Implant removal combined with total wrist denervation for painful intra-articular distal radial malunions: a prospective study

Abstract

Introduction:

The main aim of this study was to compare functional, pain and clinical outcomes between patients who underwent implant removal combined with total wrist denervation and patients who underwent implant removal alone for painful intra-articular malunion of fracture of the distal radius that was not amenable to osteotomy.

Methods:

This single-centre, prospective study included adult patients with painful intra-articular distal radial malunion non-amenable to osteotomy between 2022 and 2025. Patients were offered either implant removal combined with total wrist denervation (combined group) or isolated implant removal (isolated group). The primary endpoint was a comparison between groups of the postoperative Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and visual analogue scale (VAS) pain scores at 1 year. The secondary outcomes were the comparison of the postoperative range of motion (ROM), grip strength and complications.

Results:

Overall, 35 patients were included. In the combined group, the QuickDASH and VAS scores were significantly improved at 1 year from 45.5 (IQR: 38.6 to 50.0) to 18.2 (IQR: 13.6 to 27.3) and from 4.8 (SD 1.1) to 1.6 (SD 1.4), respectively. In the isolated group, no significant improvement in the QuickDASH nor in VAS was found. At 1 year, patients in the combined group had a significantly lower QuickDASH score, lower VAS scores and improved grip strength compared with patients in the isolated group. There was no difference between the groups regarding ROM and number of complications.

Conclusion:

The addition of total wrist denervation during implant removal appears to offer substantial symptom relief and improved function in this population.

Level of evidence:

III

Keywords

distal radial fracture osteotomies wrist denervation

Introduction

An intra-articular component is a typical feature in a distal radial fracture from high-energy trauma, particularly in young and active individuals (Meena et al., 2014). The options for surgical treatment include open reduction and internal fixation using either standard or specific plates, depending on the initial displacement and comminution of unstable fractures (Meena et al., 2014; Trumble et al., 1999). Restoration of articular congruity is a crucial objective, as an articular step-off greater than 1 mm has been significantly associated with increased postoperative pain and worse long-term functional outcomes (Mehta et al., 2000). Despite advancements in surgical techniques and implant designs, achieving and maintaining an anatomical reduction can be technically difficult, sometimes resulting in intra-articular malunion (Boe and Kennedy, 2024; Katt et al., 2020). Such malunions may lead to substantial functional impairments, including decreased range of motion (ROM), persistent pain and the early onset of radiocarpal osteoarthritis (Ring et al., 2005). Corrective osteotomy is generally advocated to address articular incongruity (del Piñal et al., 2006); however, in certain cases, particularly when the fragment size is too small or the articular surface is severely comminuted, osteotomy is not technically feasible or carries a prohibitive risk of failure owing to osteolysis (Ring et al., 2005).

Although isolated implant removal is commonly done after fracture healing to mitigate the risk of tendon irritation (Snoddy et al., 2015), particularly when standard or specific plates are used (Yu et al., 2011), isolated removal has shown inconsistent results in addressing chronic wrist pain associated with malunion (Minkowitz et al., 2007). Wrist denervation has emerged as a reliable option for reducing pain in patients with chronic wrist osteoarthritis. Denervation, although not improving ROM, offers significant pain relief and improved patient satisfaction (Swärd et al., 2022). However, the potential synergistic benefit of combining denervation with implant removal in cases of painful intra-articular malunion of the distal radius, especially when corrective osteotomy is not an option, has not been thoroughly investigated. The current literature lacks data about functional recovery, pain levels, clinical outcomes and potential complications associated with this combined approach.

The aims of the present study were to compare functional outcomes, pain reduction and clinical outcomes between implant removal combined with total wrist denervation and implant removal alone in patients with painful intra-articular malunions of fractures of the distal radius not amenable to corrective osteotomy.

Methods

Study design and patient enrolment

A single-centre, prospective cohort study was conducted between May 2022 and March 2025. Allocation to each treatment arm was non-randomized and based on patient preference. Patients aged 18–80 years with painful intra-articular malunions of fractures of the distal radius that were not amenable to osteotomy were eligible for inclusion. A painful intra-articular malunion was defined as persistent wrist pain greater than 3/10 on a visual analogue scale (VAS; 0–10) at least 3 months after the initial fracture, despite radiographic healing confirmed by arthro-computed tomography (CT) scan. Intra-articular malunion that was not amenable to corrective surgery was defined by an experienced Grade 3 (Tang and Giddins, 2016) surgeon (J-B V B) as either severe articular comminution (fragmentation, loss of bone stock), irreducible cartilage damage or early degenerative changes, or technical limitations for safe corrective osteotomy (risk of nonunion, poor bone quality or high risk of complications outweighing the potential benefits of corrective surgery). Patients were excluded if they had other identifiable sources of wrist pain, including ligamentous injuries diagnosed on CT scan or insufficient follow-up after initial fracture (<1 year for standard plates, <5 months for specific plates) to avoid including pain from tendon irritation. Patients with missing essential clinical data or those lost to follow-up were also excluded.

