The Sauvé-Kapandji Procedure for Disorders of the Distal Radio Ulnar Joint in Patients with Rheumatoid Arthritis.
Ricardo Monreal* and Enrique Faedo
Centro Médico MEDEX, South America
Submission: August 29, 2016; Published: September 16, 2016
*Corresponding author: Ricardo Monreal, Centro Médico MEDEX, República de Panama 3065 2do piso, San Isidro-Lima, Peru, South America
How to cite this article: Ricardo M, Enrique F. The Sauvé-Kapandji Procedure for Disorders of the Distal Radio Ulnar Joint in Patients with Rheumatoid Arthritis. Ortho & Rheum Open Access J. 2016; 2(4): 555593. DOI: 10.19080/OROAJ.2016.02.555593
Results: The range of pronation and supination improved significantly. There was normal pronation or supination in 100% of wrists after operation. Painless bone union was achieved in all patients and carpal shift was unchanged when compared to films taken immediately after surgery. There was no dislocation of the ulnar stump on lateral radiographs.
Rheumatoid arthritis (RA) involves the wrist in up to 95% of cases. The distal radioulnar joint is affected in 31-75% of these patients and is frequently the first compartment of the wrist involved . Long-standing rheumatoid arthritis results in ligamentous laxity. At the distal radioulnar joint this leads to the so-called ‘caput ulnae syndrome’ , dorsal subluxation of the distal part of the ulna, supination of the carpus on the forearm, and palmar dislocation of the tendon of the extensor carpi ulnaris [3-6]. The most common treatment for disorders of the distal radioulnar joint has been a transverse distal ulnar resection (Darrach procedure) . However, postoperative ulnar carpal impingement syndrome, wrist instability, extensor tendon rupture, and diminished grip strength have all been associated with the Darrach procedure [8-11]. Another alternative in the management of distal radioulnar joint disorders is an arthrodesis with creation of a surgical pseudarthrosis of the distal ulna (Sauvé-Kapaandji procedure . The aim of this study was to review our clinical experience with the Sauvé-Kapandji procedure in the reconstruction of the rheumatoid distal radioulnar joint.
Twelve patients (12 wrists) having Sauvé-Kapandji procedure for the DRUJ between the years 2006-2014 were retrospectively reviewed. There were 7 males and 5 females. The mean age was 51 years (range, 31 to 71 years, SD=12.8) and the mean duration of follow-up was 16 months. The indications for surgery were prolonged pain on prosupination, tenderness over the DRUJ, and discomfort with a piano- key test as well as radiographic findings of DRUJ arthritis. Wrist posteroanterior (PA) views were used to evaluate the existence of DRUJ arthritis. All patients provided informed consent to participate in this study.
The operative technique consists of a dorsal approach to the
distal radio ulnar joint (DRUJ) with synovectomy and resection
of 10-15 mm segment of the ulna proximal to the ulnar head. If
ulnar recession for an ulnar positive variance is required, then
excision of an ulnar segment of appropriate size is removed to
allow the distal ulnar fragment to be pulled proximally to neutral
ulnar variance maintaining a 15 mm gap while for patients with
neutral or negative ulnar variance, a 15 mm segment of ulna is
excised before screw fixation of the DRUJ. The cartilage from the
DRUJ was removed, and the joint was fixed with one 3.5 mm Ø
cancellous screw and other 3.5 mm Ø cortical screw proximally.
Part of the pronator quadratus muscle was interposed between
the two ends of the ulna to discourage bone healing. The ECU
tendon was fixed on the dorsal aspect of the ulnar head with a
flap from the retinaculum.
A plaster splint was worn for 10 days after surgery. Active
pronationsupination exercises were started on the first
postoperative day; unrestricted mobilisation was allowed after
splint removal. Additional immobilization varied if extensor
tendon ruptures or repairs were performed. Four of the 12
wrists with an extensor tendon rupture underwent a free tendon
graft of the palmaris longus tendon. Measurements at last
follow-upincluding range of motion (ROM), pain, and x-ray films
were reviewed and compared with the preoperative values.
The ROM measurement involved dorsiflexion, palmarflexion,
pronation and supination. Differences between the groups were
analyzed by Student’s t test. A P value <0.05 was considered to be
statistically significant. With regard to supination and pronation,
80° of each was accepted as the lower limit of normal, 66°-79°
as good, 50°-65° as satisfactory, and less than 50° as poor .
