ORIGINAL ARTICLE pissn 1598-3889 eissn 2234-0998 J Korean Soc Surg Hand 2014;19(4):173-179. http://dx.doi.org/10.12790/jkssh.2014.19.4.173 JOURNAL OF THE KOREAN SOCIETY FOR SURGERY OF THE HAND Scaphoid Nonunions Treated with 1, 2-Intercompartment Supraretinacular Artery Pedicled Vascularized Bone Graft and Headless Compression Screw Fixation Dong-Hyun Kim, Yang-Guk Chung, Seung-Han Shin, Ho-Jin Gil, Jin-Woo Kang, Han-Seok Cho Department of Orthopedic Surgery, The Catholic University of Korea College of Medicine, Seoul, Korea Received: November 19, 2014 Revised: December 8, 2014 Accepted: December 9, 2014 Correspondence to: Yang-Guk Chung Department of Orthopedic Surgery, Seoul St. Mary Hospital, The Catholic University of Korea College of Medicine, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Korea TEL: +82-2-2258-2837 FAX: +82-2-535-9834 E-mail: ygchung@catholic.ac.kr *This paper was introduced at 2013 Annual Meeting of the Korean Orthopaedic Association. 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: The purpose of this study was to evaluate the clinical results of scaphoid nonunions treated with 1, 2-intercompartment supraretinacular artery (ICSRA) pedicled vascularized bone grafting (VBG) and headless compression screw fixation. Methods: Since August 1, 2005, 11 scaphoid nonunions with avascular necrosis or bone marrow edema of proximal fragments were managed with 1, 2-ICSRA pedicled VBG combined with headless compression screw fixation. The mean age was 37.1 years (range, 21-66 years). 8 patients had avascular necrosis (AVN) of proximal fragments and 3 patients had bone marrow edema in proximal fragments. Serial radiographic evaluations were performed in every 4-8 weeks for bone union and follow up computed tomography scanning were checked in 8 patients. Results: Bone unions were obtained in all 11 patients at 4.9 months (range, 3-9 months) after operation. At last follow up, the average range of motion was 82.5% and the grip power was 84.1% compared to the contralateral side. The mean New York Orthopaedic Hospital wrist score at last follow up was 83.2 (range, 58.1-93.3). Conclusion: Combined 1, 2-ICSRA pedicled VBG and headless compression screw fixation were