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1 PSJHJOBM! BSUJDMF 대한족부족관절학회지 : 제 15 권제 2 호 2011 J Korean Foot Ankle Soc. Vol. 15. No. 2. pp.79-85, 2011 급성아킬레스건파열의수술적치료 : 경피적봉합술과관혈적봉합술의비교 건양대학교의과대학건양대학교병원정형외과 Surgical Treatment of the Ruptured Achilles Tendon: A Comparative Study between Percutaneous and Open Repair Do-Yeon Kim, M.D., Sang-Bum Kim, M.D., Youn-Moo Heo, M.D., Jung-Bum Lee, M.D., Jae-Woo Lim, M.D., Hyeong-Tak Oh, M.D. Department of Orthopedic Surgery, Konyang University College of Medicine, Daejeon, Korea =Abstract= Purpose: The purpose of the present study was to compare and analyze the clinical outcomes of the percutaneous and open repair of acute Achilles tendon ruptures. Materials and Methods: We performed a retrospective study on 24 patients (group 1) managed with percutaneous repair, and 21 patients (group 2) managed with open repair for acute Achilles tendon rupture. The postoperative evaluations were done by an Arner-Lindholm scale and AOFAS score. Postoperative overall satisfaction and cosmetic satisfaction were also evaluated. Results: By Arner-Lindholm scale and AOFAS score, there was no difference between two groups (p<0.05). As for postoperative overall satisfaction, 5 cases were very satisfied, 16 cases were satisfied and 3 cases were fair in group 1. In group 2, 12 cases were very satisfied, 9 cases were satisfied. For postoperative cosmetic satisfaction, 13 cases were satisfied, 11 cases were fair in group 1. In group 2, 9 cases were very satisfied, 12 cases satisfied. In open repair group, a case of deep wound infection and three cases of skin necrosis were reported as complication. 2 cases of sural nerve injury were seen in percutaneous repair group and were recovered within 3 months. Conclusion: Percutaneous repair of acute Achilles tendon ruptures have high level of cosmetic satisfaction compared with open repair without any significant difference in clinical outcomes. Key Words: Achilles tendon, Acute rupture, Percutaneous repair, Open repair 서 론 Received: April 18, 2011 Revised: May 7, 2011 Accepted: May 11, 2011 Jung-Bum Lee, M.D. Department of Orthopedic Surgery, Konyang University Hospital, 685 Gasuwon-dong, Seo-gu, Daejeon , Korea Tel: Fax: valeeno1@kyuh.co.kr 최근들어스포츠활동의증가에따라급성아킬레스건파열의빈도도증가하는추세에있다. 1,2) 급성아킬레스건파열의치료는아직까지도많은논란이있으며기본적으로보존적인방법과수술적방법으로구분할수있으나수술적건봉합술이대세를이루고있다. 3-5) 수술적방법에있어

