Sauvé-Kapandji procedure is a distal radial-ulnar arthrodesis
accompanied by resection of the osseous cylinder proximal to the
joint. Prono-supination is performed in this space created upstream
to the arthrodesis.
What is Ulnar Impaction Syndrome (UIS) ?
Impaction Syndrome( or " syndrome du cubitus long" for
French spoken people) is a positive ulnar variance, that is, that
the cubitus is too long regarding the radius.
UIS may be congenital or acquired.
This median is measured by posterioanterior radiographs under
various methodologies :
The lower radio-cubital median is given by the distance of the
radial point measured on the perpendicular passing over the radial
point in the cubital line.
The lower radio-cubital median or ulnar variance is neutral when
its values are around 2 mm. It is positive when the radial point
is above the cubital line.
Along life, the ulna tends to "depression" caused by
forces, and the distal radial ulnar median settles with time.
Finally, the cubitus is long in the congenital malformations such
as the Madelung's disease.
The form of the lower extremity of the ulnar is variable :
of the lower extremity may be prominent and susceptible to causing
conflicts with the carpal when developing a long ulna provided
the distal radio-ulnar median is normal.
sytloid may be very long and touch upon the triquetrum, causing
potential conflict. Sometimes the ulnar styloid is non existent.
These elements have their own pathologies, similar to those of
the UIS. Most often, 80% of the forces from the radius to the
carpal pass through the radial-carpal compartment. The longer
the cubitus, the more forces travel through the ulno-carpal compartment,
causing internal hyperpressure of the carpal.
Post-traumatic lesions are variable :
triangular ligament dislocations, distal or proximal ulnar styloid
fracture, ulnar fracture, ulnar luxation or subluxation, which
modify the pressure on the carpal. The most common result of fractures
of the radius is the long ulna, with its secondary pathology :
most frequent pains after fracture of radius occur in the internal
compartment of this joint.
Pre-existent degenerative lesions and traumatic lesions may also
Prono-supination repetitive motion may cause :
of the central avascular part of the triangular ligament, with
fairly broad perforation.
wear and tear connected first to the lunatum and then to the triquetum,
with full separation of the cubito-carpal interline elements.
are the symptoms ?
Clinical symptoms involve prono-supination pains. Reduction of
motion and strength may occur at ulnar flexion of the wrist.
complimentary examinations are helpful ?
plain radiographs are normal, except for results of distal radius
fracture. It is important to have postanterior views of the forearm
to determine if the radius and the ulnar are parallel. Subluxation
of the ulnar, usually posterior, will be observed, as this may
be the cause for painful complication after most of the treatment
methodologies of a long ulna.
arthroscanner and arthroscopy allow precise diagnosis of the lesions
(ulnar abutment syndrome).
Lesions observed involve perforations, usually central and degenerative
of the triangular ligament, cartilage erosions of the proximal
cup of the semilunate and the triquetal.
Ulno-carpal and secondly distal ulno-carpal arthrosis is the cause
of pain. These have been ignored for long due to standard radiographs.
How is it treated ?
that keep the distal radial-ulnar joints :
The treatment involves ulnar shortening :
There are various techniques : ulnar section above the distal
extremity of the bone, and plaque fixation, preferably through
compression, as these osteotomies do not fix easily. For other
progressive osteotomies, resection of two small osseous fragments
Ulnar shortening is indicated each time the distal radial-ulnar
is well positioned (rounded), congruent and non arthrosic.
Osteotomy will be directional, that is with oblique resection
at the anterior base if the ulnar is subluxed on the back side.
It is sometimes difficult to establish congruity of this joint,
at this level secondary arthrosis may develop.
The Wafer's procedure, which actually is the resection of the
ulnar distal cup may be performed either surgically or through
arthroscopy. Despite the apparent benignancy of the surgical procedure,
the postoperative period usually lasts long, maybe because this
is an intra-articular operation
that resect the distal radial-ulnar joint :
The oldest procedure was introduced by Darrach. It consists in
suppressing 12 mm of the distal ulnar part. This resection should
be accompanied by an arthroplasty and a stabilisation of the remaining
ulnar diaphysis. Fibrous interposition, capsule closure and readjustment
of the ECU tendon should be part of the procedure, which is not
a plain osseous excision.
Variations of the Darrach procedure are Bowers and Watson's :
the former is through oblique resection of the bone, and the latter
resection of the diaphysis over a very long oblique bone.
All the procedures achieve decomposition of the carpal, most of
the forces are transmitted through the radio carpal and pain disappears.
Results in terms of prono-supination vary.
are the specific risks ?
any procedure that involves resection of the distal ulnar extremity
pathology of the ulnar stump may occur, above all if protrudring
on the back side: this causes pain and a tendon protrudring when
Progressive approximation of the two diaphysis which are in contact
and cause pain at pronosupination. Stabilisation of this stump may
be performed in the first procedure or afterwards.