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1 대한족부족관절학회지 : 제 8 권제 2 호 2004 J Korean oot Ankle Soc. Vol 8. No. 2. pp , 2004 부산의료원정형외과학교실, 부산대학교병원정형외과학교실 * 류총일 * 정철용 김병철 최성종 정용욱 Operative Treatment of Old Neglected reiberg's Infraction (Comparison of Three Techniques) Chong-Il Yoo, M.D.*, Chul-Yong Jung, M.D., Byung-Cheol Kim, M.D., Sung-Jong Choi, M.D., Yong-Wook Jung, M.D. Department of Orthopaedic Surgery, Pusan Medical Center, Pusan, Department of Orthopaedic Surgery, Pusan National University Hospital*, Pusan, Korea =Abstract= Purpose: We compared the results of three surgical procedures of the old neglected reiberg's disease that was managed with metatarsal head reshaping, metatarsal head resection, and dorsal closing wedge osteotomy. Materials and Methods: rom march 1996 to July 2002, five cases in six patients whose metatarsal head collapse already progressed underwent operative treatment. We compared the operative results in the view point of the radiographic follow-up and lesser toe metatrasophalangeal joint scale of AOAS. Results: There were no further joint destruction and loose body formation. Also, lesser toe metatrasophalangeal joint scale of AOAS improved from average score, 38.5 (range 22~49) of preoperative one to average score, 86.6 (range, 72~100). Especially, the 2 cases that underwent dorsal closing wedge osteotomy showed most favorable result and the 2 cases with metatarsal resection showed next favorable result. The 2 cases with intra-articular loose body removal and metatarsal reshaping showed the least effective result among three operative methods. Conclusion: Our Operative experiences of old neglected reiberg's disease were all satisfactory irrespective of operative options and dorsal closing wedge osteotomy was thought to be most effective method. Key Words: reiberg's infraction,, Head resection, Dorsal closing wedge osteotomy 서 론 reiberg 병의발병원인은아직까지밝혀지지않은상태이 며오늘날까지도많은학자들에의해직접적인외상이나 1), 반복적인외력에의한피로골절 2), 혈류공급장애 3) 등의다양 Address for correspondence Chul-Yong Jung, M.D. Department of Orthopaedic Surgery, Pusan Medical Center 1330, KeoJe-dong, Yeonje-gu, Pusan, , Korea Tel: ax: chcy0707-@hanmail.net 한병인론이제시되고있다. 그중특히체중부하시중족골두에과도한압력으로발생한미세골절과연골하골의충분하지못한혈류공급이원인이되어해면골소주의함몰과연골의변성을일으킨다고보고하고있다 4). 질환의초기에는활동제한, 석고붕대고정, 중족골패드나단하지보장구등을