reliable methods for managements of scaphoid nonunions even with AVN at proximal fragments. Keywords: Scaphoid nonunion, Avascular necrosis, 1, 2-Intercompartment supraretinacular artery pedicled vascularized bone graft, Headless compression screw fixation 서론 주상골골절은수근골골절중가장흔하게발생하며이중 5%-10% 에서불유합이발생하는데이는주상골의혈행분포나활액에의한골유합의방해와같은해부학적문제, 장기간증세가없이지내는경우에있어진단및치료지연, 인대의 불안정성에기인한다 1,2. 주상골의불유합시에는수근관절의불안정성으로인하여관절증 (arthrosis) 으로진행되므로수상초기에정확한진단및골유합술이필수적이다 3. 주상골불유합의수술적치료방법으로는자가장골이식술및유경혈관화골이식술등과같은골이식술과 K-강선이나무두압박나사못을이용한안정적인내고정술등이소개되고있다. Russe Copyright c 2014. The Korean Society for Surgery of the Hand 173
J Korean Soc Surg Hand Vol. 19, No. 4, December 2014 에의해무혈성괴사가발생하지않은주상골불유합에서피질망상지주골이식술 (corticocancellous strut bone graft) 이성공적인결과를보고한바있지만 4, 근위골편에무혈성괴사가발생한경우에는단순골이식보다는혈관화골이식술이좋은결과를보고하고있다 5,6. 유경혈관화골이식술은 1991년 Zaidemberg 등 7 이주상골불유합의치료에있어서성공적인결과를보고한후많이이용되는술식중하나이다. 본연구에서는 1,2-구획간상지대동맥유경 (1,2-intercompartmental supraretinacular artery pedicled, 1,2-ICSRA pedicled) 혈관화골이식술과무두압박나사고정술을병행한 11명을 1년이상추적관찰하여임상적및방사선적결과를평가하고그유용성을보고하고자한다. 대상및방법 2005년 8월이후주상골불유합에대하여 1, 2-구획간상지대동맥유경혈관화골이식술과무두압박나사고정술을시행하고, 수술후최소 1년이상추시관찰이가능했던 11예를대상으로하였다. 11명모두남자였으며평균나이는 37.1세 ( 범위, 21-66세 ) 였고, 과거력상 9예 (81.8%) 에서 6개월이상진단이지연되어수상일로부터수술일까지의이환기간은평균 76.5개월 ( 범위, 3-480개월 ) 이었다. 주상골의불유합부위는척측편위상태에서촬영한후전면사진상, 원위골편비가 0.6 이상인경우를근위골편부불유합으로정의할때 8, 근위골편부가 4예, 근위요부가 7예였다. 자기공명영상검사에서 8예는근위골편이 T1 강조영상에서저신호를, T2강조영상에서고신호또는저신호를나타내는소견의무혈성괴사가동반되어있었고, 3예에서는뚜렷한무혈성괴사의소견은보이지않았으나근위골편전반에골수부종소견이관찰되었다. 제1 단계의주상골불유합에따른진행성붕괴 (scaphoid nonunion advanced collaps, SNAC) 가발생한경우가 3예였다. 모든예에서후방도달법을이용하여 1, 2-구획간상지대동맥유경혈관화골이식술을시행하고무두압박나사고정술을병행하였다. 수술후건측과환측의관절운동범위를신전과굴곡, 요측편위와척측편위로나누어측정하였다. 기능적결과는 New York Orthopaedic Hospital wrist scoring scale (NYOH score) 및 Modified Green and O Brien scoring scale 을이용하여평가하였다 9,10. 모든환자에서수술후 8주간무지수상단상지석고고정을시행하였으며, 4-8주간격으로단순방사선사진을촬영하여전후면과척측편위영상에서골소주의연결을확인하였고, 수술전과최종추시시의주상 -월상골각과요-월상골각을측정하여비교하였으 며, 8예에서는수술후전산화단층사진을촬영하여골유합의진행을평가하였다. 평균추시기간은 30.9개월 ( 범위, 12-85 개월 ) 이었다. 1. 수술술기전신마취하에환자를앙와위로눕히고상완부에지혈대를적용한후수술을시행하였다. 수근관절부후방에피부절개를가한후신전지대를계단모양으로절개하여제1, 2신전구획을노출하였다. 제1, 2-구획간상지대동맥을확인한후이에손상이가지않도록주의하면서요수근관절면에서 1.5 cm 상방에중심을두고약 12 5 4 mm 크기의골편을혈관과함께거상하였다. 지혈대를풀어혈관경의역방향성혈류와거상한골편에서의출혈을확인하였다 (Fig 1A). 