ORIGINAL ARTICLE pissn 1598-3889 eissn 2234-0998 J Korean Soc Surg Hand 2012;17(4):159-165. JOURNAL OF THE KOREAN SOCIETY FOR SURGERY OF THE HAND Treatment of Scaphoid Nonunions Using a Pronator Quadratus Pedicled Bone Graft Mun Suk Jang 1, Yu Seok Seo 2 1 Republic of Korea Air Force l8st Fighter Wing Medical Center, Gangneung, Korea 2 Department of Orthopedic Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea Received: August 25, 2012 Revised: November 4, 2012 Accepted: November 19, 2012 Correspondence to: Mun Suk Jang Republic of Korea Air Force l8st Fighter Wing Medical Center, 117 Wall Ho Pyong street Hak dong, Gangneung 210-060, Korea TEL: +82-33-649-3602 FAX: +82-33-645-8026 E-mail: jjangdol13@hanmail.net This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/bync/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose: This study was to evaluate the clinical results of the treatment of scaphoid nonunions using a pronator quadratus pedicled bone graft. Methods: Thirteen patients with a scaphoid nonunion were treated with pronator quadratus pedicled bone graft. The average age of the patients was 20.23 years (range: 19-22 years) and the minimum follow-up period was one year. In all patients, bone grafting was performed and screw was fixed by using a volar aspect of distal radius bone graft with pronator quadratus muscle. Results: All 13 patients showed radiographic union with the average union time of 10.8 weeks (range: 9-13 weeks). Flexion, extension, radial deviation and ulnar deviation of wrist joint improved compared to the preoperative condition (p<0.05). Postoperative scapholunate and radiolunate angle improved compared to the preoperative condition (p<0.05). Eleven patients (84.5%) showed excellent or good results according to Herbert and Fisher s score criteria of functional, subjective satisfaction and radiographic result. Conclusion: Pronator quadratus pedicled bone grafting can be considered to be easily accessible technique on vascularized bone graft for osteosynthesis of scaphoid nonunions. It is proved to be effective for bone union, increased wrist joint motion. Keywords: Scaphoid, Nonunion, Pronator quadrates pedicle bone graft 서론 주상골골절은수근골골절중가장빈도가높은골절로 1-3, 임상적또는방사선학적간과로인해진단및치료가지연되어불유합의발생빈도가 5`-10% 정도보고되고있다 4,5. 스포츠활동의증가로인해서주상골골절은비교적흔하게발생하며이에따라주상골불유합역시흔하게발생한다. 주상골골절의불유합을치료하지않는경우에는장기적으로수근관절의불안정성및퇴행성변화와더불어동통, 파악력저하, 관절강직등의문제를초래할수있어적절한치료가중요하다. 