대한정형외과학회지 : 제 40 권제 3 호 2005 J Korean Orthop Assoc 2005; 40: 가토의아킬레스건파열의수술적치료후고정방법에따른생역학적및조직학적변화 김경천ㆍ황득수ㆍ정상윤ㆍ우세민ㆍ이충희 충남대학교의과대학정형외과학교실 목적 : 아킬레스건

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1 대한정형외과학회지 : 제 0 권제 3 호 005 J Korean Orthop Assoc 005; 0: 30- 가토의아킬레스건파열의수술적치료후고정방법에따른생역학적및조직학적변화 김경천ㆍ황득수ㆍ정상윤ㆍ우세민ㆍ이충희 충남대학교의과대학정형외과학교실 목적 : 아킬레스건파열의수술후고정방법에따른생역학적및조직학적결과를비교하였다. 대상및방법 : 30 마리의수컷가토의우측아킬레스건을절단후변형된 Kessler 씨방법으로봉합하였고, 수술하지않은좌측은대조군으로하였다. I 군 (n=10) 은족저굴곡상태로장하지석고를 주간고정하였고, II 군 (n=10) 은수술 1 주일째부터전신마취하에 1 주일간격으로교정하여수술 5 주에는완전히배측굴곡시켜고정하였다. III 군 (n=10) 은외고정장치를경골과종골에고정후수술 1 주부터완전히배측굴곡이되도록하루에 mm 씩외고정장치를단축시켰다. 수술 주에아킬레스건을종골의부착부위에서절단하여각군의 5 마리는생역학적실험을실시하였고나머지 5 마리는조직검사를하였다. 결과 : 생역학검사에서제 I, II, III, 대조군에서파열하중 (N) 은각각 55.50, 97., 10.7, 10.9 이었으며, 변형률은 0., 0.9, 0.7, 0.7 이었으며, 파열에필요한에너지 (J) 는 1.3, 3.9, 51.0, 0.7 이었으며, 강도 (N/mm) 는 9.3, 17.7, 19.01, 3.33 이었다. 제 I, II, III 군간파괴하중, 변형률, 파열에필요한에너지그리고강도가 III 군으로갈수록증가하였으며, 통계학적유의성이있었다 (p<0.05). 조직학소견상 III 군으로갈수록건구조가보다성숙되어있었으며, 섬유다발이보다평행한배열양상을보였다. 결론 : 수술후치유중의아킬레스건의연속적인교정에의한인장력은생역학및조직학적으로보다정상에유사한회복양상을나타낸다. 색인단어 : 아킬레스건파열, 강도, 변형율, 인장력, 파열하중 Biomechanical and Histological Effects of Different Regimens of Immobilzation after Operative Treatment in a Ruptured Rabbit Achilles Tendon Kyung-Cheon Kim, M.D., Deuk-Soo Hwang, M.D., Sang-Yun Chung, M.D., Se-Min Woo, M.D., and Choong-Hui Lee, M.D. Department of Orthopedic Surgery, School of Medicine, Chungnam National University, Daejeon, Korea Purpose: To evaluate the effects of the different regimens of immobilization after surgery in a rabbit model. Materials and Methods: The study was performed on the right Achilles tendon of 30 rabbits. Modified Kessler method was used to suture the transected tendon. Rabbits were divided into three groups, Group I (n=10) underwent long leg cast with equinus position for weeks, Group II (n=10) underwent weekly cast correction to full dorsiflexion from 1 week after surgery, and Group III (n=10) underwent daily correction of equinous position with external fixator from 1 week after surgery. The contralateral Achilles tendon served as an unoperated control. And three groups were compared at weeks after surgery. Results: The maximal load at rupture (N) was 55.50, 97., 10.7, 10.9 for group I, II, III and control respectively. The strain was 0., 0.9, 0.7, 0.7. The stiffness (N/mm) was 9.3, 