Stabilization of the Proximal Ulnar Stump in the Sauvé-Kapandji Procedure by Reconstructing Distal Oblique Bundle

doi:10.21203/rs.3.rs-4618146/v1

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Stabilization of the Proximal Ulnar Stump in the Sauvé-Kapandji Procedure by Reconstructing Distal Oblique Bundle

https://doi.org/10.21203/rs.3.rs-4618146/v1

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Background

The most common Sauvé-Kapandji (S-K) postoperative complication is instability of the proximal Ulnar Stump. The distal oblique bundle (DOB) is a stable tissue used to stabilize the distal radioulnar joint. we have applied a method to stabilize the proximal ulnar stump by using an improved extensor carpi ulnaris to fix the ulnar stump and reconstruct the DOB to achieve a combination of dynamic and static stable tissue.

Methods

15 patients who underwent the S-K operation after partial ulnar wrist extensor tendon fixation of the ulnar stump and reconstruction of DOB to stabilize the proximal ulnar stump were recruited. After surgery, the patients' wrist pain was evaluated with a visual analog scale (VAS). The Mayo scoring system was used to evaluate total function. The imaging findings included the ulnar and radial distances and the palmar/dorsal displacement distance of the proximal ulna stump.

Results

All 15 patients were followed up for an average of 32.5 months (ranging from 9 to 60 months). The wrist pain of all patients improved from an average of 6.5 ± 2.5 points before the operation to 2.4 ± 2.1 points after the operation. The grip strength increased from 4.5 (4.3) kg before surgery to 7.5 (3.5) kg after surgery, and the forearm rotation activity improved from 61 (16)° before surgery to 81 (13)° after surgery. The average radius of the ulna decreased from 11 mm to 9 mm, but there was no significant difference among the 12 patients. Lateral X-ray imaging revealed no instability of the proximal Ulnar Stump.

Conclusion

Extensor carpi ulnaris fixation of the ulnar stump and reconstruction of the DOB can achieve the combination of dynamic and static stable tissue, which is an effective method for preventing instability of the proximal ulnar stump

Type of study/level of evidence Therapeutic IV.

distal oblique bundle

extensor carpi ulnaris

distal radioulnar joint

Sauve Kapandji

proximal ulnar stump

Patients with secondary distal radioulnar arthritis caused by primary or wrist trauma may have DRUJ disorder, distal radioulnar joint deformity or chronic instability ¹. Clinically, pain in the ulnar side of the wrist joint, decreased hand grip strength, and limited forearm rotation may occur, seriously affecting daily life ². At present, the commonly used surgical methods for treating DRUJ arthritis include the Darrach operation, Sauve ´-Kapandji (SK) operation, and joint replacement ³, each of which has its own advantages and disadvantages. The Save–Kapandji (SK) operation involves fusing the DRUJ joint and forming a false joint via osteotomy at the distal end of the ulna to prevent DRUJ dysfunction ⁴; its ulnar head is reserved to prevent ulnar deviation of the wrist. The main postoperative complication was instability of the proximal ulna stump ^5–6.

At present, ECU (extensor carpi ulnaris) dynamically stable tissue is most commonly used to fix the proximal ulnar stump to address instability of the ulnar stump 7, but the extensor carpi ulnaris tendon is a dynamic tissue that stabilizes the residual end of the ulna, and its stable strength may be insufficient. Therefore, scholars such as Jongmin Kim⁸ suggest using a combination of dynamic and static structures to fix the residual end of the ulna using the extensor carpi ulnaris tendon and interosseous membrane fixation method.

The distal oblique bundle of the interosseous membrane of the front is the tissue with a thickened distal interosseous membrane, and its existence rate is approximately 40% ⁹. It has been reported that the ^10–11 DOB is the soft tissue structure of the statically stabilized distal radioulnar joint (DRUJ). Normally, the DOB has little effect on the stability of the distal radioulnar joint, but after TFCC injury or posterior ulnar resection, the DOB plays an important role in stabilizing the distal radioulnar joint ¹². Hisao Moritomo et al. ¹³ suggested that the DOB also plays an important role in the stability of the proximal ulnar stump after Sauve Kapandji osteotomy.

This report describes the clinical results of a surgical method for stabilizing the proximal ulnar stump by fixing the ulnar stump with the ulnar extensor carpus tendon (dynamic structure) and reconstructing the DOB (static structure).

