Search

With an aging population, chronic osteoarthritic hip joint pain is becoming a major issue. Most patients with hip pain can control their pain with conservative measures but with a gradual reduction in their quality of life. When gradually reduced ambulation and pain become recalcitrant, total hip arthroplasty is the next step. For most patients, this is a good way to improve pain control and to recover some quality of life, but for a few this aggressive surgical procedure is not possible. Sometimes co-morbidities make total hip arthroplasties undesirable. At other times, the age of the patients recommends to wait for a while. In these cases, other options have to be explored. Percutaneous partial hip joint sensory denervation has become a notable option as it can provide acceptable rates of pain relief with minimal surgical aggressiveness. There are three modalities to perform it: thermal, cooled and pulsed radiofrequency.

Articular denervation was a subject of interest in treating painful pathologies of different body joints, especially in non-weight-bearing joints. Good knowledge about articular neuroanatomy is needed to perform denervation procedures effectively. Elbow denervation can be done in a large number of pathologies in young active patients who have a good or restorable range of motion. But little literature supporting elbow denervation is present. In this chapter, we provide a full description of the articular innervation of the elbow and the surgical techniques for performing partial and total elbow denervation.

At mean 125.6 months, pain was reduced from mean of 8.7 to 0.67, p

The anatomy of the innervation of the medial ankle joints is described, and related, clinically to pain following ankle injuries. Nerve block of the saphenous nerve is described. Saphenous nerve injury from tarsal tunnel decompression is discussed. The technical approaches to denervation of the medial ankle joint by resection of the saphenous nerve is described and illustrated. The results of medial ankle joint denervation are presented. The results of “total ankle denervation” are presented.

The evidence related to the neurophysiology of position sense, “proprioception,” is reviewed, and it documents that proprioception is due to sensory receptors originating in the skin, not from within the joint. The evidence is reviewed that joint denervation alone will not result in a Charcot joint.

Background Selective joint denervation has become a reliable palliative treatment, especially for painful joints in the upper and lower extremity. Methods This article highlights the life and work of Nikolaus Rüdinger (1832–1896) who first described joint innervation which became the basis of later techniques of surgical joint denervation. The historical evolution of this method is outlined. Results Rüdinger made a unique career from apprentice barber to military surgeon and anatomy professor in Munich, Germany. His first description of articular innervation of temporomandibular, shoulder, elbow, wrist, finger, sacroiliac, hip, knee, ankle, foot, and toe joints in 1857 stimulated the subsequent history of surgical joint denervation. Comparing his investigations with modern joint denervation methods, developed by pioneers like Albrecht Wilhelm or A. Lee Dellon, shows his great exactitude and anatomical correspondence despite different current terminology. Clinical series of modern surgical joint denervations reveal success rates of up to 80% with reliable long-term results. Conclusion The history of joint denervation with Rüdinger as its important protagonist offers inspiring insights into the evolution of surgical techniques and exemplifies the value of descriptive functional anatomy, even if surgical application may not have been realized until a century later.

This study aims to compare radiofrequency (RF) heat lesion size across electrodes and generator settings available for interventional pain management.Monopolar lesions are generated ex vivo in animal tissue using sharp cannulae with tip diameters 23, 22, 20, 18, 16 gauge; tip lengths 5, 6, 10, 15 mm; set temperatures 60, 70, 80, 90°C; set times 1, 1.5, 2, 3, 5, 10 minutes. Lesions are generated using the RRE electrode, cooled RF, and parallel-tip bipolar RF for comparison. Lesion sizes are assessed by automated photographic temperature inference from over 400 lesions, using multiple lesions per configuration.Monopolar lesion width and length increase with each factor (P 0.001). Increasing cannula diameter from 22 to 16 gauge increases average lesion width 58-65% (3-4 mm) at 80°C and 2 minutes. Increasing temperature from 60°C to 90°C increases lesion width 108-152% at 2 minutes. Although dimensions grow most rapidly over the first minute, average lesion width is 11-20% larger at 2 minutes, and 23-32% larger at 3 minutes, compared with 1 minute. Lesion length extends distal and proximal to the tip, and exceeds tip length by 1-5 mm at 80°C and 2 minutes. Conventional 16 gauge cannulae at 80-90°C for 2-3 minutes generate lesions of average width similar to that produced by the cooled RF configuration proposed for sacroiliac joint denervation. Bipolar RF between parallel cannulae produces a rounded brick-shaped lesion of comparable shape to three sequential monopolar lesions generated using the same cannulae and generator settings.Tip gauge, tip length, temperature, and time substantially affect RF lesion size.

Since the original description of wrist denervation, the principle of joint denervation in hand surgery has been extended to other joints like the first carpometacarpal, interphalangeal and metacarpophalangeal joints. At the wrist level as at the digital level, the results are comparable to those obtained with other surgical alternatives. In case of unsatisfactory results, a more traditional intervention remains always possible.

Zygapophyseal or facet joints are formed by the inferior and superior processes of two adjacent joints. These joints limit excessive mobility and distribute the axial loading over a broad area. The facet joints located at the dorsal side of the spine together with the intervertebral disc at the ventral side form the three moving parts of the motion segment. Compared to the lumbar facet joints, the cervical facet joints are relatively big joints. The facet joints are innervated by the medial branch of the dorsal ramus of the spinal nerve.