17.7, 19.01, The absorbed energy to rupture (J) was 1.3, 3.9, 51.0, 0.7. Values among groups were significantly different considering the maximal load, strain, stiffness, and absorbed energy to rupture (p<0.05). Histo- 통신저자 : 황득수대전광역시중구대사동 0 충남대학교병원정형외과학교실 TEL: FAX: Address reprint requests to Deuk-Soo Hwang, M.D. Department of Orthopaedic Surgery, School of Medicine, Chungnam National University, 0 Daesa-dong, Jung-gu, Daejon , Korea Tel: , Fax:

2 가토의아킬레스건파열의수술적치료후고정방법에따른생역학적및조직학적변화 31 logical finding was revealed more mature restoration and more parallel arrangement of fiber bundles in the group II, and especially group III. Achilles tendon rupture, Maximal load, Strain, Stiffness, Tensile loading. Conclusion: Tensile loading of the healing tendon by postoperative continuous correction leads to changes in more similar to the normal Achilles tendon, biomechanically and historically. Key Words: Achilles tendon rupture, Maximal load, Strain, Stiffness, Tensile loading 아킬레스건의구조적인변화는인대의손상이나골절후고정등에서장력의변화후에발생할수있으며아킬레스건의생체역학적특성을약화시키고, 기계적인스트레스에대한저항력의저하시켜, 15주간의고정을거친아킬레스건의콜라겐섬유는더얇아지고약해진다고보고되었다 1). 아킬레스건파열에대한치료는 1575년 Ambrose Pare 에의해처음으로보고된이래여러학자들에의해수술적및비수술적방법들이소개되어왔으나, 치료후합병증을최소화하고, 조기보행을시킬수있는치료방법의선택에대해많은이견이있으며, 이전의연구들에서는생역학적인건의최종적치유보다는수술후초기의건치유과정에만중점적으로몰두한경향이있었다,,13,1,17). 또한수술후움직임이지속적인고정과비교하여연속적인건치유단계들의근본적인변화를야기하는지아니면단순히생역학적특성의회복을가속시키는건지는여전히논쟁의여지가있다. 본연구의목적은아킬레스건파열에서수술적봉합후건의전체적인치유과정에서고정과비교하여주기적및연속적인움직임이치유과정에미치는효과와영향에대해생역학적실험및조직학적실험을통하여연구하고자하였다. 대상및방법실험동물은 30마리의뉴질랜드종수컷흰토끼 (New Zealand white) 를사용하였으며, 평균나이는.7 개월 (.-7.3개월 ), 평균무게는,70 g (,50-3,010 g) 이었다. 마취는 Ketamine HCL (15 mg/kg, Ketamine, Yuhan, Korea) 와 xylazine hydrochloride ( mg/kg, Rompun, Bayer, Korea) 를둔부의근육내로투여하여전신마취를유도하였다. 우측하지의털을제거후피부에종절개를가하고근막을종절개하여아킬레스건을노출시켰다. 족관절은배측굴곡을유지하여 11번메스를이용하여아킬레스건종골부착부의 1 cm 근위부에서횡절개하였으며, 이때실제적인파열과같은가장자리가너덜너덜한파열양상을재현하기위하여절단예정부위를수차례 1 cm 정도의길이로종절개를시행한후절단하였다. 파열된건은변형된 Kessler 씨봉합법 7) 에의하여 -0 Ethibond (Ethicon Inc, U.K.) 를이용해 1회단단봉합술을시행하였으며, 봉합부를 -0 Vicryl (Ethicon Inc, U.K.) 을이용하여 회환상봉합을시행하였다. 그리고봉합된아킬레스건주위의건외막조직을충분히봉합한상태로봉합부를피복하였다. 수술하지않고고정을시행하지않은좌측아킬레스건은생역학및조직학적실험의대조군으로하였다 (I-c, II-c, III-c). 제I 군 (n=10) 은수술후족저굴곡상태로장하지석고를 주간고정하였으며, 제II군 (n= 10) 은수술후족저굴곡상태로석고고정하고수술후 1주일째부터약 30 씩 1주일간격으로 5차례전신마취하에족관절을배측굴곡상태로연속적석고교정을시행하여수술후 5주에는완전히배측굴곡시켜석고고 A B C Fig. 1. Position of ankle in the Group I, II and III at weeks after surgery.

