대한정형외과학회지 : 제 43 권제 6 호 2008 J Korean Orthop Assoc 2008; 43: 694-702 Matti-Russe 술식과 Fisk-Fernandez 술식을이용한주상골불유합치료에관한비교연구 이승환ㆍ정문상ㆍ이영호ㆍ공현식ㆍ김지영ㆍ김민범ㆍ오원석ㆍ전숙하ㆍ김정환ㆍ백구현 서울대학교의과대학정형외과학교실 A Comparative Study on the Treatment of Scaphoid Nonunion with Matti-Russe Technique and Fisk-Fernandez Technique Seung Hwan Rhee, M.D., Moon Sang Chung, M.D., Young Ho Lee, M.D., Hyun Sik Gong, M.D., Ji Yeong Kim, M.D., Min Boem Kim, M.D., Won Seok Oh, M.D., Suk Ha Jeon, M.D., Jeong Hwan Kim, M.D., and Goo Hyun Baek, M.D. Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea Purpose: Established scaphoid nonunion may lead to carpal instability and osteoarthritis. The purpose of this study is to compare the clinical and radiological results of the osteosynthesis between Matti-Russe group and Fisk-Fernandez group. Materials and Methods: Our retrospective study included 21 nonunion cases in 20 patients treated by Matti-Russe or Fisk-Fernandez technique from September 2001 to August 2006. The mean duration of follow up was 31 months. Based on the questionnaire which included clinical information and the radiologic evaluation, we compared the objective and subjective results between two surgical groups. Results: There were no significant differences between two groups in respect of the postoperative satisfaction and the pain. Both the range of motion and the grip power decreased compared to that of the unaffected side, but there were no significant differences between two groups. Also, there were no significant differences in the union rate and the rate of successful correction of DISI deformity. In all cases in which DISI deformity was detected preoperatively, the deformity was corrected postoperatively. There were 7 cases of osteoarthritis, but among them only one case appeared newly after the surgery. Conclusion: There were no significant differences between two surgical groups in clinical and radiological results. Both techniques were effective in achieving bony union and functional recovery. Key Words: Scaphoid Nonunion, Matti-Russe, Fisk-Fernandez 서론수근골골절가운데가장흔한것이주상골골절이며적절한치료를받는경우에도약 5-15% 에서불유합이발생하는것으로보고되고있다 3,19,21). 이러한확정형주상골불유합에대해적절한치료를시행하지않고방치하는경우, 장기적으로수근골불안정성및골관절염이진행하고동통, 파악력저하, 관절강직등으로인한완관절 기능부전이초래됨이밝혀져있다 5,6). 따라서, 증상의유무와관계없이일단주상골불유합이진단되면이러한방사선학적및임상적이상소견이진행하기이전에조기골유합술을시행하는것이바람직하다고하겠다. 