Case Overview

We present the case of a 59-year-old woman with central right wrist arthritis and chronic pain refractory to conservative treatment including bracing, hand therapy, and intraarticular corticosteroids. We discussed the variety of options available to her, including partial wrist denervation, proximal row carpectomy, scaphoid excision with four-corner arthrodesis, pancarpal arthrodesis, and total wrist arthroplasty. After weighing her choices, she elected to see if a partial wrist denervation would provide her with the relief she was aiming to achieve. The patient underwent a lidocaine challenge of the posterior and anterior interosseous nerves in the office; she responded well and gave consent for a surgical intervention.

Technique

The patient was placed supine on the operating table with the arm on a hand board. The patient’s surgically treated limb was then pronated, and a 4-cm incision was made approximately 1 cm proximal to the distal radioulnar joint between the radius and ulna. With the aid of loupe magnification, the epidermis and dermis were incised and dissected down to the antebrachial fascia, exposing the fourth compartment. The fourth compartment was then opened longitudinally. The surgeon then gently retracted the tendons; the posterior interosseous nerve was identified and then cauterized at the floor of the compartment. Looking more ulnar and more deeply, a small incision was made through the interosseous membrane, exposing the anterior interosseous nerve for cauterization. The tourniquet was let down and hemostasis was achieved. The fascia was then closed and the patient placed in soft dressing.

Results

Within 3 months after surgery, the patient’s pain had improved by more than 50%, and her motion remained full. No other salvage technique can boast these results. This technique as described by Berger has been well studied. Burger et al and Hofmeister et al found this technique significantly improved pain and function in patients with chronic wrist arthritis as an alternative to wrist salvage or reconstruction procedures. O’Shaughnessy et al further demonstrated its long-term benefits at 7 years after surgery with nearly 70% of patients still having pain relief.

Summary

Anterior/posterior interosseous nerve neurectomy remains a viable treatment option for patients who have pain secondary to chronic wrist arthritis and for whom salvage/reconstruction options are less desirable. There is little detriment to trying this procedure before moving on to a surgery that requires bony anatomy changes.