3 3 김경천ㆍ황득수ㆍ정상윤외 인 Control Group Group I Group II Group III Load to failure (N) Fig.. Typical load-deflection curve of respective experimental group. 정을하였다. 제III군 (n=10) 은수술후족저굴곡상태로외고정장치로경골과종골에고정후수술후 1주부터완전히배측굴곡이되도록하루에한번 mm씩외고정장치를단축시켜교정하였다 (Fig. 1). 수술 주후수술한쪽과대조군의아킬레스건을종골부착부위에서절단하여각군의 5마리는생역학적실험을실시하였고각군의나머지 5마리는조직학적검사를시행하였다. 1. 생역학실험생역학연구는 15 마리의좌우측의절단된 30 개의아킬레스건으로측정기계의 Clamping Jaw (UTM, Ultimate Tensile Measurement, England) 사이에설치하였다. 인장력실험은 10 mm/min의속도로시행하였으며, Clamping Jaw 사이의아킬레스건길이를최초길이로기록하였으며, 평균 11.7 mm이었다, 실험하는동안하중 -신장곡선 (Load-Deflection diagram) 은측정기계의컴퓨터에의해그려졌다 (Fig. ). 곡선에서파열하중 (Rupture load, Maximum force at rupture, N) 과신장도 (Deflection, Tolerance of tensile loading before failure, mm) 가기록되었으며, 변형률 (Strain, Elongation at the point of rupture/ initial length), 파열에필요한에너지의흡수량 (Energy absorption to rupture, J), 건의강도 (Stiffness, N/mm) 를분석하였다. 아킬레스건이파열될때까지흡수된에너지의양 (J) 은하중-신장곡선에서완전파열점까지곡선의아래면적으로계산되어졌다 ( 에너지흡수율 = 최대하중 변형률 초기길이 /). 건의강도 (Stiffness) 는아킬레스건의인장력 (Tensile load) 에저항하는건의변화율 (N) 과아킬레스건신장도 (Tensile deflection) 의허용사이의관계를나타 내며, 다음과같이계산하였다. Stiffness (N/mm)=Rupture load/tensile deflection 통계학적분석을수행하기위해 SPSS win (version 11.5, SPSS inc., USA) 을사용하였고 주후생역학적분석결과를가지고각각의실험군과대조군간에 ANOVA test를사용하여비교하였다. 실험군과대조군간그리고각각의대조군간서로통계학적으로분석하여 Multiple Mann-Whitney test로처리되었으며, p 0.05를통계학적으로의미가있다고평가하였다.. 조직학수술후 주째 15마리양쪽의아킬레스건을종골의부착부위에서절단한후, 10% 중성완충제포르말린에고정하였다. - m 종절단하기위해조직을탈수화시킨후파라핀에포매하였다. Hematoxylin-Eosin 염색을실시하였으며, 표준광학현미경로분석하였다. 조직내의섬유화정도와배열양상을관찰하기위하여 Masson-Trichrome 염색을동시에시행하였다. 각각의실험군의혈관화와림프구의침윤정도, 교원질화그리고활동성섬유아세포의정도를서로비교하였으며, 육아조직의확장과구성, 건조직내의섬유배열양상, 건조직내모세혈관의밀도, 운동성염증세포의분포 ( 과립구, 림프구, 대식세포등 ) 등의기준으로평가하였다. 결과 1. 생역학적결과최대파열하중 (N) 은제I, II, III 실험군이각각 55.5, 97., 10.7이었고, 각각의대조군은 179., 11., 1.09이었다 (Table 1). 이들결과에서파열하중은제 I, II, III 실험군순서로점차증가하였으며통계학적유의성을보였으나 (p<0.001), 제I, II 실험군에서각군의대조군과의차이는통계학적으로유의성은없었고 (p>

4 가토의아킬레스건파열의수술적치료후고정방법에따른생역학적및조직학적변화 33 Table 1. Data of mechanical test of achilles tendon of experimental and control group Group I Group II Group III (I-c*) (II-c) (III-c) p value Rupture load (N) <0.05 (179.0) (11.) (1.09) Strain <0.05 (0.) (0.) (0.9) Energy absorption (J) <0.05 (57.55) (1.1) (.9) Stiffness (N/mm) <0.05 (.11) (3.13) (.7) c*; control group, p value; p<0.05 for Group I, II, III. 0.05), 제III 실험군은대조군과통계학적으로유의한차이를보였다 (p<0.05). 제I, II, III 실험군은정상측인대조군의최대파열하중의평균 1.3%, 3.7%, 77.03% 에서봉합된건이파열되었다. 변형률은제I, II, II 실험군이 0., 0.9, 0.7이었고, 각각의대조군은 0., 0., 0.9이었다. 