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The Sauvé-Kapandji procedure
125
EDITORIAL
THE
SAUVI&KAPANDJI
PROCEDURE
Some years ago in a congress a surgeon asked me how I could have invented this procedure in 1936. I was too young at this date, but my father, M. Kapandji, was the originator. At that time he was a young assistant of Professor Louis SauvC (pronounced Saw-vey), and together they were coping with the difficult problem of chronic subluxation of the ulnar head. They were deceived by the inconstant results of the ligamentous repair (SauvC and Kapandji, 1933), and they invented the procedure (SauvC and Kapandji, 1936), consisting of arthrodesis of the distal radio-ulnar joint (D.R.U.J.) associated with segmental resection of the lower ulnar just above. The inspired idea was to combine the D.R.U.J. arthrodesis, which promotes stability of the carpus, with an ulnar pseudarthrosis, already proposed separately by Le Fort and Cololian (1918) and Baldwin (1921), so as to avoid loss of pronation and supination. They only performed this operation two or three times, then it fell into oblivion for many decades. It was performed under its own name by a Rumanian surgeon, C. Baciu, who published two papers (Baciu et al., 1965; Baciu, 1976). In English speaking countries it was known as Lauenstein’s procedure. Buck-Gramcko (1990) showed that the technique was not invented by Lauenstein (1890) whose publication describes “resection of the medial meniscus of the knee”. The mistake originated from Steindler (1946). Gon9alves (1974) was the first to clarify this question, and Taleisnik (1985) recognized the priority of Kapandji and SauvC, but continued to name the procedure “Lauenstein”, sanctioned by its use in English speaking countries. For a long time the all-purpose operation for D.R.U.J. problems was resection of the distal end of the ulna (Darrach), but this may cause instability of the carpus which has a tendency to slide and deviate ulnarly whilst the grip becomes weaker. In the past ten or 15 years, the SauvC-Kapandji procedure has been increasingly used for rheumatoid dislocation of the distal radio-ulnar joint, together with synovectomy and realignment of the dorsal tendons, instead of the Darrach procedure, and also in post-traumatic conditions such as dislocations, sprains, chronic instability of the joint and stiffness, secondary to Colles’ and Galleazzi fractures, distal ulna and ulnar head fractures, and even in certain fractures of both bones. The original technique was described for chronic instability secondary to sprains and distal radio-ulnar dislocation, and also rheumatoid disease, when the ulnar head is in its right location at the sigmoid notch level; in Colles’ fracture however, with radial shortening causing incongruency of the D.R.U.J., and positive ulnar variance, it is necessary to lift the ulnar head before
blocking it in the sigmoid notch. A second procedure, described in 1986 by Kapandji, achieves this. These procedures are now commonly used in their two alternatives. In my practice the range of pronation/ supination is restored in three to six weeks. The pain disappears except for slight discomfort when holding a weight on the supinated hand. Stability of the wrist is soon recovered allowing twisting movements. However, the success of the procedure requires two conditions : the segmental resection must not be too wide, and should be as low as possible above the remaining ulnar head so as to avoid painful ulnar stump instability, which is also possible in other procedures involving ulnar resection such as the Darrach and the Baldwin operations. The paper by Nakamura et al. in this issue (page 00) correctly presents the indications for the SauvBKapandji procedure among others applicable to chronic instability of the D.R.U.J. It gives new criteria to evaluate ulnar stump instability. It stresses the improvement in grip strength and range of motion, not only in pronation/ supination, but also in flexion/extension. However the long period of immobilization before rehabilitation is surprising. In my own practice I wait just a few days, the time of decreasing post-operative pain, before starting rehabilitation and activity. To allow this the ulnar fixation must be solid. It is difficult to assess bone union. The length of the ulnar resection, given as 15 mm., is also excessive. The authors agree that the problem of ulnar stump instability is a real one in this operation and in others such as the Darrach procedure, and Bowers’ (1985), and Watson’s (1986) operations. Two eventualities have to be considered: the first, instability without pain, is not a problem except for visible mobility of the stump, loss of strength, and a feeling of insecurity when the pronated hand supports the body weight, as in gymnastics. In the second, instability is accompanied by pain and this is a very difficult problem to cope with. Some authors have proposed lengthening of a short stump and others a looping operation with tendon transfers. Prosthetic replacement of the ulnar head is also a possibility. Certain precautions can minimize this instability. Distal placing of the lower cut, and a narrow resection of the ulna, never more than 10 mm., give a better functional result. Nakamura et al. have presented the indications for the SauvbKapandji procedure correctly, but in some cases, even with intact articular surfaces, it can be used when the ligamentous complex of the D.R.U.J. is destroyed because the results of ligamentous repair are not consistent. Finally, I wish to thank the editor of the British edition of the Journal of Hand Surgery for giving me the
126
THE
opportunity to expound my ideas on the procedure invented by my father. I am greatly honoured and also very proud to make known my father’s work. It is quite in the spirit of our dynasty. Adalbert I. Kapandji Dr Kapandji
is the son of Dr Mehmed
works as a hand of the French
surgeon
at the Clinique
Society of Hand
I. Kapandji de IYvette
(see biographical Longjumeau,
note on page 241) and
France.
