The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 87, Issue 1

Scientific Articles | January 01, 2005

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

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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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Abstract

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.

Figures in this Article

The wrist is affected in as many as 95% of patients who have rheumatoid arthritis¹. Involvement of the distal radioulnar joint leads to dorsal dislocation of the ulnar head that can cause pain, weakness, decreased forearm rotation, and rupture of the extensor tendons². Resection of the distal part of the ulna has provided one surgical approach for the treatment of this disorder. Reported operative problems associated with resection of the distal part of the ulna have included distal ulnar instability, extensor tendon rupture, ulnar translation, weakness, and wrist pain. The Sauvé-Kapandji procedure is an alternative surgical solution^3-5. In the past, good results have been reported following the use of this procedure for the treatment of posttraumatic degeneration^6,7 or rheumatoid arthritis⁵. Patients with rheumatoid arthritis, however, often have poor-quality bone stock in the distal part of the ulna. In patients with erosion of the distal part of the ulna, it can be difficult to provide sufficient osseous support for the ulnar aspect of the carpus.

We have modified the Sauvé-Kapandji procedure for patients with poor bone stock in the distal part of the ulna. The operation 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°, and inserting it into the radius. This procedure provides sufficient support for the ulnar side of the carpus. Rigid primary screw fixation of the grafted bone is obtained. The involved wrist is immobilized in a plaster cast for just three weeks. We have performed this procedure since 1997. In the present study, we describe the operative technique and report the results after a minimum duration of follow-up of three years.

Materials and Methods

Materials and Methods | Results | Discussion | References

We performed this operation in sixty-six wrists in fifty-six consecutive patients between March 1997 and September 2000. The study group included ten men (thirteen wrists) and forty-six women (fifty-three wrists). Forty-four wrists were on the right side, and twenty-two were on the left. The average age at the time of the operation was 59.3 years (range, thirty-five to seventy-seven years). The average duration of rheumatoid disease was 9.2 years (range, two to thirty years), and the average duration of follow-up was forty-eight months (range, thirty-six to sixty-five months).

All patients fulfilled the American Rheumatism Association 1987 revised criteria for the diagnosis of rheumatoid arthritis⁸. The operation was indicated for patients with painful instability of the distal radioulnar joint, restriction of forearm rotation, or extensor tendon rupture. The operation was not performed for patients with osseous ankylosis or collapse of the wrist. All wrists were grouped as stable or unstable according to the Schulthess classification system⁹ (Figs. 1-A and 1-B). Twenty-four wrists were stable, and forty-two were unstable.

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Figs. 1-A and 1-B: Radiographs illustrating the classification of rheumatoid arthritis according to the Schulthess system. Fig. 1-A Wrists with partial ankylosis or arthritis are classified as having the stable form of rheumatoid arthritis. Fig. 1-B Wrists with disintegration or collapse are classified as having the unstable form of rheumatoid arthritis.

Transfer of the extensor indicis proprius tendon was performed for the treatment of extensor tendon ruptures in eighteen wrists. The extensor digiti minimi was sutured to the extensor digitorum communis tendon of the ring finger in six patients who had a rupture of the extensor digiti minimi. Arthrodesis of the metacarpophalangeal joint of the thumb was performed in eleven patients, and arthrodesis of the interpha-langeal joint of the thumb was performed in five patients. Synovectomy of a metacarpophalangeal joint was performed in seven patients; the procedure involved the thumb in one patient, the index finger in four, and the middle finger in two. Synovectomy of the flexor tendons was performed in three patients. Arthroplasty of the carpometacarpal joint of the thumb was performed in seven patients, and implant arthroplasty of the metacarpopha-langeal joint of the middle finger was performed in one.

Pain, range of motion of the wrist, and forearm and grip strength were evaluated. Pain was evaluated with use of a visual analog scale, with 0 representing no pain and 10 representing unbearable pain. Grip strength was measured with use of a sphygmomanometer.

Radiographically, the carpal translation index was used as a measure of ulnar translation of the carpal bones¹⁰. This index represents the ratio of the distance between the center of the head of the capitate and a line drawn through the radial cortex of the radius to the length of the third metacarpal. It normally measures 0.28 ± 0.03 (mean and standard deviation) (Fig. 2). The index was measured preoperatively and at the time of follow-up in all patients by the senior author (K.M.). It was not measured preoperatively in five wrists because of erosive changes of the capitate, and it was not measured at the time of follow-up in eight wrists that had evidence of osseous ankylosis between the radius and the carpal bones. Thus, the carpal translation index was measured in fifty-three wrists. The paired t test was used for all statistical analyses, and the level of significance was set at p < 0.01.

