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1 대한골절학회지제 24 권, 제 2 호, 2011 년 4 월 Journal of the Korean Fracture Society Vol. 24, No. 2, April, 2011 수부골절불유합에대한자가장골이식술 김주용ㆍ이영근 * ㆍ안기찬ㆍ성태우 인제대학교의과대학부산백병원정형외과학교실, 다손정형외과의원정형외과 * 목적 : 수부골절후에발생한불유합의자가장골이식술의결과에대해보고하고자한다. 대상및방법 : 2006 년 10 월부터 2008 년 9 월까지수부에발생한불유합으로자가장골이식술을시행받은환자중 12 개월이상추시가능하였던 35 명의환자 예를대상으로하였다. 처음수상원인, 수상부위, 처음치료방법, 수상후골이식까지의기간, 이식골의크기, 이식골고정방법, 골유합기간및골유합정도에대해후향적으로분석하였다. 또한술후최종추시상에서측정한중수지관절, 근위지관절, 원위지관절의운동각도와시각통증척도 (VAS) 를이용하여평가하였다. 결과 : 수상원인은개방성골절 23 예 (62.2%), 압궤손상 12 예 (32.4%), 직접타격이 2 예 (5.4%) 였으며, 부위는중수골 7 예, 근위지골 17 예, 중위지골 8 예, 원위지골 5 예이었다. 수상후골이식까지의기간은평균 20.7 주였다. 이식골의고정은 K- 강선고정이 27 예 (73.0%), 금속판고정이 6 예 (16.2%), K- 강선과환상강선을이용한경우가 2 예 (5.4%), K- 강선과금속판을이용한경우가 2 예 (5.4%) 였다. 이식골의크기는평균 0.93 cm 3 이었으며골유합기간은평균 11.1 주였고, 전예에서골유합을얻었다. 결론 : 수부골절후발생한불유합치료를위해자가장골이식술은유용한치료방법이라생각된다. 색인단어 : 수부, 불유합, 자가장골이식술 Autogenous Iliac Bone Grafting for the Treatment of Nonunion in the Hand Fracture Joo-Yong Kim, M.D., Young-Keun Lee, M.D., Ph.D.*, Ki-Chan An, M.D., Tae-Woo Sung, M.D. Department of Orthopedic Surgery, Pusan Paik Hospital, College of Medicine, Inje University, Busan, Department of Orthopedic Surgery, Dason Orthopaedic Clinic*, Jeonju, Korea Purpose: To evaluate autogenous iliac bone graft for nonunion after hand fracture. Materials and Methods: From October 2006 through September 2008, we analyzed 35 patients, cases of autogenous iliac bone graft for nonunion after hand fracture that have followed up for more than 12 months. We analyzed about etiology, fracture site, initial treatment, time to bone graft, grafted bone size, grafted bone fixation method, radiologic time of bony healing and bone union rate retrospectively. Also we evaluated VAS and range of motion of each joints (MCP, PIP, DIP) at final follow-up assessment. Results: Etiology was open fracture 23 cases (62.2%), crushing injury 12 cases (32.4%), direct trauma 2 cases (5.4%). Fracture site was metacarpal bone 7 cases, proximal phalanx 17 cases, middle phalanx 8 cases, distal phalanx 5 cases. Time to bone graft was average 20.7 weeks. Grafted bone fixation method was fixation with K-wire 27 cases (73.0%), fixation with only plate 6 cases (16.2%), fixation with K-wire plus plate 2 cases (5.4%), fixation with K-wire plus cerclage wiring 2 cases (5.4%). Grafted bone size was average 0.93 cm 3 and bony union time was average 11.1 weeks and we had bone union in all cases. Conclusion: Autogenous iliac bone graft is the useful method in the reconstruction of non-union as complication after hand fracture. Key Words: Hand fracture, Nonunion, Autogenous iliac bone graft 통신저자 : 이영근전북전주시덕진구인후동 번지다손정형외과의원정형외과 Tel: ㆍ Fax: trueyklee@yahoo.co.kr 접수 : 심사 ( 수정 ): 1 차 , 2 차 게재확정 : Address reprint requests to:young-keun Lee, M.D. Department of Orthopedic Surgery, Dason Orthopaedic Clinic, , Inju-dong, Deokjin-gu, Jeonju , Korea Tel: ㆍ Fax: trueyklee@yahoo.co.kr 163

