대한수부외과학회지제 13 권제 1 호 The Journal of the Korean Society for Surgery of the Hand VOLUME 13, NUMBER 1, March 2008 주상골불유합에대한재수술의치료결과 연세대학교의과대학영동세브란스병원정형외과 강호정 정성훈 박상훈 이수건 한수봉 Revisional Surgery for Scaphoid Nonunion Ho-Jung Kang, M.D., Sung-Hoon Jung, M.D., Sang-Hoon Park, M.D., Su-Keon Lee, M.D., Soo-Bong Hahn, M.D. Department of Orthopaedic Surgery, Youngdong Severance Hospital, Yonsei University College of Medicine, Seoul, Korea Purpose: To evaluate the outcome of revisional surgery on scaphoid nonunions after operation. Materials and Methods: Five patients who underwent revision for scaphoid nonunion from May, 2000 to December, 2005, after primary surgery failure were studied. The average age was 32.8 years. Follow up period was an average 19.4 months (5~43 months). The diagnosis of scaphoid nonunion was made after an average of 52 months postoperatively. Fresh fractures were treated using internal fixation in 3 cases; K-s were fixed in 2 cases and Herbert screw was inserted in 1 case. The other two cases were treated using internal fixation and bone graft as the primary operation. Fracture fragment excision and salvage operation were excluded. Proximal pole of scaphoid included 3 cases and waist fracture 2 cases. Fixation using Herbert screw was applied on 4 patients, and one case was done using multiple Kirshner's. Results: After second surgery through fixation using Herbert screw and bone graft, union was achieved after an average 4 months on all cases except for 1 case that 통신저자 : 강호정서울특별시강남구언주로 612 영동세브란스병원, 연세대학교정형외과학교실 TEL: 02-2019-3410, FAX: 02-573-5393 E-mail: kangho56@yumc.yonsei.ac.kr required reoperation. All cases were satisfactory clinically after revisional surgery and there was no poor result. However, in three cases, mild pain persisted after union, and on final observation after the second surgery, the motion range of wrist joint showed improvement: flexion 68 on average (30~90,) extension 36 (15~80,) radial deviation 12 (10~15,) and ulnar deviation 15. Conclusion: Revisional surgery with Herbert screw and cancellous chip bone graft proved to be a useful treatment method when considering secondary surgery after scaphoid nonunion Key Words: Scaphoid, Nonunion, Revisional surgery 서 론 수근주상골은근위수근골과원위수근골을연결하는중간역할을하며, 원위요골에서수근골로이르는힘의전달에큰기능을하므로부하를많이받는곳이다. 