Archives of Hand and Microsurgery Arch Hand Microsurg 2018;23(1):35-45. https://doi.org/10.12790/ahm.2018.23.1.35 pissn 2586-3290 eissn 2586-3533 Original Article 원위주상골불유합의수술적치료 이상윤ㆍ신주철ㆍ오원택ㆍ최윤락ㆍ고일현ㆍ강호정 연세대학교의과대학정형외과학교실 Operative Treatment for Nonunion of the Distal Scaphoid Sang-yun Lee, Jucheol Shin, Won-taek Oh, Yun-Rak Choi, Il-Hyun Koh, Ho-Jung Kang Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea Purpose: The purpose of this study was to analyze the clinical and radiological outcomes of distal scaphoid nonunion patients who underwent operative treatment. Methods: From July 2006 to May 2014, there were a total of 9 distal scaphoid nonunion patients, with a mean age of 32 years. The mean time from symptom onset to operation was 15 months. Operative treatment was performed through a volar approach, osteosynthesis with an auto-iliac bone graft was performed. Union was determined through radiographs and computed tomography, while the scapholunate angle (SLA) and lateral intrascaphoid angle (LISA) were measured. Clinical outcomes were evaluated by assessing range of motion (ROM) of the wrist, the visual analogue scale (VAS), Mayo wrist score, and disabilities of arm, shoulder and hand (DASH) score. Results: The incidence of distal scaphoid nonunion was 11.8% (9/76), with all patients demonstrating union after the operation. Mean union time was 5 months and mean follow-up period was 23 months. Both SLA and LISA decreased, returning to normal range. The ROM of the wrist joint increased but not statistically significant. The postoperative VAS pain score improved, while grip strength advanced. In addition, both postoperative Mayo wrist and DASH scores document better results than those of pre-operation. Overall, there were two postoperative complication cases of joint motion limitation and pin site irritation. Conclusion: Osteosynthesis with auto-iliac bone graft for nonunion of the distal scaphoid showed good clinical and radiological outcomes. Thus, it is considered a recommendable operation in the treatment of distal scaphoid nonunion. Key Words: Scaphoid nonunion, Distal pole, Osteosynthesis 서론 주상골골절은전체수근골골절중약 70% 를차지하며보존적치료를시행하였을경우약 5% ( 범위, 0%-12%) 에서불유합이발생하고, 치료받지않은경우치료한경 우보다 2배이상에서불유합이발생한다 1,2. 주상골의혈액공급은두개의독립된혈관체계에의해받게되는데, 두혈관체계끼리상호연결이없어주상골근위부의혈액공급은전적으로골간혈액공급에의존하므로골절선이근위부에가까울수록지연유합, 불유합, 무혈성괴사가잘 Received December 15, 2017, Revised January 25, 2018, Accepted January 31, 2018 Corresponding author: Ho-Jung Kang Department of Orthopaedic Surgery, Gangnam Severance Hospital, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea TEL: +82-2-2019-3412, FAX: +82-2-573-5393, E-mail: KANGHO56@yuhs.ac Copyright c 2018 by Korean Society for Surgery of the Hand, Korean Society for Microsurgery, and Korean Society for Surgery of the Peripheral Nerve. All Rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 35