2 이용한보존적치료를이용하여중족골두에가해지는압력을감소시켜동통을경감시키는방법들이사용될수있으나, 완치가어려우며대부분의경우질환이계속진행하여골두거대증, 골극 (bone spur) 형성및관절내유리체형성등의후유증과중족족지관절관절염이남아골의돌출로인한압통이나, 중족족지관절운동의제한, 족저부과각화증 (plantar hyperkeratosis) 으로신발을신기가불편하거나보행시통증을호소하게된다. 이에대한치료로중족골두재형성술 (reshaping of metatarsal head), 근위지골기저부제거술 (proximal phalangeal base resection), 중족골두제거술 (metatarsal head head resection), 골두천공술, 중족골두배굴절골술 (dorsal closing wedge osteotomy), 그리고 silicone spacer 를이용한인공관절성형술등의수술적방법들이사용될수있다. 저자들은문헌상기술된여러방법들중에서어떤방법의선택이좋은지알아보기위하여임의로각각 2예씩을선택하여수술을시행한후그결과를비교하였다. 대상및방법 1996년 3월부터 2002년 7월까지진단이늦어졌거나오랜기간동안치료받지않아심한골두변형을가진진구성 reiberg 병 6예 5명의환자를대상으로하였으며 6예모두가여자였고, 수술당시연령은최하 35세에서최고 52세 ( 평균 46세 ) 였다. 증상이있은후수술을받기까지기간은최단 7년부터최장 30년 ( 평균 13.6년 ) 이었고 (Table 1), 수술을받게된주증상은골두크기의증가와동반된족배부골극돌출로인하여신발착용시통증이있는경우가많았으며, 골극이족저부에발생한경우는족저부과각화증 (plantar hyperkeratosis) 으로보행시통증과장시간의기립자세유지가어려운등의일상생활의불편으로본인스스로수술을원하여내원하였다. 방사선학적소견상중족골두내외측의 돌출이나타나는 Smillie stage III이 1예, 중족골두의가운데가함몰되는 Smillie stage IV가 2예였고, 중족족지관절의파괴가나타나는 Smillie stage V가 3예였다 2). 치료를위하여시행된수술방법은중족골두절제술 2예, 중족골두재형성술 2예, 그리고중족골두배굴절골술 2예를시행하였고, 관절내유리체가있는모든예에서관절내유리체제거술을시행하였다. 추시기간은최단 2년에서최장 8 년 ( 평균 5.3년 ) 이었으며, 수술결과의평가는 AOAS (American Orthopaedic oot and Ankle Society) 의소족지중족족지관절점수 7) 를이용하여평가하였다. Table 2. Mean of the lesser toe metatrasophalangeal joint score of the AOAS* for 6 patients who underwent each operations Cases mean Operation Name 결 Dorsal wedge closing OT Dorsal wedge closing OT MT head Resection MT head Resection 과 수술후 5예에서보행시동통의소실과결과에대한만족을보였으나 Smillie stage V였고중족골두재형성술시행한 1예에서추시상관절의운동성과방사선학적인관절면의일치도 (joint congruency) 는술전에비해호전되었으나보행시의동통이남았다. 이에비하여중족골두제거술을시행한 AOAS score Pre-OP *; American Orthopaedic oot and Ankle Society, ; osteotomy, ; Metatarsal. Last /U Table 1. Summary of the datas of the patients. Cases Sex Age at operation Duration of disease (years) Smillie staging Operation name /U* years III V IV V V IV Dorsal wedge closing OT Dorsal wedge closing OT MT head Resection MT head Resection *; ollow-up, ; osteotomy, ; Metatarsal

류총일 정철용 김병철 최성종 정용욱 i g u r e 1. Radiograph of metatarsal head reshaping.

$fracture, intra-articular loose body, and subchondral sclerosis.$ incongruent articular surface, but revealed increase of joint space without further deformity and

incongruent articular surface, but revealed increase of joint space without further deformity and

(A) Preoperative radiograph revealed marginal subchondral breakage, c en tral c ollaps e, and os teop

3 류총일 정철용 김병철 최성종 정용욱 i g u r e 1. Radiograph of metatarsal head reshaping. (A) Preoperative radiog rap h revealed collap se of 2nd m et at ars al h ead, su bc h ond ral fracture, intra-articular loose body, and subchondral sclerosis. (B) At 6 years and 3 months after surgery, radiographs showed c ollaps e of lateral margin and incongruent articular surface, but revealed increase of joint space without further deformity and arthritic change. i g u r e 2. Radiograph of resection of metatarsal head. (A) Preoperative radiograph revealed marginal subchondral breakage, c en tral c ollaps e, and os teop hy tes formation. ( B) I mmediate postoperative radiograph of metatarsal head resection. (C) At 8 years after resection, the radiograph represents well aligned joint axis and no other arthritic change

i g u r e 3. Radiograph of dorsal closing wedge osteotomy.

collapse, intra-articular loose body, and joint destruction.