2 164 김주용, 이영근, 안기찬, 성태우 서 수부골절환자를치료할때초기에기능소실을최소화하고, 조기골유합을위해노력하지만, 골유합을얻지못하는경우가많다. 이런불유합과지연유합은수부골절에서흔하지않지만, 대개개방성수부골절환자의 5 6% 정도에서발생하며, 분쇄골절, 골결손또는심각한상처를동반한경우에그빈도는더욱증가한다 3). 이는기능적인문제와결부되는것으로알려져있으며, 유합을얻기위해자가골이식이필요하다. 불유합이라는진단을내리기위해서는최소한 1 년은기다려야한다고주장하는이들도있으나 10), 골유합을얻기위해장기간고정을했을경우심각한기능적결손을가져올수있다. 다른부위의골이식에대한대한보고는많으나, 수부골절이후에시행된골이식에대한보고는거의없다. 이에저자들은수부골절로자가장골이식을시행받은 예에대해후향적으로연구한결과를보고하고자한다. 론 대상및방법 2006 년 10 월부터 2008 년 9 월까지저자들에의해수부골절후발생한불유합에대해자가장골이식술을시행받은환자중 12 개월이상추시가능하였던 35 명의환자 예를대상으로하였으며, 재접합술, 골종양에의한병적골절등은제외하였다. 총 35 명의환자중성별분포는남자가 29 명, 여자는 6 명으로남자가월등히많았고, 수술당시의환자의연령은평균 38 세였다. 처음수상원인및양상, 수상부위, 초기치료방법, 수상후골이식까지의치료기간, 골이식의원인, 이식골의크기, 이식골고정방법, 골유합기간, 그리고관절운동각도등에대해후향적으로분석하였다. 골유합의정의는전후면및측면단순방사선사진에서골주가교차되는것을방사선학적인골유합 (radiologic bone union) 으로, 이학적검사상에서골절부위를조작했을때통증이나타나지않고가성운동이보이지않는경우를임상적인골유합 (clinical bone union) 으로보았다. 또한불유합은 3 개월이내에방사선학적인골유합과임상적인 골유합중어느것도얻지못한경우를기준으로하였다. 관절운동은최종추시에서중수지관절, 근위지관절, 원위지관절의운동각도를측정하였으며주관적만족도의평가를위해술전및술후시각통증척도 (VAS, Visual Analogue Scale) 를측정하여 t-test (paired t-test) 를실시하였다. Table 2. Fracture site Site Distal phalanx Middle phalanx Proximal phalanx Metacarpal 결 수상원인으로는압궤손상이 12 예 (32.4%), 직접타격이 2 예 (5.4%) 였으며, 개방성골절이 23 예 (62.2%) 였다 (Table 1). 부위는중수골 7 예 (19.0%), 근위지골 17 예 (45.9%), 중위지골 8 예 (21.6%), 원위지골 5 예 (13.5%) 였으며 (Table 2), 압궤손상과개방성골절의총 35 예중 12 예 (34.3%) 에서건및신경, 혈관의동반손상이확인되었다. 초기치료방법은관혈적정복술및핀고정술이 26 예 (70.3%) 로가장많았고, 도수정복술및핀고정술 8 예 (21.6%) 그리고, 부목을이용한보존적치료가 3 예 (8.1%) 였다 (Table 3). 이후경과관찰중불유합으로판단되어자가장골이식술을시행하기까지의기간은수상일로부터평균 20.7 주였다. 이식골의고정은 K- 강선 (Fig. 1, 2, 3) 이 27 예 (73.0%), K- 강선과환상강선을이용한경우가 2 예 (5.4%), K- 강선과금속판을이용한경우가 2 예 (5.4%) 였으며, 금속판만으로고정한경우 (Fig. 4) 는 6 예 (16.2%) 였다 (Table 4). 이식골의크기는자가장골을채취하고이식부위에맞게다듬은후가로, 세로, 높이를자로측정하였으며평균 0.93 cm 3 이었다. 골유합까지의기간은평균 11.1 주 ( 일 ) 가 과 5 (13.5%) 8 (21.6%) 17 (45.9%) 7 (19.0%) Table 1. Cause of injury Cause Crushing injury Direct blow Open fracture 12 (32.4%) 2 (5.4%) 23 (62.2%) Table 3. Initial treatment Treatment Splint CRIF ORIF 3 (8.1%) 8 (21.6%) 26 (70.3%) CRIF: Closed reduction and internal fixation, ORIF: Open reduction and internal fixation.