다시지혈대의압력을올린후관절낭에관절면을따라절개를가하여불유합부위를노출시키고, 주상골의변성된부분을건강한골조직이나괴사골이드러날때까지충분히소파하였으며. 골편사이에장골에서채취한자가망상골을채우고영상증폭장치를이용하여무두압박나사못을삽입하여내고정을시행하였다. 나사못의삽입방향은주상골의장축을따라주상골결절을향하여, 주상-월상골간인대로부터 1-2 mm 요측에서 guide wire 를삽입한뒤 2.7-3.0 mm 또는 3.5-4.0 mm 직경의무두압박나사못을주상골의장축길이보다 4 mm 짧게선택하여삽입하였으며, 유경혈관화골을이식할부위를확보하기위하여주상골의중심축보다수장측에삽입하였다. 불유합부위를가로지르는혈행화골편을이식할자리를주상골의후면에홈형태로만들고 (Fig. 1B), 만들어진홈보다약간크게거상한생골편을다듬은후혈관경이꼬이지않도록주의하면서혈관부착골이압박고정 (press-fit) 되도록이식하고관절낭과절개창을봉합하였다. 곱사등 (hump-back) 변형을동반한 1예에서는자가장골골편이식술을생골이식술과병행하였고, 생골편의압박고정이충분하지않아추가로미니나사로골편을고정하였다. 수술후 8주간무지수상단상지석고고정을시행하였고이후능동적수근관절운동을허용하였으며방사선사진상골유합소견이확인될때까지과도한손의사용을제한하였다. 결과 11예중 10예에서방사선적및임상적골유합을확인할수있었으며골유합까지의기간은평균 4.9개월 ( 범위, 3-9개월 ) 이소요되었다. 나머지 1예에서는수술후 2개월까지유합의진행이지연되는소견을보여 2개월간의석고고정을추가하 174
Dong-Hyun Kim, et al. Scaphoid Nonunions Treated with 1, 2-ICSRA Pedicled Vascularized Bone Graft and Headless Compression Screw Fixation Table 1. Summary of cases (ROM, grip power, NYOH score, Green-O Brien score and radiologic results) Patient ROM (%) Grip power (%) NYOH G-O Br SL angle RL angle Preop. Postop. Preop. Postop. 1 62.0 84.0 83.0 76.0 59.0 63.6 8.6 6.2 2 - - - - 54.8 57.8 11.2 12.1 3 75.0 33.0 58.1 55.0 63.0 68.4 3.1 3.4 4 73.6 94.3 86.1 70.0 53.3 51.9 9.6 9.9 5 74.6 90.0 81.6 70.0 74.7 63.1 16.4 9.1 6 85.5 100.0 92.6 90.0 57.4 52.8 5.2 4.3 7 - - - - 63.7 68.3 9.5 9.6 8 97.8 95.7 82.8 80.0 64.4 58.6 5.9 5.8 9 90.7 93.8 88.5 75.0 59.6 59.1 4.9 5.1 10 97.0 80.0 82.4 75.0 60.6 66.8 3.9 6.9 11 87.0 96.0 93.3 90.0 69.7 61.3 10.6 9.3 Mean 82.5 84.1 83.2 75.6 61.8 61.1 8.1 7.4 ROM, range of motion; NYOH, New York Orthopaedic Hospital wrist score; G-O Br, Modified Green and O Brien's score; SL angle, scapholunate angle; Preop., preoperative; Postop., postoperative; RL angle, radiolunate angle. 여, 총 16주간시행한후골유합을얻었다. 또다른 1예에서는 SNAC stage I 소견과함께통증이지속되어수술 1년후요골경상돌기절제술및무두압박나사못제거술을시행후증상호전되어일상생활로복귀하였다. 주상-월상골, 요-월상골각은각각수술전평균 61.8 ( 범위, 54.8-74.7 ), 8.1 ( 범위, 3.1-16.4 ) 였고, 최종추시시측정한영상에서는 61.1 ( 범위, 51.9-68.4 ) 와 7.4 ( 범위, 3.4-12.1 ) 로측정되어수술전후통계학적으로유의한변화는없었다. 수술후최종추시시의수근관절의운동범위는평균굴곡 61 ( 범위, 30-75 ), 신전 61 ( 범위, 45-90 ) 척측편위 29 ( 범위, 20-35 ), 요측편위 21 ( 범위, 10-30 ) 로, 건측운동범위의 82.5% ( 범위, 62%-97.3%) 로측정되었으며파악력은건측과비교하여 84.1% ( 범위, 33%-100%) 로측정되었다. 