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1 대한안과학회지 2016 년제 57 권제 4 호 J Korean Ophthalmol Soc 2016;57(4): ISSN (Print) ISSN (Online) Original Article 골전도성삽입물을이용한안와골절정복술 Orbital Wall Reconstruction with Osteoconductive Unsintered Hydroxyapatite/Poly L-Lactide 위재민 김유정 지미정 Jae Min Wi, MD, Yu Jeong Kim, MD, Mi Jung Chi, MD, PhD 가천대학교길병원안과학교실 Department of Ophthalmology, Gachon University Gil Medical Center, Incheon, Korea Purpose: To evaluate the effect of orbital wall reconstruction with absorbable osteoconductive unsintered hydroxyapatite/poly L-lactide by assessment of the orbital volume via orbital computed tomography. Methods: 24 patients who followed up at least 6 months after orbital wall reconstruction with unsintered hydroxyapatite/poly L-lactide were included. Retrospective clinical chart reviews for clinical manifestations and complications were performed, and orbital volume measurements were taken using the Eclipse Treatment Planning System (ver.13.0, Varian Medical System Inc., Palo Alto, CA, USA) through orbital computed tomography, which were taken before operation, right after operation, and at last follow up. Results: Fourteen patients (58.3%) showed diplopia and extraocular muscle movement limitation preoperatively. Diplopia was resolved at last follow up and extraocular muscle movement limitation was improved at postoperative 6 months for all cases. The mean volumes of the fractured orbit and the unaffected orbit before operation were ± 0.45 cm 3 and ± 1.01 cm 3, respectively (p = 0.003). The mean volumes of the fractured orbit and the unaffected orbit right after operation were ± 0.91 cm 3 and ± 0.83 cm 3, respectively (p = 0.542). The mean volumes of the fractured orbit and the unaffected orbit at last follow up were ± 0.93 cm 3 and ± 0.91 cm 3, respectively (p = 0.889). Conclusions: Absorbable osteoconductive unsintered hydroxyapatite/poly L-lactide was effective for clinical improvement and orbital volume assessment in cases of orbital wall reconstruction and it can be used safely without definite implant related complications. J Korean Ophthalmol Soc 2016;57(4): Keywords: Absorbable implant, Blowout fracture, Orbital wall reconstruction, Osteoconductive implant, Unsintered hydroxyapatite/poly L-lactide Received: Revised: Accepted: Address reprint requests to Mi Jung Chi, MD, PhD Department of Ophthalmology, Gachon University Gil Medical Center, #21 Namdong-daero 774beon-gil, Namdong-gu, Incheon 21565, Korea Tel: , Fax: cmj@gilhospital.com * This study was presented as a narration at the 114th Annual Meeting of the Korean Ophthalmological Society 안와의하벽과내벽은외상에취약하여외상에의해쉽게골절되며안와내용물의이탈로인한안구함몰, 외안근을포함한안와조직의이탈과감돈등으로인한안구운동장애와복시등을일으키는경우수술적교정이필요하다. 1 안와골절정복술의목적은탈출된연부조직을복원하고안와삽입물을삽입하여수상전의안와의해부학적윤곽과용적및기능을회복하는것이다. 인공안와삽입물은흡수되는지에따라흡수성및비흡수성삽입물로나뉘는데, 흡수성삽입물은감염의위험성 c2016 The Korean Ophthalmological Society 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. 533

2 - 대한안과학회지 2016 년제 57 권제 4 호 - 이적은반면안와지지력이약하며, 비흡수성삽입물은안와지지력이강한반면흡수가안되므로후기감염, 이탈, 출혈등의위험성이있다. 2-5 비흡수성삽입물의단점을보완하기위해개발된다공성삽입물의경우삽입물의감염, 이탈등의합병증이적다고하나체내에잔존하므로여전히가능성은남아있다. 최근흡수성, 비흡수성, 다공성삽입물의장점을결합한골전도성안와삽입물에대한보고가이루어지고있다. Unsintered hydroxyapatite/poly L-lactide (OSTEOTRANS TM -MX Sheet, Takiron Co., Osaka, Japan) 는흡수성안와삽입물로분류되며흡수성합성고분자인 Poly L-lactide에인체의골성분과유사한 unsintered hydroxyapatite를혼합한제품으로적절한강도를유지하다일정기간이지나면몸안에서 poly L-lactide가녹으면서 unsintered hydroxyapatite가뼈로전환되는골전도성물질이다. 6-8 그동안안면골골절의재건시골전도성삽입물의보고는있었으나안와골절수술에서의연구는보고된바없다. 이에저자들은골전도성안와삽입물인 unsintered hydroxyapatite/poly L-lactide가안와골절정복술에있어얼마나효과적인지임상증상의호전과안와용적의변화를객관적으로측정하여알아보고자하였다. 대상과방법 저자들은 2014년 1월부터 2015년 3월까지본원에내원하여편측성안와골절로진단받고안와골절정복술에골전도성안와삽입물인 unsintered hydroxyapatite/poly L-lactide를사용한환자들중적어도 6개월이상경과관찰이가능하였던환자 24명을대상으로하였으며평균관찰기간은 ± 3.44개월이었다. 술전에일반적인안과적기본검사외복시검사, 외안근운동검사, 강제견인검사, Hertel 안구돌출계검사를시행하였으며안와전산화단층촬영을실시하여안와골절의위치와범위, 근육이나안와연부조직의감돈을확인하였다. 수술은전신마취하에서한명의술자에의해시행되었으며모두결막경유접근법을이용하였다. 수술중근육의위치를확인할수있도록하벽골절인경우하직근에, 내벽골절인경우내직근에 4-0 흑견사로견인봉합사를걸어두었다. 안와하벽골절인경우에는하안검검판의하방경계부위나약간아래에서결막절개를시행한후, 골막거상기로안윤근과안와격막사이를박리하여안와하연의골막을노출시킨뒤 #15 Bard-Parker knife로골막을절개하고골막거상기로골막하박리를시행하여골절부위를노출시키고부비동으로감돈된근육및안와연조직을골막거상 기, malleable 견인기, 흡인기등을적절히사용하여원래위치로복원하였다. Unsintered hydroxyapatite/poly L-lactide 를결손부위의크기와위치에맞도록적절히잘라서항생제를혼합한식염수에적신후골절부위에삽입하였고, 고정이잘되고위치이탈이되지않음을확인하였다. 5-0 바이크릴사로골막봉합을한후 6-0 바이크릴사로결막을연속봉합하였다. 안와내벽골절의경우에는눈물언덕을경유하여내벽에접근하였다. 수술도중자주동공크기를조사하여시신경의압박여부를확인하였고수술중 methylprednisolone 250 mg을정맥투여하였다. 술후안대는사용하지않은채 48시간동안얼음찜질을하였으며수술당일 2시간마다시력과동공대광반사를확인하였다. 수술후 3 일째퇴원후첫한달간은 1주간격으로, 그리고그후에는 1개월간격으로모든환자에서 6개월이상의경과관찰을하였다. 