이들결과에서변형률은제I, II, III 실험군순서로점차증가하였으며통계학적유의성을보였다 (p<0.001). 제I, III 실험군은각각의대조군과통계학적으로유의한차이를보이지않았고 (p>0.05), 제II 실험군은대조군과통계학적으로유의한차이를보였다 (p<0.05). 아킬레스건의파열에필요한에너지 (J) 는제I, II, III 실험군과대조군에서 1.3±.1, 3.9±., 51.0 ±5.93 이었고, 각각의대조군은 57.55±.9, 1.0± 3.3,.9±.77이었다. 아킬레스건파열에필요한에너지는제I, II, III 실험군순서로점차증가하였으며이는통계학적유의성을보였다 (p<0.001). 제I, II, III 실험군은각각의대조군과통계학적으로유의한차이를보이지않았다 (p>0.05). 또각실험군과대조군을비교했을때제I, II, III 실험군의파열에필요한에너지는각각대조군의평균 1.3%, 3.7%, 1.35% 였다. 평균강도 (N/mm) 는제I, II, III 실험군의각각 9.3 ±.51, 17.7±5.00, 19.01±.1이었으며, 각각의대조군은.11±1.0, 3.13±.07,.7±1.이었다. 아킬레스건의강도는제I, II, III 실험군순서로점차증가하였으며이는통계학적유의성을보였고 (p< 0.05), 제I, II 실험군은각각의대조군과통계학적으로유의한차이를보였으나 (p<0.05), 제III 실험군에서는대조군과통계학적으로유의한차이가없었다 (p>0.05). 3. 조직학적소견건의봉합부에서조직내육아조직의확장과구성, 모세혈관의밀도및분포, 운동성염증세포 ( 과립구, 림프구, 대식세포등 ) 의분포는세개의실험군간에실질적인차이를보이지않았다. 그러나외고정기를이용하여연속적인교정을시행하였던제III 실험군에서 I군과 II 실험군보다보다정상건에유사한복원양상을보여주었는데, 특히제I 실험군에서는섬유다발이엉켜있는듯한불규칙한양상을관찰할수있었다. 그러나제III 실험군으로갈수록섬유다발의분포가보다평행한배열양상을보여더욱정상건조직에가까운형태를나타냈으며, 콜라겐섬유의비후소견이관찰되었으며, 치유조직에서보다전형적인건세포가많이관찰되는양상을나타냈다 (Fig. 3). 고찰아킬레스건파열의다양한방법의치료에많은실험적인연구들이있었고, 대부분토끼가모델로사용되었는데, 토끼아킬레스건의생역학적특성은 McMaster 1,17) 에의해처음기술되었으며, Viidik 1) 은정상토끼아킬레스건의파열하중은 179 N에서 337 N까지다양하다고보고하였다 1-1). 본연구에서도대조군 15개의정상건의파열하중은평균 10 N으로나타났다. 그러나실제아킬레스건의파열시자주관찰할수있는건의퇴행성변화는본연구에서는고려되지않아퇴행성모델에따른추가적인연구도필요하리라고사료된다. Murrel 등 13,1) 과 Best 등 ) 에따르면쥐의아킬레스건의재생은 15일정도가걸린다고보고하였는데, 생체역학적인아킬레스건의특징은그때까지완전히회복되지않으며, Thermann 등 17) 의연구에서쥐심지어토끼에있어서도아킬레스건의회복은사람보다빠르지만생체역학적인회복은 10주가지나서도완전히이루어지지않는다고보고하였으나, 본연구에서는임상에서사람의아킬레스건파열의치료에서저자들이임상에서적용하고있는 10-1주석고고정술및주기적교정술을고려하여토끼가사람보다건의회복이빠른점을감안해보다짧은 주동안고정하여실험하였다. 임상적으로고정은퇴화를유발하고근골격계조직의특성을변화시킨다고여러문헌에서보고하고있으며 1,,,10,15). 본연구는아킬레스건의수술적치료후고정

5 3 김경천ㆍ황득수ㆍ정상윤외 인 A B Fig. 3. Photomicrograph of tendons from Groups of cast immobilization (A, Group I), cast serial correction (B, Group II), and continuous correction with external fixator (C, Group III). (Left side; H&E stain, Right side; M&T stain, 0). The specimens from Group I to Group III show the parallel arrangement of fiber bundles (arrows) indicate a more tendon specific structure of specimen orderly (Left side; H&E stain, Right side; M&T stain, 0). C 과다른두조건에서의신연및연속적의차이가건에미치는생물역학적인영향을비교하여고정이아킬레스건의재생에미치는영향을알아보고자하였는데, 생역학적검사에서치유된아킬레스건의파열하중, 변형률, 파열에필요한에너지, 강도가제I, II, III 실험군으로갈수록유의하게증가하여정상에가까운소견을보여 주었다. 이는고정군에서보다점진적인움직임으로연속적인부하를증가시킨제III 실험군에서생역학적으로정상군에유사한소견을보여주었다. 이는고정보다는주기적인교정이, 그리고이보다는연속적인움직임에의한지속적인부하가치유과정의촉진에유리함을시사한다하겠다.