주상골골절은수근골골절중에서가장높은발생빈도를보이나적절한치료로써 90~95% 의골유합을얻을수있는것으로보고되고있다 1-3. 수상후 6개월이지나도골유합의소견이방사선적으로관찰되지않는경우불유합으로진단된다. 이로인해수근부의불안정성, 운동장애와통증이소실되지않고, 방치하게되면수근관절주변의퇴행성변화 (scaphoid nonunion advanced collapse; SNAC) 로관절염이속발하게되어기능을현저하게저하시킨다 4-6. 주상골의불유합은약 5~15% 의빈도로발생되며, 이에기여하는요인으로는주상골특유의특이한혈행분포, 진단이늦어진경우, 활액에의한골절유합의방해, 골절시전위및각형성정도, 동반된수근관절의인대불안정성등이있다 7,8. 치료로는내고정술에의한골유합, 골이식및내고정술, 관절성형술및부분수근관절고정술, 근유경편골이식술등의많은수술방 8
주상골불유합에대한재수술의치료결과 법이이용되고있으며, 골이식및내고정술의수술적치료이후 95% 이상에서골유합을얻는것으로보고되고있다 1,9,10. 그러나주상골골절에대한일차적으로내고정술을시행한이후발생한불유합에대해재수술을시행한임상적결과에대한연구가많지않다. 주상골불유합의재수술적치료방법으로는환자의나이, 무혈성괴사여부, 골절의위치및퇴행성변화유무, 환자의활동력요구정도를고려하여다시골이식과내고정술을하는방법에서부터제한적수근골유합술 (limited wrist fusion), 근위수근열절제술 (proximal row carpectomy), 완관절유합술 (carpal bone fusion) 등구제술에이르기까지여러가지방법이소개된바있다 10,11. 젊고골질 (bone quality) 이좋은환자의불유합에서는가급적이면술기적으로간단하면서구제술이아닌골이식과내고정술을시도해볼수있다. 골이식의방법에따라내재골이식 (autobone graft), 개재형골이식 (intercalary bone graft) 및혈관화골이식 (vascularized bone graft) 등이이용되고있으며, 개재형골이식방법은기술적으로더어렵고, 유합율이내재골이식보다높지않다는단점이있고, 혈관화골이식은수술중혈관발견이어렵고숙련도및기술적어려움의단점이있어제한적으로사용된다 13-15. 이에저자들은주상골골절에대한수술이후발생한불유합에대해재수술로서보편화된치료방법인해면골이식및내고정술로치료한환자를대상으로그결과를보고하고자한다. 연구대상및방법 주상골골절에대하여타병원에서내고정술혹은골이식술을시행한이후, 2000년 5월부터 2005년 12 월까지발생한주상골불유합으로내원하여재수술을받은환자중에서주상골불유합에대해골이식과내고정술의재수술을실시하였던 5례를대상으로하였다. 근위수근절제술, 수근관절유합술등골이식과내고정술이아닌다른술기를이용한재수술은제외하였다. 5례중 2례는신선주상골골절에대해일차로관혈적 수술및내고정술만을시행받았던예이고, 1례는신선주상골골절에대해 Acutrak 나사를이용한경피적고정술을시행하였던예이며, 2례는불유합진단을받은후일차로골이식과내고정술을시행하였던예이다. 환자의평균연령은 32.8세 (22~51세) 였으며, 남자가 4례, 여자가 1례였다. 평균추시기간은 5~43개월 ( 평균 19.4개월 ) 이었다. 주상골근위부골절이 3례, 주상골요부골절이 2례였으며, 일차수술시신선골절 3례는수상후 3주이내에수술이진행되었다. 경피적으로 K-강선을고정한경우가 1례, 경피적으로 Acutrak 나사로고정한경우가 1례, K-강선으로고정한경우가 1례였다. 불유합으로진단받은경우는 2 례로, K-강선고정후골이식을실시하고염증및골수염발생한경우가 1례, AO 나사로골절고정후골이식을함께시행한경우가 1례였다. 수술이후불유합으로진단하기까지의평균기간은 52개월 (4~216개월) 이었고, 모든례에서수근관절통증과운동장애를호소하였으며, 방사선학적으로불유합소견이관찰되었다. 이차수술중 4례환자는재수술방법으로 Herbert 나사를이용한내고정술과함께해면골이식술을함께시행받았고, 1례는 2차재수술방법으로골이식및다발성 K-강선사용후유합추정되어내고정물제거시에불유합이관찰되어 Herbert 나사및골이식술을통한 3차수술로치료하였다. 전방수술법을시행한 4례는이전수술접근법에따라전방수술법을, 1례에서는후방도달법을사용하였다. 불유합의원인으로추정되는요인은골수염에의한것이 1례로 3차수술로치유하였고, 수술술기상내고정물의기술적문제로인한경우가 2례, 원인을알수없는것이 2례였다. 환자의당뇨등과거력및전신상태여부를확인하여전신질환의원인은없었다. 수술후방사선적추시관찰에따라평균 8주간장및단상지석고붕대고정술을실시하였다. 치료결과의임상적평가는 Maudsley와 Chen의평가기준을이용하여방사선학적골유합여부, 작업능력및수근관절의동통과운동범위에따라우수, 양호, 보통, 불량의 4등급으로분류하였다 16 (Table 1). 방사선학적결과를평가하기위하여술전과술후및 Table 1. Method of assessment in clinical result (by Maudsley and Chen) Assessment result Clinical Pain Tenderness Stiffness Excellent (-) (-) (-) Good Mild (+) Mild Fair Discomfort (+) Restriction in full motion Poor (+) Interfering normal work Limitation 9