수술후 1개월과 3개월, 6개월의소견으로증상의호전정도를등급화 (Grade) 하여평가하였는데복시의유무에따라중심시야 20 이내에복시가있으면 Grade III, 중심시야 20 이내에는없지만 사이에복시가있는경우 Grade II, 40 를넘어서주변부에서만복시가있는경우 Grade I, 복시가없는경우를 없음 (absence) 으로표시하였다. 안구운동장애는환자로하여금제일안위에서정면에위치한광원을주시하게한다음검사하고자하는외안근의최대힘이가해지는방향으로보게하여판정하였다. 전혀움직일수없어각막반사점의위치변화가없는경우를 -4 운동제한 (limitation), 각막반사점이동공연에있는경우 -3 운동제한, 동공연과각막가장자리 (limbus) 사이인경우 -2 운동제한, 각막가장자리에있으면 -1 운동제한, 각막가장자리너머까지움직여정상안과차이가없는경우 0 운동제한으로정의하여표시하였다. 9 수술전및수술직후, 수술후최종경과관찰시안와전산화단층촬영을시행하여수술전에는안와골절의위치와범위및외안근이나연부조직의감돈여부를확인하였으며, 수술직후에는안와삽입물의위치및안와골절의정복과연부조직및외안근의위치를확인하였고최종경과관찰시에는안와삽입물에의한안와벽재건의유지정도를확인하였다. 안와전산화단층촬영영상으로 The Eclipse Treatment Planning System (ver.13.0, Varian Medical System Inc., Palo Alto, CA, USA) 프로그램을사용하여수술전후의골절안및정상안의안와용적을측정하였다 (Fig. 1). The Eclipse Treatment Planning System 프로그램은각각의횡단면의안와전산화단층촬영영상에서안와용적을그린 534

- 위재민외 : 골전도성안와삽입물의수술효과 - A B Figure 1. Example of an orbital volume measurement using the Eclipse Treatment Planning System. (A) Preoperative, (B) postoperative.

3 - 위재민외 : 골전도성안와삽입물의수술효과 - A B Figure 1. Example of an orbital volume measurement using the Eclipse Treatment Planning System. (A) Preoperative, (B) postoperative. Axial plane: the anterior orbital boundary was defined by a straight line connecting the medial and the lateral orbital rims, with the posterior limit being the orbital apex. Coronal plane: the anterior orbital boundary was defined as the CT slice in which 50% of the inferior orbital rim was visible, with the posterior limit being the orbital apex. Sagittal plane: the anterior orbital boundary was defined by a straight line connecting the superior and inferior orbital rims, with the posterior limit being the orbital apex. The areas of these outlines were measured on each scan and summed for orbital volume. A red arrow indicates the left inferior wall fracture and herniated orbital tissue before operation. A green arrow indicates the reconstructed left inferior wall fracture. The figure shows a reduction in the displaced orbital wall and herniated orbital tissue compared with the preoperative status. CT = computed tomography. 후각각의안와단면에서얻은안와용적을 3차원영상으로재구성하여전체안와용적이구해지는프로그램으로편리하게사용할수있고, 재현성이높으며, 측정자간의오차및측정자내의오차가비교적적다고알려져있다. 10 안와용적측정시의경계는앞쪽은안와연내측과외측을일직선으로연결한직선으로정의하였고뒤쪽은안와첨부로정의하였다. 경계를그리는과정및측정시마다의오차를줄이기위해한명의측정자가 3회측정을시행한후구한평균값을사용하였다. 또한수술후골절안의안와용적이정상안의안와용적에얼마나유사해졌는지에착안하여다음과같이안와벽재건율을정의하였다. 