Salvage of failed Sauvé-Kapandji procedure with an ulnar head prosthesis: report of three cases

Technique for insertion of a Scheker prosthesis for failed Sauve-Kapandji with a well fixed ulnar stem: A case report

INTRODUCTION

The Scheker prosthesis is a distal radioulnar joint (DRUJ) arthroplasty used as a salvage option for many DRUJ pathologies.

PRESENTATION OF CASE

We report the case of a patient who underwent insertion of a Scheker prosthesis for continued pain and limited motion at the wrist in the setting of a failed Sauve-Kapandji with a well fixed ulnar stem and DRUJ pseudo-arthrosis.

DISCUSSION

This report aims to provide a technique for ulnar stem removal without compromising the bone needed for the Scheker prosthesis and for describing the location of a DRUJ osteotomy without compromising radio-lunate stability.

CONCLUSION

The Scheker prosthesis is able to be safely inserted for DRUJ salvage after removal of a well fixed ulnar stem if careful removal prevents destruction of the ulna, as described here.

Midterm Outcomes of the Use of a Spherical Ulnar Head Prosthesis for Failed Sauvé-Kapandji Procedures

PURPOSE

The use of a spherical ulnar head prosthesis (UHP) for the treatment of symptomatic radioulnar convergence after Sauvé-Kapandji (SK) procedure has shown promising results in the short term. This study aims to evaluate the midterm outcome of the original cohort of patients treated with this technique.

METHODS

Seventeen patients with unstable ulnar stumps confirmed both clinically and radiographically were studied. The etiology for the initial SK procedure included posttraumatic distal radioulnar joint (DRUJ) incongruity, primary DRUJ arthrosis, and dysplastic DRUJ. Fourteen of the 17 patients had a minimum of 2, and a maximum of 6, operations prior to having a spherical UHP. All patients suffered from severe pain with difficulty in performing work and daily activities. Ceramic UHP was used for all patients, except 2 in whom a cobalt chrome head was used.

RESULTS

The average follow-up was 6 years (range, 4-17 years). A marked reduction in pain was observed with 11 patients reporting that they remained pain free. The range of motion of the wrist and power grip was maintained and showed a statistically significant improvement at the late follow-up. The Disabilities of the Arm, Shoulder, and Hand score also significantly improved from 77 to 41. There were no signs of prosthetic loosening at the midterm follow-up. The 2 patients with cobalt chrome prostheses had pain and osteolysis requiring revision to total DRUJ prosthesis. Two patients with dorsal prosthetic subluxation were successfully treated with distal radial osteotomy.

CONCLUSIONS

The midterm results of ceramic spherical UHP for failed SK procedures in this small patient series are encouraging.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Unipolar ulnar head replacement for treatment of post-Darrach procedure instability

The aim of this study was to assess distal radioulnar joint stability after unipolar ulnar head replacement for post-Darrach instability. All the patients who underwent ulnar head replacement between1999 and 2015 for post-Darrach procedure instability at our clinic were reviewed. Seven Hebert-type and two uHead (SBI/Stryker) prostheses were implanted. None of the implants were cemented. We assessed stability, pain, range of motion and strength pre- and postoperatively. The changes in the radiographic appearance between immediate postoperative and the last follow-up were determined. All patients (8 patients and 9 joint replacements) had a stable distal ulnar stump at the mean follow-up of 69 months. No complications occurred and no revisions were needed. Pain on a visual analog scale (VAS) was 0 at rest and 6 during maximum effort at the last follow-up; it was 1.5 at rest and 8.5 during effort preoperatively. Wrist flexion and extension, supination and grip strength were unchanged. Pronation increased from 45° to 70°. An area of bone resorption proximal to the ulnar head implant was found in 5 cases but no secondary displacement of the implant or increased pain was reported. Ulnar head replacement stabilizes the ulnar stump. The implant acts as a spacer to place the soft tissues under tension. Distal ulnar stump instability after the Darrach procedure can be solved by a unipolar ulnar head replacement procedure.

