以第一、二伸肌腱鞘支持带上动脉为血管蒂的桡骨瓣治疗舟骨骨不连

Treatment of scaphoid nonunion by vascularized bone flap pedided on 1,2 ICSRA from the dorsum of the distal radius

目的探讨以第一、二伸肌腱鞘支持带上动脉（1，2 ICsRA）为血管蒂的桡骨瓣带蒂逆行转移治疗舟骨骨不连的手术指征、技术和疗效。方法2007年2月至2010年10月，我科对15例舟骨骨不连患者，应用以I，2 ICSRA为血管蒂的桡骨瓣远端蒂转移植骨内固定进行治疗。其中腰部骨不连9例，近端骨不连6例。9例伴有近端骨折块缺血性坏死；3例伴有舟状骨弓背畸形及嵌入体背伸不稳（DISI）；2例伴有桡骨茎突关节炎表现。所有病例均采用腕桡侧纵形切口，13例予以交叉克氏针内固定，2例行单枚Herbert螺钉附加1枚克氏针固定。12例将带血管蒂植骨块从舟骨背侧嵌插植入，3例将植骨块楔形修整后自舟骨掌侧植入。术后随访骨折愈合时间、腕痛、腕关节活动度及握力等情况。结果术后随访时间为6～21个月，平均13个月，2例失访。所有随访病例X线片显示舟骨均获得骨性愈合，平均愈合时间为14．2周。所有患者腕痛消失，腕关节屈曲（59．92±4．82）°，背伸（49．73±4．58）°。根据改良的Mayo腕关节功能评分标准评定：优9例，良2例，可2例；优良率为84．69％结论以1，2ICSRA为血管蒂的桡骨瓣逆行转移植骨手术，能促进舟骨骨不连的愈合，特别对有近端骨块缺血性坏死的患者疗效显著。

Objective To study the indication, techniques, and treatment outcomes of using a retrograde pedicled vascularized radius bone flap based on 1, 2 intcrcompartmental supraretinacular artery （ 1,2 ICSRA） to treat scaphoid nonunion. Methods Between February 2007 and October 2010, 15 patients with established scaphoid nonunion were treated with open reduction and internal fixation in addition to a retrograde pedicled vaseulafized radius bone flap based on 1, 2 ICSRA. Among these patients 9 had nonunion of the scaphoid waist and 6 had nonunion of the proximal pole of the scapboid. 9 patients were associated with avascular necrosis of the proximal fragments, 3 with humpback deformity of the scaphoid and dorsal intercalated segment instability （DISI）, and 2 with arthritis of radius styloid. In all cases a longitudinal incision was mode through radial dorsum of the wrist. Bone graft was fixed with two cross Kirschner wires in 13 cases, and with one Herbert screw and one Kirschner wire in 2 cases. 12 pedicled bone flaps were wedged in from the dorsum of the scaphoid, while 3 from the volar aspect of the scaphoid. Postoperative evaluation included the time to union, the range of motion of the wrist, pain relief and grip strength. Results Thirteen patients were follow-up and 2 were lost. Duration of follow-up ranged from 6 to 21 months, with an average of 13 months. Union rate was 13 of 13 （100%） and the averaged union time was 14.2 weeks. All patients achieved complete pain relief. The flexion and extension of the wrist were （59.92 ± 4.82）° and （49.73 ± 4.58）° respeefively. The functional results were encouraging in all patients （9 excellent, 2 good, and 2 fair）, with an excellent and good rate of 84.6%, which were measured using the modified Mayo wrist score. Conchlsion Retrograde pedicled vascularized radius bone flap based on 1, 2 ICSRA can promote scaphoid union, especially for those patients associated with proximal pole avascular necrosis.