안와벽재건율 =(1 ) 100 (%) A: 수술후골절안안와용적, B: 정상안안와용적예시 : 수술후골절안용적이정상안과같다 (A=B) 면안와벽재건율 100% 수술후골절안용적이정상안보다 10% 크다 (A=1.1B) 면안와벽재건율 90% 본연구에서통계분석은 SPSS ver. 18 (SPSS Inc., Chicago, IL, USA) 을사용하였으며, Mann-Whitney test 및 Wilcoxon signed rank test 방법을이용하여축상영상사진에서측정한안와용적을비교분석하였다. 결과 총 24명의환자가포함되었으며, 남녀의비율은남자가 17명 (70.8%), 여자가 7명 (29.2%) 이었고, 나이는 20세이하 3명 (12.5%), 21세에서 30세사이 5명 (20.8%), 31세에서 40 세사이 9명 (37.5%), 41세에서 50세사이 5명 (20.8%), 51세이상 2명 (8.3%) 이었으며, 평균나이는 35.3세였다. 수상후부터수술시까지의평균기간은 6.08일 (1-14일) 이었다. 수술전 14명 (58.3%) 의환자에서복시와안구운동장애가있었다. 수술전복시를호소한 14명중 Grade I이 2명, Grade II가 5명, Grade III가 7명이었고, 수술후 6개월째 5 명에서 Grade I의복시만남았고최종경과관찰시모두소실되었다. 안구운동장애는 -1 운동제한이 7명, -2 운동제한이 6명, -3 운동제한이 1명에서보였으며수술후 6개월째경과관찰시모두호전되었다 (Table 1). 안면감각검사는하안와연주변피부에대한감각을기준으로측정하였으며, 안면감각이상을호소하는환자들은수술전 4명 (16.7%) 이었으나, 수술후 6개월째경과관찰시모두호전을보였다. 수술전안구함몰의평균은 0.5 ± 0.7 mm, 이중안구함몰이심하거나안구함몰진행이예상되어수술의적응증이되었던환자 7명의술전안구함몰평균은 2.3 ± 0.6 mm였으며, 수술후최종경과관찰 535

4 - 대한안과학회지 2016 년제 57 권제 4 호 - Table 1. Preoperative and postoperative EOM limitation and diplopia of patients Preoperative Postoperative 6 months Final follow up EOM limitation Diplopia * EOM limitation Diplopia EOM limitation Diplopia 1-2 Gr III 0 Gr I 0 Absence 2-1 Gr II 0 Absence 0 Absence 3-1 Gr II 0 Absence 0 Absence 4-1 Gr II 0 Absence 0 Absence 5-1 Gr II 0 Absence 0 Absence 6-2 Gr III 0 Absence 0 Absence 7-2 Gr III 0 Gr I 0 Absence 8-1 Gr II 0 Absence 0 Absence 9-2 Gr III 0 Gr I 0 Absence 10-2 Gr III 0 Absence 0 Absence 11-1 Gr I 0 Absence 0 Absence 12-1 Gr I 0 Absence 0 Absence 13-2 Gr III 0 Gr I 0 Absence 14-3 Gr III 0 Gr I 0 Absence 0 limitation: no limitation with light reflection position beyond limbus. -1 limitation: limitation with corneal reflection on limbus. -2 limitation: limitation with corneal reflection between pupil margin and limbus. -3 limitation: limitation with corneal reflection in contrary pupil margin. -4 limitation: limitation with inability of the eye to move. EOM = extraocular muscle movement. * Gr I is diplopia exceed the range 40 degrees of central visual field and Gr II is diplopia within the range 20 to 40 degrees of central visual field, and Gr III is diplopia within the range 0 to 20 degrees of central visual field. 시안구함몰의전체평균은 0.1 ± 0.4 mm, 안구함몰이수술의주적응증이되었던환자군에대해서는 0.3 ± 0.2 mm 로수술후최종경과관찰시모두호전되었음을확인할수있었다. 