Once included, patients were offered two surgical options: implant removal combined with total wrist denervation (combined group) or isolated implant removal (isolated group). Patients were operated by a single experienced Grade 3 surgeon. Written informed consent was obtained from all patients and the study was approved by the institutional ethics committee (IRB 2022-013724-88).

Pre- and postoperative assessment

Demographic (sex, age) and fracture-related characteristics (type of plate, time since fracture) were collected before operation. The Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score (Beaton et al., 2005) was used to assess functional outcomes and a VAS was used to record pain levels. Range of motion (flexion, extension, pronation and supination of the wrist) was measured in degrees using a goniometer. Grip strength was measured using a hand dynamometer (JAMAR^®, Jackson, MI, USA). Patients were then assessed 1 month, 3 months, 6 months and 1 year after operation. Complications within the first year (e.g. need for revision surgery, haematoma, paraesthesia, infection) were recorded.

Operative description

Total wrist denervation was carried out concomitantly with implant removal through three surgical approaches: the anterior radial incision used for open reduction and internal fixation, an ulnar incision and a dorsal incision. Through the anterior radial approach, dissection was carried out between the flexor pollicis longus and flexor digitorum profundus to expose and remove the implant. Neurolysis of the median nerve and its palmar cutaneous branch was performed. The radial artery was isolated, with ligation of its adjacent veins followed by a 3 cm adventicectomy. The superficial radial nerve was mobilized subcutaneously by blunt dissection, elevating it from the underlying bone while maintaining contact with the skin. The ulnar approach consisted of a longitudinal incision just ulnar to the flexor carpi ulnaris tendon at the level of the ulnocarpal joint. Neurolysis of the ulnar nerve was performed, and an adventicectomy of the ulnar artery was carried out with removal of adjacent veins. The palmar cutaneous branch was similarly elevated from the deep plane by digital blunt dissection. Finally, a dorsal incision was made at the junction of the middle and distal thirds of the forearm. The posterior interosseous nerve was identified and resected. An opening was then made in the interosseous membrane, allowing identification and transection of the anterior interosseous nerve.

Endpoint measurements

The improvements in functional, pain and clinical outcomes were assessed at 1 year for each group. The primary endpoint was the comparison of the postoperative QuickDASH and VAS scores at 1 year between the combined and isolated groups. The secondary outcomes were the comparison of the postoperative ROM, grip strength and complications at 1 year between both groups. The VAS scores at 1, 3 and 6 months were also recorded and compared between both groups.

Statistical analysis

A Shapiro–Wilk test was used to assess the normality of the data distribution. Normally distributed numerical variables (age, time since fracture, VAS, grip strength) were expressed as means with standard deviations (SD) and non-normally distributed variables were expressed as medians with interquartile ranges (25th–75th percentiles). Discrete outcomes were expressed as absolute (n/N) frequencies. All data were analysed by a statistician using the R software (4.2.2) (https://www.r-project.org/). For data with normal distribution, an unpaired Student’s t-test was used and a Wilcoxon signed-rank test was used in the case of non-normal distribution. The complication rate was assessed using Fisher’s exact test. The significance threshold was set at p < 0.05.

Results

Forty-three patients were included in the study: 13 underwent implant removal combined with total wrist denervation and 30 underwent implant removal alone. In the isolated group, eight patients were lost to follow-up; therefore, only 22 patients were included in the final analysis. Among them, six had no available data beyond 6 months and two underwent subsequent surgical procedures (one radioscapholunate arthrodesis and one secondary denervation for persistant pain). No significant difference in age was found between the two groups (Table 1). At inclusion, there was no significant difference between the combined and isolated groups regarding the QuickDASH score, ROM parameters and grip strength (Table 2).

Table 1.

Demographic characteristics of the two groups.

Patient demographic	Combined group (n = 13)	Isolated group (n = 22)	p-Value
Age in years; mean (SD)	46.1 (15.5)	50.9 (14.8)	0.412
Male (n)	9	15	1.000
Type of plates (n)			0.200
Standard plates	5	14
Specific plates	8	8
Time since fracture in months; mean (SD)	7.5 (2.7)	8.1 (2.5)	0.520

Combined group: patients who underwent plate removal combined with total wrist denervation.

