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Modified Sauvé-Kapandji Procedure for Disorders of the Distal Radioulnar Joint in Patients with Rheumatoid Arthritis
Satoru Fujita, MD1; Kazuhiro Masada, MD2; Eiji Takeuchi, MD2; Masataka Yasuda, MD2; Yoshio Komatsubara, MD3; Hideo Hashimoto, MD2
1 Department of Orthopaedic Surgery, Takarazuka Dai-ichi Hospital, 19-5 Kougetsu-cho, Takarazuka, Hyogo 665-0832, Japan
2 Department of Orthopaedic Surgery, Osaka Rosai Hospital, 1179-3 Nagasone-cho, Sakai, Osaka 591-8025, Japan. E-mail address for K. Masada: damasaclinic@ksf.biglobe.ne.jp
3 Department of Orthopaedic Surgery, Yukioka Hospital, 2-2-3 Ukita-cho, Kita-ku, Osaka 530-0021, Japan
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at Osaka Rosai Hospital, Osaka, Japan

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 Jan 01;87(1):134-139. doi: 10.2106/JBJS.C.01600
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Background: The Sauvé-Kapandji procedure has become popular for the treatment of disorders of the distal radioulnar joint in patients with rheumatoid arthritis, but this procedure is impossible to perform in patients with poor bone quality in the distal part of the ulna. We have modified the procedure for patients with poor bone quality in the distal part of the ulna. The modified procedure involves resecting the distal part of the ulna, making a drill-hole in the ulnar cortex of the distal part of the radius, rotating the resected portion of the ulna 90°, inserting it into the distal part of the radius, and fixing it at that site with use of an AO cancellous-bone screw. In the present report, we describe the new operative technique and report the results after a minimum duration of follow-up of three years.

Methods: This operation was performed in fifty-six patients (sixty-six wrists) with rheumatoid arthritis. The mean age at the time of the operation was 59.3 years. The mean duration of follow-up was forty-eight months. Patients were evaluated in terms of wrist pain, grip strength, and range of motion. Radiographic evaluation included calculation of the carpal translation index to assess the extent of ulnar translation of the carpus.

Results: Osseous union was achieved in all cases. Wrist pain resolved or decreased in all patients. The mean total range of forearm rotation increased from 144° preoperatively to 167° at the time of the most recent follow-up (p < 0.01). The mean carpal translation index did not change after the operation.

Conclusions: The modified Sauvé-Kapandji procedure results in rigid fixation of the grafted bone. The technique provides sufficient osseous support of the carpus even in patients with rheumatoid arthritis and poor bone quality in the distal part of the ulna.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Kazuhiro Masada
    Posted on January 27, 2005
    Dr. Masada responds to Dr. Daecke
    Masada Clinic, Osaka, Japan

    To the Editor:

    The most important thing is that all patients in our series had rheumatoid arthritis. In my exterience, it is impossible to suture the ruptured TFCC in RA during operation. Furthermore TFCC must be resected in order to perform synovectomy thoroughly in RA even in cases undergoing conventional S/K procedure. The Shelf operation is different from the Darrach procedure. Osseous ulnar support is very important to prevent ulnar translation of the carpus after resection od the distal ulna. Concerning necrosis of the resected ulna, I performed biopsy of the grafted bone 2 years after operation, Histological findings revealed the grafted bone to be viable. I think the grafted bone is small enough to survive and the cortical bone is covered by fibrous tissue. Osseous ankyrosis between the lunate and the grafted ulna found in 7 cases is a desirable change. It is unclear that osseous ankylosis is caused by the operation or by natural course of the disease.

    The reconstruction of the 6th extensor tendon sheath is limited, so I reroute the ECU tendon over the grafted bone. In earlier cases, I combined the Rowland technique to stabilize the ulnar stump. After that, I abandoned the Rowland technique because there were no differences between two groups. I believe the ulnar stump is stabilized enough by the ECU tendon and periosteum.

    I agree the radiolunate fusion combined with resection of the distal ulna is one surgical option. But the mid-carpal joint must be preserved in order to perform this procedure. In my experience, it is rare to see a well-preserved mid-carpal joint and erosive radiocarpal joint. The Shelf operation can be performed in cases showing destruction in the mid-carpal joint. I think the carpus is not necessarily supported by regular joint cartilage.

    In Chiari's pelvic osteotomy,the femoral head is not supported by joint cartilage but by osteotomized bone. The surface of the osteotomized bone is covered by fibrous tissue. In RA cases, joint cartilage is often destroyed even in less severe forms. The carpus is supported by the ulnar head having irregular joint cartilage in cases undergoing conventional S/K procedure. In our technique the carpus is supported by the smooth cortical bone. We think our technique is better than the conventional one.

    KAZUHIRO MASADA MD Masada clinic 779-2 Nagasone-cho, Sakai 591-8025, Osaka, Japan

    Wolfgang Daecke
    Posted on January 24, 2005
    Sauvé-Kapandji procedure
    Hand and Microsurgery, Department of Orthopaedic Surgery, University of Heidelberg, Germany

    In their recent publication, Fujita et al. recommend a modified Sauvé -Kapandji procedure for patients with DRUJ disorders and poor bone quality, as is the case in rheumatoid arthritis. They report that a fusion of the DRUJ was achieved in every patient after application of their modified technique. However, the rationale behind this modification is unclear. In order to rotate the distal ulnar segment 90°, the major ulnar wrist stabilizer (TFFC, ulnocarpal ligaments,…) must be resected completely, resulting in a destabilization of the wrist which is comparable to the Darrach procedure. The authors note that this destabilization is compensated by building an ulnar shelf out of the radial cortex of the distal ulnar shaft. However, the ulnar shelf is covered only with cortical bone and devascularized periosteum. In contrast, at least in the cases demonstrated in Fujita`s paper, performing the original Sauvé-Kapandji procedure would still leave the ulnar head covered by physiologically adapted cartilage. Obviously, osseous ankylosis between lunate and ulnar grafts, as was observed in 7 of 66 patients, has to be considered as a result of this modification. Furthermore, the total distal ulnar segement is avascular, with a high risk of partial or complete necrosis as was seen in 6 of the cases already. By rotating the distal ulnar, the reconstruction of the 6th extensor sheath is limited, thus increasing the risk of instability of the ulnar stump in addition to volar wrist instability.

    We agree with the authors that in severe forms of rheumatoid arthritis with vastly destroyed ulnar head, application of the original Sauvé-Kapandji procedure is not always possible, but we are not convinced that the modification of Fujita is a solution to this problem. In those cases with instability of the carpus and destruction of the DRUJ, a Darrach procedure in combination with a radio-lunate fusion is recommended. This way a reliable stabilization of the carpus can be achieved. In less severe forms with partially preserved ulnar head, the original Sauvé-Kapandji procedure with a long upper ulna segment for decreasing the risk of ulnar instability still remains the foremost treatment option.

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