불유합에대한수술적치료방법으로내재골이식 (inlay bone graft), 개재형골이식 (interpositional bone graft) 등의고전적인골이식술이이용되고있다 6. 최근에들어서근위부골절, 골절편의무혈성괴사및기존의골이식실패등골유합이어려운예에대해혈관화골이식을이용한치료법이이용되고있다. 그러나혈관화골이식술은술기가어려워경험이적은술자가시술하기는쉽지않다. 방형회내근유경골편이식술은 1965년 Judent 와 Rot-Camile 7 에의해시행된후비교적쉬운술기로손목주변의불유합및무혈성괴사에서혈관화골이식으로써사용되고있다. 그러나국내에서는 Copyright c 2012. The Korean Society for Surgery of the Hand 159
J Korean Soc Surg Hand Vol. 17, No. 4, December 2012 방형회내근유경골편을이용한골이식술에대한보고는적다. 이에저자들은주상골불유합의치료에방형회내근유경골편이식술을이용한치료결과를분석평가하였다. 대상및방법 1. 수술술기수술은전예에서수장부주상골결절에서부터원위부요골까지절개를가하여주상골의불유합부위를노출시켰다. 요주상유두골인대를분리후에주상골불유합부위를소파하고, 딱딱한부위를절제하여 10-20 mm 정도의타원형상당의공간을주상골축을따라만들었다. 그리고방형회내근유경골편이식술을하기위해서장무지외전근이붙는원위부 요골면에서방형회내근이붙는골편을골절단기 (osteotome) 을통해서분리하였다. 이때골편에서방형회내근이떨어지지않도록주의해야한다. 그리고방형회내근이붙는척골부위를골절단기를통해약화시켜 (undermine), 주상골불유합부위까지방형회내근의유경골편의길이를충분히확보하고장력이가해지지않게하였다. 원위부요골골편을견인과동시에주상골의타원형공간에골편을삽입하였다 (Fig. 1). 고정시에는원위골편에서가이드핀을삽입하여근위골편으로진행하는지방향을확인한후이식골을넣고전진시켰다. 그후골편을원위부에서근위부로 Acutrack headless compression screw (Acumed, Hillsboro, OR, USA) 를이용하여견고한고정을시행하였다 8,9. Fig. 1. (A) The pronator quadratus pedicled bone graft is obtained from styloid process of distal radius. Bone graft was inserted into the non-union site and fixed using Acutrack compression crew. (B, C, D) Intraoperative photographs show the surgical approach between the flexor carpi radialis and radial vessels, the graft after its detachment from the styloid process of the raidus and its insertion into the non-union site. 160
Mun Suk Jang, et al. Treatment of Scaphoid Nonunions Using a Pronator Quadratus Pedicled Bone Graft 2. 수술후관리수술후전예에서단상지무지수상석고고정을시행하였으며 2주간격으로골유합여부를확인하기위한방사선촬영을시행하였다. 방사선학적골유합소견이확인되면제거가능한단상지부목으로교체하고완관절운동치료를시작하였고부목은 4주간더착용하였다. 3. 대상및방법단순방사선에서수근관절의관절염이동반되지않는주상골불유합환자에대해 2009년 4월부터 2011년 6월까지본원에서방형회내근유경골편이식술을시행받고 1년이상추시가가능한군인 13명을대상으로시행하였다. 연구대상으로는주상골불유합환자중곱사등변형 (humpback deformity) 이없으면서불유합면의경화, 낭종, 골극혹은무혈성괴사가있는경우를택하였다. 환자의성별은모두남자였으며, 평균연령은 20.23세 ( 범위 : 19-22세 ), 손상후불유합수술까지의기간은평균 10.84개월 ( 범위 : 7-13개월 ) 이었다. 손상당시주상골골절로진단후석고부목으로치료받았으나불유합이발생한경우가 5예였으나, 8예의경우초기에주상골골절로 진단받지못하고치료를받지않았다. 근위부골절이 5예가있었으며그중 3예에서무혈성괴사가있었으며원위부골절이 8예가있었다 (Table 1). 방사선학적평가는완관절후전면, 측면, 척측위후전면, 측면사진촬영을이용하였고, 골절부위를가로지르는골소주가두개이상의촬영사진에서관찰될때방사선학적골유합으로판정하였다. 최종추시때의임상결과는환자의주관적및기능적만족도와방사선학적결과항목을점수화한 Herbert and Fisher 점수를기준으로평가하였다 (Table 2) 10. 그리고수술전후의수근관절의운동범위와주상-월상각과요-월상각을평가하였다. 통계분석은 SPSS ver. 17.0 (SPSS Inc., Chicago, IL, USA) 을이용하여비모순검정방법인 Wilcopxon-signed rank test를시행하였으며 p값이 0.05 이하인경우를통계적으로유의성이있는것으로판정하였다. 