2 서도관혈적인건봉합술, 경피적건봉합술로대변되던수술법이최근들어합병증을최소화하기위한노력으로고안된최소절개또는관절경을이용한변형된수술법등이새로이보고되고있다. 6-8) 수술적복원기법의기본원칙은재발없는빠른회복으로사회로의조기복귀하는것이며그러기위해서견고한봉합과재활운동의조기시작이강조되었다. 9) 기존의관혈적정복술은견고한봉합으로재발가능성은적을지라도작지않은피부절개로인한창상치유의문제점들이제기되고있다. 10) 이러한문제점들을보완하기위해경피적건봉합술이시도되었는데이방법또한재파열및비복신경손상등의문제점이보고되면서변형된형태의경피적건봉합술이시도되고있다. 11,12) 저자들은아킬레스건파열에대해기본적인수술기법인관혈적및경피적건봉합술을시행후그임상적결과를비교분석하여아킬레스건파열시각각의술법의임상적유용성에대하여평가해보고자한다. 대상및방법 본연구는 2006년 1월부터 2009년 6월까지급성아킬레스건완전파열로본원에내원하여개방적봉합술을시행받은 24명 24예 (1군), 경피적봉합술을시행받은 21명 21 예 (2군) 를대상으로하였다. 환자들의인적자료, 수상부위및경위, 수술직후결과및추시결과등을이학적검사및문진등을통해조사분석하였다. 1. 연구대상 대상자들은경피적또는관혈적건봉합술중하나의방법으로만수술을시행받았으며순차적으로번갈아수술방법을정하여두그룹으로분류하였다. 성별분포는 1군은남자 22예 (91.7%), 여자 2예 (8.3%) 이었으며 2군은남자 18 예 (85.7%), 여자 3예 (14.3%) 이었다. 수상시평균연령은 1 군이 40.6세 (18~52세), 2군이 39.9세 (28~50세 ) 이었다. 연령별로는 1군은 10대가 1명, 20대가 1명, 30대가 7명, 40대가 12명, 50대가 3명이었으며 2군은 10대가 0명, 20대가 3 명, 30대가 8명, 40대가 6명, 50대가 4명이었다. 좌, 우측의발생빈도는 1군이 13:11, 2군이 15:6로좌측이우측보다약간많았다. 환자직업군은 1군에서는사무직근로자 13 명, 직업군인이 6명, 주부, 교사, 학생등기타가 5명이었으며, 2군에서사무직근로자가 14명으로가장많았고, 직업군인이 4명, 가정주부, 교사, 목사등기타가 3명이었다. 수상기전은전예에서족관절이족배굴곡상태에서비복- Table 1. Patient Data Open repair group Percutaneous repair group No. % No. % Patients Gender Male Female Side Left Right Injured during sports activites Type of sport activitess Soccer Sepactakrow Volleyball Badminton Body mass index (kg/m 2 ) 30 (obese) ~29.9 (over weight) ~24.9 (normal weight) (under weight) Mean age, yr 가자미근의심한수축에의한간접파열로발생하였으며, 운동중손상이가장빈번하게발생하였는데 1군에서 14예 (58.3%), 2군은 16예 (76.2%) 가운동에의한손상이었다. 운동종목은축구, 배드민턴, 배구, 족구등이있었으며그외의경우는대부분이실족에의한경우였다 (Table 1). 내원시시행한이학적검사중 45명전예에서톰슨압박검사 (Thompson squeeze test) 양성소견및외견상파열부위의함몰소견 (dimpling) 을보였다. 내원당시시행한초음파검사에서파열위치는 1군에서는아킬레스건종골부착부의평균상방 4.9 cm (3.3~7.9 cm) 에위치하였으며, 2군에서 5.1 cm (2.7~8 cm) 이었다. 평균파열간격은 1군에서 1.6 cm (0.5~4.2 cm), 2군에서 1.4 cm (0.8~3.3 cm) 이었다. 본연구대상중 2군은단일술자에의해서수술시행되었다. 단개방성파열은제외하였다. 2. 수술적기법 1) 관혈적건봉합술척추또는전신마취후환자를복와위에서환측대퇴근위부에지혈대를적용하였다. 뒤꿈치의내측으로부터종아리까지약 8~10 cm 정도의피부종절개를시행하며소복재정맥및비복신경이다치지않도록주의한다. 건주위조직을조심스럽게박리한후건의파열을확인하고필요

급성 아킬레스건 파열의 수술적 치료: 경피적 봉합술과 관혈적 봉합술의 비교 찰하여 건외막 조직 내에서 건의 활주작용(gliding function) 의 방해를 피하였다.

파열된 건을 변형 된 Kessler씨 봉합법에 의하여 하나는 건의 전방에, 다른 하나는 건의 후방에 Ethibond (Ethicon Inc. N.J., U.S.

First, a long needle was transversely passed through the tendon (A), followed by a (diagonal) cross-suture (B).

11 blade to enable the surgeon to bury the suture subcutaneously (B).