골유합술의역사적배경을살펴보면, 1937년 Matti 가제안한후방도달법을이용한해면골내재골이식술 (cancellous inlay bone graft) 은이후 Russe에의하여 통신저자 : 백구현서울시중구연건동 28 번지서울대학교의과대학정형외과학교실 TEL: 02-2072-3787 ㆍ FAX: 02-764-2718 E-mail: ghbaek@snu.ac.kr Address reprint requests to Goo Hyun Baek, M.D. Department of Orthopedic Surgery, Seoul National University College of Medicine, 28, Yongon-dong, Chongno-gu, Seoul 110-744, Korea Tel: +82.2-2072-3787, Fax: +82.2-764-2718 E-mail: ghbaek@snu.ac.kr 694
Matti-Russe 술식과 Fisk-Fernandez 술식을이용한주상골불유합치료에관한비교연구 695 전방도달법을이용한피질망상지주골이식술 (corticocancellous strut bone graft) 로변형되어오랜기간표준적인술식으로자리잡았다 9,24,26). (Matti-Russe 술식 ) 또한, 1980년 Fisk는요측도달법을이용한전방쐐기형삽입골이식술 (volar wedge shaped interpositional bone graft) 을제안하였는데, 이후 Fernandez, Cooney 등에의해전방도달법, 자가장골이식술및내고정술을시행하도록변형되어전위성주상골불유합에유용한방법으로쓰이고있다 8,9) (Fisk-Fernandez 술식 ). 기존에이미 Matti-Russe 술식과 Fisk-Fernandez 술식의장단점과이상적인적응증들이알려져있지만, 실제로이두술식을사용한집단간에임상적, 방사선학적결과를비교한연구는드물다. 본연구에서는 Matti- Russe 술식및 Fisk-Fernandez 술식을시행한주상골불유합 21예에대하여그방사선학적및임상적결과에대하여비교분석하고자한다. 대상및방법 2001년 9월부터 2006년 8월까지 5년간확정형주상골불유합으로수술받았던 36명의환자가운데인터뷰가가능했던 21명의환자를대상으로하였다. 이가운데 Matti-Russe 술식으로수술한경우가 12예로, 모두남성이었고수술당시의평균연령은 29세 (15-63 세 ), 평 균불유합기간은 26개월 (4-96 개월 ), 평균추시기간은 34개월 (13-56 개월 ) 이었다. 한편, Fisk-Fernandez 술식으로수술한경우는 9예로, 이중 8명이남성이었고수술당시의평균연령은 26세 (14-38세), 평균불유합기간은 26개월 (6-60 개월 ), 평균추시기간은 28개월 (12-42개월 ) 이었다. 환자를두술식군으로나눈기준은술자 (surgeon) 를기준으로하였는데, 수술은두술자에의해독립적으로시행되었고한술자는 Matti-Russe 술식및 K 강선고정술을, 다른술자는 Fisk-Fernandez 술식및나사고정술을시행하였다. 수상기전으로는손을짚고넘어진경우가 8예 (38%), 스포츠활동과연관된경우가 7예 (33%), 주먹으로가격하다가발생한경우가 5예 (24%), 교통사고와연관된경우가 1예 (5%) 였다. 한편, 우세수 (dominant hand) 가이환된경우는 21예가운데 12예 (57%) 였다 (Table 1). 불유합부위는주상골종축을따라 3등분하여근위부, 요부, 원위부로구분하였는데, Russe 군의경우요부골절이 9예 (75%), 원위부골절이 1예 (8%), 근위부골절이 2 예 (17%) 였다. Fernandez 군의경우요부골절이 8예 (89%), 근위부골절이 1예 (11%) 였다. 무혈성괴사의판정기준은일단단순방사선영상에서근위골편의골밀도증가 (sclerotic change) 와골소주소실 (loss of trabeculation) 여부를보았고 13), MRI 를시행한경우에는 T1 Table 1. Demographic Features and Preoperative Radiologic Evaluation Russe Group Fernandez Group p-value Age at Operation 29 (15-63) years 26 (14-38) years 0.51 Follow Up Period 34 (13-56) months 28 (12-42) months 0.23 Nonunion Duration 26 (4-96) months 26 (6-60) months 0.97 Sex Male 12 (100%) 8 (89%) Female 0 1 (11%) 0.43 Dominant Hand Right 11 (92%) 9 (100%) Left 1 (8%) 0 1.00 Dominant Hand 8 (67%) 4 (44%) 0.40 Location Distal 1 (8%) 0 (0%) Waist 9 (75%) 8 (89%) 0.60 Proximal 2 (17%) 1 (11%) Injury Mechanism Fall 4 (33%) 4 (44%) Sports 4 3 (33%) Punch 4 1 (11%) TA 0 1 Avascular Necrosis 2 (17%) 3 (33%) 0.61 Osteoarthritis 4 (33%) 2 (22%) 0.66 DISI 3 (25%) 4 (44%) 0.40