안와전산화단층촬영영상으로수술전후의골절안및정상안의안와용적을측정한결과, 수술전골절안의평균안와용적은 ± 0.45 cm³, 정상안의평균안와용적은 ± 1.01 cm³ 로골절안의안와용적이정상안에비해유의하게컸다 (p=0.003). 수술직후골절안의평균안와용적은 ± 0.91 cm³, 정상안의평균안와용적은 ± 0.83 cm³ 였으며 (p=0.542), 수술후 6개월이상최종경과관찰시골절안의평균안와용적은 ± 0.93 cm³, 정상안의평균안와용적은 ± 0.91 cm³ 로수술직후와최종경과관찰시골절안과정상안의안와용적에는유의한차이가보이지않았다 (p=0.889). 수술전에골절로인해커진안와용적이수술직후감소하여양쪽안와용적의유의한차이가없어졌음을확인할수있었으며, 안와벽재건율은수술직후 ± 1.21%, 최종경과관찰시 ± 2.38% 로확인되었고, 수술직후와최종경과관찰시통계적으로유의한차이를보이지않았다 (p=0.481) (Fig. 2). 또한수술후시력감소나삽입물의감염및이탈, 노출등의심각한합병증의발생은관찰되지않았다. 고찰 안와골절정복술은골절틈새로유출된조직을들어올리고안와삽입물을삽입하여안와의기능적, 해부학적결손을방지하는데그목적이있다. 이상적인안와삽입물은생체적합성을갖는소재로화학적, 생물학적으로불활성이며, 체내에서지지체역할을수행할수있어야하고, 탈출, 노출, 이동, 염증, 감염등이최소화되어야한다. 11 이러한안와삽입물은크게뼈, 연골과같은자가조직과인공삽입물로나뉘며자가조직은최근거의사용되지않는다. 인공삽입물은크게흡수성및비흡수성소재로나뉠수있다. 흡수성물질중수년전부터널리사용되고있는 polylactic acid (PLA) 중합체의경우, 감염의문제가상대적으로적지만장기적인지지력등구조적인안정성에제한이있고, 비흡수성삽입물의경우, 구조적인안정성이뛰어난대신섬유혈관조직의증식이안되므로삽입물의감염, 이탈, 출혈이발생할위험이많다. 비흡수성삽입물중다공성삽입물로는 hydroxyapatite, porous polyethylene 등이있는데구조적특성상수많은미세구멍이있어섬유혈관조직이자라들어갈수있어이론적으로이탈, 노출, 감염의합병증이적지만체내에잔류하기때문에여전히감염의위험이있으며외안근이나안와내섬유지방조직이삽입물과유착을일으켜안구운동제한을일으킬수있다는점, 그리고주위조직과의단단한결합으로재수술이어렵다는단점이있다. 2-5 다공성안와삽 536

$- 위재민외 : 골전도성안와삽입물의수술효과 - A B C D Figure 2. Serial orbital computed tomography. (A) Preoperative orbital CT shows a right floor fracture with herniated tissue into the maxillary sinus.$

5 - 위재민외 : 골전도성안와삽입물의수술효과 - A B C D Figure 2. Serial orbital computed tomography. (A) Preoperative orbital CT shows a right floor fracture with herniated tissue into the maxillary sinus. Postoperative serial orbital CTs show a radiopaque orbital implant right after operation (B), postoperative 6 months (C), and postoperative 12 months (D). (D) Postoperative 12 month CT shows the implant is thickened and pores are filled with adjacent bone density material. This patient s orbital wall reconstruction rate was 101.4% right after operation (B) and 100.5% at postoperative 12 months (D). CT = computed tomography. 입물중 synthetic hydroxyapatitie는염기성인산칼슘으로암석, 골격, 치아에서발견되며뼈와주성분이같은세라믹으로인공뼈대체제로널리이용되나깨지기쉽고하중을받는부위에서충분한강도를유지하지못한다는단점이있다. 본원에서는흡수성삽입물로분류되는골전도성안와삽입물인 unsintered hydroxyapatite particles/poly L-lactide가안와골절의재건에있어얼마나효과적인지임상증상의호전과안와용적의변화를통해알아보았다. 본연구에서사용한 unsintered hydroxyapatite/poly L-lactide는생체활성을갖는바이오세라믹스미립자인 unsintered hydroxyapatite 와합성고분자인 poly L-lactide를특수한방법으로복합한안와삽입물이다. 