CPT® Code 25830

1. Indications

The Sauvé-Kapandji procedure, represented by CPT® Code 25830, is indicated for several specific conditions affecting the distal radioulnar joint. These indications include:

• Arthritis - A degenerative condition that can lead to pain and loss of function in the joint.
• Nonunion of wrist fractures - A situation where a fractured bone in the wrist fails to heal properly, necessitating surgical intervention.
• Distal radius epiphysiodesis - A procedure that may be performed to halt the growth of the distal radius, often in pediatric patients.
• Madelung deformities - A congenital condition characterized by abnormal wrist bone development, leading to functional impairment.
• Joint instability - A condition where the joint does not maintain its normal position, resulting in pain and dysfunction.
• Triangular fibrocartilage complex tears - Injuries to the fibrocartilage structure that stabilizes the wrist, which can cause pain and instability.
• Ulnocarpal impaction syndrome - A condition where the ulnar bone impacts the carpal bones, leading to pain and limited motion.

2. Procedure

The Sauvé-Kapandji procedure involves several detailed steps to achieve the desired outcome of joint fusion and ulnar resection. The procedure is initiated with an incision made on the dorsal aspect of the arm, where the dorsal sensory branch of the ulnar nerve is identified and protected to prevent nerve damage during surgery.

• Step 1: The 5th extensor compartment is divided longitudinally, allowing for retraction of the extensor digiti minimi tendon toward the radius. This step is crucial for gaining access to the underlying structures.
• Step 2: The dorsal distal radioulnar joint capsule is also divided longitudinally near its insertion into the radius and removed. This facilitates exploration of the ulnar head and neck, which are essential for the subsequent steps of the procedure.
• Step 3: The extensor carpi ulnaris (ECU) tendon, located dorsal to the styloid process of the ulna, is preserved to maintain wrist function.
• Step 4: The forearm is pronated, and joint cartilage along with subchondral bone from the ulnar head is removed, creating a flat or convex surface of cancellous bone that is necessary for the fusion.
• Step 5: A hole is drilled through the center of the denuded ulnar head, exiting anterior to the ECU sheath. This hole is critical for the subsequent fixation of the ulnar head to the radius.
• Step 6: Using sharp dissection, the exit hole in the extensor retinaculum is enlarged to facilitate the passage of surgical instruments.
• Step 7: An osteotomy is performed on the head of the ulna just proximal to the end of the joint cartilage using a saw or cutting forceps. This allows for the ulna to be displaced and rotated into supination, providing better visualization of the radial sigmoid notch and the proximal ulnar stump.
• Step 8: A portion of the ulnar shaft proximal to the fusion site is resected using a saw or small bone rongeur, which is necessary to prepare the site for fusion.
• Step 9: Gentle retraction on the soft tissue exposes the insertion sites of the pronator quadratus muscle and interosseous membrane, allowing for thorough preparation of the fusion site.
• Step 10: Bone debris is removed along with the periosteum of the ulnar segment to ensure a clean surface for fusion.
• Step 11: The joint cartilage and subchondral bone of the radial sigmoid notch are excised to prepare the radius for the ulnar head reduction.
• Step 12: A screw is inserted into the drill hole created in the ulna, and the ulnar head is reduced opposite the radius. This step is critical for achieving stability in the joint.
• Step 13: The screw is advanced into the radius until the two surfaces are moderately compressed, ensuring that the head of the screw does not protrude along the ulna, which could lead to complications.
• Step 14: Finally, the incision is closed in layers, and the wrist is immobilized to promote healing and stability post-surgery.

3. Post-Procedure

After the completion of the Sauvé-Kapandji procedure, post-operative care is essential for optimal recovery. The wrist is immobilized to prevent movement that could disrupt the healing process. Patients are typically monitored for any signs of complications, such as infection or improper healing. Rehabilitation may be initiated after a period of immobilization, focusing on restoring range of motion and strength in the wrist and forearm. Follow-up appointments are necessary to assess the fusion and overall recovery progress.