(C), and the next cross through the tendon was done proximally.

symmetrically back until both ends of the torn Achilles tendon were completely approximated and the defect was no

3 급성 아킬레스건 파열의 수술적 치료: 경피적 봉합술과 관혈적 봉합술의 비교 찰하여 건외막 조직 내에서 건의 활주작용(gliding function) 의 방해를 피하였다. 아킬레스건 파열의 단단봉합술을 시 행하고 봉합부를 환상 봉합을 실시한 다음 아킬레스건 주 위의 건외막 조직을 충분히 봉합하여 건외막의 혈액 순환을 하다면 최소한의 변연 절제를 시행한다. 파열된 건을 변형 된 Kessler씨 봉합법에 의하여 하나는 건의 전방에, 다른 하나는 건의 후방에 Ethibond (Ethicon Inc. N.J., U.S.)를 이용하여 양측 단의 봉합을 시행하고 각각 양측 면에서 결 A B C D E F Figure 1. The procedure was started and finished medially and distally. First, a long needle was transversely passed through the tendon (A), followed by a (diagonal) cross-suture (B). At each site of the first needle entrance or exit, the incision was widened in a longitudinal direction with a NO. 11 blade to enable the surgeon to bury the suture subcutaneously (B). A small hemostat could also be used to widen the hole and to facilitate burying the suture. (C), and the next cross through the tendon was done proximally. Next, both thread ends were led extratendionously back through the second and third holes distally (D) and pulled symmetrically back until both ends of the torn Achilles tendon were completely approximated and the defect was no longer palpable (D). After approximating the torn Achilles tendon ends, the lateral end of the thread was passed medially (E), and after final simultaneous tightening of both ends of the thread, the suture was tied (F). The knots were buried subcutaneously in the previously widened second medial stab incision (F)

4 최대한유지한상태로봉합부를피복하였다. 2) 경피적건봉합술척추또는전신마취후환자를복와위에서환측대퇴근위부에지혈대를적용하였다. 수술준비는수술중복원한아킬레스건의장력을정상측과비교할수있도록양측하지모두에대해시행하였다. Cretnik 등 12) 이제안한 Ma와 Griffith의술식을변형한방법으로경피적봉합술을시행하였으며, 전예에서 2번 Ethibond (Ethicon Inc. N.J., U.S.) 봉합사를사용하여수술을시행하였다. 술전파열위치및간격확인을위해초음파를사용하였으며파열부위를촉지하고아킬레스건부착부위의약 1.5 cm 상방에서 5 mm 피부종절개후내측에서외측으로평행하게봉합사를통과시키고반대편에같은절개창으로봉합사를빼낸후, 사선으로교차시켜파열부위약 1 cm 원위부에서통과시킨다. 이때작은지혈겸자를사용하여봉합사가피하로묻히게한다. 