결과 전예에서방사선학적으로골유합을확인할수있었으며, 수술후방사선학적골유합까지의평균기간은 10.76주 ( 범위 : Table 1. Demographic data Patient Age/sex Cause of injury Duration of Initial Time to Preoperative Type of injury (mo) treatment union (wk) X-ray nonunion 1 19/M Sport injury 7 Cast 11 Middle third Fibrous 2 20/M Sport injury 9 Cast 11 Middle third Fibrous 3 21/M Sport injury 10 None 9 Proximal third Scleortic 4 22/M Sport injury 9 Cast 8 AVN proximal third Scleortic 5 19/M Sport injury 11 None 10 AVN proximal third Scleortic 6 19/M Sport injury 12 Cast 9 Middle third Fibrous 7 20/M Sport injury 13 None 10 Middle third Fibrous 8 22/M Sport injury 12 None 11 Proximal third Fibrous 9 19/M Sport injury 13 Cast 9 AVN proximal third Fibrous 10 19/M Sport injury 9 None 11 Middle third Scleortic 11 20/M Sport injury 10 None 12 Middle third Scleortic 12 22/M Sport injury 13 None 16 Middle third Scleortic 13 21/M Sport injury 13 None 13 Middle third Scleortic AVN: avascular necrosis. Table 2. Herbert and Fisher s score Result Grade Patient satisfaction Clinical result Radiographic result Excellent 0 Very happy asymptomatic Normal function unrestricted use Sound union no deformity Good 1 Improved minimal symptoms Minimal loss of function Apparent union minimal deformity unrestricted use Fair 2 Unchanged moderate symptoms Some restriction marked loss Doubtful union marked deformity of function Poor 3 Worse symptoms Marked loss of function restricted Non union loosening of the fixation use 161
J Korean Soc Surg Hand Vol. 17, No. 4, December 2012 Fig. 2. A 21-year-old man underwent the osteosynthesis using pronator quadratus pedicled bone grafting. (A) Preoperative plain radiograph shows scaphoid waist non-union. (B) Preoperative computed tomography image shows sclerotic change of proximal fragment and osteophytes. (C) Postoperative X-ray. (D) At 9 weeks after operation, healing was achieved and clinical result was excellent. Table 3. Comparison of postoperative and preoperative values Measurement Preoperative Postoperative p-value (<0.05) Flexion 52.3 58.76 0.0 Extension 53.76 59 0.0 Radial-deviation 9.76 13 0.0 Ulnar deviation 26.7 33.9 0.0 Scapho-lunate angle 63 56 0.0 Radio-lunate angle 4.9 1.2 0.0 9-16주 ) 였다 (Fig. 2). 수근관절의굴곡, 신전, 요측변위및척측변위의운동범위가수술전평균 52.3, 53.8, 9.76, 26.7 에서최종추시에평균 58.8, 59.0, 13.0, 33.9 로측정되어서수술전후에유의하게증가하였다 (p<0.05) (Table 3). 