(C) Immediate postoperative radiograph of dorsal closing wedge osteotomy. The radiograph showed clean and well aligned joint, no residual osteophytes and loose body.

e. 예나중족골두배굴절골술을시행한예에서는증상의호전과보행시의동통이소실되었으며관절운동의제한도호전되었다. 술전과술후에채점한 AOAS 의소족지중족족지관절점수는술전평균 38.5점 (22~49) 에서술후평균 86.6 점 (72~100) 으로향상을보여최우수 3예, 우수 2예, 양호 1 예를나타내었다 (Table 2).

4 i g u r e 3. Radiograph of dorsal closing wedge osteotomy. (A) Preoperative anterior-posterior radiograph showed huge osteophytes in dorsum of met at ars al h ead, m edi olat eral m arg in al proj ec t ion of met at arsal head, central collapse, intra-articular loose body, and joint destruction. (B) P reoperat i ve lat eral radiog rap h revealed hu ge d orsal ost eoph y t e and plantar loose body which looked like sesamoid bone. (C) Immediate postoperative radiograph of dorsal closing wedge osteotomy. The radiograph showed clean and well aligned joint, no residual osteophytes and loose body. (D) At 2 year after osteotomy, the radiograph showed 2 mm joint space widening, congruent joint margin without destruction of met atarso- ph alang eal j oin t artic ular s urf ac e. 예나중족골두배굴절골술을시행한예에서는증상의호전과보행시의동통이소실되었으며관절운동의제한도호전되었다. 술전과술후에채점한 AOAS 의소족지중족족지관절점수는술전평균 38.5점 (22~49) 에서술후평균 86.6 점 (72~100) 으로향상을보여최우수 3예, 우수 2예, 양호 1 예를나타내었다 (Table 2). 각술식에대한비교에서중족골두재형성술을시행한 2예는소족지중족족지관절점수가술전평균 35.5점에서술후평균 78.5점으로향상되었으나 1예에서보행시동통의잔존에따른환자의불만족이있었으며 (ig. 1), 중족골두제거술을시행한 2예는술전평균 37 점에서술후 85점으로임상적및방사선학적을향상된결과를보였고 (ig. 2), 중족골두배굴절골술을시행한 2예는술전평균 43점에서술후평균 96.5점으로임상적으로가장 좋은결과를보였다 (ig. 3). 방사선학적인추시상전례에서수술직후단순방사선사진보다더이상의관절파괴나질환의진행은없었다. 고찰제2,3족지에주로발생하는 reiberg 병의발병원인과진행에대한병태생리는아직까지정확하게밝혀지지는않았지만 reiberg 1) 가 1914 년에처음으로소개할당시외상이직접적인원인이라고한이후여러저자들에의하여다양한병인론들이소개되었고그중외상설및혈류장애설이가장주목받고있다. Smillie 2) 는반복적인외력에의한피로골절을설명하면서이러한현상은구조적으로짧고, 내반되어있으