Distal radio-ulnar implant arthroplasty: a systematic review

The use of implant arthroplasty in the hand and wrist is increasing, often with little evidence of outcomes in the literature. We therefore undertook a systematic review of the outcomes of distal radio-ulnar joint arthroplasties following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Papers were assessed for outcomes, implant survival and methodological quality. Fourteen papers assessed ulna head replacements. The implant survival rate was 93% at a mean follow-up of 45 months. One paper assessed a partial ulna head replacement. Fourteen papers assessed total distal radio-ulnar joint replacements; all but two used the Aptis prosthesis. These implants had a survival rate of 97% at a mean of 56 months. Complications rates were 28% in both groups, and many were major. Although these data are impressive, worldwide there are many more implants placed and not followed up. All studies were level IV and V studies with low Coleman scores. This systematic review demonstrates that implant arthroplasty for the distal radio-ulnar joint has produced acceptable results in small numbers of patients. Whilst these short term outcomes are encouraging, the indications should be carefully considered and there should be proper consideration of the potential for later failure.

LEVEL OF EVIDENCE

III.

The Primary Sauve–Kapandji Procedure—For Treatment of Comminuted Distal Radius and Ulnar Fractures

We have performed primary Sauve–Kapandji procedures on four patients with severe open comminuted fractures of both the distal radius and ulna. The fragmented distal ulna was fixed to the sigmoid notch in order to stabilize the ulnar side of the carpus, and a proximal pseudoarthrosis was maintained for forearm rotation. All the distal radial fractures united without major complications. The mean wrist flexion/extension arc was 76°, the mean pronation/supination arc was 135°, and grip strength was 64% of the contralateral side. All patients returned to their work or daily activities within short time period without any additional surgical treatment, except for removal of implants in three patients. The primary Sauve–Kapandji procedure is effective for the reconstruction of severely combined distal radius and ulnar fractures.

Arthroplasty of the distal ulna distal in managing patients with post-traumatic disorders of the distal radioulnar joint: measurement of quality of life

Objective

To measure the quality of life and clinical–functional results from patients diagnosed with osteoarthrosis of the distal radioulnar joint who underwent surgical treatment using the technique of total arthroplasty of the ulna, with a total or partial Ascension^® prosthesis of the distal ulna.

Methods

Ten patients were evaluated after 12 months of follow-up subsequent to total or partial arthroplasty of the distal ulna. All of them presented post-traumatic osteoarthrosis and/or chronic symptomatic instability of the distal radioulnar joint. The study was prospective. Seven patients had previously undergone wrist procedures (two cases with Darrach, three with Sauvé–Kapandji and two with ligament reconstruction of the fibrocartilage complex) and three presented fractures of the distal ulna that evolved with pain, instability and osteoarthrosis of the distal radioulnar joint. The following were assessed: quality of life (DASH scale); percentage degree of palm grip strength (kgf) and pronosupination range of motion in relation to the unaffected side; pain (VAS); return to work; subjective evaluation of radiography; and complications.

Results

The patients presented a mean range of motion of 174.5° (normal side: 180°). Quality of life was analyzed by applying the DASH questionnaire and the mean value found was 5.9. The mean pain score using the VAS was 2.3. The mean degree of palm grip strength (kgf) was 50.7, which represented 90.7% of the strength on the unaffected side. The complication rate was 10%: this patient presented slight dorsal instability of the ulna and persistent pain, and did not return to work. This patient is still being followed up in the outpatient clinic and occupational therapy sector, with little improvement. He does not wish to undergo a new procedure. The mean length of follow-up was 16.8 months, with a minimum of 10 and maximum of 36 months.

Conclusion

This concept is subject to the test of time. Implantation of a prosthesis is a very interesting addition to the surgical arsenal for those who are specialists in hand surgery. Arthroplasty of the distal ulna is a safe and effective method with clinical–functional and quality-of-life improvements for patients and presents a low complication rate.

Management of complications of wrist arthroplasty and wrist fusion

The human wrist joint is unique from functional and anatomic standpoints. Numerous articulations exist within the wrist that allow for many options for partial wrist fusion and arthroplasty. In cases of pancarpal disease, fusion or arthroplasty of the entire wrist joint can be performed. Because of the high functional demand of the wrist, many of these surgical options can fail, leading to devastating complications. This article addresses the types of fusions and arthroplasties available for the wrist and discusses the potential complications associated with each. Methods to prevent these complications are presented and those to treat them once they have occurred are discussed.

Implant arthroplasty for treatment of ulnar head resection-related instability

Resection of the ulnar head in cases of debilitating pain owing to arthrosis of the distal radioulnar joint can provide satisfying relief. However, there is mounting evidence that pain with heavier use, instability, and torque-generating weakness in more active individuals may result in less satisfying outcomes. Implant arthroplasty can provide a means to stabilize the radius to the ulna after ulnar head resection, but it requires significant attention to requisite soft tissue stabilization and alignment of the distal radius to the implant to be successful.

Ulnar head replacement and related biomechanics

A stable distal radioulnar joint (DRUJ) is mandatory for the function and load transmission in the wrist and forearm. Resectional salvage procedures such as the Darrach procedure, Bowers arthroplasty, and Sauvé-Kapandji procedure include the potential risk of radioulnar instability and impingement, which can lead to pain and weakness. Soft tissue stabilizing techniques have only limited success rates in solving these problems. In an attempt to stabilize the distal forearm mechanically following ulnar head resection, various endoprostheses have been developed to replace the ulnar head. The prostheses can be used for secondary treatment of failed ulnar head resection, but they can also achieve good results in the primary treatment of osteoarthritis of the DRUJ. Our experience consists of twenty-five patients (follow-up 30 months) with DRUJ osteoarthritis who were treated with an ulnar head prosthesis, with improvement in pain, range of motion, and grip strength. An ulnar head prosthesis should be considered as a treatment option for a painful DRUJ.

Salvage of failed resection arthroplasties of the distal radioulnar joint using an ulnar head prosthesis: long-term results

PURPOSE

The aim of this prospective multicenter study was to evaluate the long-term outcome of the Herbert ulnar head prosthesis for painful instability of the distal radioulnar joint (DRUJ) following resection of the ulnar head.

METHODS

Twenty-three patients were treated with a Herbert ulnar head prosthesis in 3 international hand centers. One patient was excluded from the study because a septic prosthesis had to be removed after 3 months. Sixteen of the remaining 22 patients could be assessed at 2 follow-up times, 28 months (range, 10-43 mo) and 11 years and 2 months (range, 97-158 mo) after surgery, for DRUJ stability, forearm rotation, grip strength, pain level (0-10), and satisfaction (0-10). Standardized radiographs of the wrist were evaluated for displacement of the ulnar head and loosening or bony reactions at the sigmoid notch or the ulna shaft.

RESULTS

All patients demonstrated a clinically stable DRUJ at the latest examination, and no patient required further surgery at the DRUJ since the short-term evaluation in 1999. Average pain measured 3.7 before surgery, 1.7 at the short-term follow-up, and 1.7 at the long-term follow-up; patients' satisfaction, 2.2, 8.2, and 8.9; pronation, 73°, 86°, and 83°; supination, 52°, 77°, and 81°; and grip strength, 42%, 72%, and 81% of the unaffected side. All clinical parameters improved significantly from before surgery to the short-term follow-up, with no further statistically significant change between the short-term and long-term follow-up. Radiographs demonstrated no signs of stem loosening or incongruity of the DRUJ.

CONCLUSIONS

The previously reported short-term results with the Herbert prosthesis did not deteriorate in the long term. Reconstruction of the DRUJ with this prosthesis in painful radioulnar impingement following ulnar head resection is a reliable and reproducible procedure with lasting results.

Initial shortening and internal fixation in combination with a Sauvé-Kapandji procedure for severely comminuted fractures of the distal radius in elderly patients

We identified 11 women with a mean age of 74 years (65 to 81) who sustained comminuted distal radial and ulnar fractures and were treated by volar plating and slight shortening of the radius combined with a primary Sauvé-Kapandji procedure. At a mean of 46 months (16 to 58), union of distal radial fractures and arthrodesis of the distal radioulnar joint was seen in all patients. The mean shortening of the radius was 12 mm (5 to 18) compared to the contralateral side. Flexion and extension of the wrist was a mean of 54° and 50°, respectively, and the mean pronation and supination of the forearm was 82° and 86°, respectively. The final mean disabilities of the arm, shoulder and hand score was 26 points. According to the Green and O'Brien rating system, eight patients had an excellent, two a good and one a fair result. The good clinical and radiological results, and the minor complications without the need for further operations related to late ulnar-sided wrist pain, justify this procedure in the elderly patient.