This study was approved by the hospital ethics committee. From January 2018 to January 2021, 15 Sauv é Kapandji (S-K) patients who underwent partial ECU tendon fixation of the ulnar stump and reconstruction of the DOB at our hospital were retrospectively studied, including 8 males and 7 females. The average age was 58.3 years, ranging from 49 to 72 years. There were 11 cases on the right side and 4 cases on the left side. Among these cases, 6 patients had DRUJ primary osteoarthritis, 4 patients had posttraumatic osteoarthritis after malunion of the distal radius fracture, 3 patients had rheumatoid distal radioulnar arthritis, and 2 patients had Madelung deformity. All patients complained of wrist pain, limited forearm rotation and decreased hand grip strength. X-ray showing distal radioulnar arthritis.

Surgery

An 8 cm dorsal S incision was made on the radial side of the ulnar head and extended to the proximal end of the ulnar shaft.(Fig. 1).

The extensor retinaculum was cut at the edge of the ulna, and a 1 cm flap was lifted to expose the ECU and extensor digiti minimus tendon. The DRUJ was exposed between the extensor digiti minimus tendon and the extensor carpi ulnaris tendon.

A 10 mm long bone segment and its periosteum were removed from the distal part of the ulna. The distal radioulnar articular surface was removed.

The DRUJ was fixed by a 1.6 mm Kirschner wire and cancellous bone screw through the joint (Fig. 2).

Two centimeters from the proximal end of the osteotomy, a 10 cm long wrist extensor ulnaris tendon was formed by longitudinal splitting (Fig. 3)

This tendon passes through the ulnar collateral ligament and TFCC from the back to the palm (Fig. 4).

The tendon then passes through the marrow cavity of the distal ulna and exits through the dorsal cortical foramen of the ulnar stump.

The ECU is tightened and fixed below the sigmoid notch of the radius (the anchor can be used for fixation) (Fig. 5).

After surgery, the upper limb is immobilized in a long arm cast in a flexed and rotated position for 3 weeks and then replaced by a short arm splint for 3 weeks, allowing forearm rotation. Active finger flexion and extension activities are allowed on the second day after surgery, and all-round functional exercises of the forearm are performed 6 weeks after surgery.

X-ray imaging evaluation

On the X-ray anteroposterior film, the ulna distance (ulna width), ulna space, and interosseous distance (the distance between the radial edge of the ulna and the radial ulna edge at the level of the distal end of the proximal ulna stump) were measured. On the lateral image, the dorsal metacarpal distance (the vertical distance between the dorsal cortex of the proximal ulna stump and the dorsal cortex of the radius) and other indicators were measured to assess the instability of the proximal ulna stump. We also evaluated the dynamic instability of the proximal ulna stump through dynamic X-ray imaging. The dynamic X-ray film was taken when the patient kept a 5 pound lead weight, and the forearm was in the neutral, pronation and supination positions. (Fig. 6)

Pain assessment

The subjective pain of the patients was evaluated by the visual analog scale (VAS) [12] before and after surgery at the last follow-up. The VAS score was 0, painless; less than 3 points, with slight pain; 4–6 points, pain and sleep disturbance, tolerable; and 7–10 points, strong pain, unbearable.

Functional assessment

The objective functional parameters included preoperative and postoperative hand grip strength and wrist mobility.

A Jamar dynamometer was used to measure the grip strength of the wrist.

A goniometer was used to measure wrist mobility.

The total function of the wrist joint was evaluated with the Mayo scale ¹⁴, including the degree of pain, functional status, range of motion, and grip strength of the wrist joint, with 25 points for each part, excellent: 90–100 points; good: 80–90 points; acceptable: 60–80 points; and poor: less than 60 points.

Statistical analysis

A paired t test was used for statistical analysis. A p value of<. 05 was considered to indicate statistical significance.

All 15 patients were followed up for an average of 32.5 months (9-60 months). Postoperative incisions were all healed in phase I, without joint infection, nerve or blood vessel injury or other complications. X-ray examination revealed that 18 patients who underwent distal radioulnar joint fusion had healed, and detailed follow-up data were available (Table 1).

Pain

There were 7 patients with severe pain, 6 patients with moderate pain, 10 patients without pain and 3 patients with mild pain in the ulnar stump after surgery.

Grip strength

The average preoperative grip strength of the affected wrist was 18 kg (51% of contralateral wrist). After surgery, the average grip strength increased to 29 kg (75% of the opposite side). The grip strength of all patients significantly improved (p<0.01).