5 류총일 정철용 김병철 최성종 정용욱 며, 과다운동성을가지는제1 중족골이동반된경우에잘발생할것이라고보고하였다. Breck 8) 은 1000 예의골연골증분석보고에서 80% 가하지에집중적으로발생한다는것으로보아외상과반복적인외력이작용할것으로보고하였고, Braddock 9) 은사체연구를통한실험적인연구에서제2중족골골단은 11세에서 12.5세사이의발달기에가장손상받기쉬우며, 또한가동성이적은구조적인문제도관련인자로보고하였다. 많은다른저자들은굽이높은구두나스포츠활동에의한압박이나반복적인외상, 상대적으로긴중족골두로인해골두배측골소주의외상성손상 (dorsal trabecular stress injury) 을받아항상중족골두의전측과배측 (anterior and dorsum) 에병변이발생한다는점을들어외상에의한병인을보고하였다 10~12). reiberg 병의발병원인으로중족골두에공급되는혈류의장애역시많은보고가있었으며 12,13,), 중족골두의선천적인혈액공급의이상이나혈관의손상, 지방색전증, 과응고상태, 골수강내의압력상승등이관련인자로거론되었다 14,15). 아직까지도정확한병인에대하여정의되지는않았지만최근에는단일병인에의한발생보다는전술한다양한요인들의상호작용으로인한다인자성병인론이우세를차지하고있다 16~18). reiberg 병의병태생리에대한연구는 Smillie 2) 가 5가지의병리단계 (pathologic staging) 를방사선학적인소견과연관하여분류하였으며 Gauthier 와 Elbaz 6) 는해부학적인진행과정을바탕으로한 5단계의진행을보고하였고, Omer 19) 는 reiberg 병을포함한모든골연골증의병태생리를조직학적인변화와진행을근거로한 3단계로분류하였다. 본논문에서는방사선학적인소견을근거로한 Smillie 의 staging을사용하여 stage III 1예, stage IV 2예, stage V 3예의전체 6예, 5명의환자를대상으로하였다. 치료원칙은다른질환에서와마찬가지로병의진행이초기일때는보존적치료를먼저시행하고보존적치료의결과가만족스럽지않을때수술적치료를한다. 보존적치료의목적은발병원인인자를최소화하여중족골골단이나관절의변형 (epiphyseal or articular deformity) 을적게하고통증을줄이는데있다. 보존적치료는질병의초기에사용하였을때효과있는것으로보고되고있고 10), Hoskinson 20) 은전체 28명의환자에서보존적요법으로만치료한 16명중 11명이최종추시상증상의완화와동통의소실을보고하였지만, Sproul 21) 은보존적치료를한대부분의환자에서지속되는통증으로수술이필요했다고보고하였다. 질병의진행이심하지않은환자에대하여보존적인처치를통한통증소실을확인하였으나, 본 6예의환자들은 Smillie staging III 이상으로전예에서동통이심하였고, 중족족지관절의운동범위가현저하게감소되어있었으며, 일부에서는중족골두의변형과관절염변화가시작된상태로모두수술적인처치를시행하였다. 수술적치료의목적은중족골두주변의유리체, 가골 (osteophytes) 로인해족저부혹은배부에발생한과각화증 (hyperkeratosis) 이나골극 (bone spur) 으로신발을신을때나보행시발생하는통증을제거하기위해비후된활액막제거, 중족골두나근위지골절제, 파괴된관절면의제거혹은남아있는정상관절면을이용해기능을할수있는관절면으로전환시켜통증을제거하고관절의기능회복시키는것이다. 수술적치료의종류는이환된중족골두나근위지골기저부절제술 20,22), 중족골두배부의함몰된관절면의해면골이식술 2), 중족족지관절의 K-강선을이용한관절고정술 23), 중족골두배굴절골술 6), 관절재형성술 5), 중족골단축술, 인공관절대치술, silicon spacer 를이용한인공물삽입관절성형술 6,24) 등으로다양하며, 이들각술기에대한정확한적응기준은아직명확하지않다. 절제술은많은저자들에의하여만족스런결과가보고되었지만 1,2,19), 진행성무지외반증, 족지단축, 전이성중족골동통 (transfer metatarsalgia) 을야기시키고, 최근의많은학자들은심각한중족골아치 (alignment of the metatarsal arch) 의소실을초래하여족지의변형과보행의불균형을일으킨다고보고하였다 13,17). 그러나최근에도아주진행된 reiberg 병에한해서는중족골두절제술을시행할것을주장하는보고도있다 18,23). 저자들이중족골두절제술을시행한 2예의진행된 smillie staging IV, V의환자에서평균 6.2 년의추시상중족골아치의변형이나제2 족지의단축은없었으며보행시동통도호전을보여변형이진행된후기의환자에게간단하게사용할수있는술식으로사료된다. reiberg 병에대해사용할수있는또다른술식으로 silicon spacer를이용한인공관절성형술이있으나, 감염이나, 활액막염, 삽입물의파손, 전이성중족골동통의잠재적위험을안고있어사용에제약이따른다 6,23,25). 관절내유리체제거술및중족골두재형성술은 Mann 5) 에의하여시행된중족골의길이와기능을그대로유지하면서관절내파괴된연골부위의절제와유리체를제거하는술식으로많은보고에서좋은결과를나타내고있으나 5,6,11,26), 저자들의경우에는비교적효과적인술식으로는생각되나이환된중족족지관절의운동제한이남았으며, 손상된관절연골을그대로남겨둠으로써조기퇴행성변화의가능성을배제할수없는문제점이있었고, 1예에서는 6년 3개월간의추시에도지속적인동통이남아다른술식에비하여양호하지못한