$A 28-year-old man sustained middle phalanx fracture of$ $shows bony gap of the fracture site at 3 months after$ initial operation.

$the X-ray shows the medullary bridge of the fracture$ K-wire removal shows the filling of the bony gap.

He ultimately recovered 70% of his finger motion, had no

$A 22-year-old man sustained distal phalanx open fracture$ of left index finger.

(B) Antibiotics mixed cement was inserted after

3 수부골절불유합에대한자가장골이식술 165 Fig. 1. A 28-year-old man sustained middle phalanx fracture of right index finger by belt injury. (A) The anteroposterior view of the preoperative X-ray shows bony gap of the fracture site at 3 months after initial operation. (B) Immediate postoperative X-ray shows autogenous iliac bone graft and K-wire fixation. (C) At eight weeks after autogenous iliac bone graft, the X-ray shows the medullary bridge of the fracture site. (D) The anteroposterior view of the X-ray after K-wire removal shows the filling of the bony gap. (E) Finger extension and (F) Flexion at final evaluation. He ultimately recovered 70% of his finger motion, had no pain, and used his finger in pinching and griping activities. Fig. 2. A 22-year-old man sustained distal phalanx open fracture of left index finger. The osteomyelitis was developed after K-wires fixation at local clinic. (A) The anteroposterior view of the preoperative X-ray shows osteolytic lesion of distal phalanx. (B) Antibiotics mixed cement was inserted after debridement and curettage. (C) At four weeks after antibiotics mixed cement insertion, autogenous iliac bone graft and K-wire fixation was done. (D) The X-ray after K-wire removal shows the bony union. (E) Finger extension and (F) Flexion at final evaluation. He ultimately recovered nearly complete of his finger function.

$fracture of left index finger.$ $(B) Preoperative X-ray shows bony gap of the fracture$ site at 3 months after initial operation.

(E) Finger extension, 0 o and (F) Flexion, 70 o at

$A 39-year-old woman sustained multiple open fracture$ $Multiple fractures were fixed mulitple K-wires at the$ $fracture (B) Immediate postoperative X-ray shows$ autogenous iliac bone graft and miniplate fixation.

autogenous iliac bone graft and miniplate fixation.

4 166 김주용, 이영근, 안기찬, 성태우 Fig. 3. A 52-year-old woman sustained middle phalanx open fracture of left index finger. (A) The anteroposterior view of the X-ray shows after initial opertaion. (B) Preoperative X-ray shows bony gap of the fracture site at 3 months after initial operation. (C) Immediate postoperative X-ray shows autogenous iliac bone graft and K-wire fixation. (D) The X-ray after K-wire removal shows the bony union. (E) Finger extension, 0 o and (F) Flexion, 70 o at final evaluation. Fig. 4. A 39-year-old woman sustained multiple open fracture and dislocation of left hand by machine injury. Multiple fractures were fixed mulitple K-wires at the time of injury. (A) Preoperative view shows non-union of 5th metacarpla fracture site at 3 months after initial operation. (B) Immediate postoperative X-ray shows autogenous iliac bone graft and miniplate fixation. (C) At 10 weeks after autogenous iliac bone graft, the anteroposterior view of the X-ray shows cortical continuity of the fracture site. (D) The anteroposterior view of the X-ray after miniplate removal shows the filling of the bony gap.