강호정 정성훈 박상훈 이수건 한수봉 최종추시시수근관절전후면및측면방사선촬영과수근관절을척측, 요측굴곡및 30도외회전후촬영한주상골사진및 CT를기본으로하였다. 골절선을가로지르는골소주가있고, 골절간격이사라질때를골유합의기준으로삼았으며 3,11, 최종추시시와술전방사선소견을비교하여주상-월상각 (scapholunate angle) 의변화정도를평가하였다. 결과 1. 수술전소견 남자가 4례, 여자가 1례였으며우측부 2례, 좌측부에 3례가발생하였다. 수상의원인으로는손을짚고넘어진경우가 3례가가장많았고, 교통사고가 1례, 외력에의한직접손상이 1례였다. 1차수술전주상골골절이발생했을때 2 mm 이상의전위를보인경우가 1례였으며, 나머지 3례는기록이나방사선사진이없어서판단하기어려운경우였다. 재수술전 CT 검사나단순방사선사진에서주상골의근위부경화소견을보이는경우가 2례관찰되었다. 2. 동통평균 19개월의마지막추시관찰에서 2례는휴식과운동시동통이전혀없었고, 3례는각각휴식이나운동시에동통을호소하였으나, 수술전과비교하여모두동통의완화가있었다. 하지만 3례는마지막추시관찰까지경도의지속적인통증을호소하였다. 3. 임상적평가치료의평가기준으로 Maudsley와 Chen의평가기준 16 을사용하였으며 Herbert 나사내고정술후골이식을한총 5례중 2례에서우수, 1례에서양호, 2례에서보통의결과를얻었으며불량의결과는없었다. 수술전운동범위는완관절신전 (dorsiflexion) 45도 (20~67도), 완관절굴곡 (plantar flexion) 25도 (10~50도), 요측변위 5도 (0~15도), 척측변위 10 도 (5~10도) 였으며, 재수술후운동범위는완관절신전 70도 (50~80도), 완관절굴곡 50도 (25~75도), 요측변위 12도 (10~15도), 척측변위 15도로완관절운동범위의일부제한이보이나운동범위의호전이관찰되었고, 통계학적으로유의하였다.(p<0.01) 4. 방사선학적평가주상골불유합에대해 Herbert 나사내고정술및해면골이식술을이용한재수술이후 5례에서전부골유합을얻을수있었다. 골유합까지의평균기간은 4개월이소요되었다. 술전주상골불유합의 Mack분 류상 17 단순불유합 2 례, 불안정불유합 1 례, 요주상관 절의퇴행성변화동반한경우가 2례보였고, 술후추시결과상요주상관절의퇴행성변화가 3례에서관찰되었다. 수술전주상-월상골각은평균 57도 (48~8 도 ) 에서수술후평균 46도 (41~55도) 로호전되는양상을보였으며, 모든례에서후방굴곡불안정성 (DISI) 등의기형은관찰되지않았다. Table 2. Summary of cases Sex/ Hand Fracture Sclerosis Radio Internal Surgical Nonunion Internal ROM ROM Posto- Age location of proximal carpal fixationof 1 st approach duration fixation of (DF/ (RD/ perative pole arthritis surgery 2 nd surgery PF) UD) pain 1 F/27 Left Waist No No Herbert Herbert Volar 18 mos screw screw 80/75 15/15 (-) 2 M/51 Left Waist No No AO screw & Herbert Volar 18 yrs Bone graft screw 50/25 10/15 (+) 3 M/24 Right Proximal Yes Yes Herbert screw, Kirschner s Volar 7 mos Kirschner s 75/50 15/15 (-) Kirschner s 4 M/22 Right Proximal No No Kirschner s Volar 4 mos (2nd op) Herbert screw 80/55 10/15 (-) (3rd op) 5 M/40 Left Proximal Yes Yes Kirschner s Dorsal 18mos Herbert screw 65/45 10/15 (+) & Bone graft 10
