舟状骨偽関節に対する有茎血管柄付き骨移植術の経験

Treatment of Scaphoid Nonunions with a Pedicled Vascularized Bone Graft : Case Report

　抄録：難治性舟状骨偽関節の2例にZaidembergの方法に準じた橈骨背側からの有茎血管柄付き骨移植術を行い，良好な結果が得られたので報告する．症例1は17歳，男性．左手を強打し受傷し，前医にて骨接合術を施行されるも偽関節となった．初回手術後8カ月にて血管柄付き骨移植術を施行した．術後12カ月にて骨癒合は良好で，手関節掌背屈可動域は45°と制限が残るが，握力は健側比45％から71％に改善した．症例2は34歳，男性．8年前に転倒し受傷した．骨接合および骨移植術を行うも骨癒合が得られず，術後6カ月にて血管柄付き骨移植術を施行した．術後15カ月にて骨癒合は良好で，握力は健側比33％から84％に，手関節掌背屈可動域は60°から105°へ改善した．舟状骨偽関節のなかで，既に手術が行われている場合や，近位骨片に虚血性壊死がある場合，偽関節形成後の経過の長い場合には血管柄付き骨移植術がよい適応であると思われる．

　Two patients with established scaphoid nonunion were treated with vascularized pedicle bone grafting from the radius, as described by Zaidemberg et al. in 1991. Both patients were male and the ages at operation were 17 and 34 years. One patient underwent open reduction and internal fixation with a scaphoid screw for acute fracture of the left scaphoid 8months before vascularized bone grafting. MRI revealed a vascular necrosis of the proximal pole of the scaphoid. The other patient had suffered from left wrist pain for 8 years after a motorbike accident and was treated by conventional bone grafting with a scaphoid screw. Unfortunately, the grafted bone was absorbed and union was not obtained. In both patients vascularized bone was harvested from the dorsoradial border of the radius and then transferred to the volar aspect of the scaphoid and grafted. The two nonunions healed at 6 weeks and 10 weeks postoperatively. Pain on motion was markedly decreased and grip strength of the wrist improved after surgery. Vascularized bone grafts are indicated in the failed cases after conventional bone grafts and in the presence of avascular necrosis accompanied with proximal pole nonunion.