4,5,7 그제조과정을살펴보면, 우선탄산칼슘 (CaCO 3) 과무수인산수소칼슘 (CaHPO 4) 이가수분해되면서 unsintered hydroxyapatite가생성된다. 12 일반적으로분체를녹는점이하또는부분적용융정도로가열하여단 단한결합체로만드는소결방식을쓰는데비해 hydroxyapatite의생성과정에는미소결방식 (unsintering) 을채택한다. 그이유는소결방식을이용하여만든합금은절삭성이떨어져금속표면이매끄럽지못하고이는인체내에삽입되었을때주변조직을마모시키거나손상을줄수있기때문이다. 13 이렇게생성된 unsintered hydroxyapatite는평균직경이 μm에달하며이후이차물질 ( 평균직경 5-20 μm) 로뭉쳐지고다시분쇄과정을거쳐평균직경 3-5 μm 입자가된다. 6,12 Unsintered hydroxyapatite를이크기 ( 직경 3-5 μm) 로만드는이유는이크기의입자가탐식작용을통해 poly L-lactide에합성되기에적절하기때문이다. 6,12 Unsintered hydroxyapatite/poly L-lactide의가장큰특징은안와삽입물삽입후골절된부위가안정적으로고정될때까지적절한강도를유지하다일정기간이지나면몸안에서 poly L-lactide가녹으면서 unsintered hydroxyapatite가정상적인인체골로전환되는골전도성 (osteoconduction) 기 537

6 - 대한안과학회지 2016 년제 57 권제 4 호 - 능이다. 6-8 또한 X-ray 가시화가가능하여전산화단층촬영을통한예후추적이가능하다. 14 본연구에서수술후 6개월이상경과관찰하는과정중에모든환자에서복시, 안구운동장애, 안구함몰, 하안와연감각감퇴등안와골절과관련된임상징후와증상에있어서호전을보였다. 복시를보인 14명의환자중수술후 1 개월째 7명, 수술 3개월째에는 8명, 수술 6개월째 9명, 최종경과관찰시에는 14명모두에서복시의소실을보였고안구운동장애소견은수술후 6개월째경과관찰시모든환자에서호전을보였다. 술전안구함몰이심하거나안구함몰진행이예상되어수술의적응증이되었던환자 7명의술전안구함몰평균은 2.3 ± 0.6 mm, 이들의술후안구함몰평균은 0.3 ± 0.2 mm로수술후최종경과관찰시호전되었음을확인할수있었다. 안면감각이상을호소하는환자들은수술전 4명 (16.7%) 이었으나, 수술후 6개월째경과관찰시모두호전을보였다. 이와같이 unsintered hydroxyapatite/poly L-lactide를이용한안와벽재건술시빠른증상의회복이가능하다는점을알수있었다. 안와전산화단층촬영을이용하여수술전, 수술직후, 수술후최종경과관찰시안와용적을측정한결과, 수술전에비해수술직후골절안의안와용적이유의하게감소하여 (p=0.004) 수술직후및최종경과관찰시골절안과정상안의안와용적사이에유의한차이가없음을확인할수있었다 (p=0.841, 0.668). 안와벽재건율은수술직후 ± 1.21%, 최종경과관찰시 ± 2.38% 로확인되었으며, 수술직후와최종경과관찰시통계적으로유의한차이를보이지않았다 (p=0.481). 기존의연구들에서다른안와삽입물에대한재건효과분석시술전과술후두차례만안와용적을측정하여시간경과에따른안와벽재건율의추이를살펴보지못하였지만본연구를통해 unsintered hydroxyapatite/poly L-lactide를이용한안와벽재건술시행시안와벽재건율이수술직후 ± 1.21% 로재건효과가우수하였으며시간경과에따라재건효과가약간감소하기는하나수술직후와비교하여유의한차이가없어 (p=0.481) 재건효과유지면에서도우수한안와삽입물임을확인할수있었다. 또한최종경과관찰시까지 unsintered hydroxyapatite/ poly L-lactide의감염및이탈, 노출등의삽입물과관련한심각한합병증은발생하지않았다. 이와같이골절로인한임상징후및증상의호전이외에안와용적측정을통한정량적인분석을통해서도 unsintered hydroxyapatite/poly L-lactide가안구및안와내용물에대해지지력이뛰어나면서도감염, 탈출등의합병증이없어안전하게사용할수있는삽입물임을확인할수있었다. 안와골절에국한된것은아니나골절수술에있어서 unsintered hydroxyapatite/poly L-lactide의효과에대해살펴본연구중에서 Hayashi et al 15 은안면부골절환자 17명을대상으로전두골및상악골골절에 unsintered hydroxyapatite/ poly L-lactide를이용하여재건술을시행한결과를발표하였다. 그연구에따르면술후평균 21.8개월추적관찰한결과전두골의골과형성 1예, 전두관골봉합에서의이물반응 1예를제외하고특별한합병증은발견되지않았으며, 60개월로장기간경과관찰한사례에서도골절부위의복원이잘유지되는등전반적으로우수한술후결과를보고하였다. 본연구의한계점은평균관찰기간이 ± 3.44개월로, 안와삽입물에관한여타연구에서의평균관찰기간과비교하였을때짧지않으나 Shikinami et al 6 의연구결과를토대로하였을때, 추가적인경과관찰이필요하다는점이다. Shikinami et al 6 은토끼를이용한동물실험에서토끼의대퇴골골수강내에 unsintered hydroxyapatite particles/poly L-lactide composite를주입한후변화과정을살펴본결과, 2.5년이지난후 poly L-lactide의분자량이급속히감소하기시작하고합성물내에서 unsintered hydroxyapatite의비율이증가하기시작하며, 5년이지난후에는합성물내에서 poly L-lactide가완전히자취를감추고, 5.5년이지난후에는거의대부분의 unsintered hydroxyapatite가정상적인인체골조직으로전환되었다고발표하였다. 이렇듯 unsintered hydroxyapatite particles/poly L-lactide의경우 5-6년에걸쳐 poly L-lactide가천천히흡수되면서 unsintered hydroxyapatite가정상적인인체골로전환되는특성이있는것으로알려져있어, 추후삽입물의흡수가이루어지고인체골로대체된이후에도장기적인안와용적유지여부및감염, 이탈등삽입물과관련된합병증발생유무에대한추가적인경과관찰이필요할것으로사료된다. 결론적으로흡수성골전도성삽입물인 unsintered hydroxyapatite/poly L-lactide는향후흡수및골전도가완료되는시점까지추가적인경과관찰이필요하기는하나생체분해성및생체적합성을갖는소재로충분한안와벽지지효과가있으며, X-ray 가시화로전산화단층촬영을통한예후추적이가능하여안와골절의재건술시에뚜렷한합병증없이안전하게사용할수있는안와삽입물이라판단된다. REFERENCES 1) Jeon SY, Kim C, Ma Y, Hwang E. Microsurgical intranasal reconstruction of isolated blowout fractures of the medial orbital wall. Laryngoscope 1996;106: ) Choi JC, Fleming JC, Aitken PA, Shore JW. Porous polyethylene channel implants: a modified porous polyethylene sheet implant designed for repairs of large and complex orbital wall fractures. 538

7 - 위재민외 : 골전도성안와삽입물의수술효과 - Ophthal Plast Reconstr Surg 1999;15: ) Block MS, Kent JN. Correction of vertical orbital dystopia with a hydroxyapatite orbital floor graft. J Oral Maxillofac Surg 1988; 46: ) Jordan DR, St Onge P, Anderson RL, et al. Complications associated with alloplastic implants used in orbital fracture repair. Ophthalmology 1992;99: ) Scales JT. Discussion on metals and synthetic materials in relation to soft tissues; Tissue reaction to synthetic materials. Proc R Soc Med 1953;46:647. 6) Shikinami Y, Matsusue Y, Nakamura T. The complete process of bioresorption and bone replacement using devices made of forged composites of raw hydroxyapatite particles/poly l-lactide (F-u-HA/ PLLA). Biomaterials 2005;26: ) Shikinami Y, Okuno M. Bioresorbable devices made of forged composites of hydroxyapatite (HA) particles and poly-l-lactide (PLLA): Part I. Basic characteristics. Biomaterials 1999;20: ) Shikinami Y, Okuno M. Bioresorbable devices made of forged composites of hydroxyapatite (HA) particles and poly L-lactide (PLLA). Part II: practical properties of miniscrews and miniplates. Biomaterials 