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Treatment of the distal radioulnar articulation disorders by the Sauvé-Kapandji technique

Abstracts

A retrospective study of 10 cases of derrangement of the distal radioulnar joint treated with the technique of Sauvé-Kapandji was carried out. Derrangements resulted from trauma (7), degeneration (2) and congenital disease (1) and the main preoperative complaints were pain, limitation of pronation and supination and deformity. The patients' average age by the time of the operation was 37.8 years (range: 19 - 68 years). All were submitted to clinical, functional and radiographic evaluation at 28.3 months after the operation on average, particular attention being paid to an anteroposterior X-ray view with the hand in a moderate hand grip effort. All patients improved from their complaints and the final results were considered satisfactory (excellent or good) in 8, and unsatisfactory (regular) in 2. The distal radioulnar arthrodesis healed uneventfully in 9 cases, independently from the type of fixation used. The X-ray view under strain showed that all patients presented dislocation of the ulna towards the radius, but this apparently did not interfere with function. It was concluded that Sauvé-Kapandji's technique is efficient to treat derrangements of the distal radioulnar joint, since it does not imply significant functional loss.


Foi realizado um estudo retrospectivo de 10 casos de desarranjo da articulação radio-ulnal distal tratados pela técnica de Sauvé-Kapandji. Os desarranjos eram resultantes de trauma (7), degeneração (2) e doença congênita (1) e as principais queixas pré-operatórias eram a dor, limitação da prono-supinação e deformidade. A idade média dos pacientes na época da operação era de 37,8 anos. Os pacientes foram submetidos a avaliação clínico-funcional e radiografica com um seguimento pós-operatório médio de 28,3 meses, particular atenção tendo sido dada a uma incidência radiográfica anteroposterior sob esforço de preensão manual. Todos os pacientes obtiveram melhora de suas queixas e o resultado final foi considerado satisfatório (excelente e bom) em 8, e insatisfatório (regular) 2. A artrodese da articulação radio-ulnal consolidou em 9 casos, independentemente do tipo de fixação empregado. O exame radiográfico sob esforço mostrou que todos os pacientes apresentavam deslocamento radial da ulna, mas isso aparentemente não interferiu com a função. Concluiu-se que a técnica de Sauvé-Kapandji é eficiente para o tratamento dos desarranjos da articulação radio-ulnal distal, pois ela não implica em perda funcional importante.


ARTIGO ORIGINAL

Treatment of the distal radioulnar articulation disorders by the Sauvé-Kapandji technique

Nilton MazzerI; Cláudio Henrique BarbieriII; Marcia Maradei Pereira Tuma MartinsIII; Andrei Garcia de SouzaIII

IProfessor Asocciado

IIProfessor Titular

IIIMédico residente R4

SUMMARY

A retrospective study of 10 cases of derrangement of the distal radioulnar joint treated with the technique of Sauvé-Kapandji was carried out. Derrangements resulted from trauma (7), degeneration (2) and congenital disease (1) and the main preoperative complaints were pain, limitation of pronation and supination and deformity. The patients' average age by the time of the operation was 37.8 years (range: 19 - 68 years). All were submitted to clinical, functional and radiographic evaluation at 28.3 months after the operation on average, particular attention being paid to an anteroposterior X-ray view with the hand in a moderate hand grip effort. All patients improved from their complaints and the final results were considered satisfactory (excellent or good) in 8, and unsatisfactory (regular) in 2. The distal radioulnar arthrodesis healed uneventfully in 9 cases, independently from the type of fixation used. The X-ray view under strain showed that all patients presented dislocation of the ulna towards the radius, but this apparently did not interfere with function. It was concluded that Sauvé-Kapandji's technique is efficient to treat derrangements of the distal radioulnar joint, since it does not imply significant functional loss.

INTRODUCTION

Derrangements of the distal radioulnar joint of any etiology significantly impair the wrist and the hand function1, since they frequently cause pain, important limitation of pronation-supination and reduction of grip strenght1,2 .

The dearrangements predominant etiologies are the traumatic, degenerative and congenital lesions. In the first group, the most frequent are fracture sequelae in the distal end of the radius and, the less frequent, Galeazzi fracture and other fractures of the forearm3,4; in the second group, rheumatoid arthritis1,2,5; and in the third, less frequent than the first two groups, Madelung disease and others1,6 .

The usually chronic treatment of these derrangements, continues to challenge the surgeons, in view of the anatomical and functional complexity of the distal radioulnar joint2. Several techniques were proposed to re-establish the lost movements and alleviate pain, as for instance, Darrach's1 (ressection of the distal ulna), Bowers'8 (hemiressection-interposition) and Baldwin's9 (ressection of the ulnar neck) operations. Darrach's surgery is better indicated for elderly patients, with a not very long life expectancy, since the distal radioulnar articulation impairment is intense. Bowers' intervention is reserved for adult or elderly patients not importantly lesioned in the triangular fibrocartilage7. Baldwin's is, probably, the less frequently indicated.