주상골불유합에대한재수술의치료결과 증례보고증례 1 22세남자환자로 2003년 8월실족사고로개인병원에서우측수부주상골근위부골절진단받고관혈적정복및경피적 K-강선이용한수술받은환자로수술후감염소견보여 4개월간치료하였으나감염지속되어 (Fig. 1A) 술후 16주만에 K-강선을제거하고본원으로전원되었다 (Fig. 1B). 전원이후골수염에대한소파술후주상골주변부해면골이식과 K-강선 (size #2) 을이용한이차고정을시행하였다 (Fig. 1C). 술후 1년 3개월에유합소견보여 (Fig. 1D) 내고정제거를위해 3차수술시행하였으나, 다발성 K- 강선제거후에술장소견상주상골의불유합소견및주상골주변부에는이식골의생존으로일부골용량 (bone stock) 이잔존하여 3차수술로골이식과 Herbert 나사로재고정한환자이다 (Fig. 1E). 최종추시상주상골의골유합을얻었으며, 술후운동범위는완관절신전 80도, 완관절굴곡 55도, 요측변위 10도, 척측변위 15도였으며, 임상결과는우수하였다 (Fig. 1F). 증례 2 51세남자환자로 18년전낙법시범도중사고로좌측수부주상골요부불유합진단받고외상후 1년지내다가불유합에대해골이식과관혈적정복및 AO small bone 나사로내고정한환자로수술후지속적인통증이있어 18년동안주상골불유합진단받은상태로별다른치료없이지내던중내원 6개월전부터통증심해져서본원내원하였다 (Fig. 2A, B). 2차수술시주상골의보존을위해불유합부분을통하여 AO 나사를자른이후에제거하였고 (Fig. 2C), 골소실이 Fig. 1. (A) 1st postoperative photograph. Drainage sinus was found. (B) Initial radiograph at 1 st admission. The multiple cystic & osteolytic nonunion of proximal scaphoid was seen after removal of Kirshcner s s. (C) 2 nd postoperative radiograph. The scaphoid nonunion was treated with bone graft and multiple Kirschner's s fixation along periphery of scaphoid due to large cavitary defect. (D) After 1 year postoperatively, the scaphoid seemed to be united. (E) Immediate 3 rd postoperative radiograph. The scaphoid nonunion was found intraoperatively after removal of Kirschner s s and treated with cancellous chip bone graft and Herbert screw. (F) Radiograph after 1 year following surgery demonstrate good bony union. 11
강호정 정성훈 박상훈 이수건 한수봉 발생한나사주변부및불유합공간에해면골이식과 Herbert 나사및추가미니나사와 K-강선을이용한고정을시행하였다 (Fig. 2D). 술후 1년외래추시당시방사선사진상골유합및외상성관절염이관찰되었고, 통증은감소한양상보였으나, 운동범위는완관절신전 50도, 완관절굴곡 20도, 요측변위 10도, 척측변위 5도로운동장애가남았다 (Fig. 2E). 고찰 주상골은근위와원위수근골의요측을형성하고있는불규칙한골로서전체가관절연골로덮혀있고종축에대하여약 45도기울어져있으며 4개의수근골 과관절면을이룬다. 주변의수근골과는외부인대와내부인대에의하여서로연결되어있고, 주로요골동맥의배측수근분지와천부수장분지에의하여원위부극부위에서근위측으로혈액이공급되는구조를갖고있다. 근위극 (proximal pole) 주위는혈액공급이풍부하지않으므로골절시불유합이나무혈성괴사가일어나기쉽다 18-20. 불유합으로남아있는주상골을방치할경우에는수근관절주변의퇴행성변화를야기하여결국수근관절의기능을현저하게저하시키므로, 적극적인치료를요한다. 주상골불유합진단기준중기간은여러학자들에의해서 3~6 개월로각기달리정의되었고 3,23, 본연구에서는수상 4개월이후에골절의골절선이존재하는경우로정의내렸다. 불유합은 Fig. 2. (A) The nonunion of waist of scaphoid was seen after 18 years 1st postoperatively of AO screw fixation to waist fracture. (B) Preoperative MRI radiograph. Signal change of proximal pole and nonunion line was found. Avascular necrosis of proximal pole was suspected. (C) 2nd intraoperative photograph. Screw was removed through the nonunion site after cutting for saving scaphoid bone stock. (D) Immediate 2nd postoperative radiograph. The scaphoid nonunion was treated with bone graft. Herbert screw with additional Kirschner s and mini screw fixation was done. (E) Radiograph made 1 year following surgery demonstrates good bony union. 12
주상골불유합에대한재수술의치료결과 보통전위가있는골절의경우 35%, 원위부와중간부위에비해근위부에서 30~40% 을보고하고있고, 골이식에의한골유합술후실패와연관된인자로는무혈성괴사의존재유무와이식골편의채취부위등이보고되고있다 21. Nakamura 등 8 5년이상경과한주상골불유합, 근위부불유합, 근위부골편의무혈성괴사, 교정되지않은주상골변형이있는경우에는불량한결과를보인다고보고하였다. 또한 Inoue 등 7 은주상골불유합의치료후골유합에실패하는요인으로근위골편의무혈성괴사, 골절편의불안정성, 오래된이환기간, 주상골골절부위가상관관계가깊다고하였다. 본연구에서주상골불유합이발생한 5례의경우, 수술당시에주상골근위부무혈성괴사가있던경우가 2례있었으나술후결과에영향을미치지않았다. 골절부위, 전위정도, 수술도달법등도불유합의치료결과에영향을크게끼치지않은것으로사료된다. 수술적술기의문제로인하여견고한내고정이이루어지지않아불유합이된것으로추정되는경우가 2례였으며, 1례는감염에의한골수염으로인해발생한불유합으로추정이된다. 나머지 2례의경우는원인을알수없었다. 주상골불유합의치료로장기간의석고붕대고정술, 관혈적정복및내고정술, 나사고정술, 관절성형술, 내고정및골이식술, 관절고정술, 다발성천공술, 근위수근열절제술등다양한방법이있으며, Russe 의골이식술 10,20 등이많이이용되어왔다. 가장널리쓰이는골이식에의한치료는 Adams와 Leonard 22 가처음고안한이래배측감입골이식, 수장측감입골이식, 쐐기형골이식술, 회내사두근유경편골이식술등이시행되고있으며, 각각의접근방법에따라골이식술의성공률에차이가있는것으로보고하고있다. Russe 10 가내재골이식술을소개한이래로, 이방법은가장표준적인치료로받아들여지고있으나, 불안정성불유합에있어서는유합률이 85% 에불과하고, 내고정을사용하지않기때문에그효과에있어서의문이있다. 강등 23 에따르면 Herbert 나사로원위부에서부터고정한 14례중해면골을이식한 9 례의평균골유합기간은 18.5주였고, 격자형골 (bone block) 을이식한 5례의평균은 21.1 주로해면골을이식한예들에서짧은골유합기간을보였으나모든예에서골유합을얻어골유합률의차이는없었다고하였다. 1차골이식에비해서 2차골이식의경우골유합율이 60% 로떨어지는것으로알려져있으며 67% 에서 2차골이식에의한골유합이이뤄진이후에도증상이남아있는것으로보고하고있다 1. Schuind 등 24 은골이식을이용한골유합술에비해서구제술을시행하는것이통증완화등에는좋은것으로주장하고있다. Smith 등 25 이주상골불유합에대한골이식실패에대해재이식술을시행한 25례에서 22례의골유합을얻었으나중수근관절의퇴행성변화가있는경우에있어서는증상의호전을보이기힘들어구제술을시행하는것이바람직한것으로보고하고있다. Herbert 나사와해면골이식을시행한본 5례에서는골유합기간이평균 16주로비교적빠른골유합기간을관찰할수있었다. 증상의호전도 5례모두에서보였다. 방사선검사상골편이전위된경우나불안정성이있는경우골이식후골절부위의안정성을유지하기위해서다양한내고정이필요하며, 내고정물의종류로는 K-강선, AO나사, Herbert나사등이사용되고있다. 내고정방법에따른골유합률의차이에대해서도많은연구가시행되었는데, Schuind 24 은 183예의주상골불유합의후향적연구에서고정방법에따른예후의차이는없다고하였으나 Ritter 등 26 은 34명의환자에서 K-강선, Herbert 나사, AO cannulated 나사로고정한세군을비교한결과, K-강선을사용한군에서골유합에시간이더욱많이걸리는것으로보고하였다. 또한 Merrell 등 27 은 1827례의주상골불유합에서금속나사로고정한경우에서는 94% 의골유합율을보였으나, K-강선으로고정한경우에는 77% 의골유합율을보였다고한다. 저자는 5례의환자에있어서 Herbert 나사를이용하여내고정술을시행하였으며, 이러한골이식후내고정을통해서불유합되었던주상골의골유합을얻을수있었다. 