Archives of Hand and Microsurgery Vol. 23, No. 1, March 2018 일어나게된다. 주상골불유합은수근관절의기능이상, 정렬이상및불안정성, 주상골주위관절의관절염을초래하며주상골불유합진행성붕괴 (scaphoid nonunion advanced collapse) 로진행하게된다 3. 원위주상골골절은골절위치에따라원위 1/3-1/4에해당하는부위이며골절선은대능형골 (trapezium) 과소능형골 (trapezoid), 유두골 (capitate) 의관절면과접하거나주상골원위결절부를침범한다. 기존의연구에따르면주상골의원위 1/3 골절은 8%-20% 의빈도를보이고대부분의경우골유합이되는것으로알려져있다 4,5. 드물게불유합이발생하는데이는수상후부적절한고정및치료지연등에의해발생하는경우가대부분이다 6. 기존이론들과는달리 Gelberman과 Menon 7 에따르면주상골원위부에분기점 (watershed zone) 이존재하며, 골절이분기점에존재할경우불유합이잘일어난다고하였다 (Fig. 1). 또한 Moritomo 등 8 은운동역학적으로골편간의움직임이근위부에비해원위부에서많기때문에상대적으로불안정하다고하였다. 이러한해부학적, 운동역학적특징으로원위부주상골골절시드물지만불유합이발생하며, 후방개재분절불안정성 (dorsal intercalated segment instability) 또한발생할수있다 9. 본연구는원위주상골불유합의발생률및변형정도, 수술후임상적, 방사선학적결과에대해후향적으로분석하여원위주상골불유합의수술적치료의효과를알아보고자하였다. 대상및방법 2006 년 7 월부터 2014 년 5 월까지강남세브란스병원에 서주상골불유합으로진단을받고치료받은환자총 76 예중, 단순방사선검사및 3차원컴퓨터단층촬영영상검사 (three dimensional computed tomography, 3D CT) 를이용하여골절선이 Mayo 분류 (Table 1) 10 상 distal third 원위부에존재하는, 대능형골과소능형골, 유두골의관절면을침범하거나주상골원위결절부를침범하는주상골골절후불유합을포함한 9명의환자를대상으로후향적으로분석하였다. 첫수상후 3개월이상경과하였고방사선학적으로경화, 낭포성변화 (cystic change) 또는 2 mm 이상의간격이존재하는경우를불유합으로정의하였다 11. 이중남성이 7명, 여성이 2명이었다. 이전에주상골골절로수술적치료를받았거나동측손목수술을받은환자는제외하였다. 해당환자군의전자의무기록을통해성별, 수상당시나이, 수상기전, 진단당시초기치료방법, 수술방법을분석하였다. 수상당시나이는 32.4세 ( 범위, 18-66세 ) 였다. 수상기전으로는넘어져손을짚으며수상한경우가 4예, 펀치머신으로인한수상이 2예, 원동기교통사고로인한직접충돌 1예, 원인이불확실하거나수상력을기억하지못하는경우가 2예였다. 수상당시초기치료로무지석고고정을시행한환자가 4예, 초기수상이후치료를받지않고간과된환자가 5예였다. 과거력상 9예에서수상일로부터수술일까지의이환기간은평균 15.2개월 ( 범위, 3-48개월 ) 이었다 (Table 2). 수상후골절선의양상은 7예의경우, Herbert 분류 B1 에해당하는원위부사선 (oblique) 양상이었으며, 2예의경우에서는횡골절 (transverse type) 양상이었고 9예모두 Prosser 분류 IIC에해당하였다 (Table 1) 2,12. 원위부골절의관절면이경화된경우가 2예가있었고, 평균원위부전후면길이는 7.8 mm로측정되었다. 수술전 3D CT를 1 Proximal Distal 2 Proximal Distal Fig. 1. Watershed zone: distal third. Data from the article of Gelberman et al. 7 (J Hand Surg Am. 1980;5:508-13). 36 www.handmicro.org
Sang-yun Lee, et al. Osteosynthesis for Distal Scaphoid Nonunion Table 1. Classifications of distal scaphoid fractures of three different groups Herbert 2 Mayo clinic 10 Prosser (distal pole) 12 Type A (stable) - A1: tubercle - A2: incomplete Type B (unstable) - B1: distal oblique B1 A2 A1 Distal articular surface Distal - Distal articular surface - Distal tubercle - Distal third 2 1 3 Distal tubercle Distal third Type I - Fractures of tuberosity Type II - Distal intra-articular Type III - Ostéochondral fracture I IIA IIB IIC III 통해주상골부분만따로 3차원적재구성을하였으며, 원위부모양은직사각형 (rectangle) 또는삼각형 (triangle) 모양으로관찰되었다. 