Metacarpophalangeal joint osteoarthritis is a relatively common condition that hand surgeons have to deal with. When daily activities are impaired by pain and all conservative measures have failed, surgical treatments such as arthrodesis or joint replacement are indicated. In this article, a technique for joint denervation is presented as a treatment for painful degenerative or posttraumatic osteoarthritis. Its preliminary results, potential complications, and contraindications are also discussed.

Wrist joint denervation for treatment of painful arthrosis was carried out in 36 patients in the last five years. 33 Patients could be followed up. Besides subjective reports on pain and maximum stress, strength, mobility and the X-ray of the wrist-joint were also considered in the evaluation of the results. As a whole, a success rate of 84% could be attained. We have not observed disorders of sensitivity or trophic alterations. An increase of symptoms after the second postoperative year was noteworthy.

The knowledge gained in anatomical studies on the sensory innervation of the ankle joint was applied to 11 patients suffering from post-traumatic arthrosis of the ankle joint who underwent denervation operations following successful test blocks. In order to achieve an ankle joint denervation as complete as possible while maintaining the sensitivity of the sole and dorsum of the foot, neurotomies away from the joint were performed in the saphenous, sural, and deep peroneal nerves as well as the interosseous branch, whereas the tibal nerve and the superficial peroneal nerve were skeletized by neurotomy of the branches to the ankle joint only. Good results were obtained in seven out of 10 patients examined in the follow-up.

Summary The anatomical studies conducted by us have confirmed the finding that all the major nerves of the lower leg-the saphenous, tibial, sural, superficial peroneal, and deep peroneal nerve-are involved in the sensory innervation of the ankle joint. All these nerves contribute to the innervation of both the ankle joint and the talocalcaneonavicular joint. The results obtained illustrate the vast inter- and intra-individual variation of the nerves' pattern of distribution. It was noted in particular that certain rami for the ankle joint branch off from the main nerves quite proximally, such as at the beginning of the distal third of the lower leg. The interosseous branch as a terminal ramus of a muscular branch of the deep peroneal nerve is an observation which is of particular interest.

Pain impulses from neuroma of the overlying skin territory can effectively be stopped by neuroma excision and nerve reconstruction or relocation into muscle, vein, or bone or nerve-to-nerve techniques. Clinical series in the literature prove that the positive results obtained for partial joint denervation and surgical neuroma therapy in the upper extremity also apply to lower-extremity joints (eg, the ankle and sinus tarsi). Based on a thorough examination and patient selection, a reliable and simple operation effectively alleviates symptoms and may prevent more invasive traditional surgical techniques. These techniques offer an ambulatory, minimally invasive, and rehabilitation-free approach for an increasing number of patients.

First carpometacarpal joint osteoarthritis is one of the most common conditions hand surgeons have to deal with. In this article, a more radical technique for joint denervation is presented as a treatment for painful degenerative or posttraumatic osteoarthritis. Moreover, a preliminary report of 18 cases treated with this technique is presented to support its benefits.

Partial joint denervation is the concept of preservation of joint function and relief of joint pain by interrupting the neural pathways that transmit the pain message from the joint to the brain. When traditional, nonoperative, musculoskeletal approaches fail, the surgical approach may require joint fusion or replacement arthroplasty. The purpose of this article is to extend these concepts from the wrist to the elbow and shoulder.For each joint, research required (1) anatomical dissection to identify innervation of the specific joint, (2) identification of route through which to administer local anesthetic based on new anatomical knowledge, (3) demonstration that pain relief is possible by injection of local anesthetic in patients who have failed traditional musculoskeletal treatments for that joint, (4) creation of surgical approach(es) to resect involved nerve(s), and (5) documentation of success of this approach with an appropriate patient population.The results obtained for partial joint denervation of the wrist can be applied successfully to the elbow and shoulder. If anesthetic block of joint innervation results in greater than or equal to a five-point reduction in visual analogue scale score, 90 percent of the patients can expect good to excellent pain relief from partial joint denervation.Partial joint denervation offers an outpatient, ambulatory operative approach that is joint sparing and rehabilitation free. For plastic surgery, this concept opens new areas for patient care, permitting relief of pain and restoration of function to joints even proximal to the wrist, permitting plastic surgeons to bring this hope to our orthopedic and pain management colleagues.

Partial joint denervation is the concept of preservation of joint function and relief of joint pain by interrupting neural pathways that transmit the pain message from the joint to the brain. Partial denervation of painful wrist, elbow, and shoulder joints was described in part I. Application of these principles to the knee and ankle is described in part II.Cadaveric anatomical studies identified innervation of the knee and the ankle (sinus tarsi) to provide a guide to nerve blocks and surgical intervention. Patients were evaluated who had sports injuries, trauma, osteoarthritis, or previous arthroplasty/scope procedures of the knee and/or ankle who failed to respond to traditional musculoskeletal approaches.The results obtained for partial joint denervation of the upper extremity can be applied successfully to the knee and ankle joints. If anesthetic block of joint innervation results in a reduction of 5 or more the visual analogue scale, 90 percent of the patients can expect good to excellent pain relief from partial joint denervation.For patients with a structurally intact joint but with chronic knee or ankle pain after trauma or arthroplasty, this approach provides an outpatient, ambulatory operative approach that is joint sparing and can be rehabilitation-free. Partial joint denervation in the lower extremity offers plastic surgeons the opportunity to help our colleagues in orthopedic surgery, podiatric medicine, and pain management with some of their most difficult pain-related lower extremity patient problems.