영상의학적변화로는주상-월상각과요-월상각은수술전평균 63.0, 평균후방신전 4.9 에서수술후 56.0 와후방 1.2 로수술전과수술후에유의하게향상되었다 (p<0.05) (Table 3). 수술전후에서후방개재불안정성을보였던예는없었다. Herbert and Fisher 점수를기준으로평가한기능적및주관적만족도에서 13예중 8예에서매우우수, 3예에서우수, 2 예에서양호로나타났다 (Table 4). 수술중에주상골의불유합상태는 7예에서경화성상태였으며, 6예는섬유화된상태로관찰되었다. 고찰 저자들이시행한주상골불유합에대한방형회내근의유경골편이식술은골유합및손목관절의운동성향상이나타났다. 주상골불유합이나타나는주된원인으로는부적절한치 Table 4. The Overall results of pronator quadrates pedicle bone graft of non-uinon scaphoid fracture (Herbert and Fisher s score) Result Non-union scaphoid fracture Percentage (%) Excellent 4 30.7 Good 7 53.8 Fair 2 15.4 Poor 0 0 Total 13 100 료, 진단의지연, 골절의부위나방향, 골편의전위와수근불안정등이있다 11,12. 치료받지않는주상골골절은시간이지남에따라퇴행성변화가진행하는데주상골에만국한되지않고요주상골을침범하고수근관절전체에퇴행성변화가나타나주상골불유합진행성붕괴로이른다 13. 특히근위골절의경우혈류장애로인한근위골절편의무혈성괴사가능성이높고근위골절편이작아서견고한고정이힘들어불유합의확률이높다 14. 주상골불유합의치료방법으로다양한골이식방법이소개되었다. 1937년 Matti에의해보고된내재골이식방법은 Russe 6 에의해피질망상지주골이식술으로변형되어가장보편화되어있고 70-90% 정도의유합률을보고하고있다. 그러나근위골편의무혈성괴사가존재할경우나기존의골 162
Mun Suk Jang, et al. Treatment of Scaphoid Nonunions Using a Pronator Quadratus Pedicled Bone Graft 이식방법이실패한경우고식적인골이식술후의유합률은낮은것으로알려져있다 15-17. 이러한단점을극복하기위한방법으로주상골불유합에대한유경골편이식술을시행하였다. 유경골편이식술에는원위대퇴골이나장골로부터유리혈관화골이식술을하는방법, 주상골주위에서도서형피판 (islandflap) 의형태로시행하는이식술등여러방법들이소개되었다 8,10,13,17,18. 이중가장보편화되어있는방법이원위요골부위에서 1, 2구획간상지대동맥을혈관경으로하는이식골을이용하는것이다 8. 그러나혈관화골이식술은경험이적은술자에게있어서는시도하기가쉽지않고술기가어렵다. 또한혈관경을다치지않게유지하면서정확하게골절을정복한채로삽입하고고정하기가어려우며, 곱사등변형 (humpback deformity) 및후방개재분절불안정을동반한주상골불유합의경우동반된문제점을교정하기가어렵다 17. 그래서시행한방형회내근유경골편이식술은, Kawai 와 Yamamoto 19 가주상골불유합에대해처음으로환자 8명을대상으로시행한결과골유합및손목관절운동성증진그리고통증호전을보고하였다. 최근에 Noaman 등 20 은 45 명을대상으로수장측방형회내근유경골편이식술을시행한결과 Herbert and Fisher s score 상 91.5% 에서우수이상의결과가나타났으며, 손목관절의운동성이굴곡-신전에서 10%, 요골-척골에서 15% 의향상이나타났다. 또한방형회내근유경골편이식술은원위요골골절수술적치료방법과유사하게절개를시행하기때문에쉽게접근이가능하고상처부위를최소화할수있다. 그리고주상골부위의혈류를보존할수있으며, 손목관절의굴곡과신전의소실을최소화시킬수있다. 특히전방접근법을통한수술방법은후방개재성불안정성이있을경우교정할수있어수술후손목관절의운동성을향상시킬수있다 19,20. 그리고방형회내근유경골편이식술을시행할경우골유합까지의기간에대해저자는약 11 주를보고하였다. 이밖에도유경골편이식술을시행한 Park 18 은 11 주, Doi 등 16 은평균 12주, Malizos 등 21 은 6-12주를보고하였다. 반면에기존의골이식방법을사용한경우, Stark 등 22 은평균17주를보고하였다. 유경골편이식술의내고정의방법으로는 K-강선, Herbert 나사그리고 Acutrack 나사등이널리이용되고있고, 생흡수성나사못을이용한방법도좋은결과를얻고있다. 본연구증례들은불유합부위에대하여 Acutrack 나사를이용하여고정하는술식을시행하였다. 근위부골편이너무작거나균열되어서골절편골절이될가능성을제외하면, 금속나사의고정은골절부를압박하여유합을촉진시키고견고한고정으 로수술후조기의관절운동을가능하게한다 9. 이처럼유경골편이식후금속나사로고정한술식은유합기간이짧아조기의관절운동이가능하여수술후재활및일상생활의복귀에긍정적인영향을줄것으로생각된다. 그러나방형회내근유경골편이식술은방형회내근이짧은경우, 골의피질의두께가얇아이식골채취에용이하지않는단점을가지고있다. 