수술후 NYOH score 는평균 83.2점 ( 범위, 58.1-93.3점 ) 이었으며, Modified Green and O Brien score 는평균 75.6 점 ( 범위, 55-90점 ) 이었다 (Table 1). 1. 증례 1) 증례 1 29세남성으로약 1년간의우측수근부통증을주소로내원하였으며직업은군인이었다. 단순방사선검사상주상골근위 Fig. 1. Technique of 1, 2-intercompartment supraretinacular artery (ICSRA) pedicled vascularized bone graft using a dorsal approach for scaphoid nonunions. (A) The 1, 2-ICSRA pedicled vascularized bone graft was elevated from the dorsal surface of distal radius. The perfusion status of elevated bone graft was confirmed after tourniquet release. (B) After headless compression screw fixation, a slot for pedicled vascularized bone graft was prepared at dorsal surface of scaphoid with osteotome and curet. 175
J Korean Soc Surg Hand Vol. 19, No. 4, December 2014 부의불유합과경화소견이관찰되었다 (Fig. 2A). 수술전시행한자기공명영상검사에서주상골근위부의불유합및근위골편의무혈성괴사소견이관찰되었다 (Fig. 2B). 무두압박나사못고정술과1, 2-구획간상지대동맥유경혈관화골이식술을시행하였고 (Fig. 2C), 수술후 3개월에시행한단순방사선사진에서골유합소견을보였으며추가붕괴소견은없었다 (Fig. 2D). 수술후 23 개월추시상수근관절의능동적운동범위는굴곡 65, 신전 60, 요측편위 30, 척측편위 20 로측정되었다. 환자는수술후통증없이일상생활로복귀하였다. 2) 증례 2 35세남성으로 1년간의수근부통증을호소하며외래로내원하였으며직업은방사선기사였다. 단순방사선사진상주상골불유합소견및경화소견이관찰되었으며 (Fig. 3A) 수술전시행한자기공명영상에서는근위골편전체와원위골편일 부분에서골부종을시사하는음영변화를보였다 (Fig. 3B). 1, 2-구획간상지대동맥유경혈관화골이식및무두압박나사못고정술을시행하였고 (Fig. 3C), 수술후12개월에시행한전산화단층사진에서골유합소견을확인할수있었다 (Fig. 3D). 수술후 19 개월추시상수근관절의능동적운동범위는굴곡 55, 신전 60, 요측편위 15, 척측편위 35 로, 건측에비하여 73.6% 의운동범위를보였고, 파악력은건측의 94.3% 였다. NYOH score 는 86.05점이었으며 Modified Green & O`brien criteria 는 70점이었다. 환자는다시원래의직업으로복귀하였다. 고찰 주상골골절은수근골골절중가장흔하게발생하며불유 Fig. 2. The patient with a complaining of right wrist pain for 1 year. (A) The radiograph showed nonunion & sclerotic change of scaphoid proximal pole. (B) Magnetic resonance imaging showed avascular necrosis of proximal pole of scaphoid. (C) Headless compression screw fixation and 1, 2-intercompartment supraretinacular artery pedicled vascularized bone graft were performed. (D) At postoperative 3 months, complete bone union has progressed. Fig. 3. The patient has been complaining with a right wrist pain for 1 year. (A) The radiograph showed scaphoid nonunion and sclerotic change. (B) Magnetic resonance imaging showed bone marrow edema of whole proximal fragment and large portion of distal fragment of scaphoid, which suggested precarious perfusion status. (C) 1, 2-intercompartment supraretinacular artery pedicled vascularized bone graft and headless compression screw fixation were performed. (D) At postoperative 12 months, computed tomography scan revealed progression of bone union and no more scaphoid collapse. 176