모든증례에서수장측도달법을이용하여불유합부위를확인후정상주상골길이를수복한상태로원위, 근위골편사이에임시 K-강선고정을하였고, 이후골결손부를측정하여크기와모양에따른 3차원적자가장골피질- 해면골덩어리혹은해면골편이식술을시행하였다 (Fig. 2). 피질-해면골이식이 8예, 해면골단독이식이 1예에서시행되었다. K-강선과무두나사 (Headless compression screw; Synthes, Waldenburg, Switzerland), 소형나사 (mini screw, LCP Compact Hand or Modular Hand System; Synthes) 로고정한환자가 4예, 무두나사와소형나사를이용한환자가 2예였다. 그외에도 K-강선과소형나사를이용한환자가 1예, 다발성 K-강선만을이용한환자가 1예, 무두나사 3개를이용하여고정한환자 1예가있었으며굴곡변형이심한경우임시 K-강선고정을시행하였다 (Fig. 3). 소형나사는자가장골중피질골을고정하는데에이용되었다 (Fig. 4). 수술전후 CT 분석은모든예에서시행하였다. 영상학적으로골간간격이사라지면서골절선을가로지르는골소주가있고손목전후, 측방, 사면단순방사선검사뿐만아니라척측편위 (ulnar deviation view) 및당구위치 (billiard view) 방사선검사상으로도골편간전이가없을때를골유합기준으로삼았다. 단순방사선상수술전, 후의주상월상각 (scapholunate angle) 과 CT상시상면에서의수술전, 후의주상골내각 (lateral intrascaphoid angle) 에대 www.handmicro.org 해측정하여비교하였다. 임상적결과에대한분석은수술후최소 1년이상의추시기간을두고수술전과후의 visual analogue scale (VAS) 통증점수를측정하여동통에대해평가하였으며, 관절운동범위를신전과굴곡, 요측변위와척측변위로나누어수술전과후에측정하였고수술후환측의운동범위를건측의운동범위와비교하여평가하였다. 수술전후 Mayo wrist score (MWS) 를측정하였고파악력은수술후측정한파악력을건측과비교하였다. 수술후 disabilities of arm, shoulder and hand (DASH) score 평가법을설문조사를통해측정하였다. 통계적분석은 IBM SPSS Statistics ver. 23.0 (IBM Co., Armonk, NY, USA) 프로그램을이용하였다. 각항목은모두연속형자료로서 Shapiro-Wilk 정규성검정상정규성을띄어 paired t-test를사용하였고, 유의수준은 p<0.05로하였다. 본연구는강남세브란스병원연구윤리위원회의승인을받고진행되었다 (IRB No. 3-2017-0086). 결과 주상골불유합으로진단받은 76예중원위주상골불유합으로수술적치료를시행받은 9예의평균추시기간은 22.6개월 ( 범위, 12-36개월 ) 이었다. 모든증례에서골유합소견을보였으며유합까지의평균기간은 4.9개월 ( 범위, 3-8개월 ) 이었다. VAS 통증점수는수술전평균 6.8에서수술후평균 37
Archives of Hand and Microsurgery Vol. 23, No. 1, March 2018 Table 2. Summary of cases Case no. Sex Age (yr) Mechanism of injury Period from symptom onset to date of operation (mo) Material of fixation Follow-up duration (mo) Time to bone union (mo) Flexion range of motion Extension range of motion Pre Post Pre Post Etc. 1 M 25 Punch machine 14 1 Herbert screw +1 K-wire +1 mini screw 2 F 31 Unknown 6 1 Leibinger screw +2 K-wires 3 M 29 Punch machine 8 3 CCS screws +2 temporary K-wires 4 M 18 Slip down 36 1 Herbert screw 5 M 27 Motorcycle traffic accident +1 K-wire +1 mini screw 3 1 Herbert screw +1 K-wire +1 mini screw 15 5 50 65 35 45 K-wire and mini screw removal at 1 year and 2 months after surgery 27 4 50 30 35 30 Hardware irritation All hardware removal at 9 months after surgery 12 4 60 55 50 55 No hardware removal 36 6 55 65 50 50 K-wire and mini screw removal at 2 years and 11 months after surgery 16 6 35 30 20 20 K-wire and mini screw removal at 1 year and 3 months after surgery 6 M 45 Slip down 5 2 HCS+1 mini screw 28 4 35 50 30 35 All hardware removal at 1 year and 11 months after surgery 7 M 35 