또한중간부또는원위부주상골불유합에대해서는고전적인골이식술로높은골유합성공률과좋은임상결과가나타나서기술적으로어려운유경골편이식술이꼭필요하다고는할수없다. 결과적으로본연구에서는방형회내근유경골편이식술을근위골편의무혈성괴사를포함한주상골불유합 13예에대해서시행결과높은유합률과짧은유합기간을보였다. 또한손목관절의운동성이굴곡-신전및요골-척골모두에서향상되었으며, 손목관절의주상-월상각과요-월상각이의미있게교정되었다. 또한 Herbert and Fisher 점수상 2예를제외하고우수이상의높은점수가나타났다. 그러나본연구의제한점으로는방형회내근유경골편이식술을시행한환자표본수가적고수술을시행받은환자들의수술전상태가모두근위부무혈성괴사가있지않았으며, 군인이라는젊고건강한환자를대상만으로시행하였다는것이다. 또한방형회내근의유경골편의길이에따른혈류공급에미치는영향을직접적으로비교연구할수가없어서향후충분한증례분석이필요하다. 결론 주상골불유합이진단되었을때, 원위요골의방형회내근유경골편이식술은단일절개에따른상처의최소화및유경골편이식술에좀더손쉽게접근할수있다. 골유합및손목관절의운동성향상을가져올수있는효과적인수술기법이라고생각된다. 참고문헌 1. Cooney WP 3rd, Dobyns JH, Linscheid RL. Nonunion of the scaphoid: analysis of the results from bone grafting. J Hand Surg Am. 1980;5:343-54. 2. Cooney WP, Linscheid RL, Dobyns JH, Wood MB. Scaphoid nonunion: role of anterior interpositional bone grafts. J Hand Surg Am. 1988;13:635-50. 3. Gelberman RH, Wolock BS, Siegel DB. Fractures and 163
J Korean Soc Surg Hand Vol. 17, No. 4, December 2012 non-unions of the carpal scaphoid. J Bone Joint Surg Am. 1989;71:1560-5. 4. Proctor MT. Non-union of the scaphoid: early and late management. Injury. 1994;25:15-20. 5. Tomaino MM, King J, Pizillo M. Correction of lunate malalignment when bone grafting scaphoid nonunion with humpback deformity: rationale and results of a technique revisited. J Hand Surg Am. 2000;25:322-9. 6. Russe O. Fracture of the carpal navicular. Diagnosis, non-operative treatment, and operative treatment. J Bone Joint Surg Am. 1960;42:759-68. 7. Judet R, Rot-Camille R. Fractures et pseudarthroses du scaphoide carpien. Utilisation d un greffon pedicule. Actua Chir Orthop. 1965;4:196-214. 8. Lee JY, Sohn HM, You JW, Kim DH, Kim DY. Treatment of nonunion of proximal scaphoid fractures using vascularized bone graft. J Korean Orthop Assoc. 2005; 40:471-6. 9. Robbins RR, Ridge O, Carter PR. Iliac crest bone grafting and Herbert screw fixation of nonunions of the scaphoid with avascular proximal poles. J Hand Surg Am. 1995;20:818-31. 10. Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br. 1984;66:114-23. 11. Leslie IJ, Dickson RA. The fractured carpal scaphoid. Natural history and factors influencing outcome. J Bone Joint Surg Br. 1981;63-B:225-30. 12. Prosser GH, Isbister ES. The presentation of scaphoid non-union. Injury. 2003;34:65-7. 13. Cheon SJ, Cha SH, Kim HT. A comparative study of three different bone grafting methods for treatment of scaphoid nonunion. J Korean Orthop Assoc. 