The assessment of pain was evaluated according to the Mayo
Wrist Score (MMWS) . Standard anteroposterior and lateral
radiographs of the wrists were made. Features noted were fusion of the DRUJ, and carpal shift. Carpal shift was measured
by the method shown in (Figure 1). This has been adapted from
the method described by Gilula and Weeks . The lunate
measurement medial to the ulnar border of the radius (d-d) was
compared in the immediate postoperative and follow-up x-rays.
Grip strengths were not objectively measured, because they
reflect multifactorial problems in the rheumatoid that cannot be
appropriately controlled when evaluating a single joint .
(Table 1) Clinical assessment indicated that there was
no significant change in the dorsiflexion or palmarflexion of
the wrist joint, while the range of pronation and supination
improved significantly (p < 0.05).There was normal pronation
or supination in 100% of wrists after operation (Figure 2).
Preoperatively, all patients had moderate to severe pain facing
the distal radioulnar joint but painless bone union was achieved
in all patients. Carpal shift was unchanged when compared to
films taken immediately after surgery (Figure 3). There was no
dislocation of the ulnar stump on lateral radiographs.
Rheumatoid arthritis (RA) involves the wrist in up to 95%
of cases. The distal radioulnar joint is affected in 31-75% of
these patients and is frequently the first compartment of the
wrist involved . Wrist involvement in rheumatoid arthritis
(RA) usually begins on the ulnar side, and distal radioulnar joint
(DRUJ) disorders such as arthritis and subluxation are a very
common problem. The stability of the DRUJ is assured by the
triangular fibrocartilaginous complex (TFCC) and the extensor
carpi ulnaris (ECU). Additional stabilizers are the interosseous
membrane and the pronator quadratus muscle. The distal
radioulnar (DRU) joint is the keystone weight-bearing joint of
the distal forearm. In rheumatoid arthritis, the ulnar column of
the carpus tends to slide anteriorly with supination of the carpus.
The DRU joint can dislocate with accentuation of the prominence
of the ulnar head as a result of the anterior dislocation of the
carpus and the radius. This creates caput ulnae syndrome .
The main goal of surgery of the rheumatoid wrist is a pain-free
wrist with restoration of painless pronation/supination.
For DRUJ problems secondary to RA, there are two operations
that are effective: resection the distal ulna and arthrodesis
of the distal radioulnar joint combined with the creation of a
pseudarthrosis of the distal ulna. Traditionally, resection of
the distal ulna (the Darrach procedure) has been the operation
of choice for most problems involving distal radioulnar
degeneration but reported postoperative problems with this procedure have included distal ulnar instability, translation of
the carpal bones in the ulnar direction, weakness, and pain of
the wrist [8,9].
The resection of the distal end of the ulna was first report
by Moore  in 1880 and popularized by Darrach [18,19] in
1912. The procedure was originally described and used in the
treatment of traumatic derangements of the distal radio ulnar
joint and the first report of its use in rheumatoid wrist surgery
came from Smith Petersen . This is an effective procedure in
alleviating pain from DRUJ disease and distal ulna impingement
on the carpus. The main concern of the Darrach procedure for
RA is the potential ulnar translation of the carpus for patients
with weak ligamentous support. For patients whose lunates are
already migrating ulnarly, a concomitant radio-lunate fusion can
be performed, provided that the midcarpal joint is intact.
Another option is the Sauvé-Kapandji procedure  for
treating caput ulnae syndrome involving radioulnar arthrodesis
with resection of an ulna segment. The review of literature
shows clearly the positive effect of this procedure in terms
of function [21-25]. Alternatively, arthrodesis of the distal
radioulnar joint combined with a proximal ulna ostectomy and
creation of a pseudarthrosis of the distal ulna to provide rotatory
function (Suavé-Kapandji procedure) should be considered.
The preserved ulna head gives support to the ulnar carpus and
prevents ulnar translation of the carpus. A potential problem is
the unpredictable fusion of the DRUJ when the bone stock in RA
is not sufficient.
An interesting variation of this procedure is the Masada’s
shelf arthroplasty procedure  in which the excised distal
ulna is turned 90 degrees and inserted into the radius to promote
better bone contact for fusion. There is a recent interest in
replacing the distal ulna with prosthesis. The long-term outcome
of this procedure has not been proven. DRU joint prostheses are
under development and today are only indicated as a salvage
The sequential rupture of the extensor tendons of the
fingers, beginning with the little finger, is a common and
disabling complication of rheumatoid arthritis. It results from
tenosynovial invasion of tendons or, more commonly, from their
attrition on the ulnar head, as described in osteoarthritis of the
distal radioulnar joint by Vaughan‐Jackson . In our series 4
wrists with extensor tendon rupture underwent a free tendon
graft of the palmaris longus tendon.