696 이승환ㆍ정문상ㆍ이영호외 7 인 영상에서근위골편의골수신호강도 (bone marrow signal intensity) 감소를추가로고려하였다. Russe 군의경우 2예 (17%), Fernandez 군의경우 3예 (33%) 에서무혈성괴사가관찰되었다. 술전골관절염에대한판정은, 단순방사선검사소견상요골경상돌기의첨변형 (radial styloid pointing), 관절간격의감소, 연골하낭포나골극형성등을기준으로하였다 22,25). Russe 군에서는 4예 (33%), Fernandez 군에서는 2예 (22%) 에서관절염이확인되었는데, 1예를제외하고는모두요골주상골간관절에국한된조기관절염이었다. 수근골불안정성은단순방사선사진측면상에서요골월상골각이 10도이상혹은주상월상골각이 70도이상인경우후방개재분절불안정성 (DISI) 이동반된것으로판정하였다 16,25). Russe 군가운데 3예 (25%) 에서 DISI 소견을보였으며, Fernandez 군은 4예 (44%) 에서 DISI 소견을보였다. 수술후평가항목으로서, 동통의정도를 4단계 ( 동통없음 / 경도 / 중등도 / 고도 ) 로나누어평가하였고환자의만족도역시 4단계 ( 매우좋음 / 좋음 / 양호 / 불량 ) 로구분하여설문하였다. 동통과만족도의기준은기존논문의분류기준을원용하였다 8,24). 또한, 환자의완관절운동범위를각도계 (goniometer) 를이용하여건측및환측에대하여측정하였고, 파악력 (grip strength) 을악력계 (hydraulic hand dynamometer, FEI, Irvington, NY) 를이용건측및환측에대해 3회시행하여평균값을구하였다. 방 사선학적으로는골유합달성여부, 술후관절염및 DISI 정도를평가하였다. 통계분석은 SPSS v. 12.0 을이용하여 Student t- test, chi-square test 및 Chi-spuare test 로시행하였고, p값이 0.05 이하인경우를유의성이있는것으로판정하였다. 결과동통의정도는경도이하의동통만을호소한경우가 Russe 군의경우 10예 (83%) 였고 Fernandez 군의경우 8예 (89%) 였다. 환자의만족도는좋음이상의답을한경우가 Russe 군의경우 11예 (91%) 였고 Fernandez 군의경우 8예 (89%) 였다. 동통및만족도모두두수술군사이에통계적으로유의한차이는없었다 (Fig. 1, 2). 관절운동범위는 Russe 군의경우환측후방굴곡-전방굴곡- 요측편위- 척측편위평균치가건측의 86%-82%- 77%-91% 였고, Fernandez 군의경우 84%-80%- 75%-83% 였다. 두군에서모두술후관절운동범위가건측에비해통계적으로유의하게감소해있었다. 한편, 술후 Russe 군의환측척측편위가 Fernandez 군보다유의하게높게나왔고, 그외에는두군사이에유의한차이가없었다. 파악력은두군모두환측의평균치가건측에비해감소해있었지만, Fernandez 군의경우그차이가통계적으로유의하지는않았다 (p=0.098). 두수술군사이 Fig. 1. Comparison of postoperative pain between two groups. There was no significant difference in pain statistically (p=0.940). Fig. 2. Comparison of postoperative satisfaction between two groups. There was no significant difference in satisfaction statistically (p=0.671).
Matti-Russe 술식과 Fisk-Fernandez 술식을이용한주상골불유합치료에관한비교연구 697 Table 2. Postoperative Results - Clinical and Radiological Evaluation Russe group Fernandez group p-value Fixation K-wire Screw Union Time 8.6 months 6.6 months 0.288 Fixation Time Long arm cast for 2 week, Munster or Short arm cast for 6 week short arm cast for 4 week Range of Motion* DF Affected 66.7±7.5 63.9±12.4 0.531 Unaffected 78.3±5.8 75.6±11.6 0.522 p-value <0.001 0.009 VF Affected 60.4±9.2 59.4±12.9 0.850 Unaffected 72.5±10.8 74.4±3.0 0.607 p-value <0.001 0.005 Rd Affected 