Sauvé and Kapandji, in 19362,3,10 described their technique consisting of distal radioulnar articulation fusion by cruentation of the articular surfaces and fixation with Kirschner wires or screws, adding the ressection of a 10 to 20 mm segment of the ulna distal metaphysis in order that a pseudoarthrosis develops at that point.

The Sauvé-Kapandji operation is indicated to treat dearrangements of the distal radioulnar articulation from several and different etiologies, but resulting in incongruity, instability and pain, refractary to non-surgical treatment2,8,12. It is, also, a salvation procedure for previous tentatives of unsuccessful surgical treatment, as the Bowers' hemiressection-interposition9. The main contraindications for the operation are active septic arthritis, the ulna insufficient lenght as, for instance, after the Darrach operation or tumoral ressection, and absence of the radius head2.

The Sauvé Kapandji operation won several adepts during the last years, face the good results which were obtained, mainly due to pain alleviation and pronation-supination improvement8,11. Several advantagens have been reported mainly when comparing it to Darrach's surgery. Thus, maintenance of the ulna head propitiates maintenance of the esthetic appearance of the wrist and hinders luxation of the carpus ulnar flexor tendon, and the ulna distal articular surface, untouched, conserves the physiological transmission of forces between the hand and the forearm2,3.

The main disadvantage, also the most commonly reported complication, is the instability of the ulna proximal segment2,3. Nevertheless, it can be corrected during the same operation or, in a later occasion, by fixation of a distal band of the carpus ulnar flexor or extensor tendons, maintained in its original insertion into the ulna proximal stump, through its medular canal. Rupture of the extensor tendon common to the fingers can seldom occur13.

The aim of this study was to retrospectively study patients operated on by the Sauvé-Kapandji technique, all carriers of sequelae from several etiologies and compare our results with the literature.

MATERIAL AND METHODS

From February, 1995, to April, 1999, ten wrists in ten patients carriers of derrangements of the distal radioulnar articulation were operated on by the Sauvé-Kapandji technique. Six female and four male patients with average age 37.8 years by the time of operation (range: 19 to 68 years). The right wrist was impaired in seven cases and the average time between the beginning of the symptoms and the surgical intervention was 23.7 months (range: 3 to 96 months) (Table 1).

The primary pathologies that caused the articulation dearrangement were trauma sequelae in seven patients, degenerative lesion in two, and obstetric paralysis in one. From the seven cases of trauma sequelae, five (numbers of order 1, 2, 4, 9, 10) were secondary to fractures in the distal end of the radius, one (number of order 3) to a Galeazzi fracture and one (number of order 5) to diaphyseal fracture of the forearm bones.

Among the two wrists with degenerative lesion (numbers of order 7 and 8), one resulted from rheumatoid arthritis and the other from ulnocarpal impact, after wrist total arthrodesis. Only one patient (number of order 6) was referred to surgery due to a congenital pathology sequela (obstetric paralysis), with the forearm fixed in supination and the wrist in radial deviation and extension.

The main complaints justifying the indication for Sauvé-Kapandji surgery were limited pronation-supination, pain during usual activities and wrist deformities.

Surgical procedure

The patients were operated on under regional (8) or general (2) anesthesia. The approach to the distal radioulnar articulation was made through dorsal longitudinal incision on the ulna or triradiate. Initially, the articulation was opened, and then cruentation was made of the articular surfaces until the spongy bone was visible, just under the subcontral bone. Afterwards, ressection osteotomy was made of a metaphyseal bone segment with 11.7 mm (range: 10 to 17 mm) average lenght, in the ulna neck region. Optionally, osteotomy was carried out before opening, cruentation and fixation of the joint. When it is carried out complete handling of the ulna head is possible, easing its positioning that, ideally, should be at the same height of the radiocarpal articular surface, preventing shock with the pyramidal bone. After positioned, the ulna head was fixed to the radius in four patients by interfragmentary compression with a 3.5 mm diameter screw, in other four with a screw associated to a Kirschner wire, and in two with two parallel Kirschner wires. Associate procedures were carried out in five wrists: stabilization of the ulna proximal segment with a band of the carpus ulnar extensor tendon (2), wrist total arthrodesis (2), and corrective osteotomy of the radius and tenolysis of the flexor tendons (1). Bone grafting was used in only one case to improve contact among the articular surfaces to be arthrodesed, having the ulna resected segment as source.