5 수부골절불유합에대한자가장골이식술 167 Table 4. Grafted bone fixation method Method K-wire only K-wire+plate K-wire+cerclage wiring Plate only 27 (73.0%) 2 (5.4%) 2 (5.4%) 6 (16.2%) 걸렸다. 전례에서골유합을얻었으며, 고정방법에따른유합율및골유합까지의기간에서통계학적유의성은찾을수없었다. (p=0.2, >0.5) 최종추시에서시행한관절운동각도의평균값은중수지관절에서 32.2 o, 근위지관절 36.4 o, 원위지관절 5.0 o 이었으며, 시각통증척도는그평균과표준편차가술전 2.95±1.88 에서술후 0.45±0.83 로유의한차이를보였고 (p=0.02) 감염등의합병증은없었다. 고 수부의중수골및수지골절의경우, 특히비개방성골절이라면대부분 3 6 주이내에골유합을얻을수있는것으로알려져있다 1). 고에너지압궤손상과같은심한개방성골절의경우광범위한연부조직손상및분절골결손이동반되어골유합을얻는데더많은시일이필요할것이며 2), 추가적으로수술적인치료가시행되는경우가많다 9). Jupiter 등 6) 은중수골과수지골의지연유합및불유합의치료증례 25 예보고에서처음수상원인으로 13 예가개방성골절과연관이있다고발표하였고, 저자들의증례에서도개방성골절이 23 예 (62.2%) 로대부분을차지함을확인할수있었다. 이러한경우에고정기간이늘어나고, 추가적인시술로건및관절막의유착에의한관절강직및연부조직구축등기능적으로좋지않은결과를초래하게된다. 따라서불유합치료에서는수술치료의득과실, 그리고긍극적으로추구하는수부의기능등에대한정확한분석이반드시선행되어야한다. 자가골이식술은특히수부의불유합에서표준적인치료로많이이용되어왔으며 7), 골격의회복을위한필수적인요소이다 5). 해면골이식은골유합에적절한자극을제공하며, 피질골이식은내고정기구와함께골격에가해지는부하를견디게한다 3). 저자들은피질골이식을통해골격을만든다음해면골이식을필요에따라추가하여골유합을촉진시켰다. 최근에는조기에골이식을시행하여골유합까지의시간을단축시키고, 고정기간을줄여연부조직구축을줄이며, 동시에건박리술혹은관절박리술을시행하여더나은수부기능을얻을수있다는보고들이많 찰 다 4,8,9,11,12). 여기에서제기할수있는문제는수부골절에서조기와불유합을판정하는시기의문제이다. 불유합진단을내리기위한기간을최소한 1 년으로보는이들도있고 10), Jupiter 등은 4 개월까지골유합의소견이보이지않을때이를불유합으로보고여러가지치료를시행했다 6). 저자들은조기에치료를시작하고자하는의도로, 3 개월을기준으로방사선학적및임상적인골유합을통해불유합을판단하였다. Saint-Cyr 등 9) 은 7 명의분절골결손및연부조직손상을동반한 type III 개방성수부골절의환자에게즉각적으로골이식술을시행하고, 최종추시상 92% 의골유합소견을얻었으나, 감염이발생한경우는한예도없었다고보고하였다. 이보고에서저자들은이식전에광범위한변연절제술을통해생존이의심되는조직을완전히제거하는것이중요함을강조하였다. Stahl 등 11) 도골소실을동반한수지의개방성골절환자의증례보고에서조기에골이식을이용한치료를통해양호한결과를얻었으며, 감염이발생한경우는없었다고하였다. 또한, 골결손의크기가 2 cm 이상이면서, 변연절제술이충분히이루어져창상이깨끗하다고판단되며, 풍부한혈행공급이이루어질때조기골이식술을시행할것을강조하며, 이러한조건들이갖추어지지않았을때에는골이식술이지연되어야한다고보았다. 이렇게조기골이식술의장점과안정성을강조하는여러보고들가운데 4), 변연절제술을확실하게시행하였다하더라도, 생존이불확실하고감염을일으킬만한조직을최대한제거하는것에주관적인판단이들어갈수밖에없다. 따라서개방성창상이있는곳에골이식술을시행할때부담을가질수밖에없으며, 적절한시기를결정하는것도쉽지않다. 저자들의경우도가장조기에골이식술을시행한경우가수상후 13 일째로감염등의합병증은발생하지않았지만, 적응증만된다면앞으로좀더조기에골이식술을시행함으로써환자들의이환기간을줄이고, 더나은수부기능을회복할수있도록노력하고자한다. Jupiter 등 6) 은중수골과수지골의지연유합및불유합의치료증례 25 예를보고하면서, 초기의적절하지못한골절의고정이이러한합병증을일으킨가장큰요인이었으며, 무엇보다도재고정및골이식등을이용한수술이후조기관절운동이중요함을강조하였다. 또한근위지골에가장많이발생하였음을보고하였는데, 이는저자들의보고에서도확인할수있었다. 저자들의보고는골이식술에초점을두고있지만, Jupiter 등 6) 은불유합의예방및치료에서또하나의중요한점은견고한골고정이라고보고하였으며, 안정적이며견고한골고정은정렬을유지하고골유합을얻으며즉시운동을허용하는데필수적인요소이다. 하지만,