2001;22: ) Oum BS. Eye Exam, 3rd ed. Goyang: Naewaehaksool, 2013; ) Mesbahi A, Thwaites DI, Reilly AJ. Experimental and Monte Carlo evaluation of eclipse treatment planning system for lung dose calculations. Rep Pract Oncol Radiother 2006;11: ) Ye J, Kook KH, Lee SY. Evaluation of computer-based volume measurement and porous polyethylene channel implants in reconstruction of large orbital wall fractures. Invest Ophthalmol Vis Sci 2006;47: ) Matsuda N, Kaji F. Form control of crystals and aggregation of hydroxyapatites. In: Kokubo T, Nakamura T, Miyaji F, eds. Bioceramics. Oxford: Pergamon Press, 1996; v. 9. chap ) Ducheyne P, Qiu Q. Bioactive ceramic: the effect of surface reactivity on bone formation and bone cell function. Biomaterials 1999;20: ) Matsusue Y, Niibayashi H, Aoki Y. Bone fusion using HA/PLLA composite, a material characterized by its excellent resorbability in the living body. J Orthop Surg (Hong Kong) 1999;50: ) Hayashi M, Muramatsu H, Sato M, et al. Surgical treatment of facial fracture by using unsintered hydroxyapatite particles/poly l-lactide composite device (OSTEOTRANS MX(R)): a clinical study on 17 cases. J Craniomaxillofac Surg 2013;41: = 국문초록 = 골전도성삽입물을이용한안와골절정복술 목적 : 흡수성골전도성안와삽입물인 unsintered hydroxyapatite/poly L-lactide 를이용한안와골절정복술의효과를안와전산화단층촬영을통한안와용적분석을이용해알아보고자하였다. 대상과방법 : Unsintered hydroxyapatite/poly L-lactide 를이용한안와골절정복술후 6 개월이상추적관찰된 24 명의환자를대상으로후향적의무기록분석을통해임상소견, 합병증을확인하였고, 수술전, 수술직후, 최종경과관찰시안와전산화단층촬영영상을 The Eclipse Treatment Planning System (ver.13.0, Varian Medical System Inc., Palo Alto, CA, USA) 을이용하여안와용적을측정하였다. 결과 : 수술전 14 명 (58.3%) 의환자에서복시및외안근운동장애가있었으나복시는모든환자에서최종경과관찰시, 안구운동장애는수술후 6 개월째모두개선되었다. 수술전골절안의평균안와용적은 ± 0.45 cm 3, 정상안은 ± 1.01 cm 3 였고 (p=0.003), 수술직후골절안의평균안와용적은 ± 0.91 cm 3, 정상안은 ± 0.83 cm 3 였으며 (p=0.542), 최종경과관찰시골절안의평균안와용적은 ± 0.93 cm 3, 정상안은 ± 0.91 cm 3 였다 (p=0.889). 결론 : 안와골절정복술시흡수성골전도성기능을가진 unsintered hydroxyapatite/poly L-lactide 는안와재건효과가우수함을임상소견의호전및안와용적분석을통해확인할수있었으며, 뚜렷한합병증없이사용할수있는삽입물이다. < 대한안과학회지 2016;57(4): > 539

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01[1].È²ÁßÇõ( ).hwp 안와골절복원술후의복시와안구함몰 : 안와골절시발생하는복시와안구함몰은수술후에도호전되지않는경우가많아기능및미용상문제를유발하기도한다. 저자들은안와골절환자에서안와골절복원술후복시와안구함몰의발생과관련된여러인자를분석하고, 이러한인자와관련된수술결과를알아보았다. : 1995년 3월부터 2002년 6월까지안와골절로안와골절복원술을시행한 50안을대상으로환자의나이, 골절의크기, 수술시기,