다음으로파열부위근위의약 5 cm 상방에서피부절개창을만들어수직으로실을빼낸후사선으로교차시켜파열부위약 1 cm 위에서통과시킨다. 이후족관절을족저굴곡시킨후봉합사를원위부로견인하여파열부위를정복후, 외측에있는봉합사를평행하게내측으로통과시켜내측에서긴장매듭하였다 (Fig. 1). 이후양측의긴장도를비교하였으며피부봉합전적절한정복이이루어졌는지를확인하기위해술후건파열부위의간격을초음파를통해측정하였다. 3) 수술후조치슬관절 25도굴곡, 족관절은봉합후족저굴곡된상태에서장하지고정을 6주간시행하였다이후부츠보조기 (walker boots) 나 AFO 보조기 (anklefoot orthosis) 를착용후능동적족관절운동을시작하였다. 술후 6주에는환자스스로수동적족관절운동을시행하도록하였으며, 보조기착용상태에서체중의 50% 정도의부분체중부하를허용하였다. 술후 8주에족저굴곡근력강화운동및보조기착용상태에서완전체중부하를허용하였다. 술후 10~12 주에보조기제거후완전체중부하및뒤꿈치들기근력운동을적극적으로시행하였으며, 이시기까지족관절의최대운동범위를얻도록노력하였다. 3. 수술후평가술후임상적결과분석에대해서는 Arner-Lindholm 평가기준 13) (Table 2) 과미국정형외과족부족관절학회족관절-후족부기능평가기준 (American Orthopedic Foot and Table 2. Arner-Lindholm Scale Poor Dissatisfied or marked discomfort Limp, inability to tip toe Calf circumference > 3 cm Ankle ROM: DF decrease > 10 or PF decreased > 15 Good Mild discomfort Slightly decreased walking power, tip toe, calf muscle power Calf circumference < 3 cm Ankle ROM: DF decrease > 15 (PF/DF) Excellent Free from discomfort and essentially normal function Normal walking power, tip toe, calf muscle power Calf circumference < 1 cm Ankle ROM decrease < 5 (PF/DF) Table 3. AOFAS Ankle-Hindfoot Score Pain (total 40 points) Function (total 50 points) Limitation of activity or requirement of support 10 Maximal walking distance, blocks 5 Walking surfaces 5 Gait abnormality 8 Sagittal motion (flexion plus extension; degrees) 8 Hindfoot motion (inversion plus eversion) 6 Ankle/hindfoot stability (anteroposterior, varus-valgus) 8 Alignment (total 10 points) Ankle Society Ankle-Hindfoot Functional Score, AOFAS) 14) (Table 3) 을사용하였으며, 술후전체적인환자만족도및술후흉터및상처에대한만족도등에대해서도분석하였다. 또한 6개월추시에서양쪽발뒤꿈치들기시뒤꿈치와지면사이거리의양측간의차이를측정하였으며술후발생한합병증에대해서도조사하였다. Arner-Lindholm 평가기준은불편감정도, 보행근력, 뒤꿈치들고서기, 종아리근력, 족관절운동정도, 중간장딴지둘레등의항목에대한평가를기준으로하여우수, 양호, 불량으로구분하였다. 족관절운동범위측정은각도측정기를이용하여술후 6주, 12주, 최종추시시에측정하였다. AOFAS 기능평가는동통, 기능및정렬등 3개소분류로구분되며, 기능평가는최대보행거리, 보행표면및보행조건등에대해서조사분석하였다. 환자의만족도는최종추시시술후전반적인결과및술후상처에대한환자의주관적인평가로매우만족, 만족, 보통, 불만족등의 4단계로각각분류평가하였다. 결 과 본연구의술후추시기간은개방적봉합술그룹 (1 군 ) 에

