Review Question - QID 219570

In patients with scapholunate advanced collapse (SLAC), isolated wrist denervation is most appropriate in laborers with early stages of radiocarpal arthritis and maintained range of motion.

Scapholunate advanced collapse represents a specific pattern and sequence of degenerative arthritis following an untreated scapholunate ligament injury. Arthritis begins between the scaphoid and radial styloid (SLAC I) before progressing to the entire scaphoid facet (SLAC II) and finally affecting the capitolunate articulation (SLAC III). Following failure of nonoperative management, early SLAC wrists (Stage I SLAC) can be treated with isolated radial styloidectomy in instances of radial impingement. Isolated anterior and posterior interosseous nerve denervation can also be performed in SLAC I wrists, which has demonstrated good long-term (> ten years) outcomes. For more severe SLAC stages, scaphoidectomy with four-corner fusion and proximal row carpectomies become the most appropriate treatment depending on more nuanced indications, with both surgeries demonstrating comparable outcomes.

Chin et al. performed a systematic review of 12 studies examining outcomes, including pain, grip strength, satisfaction, and return to work in those undergoing partial and complete (per Wilhem's technique; see below) wrist nerve denervation procedures. The authors noted significant reductions in both techniques concerning pain lasting out to 12 years, in addition to improvements in grip strength and satisfaction for both partial and complete wrist denervations. However, they noted slightly better degrees of improvement overall with complete wrist denervations than partial. The authors concluded that the procedure improves pain, function, and satisfaction in select patients with chronic wrist pain.

Wilhem performed a review delineating the multiple sources of innervation to the wrist capsule, noting its branches derive from the posterior interosseous nerve, superficial branch of the radial nerve, lateral antebrachial cutaneous nerve, median nerve proper, anterior interosseous nerve, ulnar nerve, and posterior antebrachial cutaneous nerve. The author then discusses the indications and preoperative evaluation of a painful wrist, providing techniques for injections of each specific nerve distribution before discussing the surgical technique for denervating each nerve. The review then concludes by discussing wrist denervation outcomes, highlighting that 62.5% of patients rated their pain relief as 'excellent' or 'good' at 10.5 years following the procedure.

Pomares and Lallemand review the indications and advantages of wrist denervation in select patients before reporting on the improvements in techniques surrounding chronic wrist pain. The authors also note recent studies better characterizing the sources of innervation to the wrist capsule as reasons for the technique's increased utilization, citing recent meta-analyses highlighting its efficacy for pain relief, function, and strength extending into the long term as evidence.

Incorrect Answers:
Answer 1: This profile would be best treated with isolated radial styloidectomy
Answer 3: This profile would be best treated with a wrist fusion
Answer 4: This profile would be best treated with scaphoidectomy and four-corner fusion
Answer 5: This profile would be best treated with proximal row carpectomy