See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/221696956

Denervation of the Distal Interphalangeal Joint

Article in Techniques in Hand and Upper Extremity Surgery · March 2012

DOI: 10.1097/BTH.0b013e3182296e68 · Source: PubMed

CITATIONS READS

9 462

1 author:

Joan M Arenas-Prat
Derby Hospitals NHS Foundation Trust
25 PUBLICATIONS 102 CITATIONS

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

coronavirus View project

All content following this page was uploaded by Joan M Arenas-Prat on 17 March 2018.

The user has requested enhancement of the downloaded file.

 TECHNIQUE

Denervation of the Distal Interphalangeal Joint

Joan M. Arenas-Prat, MD*w

INNERVATION OF THE DISTAL

Abstract: Distal interphalangeal joint osteoarthritis is one of the most
common conditions hand surgeons have to deal with. When daily
manual activities are impaired by symptoms, surgical treatment is
indicated. Usually, this is carried out by means of arthrodesis, being
joint replacement another option. In this study, a technique for distal
interphalangeal joint denervation is presented as a treatment for painful
degenerative or posttraumatic osteoarthritis. Potential complications
and contraindications are also discussed.
Key Words: denervation, distal interphalangeal joint, osteoarthritis
(Tech Hand Surg 2011;00: 000–000)
INTERPHALANGEAL JOINT
The distal interphalangeal joint has a mixed and overlapped
innervation carried out by the following nerve branches.2,3
 Articular branchlets from the main ulnar and radial
digital nerves, either directly from the main trunk of the
digital nerve or from twigs arising from the branches of
the trifurcation.
 Articular branchlets from the dorsal digital nerves.
SURGICAL TECHNIQUE
The patient is positioned supine with the arm supported on a
hand table. Under ring block anesthesia and digital tourniquet,

D istal interphalangeal joint osteoarthritis is one of the most

common conditions hand surgeons have to deal with. In
this study, a new technique for joint denervation is presented as
a proximally based skin flap is raised from the epinichium and
extended as far as 5 mm proximally to the intra-articular space
of the distal interphalangeal joint (Fig. 1). Both incisions
a treatment for painful degenerative or posttraumatic osteoar- should be curvilinear and extend from dorsal to volar until they
thritis. reach the midlateral line at joint level (Fig. 2). A broad-based
Classically, surgical treatment of painful osteoarthritis of flap is important to keep a good vascularity of the skin and also
the interphalangeal joint has been either arthrodesis or, less allows a much easier access to the volar surface of the joint to
frequently, joint replacement arthroplasty. These are effective severe the branchlets from the digital nerve. The size of this
techniques but the range of motion of the joint is impaired and
they involve the insertion of metalwork or other types of
implants. Denervation, apart from being technically much
more simple, offers also a satisfactory pain relief to the patient
and presents less morbility and postoperative complications.
So far, interphalangeal denervation has been performed at
proximal level.1 In this study, a technique to denervate the
distal joint is presented and based on the same principles.

INDICATIONS AND CONTRAINDICATIONS

Apart from more traditional techniques such as arthrodesis or
arthroplasty, joint denervation can be a very useful treatment
for painful degenerative or posttraumatic osteoarthritis. Its
main advantages are a shorter recovery time, no use of
metalwork or other types of implants, no interference with
biomechanics and range of motion of the joint and virtually no
loss of pinch or grip strength. Moreover, denervation does not
preclude further surgery if the results are not satisfactory.
Owing to the lack of bone or ligament involvement,
denervation has virtually no specific contraindications except
those patients with severely disabling deformities where an
arthrodesis would be more appropriate to correct the functional
impairment apart from the pain.

