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1 대한정형외과학회지 : 제 43 권제 5 호 2008 J Korean Orthop Assoc 2008; 43: 소아에서잠김금속판을이용한장관골골간단부병적골절의치료 정성택ㆍ정광철ㆍ김현종ㆍ이진호 전남대학교의과대학정형외과학교실 Treatment of Metaphyseal Pathologic Fractures of Long Bone Using Locking Compression Plate in Children Sung-Taek Jung, M.D., Kwang-Cheul Jeong, M.D., Hyun-Jong Kim, M.D., and Jin-Ho Lee, M.D. Department of Orthopaedic Surgery, Chonnam National University Hospital, Gwangju, Korea Purpose: To evaluate the results of operative treatment for metaphyseal pathologic fracture of long bone in children using Locking Compression Plate (LCP). Materials and Methods: Six children were enrolled in this study. The locations of fracture were proximal femur in five children and distal femur in one child. Pathologic diagnosis was aneurysmal bone cyst, in three children and simple bone cyst, enchondroma, and nonossifying fibroma, in other three children. All six children were underwent curettage of bone lesion and bone grafting, then the fractures were internally fixed using LCP. Results: All fractures were united at six to ten weeks after operation. Healing of bone lesions except one case was observed. There were no mechanical complications, no loss of reduction and malunion. Also, we couldn't find any complication associated with physeal injury, such as leg length discrepancy of lower extremities. Conclusion: Internal fixation of metaphyseal pathologic fracture of long bone using LCP in children is technically easy and offers secure fixation despite anatomic and biologic characteristics of this type of fracture due to biologic and biomechanical advantages of LCP. Key Words: Metaphysis, Pathologic fracture, Locking compression plate 서론소아의장관골골절은연령, 동반질환, 해부학적위치등에따라다양한치료방법이고려되어야한다. 특히소아에서발생한병적골절의경우성인과달리대부분의기저질환이양성골병변이며이러한병적골절을잘일으키는것으로알려진양성골종양에는고립성골낭종 (Simple Bone Cyst), 비골화성섬유종 (Nonossifying Fibroma), 섬유성골이형성증 (Fibrous dysplasia), 동맥류성골낭종 (Aneurysmal Bone Cyst) 등이있으며, 흔한발생장소로는상완골근위부, 대퇴골근위부, 대퇴골원위부등이있다 9). 이러한양성골종양에의한병적 골절의치료는기저병변의종류, 위치, 환자의나이, 골절의형태등에따라달라질수있으며, 상지의경우보존적방법으로도초기치료가가능하나대퇴골근위부와같이하중이많이가해지는부위에발생한경우대부분의경우에서수술적치료를필요로한다 7,8,15,17). 하지만골성숙이이루어지지않은소아에서발생한하지골간단부의병적골절의경우작은골간단부골편과인접한성장판, 그리고골종양에의해더욱얇아진피질골등의문제로고정물의선택에있어제한점을가진다 7,11). 이에저자들은하지장관골의골간단부에발생한양성골종양에의한병적골절에대해시행한잠김금속판 (Locking 통신저자 : 정성택광주시동구학동 8 전남대학교의과대학정형외과학교실 TEL: ㆍ FAX: stjung@chonnam.ac.kr Address reprint requests to Sung-Taek Jung, M.D. Department of Orthopaedic Surgery, Chonnam National University Hospital, Hak 1-dong 8, Gwangju , Korea Tel: , Fax: stjung@chonnam.ac.kr 539