Case report: revision of failed Sauvé-Kapandji procedure with an ulnar head prosthesis

The Sauvé-Kapandji procedure has been developed in order to solve distal radioulnar joint (DRUJ) disorders. Postoperative results are variable. Complications such as painful ulnar stump, ulnar instability and loss of grip strength have often been described. We report the case of a painful ulnar stump instability resulting from a Sauvé-Kapandji procedure. After several attempted salvage procedures, a custom-made Herbert distal ulnar head prosthesis was implanted. Long-term results showed complete pain relief, improvement of the range of motion and satisfactory grip strength recovery. Our findings confirm that the Herbert custom-made ulnar head prosthesis appear to be a reliable salvage solution for failed Sauvé-Kapandji procedures.

Salvage of the unstable Sauvé-Kapandji procedure: a new technique

The Sauvé-Kapandji procedure has been commonly performed in the setting of posttraumatic osteoarthritis of the distal radioulnar joint. A recognized complication is instability of the proximal ulnar stump, which may occur in up to 33% of cases. Salvage of the failed Sauvé-Kapandji procedure in this setting is difficult and can sometimes involve sacrifice of forearm rotation. We report the results of 3 cases of a new salvage procedure in this setting. The radioulnar pseudarthrosis was taken down; ulnar continuity was restored with an intercalary graft; and forearm rotation was restored with matched hemiresection and interposition arthroplasty at the site of previous radioulnar fusion. Postoperatively, all patients achieved good forearm rotation (mean supination, 60 degrees; mean pronation, 65 degrees), had no symptoms of instability, and were satisfied with the results of the procedure. Disabilities of the Arm, Shoulder and Hand scores improved from preoperative mean of 55 to postoperative mean of 18.

Hemiarthroplasty of the distal ulna with an eccentric prosthesis

Replacement arthroplasty of the ulnar head is indicated primarily for stiffness and pain as a consequence of rheumatoid, degenerative, and posttraumatic arthritis of the distal radioulnar joint. It is also successfully used in the setting of previous failed excisional arthroplasty of the distal ulna. A distal ulnar hemiarthroplasty, which anatomically recreates the native ulnar head by employing an eccentric design, is discussed. The surgical technique includes a dorsal approach and careful repair of the soft tissue stabilizers.

Treatment of failed Sauvé-Kapandji procedures with a spherical ulnar head prosthesis

Radioulnar convergence is a painful complication after a Sauvé-Kapandji procedure, with a reported incidence of 13% to 39%. We evaluated 10 patients with painful radioulnar convergence treated with a spherical ulnar head prosthesis proximal to the radioulnar fusion mass. At a mean follow-up of 2.6 years, patients were evaluated clinically and radiographically to determine whether an ulnar head replacement could restore forearm stability, prevent radioulnar convergence, and reduce pain. Postoperatively, no patient had subjective complaints of radioulnar convergence or clinical signs of distal ulnar instability. Pain had improved in all patients. Grip strength, expressed as a percentage of the uninjured hand, improved on average from 27% to 55%. Range of motion improved in seven patients, worsened in two and remained the same in one. Nine of 10 patients returned to their previous occupation with an average working capacity of 76%. The prosthesis was stable radiographically in all patients. Complications included two fractures of the radioulnar fusion mass and the development of painful periprosthetic calcifications in one patient. Placement of a spherical ulnar head prosthesis after a Sauvé-Kapandji procedure provides adequate early results for patients with painful radioulnar convergence.

LEVEL OF EVIDENCE

Therapeutic study, level IV (case series).

Treatment of the neglected distal radius fracture

Operative treatment of inadequately or imperfectly treated fractures of the distal radius can improve wrist and hand function substantially, but rarely restores the limb to normal. Patients with malunion of the distal radius present either with poor radiographic alignment before complete healing of the fracture (nascent malunion) or with functional problems that may be related to inadequate alignment of a healed fracture (mature malunion). Corrective osteotomy is offered to patients who have sufficient malalignment that the surgeon thinks problems are inevitable or to patients in whom the functional deficit can be related clearly to the malunion. Ununited fractures are associated with painful instability of the wrist and very poor hand function. Operative treatment has proved successful even when the distal fragment is small. Operative treatment for reconstruction of the distal radius has been facilitated by the introduction of plates with angular stable screws (screws that lock into the plate). Painful arthritis is salvaged with arthrodesis.

