The document discusses a study evaluating the clinical and radiographic outcomes of a modified Sauve-Kapandji procedure for patients with old fractures of the distal radius. The modified procedure involves resection and reinsertion of the distal ulna into the distal radius after a 90-degree rotation. The study reviewed 15 patients who underwent the procedure with at least 7 months of follow up. Results found 80% of patients had excellent outcomes with reduced pain, improved range of motion, and grip strength. The modified Sauve-Kapandji procedure provides an effective treatment for chronic distal radioulnar joint disorders in patients with old distal radius fractures.

1. MODIFIED SAUVE-KAPANDJI
PROCEDURE FOR PATIENTS
WITH OLD FRACTURES OF THE
DISTAL RADIUS
Zhitao Guo, Yuli Wang, Yacong Zhang
Open Medicine journal 2017
Dr.PONNILAVAN

2. Articulations of wrist
The wrist comprises 3 movable joints:
Distal radio-ulnar joint,
 radio-carpal joint (b/w
Radius & proximal row of carpal bones) &
midcarpal joint (b/w the proximal and
distal rows
of carpal bones).

3. DRUJ ANATOMY
Scaphoid
Lunate
Triquetrum
ULNO-LUNATE &
ULNO-TRIQUETRAL LIGAMENTS
VOLAR RADIO-ULNAR
LIGAMENT
DORSAL RADIO-
ULNAR
LIGAMENT
EXTENSOR CARPI ULNARIS

4. TFCC
- Dorsal & Volar radioulnar
ligaments
- Ulnar collateral ligaments
- Meniscal homologue
- Articular disc
- Extensor carpi ulnaris sheath

5. TFCC
Begins - ulnar side of lunate
fossa of radius
Attachment- to the ulnar head
and the ulnar styloid at its base.
It is subsequently joined by the ulnar collateral
ligament, & its distal insertion is triquetrum,
hamate, & 5TH metacarpal base.
Articular surface contact in shallow sigmoid
notch accounts for about 20% of DRUJ stability
& allows dorsopalmar translation of abt 1 cm
with forearm in neutral position.

6. INTRODUCTION
Distal radius fractures accounts for 75% of all the forearm fractures
Injuries to DRUJ with a Distal Radius fracture can result in
Pain of the Wrist
Decreased forearm rotational movements
Instability of the ulna and loss of function

7. Test for DRUJ instability:
The patient’s elbow is flexed 90
degree on the table. The
physician uses
one hand to stabilize the
patient’s wrist and the other
hand to hold
the distal ulnar and to try to
displace dorsally (a) and
palmarly (b).
A B

8. The various surgical
techniques include
 Distal ulna resection
 Partial resection with
interposition
arthroplasty
 Sauve-kapandji
procedure

9. Limitations
Diminished
grip strength
Instability of
wrist
Rupture of
the extensor
tendons and
ulnar carpal
structures

10. Sauve-Kapandji
procedure
In 1936, Sauve and Kapandji presented the procedure, an arthrodesis across
the DRUJ and created a pseudarthrosis of the ulna, proximal to the fusion, to
restore pronation and supination

12. modified Sauve-Kapandji
procedure
FCU
ECU
Pronator
quadratus
Distal radioulnar arthrodesis with distal ulnar
pseudarthrosis (modified Sauvé-Kapandji
procedure)
stabilization of proximal ulnar segment with distally based slip of
flexor carpi ulnaris tendon (FCU).
Nonunion gap is filled with pronator quadratus, which is sutured
to tendon sheath of extensor carpi ulnaris
muscle (ECU)

13. The modified Sauve-Kapandji
procedure involves resection of
the distal ulna with reinsertion of
the bone into the distal radius
after a 90-degree rotation.
This provides improved bone stock and
allows the procedure to be performed
in the setting of destruction of the
ulnar head, while potentially reducing
the rate of nonunion.

14. • The Sauve-Kapandji procedure can be performed for disorders
of the DRUJ after all fracture are healed and nonoperative
treatment has failed.