Dong-Hyun Kim, et al. Scaphoid Nonunions Treated with 1, 2-ICSRA Pedicled Vascularized Bone Graft and Headless Compression Screw Fixation 합의빈도가높은데이는주상골의혈행분포나활액에의한골유합의방해와같은해부학적문제와, 장기간증세가없이지내는경우에있어진단및치료지연및인대의불안정성에기인한다고하였으며 1,2, 주상골의불유합시에는수근관절의불안정성으로인하여관절증 (arthrosis) 으로진행되거나주변인대관계에의해 humpback 변형이동반될수있어 3, 수술등의적극적인치료가필요하다고하였다 11. 주상골불유합의수술적치료에는불유합의정도에따라서여러가지방법들이사용되고있다. 지연유합을보일경우에는경피적핀고정술만을시행할수있고, 섬유성불유합 (Fibrous nonunion) 또는경화성병변 (Sclerotic nonunion) 이동반된불유합에서는적절한골이식과견고한내고정을시행할수있는데, 최근의연구결과에따르면비혈행성골이식과내고정을이용한주상골불유합의수술적치료후 47% 에서 100% 까지의유합률을보고하고있다 12. 주상골요부의 Humpback 변형이동반된경우에는수장측접근을통해서쐐기형골이식 (wedge bone graft) 를시행한경우에서좋은결과를보고하였다 13. 주상골근위극의불유합인경우에는혈행이유지된다면, 기존의골이식및내고정만을시행해도골유합을얻을수있지만, 무혈성괴사가동반된경우에서는골유합에실패할가능성이많다 14. Matti-Russe 골이식술의경우에서도, 여러문헌에서높은유합률이보고되어보편적으로사용되고있으나, 근위골편의골괴사가동반되었을경우유합률이낮다는단점이있다. Green 4 은수술중근위골편의혈행이확인될경우에유합률을 92% 라고보고하였으며, 근위골편의무혈성괴사를보인경우에서는불유합률이 100% 라고보고하였다. 유경혈관화골이식술은 1991년 Zaidemberg 등 7 이치료에성공적인결과를보고한후많이이용되는술식중하나로써, 근위골편의골괴사가동반되었을경우에다른술식에비해높은골유합률이보고되고있고, 골유합까지의기간이짧아정상생활로의복귀가빠른장점이있다 10,14. 유경혈관화골이식술은원위대퇴골이나장골에서시행하는방법도소개되어있는데 15, 신체의두부위를절개한다는점, 혈관의해부학적변이가있다는점에서제한점이있다. 원위요골부위 1, 2 구획간상지대동맥혈관경을이용한방법은이러한단점을보완하여가장보편적으로사용되는방법으로 Doi 등 16 과Boyer 등 17 은근위골편골괴사가있는주상골불유합에서유경혈관화골이식을시행한바 60%-100% 의유합률을보고하였다. 본연구에서는주상골의무혈성괴사가있는부분에대해서소파술을시행하고, 소파술후발생한골결손부위및낭종이있던부위에대해서는부분적으로자가장골이식술을시행하였으며, 무두압박나사못을이용하여내고정을시행한뒤에유경혈관 화골이식술을시행한바, 수술후 100% 의유합률을얻을수있었다. 수술중근위골편의점상출혈을확인하지않은것은본연구의한계라고할수있으나자기공명영상검사상의음영변화가지혈대를풀었을때근위골편의점상출혈을보이는수술소견과가장근접하므로 18 본연구에서는수술전자기공명영상검사소견과골소파술시의육안적소견을종합하여골괴사여부를판단하였다. 11예중 3예에서근위골편의무혈성괴사소견이아닌, 골부종소견을보였는데급성골절이아닌불유합에서보이는골절면에국한되지않은광범위한골부종은빈약한혈행과무혈성괴사로의진행을시사하는소견으로생각할수있으며 19, 생골이식술은골유합시기를앞당기고유합률을높이는데도움이될것으로판단되어나머지 8예와마찬가지로유경혈관화골이식술을시행하였다. 주상골불유합의골이식을통한수술적치료후골유합까지의기간에대해서는 Doi 등 16 이평균 12 주, Malizos 등 15 은 6-12 주, Park 등 13 은 10.7주로보고하였으나, 본연구에서는평균 4.9개월 ( 약 20주 ) 에유합을얻어조금더긴유합기간을보였다. 이러한결과는수술의적응증을좀더넓게적용하여, 주상골근위부무혈성괴사의비율이 11예중 8예로타병원의연구에비하여높았기때문이라생각된다. 주상골의내고정에있어서 K-강선과무두압박나사못을사용할수있는데, K-강선의경우에는고정력이불충불할수있고, 무두압박나사못의경우혈관경을손상시킬가능성이있으며골편의크기가작을경우고정에어려움이있다는단점이있다. 