Slip down 48 2 HCS+1 mini screw 12 3 45 55 30 40 No hardware removal 8 F 66 Unknown 5 3 K-wires 26 8 40 45 45 40 Hardware irritation All hardware removal at 1 year and 2 months after surgery 9 M 19 Slip down 12 2 HCS+1 K-wire +1 mini screw 31 4 70 65 50 45 All hardware removal at 1 year and 1 month after surgery K-wire: Kirschner s wire, CCS: cannulated cancellous screw, HCS: Headless compression screw. 38 www.handmicro.org
Sang-yun Lee, et al. Osteosynthesis for Distal Scaphoid Nonunion Fig. 2. Intraoperative bone defect measuring and osteosynthesis with auto-iliac corticocancellous block bone graft. A B C D E F G H I Fig. 3. A 29-year-old man who was induced osteosynthesis. (A, B) A preoperative plain radiographs showed distal scaphoid nonunion (arrows). (C-E) Preoperative computed tomography scan showed sclerosis at nonunion site and dorsal intercalated segment instability (DISI) deformity (arrowheads). (F, G) Immediate postoperative images (volar approach, 3 Headless screws, 2 temporary K-wires with auto iliac corticocancellous bone graft). (H, I) Radiograph at 1 year after the operation showed bone union. Some DISI deformity remains, but overall alignment is maintained. www.handmicro.org 39
Archives of Hand and Microsurgery Vol. 23, No. 1, March 2018 A B C D E F G H Fig. 4. A 26-year-old man who was induced osteosynthesis. (A, B) A preoperative plain radiographs showed distal scaphoid nonunion (arrow). (C, D) Preoperative computed tomography scan showed sclerosis at the nonunion site, scaphoid nonunion advanced collapse and dorsal intercalated segment instability (DISI) deformity (arrowheads). (E, F) Immediate postoperative images (volar approach, Headless screw, K-wire and mini-screw fixation with auto iliac corticocancellous bone graft and radial styloidectomy). (G, H) Radiograph at 1 year after the operation showed bone union. Some DISI deformity remains, but overall alignment is maintained. 2.4로통계적으로유의한감소를보였다. 완관절의운동범위는수술전과비교하였을때신전각은평균 38.3 에서 40.0 로, 굴곡각은 48.9 에서 51.1 로, 요측굴곡은 15.2 에서 16.5 로, 척측굴곡은 19.8 에서 22.5 로측정되었으나통계학적으로유의하지않았다. MWS는수술전평균 46.0점에서수술후평균 85.3점으로유의하게향상되었으며, 파악력은수술전건측에비해평균 67.0% 에서수술후평균 80.5% 로호전되었다. DASH score는술전 23.3 에서수술후 6.7로감소하였다. 방사선학적변화는주상월상각이수술전평균 71.7 에서수술후평균 53.5 로감소하였으며, 주상골내각은수술전평균 66.8 에서수술후평균 29.7 로감소하였다 (Table 3). 합병증으로는수술후손목신전, 굴곡각도 30 미만의 관절운동제한이 2예있었고, 그중 1예는수술전부터운동범위제한이존재하였던경우였다. 임시 K-강선고정으로인한불편감, 통증및운동범위제한은핀제거후모두사라졌으나, K-강선만을이용하여내고정시행한환자에서 K-강선삽입부위돌출및동통지속되어수술후 1년 2 개월째제거한경우가 1예있었다. 또한 K-강선과소형나사를이용하여고정한환자 1예에서수술후 9개월에 K- 강선삽입부위자극및운동제한증상으로고정장치제거술을시행하였다 (Table 4). 고찰 주상골골절은수근골골절중가장흔한형태의골절이 40 www.handmicro.org