6 168 김주용, 이영근, 안기찬, 성태우 비교분석을통해서초기의골고정의견고함또는방법이불유합의발생에미치는영향에대해서는이전에보고된바가없었으며, 이는이보고의제한점이자앞으로저자들에게남겨진과제이다. 다만이식골의고정방법은전례에서골유합을얻어그차이점을발견할수없었다. 이는피질골이식뿐만아니라충분한해면골이식을동반하였고, 처음보다좀더견고하게고정하려했기에가능했다고볼수있다. 저자들의결과에서볼때최종추시에서관절운동범위가많이감소된원인으로는주로초기수술시 K-강선으로고정을하였고, 조기에골유합이일어나지않아관절운동을빨리시작하지못하였으며, 골이식이후추가적으로관절고정기간이늘어났기때문으로볼수있다 6). 저자들은이번분석을통해서불유합은분쇄골절혹은방사선학적으로골결손을동반한개방성골절과심한압궤손상의경우에잘발생하는것을알수있었으며, 초기수술당시 K-강선으로고정한경우에도불유합의빈도가높게나오는것을알수있었다. 또한골이식술은수부기능재건에반드시필요하고유용하며, 골결손의복원에가장중요한요소임을확인할수있었다. 수부에서발생한불유합은수상당시에이미신경손상, 건손상및연부조직손상등을동반하는복합적인손상인경우가대부분이기에 6) 이전의수부기능으로완전히회복하는것이힘든경우가많지만, 골이식등의치료를적극적으로고려하고그시기를잘결정하여시행하여더나은수부기능을환자들에게제공해줄수있다. 결 저자들은수부골절후발생한불유합에대하여자가장골이식을시행하여만족할만한결과를얻었을수있었기에, 자가장골이식은골결손의치유뿐아니라조기골유합을얻는데유용한치료방법이라생각된다. 3 개월까지기다린후에도골유합을보이지않는수부골절에대해서골유합을기다리며고정기간을연장시키는것보다조기에골이식및견고한고정을시행하여골유합을촉진시키고, 조기관절운동을가능하게하는것이궁극적으로더나은수부기능을얻을수있는방법으로볼수있다. 론 참고문헌 1) Barton NJ: Fractures of the shafts of the phalanges of the hand. Hand, 11: , ) Duncan RW, Freeland AE, Jabaley ME, Meydrech EF: Open hand fractures: an analysis of the recovery of active motion and of complications. J Hand Surg Am, 18: , ) Freeland AE, Rehm JP: Autogenous bone grafting for fractures of the hand. Tech Hand Up Extrem Surg, 8: 78-86, ) Gonzalez MH, McKay W, Hall RF Jr: Low-velocity gunshot wounds of the metacarpal: treatment by early stable fixation and bone grafting. J Hand Surg Am, 18: , ) Gross TP, Cox QG, Jinnah RH: History and current application of bone transplantation. Orthopedics, 16: , ) Jupiter JB, Koniuch MP, Smith RJ: The management of delayed union and nonunion of the metacarpals and phalanges. J Hand Surg Am, 10: , ) Rinaldi E: Autografts in the treatment of osseous defects in the forearm and hand. J Hand Surg Am, 12: , ) Saint-Cyr M, Gupta A: Primary internal fixation and bone grafting for open fractures of the hand. Hand Clin, 22: , ) Saint-Cyr M, Miranda D, Gonzalez R, Gupta A: Immediate corticocancellous bone autografting in segmental bone defects of the hand. J Hand Surg Br, 31: , ) Smith FL, Rider DL: A study of the healing of one hundred consecutive phalangeal fracture. J Bone Joint Surg Am, 17: , ) Stahl S, Lerner A, Kaufman T: Immediate autografting of bone in open fractures with bone loss of the hand: a preliminary report. Case reports. Scand J Plast Reconstr Surg Hand Surg, 33: , ) Sundine M, Scheker LR: A comparison of immediate and staged reconstruction of the dorsum of the hand. J Hand Surg Br, 21: , 1996.

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( )Jkfs095.hwp 대한골절학회지제 19 권, 제 4 호, 2006 년 10 월 Journal of the Korean Fractrure Society Vol. 19, N o. 4, October, 2006 팔씨름에의해발생한상완골간부및내상과골절 윤여헌 하종경 * 최경업 * 이관희 신상진 이화여자대학교의과대학목동병원정형외과, 서울적십자병원정형외과 * 목적 : 팔씨름중발생한상완골골절의발생기전및치료의결과를분석하였다.