Does the orientation of the distal radioulnar joint influence the force in the joint and the tension in the interosseous membrane?

OBJECTIVE

To investigate the effect of change in the orientation of the distal radioulnar joint on the force in the joint and the strain in the interosseous membrane.

DESIGN

Biomechanical study in fresh frozen cadavers.

BACKGROUND

The articular surfaces of the distal radioulnar joint may be orientated in parallel with the long axis of the forearm (a Type I joint) or at an oblique angle opening distally to the ulnar side (a Type II joint).

METHODS

Three cadaveric upper limbs were held on a custom built frame allowing measured rotation and axial loading across the wrist. Measurements of force in the distal radioulnar joint and strain in the interosseous membrane were taken and repeated after replacement of the distal radioulnar joint with prosthetic Type I and Type II joints.

FINDINGS

The force in the joint and the strain in the interosseous membrane increased with increasing load across the wrist (P < 0.0001). The force in the Type I joint was reduced compared to the normal or Type II joint. This difference was greater with increasing load and was significant at 8 kg (P < 0.001). The strain in the interosseous membrane was maximal at neutral forearm rotation and decreased with increasing pronation and supination.

INTERPRETATION

The force in the joint is greater with the Type II distal radioulnar joint. We believe this compressive force increases joint stability and this orientation of the articular surfaces should be considered in the design of a total distal radioulnar joint arthroplasty.

[Salvage operations and their differential indication for the distal radioulnar joint]

The most common cause of an arthritically damaged distal radioulnar joint is a malunion of a distal radius fracture. Therapeutically, ulnar head resection, hemiresection-interposition-technique, Kapandji-Sauvé procedure and implantation of an ulnar head prosthesis have been described. None of these procedures is able to restore the complete function of the joint. Therefore, anatomical reconstruction of the joint in acute or secondary correction osteotomy for malunited fractures of the distal radius should be performed to avoid the development of the arthrosis. Numerous clinical studies have demonstrated a similar reduction of the clinical symptoms for all procedures. Therefore, classification of the different procedures has to consider the number of complications. Biomechanically, partial resection of the distal ulna will destabilize the distal radioulnar context and clinically may lead to painful radioulnar and/or dorsopalmar instability of the distal ulnar stump. Biomechanically and clinically, this complication, next to secondary extensor tendon ruptures, has to be expected far more often following complete resection of the ulnar head than in the alternative procedures. We do not see any remaining indication for complete resection of the ulnar head. Clinical results and the occurrence of painful instability of the distal ulnar stump have been reported almost identically for the hemiresection-interposition technique and the Kapandji Sauvé procedure. Therefore, both procedures appear to be equally suitable for the treatment of painful arthrosis of the distal radioulnar joint. In patients with a preexisting instability of the distal radioulnar joint, or a major deformity of the radius or the ulna, we prefer to perform the hemiresection-interposition-technique. In these conditions we consider the remaining contact of the triangular fibrocartilage complex with the distal end of the ulna a biomechanical advantage to reduce the risk of secondary instability. Biomechanically as well as clinically, replacement of the ulnar head using a prosthesis has been shown to either avoid or solve the problem of instability. We therefore consider ulnar head replacement the treatment of choice in secondary painful instability following resection procedures at the distal end of the ulna. Primary ulnar head replacement should be considered in special indications until long-term follow-up results are available.

MR imaging findings in ulnar-sided wrist impaction syndromes

Ulnar-sided wrist impaction syndromes are a common source of ulnar pain and limitation of motion. These conditions refer to a group of pathologic entities that result from repetitive or acute forced impaction between the distal ulna and ulnar carpus or distal radius and surrounding soft tissues. MR imaging allows earlier detection of the bone and soft-tissue lesions that are present in the different ulnar-sided wrist impaction syndromes and is helpful in formulating the extensive differential diagnosis in patients with ulnar wrist pain and limitation of motion.