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Fig. 2: The carpal translation index is calculated as the ratio of the distance between the center of the head of the capitate and a line drawn through the radial cortex of the radius (B) to the length of the third metacarpal (A). This index normally measures 0.28 ± 0.03 (mean and standard deviation).

Operative Technique

A 7-cm longitudinal skin incision is made on the dorsal aspect of the wrist to locate the ulna. Care must be taken to preserve the dorsal sensory branch of the ulnar nerve. The fourth compartment of the extensor retinaculum is then opened and reflected ulnarly. The extensor digitorum communis and extensor digiti minimi tendons are retracted radially. A neurectomy of the posterior interosseous nerve is performed along with ligation of its accompanying vessels¹¹. The capsule of the distal radioulnar joint is then incised longitudinally, and the distal part of the ulna is dissected subperiosteally (Fig. 3-A).

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Fig. 3-A and 3-B: The distal radioulnar joint capsule is incised longitudinally, and the distal part of the ulna is dissected subperiosteally. Fig. 3-B An osteotomy is performed 30 mm proximal to the distal end of the ulna with use of an oscillating saw.

An osteotomy is performed 30 mm proximal to the distal end of the ulna with use of an oscillating saw (Fig. 3-B). A thorough synovectomy of the distal radioulnar joint is performed, the periosteum of the resected portion of the ulna is removed, and the pronator quadratus muscle is then partially interposed at the osteotomy site.

In most cases, the triangular fibrocartilaginous complex is found to be ruptured, exposing the radiocarpal joint. Next, a 10-mm-diameter hole is created at the sigmoid notch of the radius with use of a power drill and curet (Fig. 3-C). All soft tissue is removed from the resected portion of the ulna, which is then rotated 90° and inserted into the hole in the radius. The shelf that is created should have a length of 12 to 15 mm. The ulnar graft is fixed in the drill-hole with a cancellous-bone screw (Fig. 3-D). Care must be taken not to overtighten the screw. The free end of the ulnar shaft is then stabilized by closing the periosteum and the capsule over the end of the bone and along the length of the pseudarthrosis. The extensor carpi ulnaris sheath is closed superficial to the extensor carpi ulnaris tendon to prevent it from subluxating during forearm rotation. A layered closure is performed, and a bulky dressing is applied for two days. A short-arm plaster cast is then applied and worn for three weeks. Patients undergoing tendon transfer because of an accompanying extensor tendon rupture are provided with a dynamic splint, which is worn for six weeks after the operation.

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Fig. 3-C and 3-D: A 10-mm-diameter drill-hole is made in the ulnar side of the distal part of the radius at the sigmoid notch. Fig. 3-D The ulnar graft is inserted into the drill-hole and is fixed with a cancellous-bone screw.

Results

Materials and Methods | Results | Discussion | References

Osseous union was achieved uneventfully in all cases (Figs. 4-A, 4-B, 4-C, 4-D). The average time to osseous union was 6.2 weeks. Resorption of the grafted bone was seen in six cases, but it was localized around the screw head. New-bone formation in the gap between the two ulnar fragments was observed in eight cases, but it did not appear to affect forearm rotation. Wrist pain resolved or was substantially reduced in all patients after the operation. The visual analog scores decreased from a mean of 8.2 (range, 4.6 to 9.9) before the operation to 1.0 (range, 0 to 2.0) after the operation (p < 0.01) (Table I). The mean preoperative range of motion was 35° of extension, 43° of flexion, 75° of pronation, and 69° of supination. The mean range of motion at the time of follow-up was 44° of extension, 28° of flexion, 82° of pronation, and 85° of supination. The total arc of wrist extension and flexion decreased by 6° after the operation. The total arc of forearm rotation, however, increased by 23° (p < 0.01). Instability of the distal ulnar stump was found in all patients, although most were not troubled by symptoms and experienced only minor, if any, discomfort. The mean carpal translation index (and standard deviation) was 0.31 ± 0.05 before the operation and 0.32 ± 0.05 at the time of follow-up (Table I). The mean index was 0.31 ± 0.04 preoperatively and 0.32 ± 0.05 at the time of follow-up in stable wrists, and it was 0.32 ± 0.06 preoperatively and 0.33 ± 0.04 at the time of follow-up in unstable wrists. Thus, we did not find ulnar translation of the carpus postoperatively, even in patients with unstable forms of rheumatoid arthritis of the wrist.