17.1±5.8 17.8±6.7 0.806 Unaffected 22.1±4.5 23.9±6.0 0.462 p-value 0.001 0.01 Ud Affected 43.3±2.5 38.3±7.1 0.034 Unaffected 47.1±2.6 46.1±2.2 0.364 p-value 0.002 0.008 Grip Power Affected 85.5±17.4 74.9±22.2 0.375 Unaffected 98.0±17.5 92.1±22.2 0.522 p-value 0.013 0.098 Radiolunate (RL) Angle Preoperative 6.6±10.9 6.9±12.1 0.953 Postoperative 0.1±5.1 5.4±9.5 0.112 p-value 0.023 0.009 Scapholunate (SL) Angle Preoperative 61.9±10.7 61.4±11.6 0.925 Postoperative 55.9±5.2 53.1±5.8 0.269 p-value 0.039 0.020 RL Angle 6.7±8.7 12.3±10.7 0.213 SL Angle 6.0±8.9 8.3±8.6 0.552 *DF, dorsiflexion; VF, volar flexion; Rd, radial deviation; Ud, ulnar deviation. 에파악력의유의한차이는없었다 (Table 2). 방사선학적항목들을살펴보면, 골유합을달성하지못한경우가 Russe 군에서 1예 (8%), Fernandez 군에서 1 예 (11%) 있었다. 술후관절염은 Russe 군의경우술전관절염이있었던 4예이외에새롭게관절염이발생한경우는없었고, Fernandez 군의경우술전관절염이있었던 2예이외에새롭게술후관절염이발생한경우가 1예있었고기존의관절염이진행한경우가또한 1예관찰되었다. 술전 21예가운데 7예에서 DISI 가관찰되었는데술후모두정상범위로교정되었다. 수술전후를비교하였을때두군에서모두요골월상골각및주상월상골각이통계적으로유의하게교정된소견을보였다. 하지만, 두군사이에교정된각도의유의한차이가있지않았다 (Table 2, Fig. 3, 4). 고찰술후동통과만족도에있어서두군사이에유의한차이는없었으며대부분의경우에서경도이하의동통과좋음이상의만족도를보였다. 기존의연구에서 Hooning van Duyvenbode 등 12) 은동통이완화된경우를 76%, Eggli 등 8) 은경도이하의동통을호소한경우를 68% 로각각보고한바있다. Rajagopalan 등 21) 은술후환자의만족도가좋음이상인경우를전체의 86% 로보고하였고, Inoue 와 Sakuma 13) 는 71% 로보고하였다. 따라서본연구결과가기존의결과와비교할때비슷하거나더양호한수준임을알수있다. 한편, 술후만족도를불량으로응답한경우가각각 1예씩있었는데, 불량으로응답한 2
698 이승환ㆍ정문상ㆍ이영호외 7 인 Fig. 3. Osteosynthesis using Matti-Russe technique. (A, B) Preoperative plain radiograph showed cyctic change around nonunion site and sclerotic change in proximal fragment. (C) Low signal intensity in proximal fragment in T1-weighted MRI image suggested osteonecrosis. (D, E) There are multiple Kirschner wires used for internal fixation of scaphoid in immediately postoperative plain radiograph. (F, G) After 1 year and 8 months from the operation, the bony union was solid and the alignment was well maintained. 예는각각진행성관절염과반사성교감신경이영양증으로중등도이상의동통을호소했던환자들이었다. 이는술후동통의정도가환자의만족도를결정하는주요인자임을시사한다. 관절운동범위는두군모두환측이건측에비해유의하게감소해있었다. 문헌을살펴보면, Rajagopalan 등 21), Jiranek 등 14), Stark 등 24), Eggli 등 8) 은술후환측의관절운동범위가건측에비하여유의하게감소함을보인바있다 (Table 3). 또한, 두군사이에술후관절운동범위는 척측편위를제외하면유의한차이가없었다. 예외적으로 Russe 군의술후척측편위가 Fernandez 군에비해큰것으로나왔는데, 그평균치의차이가불과 5도에불과하여관찰자내측정오류 (intraobserver error) 를고려할때임상적인의미가없을것으로생각한다. 술후파악력은 Russe 군의경우환측의평균이건측의 87%, Fernandez 군의경우 81% 수준으로감소해있었다. 문헌상으로도환측의파악력이건측에비하여 81-88% 수준으로감소한다고알려져있다 8,21,24,26).
Matti-Russe 술식과 Fisk-Fernandez 술식을이용한주상골불유합치료에관한비교연구 699 Fig. 4. Osteosynthesis using Fisk-Fernandez technique. (A, B) Preoperative plain radiograph showed sclerotic change around nonunion site. (C) The sagittal MRI image showed advanced humpback deformity. (D, E) Humpback deformity was corrected in immediately postoperative plain radiograph. (F, G) At final, the bony union was solid and the alignment was well maintained. 술후골유합률은 Russe 군이 92%, Fernandez 군이 89% 로나타났고두군사이에유의한차이는없었다. 문헌상으로는술후골유합률은 80-97% 사이 5,7,13,18,21,23) 이며 (Table 3), 골유합에영향을주는요인으로골절위치, 무혈성괴사여부, 전위나 DISI 등을들고있다 5,8,24). Nakamura 등 19) 은 Matti-Russe 술식과 Fisk-Fernandez 술식간에골유합률의유의한차이가없음을보인바있다. 본연구에서, Russe 군에서골유합달성에실패한 1예는근위부골절이면서무혈성괴사가동반된 경우였는데, 방사선추시상에서술후불유합부위의골간격이증가하는양상및 K 강선주변의골용해소견을보여불유합부위의내고정이견실하지못했을가능성을시사하였다. 이환자의경우진행성관절염이동반되어근위골편절제술및자가건이식술을시행하였다. Fernandez 군에서골유합에실패했던 1예는직업군인으로술후의료진의지시를따르지않고자가로석고고정을풀고스포츠활동을했던환자로, 내고정용스크류주위로골용해관찰되는등조기해리 (loosening) 가있었던
700 이승환ㆍ정문상ㆍ이영호외 7 인 Table 3. Summary of the Previous Studies of Conventional Osteosynthesis Author Publication Case Osteosynthesis technique Internal fixation Union Rate Range of Motion* Function Grip Strength DF VF Rd Ud This Study 21 Russe 12 K-wire 92% 86% 82% 77% 91% 87% Fernandez 9 Screw 89% 84% 80% 75% 83% 82% Cooney et al. 1980 44 Russe K-wire 86% No change from 80% Preoperative value Warren-Smith 1988 50 Russe 28 K-wire 61% 91% 111 lb et al. Fernandez 22 Herbert Screw 82% 95% 126 lb Daly et al. 1996 26 Fernandez Herbert Screw 95% 82% 94% Shah et al. 1998 50 Fernandez Herbert Screw 80% Subjective rating above 'excellent' or 'good' : 78%, Objective rating above 'excellent' or 'good' : 82% Fernandez et al. 1990 20 Fernandez Cortical Screw 95% 80% 83% 71% 87% 98% Hooning Van Duyvenbode et al. 1991 77 Russe 93% 81% 81% 74% 75% Dominat hand: 93%, non-dominant hand: 84% Eggli et al. 2002 37 Fernandez Herbert Screw 95% 84% 83% 70% 90% 88% Clinical rating above 'excellent' or 'good': 70% *DF, dorsiflexion; VF, volar flexion; Rd, radial deviation; Ud, ulnar deviation. 환자였다. 이환자의경우 Fernandez 술식으로재수술시행하여성공적인골유합을달성하였다. Shah 등 23) 은술후골유합달성에실패한 10예가운데 8예에서무혈성괴사가동반되어있음을보고한바있다. 반면, 김등 1) 은방사선학적소견만으로무혈성괴사를판정할수는없으며, 실제로술전무혈성괴사로보았던 3예에서수술장내소견상점상출혈을관찰할수있었고통상적인 Matti-Russe 술식으로모두성공적인골유합을달성한것을보고한바있다. 본연구에서는술전무혈성괴사로보았던 5예가운데 3예에서성공적인골유합을달성하였고, 유합에실패한나머지 2예가운데 1예에있어서도환자가술후고정을제대로따르지않아조기해리가있었던경우로 Fernandez 술식으로재수술하여골유합을달성한바있다. 한편, 무혈성괴사가있는경우의유경혈관화골이식술은연구자에따라골유합율이 60-100% 로편차가크고 2,11,17,20) 조기유합이가능한것으로보고되나실제임상에서고정기간의의미있는단축을기대하기는힘들다. 또한, 유경혈관화골이식술은기술적으로난이도가높고굴곡변형을효과적으로교정하기어려운문제점이있다. 이상의사실들을종합하였을때, 저자들은그간의경험과본연구결과등을토대로무혈성괴사가 동반된경우에도 Russe 혹은 Fernandez 술식으로만족스러운골유합을기대할수있으며중요한것은술자의기술적숙련도라고생각한다. 관절염과술후동통의관계를살펴보면, 술후관절염을보인총 7예가운데중등도이상의동통을호소한경우는단 1예였고이는방사선학적으로진행성관절염을동반한경우였다. 한편, 많은문헌들에서환자의증상이관절염을포함한방사선학적소견, 불유합기간, 수근골불안정성등과상관관계가없으며 16,18,22), Stark 등 24) 은이를 ' 점진적인적응 (gradual adaptation)' 의결과로설명한바있다. 본연구에서술전 DISI 가관찰된경우는 33% 였다. 문헌을살펴보면, DISI 의비율이 21.4-56% 로다양하게보고되고있고, 많게는 76% 에서 DISI 가발생한다고보고한경우도있다 12,13,19,22). Fisk 는이러한굴곡변형을교정함으로써주상골의길이를회복하고전방요수근인대를긴장시켜월상골의후방회전을정상화시킬수있다고하였다 10). Eggli 등 8) 은이렇게월상골의병적회전을교정하여관절염의발생과수근골붕괴를막을수있다고하였고, Amadio 등 1) 과 Nakamura 등 19) 은곱사등변형 (humpback deformity) 이있는경우골관절염의진행이