5 급성아킬레스건파열의수술적치료 : 경피적봉합술과관혈적봉합술의비교 Table 4. Demographic Data of the Acute Achilles Tendon Rupture Patients with Open Repair Case Sex Age Cause of injury Height of lesion Initial gap Ankle ROM (PF/DF) Mid-calf circumference difference AOFAS score Arner Lindholm Scale Patient satisfaction Satisfaction for postop scar Postop complication 1 M 18 Misstep / Good Satisfied Ordinary Infection 2 M 46 Badminton / Exellent Satisfied Ordinary Weakness 3 M 49 Soccer / Exellent Satisfied Ordinary Skin necrosis 4 M 41 Soccer / Good Satisfied Ordinary None 5 M 39 Sepaktakraw / Exellent Satisfied Satisfied Weakness 6 M 38 Soccer / Exellent Satisfied Ordinary None 7 F 39 Volley ball / Good Satisfied Ordinary Weakness 8 M 40 Soccer / Exellent Very satisfied Satisfied None 9 M 41 Soccer / Good Satisfied Satisfied Weakness 10 M 34 Soccer / Exellent Satisfied Satisfied Pain 11 M 28 Misstep / Exellent Satisfied Satisfied None 12 F 51 climbing / Good Satisfied Ordinary Pain 13 M 43 Volley ball / Exellent Satisfied Satisfied None 14 M 52 Misstep / Good Satisfied Satisfied Skin necrosis 15 M 33 Misstep / Exellent Satisfied Ordinary None 16 M 40 Misstep / Exellent Satisfied Satisfied Pain 17 M 50 Sepaktakraw / Exellent Very satisfied Ordinary None 18 M 42 Soccer / Exellent Very satisfied Very satisfied Pain 19 M 39 Soccer / Exellent Satisfied Very satisfied Pain 20 M 37 Soccer / Exellent Very satisfied Satisfied None 21 M 48 Misstep / Exellent Very satisfied Very satisfied weakness 22 M 41 Soccer / Exellent Satisfied Ordinary Skin necrosis 23 M 46 Soccer / Exellent Satisfied Satisfied None 24 M 40 Soccer / Exellent Satisfied Satisfied Pain 서평균 25개월 (6~35개월), 경피적봉합술그룹 (2군) 에서평균 20개월 (6~32개월) 이었다. 술후 6개월후중간장딴지둘레 (mid-calf circumference) 의양측간의차이는 1군에서는평균 0.93 cm (0.5~2.1 cm) 이었는데 0~1.0 cm 차이가 16예 (66.7%), 1.1~2.0 cm의차이가 7예 (29.2%) 였고 2군에서평균 0.77 cm (0.2~2.0 cm) 이었는데 0~1.0 cm 차이가 16예 (76.2%), 1.1~2.0 cm의차이가 5예 (23.8%) 였다 (Table 4, 5). 족관절의수동적최대운동범위는 1군에서족배굴곡의경우환측이평균 9.6도, 족저굴곡의경우환측이평균 42.3도였으며 2군에서는족배굴곡의경우환측이평균 8.6 도, 족저굴곡의경우환측이평균 31.1도였다. 수상전의일상활동으로복귀하는데걸리는시간은 1 군에서평균 12.9개월 (8~20개월) 이소요되었으며 2군에서는평균 7.8개월 (6~12개월) 이소요되었다. 술후임상적결과는 Arner-Lindholm 평가기준에따라 1군에서우수 17예, 양호 7예였으며, 2군에서는우수 12예, 양호 9예였다. AOFAS 점수는 1군에서평균 94.1점 (81~100점), 2군에서는평균 94.7점 (91~100 점 ) 으로양군간차이는없었다 (p=0.624). 수술및수술후생활에대한만족도는 1군에서매우만족이 5예 (20.8%), 만족이 16예 (66.7%), 보통이 3예 (12.5%) 의결과를보였으며, 2군에서는매우만족이 12예 (57.1%), 만족이 9예 (42.9%) 의결과를보였다. 술후상처및흉터에대한만족도는 1군에서는매우만족이 0예, 만족이 13예 (54.2%), 보통이 11예 (45.8%) 의결과를보였으며, 2군에서는매우만족이 9예 (42.9%), 만족이 12예 (57.1%) 의결과를나타내었다. 합병증으로관혈적건봉합술을시행한군에서심부감염이 1예, 피부괴사가 3예있었으며경피적건봉합술을시행한군에서는비복신경손상이 2예있었으나추시 3개월안에회복되었다. 고찰아직까지도아킬레스건파열시가장좋은치료방법에대한의견이분분하다. 아킬레스건파열의관혈적건봉합기법은여러치료방법중해부학적및기능적인회복에있어가장효과적인치료방법이다. 기존의관혈적건봉합술