2010;45:179-87. 14. Ricardo M. The effect of ultrasound on the healing of muscle-pediculated bone graft in scaphoid non-union. Int Orthop. 2006;30:123-7. 15. Boyer MI, von Schroeder HP, Axelrod TS. Scaphoid nonunion with avascular necrosis of the proximal pole. Treatment with a vascularized bone graft from the dorsum of the distal radius. J Hand Surg Br. 1998;23:686-90. 16. Doi K, Oda T, Soo-Heong T, Nanda V. Free vascularized bone graft for nonunion of the scaphoid. J Hand Surg Am. 2000;25:507-19. 17. Park MJ, Lee JS, Shin SK. Treatment of scaphoid nonunionusing a pedicled vascularized bone graft. J Korean Orthop Assoc. 2006;41:871-6. 18. Park JW. Scaphoid fractures and nonunions: recent trends of treatment. J Korean Soc Surg Hand. 2011;16: 116-26. 19. Kawai H, Yamamoto K. Pronator quadratus pedicled bone graft for old scaphoid fractures. J Bone Joint Surg Br. 1988;70:829-31. 20. Noaman HH, Shiha AE, Ibrahim AK. Functional outcomes of nonunion scaphoid fracture treated by pronator quadratus pedicled bone graft. Ann Plast Surg. 2011; 66:47-52. 21. Malizos KN, Dailiana ZH, Kirou M, Vragalas V, Xenakis TA, Soucacos PN. Longstanding nonunions of scaphoid fractures with bone loss: successful reconstruction with vascularized bone grafts. J Hand Surg Br. 2001;26:330-4. 22. Stark HH, Rickard TA, Zemel NP, Ashworth CR. Treatment of ununited fractures of the scaphoid by iliac bone grafts and Kirschner-wire fixation. J Bone Joint Surg Am. 1988;70:982-91. 164
Mun Suk Jang, et al. Treatment of Scaphoid Nonunions Using a Pronator Quadratus Pedicled Bone Graft 방형회내근유경골편이식술을이용한주상골불유합의치료 장문석 1 서유석 2 1 공군 18 전투비행단항공의무대대, 2 순천향대학교부천병원정형외과학교실 목적 : 주상골불유합을방형회내근유경골편이식술을이용하여치료한임상적인결과를평가하였다. 대상및방법 : 주상골불유합으로방형회내근유경골편이식술을시행받은환자 13명을대상으로하였다. 환자의평균연령은 20.23세 ( 범위 : 19-22세 ), 최소추시기간은 1년이었다. 모든예에서수장측원위요골에서방형회내근을이용하여유경골편이식술을하고나사로고정술을시행하였다. 결과 : 모든 13명환자에서방사선학적으로골유합을확인할수있는평균기간은 10.76주 ( 범위 : 9-13주 ) 였다. 모든예에서수근관절의굴곡, 신전, 요측변위및척측변위의운동범위가수술전보다유의하게향상되었다 (p<0.05). 또한수술후주상 -월상각과요-월상각도수술전보다유의하게향상되었다 (p<0.05). Herbert and Fishers 점수를기준으로평가한기능적, 주관적인만족도그리고방사선학적결과에서우수이상이 13예 (84.5%) 였다. 결론 : 주상골불유합의치유를위한방형회내근유경골편이식술은접근이쉬운혈관화골이식술로골유합및손목관절의운동성향상을가져올수있는효과적인수술기법이라고생각된다. 색인단어 : 주상골, 불유합, 방형회내근유경골편이식술 접수일 2012 년 8 월 25 일수정일 2012 년 11 월 4 일게재확정일 2012 년 11 월 19 일교신저자장문석강원도강릉시학동월호평길 117 공군제 18 전투비행단, 제 18 전투비행단항공의무대대 TEL 033-649-3602 FAX 033-645-8026 E-mail jjangdol13@hanmail.net 165