2 540 정성택ㆍ정광철ㆍ김현종외 1 인 Table 1. Demographic Data Age Fracture Pathologic Union F/U Case Gender Graft (years) Site Diagnosis (weeks) (Months) 1 11 M Proximal femur ABC Fibula M Distal femur NOF M Proximal femur ABC Fibula M Proximal femur SBC Fibula M Proximal femur Enchondroma Fibula M Proximal femur ABC Fibula 6 12 *ABC, aneurismal bone cyst; NOF, non-ossifying fibroma; SBC, Simple bone cyst. Compression Plate; LCP) 를이용한수술적치료의결과에대해보고하고자한다. 대상및방법 2004년부터 2006년까지하지장관골의골간단부에발생한병적골절에대해잠김금속판을이용하여수술적치료를시행받았던 6명의소아환자를대상으로하였다 (Table 1). 추시기간은최소 12개월이었으며, 평균추시기간은 21.3개월 (12-40개월) 이었다. 6명의환아모두남자였으며, 평균연령은 12.0 세 (9-16 세 ) 로전예에서수상당시성장이남아있는상태였다. 골절의위치는대퇴골근위부가 5예였으며, 나머지 1예는대퇴골원위부였다. 술후조직학적으로확진된기저병변은동맥류성골낭종이 3예로가장많았으며, 기타단순골낭종, 내연골종 (Enchondroma), 비골화성섬유종이각각 1예였다. 수술은전예에서수상후 3일이내에시행되었으며, 수술방법은먼저환자를일반수술대에근위대퇴골의경우측와위로, 원위대퇴골의경우앙아위로위치한후골절부를노출시켰으며, 골절부를통하여기저병변에대한철저한소파술시행후골이식시행하였다. 골이식물로는근위대퇴골에발생한 5예의경우평균 8.6 (6.5-15) cm 길이의비교적큰골결손이발생하였으며, 생역학적으로하중을많이받는부위인점을고려하여기계적안정성을높이기위해자가비골지주이식과황산칼슘 (, Wright Medical Co. Arlington TN, USA) 이식을동시에시행하였으며, 병변의크기가작았던원위대퇴골에발생하였던 1예에서는황산칼슘이식 만을시행하였다. 자가비골이식을시행하였던예에서는먼저동측에서자가비골을채취한후본수술을시행하였으며, 본저자들에의해고안된방법을이용하여비골의채취및공여부에대한황산칼슘이식을시행하였다 14). 골이식이끝난후잠김금속판을이용한내고정시가능한잠김나사못 (Locking Head Screw) 을이용하였으며, 성장판손상을피하기위해나사못의방향조정이필요한경우, 골편의간접정복을위해필요한경우등에있어서는일반나사못을혼합하여사용하였다. 마지막으로술후 6-8 주간석고고정시행후부분체중부하목발보행시행하였으며술후약 3개월에완전체중부하를허용하였다. 치료결과의평가를위해술후주기적단순방사선사진을통해골절의유합여부및시기를확인하였으며, 최종추시방사선사진상기저병변의치유여부와골절정복의소실에따른부정유합, 대퇴골두무혈성괴사그리고금속판의파단, 나사못의이탈과같은기계적합병증등의유무에대해확인하였고, 동시에원격방사선사진 (Teleoroentgenography) 을이용하여성장판손상에따른하지부동, 하지정렬의변화등의여부도확인하였다. 또한임상적평가를위해고관절및슬관절의운동범위와보행시파행의여부를확인하였다. 결과추시방사선사진상술후 6-10주에전예에서골유합소견관찰되었으며최종추시방사선사진상전체 6예중 5예에서는기저병변의완전한치유관찰할수

$(A) Preoperative plain radiograph of 9-year-old boy shows expansile radiolucent lesion and associated fracture in left proximal femur.$ $and internal fixation of fracture using LCP.$ $(C) Plain radiograph taken 14 months after surgery shows solid fracture union and healing of underlying aneurismal bone cyst. Fig. 2.$ $cyst (C) Plain radiograph taken 8 months after surgery shows healing of cystic lesion and solid union of fracture without complications. 있었다 (Fig.$ 1, 2). 대퇴골근위부에발생한동맥류성골낭종에의한병적골절에대해수술시행하였던 1예에서낭종의불완전치유를보여술후 10개월에소파술및골이식시행후외래추시중이다. 전예에서금속판의파단, 나사못의이탈등의기계적합병증은관찰되지않았으며, 정복의소실에따른부정유합도관찰할수없다.

1, 2). 대퇴골근위부에발생한동맥류성골낭종에의한병적골절에대해수술시행하였던 1예에서낭종의불완전치유를보여술후 10개월에소파술및골이식시행후외래추시중이다. 전예에서금속판의파단, 나사못의이탈등의기계적합병증은관찰되지않았으며, 정복의소실에따른부정유합도관찰할수없다.