술장소견상변형이심한양상을보여서 2개의 K-강선을이용한일시적고정을통해 alignment와 contour를맞추어본다음골소실부분에해면골이식을시행하고 Herbert 나사를삽입하여변형의교정과함께주상골의길이를유지하였다. 이렇게주상골불유합에서골유합을얻은경우에있어서도기능적측면에서동통과운동범위제한등이나타날수있다. 본연구에서는골유합은모든례에서이루어졌으며, 술전요주상관절염이동반된 2례를포함한모든환자에서통증의완화소견및운동범위의호전을보였다. 술전과비교하여통증과운동범위호전이관찰되었지만, 경한통증과부분적인운동제한이남아있는례가 3례관찰되었다. 결론 주상골골절수술후발생한불유합의치료로부분관절유합술이나주상골절제술, 근위수근열절제술등의구제술을시행하였을경우에는통증완화는가능하나운동범위의제한이심한단점이있으나 Herbert 나사내고정술및해면골이식술을이용한재수술을시행한경우에는통증의호전을보이면서운동범위의 13
강호정 정성훈 박상훈 이수건 한수봉 보존및향상을관찰할수있었다. 일차수술이실패한주상골불유합의치료방법으로서 Herbert나사를이용한내고정술및해면골이식술은효과적인치료방법으로사료된다. 참고문헌 01) Cooney WP, Dobyns JH, Linscheid RL. Nonunion of the scaphoid: analysis of the result from bone grafting. J Hand Surg. 1980;5: 343-54. 02) Gelberman RH, Wolock BS, Siegel DB. Fractures and nonunion of carpal scaphoid. J Bone and Joint Surg. 1995;77(6): 883-93. 03) Bunker TD, McNAmee PB, Scott TD. The Herbert screw for scaphoid fractures. A multicentre study. J Bone and Joint Surg Br. 1987;69(4): 631-4. 04) Jiranek WA, Ruby LK, Millender LB, Bankoff MS, Newberg AH. Long-term results after Russe bone grafting: the effect of malunion of the scaphoid. J Bone and Joint Surg. 1984;66B: 114-23. 05) Berger RA. The anatomy of the scaphoid. Hand Clin. 2001;17(4): 525-32. 06) Ruby LK, Stinson J, Belsky MR. The Natural History of Scaphoid Nonunion. A Review of Fifty-five Cases. J Bone and Joint Surg. 1985;67-A: 428-32. 07) Inoue G, Shionoya K, Kuwahata Y. Herbert screw fixation for scaphoid nonunions. Clin Orthop.1997;343: 99-106. 08) Nakamura R, Hori M, Horii E, Miura T. Scaphoid nonunion: factors affecting the functional outcome of open reduction and wedge grafting with Herbert screw fixation. J Hand Surg. 1999;24-A: 761-76. 09) Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone and Joint Surg. 1984;66B: 114-23. 10) Russe O. Fracture of the carpal navicular. Diagnosis, nonoperative and operative treatment. J Bone and Joint Surg. 1960;42-A: 759-68. 11) Matti H. Technik and resilte, meiner pseudoarthosen-operation. Z Chir. 1975;63: 1442-53. 12) Mulder JD. The results of 100cses of pseudoarthrosis in the scaphoid bone treated by the Matti-Russe operation. J Bone and Joint Surg Br. 1968;50(1): 110-15. 13) Cooney WP, Linscheid RL, Dobyns JH, Wood MB. Scaphoid nonunion : role of anterior interpositional bone grafts. J Hand Surg. 1988;13(5): 635-50. 