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1 대한족부족관절학회지 : 제 12 권제 1 호 2008 J Korean Foot Ankle Soc. Vol. 12. No. 1. pp.26-30, 2008 무지외반증의근위갈매기형절골술후고정방법에따른결과차이 서울보훈병원정형외과 김택선 강규복 강종우 김학준 The Differences between Fixation Devices for Proximal Chevron Osteotomy in Hallux Valgus Surgery =Abstract= Taik-Seon Kim, M.D., Kyu-Bok Kang, M.D., Jong-Woo Kang, M.D., Hak-Jun Kim, M.D. Department of Orthopaedic Surgery, Seoul Veterans Hospital, Seoul, Korea Purpose: The authors evaluated the differences between K-wires and Bold screw for fixing the proximal metatarsal chevron osteotomy of moderate and severe hallux valgus. Materials and Methods: There were 59 patients (81 feet) who were moderate and severe degree hallux valgus according to the classification of Mann. They all got the proximal chevron osteotomy when correcting the deformity. All patients were followed up at least 6 months. We divided the patients into 2 groups, K-wires fixed group as A, Bold screw fixed group as B. Group A were 42 patients (63 feet) and Group B were 18 patients (19 feet). Among the Group B, 2 feet who were failed to fix the oetotomy site with Bold screw, were fixed with K-wires during operation. We measured the AOFAS score preoperatively, postoperatively and at final follow-up, VAS score at 2 weeks after the operation. Also preoperative, postoperative and follow-up hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured for each patients. Results: Mean follow up period was 1.34 year (range: 6 months-6.16 years). Mean VAS score of group A was 3.21±1.7 and group B 1.76±1.0. Preoperative mean AOFAS score of group A was 45.61±8.3, group B 44.41±8.9, the final mean score of group A was 88.87±8.3 and group B 92.47±4.4. Preoperative mean HVA was 30.82±6.6 degrees in group A and 32.88±14.5 degrees in group B, the final mean angle of group A was 14.89±8.3 degrees and group B 17±4.4 degrees. The preoperative mean IMA of group A was 13.69±3.6 degrees and group B 12.35±5.2, the final mean angle of group A was 9.26±3.6 degrees and group B 12.35±5.8 degrees. Conclusion: There were no statistical differences in radiologic and clinical results (p>0.05) but, group B exceeded group A in VAS score (p=0.0007) and had no statistical significance in terms of reduction angle loss (p=0.06). Early returning to normal life activity may be possible for patients using Bold screws. Key Words: Hallux valgus, Proximal chevron osteotomy, Bold screw, K-wire Address for correspondence Hak-Jun Kim, M.D. Department of Orthopaedic Surgery, Seoul Veterans Hospital 6-2 Dunchondong Gandonggu, Seoul, , Korea Tel: Fax: dakjul@hanmail.net 서 론 무지외반증은제 1 중족족지관절에서외측변형을일으