Isolated group: patients who underwent plate removal alone.

Table 2.

Pre- and postoperative values in the two groups.

Variable	Combined group (n = 13)			Isolated group (n = 22)
Variable	Preoperative	Postoperative	p-Value	Preoperative	Postoperative	p-Value
QuickDASH	45.5 (38.6-50.0)	18.2 (13.6-27.3)	0.001	43.2 (29.9-47.2)	40.9 (27.3-45.5)	0.415
VAS	4.8 (1.1)	1.6 (1.4)	<0.0001	3.9 (1.5)	3.4 (1.4)	0.357
ROM (degrees)
Flexion	30 (20–40)	30 (30–35)	0.917	30 (20–40)	30 (21–40)	0.917
Extension	30 (20–40)	30 (20–40)	0.0583	30 (20–30)	30 (20–34)	0.0548
Pronation	90 (80–90)	90 (80–90)	1	85 (80–90)	90 (80–90)	0.705
Supination	90 (90–90)	90 (90–90)	1	90 (80–90)	90 (80–90)	0.684
Grip strength (kg)	19.0 (6.0)	26.8 (5.8)	0.0015	16.6 (5.5)	20.2 (5.7)	0.005

QuickDASH: Quick Disabilities of the Arm, Shoulder and Hand; ROM: range of motion; VAS: visual analogue scale.

Combined group: patients who underwent plate removal combined with total wrist denervation.

Isolated group: patients who underwent plate removal alone.

Normally distributed numeric variables are expressed as mean (SD). Non normally distributed numeric variables are expressed as median (interquartile range (25th–75th percentiles)).

Significant p-values are shown in bold font.

In the combined group, the QuickDASH score decreased significantly after operation and pain levels (VAS) improved significantly. There was no significant change in wrist ROM, including flexion, extension, pronation or supination in either group (Table 2). However, grip strength increased significantly. The most common complications were transitory paraesthesias (less than 3 months; two patients) and minor haematoma (one patient), without the need for revision surgery.

In contrast, patients in the isolated group showed no significant improvement in the QuickDASH score or in VAS pain levels. There was no significant improvement in wrist ROM (Table 2). However, grip strength also improved significantly in this group. The most common complication was a minor haematoma (one patient) without the need for revision surgery.

At 1 year, patients in the combined group had a significantly lower QuickDASH score, lower pain levels and better grip strength compared with patients in the isolated group. There was no difference between the two groups in postoperative ROM and number of complications (Table 3). The VAS scores over time are shown in Figure 1.

Table 3.

Comparison of QuickDASH, pain score, ROM, grip strength and number of complications in the two groups after operation.

Outcome measure	Combined group (n = 13)	Isolated group (n = 22)	p-Value
QuickDASH	18.2 (13.6–27.3)	40.9 (27.3–45.5)	0.004
VAS	1.6 (1.4)	3.41 (1.4)	0.002
ROM (degrees)
Flexion	30 (30–35)	30 (21–40)	0.986
Extension	30 (20–40)	30 (20–34)	0.82
Pronation	90 (80–90)	90 (80–90)	0.864
Supination	90 (90–90)	90 (80–90)	0.398
Grip strength (kg)	26.8 (5.8)	20.2 (5.7)	0.003
Complications	3/13	1/22	0.134

QuickDASH: Quick Disabilities of the Arm, Shoulder and Hand; ROM: range of motion; VAS: visual analogue scale.

Combined group: patients who underwent plate removal combined with total wrist denervation.

Isolated group: patients who underwent plate removal alone.

Normally distributed numeric variables are expressed as mean (SD). Non-normally distributed numeric variables are expressed as median (interquartile range (25th–75th percentiles)).

Significant p-values are shown in bold font.

Discussion

The findings of this study to assess the role of denervation for pain management in patients with persistent symptoms after intra-articular fracture of the distal radius who are not candidates for corrective osteotomy show that combining total wrist denervation with implant removal leads to better functional and pain outcomes than implant removal alone at 1 year.

The study shows that isolated implant removal alone does not provide significant pain relief or functional improvement in patients presenting with chronic intra-articular malunions not amenable to osteotomy. This supports the notion that residual incongruity and secondary arthritis are major pain generators in these cases, and isolated implant removal, which is frequently done owing to the wide use of specific plates and their increased prominence (Meyer et al., 2022), is unlikely to address these problems unless implant prominence or tendon irritation is the primary cause of discomfort (Bushnell and Bynum, 2007).