14) Dias JJ, Taylor M, Thompson J, Brenkel IJ, Gregg PJ. Radiographic signs of union of scaphoid fractures. An analysis of inter-observer agreement and reproducibility. J Bone and Joint Surg Br. 1988;70(2): 299-301. 15) Fernandez DL, Eggli S. Nonunion of the scaphoid. Revascularization of the proximal pole with implantation of a vascular bundle and bone grafting. J Bone and Joint Surg. 1989;71-A: 1560-5. 16) Maudsley, Chen SC. Screw fixation in the management of the fractured carpal scaphoid. J Bone and Joint Surg Br 1972;54(3): 432-41. 17) Mack GR, Bosse MJ, Gelberman RH, Yu E. The natural history of scaphoid nonunion. J Bone and Joint Surg. 1984;66(4) 504-10. 18) Berger RA, Crowninshield RD, Flatt AE. The Three- Dimensional Rotational Behaviors of the Carpal Bone. Clin Orthop. 1982;167:303-10. 19) Botte MJ, Mortensen WW, Gelberman RH, Rhoades CE. Internal Vascularity of the Scaphoid in Cadavers after Insertion of the Herbert Screw. J Hand Surg. 1988; 13-A: 216-20. 20) Green DP. The Effect of Avascular Necrosis on Russe Bone Grafting for Scaphoid Nonunion. J Hand Surg. 1985;10-A: 597-605. 21) Taleisnik J, Kelly P. The extraosseous and Intraosseous blood supply of the scaphoid bone. J Bone and Joint Surg. 1966;48(6): 1125-37. 22) Adams JD, Leonard RD. Fracture of the carpal scaphoid. A new method of treatment with report of one case. New England J Med. 1928;198: 401-4. 23) Kang ES, Kang HJ, Lee JM, Shin SJ, Hahn SB. Comparison between Kirschner's and Herbert's screw fixation in Scaphoid nonunion. J of Korean Hand Surg. 1999; 4(2): 151-8. 24) Schuind F, Haentjens P, Innis V, Maren CV, Garcia-Elias M, Sennwald G. Prognostic factors in the treatment of carpal scaphoid nonunions. J Hand Surg. 1999;24-A: 761-76. 25) Smith BS, Cooney WP. Revision of failed bone grafting for nonunion of the scaphoid. Treatment options and results. Clin Orthop. 1996;327: 98-109. 26) Ritter K, Giacchino AA. The treatment of pseudoarthrosis of the scaphoid by bone grafting and three methods of internal fixation. Can J Surg. 2000;43(2): 118-24. 27) Merrell GA, Wolfe SW, Slade JF 3rd. Treatment of scaphoid nonunions: quantitative meta-analysis of the literature. J Hand Surg. 2002;4(2): 685-91. 14