6 Table 5. Demographic Data of the Acute Achilles Tendon Ruputure Patients with Percutanous Repair Case Sex Age Cause of injury Height of lesion Initial gap Ankle ROM (PF/DF) Mid-calf circumference difference AOFAS score Arner Lindholm Scale Patient satisfaction Satisfaction for postop scar Postop complication 1 M 30 Soccer / Exellent Very satisfied Satisfied None 2 M 28 Sepaktakraw / Good Very satisfied Very satisfied None 3 F 33 Misstep / Exellent Very satisfied Very satisfied Sural n. injury 4 M 35 Soccer / Good Very satisfied Satisfied None 5 M 28 Soccer / Exellent Satiesfied Satisfied None 6 M 58 Misstep / Exellent Very satisfied Very satisfied None 7 M 43 Bandminton / Good Satiesfied Very satisfied None 8 M 54 Volley ball / Exellent Very satisfied Very satisfied None 9 M 46 Stretching / Good Satiesfied Very satisfied None 10 M 41 Soccer / Good Satiesfied Satisfied None 11 M 33 Soccer / Exellent Very satisfied Satisfied None 12 F 37 Bandminton / Good Satiesfied Very satisfied None 13 M 42 Soccer / Exellent Satiesfied Satisfied None 14 F 51 Misstep / Good Very satisfied Very satisfied None 15 M 50 Soccer / Exellent Satiesfied Satisfied None 16 M 35 Bandminton / Good Satiesfied Satisfied Pain 17 M 41 Misstep / Good Very satisfied Satisfied None 18 M 30 Soccer / Good Very satisfied Satisfied None 19 M 47 Misstep / Exellent Very satisfied Satisfied None 20 M 28 Sepaktakraw / Exellent Very satisfied Very satisfied None 21 M 34 Soccer / Exellent Satiesfied Very satisfied Pain 은견고한건고정으로조기관절운동및재활에유용하나 7~8 cm 정도의종적절개가필요하며파열된건의노출및혈액순환의장애가발생하게되어창상감염및피부괴사, 창상반흔, 동통, 압통및종괴, 건주위조직복원장애에따른아킬레스건유착과건치유지연등많은수술창상에의한문제점이제기되고있다. 15) 이와같은상처치유와관련된합병증인창상감염과피부괴사는흔히대개종골부착부위에서 4~6 cm 상방에서관찰되고있다. 16) Cetti 등 4) 은 56명의관혈적아킬레스건봉합환자에서 4% 는심부창상감염, 2% 는지연치유, 10% 는반흔조직, 12% 는지각장애가있었음을보고하였다. 이와같은창상감염및반흔조직유착같은문제때문에관혈적봉합술과연관된연부조직문제를피하기위하여경피적접근법이제시되었다. 7,8,11,17) 그러나초기강도가관혈적방법의반정도가량되며비복신경손상및재파열의가능성이많다는단점이있다. Ma와 Griffith 18) 는작은개방창을통해봉합사를경피적으로삽입함으로써건복원을시행한 18명중 2명만이경미한창상문제를보였을뿐감염이나재파열예는없었다고보고하였다. Maffulli 19) 는변형된경피적건봉합을통해봉합된건의긴장력에있어기존의경피적봉합기법에비해두배정도의강도를나타내기때문에조기체중부하보행이가능하며재파열의빈 도를줄이고비복신경손상을최소화할수있음을보고하였다. 또한 Gigante 등 20) 은경피적봉합술이관혈적봉합술과비교하였을때임상결과의차이는없음을주장하였다. 본연구에서경피적건봉합에사용된술식은미용적으로환자의만족도가높았으며전반적으로기존의개방성 modified Kessler 봉합술과유사한좋은기능회복결과를보였다. 또한작은절개로인해건주위조직의손상을최소화함으로써파열건의치유가빠르며, 건유착이적었다. 무엇보다도환자들은작은창상반흔의미용적인효과에대해만족해하는경향을보였다. 고전적인관혈적접근법과비교할때임상적결과에있어큰차이를보이지않았으나관혈적인건봉합술의경우창상봉합부위의심부감염이일부발생하였음을확인할수있었다. 또한본연구의경피적건봉합술군의경우변형된방법의경피적건봉합법을사용함으로써재파열의합병증이발생하지않음을확인하였으며 Kessler 또는 Krackow 등의개방적봉합술에사용되는봉합법과개선된방법의경피적건봉합법의봉합강도를직접비교분석하는연구를착안해볼수있을것이다. 더나아가기존의흔히사용되었던방법외에합병증을최소화할수있는여러기법들이소개되고있는데그중 Maffulli 19) 는절개부위를최소화하여수술창상에의한합병증을감소되었음을보고하였고, Kakiuchi 21) 는파열부위에