자가비골이식을시행하였던 5예중 4예에서는공여부의완전한재형성을관찰할수있었으며, 비교적나이가많고추시기간이짧았던증례 4의경우자기비골이식과관련된다른합병증은없고재형성이진행중에있어좀더추시가필요할것으로사료된다.

3 소아에서잠김금속판을이용한장관골골간단부병적골절의치료 541 Fig. 1. (A) Preoperative plain radiograph of 9-year-old boy shows expansile radiolucent lesion and associated fracture in left proximal femur. (B) Immediately postoperative radiograph shows curettage and autologous fibula and calcium sulfate (osteoset R ) graft for the aneurismal bone cyst and internal fixation of fracture using LCP. (C) Plain radiograph taken 14 months after surgery shows solid fracture union and healing of underlying aneurismal bone cyst. Fig. 2. (A) Preoperative plain radiographs of 16-year-old boy show large radiolucent cystic lesion and associated comminuted fracture in left proximal femur. (B) Immediately postoperative plain radiographs shows curettage and autologous fibular and calcium sulfate (osteoset R ) graft for the simple bone cyst and internal fixation of fracture using LCP. (C) Plain radiograph taken 8 months after surgery shows healing of cystic lesion and solid union of fracture without complications. 있었다 (Fig. 1, 2). 대퇴골근위부에발생한동맥류성골낭종에의한병적골절에대해수술시행하였던 1예에서낭종의불완전치유를보여술후 10개월에소파술및골이식시행후외래추시중이다. 전예에서금속판의파단, 나사못의이탈등의기계적합병증은관찰되지않았으며, 정복의소실에따른부정유합도관찰할수없다. 또한최종추시방사선사진상성장판손상에따른하지부동, 하지정렬의변화등을보인예는없었으나, 향후이에대해서는좀더장기적인추시가필요할것으로사료된다. 자가비골이식을시행하였던 5예중 4예에서는공여부의완전한재형성을관찰할수있었으며, 비교적나이가많고추시기간이짧았던증례 4의경우자기비골이식과관련된다른합병증은없고재형성이진행중에있어좀더추시가필요할것으로사료된다. 임상적결과로전예에서최종추시상완전한관절운동범위를회복하였으며보행시파행을보인예는없었다. 고찰양성골종양에의한하지골간단부병적골절의치료는생역학적으로하중을많이받는부위이며, 주위의강한근육의힘에의해골절의전위가쉽게일어나고, 또한기저병변으로인해골유합이지연될수있기때문에보존적치료는쉽지않은것으로보고되고있으며 7-9), 여러저자들에의해수술적치료가권장되고있다 1,4,6,7,9,10,12,1,17). 이러한하지골간단부병적골절의수술시기저병변에대한철저한소파술및골이식을통한병변의재발을방지하여야하며, 또한안정적인고정을통하여변형을방지하며골유합을이룰수있어야한다. 이러한안정적인고정을얻는데있어소아의골간단부는그해부학적특징으로인해많은제한점이있다. Malkawi 등 7) 은소아에서발생한대퇴골전자하부병적골절에대한수술적치료의결과를보고하면서소아에있어골절에대한내고정의해부학적제한점을이야기하였다. 이러한제한점은첫째, 대퇴경부의작은직경으로인해굴곡칼날금속판 (Angled Blade Plate) 과같이비교적크기가큰내고정

4 542 정성택ㆍ정광철ㆍ김현종외 1 인 물을위치하는데있어어려움이있을수있으며, 둘째, 주위의성장판의존재로인해충분한내고정이어려울수있으며, 셋째, 기저병변으로인한골결손및얇은피질골로인해견고한내고정이어려울수있다는점이다. 지금까지여러저자들에의해이러한해부학적제한점을극복하기위한여러가지수술방법들이제안되어왔다. 많은저자들은굴곡칼날금속판과압박고나사못 (Compression Hip Screw) 을이용한수술적치료에대해보고하였고 6,12,17), Roposch 등 10) 은단순골낭종에의한병적골절에대한치료로유연성골수강내금속정 (Flexible Intramedullary Nail) 을이용한치료를발표였으며, 9예의근위대퇴부골절중 5예에서내반변형이발생하였다고보고하여이치료의한계점을보였다. Erol 등 1) 은소아에서발생한골낭종에의한병적골절의치료에대한분류를발표하였으며, 그들은병변의크기가커서성장판하방에나사못을고정시키기에충분한골이남아있지않은경우성장판을가로지르는 2개의핀을이용하여고정하고고수상석고를시행할것을제안하였다. 또한최근 Vigler 등 15) 은근위대퇴골에발생한병적골절에대한치료방법중하나로외고정장치를이용한치료를소개하였다. 본저자들은 2004년부터대퇴골골간단부의병적골절이발생하였던 6명의소아에대해잠김금속한을이용한수술적치료를시행하였으며, 이중 1예에서기저병변의불와전치유관찰되어재수술이필요하였으나, 기타골유합의문제, 정복소실에따른부정유합, 기계적합병증, 성장판손상등과같은문제로인해재수술이필요하였던예는없었다. 이처럼해부학적으로, 그리고생물학적으로취약한골절의치료에있어잠김금속판의사용은잠김금속판의생역학적, 생물학적특징으로인해기존의다른내고정물에비해많은장점을가지고있다 2,3,5,13,16). 첫째, 대퇴골골간단부와같이많은체중부하를받는부위의골절은짧은골간단부골편을견고하게고정하는것이필요하며, 지금까지는굴곡칼날금속판이나압박고나사못등이가장많이사용되어왔으나소아의경우대퇴경부의직경이작아이러한내고정물을정확히위치시키는데어려움이있다. 하지만잠김금속판은방향조절이가능한일반나사못과잠김나사못을적절히혼합하여사용함 으로써짧은골간단부골편을좀더쉽고효과적으로안정되게고정할수있다. 둘째, 이러한나사못의적절한혼합사용으로주위의인접한성장판의손상을피하면서골편의고정이가능하다. 셋째, 기저병변에대한철저한소파술후발생되는골결손및얇은피질골로인해안정적인고정의유지가어려운문제가발생한다. 하지만잠김금속판의경우금속판과잠김나사못이하나의안정적인구조물을형성함으로써각변형에대한안정성과축성안정성이뛰어나며, 나사못의움직임 (toggle) 이나이탈이발생하지않아술후정복의소실을감소시킬수있다. 넷째, 잠김금속판은기존의금속판과는달리안정성을위해금속판과피질골사이에압박이필요하지않기때문에골막의혈액공급을차단하지않음으로써골절의치유및기저병변의치유를향상시킬수있다. 마지막으로장기간지속된양성골종양에의해대퇴골근위부의골변형이발생한경우에있어고정된각을가지는굴곡칼날금속판이나압박고나사못의사용에제한을받을경우에도유용하게사용할수있다. 본저자들은비록증례수가적고추시기간은짧지만소아환자에서양성골종양에의해발생한하지골간단부의병적골절에대해잠김금속판을이용하여수술적치료를시행함으로써특별한합병증없이양호한임상적결과를얻을수있었다. 결론소아에서양성골종양에의한하지의골간단부의병적골절은그해부학적, 생물학적특징으로인해치료에있어많은제한점을가지고있다. 잠김금속판의생역학적특징과생물학적장점을적절히이용함으로써비교적기술적으로도쉬우면서견고한고정을얻을수있어합병증을최소화하면서양호한골유합을기대할수있을것으로생각된다. 참고문헌 1. Erol B, Pill SG, Guttenberg ME, Meyer JS, Dormans JP: Pathologic hip fracture in a 4-year-old boy. Clin Orthop Relat Res, 403: , Gardner MJ, Brophy RH, Campbell D, et al: The mechanical behavior of locking compression plates compared with dynamic compression plates in a cadaver radius model. J

5 소아에서잠김금속판을이용한장관골골간단부병적골절의치료 543 Orthop Trauma, 19: , Gautier E, Sommer C: Guidelines for the clinical application of the LCP. Injury, 34(Suppl 2): B63-76, Gennari JM, Merrot T, Piclet/Legre B, Bergoin M: The choice of treatment for simple bone cysts of the upper third of the femur in children. Eur J Pediatr Surg, 6: 95-99, Haidukewych GJ: Innovations in locking plate technology. J Am Acad Orthop Surg, 12: , Jaffe KA, Dunham WK: Treatment of benign lesions of the femoral head and neck. Clin Orthop Relat Res, 257: , Malkawi H, Shannak A, Amr S: Surgical treatment of pathological subtrochanteric fractures due to benign