Modified sauve kapandji procedure for patients with old fractures

WRIST

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, & 5 TH 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

7. Test for DRUJ instability : The patient’s elbow is flexed 90 d egree 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. 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

10. 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)

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

12. MODIFIED PROCEDURE

13. Indications

14. AIM

15. Patients and methods

16. Surgical techniques and postop management

17. RESULTS

18. 3 cases are ulnar styloid fracture There are varying degrees of shortening and deformity on distal radius.

19. 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.

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

21. 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° 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 Total point scores Total point scores 90-100 Excellent 80 - 89 Good 65 -79 Fair ＜65 Poor

22. 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.

23. Discussion

24. 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.

25. 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.

26. 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.

27. Complications

28. Take home message

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