Movement

The average preoperative range of motion of the affected wrist was 35° of extension and 42° of flexion. After the operation, the average range of motion improved to 40° of extension and 47° of flexion. Neither of these improvements was significant. The average preoperative forearm rotation was 56° pronation and 38° supination. The average forearm rotation was 68° pronation and 51° supination. Both improvements were significant (p<0.01) (Table 1). Mayo's score was 79.4 ± 16.4.

X-line assessment

Preoperative and postoperative X-ray images were evaluated (Table 2). The average ulnar resection fragment measured on neutral posterior anterior (PA) X-ray was 10 mm (range, 8 to 12 mm). The mean preoperative ulnar radial distance was 11 mm. After surgery, it was reduced to 9 mm, but this change was not significant. No scallops or hardening were found on the PA X-ray. Our series of posterior radiographs did not show a significant difference in the vertical distance between the dorsal ulnar cortex and the dorsal radial cortex. When holding a 5 pound weight, no anterior posterior instability is observed in the side view.

instability is observed in the side view.

The ulnar stump was maintained at the one-year follow-up (paired t test; *p value of <0.05 was considered to indicate statistical significance).

Complications

One patient had limited rotation of the forearm at 4 months after surgery due to fusion of the joint. After resection of the bridge, the rotation improved, and the other patients had no complications, such as nonunion of the fracture or spontaneous rupture of the extensor tendon.

Case

Patient; Female; 50 years old; Diagnosis: Rheumatoid arthritis of the right wrist joint and distal radioulnar joint. Preoperative indication of limited forearm pronation and supination mobility.Preoperative X-ray shows rheumatoid distal radioulnar arthritis, wrist joint space narrowing, and bone erosion. Intraoperative: ulnar osteotomy. During surgery, a false joint is formed after ulnar osteotomy, and a hole is drilled in the proximal residual end of the ulna to facilitate tendon penetration. Part of the ulnar extensor wrist tendon was taken during surgery to fix the proximal residual end of the ulna and reconstruct the DOB. One year after surgery, X-ray of the wrist joint showed good fusion of the distal radioulnar joint. 1-year follow-up after surgery: Significant improvement in forearm pronation and supination activity.(figure 7)

Distal radioulnar arthritis can be caused by a variety of factors, including wrist pain, limited forearm rotation, and severe effects on daily life. To treat DRUJ disorders, the Darrach operation¹⁵ was the first operation in which the ulnar head was resected. However, due to the loss of ulnar support of the ulnar head for the wrist joint, it is recommended for elderly patients with low demand. In 1936, Sauv é and Kapandji ¹⁶ first reported the Sauv é - Kapandji (S-K) operation. Compared with the Darrach operation, this operation retains the CC and ulnar capitulum, providing sufficient bone for the ulna to support the wrist bone and allowing the forearm to rotate in the pseudo joint area; it can also increase grip strength, reduce the risk of ulnar displacement, and is widely used in clinical practice. However, after ulnar osteotomy, instability of the proximal end of the ulna can easily occur. Svenna et al. ¹⁷ reported that the incidence of instability of the proximal end of the ulna was 14%. The instability of the proximal end of the ulna can lead to weakening of the hand grip, instability of the wrist joint, impact of the ulna and radius, and spontaneous rupture of the extensor digitorum tendon. During forearm rotation or weight lifting. This pain is believed to be caused by the dynamic instability of the proximal ulnar stump secondary to the resection of a small segment of the distal ulnar shaft.

To reduce the instability of the proximal stump, Kapandji et al. ¹⁸ suggested reducing the length of the ulnar shaft as much as possible and placing the pseudarthrosis at the distal end. Minami et al. ¹⁹ reported that there is no correlation between the instability of the proximal ulnar stump and the length of the pseudarthrosis, and if the ulnar shaft is cut too short, it is easy to cause bone bridges at the pseudarthrosis. At present, the soft tissue around the proximal ulna stump is often suspended to stabilize the proximal ulna stump ²⁰.

The tissues that stabilize the instability of the proximal ulnar stump mainly include 1. dynamic stabilizing tissues, including the ulnar extensor carpi radialis brevis tendon and the ulnar flexor carpi radialis brevis tendon; and 2. static stabilizing tissues, including the interosseous membrane.