2 무지외반증의근위갈매기형절골술후고정방법에따른결과차이 A B Fi g u r e 1. (A) A 75 year old male had the proximal chevron osteotomy on his left foot fixed with K-wires. Hallux valgus angle and 1-2 in term etatars al an gles w ere c orrec ted after operation on rad iog raphs. (B) There was seen reduction loss at 6 months follow-up radiograph. The reduction angles of Hallux valgus and 1 st -2 nd in term etatars al w ere los t s ig n ifi cant ly. 키고제1 중족골두의내측비대를초래하며나아가다른족지의변형을일으키는복합질환이다. 이에대한수술적치료로연부조직교정술, 제1 중족골원위부절골술, 제1 중족골근위부절골술, 제1 근위족지절골술, 절제관절성형술, 관절고정술등다양하게있으며 2), 그중갈매기형절골술은수기가간단하고제1 중족골원위부절골술및연부조직교정술을병행시행하였을경우좋은결과를얻을수있어현재가장보편화된수술술기이다 9). 갈매기형절골술시절골술후고정방법으로보통 K-강선을사용하며일부에서는나사못을이용한고정을시행하고있다 7). 갈매기형절골술후단기및장기추시시좋은결과를거두었다는여러보고가있으나 6,7,10,13) 절골술후고정방법에따른차이에대한보고 1,5) 는많지않다. 이에저자들은 6개월이상추시 Table 1. Clinical Results of Proximal Chevron Osteotomy for Hallu x Valgu s AOFAS score Preoperative Postoperative VAS Group A* 45.61± ± ±1.7 Group B 44.41± ± ±1.0 P Value *Group A, Group fixed with K-wire; Group B, Group fixed with Bold screw; AOFAS, American Orthopaedic Foot and Ankle Society; VAS, Visual Analogue Scale at postoperative 2 weeks. 가능하였던중등및중증무지외반증에대하여실시한근위갈매기형절골술에서 K-강선및 Bold 나사를이용하여고정한후의결과를비교분석하였다. 1. 연구대상 대상및방법 2002 년 1월부터 2005 년 12월까지중등도및중중무지외반증으로진단되어근위중족골갈매기형절골술을시행하였던환자중 6개월이상 ( 범위, 6개월 ~6.16 년 ) 추시가능하였던 48예 68족을대상으로하였다. 절골술후고정시행시 2개의 K- 강선을이용한경우를 A군, 1개의 Bold screw (Newdeal, Integra, Lyon, France) 를이용한경우를 B군으로구분하였으며, A군은 42명 63족이었고, B군은 18명 19족이었다. A군의평균연령은수술당시 56세 ( 범위, 34-75세 ) 이었으며 B군은 61세 ( 범위, 세 ) 이었다. 모든예에서근위족지쐐기절골술및외측절개를통한무지내전건및외측관절낭절제술을시행하였다. A군에서는 1예에서불유합이발생하였고, B군에서 2예에서수술도중 Bold 나사못을이용한고정이실패하여 K- 강선을이용하여고정하였다. 통계학적연구에서는이 3예를제외하였다

3 김택선 강규복 강종우 김학준 A B Fi g u r e 2. (A) 4 8 year old female had t h e proxi mal c h evron os t eot omy on h er right foot fixed with Bold screw. Hallux valgus angle and 1-2 intermetatarsal angles were corrected by proximal chevron osteotomy on radiographs. (B) Reduction loss was not so significant at 6 months follow-up radiograph. 2. 수술방법및술후처치수술은전례에서앙와위에서시행하였고, 외측절개를통해무지내전건전이를포함하여외측연부조직을교정술을시행하였으며, 내측절개를통하여중족골두내측돌출부제거술을시행한후근위갈매기형절골술을이용하여교정한후교정각의소실및불유합의방지를위해절골면에절제된돌출부를삽입하여절골면에수직이되게 K-강선을 2개고정하여 A군으로정하고, B군에서는절골선에수직이되게근위족저부에서시작하여원위족배부방향으로 Bold 나사못을 1개고정하였다. 중족골의교정후육안으로무지외반각의교정이불충분하고제1 족지의회내변형이동반되어있을때에는근위지골쐐기절골술 (Akin 절골술 ) 을시행하였다. 술후 K-강선을이용한경우는술후 6주에 K-강선제거술을시행하였고 Bold 나사를이용한경우는제거술을시행하지않았으며양군모두술후석고붕대고정은시행하 지않았고, 술후 4일째부터본원에서고안한술후신발을신은후후족부를이용한부분체중부하를시행하였다. 환자의통증정도에따라서서히전족부의체중부하를시행하였으며술후 8주째전체중부하를허용하였으며일상적인신발의착용은술후 3개월째시행하였다. 3. 