He is past President
Surgery.
References BACIU, C. (1976). L’opCration de Kapandji-Saw6 dam le traitement des cals vicieux de l’extrtmit& infbrieure du radius. Annales de Chirurgie, 31: 323329. BACIU, C., ZGABURA, I., ROVENTA, N. and CHICU, E. (1965). RCsultats &ignCs apr&s I’opCration de Saw&Kapandji pourle traitement des fractures de Pouteau-Colles vicieusement consolidtes. Acta Orthopaedica Belgica, 3 1: 92&9X. BALDWIN, W. I. (1921). Orthopaedic surgery of the Hand and the Wrist. In: Jones, Sir R. (Ed) Orthopaedic Surgery of Injuries. London, Henry Frowde and Hodder and Stoughton, 1921: 241-282. BUCK-GRAMCKO, D. (1990). On the prioritiesof publicationofsome operative procedures on the distal end of the ulna. Journal of Hand Surgery, Vol 15B : 4: 416-420.
JOURNAL
OF HAND
SURGERY
VOL.
17B No. 2 APRIL
1992
BOWERS, W. H. (1985). Distal radioulnar joint arthroplasty: the hemiresectioninterposition technique. Journal of Hand Surgery, 10A: 2: 169-178. GONCALVES, D. (1974). Correction of disorders of the distal radio-ulnar joint by artificial pseudarthrosis of the ulna. Journal of Bone and Joint Surgery, 56B : 3 : 462464. KAPANDJI, I. A. (1986). Operation de Kapandji-Saw&. Techniques et indications dans les affections non rhumatismales. Annales de Chirureie de IaMain, 5: 3: 181-193. LAUENSTEIN, C. (1890). Zur Frage der Dtrangement internee des Kniegelenks. Deutsche Medizinische Wochenschrift, 16: 169-170. LE FORT, R. and COLOLIAN, P. (1918). Les pseudarthroses et pertes des substance de la diaphyse du cubitus et en particulier de sa moitit infbrieure. ConsidCrations cliniques et thkrapeutiques. Revue d’OrthopCdie, 3e sCrie, 6: 117-150. SAUVB, L. AND KAPANDJI, M. (1933). Constitution d’un ligament pericubital infkrieur. Boll. Mem. Sot. Nat. Chir, Paris. 59: 237-239. SAUVk, L. and KAPANDJI, M. (1936). Nouvelle technique de traitement chirurgical des luxations rkcidivantes isoltes de I-extrimit(t infhrieure du Cubitus. Journal de Chirurgie, 47: 589-594. STEINDLER, A. The traumaticDeformitiesandDisabilitiesofthe UpperExtremity. Springfield, Illinois, Charles C. Thomas, 1946. TALEISNIK, J. The Wrist. New York, Churchill Livingstone, 1985. WATSON, H. K., RYU, J. and BURGESS, R. C. (1986). Matched distal ulnar resection. Journal of Hand Surgery, 1lA: 6: 812-817.
Q 1992 The British Society
for Surgery
ofthe
Hand
EDITORIAL
THE
SAUVI&KAPANDJI
PROCEDURE
Some years ago in a congress a surgeon asked me how I could have invented this procedure in 1936. I was too young at this date, but my father, M. Kapandji, was the originator. At that time he was a young assistant of Professor Louis SauvC (pronounced Saw-vey), and together they were coping with the difficult problem of chronic subluxation of the ulnar head. They were deceived by the inconstant results of the ligamentous repair (SauvC and Kapandji, 1933), and they invented the procedure (SauvC and Kapandji, 1936), consisting of arthrodesis of the distal radio-ulnar joint (D.R.U.J.) associated with segmental resection of the lower ulnar just above. The inspired idea was to combine the D.R.U.J. arthrodesis, which promotes stability of the carpus, with an ulnar pseudarthrosis, already proposed separately by Le Fort and Cololian (1918) and Baldwin (1921), so as to avoid loss of pronation and supination. They only performed this operation two or three times, then it fell into oblivion for many decades. It was performed under its own name by a Rumanian surgeon, C. Baciu, who published two papers (Baciu et al., 1965; Baciu, 1976). In English speaking countries it was known as Lauenstein’s procedure. Buck-Gramcko (1990) showed that the technique was not invented by Lauenstein (1890) whose publication describes “resection of the medial meniscus of the knee”. The mistake originated from Steindler (1946). Gon9alves (1974) was the first to clarify this question, and Taleisnik (1985) recognized the priority of Kapandji and SauvC, but continued to name the procedure “Lauenstein”, sanctioned by its use in English speaking countries. For a long time the all-purpose operation for D.R.U.J. problems was resection of the distal end of the ulna (Darrach), but this may cause instability of the carpus which has a tendency to slide and deviate ulnarly whilst the grip becomes weaker. In the past ten or 15 years, the SauvC-Kapandji procedure has been increasingly used for rheumatoid dislocation of the distal radio-ulnar joint, together with synovectomy and realignment of the dorsal tendons, instead of the Darrach procedure, and also in post-traumatic conditions such as dislocations, sprains, chronic instability of the joint and stiffness, secondary to Colles’ and Galleazzi fractures, distal ulna and ulnar head fractures, and even in certain fractures of both bones. The original technique was described for chronic instability secondary to sprains and distal radio-ulnar dislocation, and also rheumatoid disease, when the ulnar head is in its right location at the sigmoid notch level; in Colles’ fracture however, with radial shortening causing incongruency of the D.R.U.J., and positive ulnar variance, it is necessary to lift the ulnar head before
blocking it in the sigmoid notch. A second procedure, described in 1986 by Kapandji, achieves this. These procedures are now commonly used in their two alternatives. In my practice the range of pronation/ supination is restored in three to six weeks. The pain disappears except for slight discomfort when holding a weight on the supinated hand. Stability of the wrist is soon recovered allowing twisting movements. However, the success of the procedure requires two conditions : the segmental resection must not be too wide, and should be as low as possible above the remaining ulnar head so as to avoid painful ulnar stump instability, which is also possible in other procedures involving ulnar resection such as the Darrach and the Baldwin operations. The paper by Nakamura et al. in this issue (page 00) correctly presents the indications for the SauvBKapandji procedure among others applicable to chronic instability of the D.R.U.J. It gives new criteria to evaluate ulnar stump instability. It stresses the improvement in grip strength and range of motion, not only in pronation/ supination, but also in flexion/extension. However the long period of immobilization before rehabilitation is surprising. In my own practice I wait just a few days, the time of decreasing post-operative pain, before starting rehabilitation and activity. To allow this the ulnar fixation must be solid. It is difficult to assess bone union. The length of the ulnar resection, given as 15 mm., is also excessive. The authors agree that the problem of ulnar stump instability is a real one in this operation and in others such as the Darrach procedure, and Bowers’ (1985), and Watson’s (1986) operations. Two eventualities have to be considered: the first, instability without pain, is not a problem except for visible mobility of the stump, loss of strength, and a feeling of insecurity when the pronated hand supports the body weight, as in gymnastics. In the second, instability is accompanied by pain and this is a very difficult problem to cope with. Some authors have proposed lengthening of a short stump and others a looping operation with tendon transfers. Prosthetic replacement of the ulnar head is also a possibility. Certain precautions can minimize this instability. Distal placing of the lower cut, and a narrow resection of the ulna, never more than 10 mm., give a better functional result. Nakamura et al. have presented the indications for the SauvbKapandji procedure correctly, but in some cases, even with intact articular surfaces, it can be used when the ligamentous complex of the D.R.U.J. is destroyed because the results of ligamentous repair are not consistent. Finally, I wish to thank the editor of the British edition of the Journal of Hand Surgery for giving me the
126
THE
opportunity to expound my ideas on the procedure invented by my father. I am greatly honoured and also very proud to make known my father’s work. It is quite in the spirit of our dynasty. Adalbert I. Kapandji Dr Kapandji
is the son of Dr Mehmed
works as a hand of the French
surgeon
at the Clinique
Society of Hand
I. Kapandji de IYvette
(see biographical Longjumeau,
note on page 241) and
France.
He is past President
Surgery.
References BACIU, C. (1976). L’opCration de Kapandji-Saw6 dam le traitement des cals vicieux de l’extrtmit& infbrieure du radius. Annales de Chirurgie, 31: 323329. BACIU, C., ZGABURA, I., ROVENTA, N. and CHICU, E. (1965). RCsultats &ignCs apr&s I’opCration de Saw&Kapandji pourle traitement des fractures de Pouteau-Colles vicieusement consolidtes. Acta Orthopaedica Belgica, 3 1: 92&9X. BALDWIN, W. I. (1921). Orthopaedic surgery of the Hand and the Wrist. In: Jones, Sir R. (Ed) Orthopaedic Surgery of Injuries. London, Henry Frowde and Hodder and Stoughton, 1921: 241-282. BUCK-GRAMCKO, D. (1990). On the prioritiesof publicationofsome operative procedures on the distal end of the ulna. Journal of Hand Surgery, Vol 15B : 4: 416-420.
JOURNAL
OF HAND
SURGERY
VOL.
17B No. 2 APRIL
1992
BOWERS, W. H. (1985). Distal radioulnar joint arthroplasty: the hemiresectioninterposition technique. Journal of Hand Surgery, 10A: 2: 169-178. GONCALVES, D. (1974). Correction of disorders of the distal radio-ulnar joint by artificial pseudarthrosis of the ulna. Journal of Bone and Joint Surgery, 56B : 3 : 462464. KAPANDJI, I. A. (1986). Operation de Kapandji-Saw&. Techniques et indications dans les affections non rhumatismales. Annales de Chirureie de IaMain, 5: 3: 181-193. LAUENSTEIN, C. (1890). Zur Frage der Dtrangement internee des Kniegelenks. Deutsche Medizinische Wochenschrift, 16: 169-170. LE FORT, R. and COLOLIAN, P. (1918). Les pseudarthroses et pertes des substance de la diaphyse du cubitus et en particulier de sa moitit infbrieure. ConsidCrations cliniques et thkrapeutiques. Revue d’OrthopCdie, 3e sCrie, 6: 117-150. SAUVB, L. AND KAPANDJI, M. (1933). Constitution d’un ligament pericubital infkrieur. Boll. Mem. Sot. Nat. Chir, Paris. 59: 237-239. SAUVk, L. and KAPANDJI, M. (1936). Nouvelle technique de traitement chirurgical des luxations rkcidivantes isoltes de I-extrimit(t infhrieure du Cubitus. Journal de Chirurgie, 47: 589-594. STEINDLER, A. The traumaticDeformitiesandDisabilitiesofthe UpperExtremity. Springfield, Illinois, Charles C. Thomas, 1946. TALEISNIK, J. The Wrist. New York, Churchill Livingstone, 1985. WATSON, H. K., RYU, J. and BURGESS, R. C. (1986). Matched distal ulnar resection. Journal of Hand Surgery, 1lA: 6: 812-817.
Q 1992 The British Society
for Surgery
ofthe
Hand