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Figs. 4-A through 4-D: A fifty-three-year-old man who complained of pain in the right wrist and an inability to fully extend the little finger was managed with the modified Sauvé-Kapandji procedure combined with suture of the ruptured extensor digiti minimi tendon to the adjacent extensor digitorum communis tendon of the ring finger. Figs. 4-A and 4-B Preoperative anteroposterior and lateral radiographs demonstrating slight erosive changes of the midcarpal and radiocarpal joints and a scapholunate dissociation. The wrist joint was classified as unstable.

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Figs. 4-C and 4-D: Anteroposterior and lateral radiographs, made five years after the operation, showing complete osseous union with good preservation of the radiocarpal joint. Resorption of the grafted bone is not seen. The wrist pain had resolved, the grip strength had improved substantially, and supination of the wrist had improved from 30° to 90°. The patient had returned to his previous occupation as a tailor. The carpal translation index had increased from 0.30 before the operation to 0.39 at the time of follow-up.

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TABLE I Mean Preoperative and Postoperative Data

	Preoperative Data	Postoperative Data	P Value^*
Visual analog score for pain	8.2	1	<0.01
Grip strength (mm Hg)	105	113	NS
Extension/flexion (deg)	35/43	44/28	NS
Pronation/supination (deg)	75/69	82/85	<0.01
Carpal translation index	0.31 ± 0.05	0.32 ± 0.05	NS

NS = not significant.

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TABLE I Mean Preoperative and Postoperative Data

	Preoperative Data	Postoperative Data	P Value^*
Visual analog score for pain	8.2	1	<0.01
Grip strength (mm Hg)	105	113	NS
Extension/flexion (deg)	35/43	44/28	NS
Pronation/supination (deg)	75/69	82/85	<0.01
Carpal translation index	0.31 ± 0.05	0.32 ± 0.05	NS

NS = not significant.

Osseous ankylosis between the lunate and the ulnar graft occurred in seven wrists, and ankylosis of the entire wrist joint occurred in one.

Discussion

Materials and Methods | Results | Discussion | References

Previously, we had used the conventional Sauvé-Kapandji procedure to treat disorders of the distal radioulnar joint in patients with rheumatoid arthritis. However, it often was impossible to perform the conventional Sauvé-Kapandji procedure, especially in patients with poor bone quality in the distal part of the ulna. Another problem associated with the conventional Sauvé-Kapandji procedure is nonunion. Rothwell et al.¹² performed this procedure in nineteen wrists with rheumatoid arthritis and found that six were not fused at the time of follow-up. To address these problems, we modified the procedure to create a sufficient osseous shelf in patients with poor bone quality in the distal part of the ulna.

Simmen and Huber⁹, in a study of patients with rheumatoid arthritis who had not had an operation on the wrist joint, reported that the amount of ulnar translation of the carpal bones over a period of ten years ranged from 3.8 mm in patients with stable forms of the disease to 9.5 mm in those with unstable forms of the disease. Van Gemert and Spauwen¹³, in a study of patients with rheumatoid arthritis who had had unilateral resection of the distal part of the ulna, reported that the average amount of ulnar translation of the carpal bones was 5.3 mm in the treated wrist compared with 3.7 mm in the untreated wrist after an average of 6.2 years. In the current study, there was a negligible change (0.01) in the carpal translation index after an average of forty-eight months.

Osseous ankylosis between the radius and/or the ulnar graft and the carpal bones occurred postoperatively in eight hands. Seven of the eight wrists demonstrated ankylosis between the ulnar graft and the carpal bones. In those cases, ulnar dislocation of the carpal bones might have occurred without the ulnar shelf support. Restriction of forearm rotation was not encountered after the operation in any patient, and the mean amount of supination improved by 60°.

Several reports have described pain and instability of the ulnar stump following the Sauvé-Kapandji procedure¹⁴. Taleisnik¹ reported instability of the ulnar stump in seven of forty wrists following this procedure. In the present series, patients did not have symptoms of instability, although only the periosteum and the capsule were closed.

We were concerned about the possibility of necrosis of the grafted ulnar fragment. Although six wrists in the current series showed resorption of the grafted bone, the resorption was localized to the area just around the screw head.