Sang-yun Lee, et al. Osteosynthesis for Distal Scaphoid Nonunion Table 3. Clinical and radiologic outcomes at last follow-up Variable Preoperation Postoperation p-value* Range of motion ( ) Flexion 48.9 51.1 >0.05 Extension 38.3 40.0 >0.05 Radial deviation 15.2 16.5 >0.05 Ulnar deviation 19.8 22.5 >0.05 Grip strength (%) 67.0 80.5 <0.01 VAS pain 6.8 2.4 <0.01 MWS 46.0 85.3 <0.01 DASH score 23.3 6.7 <0.01 SLA ( ) 71.7 53.5 <0.01 LISA ( ) 66.8 29.7 <0.01 Values are presented as mean only. VAS: visual analogue scale, MWS: Mayo wrist score, DASH: disabilities of arm, shoulder and hand, SLA: scapholunate angle, LISA: lateral intrascaphoid angle. *p-values are assessed by two-sample t-test, Welch two-sample test or Wilcoxon rank sum test in continuous values, and by Fisher test in categorical values. Percentage compared to contra-lateral side. p<0.05. Table 4. Postoperative complication Variable Cases Limited range of motion 2 Pin site irritation 2 Delayed AVN 0 Asymptomatic nonunion 0 Advanced arthritis 0 AVN: avascular necrosis. 며해부학적으로요부 (waist) 에서많이발생하고약 5%- 10% 에서불유합이발생한다고알려져있다 13. 주상골의특 징적인혈행분포와수근불안정성등으로불유합이발생 하고주상골불유합을치료하지않고방치할경우에는수 근관절주변의퇴행성변화를야기하여관절의기능이저 하되고곱사등변형을초래하기때문에적극적인수술적 치료가필요하다 14,15. Oron 등 9 은원위주상골불유합이 주상골불유합의 4.1% 에서발생함을발표한바있다. 이 전연구들에서원위주상골골절은발생빈도가낮고치 료경과가양호한것으로알려져왔으며, 드물게불유합이 발생하는데 Wong 과 von Schroeder 6 은수상후부적절 한고정및치료지연등에의해발생하는경우가대부분이 라하였다. 본연구의대상자들또한과거력상수상후적 절한진단과치료가이루어지지않은것으로생각되며, 수 상직후병원내원한환자는원동기교통사고환자단 1 예 였으나이환자도처음원위요골골절진단후 4 주간의설 탕집게부목고정이외특별한처치없이추시이탈되었다. Gelberman과 Menon 7 이진행한연구에서는원위주상골골절후불유합은근위부와원위부혈관체계사이의분기점에서발생한다고보고하였으며이분기점은주로원위 1/3 지점에위치한다고하였다. 또한 Moritomo 등 8 의주상골불유합의운동역학적연구에서는골편간의움직임이주상골의근위부골절에비해원위부골절시에많았으며상대적으로불안정하였다고보고한바있다. 이러한해부학적, 운동역학적특징으로주상골원위부골절시원위부골량이부족하고움직임이많이일어나서점차결손부가더욱커지며불유합이발생하는경우가종종있다. 본연구에서는첫수상후 3개월이상경과하였고, 골절선이 Mayo 분류상 distal third 원위부에존재하는대능형골과소능형골, 유두골의관절면을침범하거나주상골원위결절부를침범하는골절선이존재하는경우를원위주상골불유합으로정의하였다 16. 이러한기준에따라분석하였을때, 본원에서 2006년 7월부터 2014년 5월까지 76예의주상골불유합중원위주상골불유합은 9예 (11.8%) 로기존연구보다높은발생률을보였다. 원위주상골불유합의형태는 Oron 등 9 이모든증례에서 Prosser 분류 IIC에해당하였고후방개재분절불안정성이모든증례에서발생하였음을발표하였다. 본원에서의원위주상골불유합의모든증례또한 Prosser 분류 IIC에해당하였고, 9예중 7예는원위부사선양상, 2예는횡골절양상이었다. 원위부골편의모양은직사각형또는삼각형모양이었다. 9예중 8예에서후방개재분절불안정성및곱사등변형관찰되어이전연구들과는다르게원위부 www.handmicro.org 41
Archives of Hand and Microsurgery Vol. 23, No. 1, March 2018 주상골불유합시불안정성및변형의발생이높은빈도에서관찰되었다. 본연구의저자들은원위주상골불유합에서골유합술등의적극적인수술적치료로주상골의안정성회복을얻고자하였다. 원위골편의골량이작고얇은특성이있어수술시기술적으로정확한 3차원적골이식을필요로하였고, 골편간움직임이많은운동역학적특징때문에안정적인고정에어려움이있어고정을위해두개또는다발성나사를이용한고정술이필요한경우가있었다. 수술적치료에는골이식술, 요골경상돌기절제술, 원위골편절제술등여러가지수술방법들이소개되었으나, 골이식및내고정술이가장효과적인것으로알려져있다 17,18. 본연구에서는모든증례에서자가장골이식술을시행하였으며, 피질-해면골이식이 8예, 해면골이식이 1예에서시행되었다. 최근 3D 프린터가소개되며의료분야에도응용하려는노력이있었다. 