본연구에서는혈관경의손상이나이식골의파손을방지하기위하여전예에서먼저무두압박나사못을이용하여압박고정을시행하여불유합부위를확실하게안정시킨뒤유경혈관화이식골을감입시키는수술방법을통하여좋은결과를얻을수있었다. 주상골불유합의자연경과가대부분에있어각변형이나관절염을동반한다는것을고려할때, 불유합부위의재혈관화뿐만아니라골절부위의안정성또한중요한요소라생각하여무두압박나사못을이용하여압박고정을시행하였다. 근위골편의무혈성괴사와 humpback 변형이동반된 1예에서는유경혈관화골이식술과자가장골을이용한쐐기형골이식술을병행하였는데, 이는주상골의혈액공급을개선하여빠른골유합을촉진하는것도중요하지만, 환자의증상이불유합에의한증상보다는주상골모양의변형에의한것이므로, 혈행공급을개선함과동시에변형에대한교정술을시행한것이다. 유경혈관화이식골을쐐기모양으로넣는것을고려할수있으나이경우기술적으로어렵고, 혈관경이손상되면골유합을얻을수없을뿐아니라변형의교정역시 177
J Korean Soc Surg Hand Vol. 19, No. 4, December 2014 시간이지나며붕괴될가능성이높기때문에자가장골을이용하여추가적인쐐기골이식술을시행하였다. 수술후운동범위에대해서 Rajagopalan 등 12 은건측에비해굴곡 -신전각이 29%, 요-척굴곡각이 40% 정도감소한다고하였으나, 본연구에서는건측에비하여평균 17.5% 의감소를보여우수한결과를보였으며모든환자에서일상생활로의복귀가가능하였다. 본연구의대상이적고자가장골망상골이식술을병행하였기때문에전예에서골유합을얻을수있었던것이반드시유경혈관화골이식술때문이라말하기에는어려움이있지만근위골편의무혈성괴사를동반한불유합의경우에도전예에서골유합을얻어혈행장애를동반한주상골불유합에적용할수있는신뢰할만한술식으로판단된다. 결론 주상골의불유합에대하여 1, 2-구획간상지대동맥유경혈관화골이식술과병행한무두압박나사고정술은근위골편에무혈성괴사를동반한불유합의경우에도재혈관화를통한골유합과증상및수근관절의기능을호전시켜관절고정술혹은근위수근열절제술을대신하여선택할수있는유용한술식으로생각된다. REFERENCES 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. 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. 4. Green DP. The effect of avascular necrosis on Russe bone grafting for scaphoid nonunion. J Hand Surg Am. 1985;10:597-605. 5. Pokorny JJ, Davids H, Moneim MS. Vascularized bone graft for scaphoid nonunion. Tech Hand Up Extrem Surg. 2003;7:32-6. 6. Shin AY, Bishop AT. Pedicled vascularized bone grafts for disorders of the carpus: scaphoid nonunion and Kienbock s disease. J Am Acad Orthop Surg. 2002;10: 210-6. 7. Zaidemberg C, Siebert JW, Angrigiani C. A new vascularized bone graft for scaphoid nonunion. J Hand Surg Am. 1991;16:474-8. 8. Nakamura R, Imaeda T, Horii E, Miura T, Hayakawa N. Analysis of scaphoid fracture displacement by threedimensional computed tomography. J Hand Surg Am. 1991;16:485-92. 9. McQueen MM, Gelbke MK, Wakefield A, Will EM, Gaebler C. Percutaneous screw fixation versus conservative treatment for fractures of the waist of the scaphoid: a prospective randomised study. J Bone Joint Surg Br. 2008;90:66-71. 10. Gartland JJ Jr, Werley CW. Evaluation of healed Colles' fractures. J Bone Joint Surg Am. 1951;33:895-907. 