Matti-Russe 술식과 Fisk-Fernandez 술식을이용한주상골불유합치료에관한비교연구 701 빨라지고임상적으로도결과가좋지못함을보고하였다. 따라서, 어떤술식으로수술을하건이러한굴곡변형을교정하는것은중요한목표가되어야한다. 본연구에서는 Russe 군과 Fernandez 군에서모두굴곡변형을효과적으로교정할수있는것으로나타났는데, 이는 Russe 술식으로도각변형의교정및유지에필요한충분한지지력 (buttress effect) 를기대할수있음을의미한다. 끝으로각술식의이상적인적응증에대해고찰해보면, Russe 술식은비전위성불유합혹은전위성불유합이지만각변형이나 DISI 가심하지않은경우, 그리고근위부불유합으로서무혈성괴사가동반된경우에적응이될것이고, Fernandez 술식은전위성불유합으로서각변형이나 DISI 가심하여다른방법으로이를교정하기가어려운경우적응이되는것으로어느정도동의가이루어지고있다 4,8,9,26). 하지만, 본연구는수술의임상적, 방사선학적결과가특정수술술기의선택보다는술자의기술적숙련도, 술후관리에있어서환자의순응도등에의해결정됨을시사한다. 결론기존에이미 Matti-Russe 술식과 Fisk-Fernandez 술식의장단점과이상적인적응증들이알려져있지만, 실제로이두술식을사용한집단간에임상적, 방사선학적결과를비교한연구는드물다고하겠다. 본연구결과를정리하면, 두수술군간에임상적결과, 즉, 관절운동범위, 파악력, 만족도, 동통등과방사선학적결과, 즉골유합률, 관절염, DISI 등이통계적으로의미있는차이를보이지않았다. 결론적으로, 어떠한술식을사용하건간에경험이풍부한술자의기술적숙련도가전제되는경우소기의수술목적을충분히달성할수있다고말할수있을것이다. 참고문헌 1. Amadio PC, Berquist TH, Smith DK, Ilstrup DM, Cooney WP 3rd, Linscheid RL: Scaphoid malunion. J Hand Surg Am, 14: 679-687, 1989. 2. 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, 23: 686-690, 1998. 3. Chen CY, Chao EK, Lee SS, Ueng SW: Osteosynthesis of carpal scaphoid nonunion with interpositional bone graft and Kirschner wires: a 3- to 6-year follow-up. J Trauma, 47: 558-563, 1999. 4. Cooney WP: Bone-grafting techniques for scaphoid nonunion. Tech Hand Up Extrem Surg, 1: 148-167, 1997. 5. Cooney WP 3rd, Dobyns JH, Linscheid RL: Nonunion of the scaphoid: analysis of the results from bone grafting. J Hand Surg Am, 5: 343-354, 1980. 6. Daecke W, Wieloch P, Vergetis P, Jung M, Martini AK: Occurrence of carpal osteoarthritis after treatment of scaphoid nonunion with bone graft and herbert screw: a long-term follow-up study. J Hand Surg Am, 30: 923-931, 2005. 7. Daly K, Gill P, Magnussen PA, Simonis RB: Established nonunion of the scaphoid treated by volar wedge grafting and Herbert screw fixation. J Bone Joint Surg Br, 78: 530-534, 1996. 8. Eggli S, Fernandez DL, Beck T: Unstable scaphoid fracture nonunion: a medium-term study of anterior wedge grafting procedures. J Hand Surg Br, 27: 36-41, 2002. 9. Fernandez DL: A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability. J Hand Surg Am, 9: 733-737, 1984. 10. Fisk GR: An overview of injuries of the wrist. Clin Orthop Relat Res, 149: 137-144, 1980. 11. Harpf C, Gabl M, Reinhart C, et al: Small free vascularized iliac crest bone grafts in reconstruction of the scaphoid bone: a retrospective study in 60 cases. Plast Reconstr Surg, 108: 664-674, 2001. 