In the immediate post-operatory period, the patients were immobilized with an antebrachial-palmar plaster cast during a mean period of 5.4 weeks (range: 2 to 6 weeks) and were referred to physiotherapy.

Re-evaluation of the patients

The mean follow-up period in this re-evaluation was 28.3 months (range: 9 to 58 months) and a protocol based in the clinical evaluation was used, including goniometric determinations of movement amplitude of the wrist and forearm, particularly pronation-supination, and the measurement of the manual grip force with a dynamometer. The radiographic evaluation included conventional incidences (posterior-anterior and lateral of the wrist) and a posterior-lateral incidence with the patient exerting manual grip by holding a 2 kg weight. The two posterior-lateral incidences were carried out with the upper limb totally contacting the X-rays table and the elbow bending 90o.

Besides the clinical-radiographic objective evaluation a subjective evaluation was made, both by the patients and the doctor, aiming basically satisfaction with the functional result and occasional complaints, provided they were founded.

The X-rays were evaluated according to the technique described by Nakamura et al.14, modified according to the purposes of this study. Ulnar flaw, resulting from segmental resection and correspondent to the extension of the created pseudoarthrosis, and the radioulnar distance, between the middle point of the ulna diaphysis, immediately proximal to the stump irregularity, and the middle point of the radius diaphysis, at the same height (Figure 1). That distance was measured in the conventional posterior-anterior incidences and with load, and the difference between the two results was called ulnar displacement in the radius direction, that is, it is the ulna instability quantification in the radioulnar plan.


The results were classified as satisfactory (excellent and good) or non-satisfactory (regular and bad), and this was a subjective determination, since the sample was small and heterogeneous, as a function of the different etiologies.

RESULTS

The final evaluation of the patients was fundamentally based in the remaining symptomatology, resuming or not the previous activities and in the patients' opinion, considering also the severity of the pathology.

All the patients showed some grade of improvement after the intervention. In the overall evaluation, eight patients had results considered satisfactory, five excellent and three good, and two patients presented non-satisfactory results, since they were only regular. No manifestedly bad results were obtained.

Clinical Results

Pain: five patients did not report any pain, while three informed pain only during intense effort, and one pain with effort.

Mobility: pronation-supination was on average 148o, or 90% normal, from 112o to 175o (67% to 100% normal). Flexure-extension of the wrist varied from 66o to 144o (40% to 90% of normal), averaging 104o, or 40% normal, however the patients with total wrist arthrodesis were not considered (numbers of order 7, 8 and 9) (Table 2).

Grip strenght: on average 16 Kgf, representing 68% of the normal contralateral side. Range was 4 to 30 Kgf corresponding, respectively, to 20% and 115% of normal. In two patients (numbers of order 7 and 8), strenght exceeded the opposite side, since both presented the same pathology in the contralateral wrist (Kienböck disease and rheumatoid arthritis, respectively), not yet treated (Table 3).

X-rays results

Distal radioulnar articulation arthrodesis was made in 9 among the 10 wrists (Figura 2).

The left out case (Figure 3, number of order 4), had no additional procedures carried out, since pain and instability in the ulna head were absent.

In all the cases, the segment resection evolved to pseudoarthrosis and this ulnar flaw measured 10 to 17 mm, 11.7 mm on average (Table 4). The conventional posterior-anterior incidence evidenced that the average radioulnar distance was 18.8 mm (range: 11 to 26 mm). With the 2 kg load, it was reduced to 12.75 mm (range: -5.5 to 21 mm). Considering these values, the ulnar displacement in the direction of the radius was observed in all the patients, 6.05 on average (range: 1 to 16.5), evidencing instability of the ulna proximal stump in the radioulnar plan.

The presence of forearm instability was not a specific complaint of the patients and apparently did not influence the final clinical results (Table 4).

Complications

Three patientes presented complications. In one case, superficial infection, treated with systemic antibioticotherapy, and asymptomatic dorsal instability of the ulna proximal stump (number of order 1). In another (number of order 2), there was partial consolidation of the ulna osteotomy but re-intervention was not necessary. In the third (number of order 7), painful instability occurred in the ulna proximal stump, and a stabilization procedure was indicated with a band of the carpus ulnar extensor tendon, not yet consented by the patient.

Eight patients resumed their previous usual or professional activities. One (number of order 10) alleged that the lesion, in the dominant member, hindered him from working. The other (number of order 7) submitted to total arthrodesis in both wrists had no usual or professional activity, being limited to activities as hygiene and alimentation.

DISCUSSION

The Sauvé and Kapandji technique for the treatment of the distal radioulnar articulation derrangements is not universally accepted. However, samples greater than the one analyzed in this study, have shown its efficiency to solve these conditions with a relatively low incidence of complications1,3,4 and the results of this study confirm that observation, accepted and published in the literature.