15. The modified
procedure
maintains the
ulnocarpal
buttress
Preserves
the TFCC and
Ulnocarpal
ligaments Provides
physiological
pattern of force
transmission from
hand to forearm,&
maintains ECU
tendon in its
compartment.
MODIFIED PROCEDURE

16. Indications
• Post-traumatic osteoarthritis of the joint
• Chronic irreducible dislocation of the ulnar head with extensive
limitation of forearm rotation
• Posttraumatic synostosis of the distal part of the forearm
• Simultaneous arthritic or Post-traumatic destruction of the sigmoid
notch and lunate fossa,
• Need for salvage after a failed hemiresection arthroplasty.

17. To evaluate the clinical & radiographic outcomes of
a modified Sauve-Kapandji procedure for patients
with old fractures in the distal radius.
AIM

18. The Modified Sauve-kapandji procedure is now an
established treatment option in the setting of postoperative
disorders of DRUJ
This study reviews the clinical experience with the modified
Sauve-Kapadnji procedure for chronic disorders of the DRUJ
in patients with old fractures of the distal radius.

19. Patients and methods
15 consecutive pts
were selected &
followed prospectively
with post-operative
derangement of DRUJ
b/w 2014 & 2016.
All patients had
at least one
previous
operation on the
involved wrist
They were still
having pain &
functional
limitations for 7
mts to one year
after the
operation

20. Surgical techniques and postop
management
Incision
5 to 6 cm proximal to the
prominence of the ulnar
head
Ending at the level of the
pisiform
longitudinal skin incision
over the subcutaneous
border of the ulna
between the flexor carpi
ulnaris (FCU) and
extensor carpi ulnaris
(ECU) tendons.

21. Identify and protect the
dorsal sensory branch of
the ulnar nerve.
After a thorough DRUJ
synovectomy, the ulnar
notch of the radius and
the ulnar head were
decorticated.
• The resulting space
b/w ulna head &
distal radius is
measured.

22. A segment of
bone of
equivalent length
is resected from
the distal ulna to
use as an
intercalary graft.
Rotated and
inserted into the
DRUJ to bridge
the gap between
the ulnar head
and the ulnar
notch of the
radius.
K wire was used
to fix the bone
segment and the
distal end of the
radius.
• The second k
wire was
drilled into the
DRUJ
proximally to
stabilize the
DRUJ.

23. Proximal stump can be
stabilized with gliding
of the FCU & ECU.
Postoperatively
the limb is
immobilized in a
cast for 4 weeks
with the forearm in
45 degrees
supination.
After 4 weeks
mobilization
started with
functional
casting

24. RESULTS
The modified Sauve-Kapandji
procedure was performed in 15
patients with post-operation
derangement of the DRUJ
Study done from 2014 to 2016.
All presented with pain in DRUJ
and impaired rotation of the
forearm.

25. Out of 15
10 men and 5
women
6 left and 9 right
Mean age 40
years at the time
of surgery
Followed up
upto 20 months
7 are complicated
with malunion of
comminuted
fractures
4 cases are
complicated with
DRUJ dislocation
3 cases are
ulnar
styloid
fracture
There are
varying degrees
of shortening
and deformity
on distal radius.

26. 55yr/M
Preoperative x-ray film showed
separation of DRUJ.
MRI - slight osteoarthritis of the
DRUJ
All patients underwent Xray, MRI
and clinical examination before the
operation and at the final follow-
up.

27. Pain
Features Points
No pain 25
Mild, occasional 20
Moderate,
tolerable
15
Severe to
intolerable
0
Functional status
Features Points
Return to regular
employment
25
Restricted
employment
20
Able to work, but
unemployed
15
Unable to work
because of pain
0
Modified Mayo Wrist Score

28. Range of motion
Features Points
≥120° 25
100 to 119° 20
90 to 99° 15
60 to 89° 10
30 to 59° 5
0 to 29° 0
Grip strength (% of normal)
Features Points
90 to 100 25
75 to 89 15
50 to 74 10
25 to 49 5
0 to 24 0
Total point scores
Total point
scores
90-100 Excellent
80 - 89 Good
65 -79 Fair
＜65 Poor

29. At the final follow-up
80% patients (12 excellent, 2 good results, 1 fair) have achieved excellent.
Preoperatively, all patients had moderate to severe pain.
At the latest follow-up, fourteen patients had no pain.
Only one patient had mild pain.

30. Range of motion (ROM)
Pronation improved from a preoperative mean of 48
degree to a postoperative mean of 88 degree ,
Supination progressed from a preoperative mean of
51 degree to a postoperative mean of 86 degree.

31. • Grip strength
• Preoperative mean of 51%
• Postoperative mean of 88% on the ipsilateral side compared with the
contralateral side.
• The same patient, X-ray film on POD 1 and 4 months after the
procedure showed that the pseudoarthrosis gap of the ulna was well
preserved and that the stability of the proximal ulnar stump also was
preserved.

32. Discussion
The Sauve-Kapandji procedure is useful for treating
various pathologic conditions that alter normal
function of the DRUJ.
This technique preserves the head of the ulna and
minimizes the potential for some of the
complications that can follow its excision.

33. The modification of Sauve-Kapandji procedure is a reliable salvage operation for young
active patients with chronic post-traumatic derangement.
Mohamed et al reported that 18 patients with chronic post-traumatic derangement of
DRUJ were treated by a modified Sauve-Kapandji. 12 patients had satisfactory outcome
and 4 patients presented a fair outcome by using the modified Mayo wrist scoring
system.

34. Stabilization of the proximal ulnar stump associated with Sauve-Kapandji procedure is
a useful procedure to prevent an unstable ulnar stump in the treatment of
osteoarthritis of the DRUJ.
Modifications were performed in order to control stump instability.
Akio Minami et al reported thirteen osteoarthritic wrists treated by the method of
stabilizing the proximal stump of the ulna during the Sauve-Kapandji procedure by
using a half-slip of the extensor carpi ulnaris and found to have satisfactory outcome.

35. Sauve–Kapandji procedure is a common treatment for rheumatoid
wrist.
Since the procedure does not fuse the carpal with the forearm bone,
this procedure alone could not prevent postsurgical progression of
carpal translocation.
It has an advantage over wrist fusion since this procedure can
preserve wrist motion after surgery.
It was performed on 56 patients with rheumatoid arthritis
All patients achieved osseous union, wrist pain resolved or
decreased, and mean total range of forearm rotation increased by
23°

36.  Ota N et al concluded that modified Sauve-Kapandji procedure was a
useful reconstruction procedure in patients with severe RA with poor
bone quality.
• Kawabata A et al reported with the mean follow-up of 93.1 months.
• The wrist pain reduced
• ROM increased significantly regarding pronation and supination but
decreased significantly in flexion.

37. • The modified Sauve–Kapandji procedure is an alternative salvage
procedure to restore forearm rotation of revascularized hands.
• Wang W et al evaluated the patients with forearm rotation limitation
after successful wrist-level revascularization who underwent a
modified Sauve-Kapandji procedure.
• The Surgery disturbed the stability of the DRUJ and gave rise to
forearm rotational loss.
• Stable DRUJ was achieved by the construction of a quadrilateral frame
by performing fusion of the DRUJ using a bone graft and found that
good results were achieved.

38.  W. Zhang et al performed a wrist arthrodesis reconstruction
combining with a modified Sauve-Kapandji procedure for patients
with a giant cell tumour of the distal radius.
 followed for a mean of 36 months
 The mean wrist ROM of the supination and pronation respectively
was 75° and 70°.
 Grip strength - mean of 71% of the preoperative grip strength.
 Concluded as an efficient technique for the treatment of a distal
radius giant cell tumor.

39. Complications
-if not done proper -
instability of the proximal
ulna stump, which is again
quite difficult to treat.
-Reossification of the
pseudarthrosis site in the
ulna and instability of the
proximal ulnar stump.
• To prevent the latter
complication, an additional
palmar tenodesis with a distally
based tendon strip of the flexor
carpi ulnaris was used to stabilize
the proximal stump

40. Take home message
The modified Sauve-Kapandji procedure is now
an established treatment option for
symptomatic DRUJ dysfunction.

41. THANK U