연구방법평가방법은환자의임상적평가와방사선학적평가로, 임상적평가는미국정형외과족부족관절학회평가표 (AOFAS score, American Orthopaedic Foot and Ankle Society score) 를이용하여일상생활의만족도및동통유무, 활동성, 신발선택의자유도, 제1 중족족지관절운동범위, 지간관절의운동제한여부, 중족족지관절의안정성, 중족족지관절에연관된굳은살에대해조사하여합한점수를비교하였고, VAS (Visual Analogue Scale) 점수를이용하여술후 2주째의주관적통증의정도를측정하였다. 방사 Table 2. Radiologic Results HVA IMA Preoperative Postoperative Postoperative 6 month Preoperative Postoperative Postoperative 6 month *Group A 30.82± ± ± ± ± ±3.6 Group B 32.88± ± ± ± ± ±5.8 *Group A, Group fixed with K-wire; Group B, Group fixed with Bold screw; HVA, Hallux Valgus Angle; IMA, Intermetatarsal Angle

4 무지외반증의근위갈매기형절골술후고정방법에따른결과차이 선학적평가는수술전과후, 그리고마지막추시체중부하전후면족부방사선사진의무지외반각과제1-2 중족골간각변화를비교분석하였다. 무지외반의정도는 Mann 의분류 4) 에따른경도, 중등도, 중증으로분류하였으며경도는무지외반각이 25 이하, 제1-2 중족골간각이 11 이하범위에있으면서비골종자골위치가아탈구 50% 이내범위로정의하였고중등도는무지외반각이 이하, 제 1-2 중족골간각이 이하범위에있으면서비골종자골위치가아탈구 % 아탈구위치에놓인경우로정의하였으며중증은무지외반각이 40 이상, 제1-2 중족골간각이 16 이상범위에있으면서비골종자골위치가아탈구 100% 이상의범위로정의하였다. 통계학적검정은 Epi Info 2002 (CDC, Atlanta, USA) 프로그램을이용하여 student t-test 를이용하여 p<0.05 를유의한결과로판정하였다. 결과 1. 임상적결과미국정형외과족부족관절학회점수는술전 A군에서평균 45.61±8.3 점에서마지막추시시평균 88.87±8.3 으로 B군은평균 44.41±8.8 점에서마지막추시시평균 92.47±5.7 으로개선된결과를보였다. 술전과마지막추시시설문조사에서미국정형외과족부족관절학회점수에서 A, B군간의통계학적유의성은없었다 ( 각각 p=0.63, 0.08). 술후 2주째측정한 VAS 점수는 A군에서평균 3.21±1.7이었고, B 군에서는 1.76±1.0 이었으며두군간에통계학적으로유의한차이를보였다 (p=0.0007). 2. 방사선학적결과방사선학적평가로무지외반각은 A군에서는술전평균 30.82±6.6 도에서술후평균 8.49±6.5 도로, B군은술전평균 32.88±14.5 도에서술후평균 10.71±5.6도로교정되었으며, 제1-2 중족골간각은 A군에서술전 13.69±3.6 에서술후 6.03±3.6 으로, B군에서는술전 15.59±5.2 에서술후 9.82±5.14 로교정된결과를보여주었다. 두군에서의방사선학적결과를비교분석한결과통계학적유의성은없었다 (p>0.05). 술후교정각과비교해서 6개월째측정한양군의무지외반각및제1-2 중족골간각은 A군에서평균 6.6 도및평균 3.3 도, B군에서는평균 6.2 도및평균 2.5 도의교정각소실양상을보였다. 교정된무지외반각의소 실은 A군및 B군에서통계학적으로의미있게소실되었으나 (p<0.05), 제1-2 중족골간각은 A군에서는최종추시시의미있는교정각소실을보인반면 (p<0.05), B군에서는통계학적으로의미가없었다 (p=0.06). A군중 1예 1족 (1.2%) 에서불유합이발생하여재수술을시행하였다. B군중 2예 2족 (10.5%) 은 Bold 나사못을이용한고정술을시도하였으나실패하여 K-강선으로고정하였다. 고찰무지외반증은 1891 년 Carl Heuter 에의하여처음으로보고된후여러학자들에의해많은연구가있었으나아직까지도치료방법등에대한논란이많다 2,12). 무지외반증의중등도및중증의치료법으로다양한중족골기저부절골술식이소개되어있고그중중족골근위갈매기절골술은다른절골술에비해술기가쉽고중족골단축이작다는장점이보고되었다 6,7,10,13). 근위갈매기형절골술후의고정은나사못이나 K-강선을사용할수있으나여러저자들이 K- 강선고정을선호한다 7,8,10,13). Petroutsas 와 Trnka 11) 는무지외반증에대한 Ludloff 절골술시 Bold 나사못을이용한고정방법을소개하였고좋은결과를보였다는발표를하였다. 또한 Crosby 와 Bozarth 5) 는근위갈매기형절골술시행후에 K-강선과 Herbert 나사못, 고정하지않은군으로분류하여시행한결과에서는세군간에통계학적으로의미있는차이를보여주지못했고나사못을이용한경우에는수술시간이길고가격이비싼단점이있다고보고하였으나, 그추시기간이짧고추시관찰기간중교정각도에대한고찰이없는단점이있었다. Anderson 과 Davis 1) 는근위갈매기형절골술시행후에유관나사를이용한고정을제안하여보다견고한고정을얻을수있다고제안하였다. 또한 Bozkurt 등 3) 은근위반월상절골술후나사산 K-강선과유관나사못을비교한생역학적연구에서유관나사못의고정력이우수함을보고하였다. 본원에서는근위갈매기형절골술후고정방식으로 2개의 K-강선과 1개 Bold 나사못을이용한결과대부분의방사선학적임상적결과는통계학적으로의미있는차이를보이지않았지만, 술후 2주째측정한 VAS 점수에서 Bold 나사못을사용한군이의미있게낮은점수를보여이는견고한고정으로절골부위의유동성 (motion) 이적으며나사못의끝이골질속으로들어가연부조직자극이덜한것으로사료된다. Bold 나사못을이용한군이 K-강선으로교정한군보다