The DOB is the thickened part of the interosseous membrane at the distal end of the forearm. DOB starts at the distal sixth of the ulna and ends at the lower dorsal edge of the sigmoid notch of the radius ²¹. DOB has an anatomical relationship with the triangular fibrocartilage complex (TFCC) and is connected with some of its palmar and radial ligaments; it is considered to be the equidistant stable tissue of the distal radioulnar joint ²². As the secondary stabilizing tissue of the lower radioulnar joint (DRUJ), the DOB has little influence on the stability of the distal radioulnar joint under normal conditions of the TFCC. However, after S-K surgery, the DOB plays an important role in stabilizing the proximal end of the ulna, but the incidence of DOB is only 29% ⁹.

At present, many techniques, including ulnar wrist extensor tendon fixation, ulnar wrist flexor tendon fixation, or a combination of the two techniques, describe the use of dynamic tissue to stabilize the distal ulnar stump ¹⁹. In our improved method, we reconstruct the DOB by weaving half of the ulnar wrist extensor tendon through the ulnar collateral ligament, first fixing the ulnar stump, and then finally attaching the tendon to the bottom of radial notch C. This fixation provides static and dynamic stability by connecting the dynamic stable tissue (extensor carpi ulnaris tendon) with the static stable tissue (DOB), which improves the multidirectional stability of the ulnar stump.

The common problem of instability of the proximal ulnar stump after the Sauvé Kapandji operation is radial ulnar convergence, but its specific mechanism is still unclear. This may be caused by the traction force from the muscles of the first dorsal compartment (namely, the extensor pollicis brevis and abductor pollicis longus) and the influence of the interosseous membrane. In this study, we did not observe any fan-shaped radii. We believe that fixation of the extensor carpi ulnaris tendon combined with DOB reconstruction can prevent excessive displacement of the distal ulnar stump to the radius.

In this study, there was no significant difference in the vertical distance between the dorsal cortex of the proximal ulna and the dorsal cortex of the radius on postoperative X-ray, and no patient showed evidence or instability on dynamic X-ray. We believe that reconstruction of the DOB with the ulnar extensor carpal tendon provides additional stability to prevent dorsal displacement of the proximal ulnar stump. Because the extensor carpi ulnaris tendon is confined to the sixth compartment on the dorsal side of the wrist joint, it is an important dynamic stabilizer of the ulnar head. Finally, connecting the ECU to the radial sigmoid notch to reconstruct the DOB is a reliable operation that can establish a flexible but firm connection between the distal radius and the proximal ulna stump to achieve stable forearm rotation.

Limitations of this study: 1. This was a retrospective study, which is more susceptible to bias than prospective studies.2. Prospective studies with a small sample size and short follow-up time and long-term follow-up of a large number of patients are needed to confirm the clinical results.

Ulnul extensor carpal tendon fixation of the ulnar stump and reconstruction of the DOB can achieve the combination of dynamic and static stable tissue fixation of the proximal ulnar stump, which is an effective method for preventing instability of the proximal ulnar stump after S-K surgery.

Funding

The author(s) declare that ﬁnancial support was received for the research, authorship, and/or publication of this article. This work was supported by grants from Municipal Key R&D Program of Ningbo (2022Z146), Ningbo Top Medical and Health Research Program (No.2022020506).

Ethics Statement

Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patients to publish this paper. This study was performed in line with the principles of the Declaration of Helsinki. Approval for cases investigation was obtained from the Ningbo NO.6 Hospital's ethics committee.

Competing interests

The authors declare that they have no competing interests.

Data Availability Statements

The data underlying this article are available in the article.

Author Contribution

Conceptualization, XDL. and SQY; Methodology, YPH.; Investigation, YPH and CC; Data Curation, CC ; Writing – Original Draft Preparation, SQY.and CXZ; Writing – Review & Editing, SQY, JDP; Supervision, XDL.; Project Administration, XDL.; Funding Acquisition, XW and JDP.

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Table 1 and 2 are available in the Supplementary Files section.

No competing interests reported.

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You are reading this latest preprint version

Stabilization of the Proximal Ulnar Stump in the Sauvé-Kapandji Procedure by Reconstructing Distal Oblique Bundle

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Version 1

Abstract

Figures

Introduction

Methods

Surgery

X-ray imaging evaluation

Pain assessment

Functional assessment

Statistical analysis

Results

Discussion

Conclusion

Declarations

Author Contribution

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1