12. Hooning van Duyvenbode JF, Keijser LC, Hauet EJ, Obermann WR, Rozing PM: Pseudarthrosis of the scaphoid treated by the Matti-Russe operation. A long-term review of 77 cases. J Bone Joint Surg Br, 73: 603-606, 1991. 13. Inoue G, Sakuma M: The natural history of scaphoid non-union. Radiographical and clinical analysis in 102 cases. Arch Orthop Trauma Surg, 115: 1-4, 1996. 14. 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 Joint Surg Am,
702 이승환ㆍ정문상ㆍ이영호외 7 인 74: 1217-1228, 1992. 15. Kim HJ, Chung MS, Lee JS, Lee MC: Treatment of scaphoid nonunion with Matti-Russe technigue. J Korean Orthop Assoc, 25: 103-108, 1990. 16. Mack GR, Bosse MJ, Gelberman RH, Yu E: The natural history of scaphoid non-union. J Bone Joint Surg Am, 66: 504-509, 1984. 17. 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, 26: 330-334, 2001. 18. Mulder JD: The results of 100 cases of pseudarthrosis in the scaphoid bone treated by the Matti-Russe operation. J Bone Joint Surg Br, 50: 110-115, 1968. 19. Nakamura R, Horii E, Watanabe K, Tsunoda K, Miura T: Scaphoid non-union: factors affecting the functional outcome of open reduction and wedge grafting with Herbert screw fixation. J Hand Surg Br, 18: 219-224, 1993. 20. Park MJ, Lee JS, Shin SK: Treatment of scaphoid nonunion using a pedicled vascularized bone graft. J Korean Orthop Assoc, 41: 871-876, 2006. 21. 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, 81: 48-52, 1999. 22. Ruby LK, Stinson J, Belsky MR: The natural history of scaphoid non-union. A review of fifty-five cases. J Bone Joint Surg Am, 67: 428-432, 1985. 23. Shah J, Jones WA: Factors affecting the outcome in 50 cases of scaphoid nonunion treated with Herbert screw fixation. J Hand Surg Br, 23: 680-685, 1998. 24. Stark A, Broström LA, Svartengren G: Scaphoid nonunion treated with the Matti-Russe technique. Long-term results. Clin Orthop Relat Res, 214: 175-180, 1987. 25. Vender MI, Watson HK, Wiener BD, Black DM: Degenerative change in symptomatic scaphoid nonunion. J Hand Surg Am, 12: 514-519, 1987. 26. Warren-Smith CD, Barton NJ: Non-union of the scaphoid: Russe graft vs Herbert screw. J Hand Surg Br, 13: 83-86, 1988. = 국문초록 = 목적 : 확정형주상골불유합에대하여적절한치료를시행하지않는경우수근골불안정및골관절염의진행을피할수없는것으로알려져있다. 본연구에서는 Matti-Russe 술식과 Fisk-Fernandez 술식을이용한골유합술의임상적및방사선학적결과에대해비교, 고찰하고자한다. 대상및방법 : 2001 년 9 월부터 2006 년 8 월까지본병원에서시행한주상골골유합술증례중인터뷰에응한 21 례를대상으로하였고평균추시기간은 31 개월이었다. 임상적평가로는관절운동범위, 파악력, 환자만족도, 동통수준을설문조사하고, 방사선학적평가로는골유합, 무혈성괴사, 골관절염및 DISI 여부를평가하였다. 또한, 두수술군사이에결과의차이가있는지를비교하였다. 결과 : 두수술군사이에동통이나만족도의유의한차이는없었다. 관절운동범위, 파악력모두건측에비하여감소한소견을보였으나역시두수술군사이에는유의한차이가없었다. 두수술군의골유합률및수술전후 DISI 교정각사이에도유의한차이는없었고술전관찰된 DISI 는술후모두교정된소견을보였다. 골관절염의경우전체적으로 7 예에서관찰되었는데, 그중술전에없던골관절염이새롭게나타난경우가 1 예있었다. 결론 : 두수술군사이에임상적, 방사선학적평가에있어서통계적으로유의한차이를보이지않으며, 두술식모두골유합과기능적회복에있어서효과적인방법이다. 색인단어 : 주상골불유합, Matti-Russe, Fisk-Fernandez