7 급성아킬레스건파열의수술적치료 : 경피적봉합술과관혈적봉합술의비교 만제한적인절개를가하는관혈적인방법과경피적인방법의혼합된방식을통해 20명의환자를치료한후기존의관혈적봉합술로치료한환자군과비교하여보다우수한기능회복과미용효과를보고하였다. Jung과 Paik 2) 은 Achillon을이용한최소절개술법을사용하였으며임상적인최종결과평가시에수상전상태로의복귀시기및능률도를묻는항목을포함시켰다. 또한 Tang 등 8) 은관절경을이용한경피적건봉합을시행함으로써임상적인결과의향상및회복기간의단축을확인하였다. 결 론 아킬레스건파열의수술적치료에있어서경피적봉합술은관혈적봉합술과비교하였을때미용적으로는만족스러운결과를보였으나임상적결과에는큰차이가없었으며특히개선된방법의경피적봉합술을사용함으로써재파열의감소및사회로의빠른복귀를가능하게하였다. REFERENCES 1. Bradley JP, Tibone JE. Percutaneous and open surgical repairs of Achilles tendon ruptures. A comparative study. Am J Sports Med. 1990;18: Jung HG, Paik HD. Surgical repair of Achilles tendon rupture by minimal incision technique. J Korean Foot Ankle Soc. 2005;9: Jeon TS, Kim SB, Jung WY, Heo YM, Park CY. Percutaneous repair of acute Achilles tendon ruptures. J Korean Orthop Assoc. 2009;44: Cetti R, Christensen SE, Ejsted R, Jensen NM, Jorgensen U. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med. 1993;21: Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am. 1999;81: Mukundan C, El Husseiny M, Rayan F, Salim J, Budgen A. Mini-open repair of acute tendo Achilles ruptures--the solution? Foot Ankle Surg. 2010;16: Fortis AP, Dimas A, Lamprakis AA. Repair of achilles tendon rupture under endoscopic control. Arthroscopy. 2008; 24: Tang KL, Thermann H, Dai G, Chen GX, Guo L, Yang L. Arthroscopically assisted percutaneous repair of fresh closed achilles tendon rupture by Kessler's suture. Am J Sports Med. 2007;35: Inglis AE, Scott WN, Sculco TP, Patterson AH. Ruptures of the tendo achillis. An objective assessment of surgical and non-surgical treatment. J Bone Joint Surg Am. 1976;58: Assal M, Jung M, Stern R, Rippstein P, Delmi M, Hoffmeyer P. Limited open repair of Achilles tendon ruptures: a technique with a new instrument and findings of a prospective multicenter study. J Bone Joint Surg Am. 2002;84: Cretnik A, Kosanovic M, Smrkolj V. Percutaneous versus open repair of the ruptured Achilles tendon: a comparative study. Am J Sports Med. 2005;33: Cretnik A, Zlajpah L, Smrkolj V, Kosanović M. The strength of percutaneous methods of repair of the Achilles tendon: a biomechanical study. Med Sci Sports Exerc. 2000;32: Arner O, Lindholm A. Subcutaneous rupture of the Achilles tendon; a study of 92 cases. Acta Chir Scand Suppl. 1959;116(Supp 239): Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994;15: Saxena A, Maffulli N, Nguyen A, Li A. Wound complications from surgeries pertaining to the Achilles tendon: an analysis of 219 surgeries. J Am Podiatr Med Assoc. 2008;98: Winter E, Weise K, Weller S, Ambacher T. Surgical repair of Achilles tendon rupture. Comparison of surgical with conservative treatment. Arch Orthop Trauma Surg. 1998; 117: Ceccarelli F, Berti L, Giuriati L, Romagnoli M, Giannini S. Percutaneous and minimally invasive techniques of Achilles tendon repair. Clin Orthop Relat Res. 2007;458: Ma GW, Griffith TG. Percutaneous repair of acute closed ruptured achilles tendon: a new technique. Clin Orthop Relat Res. 1977;128: Sutherland A, Maffulli N. Open repair of ruptured achilles tendon. Orthop. And Traumatol. 1998;10: Gigante A, Moschini A, Verdenelli A, Del Torto M, Ulisse S, de Palma L. Open versus percutaneous repair in the treatment of acute achilles tendon rupture: a randomized prospective study. Knee Surg Sports Traumatol Arthrosc. 2008;16: Kakiuchi M. A combined open and percutaneous technique for repair of tendo Achillis. Comparison with open repair. J Bone Joint Surg Br. 1995;77:

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar