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1 522 pissn : , eissn : Original Article J Korean Orthop Assoc 2018; 53: 초음파유도하경피적아킬레스건봉합술 : 개방적봉합술과의비교연구 강동훈 강찬 황득수 송재황 최보성 충남대학교의과대학정형외과학교실 Intraoperative Ultrasound-Guided Percutaneous Repair of a Ruptured Achilles Tendon: A Comparative Study with Open Repair Dong Hun Kang, M.D., Chan Kang, M.D., Ph.D., Deuk Soo Hwang, M.D., Ph.D., Jae Hwang Song, M.D., and Bo Sung Choi, M.D. Department of Orthopedic Surgery, Chungnam National University School of Medicine, Daejeon, Korea Purpose: To compare the clinical outcomes of ultrasound-guided percutaneous repair (USPR) and open repair in a ruptured Achilles tendon. Materials and Methods: The outcomes of 12 patients with USPR (group A) and 18 patients with open repair (group B) from January 2015 to February 2017 were analyzed retrospectively. The postoperative clinical evaluations were performed using the Arner-Lindholm scale, American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Achilles tendon total rupture score (ATRS), and visual analogue scale for the overall satisfaction and cosmetic satisfaction with the scar, and the starting time of single heel raises. The complications were also evaluated. Results: The Arner-Lindholm scale, AOFAS ankle-hindfoot score, ATRS, starting time of single heel raises were similar in both groups (all p>0.05). Group A showed a significantly higher overall patient s satisfaction and cosmetic satisfaction in than group B (all p<0.05). Two cases of Achilles tendon elongation were encountered in group A, and 1 case of re-rupture with deep infection and 1 case of superficial infection were experienced in group B. Conclusion: USPR showed good clinical outcomes and high satisfaction as well as a low rate of complications, such as sural nerve injury. Therefore, USPR can be considered as an effective surgical treatment option for Achilles tendon ruptures. Key words: achilles tendon, ultrasound, percutaneous repair, sural nerve, absorbable suture material 서론 아킬레스건파열에대하여최적의치료법에대한결론은확립되 어있지않다. 개방적봉합술은파열된아킬레스건을직접확인 하여장력을주면서정확히봉합할수있으므로재파열의빈도를 낮출수있는장점이있으나큰절개에따른감염이나유착, 창상 Received October 9, 2017 Revised November 2, 2017 Accepted December 6, 2017 Correspondence to: Chan Kang, M.D., Ph.D. Department of Orthopedic Surgery, Chungnam National University School of Medicine, 266 Munwha-ro, Jung-gu, Daejeon 35015, Korea TEL: FAX: faschan@hanmail.net ORCID: 관련합병증등이단점으로지적되어왔다. 1,2) 반면비교적양호한치료결과를보인보존적치료에대한연구들도꾸준히보고되고있고, 점차비중이늘어가고있으나, 1,3) 재파열, 건의신연 (elongation) 등의가능성이여전히잔존하고있다. 4) 이러한합병증들을보완하기위해경피적봉합술, 최소침습수술 (minimal invasive surgery, MIS) 이개발되었으나재파열, 비복신경손상등의문제가제기되었다. 2,5-8) 저자들은여러치료의합병증을더욱줄이기위해아킬레스건파열에대해초음파유도하경피적아킬레스건봉합술을시행하였으며, 개방적봉합술과의임상적결과및합병증을비교하여보다유용한수술적치료법에대해제시하고자하였다. The Journal of the Korean Orthopaedic Association Volume 53 Number Copyright 2018 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

523 Comparative Study with Two Repair Methods of Ruptured Achilles Tendon 대상및방법 1. 연구대상본연구는충남대학교병원의 Institutional Review Board (IRB) 승인을얻어진행되었다 (IRB No.: CNUH 2017-09-016).

2 523 Comparative Study with Two Repair Methods of Ruptured Achilles Tendon 대상및방법 1. 연구대상본연구는충남대학교병원의 Institutional Review Board (IRB) 승인을얻어진행되었다 (IRB No.: CNUH ). 2015년 1 월부터 2017 년 2월까지본원에서이학적검사및자기공명영상 (magnetic resonance imaging, MRI) 검사상아킬레스건파열로진단받아초음파유도하경피적아킬레스건봉합술을시행받은 12 예 (A군) 와개방적봉합술을시행받은 18예 (B군) 를대상으로하였다. 2016년 2월까지개방적봉합술을시행해왔으며, 그이후에파열간격이 40 mm 이하인경우개방적술식과보존적치료의절충적치료로경피적봉합술을시행하였다. 성별은 A군남자 11 예 (91.7%), 여자 1예 (8.3%) 였으며, B군남자 16예 (88.9%), 여자 2예 (11.1%) 였다. 수상당시나이는 A군 39.4세 (28-55세), B군 40.2세 (28-52세) 였다. 수상기전은대부분스포츠손상으로 A군 11예, B 군 16예였으며, 나머지 3예는실족에의해파열되었다. MRI상종골부착부로부터아킬레스건파열위치는 A군 58.0 mm ( mm), B군 57.6 mm ( mm) 였고, 파열간격은 A군 21.8 mm ( mm), B군 23.8 mm ( mm) 였다. 수술은수상일로부터 A군에서는 3.5일 ( 일), B군에서는 3.0일 ( 일 ) 에시행하였다 (Table 1). 급성파열의경우만을대상으로하였으며, 3주이상의만성파열, 개방성파열, 종골부착부파열, 타병원에서수술후재파열, 만성아킬레스건병증, 신경근육질환또는말초혈관질환진단을받은경우, 전신스테로이드나면역억제제치료를받은경우, 그리고최종추시기간이 6개월미만인경우는제외하였다. 두군모두단일술자에의해시행되었으며, 평균추시기간은 A군에서 11.2개월 (6-17개월), B군에서 16.0개월 (8-24개월) 이었다. 수술및하지마취는한정형외과의사에의해시행되었으며, 모든마취는초음파유도하국소신경차단술 ( 대퇴신경, 좌골신경, 후방대퇴피신경차단 ) 로시행하였다. 마취전에환자를복와 위로위치시킨후슬관절을 90 굴곡한중립위에서건측의발목각도를측정하여수술시참고로하였고, 파열부위와비복신경의주행경로를미리표시하였다. 2. 초음파유도하경피적봉합술지혈대를착용시키지않고복와위에서진행하였고, 수술장에서도초음파 (MyLab25Gold; Esaote, Genoa, Italy) 를준비하여탐촉자를소독된비닐로감쌌다. 봉합사는 1-0 Vicryl (Ethicon Inc., Somerville, NJ, USA) 을사용하였고, modified Kessler 술식을사용하여 2 strand로 2회봉합하였다 (Fig. 1). 초음파로바늘이건의실질까지두껍게통과하는지, 비복신경을손상시키지않는지실시간으로확인하면서수술을진행하였다 (Fig. 2). 건의종골부착부에서봉합사를먼저통과시켜단열원위부건단으로부터근위부건단으로통과시켰다. 근위부에서 2-3번더종축으로통과시킨후반대편으로이동하여다시근위부에서원위부종축으로통과시켰다. 종골부착부에서횡축으로통과시켜첫바늘구멍으로봉합사를빼낸후수술전건측의슬관절굴곡시발목의중립각도보다약 10 더단축하여족저굴곡된상태에서최종봉합을하였다 (Fig. 3). 같은바늘구멍을통해이과정을 1회더반복하여총 4 strand가되도록하였다. 바늘이나온구멍으로실을빼내어다시바늘을넣었기때문에바늘이봉합사를관통하여중간에끊어지지않도록주의하였고 (Fig. 4), 이를방지하기위해나머지실을바늘의진행방향과반대로당긴상태에서바늘을같은구멍으로넣어피부의아랫면을살짝긁으며들어가서봉합을진행하였다. Table 1. Characteristics of Two Groups* Characteristic Group A Group B No. of patient (male:female) 12 (11:1) 18 (16:2) Age (yr) 39.4 (28 55) 40.2 (28 52) Sports injury 11 (91.7) 16 (88.9) Level of rupture (mm) 58.0 ( ) 57.6 ( ) Gap of rupture (mm) 21.8 ( ) 23.8 ( ) Injury-operation interval (d) 3.5 ( ) 3.0 ( ) Values are presented as number only, mean (range), or number (%). Group A, patients with ultrasound-guided percutaneous repair; Group B, patients with open repair. *There were no significant differences between groups A and B. Figure 1. Illustration of the modified Kessler s suture technique in the ultrasound-guided percutaneous repair group. The procedure starts from distalolateral portion of the Achilles tendon and returns to the start point clockwise. This is repeated two times. Black dotted line: first modified Kessler s suture; Full line: second suture.

524 Dong Hun Kang, et al. B C D A Figure 2. (A) Surgical scene of intra operative ultrasound-guided percutaneous repair of the left Achilles tendon.

These show that the sural nerve becomes closer to Achilles tendon as the probe is moved from the distal to proximal portion.

개방적봉합술아킬레스건내측을따라약 6 cm 정도종절개를가한후건외막조직 (paratenon) 과건중간막 (mesotenon) 역시종절개하여파열된아킬레스건을노출시켰다. 파열된아킬레스건단을다듬은후단열근위부는 Krackow 술식을, 단열원위부는 Kessler 술식을사용하여 2개의 1-0 Vicryl로 4 strand를이용하여봉합하였다.

수술후처치수술후 4주간족저굴곡상태로비체중부하단하지석고고정을하였고, 수술 4주후부터수술 12주후까지아킬레스건보조기 (cam walker brace) 착용하에족관절족배및족저굴곡운동을단계적으로시행하였다. 수술후 4주부터는부분체중부하, 8주부터는전체중부하를시행하였다.

3 524 Dong Hun Kang, et al. B C D A Figure 2. (A) Surgical scene of intra operative ultrasound-guided percutaneous repair of the left Achilles tendon. Axial ultrasound scan, which indicates sural nerve lateral to the lesser saphenous vein and Achilles tendon at the distal portion (B), mid portion (C), proximal portion (D). These show that the sural nerve becomes closer to Achilles tendon as the probe is moved from the distal to proximal portion. Arrow and dotted ellipse: sural nerve; Asterisk ellipse: lesser saphenous vein; Triangle ellipse: Achilles tendon. 3. 개방적봉합술아킬레스건내측을따라약 6 cm 정도종절개를가한후건외막조직 (paratenon) 과건중간막 (mesotenon) 역시종절개하여파열된아킬레스건을노출시켰다. 파열된아킬레스건단을다듬은후단열근위부는 Krackow 술식을, 단열원위부는 Kessler 술식을사용하여 2개의 1-0 Vicryl로 4 strand를이용하여봉합하였다. 9) 원위및근위파열단이완전히접촉이된상태에서건측과환측의슬관절을 90 굴곡시킨후파열원위부의두봉합사를잡아당겨건측의족배굴곡각도에맞추고그매듭 (knot) 이파열단내에위치하도록하여봉합하였다. 그외건외막조직과건중간막역시 3-0 Vicryl 봉합사를이용하여봉합하였다. 9) 4. 수술후처치수술후 4주간족저굴곡상태로비체중부하단하지석고고정을하였고, 수술 4주후부터수술 12주후까지아킬레스건보조기 (cam walker brace) 착용하에족관절족배및족저굴곡운동을단계적으로시행하였다. 수술후 4주부터는부분체중부하, 8주부터는전체중부하를시행하였다. 6주후부터고무밴드 (thera band) 를이용하여저항성족배, 족저굴곡운동을시행하였고, 8주후부터는실내에서보조기없이자유로운일상생활을시작하였으며, 쪼그려앉기 (squatting) 및양쪽발꿈치들기 (double heel raise) 를허용하였다. 수술 12주후부터조깅, 한쪽발꿈치들기 (single heel raise) 를허용하였다. 수술후 3개월, 6개월, 12개월에초음파로건의연속성을확인하고, 복와위상태에서슬관절을 90 굴곡한중립위에서양측의발목각도를비교하여재파열및신연여 부를확인하였다. 5. 평가방법및통계분석술후임상적평가에대해서는 Arner-Lindholm 평가기준 ( 우수 [excellent], 양호 [good], 불량 [poor]), 10) 미국정형외과족부족관절학회족관절-후족부기능평가기준 (American Orthopedic Foot and Ankle Society [AOFAS] ankle-hindfoot functional score, 0-100) 11) 및 Achilles tendon total rupture score (ATRS, 0-100) 12) 로평가하였다. 그리고최종추시때수술후결과에대한전반적인만족도를 visual analogue scale (VAS) (0= 가장불만족, 10= 가장만족 ) 로측정하였고, 13) 반흔에대한미용적만족도의 VAS (0-10) 와한쪽발꿈치들기가능시기를조사하였다. 그외감염, 재파열, 비복신경손상등의합병증에대해평가하였다. 양군임상적결과의통계적비교는 IBM SPSS Statistics ver (IBM Co., Armonk, NY, USA) 을이용하였으며, p-value가 0.05 미만인경우통계적으로유의한것으로해석하였다. 환자수가적고정규분포를만족하지않아 Mann Whitney s U-test를사용하여분석하였고, 작은 sample size의한계를미리예측하기위하여 Priori power analysis를시행하였다. 그결과 effect size를 0.8, 통계파워는 0.8로계산하였을때필요한샘플수는 54였다. 하지만실제로측정된데이터를기반으로실제통계파워를구했을때, 0.9 이상이나왔기때문에결과신뢰에는문제가없을것으로생각된다.

525 Comparative Study with Two Repair Methods of Ruptured

(A H) Surgical procedures of intraoperative

distalolateral portion of the Achilles tendon and returns to

(I) Ruptured Achilles tendon was over-corrected about 10

elongation. This was repeated twice. 결과 Figure 4.

성별, 나이, 수상기전, 파열위치, 파열간격, 수상일로부터수술일까지의시간모두두군간유의한차이는없었다 ( 모두

3 cm) 였다 (Fig. 5). 수술후 Arner-Lindholm scale은 A군에서우수 4예 (33.

1%), 불량 1예 (5.6%) 로두군간유의한차이는없었다 (p=0.884). AOFAS 점수는 A군 92.

4 525 Comparative Study with Two Repair Methods of Ruptured Achilles Tendon A B C D E F G H I Figure 3. (A H) Surgical procedures of intraoperative ultrasound-guided percutaneous repair of the left Achilles tendon. The modified Kessler s suture is started from the distalolateral portion of the Achilles tendon and returns to the start point clockwise. (I) Ruptured Achilles tendon was over-corrected about 10 compared to opposite ankle in consideration of early elongation. This was repeated twice. 결과 Figure 4. This figure shows that the needle penetrates the suture material (Vicryl). Special attention is needed to prevent this. 성별, 나이, 수상기전, 파열위치, 파열간격, 수상일로부터수술일까지의시간모두두군간유의한차이는없었다 ( 모두 p>0.05). 피부절개길이는 A군에서는바늘구멍흔적만있었고, B군에서는평균 5.7 cm ( cm) 였다 (Fig. 5). 수술후 Arner-Lindholm scale은 A군에서우수 4예 (33.3%), 양호 8예 (66.7%) 였으며, B군에서우수 6예 (33.3%), 양호 11예 (61.1%), 불량 1예 (5.6%) 로두군간유의한차이는없었다 (p=0.884). AOFAS 점수는 A군 92.3점 (85-100점 ), B군 91.6점 (61-100점) 으로유의한차이가없었고 (p=0.755), ATRS 또한 A군 88.9점 (77-97점), B군 87.6점 (57-97점) 으로유의한차이가없었다 (p=0.983). 재파열과심부감염으로재수술을받았던 B군의 1예를제외하고양군모두한쪽발꿈치들기가가능하였고, 그시기는수술후 A군 3.75개월 (3-6개월), B군 3.65개월 (3-6개월) 로유의한차이가없었다 (p=0.645). 반면, 수술후결과에대한전반적인만족도는 A군 9.1 (7-10), B군 8.2 (2-10) 로유의

A 군의 2 예에서각각수술후 4, 6 주에보조기없이실족하여봉 합부위신연을보였으나초음파상연속성이잘유지되었고건측 A Figure 5.

5 526 Dong Hun Kang, et al. 한차이가있었으며 (p=0.035), 반흔에대한미용적인만족도역시 A 군 9.9 (9-10), B 군 6.7 (2-10) 로유의한차이가있었다 (p=0.001). 즉 Arner-Lindholm scale, AOFAS ankle-hindfoot score, ATRS, 한 쪽발꿈치들기가능시기는유사한결과를보인반면, 주관적인 만족도는초음파유도하경피적봉합술을시행한 A 군에서더높 은것으로나타났다 (Table 2). A 군의 2 예에서각각수술후 4, 6 주에보조기없이실족하여봉 합부위신연을보였으나초음파상연속성이잘유지되었고건측 A Figure 5. Surgical site scars at the last postoperative follow-up in both groups: (A) Scar in the ultrasound-guided percutaneous repair group. (B) Scar in the open repair group. The mean length of the incision was 5.7 cm. Data from the article of Kang et al. (J Korean Foot Ankle Soc. 2014;18:115-8). 9) B 의발목각도에비해 10 미만의족배굴곡을보였기에경과관찰하였으며최종추시때한쪽발꿈치들기나기능적인부분이모두호전되었다. B군에서는 1예의심부감염및재파열과 1예의천부감염이나타났다. 심부감염및재파열이발생한환자는변연절제술, 세척술로감염을조절한후회전피판술을시행하였으며이후비복건막 turn-down 피판술을시행하였다. 천부감염이발생한환자는변연절제술및세척술만으로별다른소견없이회복되었다. 고찰 스포츠활동의증가로아킬레스건파열의유병률은높아지고있으나아직일치된이상적인치료법은나와있지않다. 14) 기존의개방적봉합술에대한감염, 유착및창상관련합병증이보고되어왔고 1,2) 보존적치료에대한연구들이많이진행되면서비수술적인치료가점점대두되고있지만, 1,3) 여전히건강하고활동적인환자에서는수술적치료가선호된다. 개방적봉합술과보존적치료의중간단계의치료방법으로서 1977년 Ma와 Griffith 15) 가경피적봉합술을보고한이후많은개방적봉합술과의비교연구가진행되어왔고, 이를개선한여러 MIS에대한연구도진행중이다. 일부저자들은경피적봉합술이피부합병증을줄이면서개방적봉합술과유사하게우수한임상적, 기능적결과를보였다고하였고, 5,14,16) Hsu 등 17) 은합병증에있어서 percutaneous Achilles repair system (PARS) 과개방적봉합술간차이가없다고하였으며, Yang 등 2) 은수술시간, 감염, AOFAS 점수에서개방적봉합술보다낫다고하였다. 반면, 비복신경은다양한해부학적경로를가지므로경피적봉합술은항상비복신경의손상가능성에노출되어있고, 18) 여러연구에서경피적봉합 Table 2. Clinical Results of the Two Groups* Variable Group A (n=12) Group B (n=18) p-value Arner-Lindholm scale Excellent 4 (33.3) 6 (33.3) Good 8 (66.7) 11 (61.1) Poor 0 1 (5.6) AOFAS score 92.3 (85 100) 91.6 (61 100) ATRS 88.9 (77 97) 87.6 (57 97) Overall patient s satisfaction 9.1 (7 10) 8.2 (2 10) Cosmetic satisfaction of scar 9.9 (9 10) 6.7 (2 10) Single heel raising after repair (mo) 3.75 (3 6) 3.65 (3 6) Complications Elongations: 2 Re-rupture with deep infection: 1 Superficial infection: 1 Values are presented as number (%) or mean (range). *Significant differences in overall patient s satisfaction and cosmetic satisfaction of scar were observed between group A and B. Group A, patients with ultrasound-guided percutaneous repair; Group B, patients with open repair; AOFAS, American Orthopedic Foot and Ankle Society ankle-hindfoot score; ATRS, Achilles tendon total rupture score.

6 527 Comparative Study with Two Repair Methods of Ruptured Achilles Tendon 술시행시약 15% 의확률로비복신경이손상되었음을보고하였다. 8,19) 그리고 Soubeyrand 등 20) 에의하면경피적봉합술에서봉합사의바늘을 blind하게삽입할경우약 55% 에서아킬레스건실질내에정확하게위치하지못했다고하였고이는봉합강도를약화시키는요인으로작용할수있다. 이러한경피적봉합술들의단점들을보완하기위해저자들은초음파유도하경피적봉합술을시행하게되었고, 비복신경의위치를실시간으로확인하면서손상을 100% 피할수있었다. 그리고바늘이건의실질내로들어가는것을확인하면서진행하였기에봉합사가피하로통과하거나건의표층만통과할가능성을최소화했으며, 더강한봉합을이루도록하였다. 본연구는첫째, 기존의초음파유도하경피적봉합술 20-23) 과달리저자들의방식으로초음파유도하경피적봉합술 (A군) 을시행하여개방적봉합술 (B군) 과비교한연구라는점에서의의가있다. 둘째, 본연구에서는 2회의 2 strand의 modified Kessler 봉합술만으로재파열없이좋은임상적결과를보여특별한기구 (PARS, Achilles midsubstance speedbridge, Achillon, etc.) 및자체적개발기구 5) 나고난도의봉합술기없이도쉽고간편하게시행할수있는방법이다. McCoy와 Haddad 24) 는카데바연구에서 4 strand로아킬레스건을봉합했을때, Krackow, Bunnell, 그리고 Kessler 봉합술간의강도에유의한차이가없다고하였다. 셋째, 아킬레스건을노출시키지않아건의혈액순환을방해하지않고, 흡수성봉합사를사용하여봉합사의자극반응을낮춤으로써보다생체적합한 (biocompatible) 봉합이되도록하였다. 비흡수성봉합사는충분한기간동안인장강도가유지되지만만성적인피부자극을줄수있는반면, 9,25) 흡수성봉합사는충분한기간의인장강도유지가어렵지만, 매듭유지가잘되고자극이덜하며파열된인대의회복에도움을줄수있다는장점이있다. 9,26) 흡수성봉합사인 Vicryl (polygalactin) 은인장강도가 2주후 75%, 3주후 50%, 4주후 25% 로감소하고보통 56-70일이지나면완전히흡수되는특성이있으나, 9,25,27) 염증기 (inflammatory phase, 0-72시간 ), 증식기 (proliferation phase, 2일-6주 ) 를거쳐재형성기 (remodeling phase, 4주-12개월 ) 에이르는건자체의자연치유과정이진행되므로초기고정및단계적재활이뒷받침된다면초기의충분한봉합강도를제공하리라생각됐다. 실제로 Kocaoglu 등 28) 과 Baig 등 29) 이흡수성봉합사를이용한아킬레스건봉합술에대해보고한바에따르면, 비흡수성봉합사보다더적은자극반응, 감염등의합병증이나타났고우수한임상적결과를보였다. 저자들의이전연구 9) 및본연구에서도심부감염으로재파열된 1예를제외하고, 4주간의비체중부하단하지석고고정을비롯한수술후치료프로그램을통하여재파열없이치료할수있었다. 본연구의제한점은후향적연구로환자수가적어서표본크기및두군별정규성을만족하지못하였다는점이다. 그리고건의재형성기가 4주에서 12개월까지진행된다는점을고려할때, 최 종추시기간이짧다. 또한두군간다른봉합술을이용하였기에봉합방법이예후에영향을미칠수있는부분을고려하지않았다. 그리고두방법의수술을시행함에있어확실한적응증을설정하지않았다는점에서도제한점을가진다. 보다많은환자들을대상으로보다긴추시기간의전향적연구가필요하리라생각된다. 그리고 Clanton 등 30) 의카데바연구에따르면, MIS와개방적봉합술의최종강도는유사하나초기봉합부위신연에있어 MIS 에서더취약하다고하였고, 본연구에서도이를고려하여건측보다 10 더족저굴곡상태로단축시켜봉합하였으나 2예의수술후실족으로인한초기봉합부위신연이있었던바, 경피적봉합술및 MIS 후초기고정기간에대한추가적인연구및환자에대한교육이필요하리라생각된다. 결론 초음파유도하경피적봉합술 (A군) 은개방적봉합술 (B군) 과비교할때비슷한임상적결과를제공할뿐아니라더높은주관적, 미용적만족도와함께기존경피적봉합술의합병증인비복신경손상등을최소화할수있는결과를보였다. 아킬레스건파열의치료에있어최적의치료법에대한결론이나와있지않은바, 초음파유도하경피적봉합술은유용하게고려될수있을것으로생각된다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Khan RJ, Fick D, Keogh A, Crawford J, Brammar T, Parker M. Treatment of acute achilles tendon ruptures. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2005; 87: Yang B, Liu Y, Kan S, et al. Outcomes and complications of percutaneous versus open repair of acute Achilles tendon rupture: a meta-analysis. Int J Surg. 2017;40: Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am. 2012;94: Jacobs D, Martens M, Van Audekercke R, Mulier JC, Mulier F. Comparison of conservative and operative treatment of Achilles tendon rupture. Am J Sports Med. 1978;6: Kim JH, Gwak HC, Lee CR, Kim JG, Jeong JW. A comparative study of surgical treatment result in the ruptured Achilles

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8 529 pissn : , eissn : Original Article J Korean Orthop Assoc 2018; 53: 초음파유도하경피적아킬레스건봉합술 : 개방적봉합술과의비교연구 강동훈 강찬 황득수 송재황 최보성 충남대학교의과대학정형외과학교실 목적 : 본연구에서는아킬레스건파열시초음파유도하경피적아킬레스건봉합술과개방적봉합술의임상적결과에대하여비교, 분석하고자하였다. 대상및방법 : 2015년 1월부터 2017년 2월까지아킬레스건파열로초음파유도하경피적봉합술을시행받은 12예 (A군) 와개방적봉합술을시행받은 18예 (B군) 를대상으로하였다. Arner-Lindholm scale, American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Achilles tendon total rupture score (ATRS), 수술후만족도 ( 전반적 / 미용적 ) 에대한 visual analogue scale (VAS), 한쪽발꿈치들기가능시기로임상적평가를하였고, 그외합병증에대해평가하였다. 결과 : 각군별평균 Arner-Lindholm scale, AOFAS ankle-hindfoot score (A군: 92.3점 /B군: 91.6점 ), ATRS (A군: 88.9점 /B군: 87.6점 ), 한쪽발꿈치들기가능시기 (A군: 3.75개월 /B군: 3.65개월 ) 는통계적으로유의한차이가없었으나 (p=0.884, p=0.755, p=0.983, p=0.645) 수술후결과에대한전반적, 미용적만족도는 B군 (8.2/6.7) 에비해 A군 (9.1/9.9) 에서유의하게높았다 (p=0.035, p=0.001). A군에서 2예의봉합부위신연 (elongation) 을보였고, B군에서 1예의심부감염으로인한재파열과 1예의천부감염을보였다. 결론 : 초음파유도하경피적봉합술은개방적봉합술과비교할때비슷한임상적결과를제공할뿐아니라더높은주관적, 미용적만족도와함께비복신경손상등의합병증을최소화할수있는결과를보여아킬레스건파열의치료에있어유용하게고려될수있을것으로생각된다. 색인단어 : 아킬레스건, 초음파, 경피적봉합술, 비복신경, 흡수성봉합사 접수일 2017 년 10 월 9 일수정일 2017 년 11 월 2 일게재확정일 2017 년 12 월 6 일책임저자강찬 35015, 대전시중구문화로 266, 충남대학교의과대학정형외과학교실 TEL , FAX , faschan@hanmail.net, ORCID 대한정형외과학회지 : 제 53 권제 6 호 2018 Copyright 2018 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical