What is the recommended surgical intervention for a patient with a distal ulno-radial joint disruption, particularly those with a history of trauma or conditions like rheumatoid arthritis, who have failed conservative management?

Kapanji (Sauvé-Kapandji) Procedure for Distal Radioulnar Joint Disruption

The Sauvé-Kapandji procedure is the preferred surgical intervention for distal radioulnar joint (DRUJ) disruption in patients with rheumatoid arthritis or post-traumatic arthritis who have failed conservative management, particularly in younger, active patients. 1, 2

Patient Selection Algorithm

For younger, active patients with DRUJ disruption: Perform the Sauvé-Kapandji procedure as it provides superior functional outcomes while maintaining forearm rotation and a stable base for the ulnar carpus. 1, 2

For elderly, low-demand patients: Consider Darrach resection as an alternative, though this should be reserved specifically for this population. 1, 2

Technical Considerations

The procedure involves:

• Arthrodesis of the DRUJ to eliminate pain from the arthritic joint 1
• Creation of a pseudarthrosis proximal to the fusion site to maintain forearm rotation 1
• In patients with poor bone quality (common in rheumatoid arthritis), use the modified technique: resect the distal ulna, create a drill-hole in the ulnar cortex of the distal radius, rotate the resected ulna 90 degrees, and fix it with an AO cancellous-bone screw 3

Critical technical modification for rheumatoid patients: The modified Sauvé-Kapandji procedure achieves rigid fixation even with poor bone quality and provides sufficient osseous support of the carpus. 3

Expected Outcomes

The procedure reliably delivers:

• Complete pain resolution or significant reduction in all patients 4, 3
• Improved forearm rotation from mean 144° preoperatively to 167° postoperatively 3
• Osseous union in all cases when proper technique is used 3
• Maintained carpal alignment without progressive ulnar translation 3

Common Pitfalls and How to Avoid Them

Proximal ulnar stump instability is the most common complication. 4 To prevent this:

• Use the modified technique with half-slip of extensor carpi ulnaris tendon for stabilization 4
• Ensure adequate drill-hole size without creating stress risers that lead to breakage (occurred in 10/83 cases in one series) 4

Radioulnar convergence can occur if the transverse diameter of the DRUJ is not maintained during the procedure. 4

Pre-existing radiocarpal instability must be addressed: If present, perform concomitant partial or total wrist arthrodesis or arthroplasty at the same surgery. 2

Concurrent DRUJ Instability Assessment

Always obtain true lateral radiographs to assess for DRUJ instability, as this commonly accompanies radius-ulna fractures and requires concurrent treatment. 5

Post-Operative Management

• Initiate active finger motion exercises immediately after adequate surgical stabilization to prevent stiffness 5
• Reevaluate any patient with unremitting pain during follow-up, as this may indicate fixation failure or complications 5
• Implement a home exercise program for rehabilitation 5

Special Scenario: Distal Radius Nonunion with DRUJ Disruption

When distal radius nonunion coexists with DRUJ instability, the Sauvé-Kapandji procedure can be combined with bone grafting. 6 Consider using the resected ulnar segment (cubitus proradius transposition) as autograft for the radius nonunion site, which eliminates the need for separate iliac crest harvest in some cases. 6