11. Smith BS, Cooney WP. Revision of failed bone grafting for nonunion of the scaphoid. Treatment options and results. Clin Orthop Relat Res. 1996;(327):98-109. 12. Rajagopalan BM, Squire DS, Samuels LO. Results of Herbert-screw fixation with bone-grafting for the treatment of nonunion of the scaphoid. J Bone Joint Surg Am. 1999;81:48-52. 13. Park MJ, Lee JS, Shin SK. Treatment of scaphoid nonunionusing a pedicled vascularized bone graft. J Korean Orthop Assoc. 2006; 41:871-6. 14. Jones DB Jr, Burger H, Bishop AT, Shin AY. Treatment of scaphoid waist nonunions with an avascular proximal pole and carpal collapse. A comparison of two vascularized bone grafts. J Bone Joint Surg Am. 2008;90: 2616-25. 15. 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. 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. 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. 18. Gunal I, Ozcelik A, Gokturk E, Ada S, Demirtas M. Correlation of magnetic resonance imaging and intraoperative punctate bleeding to assess the vascularity of scaphoid nonunion. Arch Orthop Trauma Surg. 1999; 119: 285-7. 178
Dong-Hyun Kim, et al. Scaphoid Nonunions Treated with 1, 2-ICSRA Pedicled Vascularized Bone Graft and Headless Compression Screw Fixation 19. Schmitt R, Heinze A, Fellner F, Obletter N, Struhn R, Bautz W. Imaging and staging of avascular osteonecroses at the wrist and hand. Eur J Radiol. 1997;25:92-103. 1, 2- 구획간상지대동맥유경혈관화골이식술과무두압박나사고정술로치료한주상골불유합 김동현 정양국 신승한 길호진 강진우 조한석가톨릭대학교의과대학정형외과학교실 목적 : 1, 2-구획간상지대동맥 (1, 2-intercompartmental supraretinacular artery) 유경혈관화생골이식술과무두압박나사고정술로치료한주상골불유합환자의치료결과를분석하고자하였다. 방법 : 2005년 8월이후주상골불유합에대하여 1, 2-구획간상지대동맥유경혈관화골이식술과무두압박나사고정술을시행한 11명의환자를대상으로하였다. 자기공명영상검사상 8예에서근위골편에무혈성괴사가있었고, 3예에서골수내부종변화가있었다. 4-8주간격으로단순방사선사진촬영을시행하고, 8예에서는전산화단층촬영을통해골유합의진행을평가하였다. 결과 : 최종추시상, 전예에서골유합을얻었으며유합까지의평균기간은 4.9개월 ( 범위, 3-9개월 ) 이소요되었다. 운동범위는평균 82.5% 로회복되었고, 파악력은 84.1% 로회복되었다. 최종추시시 New York Orthopaedic Hospital wrist score 는평균 83.2점 ( 범위, 58-93점 ) 으로평가되었다. 결론 : 1, 2-구획간상지대동맥유경혈관화골이식술과무두압박나사고정술은주상골불유합에서근위골편의무혈성괴사를동반한경우에도골유합을얻을수있는유용한술식으로생각된다. 색인단어 : 주상골불유합, 무혈성괴사, 1, 2- 구획간상지대동맥유경혈관화골이식술, 무두압박나사고정술 접수일 2014 년 11 월 19 일수정일 2014 년 12 월 8 일게재확정일 2014 년 12 월 9 일교신저자정양국서울시서초구반포대로 222 가톨릭대학교의과대학정형외과학교실 TEL 02-2258-2837 FAX 02-535-9834 E-mail ygchung@catholic.ac.kr 179