The number of satisfactory results obtained in this study (8/10) is equivalent to the approximately 80% reported by Condamine and Aubriot1, evaluating 69 patients with several pathologies of different etiologies and belonging to different age groups (twenties to eighties) treated by the Sauvé-Kapandji technique.

Just as reported with big groups of patients1,3,4, in the traumatic radioulnar articulation dearrangements the most determinant symptom to indicate the Sauvé-Kapandji operation was limitation of pronation-supination, present in about 90% of the mentioned cases, while pain has only been present in 43% of the cases. Concerning degenerative pathologies, as rheumatoid arthritis, the evidences show that pain assumes greater importance1,5. In this group, this was observed in the only patient with that condition, being pain the main complaint.

The reason for the application of the Sauvé-Kapandji technique in the obstetric paralysis case (number of order 6) was to relieve pain, particularly at rest. That aim was achieved, and pain was observed only during excessive effort. Up to this moment, no functional or esthetic improvement was observed, since the patient continued to present scarce movement with the forearm in supination, consequent to the basic pathology and pre-existent muscular athrophy. That was, probably, a pioneer indication, since none of the revised authors had mentioned that indication.

Adequate indication and execution of this technique led to pain relief and increased mobility, mainly in pronation-supination, possibilitating to most patients to resume their working acitivities. It is true, though, that in some cases pain persistence to heavy effort, though well tolerated, restricts some activities, and this was also mentioned by other authors1,5.

The different fixation methods used for the distal radioulnar articulation arthrodesis did not influence its consolidation, since this was observed in most of the cases (9/10). In the patient consolidation did not occur as X-rays view has evidenced, the absence of symptoms indicated periodic observation and re-intervention was not considered.

The use of bone grafts, suggested by some authors2, seems unnecessary since it was used in only one occasion (number of order 8) aiming exclusively to improve adaptation of the ulna head to the radius articular surface bed.

In agreement with the other studies1,2,3, the main site of complications is the ulna proximal segment, that remained dorsally unstable in two of the ten patients (numbers of order 1 and 7), one of them painless. In the patient with painful and anti-esthetic instability (number of order 7), the probable cause was a very wide ulnar flaw (17 mm). Similarly to most of the patients of this study, it is recommended that the resected ulna segment is 10 to 12 mm long2 , and that the resection region be located inside the band of origin of the ulna squared pronator muscle. Static and dynamic instability of the ulna in the radioulnar plan was evaluated comparing the conventional radiographic incidences and load, as proposed by Nakamura et al .14. In some cases, even with no load, the ulna presents small approximation to the radius. However, when effort is made to hold the 2 kg load, manifested displacement of the ulna in the direction of the radius occurred in all cases, characterizing an instability between the radius and the ulna, which did not interfere in the final result. The relevance of this investigation was to determine the need to routinely carry out a ulna stabilization procedure and this apparently is not the case considering the absence of symptoms at least in the post-surgery studied period.

Partial consolidation of pseudoarthrosis or re-ossification of the ulna osteotomy are frequently reported, often demanding corrective re-intervention1. In this group of patients, this was observed in only one patient (number of order 2) but maybe because only 20% of the pseudoarthrosis was involved, it did not block pronation-supination and did not require re-intervention.

The association of the Sauvé-Kapandji operation with wrist total arthrodesis is not frequently reported. In this series of patients, it was employed in three (numbers of order 7, 8 and 9) and produced satisfactory results in two, mainly because it allowed almost total equivalence of pronation-supination as far as the opposite side was concerned. Actually, wrist total arthrodesis, carried out by conventional techniques as the A.O. technique, does not interfere with the radioulnar articulation, consequently it does not correct occasional pronation-supination blocks. The conclusion is that the combination of these two techniques may be useful in these cases and must be indicated.

CONCLUSION

Although this sample is relatively small and contains different etiologies dearrangement cases of the distal raioulnar articulation, the results, though preliminary, are encouraging in relation to applicatibility and efficacy of the Sauvé-Kapandji technique to treat such difficult problems. This operation confirmedly is a valuable option mainly to treat young patients with trauma sequelae, when more radical procedures as Darrach's would be disabling. Not comparing it with other procedures as Bowers's for instance, the Sauvé-Kapandji operation is an effective therapeutic weapon, and it must be recommended for cases similar to those mentioned in this study. However, though relatively simple and easy to execute, it must be acurately carried out, in order to repeat our good results.

REFERENCES

Serviço de Cirurgia da Mão e do Membro Superior e Microcirurgia.

Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - USP

14048-900 Ribeirõ Preto SP BRASIL

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Publication Dates

  • Publication in this collection
    27 June 2006
  • Date of issue
    Mar 2001
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