From the *Serveis Mèdics Penedès, 1 Creu Santa Digna, Vilafranca del
Penedès, Barcelona, Catalonia, Spain; and wPulvertaft Hand Centre, Royal
Derby Hospital, Uttoxetter New Road, Derby, England.
Conflicts of Interest and Source of Funding: The author report no conflicts
of interest and no source of funding.
Address correspondence and reprints request to Joan M. Arenas-Prat, MD,
4 Barquera, 08734 Olèrdola, Barcelona, Catalonia, Spain.
E-mail: arenasprat@hotmail.com. FIGURE 1. Broad-based dorsal skin flap. The gray line indicates
Copyright r 2011 by Lippincott Williams & Wilkins skin incision.

Techniques in Hand & Upper Extremity Surgery  Volume 00, Number 00, ’’ 2011 www.techhandsurg.com | 1
Arenas-Prat Techniques in Hand & Upper Extremity Surgery
FIGURE 2. Midlateral curvilinear incision to raise the skin flap.
Skin incision in gray.
articular branchlets makes them very difficult to identify and
for this reason, the aim of the technique is to dissect the area
rather than to visualize and divide specific nerve endings. The
FIGURE 3. A, Exposure of the articular area after the skin flap has
been raised. Dorsal and volar articular branchlets in light gray. B,
Black arrows indicate the plane of dissection. One centimeter
long gray shadowed area is the aimed region of denervation.
2 | www.techhandsurg.com
View publication stats
 Volume 00, Number 00, ’’ 2011
reflection of the dorsal flap should be as close as possible to the
paratenon of the distal 1 cm of the extensor tendon. At this
level, care should be taken to avoid damage to the nail matrix
or the insertion of the extensor tendon.
Then attention is turned onto volar, ulnar and radial
aspects of the joint, from a distance that ranges 5 mm proximal
and 5 mm distal from the intra-articular space we carry on
reflecting using dissecting scissors from proximal to distal and
as close as possible to the collateral ligaments of the joint and
the volar aspect of the flexor digitorum profundus tendon
pulleys system, basically A5 (Fig. 3B) and taking care to
protect the main digital nerve or the branches of the
trifurcation (Fig. 3A). From 1 side of the finger we should
reach the contralateral one and leaving an area of skin and
subcutaneous tissue of 1 cm of length reflected from the flexor
tendon structures at joint level (Fig. 3B). After skin closure and
a digital dressing, the patient can be discharged, and a 2-week
follow-up appointment is made for suture removal and to start
gradual mobilization as pain allows. The final results should be
evaluated 4 to 6 weeks after surgery, when most postoperative
inflammation will have subsided.
For a period of 1 year, 10 distal interphalangeal joint
denervations were performed and patients were discharged 4
months postoperatively with an open appointment. Seven
patients were pleased with the results of the procedure with
good relief of their osteoarthritic pain. So far, none of these 7
discharged patients have reattended the outpatients department
for recurrence of their symptoms. This is a period that spans
from 4 to 16 months.
In 1 of the operated patients, the symptoms remained
unchanged and 2 were not satisfied because of complications
related to the operation.
COMPLICATIONS ACTUALLY FACED AFTER
THE PROCEDURE
 One case of necrosis of the distal tip of the skin flap. This
was left undisturbed as a biological dressing to stimulate
granulation and new tissue formation. However, the
patient was not happy because of persistent pain over
the scar.
 One case of hypersensitive scar, possibly because the
dissection was done too superficially.
REFERENCES
1. Loréa P, Ezzedine R, Marchesi S. Denervation of the proximal
interphalangeal joint: a realistic and simple procedure. Tech Hand Up
Extrem Surg. 2004;8:262–265. (ISSN: 1089-3393). SOS Main, Clinique
des Diaconesses, Strasbourg Cedx, France.
2. Gray DJ, Gardner E. The innervation of the joints of the wrist and hand.
Anat Rec. 1965;151:261–266.
3. Kim YS. Innervation of metacarpophalangeal joint and distal
interphalangeal joint: an anatomical and histological study. Kaibogaku
Zasshi. 2001;76:313–322.
r 2011 Lippincott Williams & Wilkins