6 소견을보였다. 이러한지속적인동통의원인은손상된관절연골부가관절운동시접촉되면서통증이발생한것으로생각된다. 중족골두배굴절골술은 Gauthier 와 Elbaz 6) 가보고한술식으로발생부위가중족골두의배측에국한되고관절면의족저부는거의보존된다는점에착안하여이환된배측병소부위를절제하고정상인족저부관절면을절골술로배굴시켜새로운관절면을만드는방법으로 53예중 1예를제외하고는모두만족할만한결과를얻었다고보고했다. 술기가비교적간단하며, 철사만으로견고한고정을얻을수있어조기체중부하가가능하고, 골유합이쉽게이루어지며, 중족골자체의단축 (shortening) 과거상 (elevation) 에의한감압효과까지있어동통제거의장점이있다 17,27,28). 하지만보고에따라절골술로만들어진관절면이정상의관절면과완전히일치하지못하고, 족저부의피질골을유지하면서폐쇄절골을하여야하는기술적인문제와원위골편의무혈성괴사의위험성, 고정용철사에의한건염 (tendinitis) 의발생 27), 골유합이후의철사제거를위한재수술등이단점으로지적되었다 26). 저자들은중족골두배굴절골술을통한 2예의평균 5년추시에서술식이비교적간단하고, 쉽게골유합을얻었으며, 관절운동범위의회복이다른 2가지의술식에비해가장좋았다. 또한, 보행시동통의소실과방사선학적으로관절면의일치성을얻을수있었고, 환자의만족도도 3가지술식중가장높은것으로나타났다. 결론저자들은 1996년 3월부터 2002년 7월까지총 6예, 5명의간과성 reiberg 병환자에대하여중족골두절제술, 관절재형성술그리고중족골두배굴절골술을각각 2예씩시행하였으며평균 5.3년간의추시하여다음과같은결과를얻었다. 1. 전례에서모두여자였으며, 모두제2 중족골두가이환되었다. 2. 3가지다른술식을이용한모든환자에서증상의호전과양호이상의결과 (AOAS score 70점이상 ) 를얻을수있었다. 3. 각술식간의비교에서중족골두배굴절골술이가장좋은결과를보였고, 중족골두제거술, 관절재형성술순이었다. 이상의결과에서, 비록증례의수가적어그결과를통계적인처리는할수없었지만 Smillie stage III 이상의진행된진구성 reiberg 병환자에서중족골두절제술, 관절재형성술그리고중족골두배굴절골술을이용하여치료할경우 좋은결과가예상이되고특히, 중족골두배굴절골술은가장좋은결과를보이는술식이라사료된다. REERENCES 1) Addante JB, Scardinia BS and Kaufmann D: Repair of tailor's bunion by means of fifth metatarsal head resection and insertion of spherical silicon implant. Arch Pod Med oot Surg, 4: 49-52, ) Beito SB and Lavery LA: reiberg's disease and Dislocation of the Second Metatarsophalangeal Joint. Clin Podiatric Med Surg, 7(4): , ) Braddock G: Experimental epiphyseal injury and reiberg's disease. J Bone and Joint Surg [Br], 41: , ) Breck L: Osteochondrosis of the heads of the metatarsals. in An Atlas of the Osteochondroses. Springfield, Charles C. Thomas. 113, ) reiberg AH: Infarction of the second metatarsal bone. Surg Gynecol Obstet, 19: , ) Gauthier G and Elbaz R: reiberg's infraction: a subchondral bone fatigue fracture: a new surgical treatment. Clin Orthop, 142: 92-95, ) Giannestras NJ: oot Disorder: Medical and Surgical Management. 2nd ed. Philadelphia, Lea & ebiger. 176, ) Helal B and Gibb P: reiberg's disease: a suggested patterns of management. oot Ankle 8: , ) Hoskinson J: reiberg's disease: A review of the long-term results. Proc R Soc Med, 67: , ) Hungerford DS: Bone marrow pressure, venography, and core decompression in ischemic necrosis of femoral head. The Hip; Proceeding of Seventh Open Scientific Meeting of the Hip Society. St.Louis. CV Mosby. 801, ) Jones JP: Alcoholism, hypercortisonism, fat embolism and osseous avascular necrosis; Idiopathic ischemic necrosis of femoral head in adults. Stuttgart. Thieme. 112, ) Katcherian DA: Treatment of reiberg's Disease. Orthopedic Clin North America, 25(1): 69-81, ) Kehr LE: A new surgical technique for the correction of reiberg's deformity. J Am Podiatr Assoc, 72: 130, ) Kinnard P and Lirette R: reiberg's disease and dorsiflexion osteotomy. J Bone and Joint Surg[Br], 73(5): , ) Kitaoka HB, Ian J. Alexander and Harold B: Clinical Rating Systems for the Ankle-Hindfoot, Midfoot, Hallux and Lesser Toes. oot & Ankle International, Jul: 15(7): , ) Kwon CS, Ahn JK, Kim JH, Jung BH, Sung YB and Kim DS: Dorsal closing wedge osteotomy in reiberg's disease. J Korean Orthop Assoc, 31(1): , ) Mann RA and Coughlin MJ: Lesser toe deformities. Instructional course lectures, 36: ,