5 김택선 강규복 강종우 김학준 술후 6개월째측정하여계산한교정각의소실정도가의미있게작아 Bold 나사못의고정력이우수하여술후초기에일어나는교정력소실을방지하는효과가있는것으로사료된다. Bold 나사못은유관나사와같이도자핀을이용하여정복의유지가용이하며, 압박효과에의해단단한고정력을얻을수있는장점이있으나골질이불량한경우는나사못에의해피질골이파괴되어충분한압박효과를얻지못하거나, 중족골의크기가작은경우에는나사못을잘못삽입하여재삽입시삽입부위의결정이어려워나사못삽입이실패하는경우가발생할수있으므로주의를요한다. 결 론 근위갈매기형절골술후 2개의 K-강선을사용하여고정한경우와 1개의 Bold 나사못을이용하여고정한경우임상적결과에서는차이를보이지않았지만술후 2주째측정한주관적통증의소실정도와초기의우수한고정력을가진 Bold 나사못이절골술후고정에유리할것으로생각된다. 그러나, Bold 나사못고정술식의복잡성과비싼가격이사용의제한점이될수있다. REFERENCES 1. Anderson RB and Davis WH: Internal fixation of the proximal chevron osteotomy. Foot Ankle Int, 18: , Bargman J, Corless J, Gross AE and Lange F: A review of surgical procedures for hallux valgus. Foot Ankle, 1: 39-43, Bozkurt M, Tigaran C, Dalstra M, Jensen NC and Linde F: Stability of a cannulated screw versus a Kirschner wire for the proximal crescentic osteotomy of the first metatarsal: a biomechanical study. J Foot Ankle Surg, 43: , Coughlin MJ, Mann RA and Saltzman CL: Surgery of the foot and ankle, Philadelphia, Mosby Inc, , Crosby LA and Bozarth GR: Fixation comparison for chevron osteotomies. Foot Ankle Int, 19: 41-43, Easley ME, Kiebzak GM, Davis WH and Anderson RB: Prospective, randomized comparison of proximal crescentic and proximal chevron osteotomies for correction of hallux valgus deformity. Foot Ankle Int, 17: , Lee KT, Tak SB and Choi KJ: Proximal metatarsal chevron osteotomy combined with modified McBride procedures for hallux valgus patients. J Korean Orthop Assoc, 33: , Lee WC and Kim YM: Correction of hallux valgus using lateral soft-tissue release and proximal Chevron osteotomy through a medial incision. J Bone Joint Surg, 89-A Suppl 3: 82-89, Mann RA and Donatto KC: The chevron osteotomy: a clinical and radiographic analysis. Foot Ankle Int, 18: , Park HS, Park HT, Lee GS, Kim SH and Lee KT: Operative treatment for hallux valgus with proximal metatarsal osteotomy in patients over 55 years old. J Korean Foot Ankle Soc, 9: 69-73, Petroutsas J and Tmka HJ: The Ludloff osteotomy for correction of hallux valgus. Oper Orthop Traumatol, 17: , Robinson AH and Limbers JP: Modern concepts in the treatment of hallux valgus. J Bone Joint Surg, 87-B: , Sammarco GJ and Russo-Alesi FG: Bunion correction using proximal chevron osteotomy: a single-incision technique. Foot Ankle Int, 19: ,

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< DBFF8C0FA28B1E8C7D0C1D82DB1E8C5C3BCB D36372E687770> PSJHJOBM! BSUJDMF 대한족부족관절학회지 : 제 15 권제 2 호 2011 J Korean Foot Ankle Soc. Vol. 15. No. 2. pp.62-67, 2011 무지외반증에서근위갈매기형절골술후고정방법에따른차이 : K- 강선, 유관나사, 금속판 서울보훈병원정형외과 *, 고려대학교의과대학구로병원정형외과 김택선 * 김학준 박영환 임형태 *