본원에서도주상골불유합수술전골결손부재건계획을위하여 3D CT와연동하여 3차원적결손구조이식골형태를제작하였던경험이있는데골편크기가상대적으로작고컴퓨터단층촬영재건영상원본이크게정밀하지않아실제임상적적용에는제한이있었다 (Fig. 5). 본연구에서는수술전 3D CT를통해개략적인재건계획은세우되실제골이식모양재건은수술장소견에따라결정하였다 (Fig. 2). 앞으로이에대한기술개발이이루어진다면환자의건측주상골혹은한국인성별, 연령별평균주상골크기에맞추어미리 3D 모형을제작하여필요한자가장골능골이식편형태를사전에미리제작하여골이식시간을단축시킬수있을것이고더욱효율적인 3차원적골이식이이루어질수있을것이다. 본연구의모든증례에서골유합소견을보였으며수술후 VAS 점수는수술전평균 6.8에서수술후평균 2.4로통계적으로유의미하게감소하였다. 주상골불유합의수술 전운동범위는골절선이원위부에위치할수록골절부움직임이훨씬크고다양한각도의관절가동범위가이루어지면서골절부변형에적응한상태로가관절 (pseudoarthrosis) 을이루어, 의외로크게감소하지않는경우도있다. 하지만본연구대상자들은대부분수술전관절가동범위가감소하였는데이는수상후부적절한관리, 통증혹은가관절부위의비정상적인움직임등으로인해손목을활동적으로쓰지않아감소하였을가능성이있다. 수술후운동범위의경우연구자마다다양한결과를보고하고있는데 Jiranek 등 19 은주상골불유합골유합술후손목굴곡신전각이건측대비 84% 로감소되었음을보고하였고, Rajagopalan 등 20 의연구에서는골유합술후요-척측편위각도는건측대비 40% 감소, 수장-수배측굴곡은건측대비평균 20 가량감소하였다고하였으며, 이의원인으로요골경상돌기를포함한요측퇴행성변화, 수술후발생한통증, 유착, 강직등을제시하였다. 본연구에서는통계학적으로유의하지는않으나수술후모든관절가동범위가평균적으로증가하였는데, 이는술전의통증및불안정성이술후에소실된경우로해석하여야하겠다. 한편, 다른연구들과비교하였을때본연구대상자의수술후운동범위는상대적으로낮은경향을보였고 9명중 3명은수술후오히려운동범위가감소하였는데이는 Rajagopalan 등 20 이제시한원인이외에도, 가관절부위의비정상적인움직임이정상적으로돌아오고불안정성이소실되면서오히려운동범위는감소하는경우로판단하였다. 일반적으로주상월상각이 70 이상인경우후방개재분절불안정성이있다고정의하며본연구에서는수술전주상월상각이평균 71.7 에서수술후평균 53.5 로감소하였다. 또한정상적으로주상골내각은 35 미만으로 45 이상인경우곱사등변형이있다고판단하며본연구에서수술전주상골내각이수술전평균 66.8 에서수술후평균 47.06 Fig. 5. 3D printer program image: preliminary reconstruction of scaphoid nonunion. 42 www.handmicro.org
Sang-yun Lee, et al. Osteosynthesis for Distal Scaphoid Nonunion 29.7 로감소하여방사선학적결과가만족스러움을확인하였다 21. 본연구의한계점은후향적연구 (retrospective study) 이며전체 9예로전제환자수가적어통계학적인의미가크지않다는점이다. 또한다른치료방법간의환자군과직접적비교를하지않고원위주상골불유합의수술적치료의수술전과후의결과를비교하였으므로이연구를통하여어느치료가우수하다고는할수없다. 그러나이전연구에서원위주상골불유합에대한연구가이루어진적이드물고, 비교적낮은빈도로발생하며치료경과가양호하였다고알려졌던기존연구결과와는다르게본연구에서는높은발생빈도를보인것이특징적이다. 또한골량이작아고정하기힘든원위부와곱사등변형을특징으로하는원위주상골불유합의치료로, 수술장소견상관찰되는골결손정도및형태에따른 3차원적자가장골이식및관혈적고정술이고려할만한치료방법인것을확인한것에의의가있다. 결론 원위부주상골불유합의발생빈도는기존의연구결과보다높은빈도를보였다. 주상골원위부불유합의치료시자가장골이식술과동반하여시행한견고한관혈적고정술은좋은임상적, 방사선학적결과를보였으며, 안전하고효과적인수술방법으로생각된다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Hove LM. Epidemiology of scaphoid fractures in Bergen, Norway. Scand J Plast Reconstr Surg Hand Surg. 1999;33:423-6. 2. Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br. 1984;66:114-23. 3. Leventhal EL, Wolfe SW, Moore DC, Akelman E, Weiss AP, Crisco JJ. Interfragmentary motion in patients with scaphoid nonunion. J Hand Surg Am. 2008;33:1108-15. 4. Grewal R, Suh N, MacDermid JC. The missed scaphoid fracture-outcomes of delayed cast treatment. J Wrist Surg. 2015;4:278-83. 5. Mack GR, Bosse MJ, Gelberman RH, Yu E. The natural history of scaphoid non-union. J Bone Joint Surg Am. 1984;66:504-9. 6. Wong K, von Schroeder HP. Delays and poor management of scaphoid fractures: factors contributing to nonunion. J Hand Surg Am. 2011;36:1471-4. 