7 류총일 정철용 김병철 최성종 정용욱 18) McMaster M: The Pathogenesis of hallux rigidus. J Bone and Joint surg [Br], 60: 82-87, ) Murphy AG and Richardson GE: Lesser toe abnormalities. Campbell's Operative Orthopaedics, 10th edition. Mosby. 4: , ) Omer GE: Primary articular osteochondroses. Clin Orthop, 158: 33-41, ) Smillie IS: reiberg's infraction (Koehler's second disease). J Bone joint Surg [Br], 39: 580, ) Smith TWD, Stanley D and Rowley DI: Treatment of reiberg's Disease. J Bone and Joint Surg [Br]. 73: , ) Sproul J, Klaaren H and Mannarino : Surgical treatment of reiberg's infraction in athletes. Am J Sports Med, 21: , ) Stanley D, Betts RP, Rowley DI and Smith TWD: Assessment of Etiologic actors in the development of reiberg's disease. J oot Surg, 29(5): , ) Viladot A and Viladot A Jr: Osteochondroses: Aseptic necrosis of the foot, Disorder of oot and Ankle, ed2, Philadelphia, WB Saunders, , ) Wiley J and Thurston: reiberg's disease. J Bone and Joint Surg [Br], 63: 459, ) Yoon JO, Park SS, Kim EG and Lee CW: Treatment of reiberg's disease with joint debridement and reshaping of metatarsal head. J Korean Orthop Assoc, 33(4): ,

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<313120B0F8C7F6BDC42DC1A4B9AEBBF D E687770> 대한족부족관절학회지 : 제 9 권제 호 00 J Korean Foot Ankle Soc. Vol. 9. No.. pp.9-, 00 서울대학교의과대학정형외과학교실 Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Korea =Abstract= Purpose: