CHAPTER 34 Sauvé-Kapandji Procedure after Distal Radius Fractures
Injuries to the distal radioulnar joint (DRUJ) with a distal radius fracture can cause ulnar-sided wrist pain, decreased forearm rotation, instability of the ulna, and loss of function. Controversy exists as to the treatment of this disorder. Some of the options include distal ulna resection (Darrach procedure),1 hemi-resection and interposition arthroplasty,2 matched distal ulna resection,3 and the Sauvé-Kapandji procedure.4 Satisfactory outcomes have been achieved using all of these procedures.2,3,5–14 Limitations of these procedures can include diminished grip strength, instability of the wrist, rupture of extensor tendons, and ulnar carpal abutment. Consistently good results can be difficult to achieve in young, active patients.15 In this chapter we discuss the use of the Sauvé-Kapandji procedure for treatment of DRUJ derangement after distal radius fractures.
History
The first description of a pseudarthrosis of the ulna performed for distal radioulnar pathology was recorded by Lauenstein in 1887. In 1921, Baldwin described a similar procedure with fixation of the DRUJ. The first detailed description of a fusion of the DRUJ with resection of bone just proximal to the fusion site was published by Louis Sauvé and Mehmed Kapandji in 1936.4 Since this publication, there have been several modifications proposed by different authors but the name “Sauvé-Kapandji procedure” has remained.
Indications
Mikkelsen and colleagues8 used “chronic ulnar wrist pain after Colles’ fracture” as the indication for the Sauvé-Kapandji procedure. George and associates6 stated that “severe and persistent pain in the DRUJ” was the primary indication for the Sauvé-Kapandji procedure. Ulnar-sided wrist pain after distal radius fracture can be the result of a variety of conditions, including DRUJ arthritis, DRUJ instability, and ulnocarpal abutment, all of which are conditions that may be caused or compounded by a malunion of the distal radius. It is our practice to define the pathology and try to restore normal anatomy before proceeding to the Sauvé-Kapandji procedure. For example, ulnar-sided pain in a patient with a malunion of the distal radius, with no arthritis of DRUJ, is offered a corrective osteotomy of the radius. A patient with mild instability of the DRUJ and a radius in at least a neutral palmer tilt is offered an ulnar-shortening osteotomy. If the DRUJ is unstable and there is no arthritis, we will first offer a ligament reconstruction for the DRUJ. Our indications for the Sauvé-Kapandji procedure after distal radius fracture are very specific: (1) active, high-demand patient with DRUJ arthritis and (2) failed ulnar shortening or ligament reconstruction for DRUJ instability.
Contraindications
The only true contraindication is inadequate bone stock at the DRUJ. Relative contraindications include heavy smoking or medical conditions that might adversely affect bone healing. Patients should understand the limits of the procedure. The Sauvé-Kapandji procedure will not improve extension and flexion of the wrist but is excellent at restoring near-normal forearm rotation. Grip strength is improved but does not return to normal levels, and return to work rates have varied. Pain is generally significantly improved but is still mildly to moderately present with the extremes of activity.6–9,12,13
Surgical Technique
An incision is made between the fifth and sixth compartments to expose the distal portion of the ulna and the DRUJ (Fig. 34-1). Care should be taken to protect the dorsal sensory branch of the ulnar nerve. The joint capsule is elevated off of the DRUJ (Fig. 34-2). Reciprocal surfaces of the DRUJ are resected using a microsagittal saw (Fig. 34-3
