Closed rupture of a finger extensor following the Sauvé-Kapandji procedure: a case report

Radioulnar Instability and Ulnar Stump Stabilization in Distal Radio Ulnar Joint Arthritis: A Cadaver Study

BACKGROUND

Salvage procedures for distal radioulnar joint (DRUJ) arthritis, like the Darrach or Sauvé-Kapandji (S-K) procedures, often result in extensor tendon ruptures at the ulnar stump. Radioulnar instability is considered the underlying cause and stump stabilization techniques are employed. This study investigated radioulnar instability, extensor tendon irritation, and the effectiveness of stump stabilization techniques following salvage procedures.

METHODS

Six upper limbs from three cadavers were used. Forearm rotation was measured using magnetic position sensors to assess radial movement. The Darrach procedure was performed on two limbs, comparing radial motion ranges for different ulnar osteotomy positions. The risk of tendon rupture was assessed with applied weight. The S-K procedure was performed on four limbs, evaluating stump stabilization techniques and radial movement distance underweight.

RESULTS

Proximal osteotomy positions increased radial motion range. Extensor tendon irritation occurred when the load was applied to the volar and ulnar sides, particularly with a pronated forearm. Stump stabilization techniques did not significantly contribute to ulnar stump stabilization.

CONCLUSIONS

Proximal ulnar osteotomy positions in DRUJ salvage procedures led to increased radioulnar instability and potential complications. Load application on the volar and ulnar sides, especially in a pronated forearm, increased the risk of tendon rupture. Stump stabilization techniques showed limited utility in stabilizing the ulnar stump or reducing complications. These findings can inform strategies for minimizing complications in DRUJ salvage procedures.

Extensor Tendon Rupture After Distal Radioulnar Joint Surgery: A Case Series

Symptomatic arthritis of the distal radioulnar joint (DRUJ) is often treated nonoperatively but with persistent symptoms may be treated surgically with partial or complete distal ulna resection. In many of these cases, ulna resection in combination with tendon reconstruction can successfully restore hand function. We identified three patients who underwent the Darrach procedure to treat DRUJ arthritis that developed attritional ruptures due to sharp prominent bone edges or dorsal capsule disruption. In addition to our recent three patients, an additional three isolated case reports, and two cases in a 29-patient series reported post-operative extensor tendon rupture as a complication after a Darrach procedure more than 30 years ago. While extensor tendon rupture is rarely reported in recent literature as a complication of distal ulna excision, surgeons may be able to minimize the risk of this complication intra-operatively by ensuring the resected distal ulnar stump is smooth, free of bony prominences, any capsular deficiencies are reconstructed, and that extensor tendons are able to glide freely.

[Clinical application progress of the Sauvé-Kapandji procedure]

Objective

To review the clinical application progress of the Sauvé-Kapandji procedure.

Methods

The indications, techniques, effectiveness, and modifications of the Sauvé-Kapandji procedure were analyzed and evaluated by an extensive review of the relevant literature.

Results

The Sauvé-Kapandji procedure can be applied for various disorders of the distal radioulnar joint. Risk of series of complications exist, which might be reduced by modification of the procedure.

Conclusion

The Sauvé-Kapandji procedure, as a salvage operation, can be a good alternative by meticulous manipulation for appropriate cases with distal radioulnar joint disorders.

The Sauvé-Kapandji procedure: indications and tips for surgical success

Arthrodesis is the most reliable and durable surgical procedure for the treatment of a joint disorder, with the main disadvantage of loss of motion of the fused joint. The distal radioulnar joint can be arthrodesed, while forearm pronation and supination are maintained or even improved by creating a pseudoarthrosis of the ulna just proximal to the arthrodesis. This is known as the Sauvé-Kapandji procedure. This procedure is not void of possible complications, such as nonunion or delayed union of the arthrodesis, fibrous or osseous union at the pseudoarthrosis, and painful instability at the proximal ulna stump. All of these can be prevented if a careful surgical technique is used.

A comparative study of the modified Sauvé-Kapandji procedure for rheumatoid wrist with and without stabilization of the proximal ulnar stump

We compared the clinical and radiological results of the modified Sauvé-Kapandji procedure for 41 of 86 operated rheumatoid wrists with (n=22) and without (n=19) stabilization of the proximal ulnar stump with a slip of half the extensor carpi ulnaris tendon. Gender, age, and follow-up period were similar in the two groups. We found no difference clinically or on radiographs between the two groups other than better early postoperative pain relief in those stabilized. Stabilization of the proximal ulnar stump may not be necessary in the modified Sauvé-Kapandji procedure for rheumatoid wrists.

The Sauvé-Kapandji procedure

The Sauvé-Kapandji procedure is useful for treating a variety of pathologic conditions that alter the normal function of the distal radioulnar joint (DRUJ). An arthrodesis is performed between the ulnar head and sigmoid fossa of the distal radius along with creation of a soft tissue interposition pseudarthrosis just proximal to the arthrodesis site that preserves forearm rotation. Presented herein is a brief history of the procedure and the current techniques available to achieve optimum results when it is used, along with a summary of its indications and contraindications.