7. Gelberman RH, Menon J. The vascularity of the scaphoid bone. J Hand Surg Am. 1980;5:508-13. 8. Moritomo H, Murase T, Oka K, Tanaka H, Yoshikawa H, Sugamoto K. Relationship between the fracture location and the kinematic pattern in scaphoid nonunion. J Hand Surg Am. 2008;33:1459-68. 9. Oron A, Gupta A, Thirkannad S. Nonunion of the scaphoid distal pole. Hand Surg. 2013;18:35-9. 10. Cooney WP, Dobyns JH, Linscheid RL. Fractures of the scaphoid: a rational approach to management. Clin Orthop Relat Res. 1980;(149):90-7. 11. Jones DB Jr, Bürger 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. 12. Prosser AJ, Brenkel IJ, Irvine GB. Articular fractures of the distal scaphoid. J Hand Surg Br. 1988;13:87-91. 13. Kang HJ, Park H, Hahn SB. The treatment of nonunion of the scaphoid with a horse-shoe bone graft and fixation with two screws. J Korean Orthop Assoc. 2009;44:651-60. 14. Maudsley RH, Chen SC. Screw fixation in the management of the fractured carpal scaphoid. J Bone Joint Surg Br. 1972;54:432-41. 15. Gelberman RH, Wolock BS, Siegel DB. Fractures and non-unions of the carpal scaphoid. J Bone Joint Surg Am. 1989;71:1560-5. 16. Tuncay I, Doğan A, Alpaslan S. Comparison between fixation with Herbert screws and Kirschner wires in the treatment of scaphoid pseudoarthrosis. Acta Orthop Traumatol Turc. 2002;36:17-21. 17. Schneider LH, Aulicino P. Nonunion of the carpal scaphoid: the Russe procedure. J Trauma. 1982;22:315-9. 18. 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. www.handmicro.org 43
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Sang-yun Lee, et al. Osteosynthesis for Distal Scaphoid Nonunion 원위주상골불유합의수술적치료 이상윤ㆍ신주철ㆍ오원택ㆍ최윤락ㆍ고일현ㆍ강호정 연세대학교의과대학정형외과학교실 목적 : 원위주상골불유합의발생률및수술전후임상적, 방사선학적결과를후향적분석하여수술적치료의효과를알아보고자하였다. 방법 : 2006년 7월부터 2014년 5월까지원위주상골불유합으로골이식술및내고정술시행받은 9예를대상으로하였다. 평균연령은 32세, 수술일까지의이환기간은평균 15개월이었다. 전례에서수장측도달법을통해자가장골이식및내고정시행하였다. 영상학적으로골유합, 주상월상각및주상골내각의수술전후변화를, 임상적으로완관절운동범위, 시각통증등급, 악력, Mayo wrist score, disabilities of arm, shoulder and hand (DASH) score를분석하였다. 결과 : 원위주상골불유합의빈도는 11.8% 였다. 모든증례에서골유합얻었으며평균추시기간은 23개월, 유합시기는 5개월이었다. 주상월상각, 주상골내각은술후감소하여정상범위회복하였다. 운동범위는증가하였으나통계학적으로유의하지않았으며, 시각통증등급, 악력, Mayo wrist score, DASH score는유의미하게호전되었다. 합병증으로관절운동제한및핀고정부위자극각각 2예씩있었다. 결론 : 원위부불유합의발생빈도는기존의연구결과보다높은빈도를보였다. 주상골원위부불유합의치료에자가장골이식술과동반하여시행한관혈적고정술로좋은임상적, 방사선학적결과를얻었으며, 안전하고효과적인수술방법으로생각된다. 색인단어 : 주상골불유합, 원위부, 주상골유합술 접수일 2017 년 12 월 15 일수정일 2018 년 1 월 25 일게재확정일 2018 년 1 월 31 일교신저자강호정 06273, 서울시강남구언주로 211, 강남세브란스병원정형외과 TEL 02-2019-3412 FAX 02-573-5393 E-mail KANGHO56@yuhs.ac www.handmicro.org 45