The present study of sixty-six wrists demonstrated marked pain reduction, an improvement in forearm rotation, and prevention of ulnar translation of the carpal bones after a minimum duration of follow-up of three years. This modified procedure expands the indications for a shelf operation to patients in whom it is difficult to achieve osseous support for the ulnar side of the carpus with use of the conventional Sauvé-Kapandji procedure because of ulnar head destruction. ?

References

Materials and Methods | Results | Discussion | References

Taleisnik J. The wrist. New York: Churchill Livingstone; 1985. p 329-34.329 1985

Backdähl M. The caput ulnae syndrome in rheumatoid arthritis. A study of the morphology, abnormal anatomy and clinical picture. Acta Rheumatol Scand.1963;Suppl 5: 1-75.1 1963

Chantelot C, Fontaine C, Flipo RM, Migaud H, Le Coustumer F, Duquennoy A. Synovectomy combined with the Sauvé-Kapandji procedure for the rheumatoid wrist. J Hand Surg [Br].1999;24: 405-9.24405 1999 [PubMed][CrossRef]

Millroy P, Coleman S, Ivers R. The Sauvé-Kapandji operation. Technique and results. J Hand Surg [Br].1992;17: 411-4.17411 1992

Vincent KA, Szabo RM, Agee JM. The Sauvé-Kapandji procedure for reconstruction of the rheumatoid distal radioulnar joint. J Hand Surg [Am].1993;18: 978-83.18978 1993 [PubMed][CrossRef]

Lamey DM, Fernandez DL. Results of the modified Sauvé-Kapandji procedure in the treatment of chronic posttraumatic derangement of the distal radioulnar joint. J Bone Joint Surg Am.1998;80: 1758-69.801758 1998

Sauvé L, Kapandji M. Nouvelle technique de traitement chirurgical des luxations récidivantes isolées de l'extrémité inférieure du cubitus. J Chir.1936;47: 589-94.47589 1936

Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, Healey LA, Kaplan SR, Liang MH, Luthra HS, Medsger TA Jr, Mitchell DM, Neustadt DH, Pinals RS, Schaller JG, Sharp JT, Wilder RL, Hunder GG. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum.1988;31: 315-24.31315 1988 [CrossRef]

Simmen BR, Huber H. The rheumatoid wrist: a new classification related to the type of the natural course and its consequences for surgical therapy. In: Simmen BR, Hagena F, editors. The wrist in rheumatoid arthritis. Basel, Karger; 1992. p 13-25.13 1992

Chamay A, Della Santa D, Vilaseca A. Radiolunate arthrodesis. Factor of stability for the rheumatoid wrist. Ann Chir Main.1983;2: 5-17.25 1983 [PubMed][CrossRef]

Buck-Gramcko D. Denervation of the wrist joint. J Hand Surg [Am].1977;2: 54-61.254 1977 [PubMed]

Rothwell AG, O'Neill L, Cragg K. Sauvé-Kapandji procedure for disorders of the distal radioulnar joint. A simplified technique. J Hand Surg [Am].1996;21: 771-7.21771 1996 [PubMed][CrossRef]

Van Gemert AM, Spauwen PH. Radiological evaluation of the long-term effects of resection of the distal ulna in rheumatoid arthritis. J Hand Surg [Br].1994;19: 330-3.19330 1994 [PubMed]

Bowers WH. Problems of the distal radioulnar joint. Adv Orthop Surg.1984;7: 289-303.7289 1984

Topics

rheumatoid arthritis ; bone screws ; carpal bones ; pain ; radius ; ulna ; wrist ; forearm ; distal radioulnar joint

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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

Hand and Microsurgery, Department of Orthopaedic Surgery, University of Heidelberg, Germany

In their recent publication, Fujita et al. recommend a modified SauvÃ© -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 90Â°, the major ulnar wrist stabilizer (TFFC, ulnocarpal ligaments,â€¦) 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 SauvÃ©-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 SauvÃ©-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 SauvÃ©-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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Satoru Fujita, Kazuhiro Masada, Eiji Takeuchi, Masataka Yasuda, Yoshio Komatsubara, Hideo Hashimoto; Modified Sauvé-Kapandji Procedure for Disorders of the Distal Radioulnar Joint in Patients with Rheumatoid Arthritis. The Journal of Bone & Joint Surgery. 2005 Jan;87(1):134-139.

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