Management of Scaphoid Nonunion with Avascular Necrosis Using 1,2 Intercompartmental Supraretinacular Arterial Bone Grafts

　　　　　背景：舟狀骨骨折復位不良或延誤治療常導致舟狀骨癒合不良及缺血性壞死(avascular necrosis)。當手術前懷疑及術中證實舟狀骨缺血性壞死時，傳統骨移植常無法治癒，建議必須使用附血管之活骨移植(vascularized bone graft)。 方法：我們提出五例舟狀骨骨折癒合不良，經手術前評估及術中證實併有缺血性壞死，治療以第一、第二腔室間支持帶上附血管活骨移植(1, 2 ICSRA vascularized bone graft)。追蹤時間至少一年半以上，分析其功能性評估(functional outcome)及影像學結果(radiographs)。 結果：五例其中的四例，其舟狀骨骨折癒合不良處在四個月內完全癒合。另一例併發骨釘感染(pin tract infection)，在移除骨釘後半年亦完全癒合。功能性評估皆為良好。 結論：第一、二腔室間支持帶上附血管活骨移植(1, 2 ICSRA vascularized bone graft)血管位於支持帶表層，且直接滋養骨骼內。其優點為在解剖學上易於找到，易於分離出，且術後骨癒合率高，功能性評估結果良好，因此很適合做為治療舟狀骨骨折併缺血性壞死的附血管活骨移植。
　　　　　Background: Poor reduction or neglect of an unstable carpal scaphoid fracture may lead to scaphoid nonunion or avascular necrosis. When pre-operative suggestion of avascular necrosis of the proximal pole is confirmed by intra-operative evaluation, conventional bone graft is not enough and a vascularized bone graft is strongly recommended. Methods: Five patients with nonunion of scaphoid fractures associated with avascular necrosis based on results of radiography and further confirmed by magnetic resonance images and intra-operative findings were operatively managed with 1, 2 intercompartmental supraretinacular arterial (1, 2 ICSRA) vascularized bone graft combined with supplemental cancellous bone grafts from the radius. Follow-up periods were at least 18 months. The functional outcomes and radiographs were analyzed. Results: In four of the five patients, the nonunion sites united within 4 months after surgery. The other patient had a superficial pin tract infection and bone healing was complete 6 months after the operation. The functional results were good in all five patients. Conclusion: 1, 2 ICSRA is superficial to the retinaculum and runs directly into the bony tubercle. It is a proper pedicle of vascularized bone graft due to the ease of visibility and dissection. The functional results and union rates were satisfactory in our study.