Although retrospective studies and systematic reviews have reported that total wrist denervation could result in significant pain relief and high patient satisfaction in patients with chronic wrist pain from several causes, there is a lack of data concerning the role of denervation in intra-articular malunions after fracture of the distal radius not amenable to osteotomy (Dellestable et al., 2021; Picart et al., 2019; Tieman et al., 2021; Wu and Strauch, 2019). In the present study, combining total wrist denervation with implant removal resulted in clinically meaningful improvement in both the QuickDASH score, which improved by more than 20 points, suggesting a better perceived ability to carry out daily activities and fewer symptoms, and the VAS pain levels, which decreased by over 3 points after operation, suggesting a clinically relevant benefit compared with implant removal alone (Randall et al., 2022).

Denervation provides a low-risk, minimally invasive strategy to alleviate chronic wrist pain, with a very low complication rate (Picart et al., 2019), as confirmed in the present study. The procedure can be done as a one-stage procedure along with implant removal, avoiding the additional morbidity of implant removal alone and later total wrist denervation. It has a faster recovery than major salvage procedures such as total wrist arthrodesis (Rouanet et al., 2023). Previous series have reported a 48–61% rate of complications after wrist arthrodesis, requiring revision surgery in more than 33% of the cases (Hastings et al., 1996; Rouanet et al., 2023). This is much higher than the 10–13% reported rate of complications after total wrist denervation (Dellestable et al., 2021), a proportion consistent with that observed in the present cohort in which none of the patients undergoing the combined procedure required revision surgery. Moreover, denervation does not compromise wrist mobility and does not preclude subsequent reconstructive or salvage procedures, should symptoms persist or progress (Tieman et al., 2021; Wu and Strauch, 2019). Although some authors have reported modest improvements in ROM after denervation for degenerative wrist conditions (Pedrotti et al., 2024), this was not observed in our series. However, ROM was preserved in all patients, confirming that denervation is compatible with the primary goal of pain relief without mobility loss (Dellestable et al., 2021; Kadhum et al., 2020).

In this study, grip strength improved after operation in both groups. Consistent with this finding, multiple retrospective studies and systematic reviews have reported improved grip strength after total wrist denervation (Braga-Silva et al., 2011; Chin et al., 2020; Picart et al., 2019). Picart et al. (2019) reported a statistically significant increase in grip strength from 60 to 75% of the contralateral side after total wrist denervation in a cohort with a mean follow-up of 56 months. Braga-Silva et al. (2011) similarly reported improvement in grip strength from 43 to 69% of the opposite side after denervation, with sustained pain relief over 6 years. A systematic review by Chin et al. (2020) found that denervation procedures resulted in increased grip strength, with reported improvements ranging from 7 to 64% across studies. However, implant removal alone does not appear to improve grip strength in patients with intra-articular distal radial malunions (Ali et al., 2018). The observed improvement in grip strength in the isolated group in this study may be attributable to the natural recovery over time after the initial fracture rather than the implant removal itself.

This study is limited by its relatively small sample size and short follow-up, which may affect the generalizability of the results. However, results on pain and functional outcomes were significant. Although these outcomes were patient-reported, thereby providing important insight from the patient’s perspective, this can lead to bias from individual factors such as central sensitization or pain sensitivity (Beaton et al., 2005). Nevertheless, both the QuickDASH and VAS are widely used and validated in patients with upper limb disorders (Sindhu et al., 2011; Tsang et al., 2017). The study design, which consisted in a patient-choice trial rather than a randomized study, entails the potential for selection and recall bias; patients may have selected their treatment based on preconceived expectations of outcomes, which could have influenced patient-reported measures. Recall bias may also have played a role, for instance, if patients reported greater improvement over time owing to the perception that denervation is a newer, less invasive option compared with salvage procedures such as total wrist arthrodesis. Larger, randomized prospective studies with longer-term follow-up are needed to better establish the role of denervation in managing intra-articular distal radial malunions that are not amenable to corrective osteotomy. A key strength of this work is its prospective and controlled design.

In conclusion, in patients with persistent pain of the wrist and with malunions requiring implant removal that are not amenable to osteotomy, the addition of total wrist denervation during implant removal may offer substantial symptom relief and improved function, thereby potentially delaying more invasive salvage procedures.

Footnotes

Acknowledgements

We thank Verena Landel, ‘Direction de la Recherche en Santé des Hospices Civils de Lyon’, for her help in manuscript preparation.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical approval and informed consent statements

Written informed consent was obtained from all patients, and the study was approved by the institutional ethics committee (IRB 2022-013724-88).

ORCID iD

Camille Brenac

Data availability statement

Data available upon request to the authors.

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