lesions in children and adolescents. J Pediatr Orthop, 4: 63-69, Norman-Taylor FH, Hashemi-Nejad A, Gillingham BL, Stevens D, Cole WG: Risk of refracture through unicameral bone cysts of the proximal femur. J Pediatr Orthop, 22: , Ortiz EJ, Isler MH, Navia JE, Canosa R: Pathologic fractures in children. Clin Orthop Relat Res, 432: , Roposch A, Saraph V, Linhart WE: Flexible intramedullary nailing for the treatment of unicameral bone cysts in long bones. J Bone Joint Surg Am, 82: , Sabharwal S: Role of Ilizarov external fixator in the management of proximal/distal metadiaphyseal pediatric femur fractures. J Orthop Trauma, 19: , Shih HN, Cheng CY, Chen YJ, Huang TJ, Hsu RW: Treatment of the femoral neck amd trochanteric benign lesions. Clin Orthop Relat Res, 328: , Sommer C, Gautier E, Muller M, Helfet DL, Wagner M: First clinical results of the locking compression plate (LCP). Injury, 34(Suppl 2): B43-54, Jung ST, Kim BS, Xin ZF, Moon ES, Lee KB: New fibular strut graft technique to minimize donor site complications. J Korean Orthop Assoc, 42: , Vigler M, Weigl D, Schwarz M, Ben-Itzhak I, Salai M, Bar-On E: Subtrochanteric femoral fractures due to simple bone cysts in children. J Pediatr Orthop B, 15: , Wagner M: General principles for the clinical use of the LCP. Injury, 34(Suppl 2): B31-42, Wai EK, Davis AM, Griffin A, Bell RS, Wunder JS: Pathologic fractures of the proximal femur secondary to benign bone tumors. Clin Orthop Relat Res, 393: , = 국문초록 = 목적 : 소아에서발생한장관골골간단부병적골절에대한잠김금속판을이용한수술적치료의결과를평가하고자하였다. 대상및방법 : 6 명의환아를대상으로하였으며, 5 예에서는대퇴골근위부에 1 예에서는대퇴골원위부에골절이발생하였다. 기저병변에대한조직학적진단은동맥류성골낭종이 3 예, 단순골낭종, 내연골종, 비골화성섬유종이각각 1 예였다. 기저병변은소파술및골이식술을시행하였으며, 골저른잠김금속판을이용한내고정시행하였다. 결과 : 골유합은술후 6-10 주에전예에서관찰되었으며, 기저병변은전체 6 예중 5 예에서는병변의치유관찰하였다. 전예에서금속판의파단, 나사못의이탈등의기계적합병증은관찰되지않았으며, 정복의소실에따른부정유합도관찰할수없다. 또한성장판손상에따른하지부동, 하지정렬의변화등을보인예도없었다. 결론 : 소아에서양성골종양에의한하지의골간단부의병적골절은그해부학적, 생물학적특성에도불구하고압박금속판의생역학적특징과생물학적장점을적절히이용함으로써비교적기술적으로도쉬우면서견고한고정을얻을수있을것으로생각된다. 색인단어 : 골간단부, 병적골절, 잠김금속판

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untitled 대한정형외과학회지 : 제 42 권제 5 호 2007 J Korean Orthop Assoc 2007; 42: 623-629 양성골종양의치료에사용된황산칼슘의유용성 정성택ㆍ김명선ㆍ정광철 전남대학교의과대학정형외과학교실 The Usefulness of Calcium Sulfate in Treatment of Benign Bone Tumor Sung Taek Jung,