GOYAL: And then I will not infrequently make a mini arthrotomy into the thumb CMC joint, apply traction and do a synovectomy. Some of these patients will have a joint diffusion and some synovitis and just evacuating and removing that inflammation can help the patient's short term pain. After I've done that, I cauterize a volar capsule pretty aggressively and to make sure I've divided any articular branches from the thenar branch of the median nerve and the palmar cutaneous branch of the median nerve.
KANU GOYAL: And then I repair the thenar muscle, as you see there, with a couple of stitches. And then we come down and tourniquet and repair skin. I used to make a separate volar incision at the wrist flexion crease right at where palmaris is identified, the palmar cutaneous nerve and dissect that out distally and find a articular branch and divide it there. But I find that that dissection wasn't always reliable in terms of finding a articular branch, and it was maybe a little bit more painful for patients to have that skin incision than the volar radial incision that I showed here.
KANU GOYAL: So post operatively, I put them in a soft dressing for five days and then we see them back in two weeks to have stitches removed. And then at the two week mark, I really lift activity restrictions, although I tell them that if they do too much too early, they may prolong their surgical recovery. So some pearls. I think it's a very reasonable treatment option to offer to any patient who is considering surgery for basal thumb arthritis,
KANU GOYAL: that's number one. Number two, I think being aggressive with your capsular exposure, aids in a more complete denervation and that's both dorsal, ulnar, dorsal and volar aspects of the thumb CMC joint. Pitfalls; you've got to set patient's expectations appropriately. And in my experience, there is some variability in the degree of pain relief and the timing of symptom relief.
KANU GOYAL: I've had patients who have noticed significant pain relief at the two week visit and I've had others where they tell me they're not able to tell until the six week or three month visit. I've also had patients tell me they've had 40% pain relief and I've had patients tell me that they have 100% pain relief and it's not common but on occasion I'll have a patient, maybe one out of every 20 patients who did not notice any pain relief.
KANU GOYAL: So there is some literature to support this operation and a prospective study of 30 patients. In this study, they found a reduction in pain and significant improvement, improvements in the Kapandji score and keeping strength in all cases, with 75% of patients satisfied with the procedure at one year, post op. In a case series with a single incision dorsal approach, 11 out of 12 patients had complete or near-complete resolution of pain, and I believe that was at the one to two year mark
KANU GOYAL: and a similar study, 92% patient satisfaction in a retrospective review of 60 patients. Thank you for watching our surgical video on surgical denervation of the thumb CMC joint.
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