The rheumatoid wrist

Wrist involvement is common in patients with rheumatoid arthritis. Individual patient assessment is important in determining functional deficits and treatment goals. Patients with persistent disease despite aggressive medical management are candidates for surgery. Soft-tissue procedures offer good symptomatic relief and functional improvement in the short term. Extensor and flexor tendons may rupture because of synovial infiltration and bony irritation. When rupture occurs, direct repair usually is not possible. However, when joints that are motored by the ruptured tendon are still functional, tendon transfer or grafting may be considered. Because of the progressive nature of the disease, dislocation and end-stage arthritis often require stabilization with bony procedures. The distal radioulnar joint is usually affected first and is commonly treated with either the Darrach or the Sauvé-Kapandji procedure. Partial wrist fusion offers a compromise between achieving stability of the affected radiocarpal joint and maintaining motion at the midcarpal joint. For pancarpal arthritis, total wrist fusion offers reliable pain relief at the cost of motion. Total wrist arthroplasty is an alternative that preserves motion; however, the outcomes of total wrist replacement are still being evaluated.

Étude radioclinique de l'instabilité du moignon proximal de l'ulna après l'intervention de Sauvé-Kapandji pour séquelles post-traumatiques

The aim of the study was to analyse the ulnar proximal stump's behaviour after Sauvé-Kapandji procedure. The procedure was performed for post-traumatic disorders of the distal radio-ulnar joint. This is a retrospective study of 14 patients. The mean age of patients at the operation was 49 years. Most of them began immediate mobilisation into pronation and supination. After a 5 year follow-up period, the clinical examination was centred on the ulnar proximal stump. An original radiologic study was made with static and dynamic X-Ray. Seven patients indicated pain on the ulnar stump during pronosupination. A clunk on the ulnar side of the wrist was noticed by three patients and an instability of the ulnar stump was observed two times. Clinically, there were a sagittal instability in all patients and a frontal instability four times. The sagittal instability was confirmed by dynamic X-Ray on each occasion, but the frontal instability was never confirmed. Every patient had instability of the ulnar stump; however, it was well tolerated. In practice, 12 patients were satisfied or very satisfied (86%). Instability of the proximal ulnar stump remains a problem, because it occurs despite a strict technique.

A suspension procedure using the extensor carpi ulnaris tendon for distal radioulnar joint disorders

Recently the Sauve-Kapandji (S-K) procedure has become popular for the treatment of various distal radioulnar joint (DRUJ) disorders. However, some complications, especially pain over the proximal stump of the ulna due to instability of the ulna have been reported in more recent follow-up studies. To prevent the occurrence of this pain, we devised a modified S-K procedure, which we called the suspension procedure, in which the extensor carpi ulnaris (ECU) tendon was used to suspend the proximal ulnar stump. We report here the surgical technique and compare clinical and radiographic results between the suspension procedure and the S-K procedure alone. We performed the S-K procedure alone on 8 patients (original group) and the suspension procedure on 5 (suspension group). Clinical results were assessed according to the clinical evaluation scoring system described by Inoue. Radiographic evaluations included the radio-ulnar distance, the gap of the ulna, and the distance between the articular surface of the wrist and the proximal ulnar stump. In the original group, 4 patients were rated as excellent, 2 as good and 2 as fair, whereas in the suspension group, 3 were rated as excellent, 2 as good and none as fair. In regard to radiographic evaluations, there were no significant differences in any of the 3 parameters between the 2 group. This suspension procedure had an advantage over the S-K procedure alone, especially in preventing the occurrence of stump pain. As there was no significant difference in radiographic findings between the two procedures regarding the site of osteotomy, the amount of bone resection, and radio-ulnar distance, stump pain may be attributed to dynamic instability rather than to static instability.

Tratamento dos desarranjos da articulação radio-ulnal distal pela técnica de Sauvé-Kapandji. Resultados preliminares

Foi realizado um estudo retrospectivo de 10 casos de desarranjo da articulação radio-ulnal distal tratados pela técnica de Sauvé-Kapandji. Os desarranjos eram resultantes de trauma (7), degeneração (2) e doença congênita (1) e as principais queixas pré-operatórias eram a dor, limitação da prono-supinação e deformidade. A idade média dos pacientes na época da operação era de 37,8 anos. Os pacientes foram submetidos a avaliação clínico-funcional e radiografica com um seguimento pós-operatório médio de 28,3 meses, particular atenção tendo sido dada a uma incidência radiográfica anteroposterior sob esforço de preensão manual. Todos os pacientes obtiveram melhora de suas queixas e o resultado final foi considerado satisfatório (excelente e bom) em 8, e insatisfatório (regular) 2. A artrodese da articulação radio-ulnal consolidou em 9 casos, independentemente do tipo de fixação empregado. O exame radiográfico sob esforço mostrou que todos os pacientes apresentavam deslocamento radial da ulna, mas isso aparentemente não interferiu com a função. Concluiu-se que a técnica de Sauvé-Kapandji é eficiente para o tratamento dos desarranjos da articulação radio-ulnal distal, pois ela não implica em perda funcional importante.