6 가토의아킬레스건파열의수술적치료후고정방법에따른생역학적및조직학적변화 35 회복되는건에탄성이있는부하는수술후초기의치료실패를줄여준다는것이 Murrell 등 13,1) 에의해보고된바있으며, 장력이가해진부하가수술후초기에있어서도섬유모세포의이동을증가시킨다고보고하였다. 이것은신생혈관생성과콜라겐합성을회복되는부위에증가시키게되고건의치유에있어삼출그리고재생의시기에있어실패확률을줄여준다고하였다 5,11). 또한신생혈관의생성은건의치유에중요한데, 특히술후초기에혈관생성에관여하는혈관내피세포성장인자 (VEGF, vascular endothelial growth factor) 가단백질의합성에관여한다고알려져있는데 ), Bidder 등 3) 에의하면생체역학적부하는혈관내피세포성장인자의합성을증가시키고이것이혈관생성을매개한다고한다. 그러나이것을조정하는특별한분자적기전은아직알려있지않다. 그러나본연구의조직학적인소견에서신생혈관의분포나밀도는각실험군간에실질적인차이는보이지않았는데, 수술후 주에조직검사를시행하여건의치유과정의초기에보일수있는신생혈관의형성의차이가나타나지않았던것으로판단된다. Mass 등 11) 의가설에의하면회복부위의생체역학적부하가콜라겐섬유의침착을보다유기적으로배열시키고세포외기질의결합을강하게하여재생된조직을더욱강하게만들어준다고하였는데, 치유된건은지속적인운동으로콜라겐섬유가비후된다고보고하였다 9). 이런섬유들이가해지는힘의방향에평행하게정렬됨으로서큰장력에견딜수있으며, 수술후재활동안가해지는부하로인한변형에저항하는힘이증가된다고하였다 9,1,19). 본연구에서도외고정기를이용하여연속적인교정을시행하였던제III 실험군에서 I군과 II 실험군보다보다고도의복원양상을보여주었으며, 특히제I 실험군에서는섬유다발이엉켜있는듯한불규칙한양상을관찰할수있었다. 그러나제III 실험군으로갈수록섬유다발이보다평행한배열양상을보여줘좀더정상건조직에가까운형태를나타냈고, 콜라겐섬유의비후와치유조직에서다른실험군보다전형적인건세포가관찰되었다. 이는치료부위에가해지는생역학부하가콜라겐의배열을더욱유기적으로배열시키고, 치유조직의강도를향상시킨결과로판단되며, 이러한각군간의조직학적차이는제I 실험군에서제III 군으로갈수록정상아킬레스건에유사한생역학적인실험결과를뒷받침해 줄수있을것으로사료된다. 또한임상에서수술후주기적으로석고교정하는간격을줄여주거나보조기발목부위의각도조절장치로연속적인수술부의신연이가해진다면사람의경우에있어서도상기의효과를거둘수있으리라사료된다. 결론아킬레스건파열의수술적치료후고정방법에따른치료결과를생역학및조직학적으로비교한결과수술후치유중의아킬레스건의지속적이며연속적인부하를가해준실험군에서여러생역학적인특성에서정상아킬레스건에더욱유사하였으며, 조직학적소견에서도보다정상조직에가까운성숙한건조직의치유양상을보여주었다. 이는치료부위에가해지는연속적이고지속적인생역학적부하가콜라겐을더욱유기적으로배열시키고, 치유조직의강도를향상시킨결과로사료되며, 현재임상에서적용되고있는아킬레스건파열의수술후재활및수술후처치에이론적근거가될수있으리라사료된다. 참고문헌 1. Amiel D, Woo SL, Harwood FL and Akeson WH: The effect of immobilization on collagen turnover in connective tissue: a biochemical-biomechanical correlation. Acta Orthop Scand, 7: 35-33, 19.. Best TM, Collins A, Lilly EG, Seaber AV, Goldner R and Murrell GAC: Achilles tendon healing: a correlation between functional and mechanical performance in the rat. J Orthop Res, : 97-90, Bidder M, Towler DA, Gelbermann RH and Boyer MI: Expression of m-rna for vascular endothelial growth factor at the repair site of healing canine flexor tendon. J Orthop Res, 1: 7-5, Gelberman RH, Woo SL, Lothringer K, Akeson WH and Amiel D: Effects of early intermittent passive mobilization of healing canine flexor tendons. J Hand Surg, 7-A: , Haddad RJ Jr, Kester MA, McCluskey GM, Brunet ME and Cook SD: Comparative mechanical analysis of a looped-suture tendon repair. J Hand Surg, 13-A: , 19.. Hockenbury RT and Johns JC: A biomechanical in vitro com-

7 3 김경천ㆍ황득수ㆍ정상윤외 인 parison of open versus percutaneous repair of tendon of tendon Achilles. Foot Ankle, 11: 7-7, Kleinert HE, Gropper PT and Van Beek A: Trauma of the hand. Curr Probl Surg, 15: 1-5, Larsen NP, Forwood MR and Parker AW: Immobilization and retraining of cruciate ligaments in the rat. Acta Orthop Scand, 5: 0-, Liu SH, Yang RS, Shaikh RA and Lane JM: Collagen in tendon, ligament, and bone healing. A current review. Clin Orthop, 31: 5-7, Loitz BJ, Zernicke RF, Vailas AC, Kody MH and Meals RA: Effects of short-term immobilization versus continous passive motion on the biomechanical and biochemical properties of the rabbit tendon. Clin Orthop, : 5-71, Mass DP, Tuel RJ, Labarbera M and Greenwold DP: Effects of constant mechanical tension on the healing of rabbit flexor tendons. Clin Orthop, 9: , Michna H and Hartmann G: Adaptation of collagen to exercise. Int Orthop, 13: 11-15, Murrell GA, Lilly EG, Collins A, Seaber AV, Goldner RD and Best TM: Achilles tendon injuries, a comparison of surgical repair versus no repair in a rat model. Foot Ankle, 1: 00-0, Murrell GA, Lilly EG, Goldner RD, Seaber AV and Best TM: Effects of immobilization on Achilles tendon healing in a rat model. J Orthop Res, 1: 5-591, Newton PO, Woo SL, Mackenna DA and Akeson WH: Immobilization of the knee joint alters the mechnical and ultrastructural properties of the rabbit anterior cruciate ligament. J Orthop Res, 13: , Roberts JM, Goldstrohm GL, Brown TD and Mears DC: Comparison of unrepaired, primarily repaired and polyglactin meshreinforced Achilles tendon lacerations in rabbits. Clin Ortop, 11: -9, Thermann H, Frerics O, Biewener A and Krettek C: Functional treatment of acute rupture of the Achilles tendon, An experimental biomechanical study (German). Unfallchirurg, 9: , Viidik A: Tensile strength properties of Achilles tendon systems in trained and untrained rabbits. Acta Orthop Scand, 0: 1-7, Woo SL, Gomez MA, Woo YK and Akeson WH: Mechanical properties of tendons and ligaments. II. the relationships of immobilization and exercise on tissue remodeling. Biorheology, 19: 397-0, 19.

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