Review Article pissn eissn J Korean Foot Ankle Soc 2019;23(4): 무지외반증의치료에대한고찰 이

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1 Review Article pissn eissn J Korean Foot Ankle Soc 2019;23(4): 무지외반증의치료에대한고찰 이성현, 이영창 원광대학교의과대학원광대학교병원정형외과학교실 Approach for the Treatment on Hallux Valgus Sung-Hyun Lee, Yeong-Chang Lee Department of Orthopedic Surgery, Wonkwang University Hospital, School of Medicine, Wonkwang University, Iksan, Korea Although many patients who undergo bunion repair do well and have satisfactory results, a critical evaluation of these results shows the potential for improvement. Metatarsal deformity of the hallux valgus is a 3-dimensional deformity, including rotation in the coronal plane. Theoretically, it is important to understand the 3-dimensional displacement of the first metatarsal for correcting the deformities of valgus rotation in the frontal plane. Yet the current methods of metatarsal osteotomy principally attempt to correct the deformity in the transverse plane. The modified technique for the Lapidus procedure can be used in a variety of hallux valgus conditions and severities, and the early results suggest that a powerful correction can be maintained. In addition, efforts have been made to correct the 3-dimensional deformity by performing metatarsal shaft osteotomy. In the case of degenerative arthritis, first metatarsophalangeal joint arthrodesis is a good option to correct the 3-dimensional deformation. Correction of the 3-dimensional deformity, including a rotational deformity in the frontal plane of the metatarsals, should be considered when selecting surgical treatment and is essential for achieving a good prognosis for patients with hallux valgus. This article reviews the classification and treatment of hallux valgus for correction of the 3-dimensional deformity. Key Words: Hallux valgus, Metatarsal osteotomy, Metartasal pronation, Hallux adducto valgus, Tibial sesamoid 서 무지외반증 (hallux valgus) 을교정하기위해백가지가넘는수 술기법이소개되어있지만, 다양한병변을한가지수술기법으로해 결할수는없다. Mann 등이저술한책에기술된내용이다. 1) 무지 외반증은환자마다각각다른다양한병인에의해발생하고진행하 는병변이다. 족무지가외측으로편위되면서두드러지는제 1 중족골 Received October 7, 2019 Revised November 26, 2019 Accepted November 26, 2019 Corresponding Author: Sung-Hyun Lee Department of Orthopedic Surgery, Wonkwang University Hospital, School of Medicine, Wonkwang University, 895 Muwang-Ro, Iksan 54538, Korea Tel: , Fax: , kensin06@hanmail.net ORCID: Keystone of this journal was presented at the 2019 Spring Conference of The Korean Orthopaedic Association. Financial support: This study was supported by grant from Wonkwang University, Conflict of interest: None. 론 두의내측돌출부통증 (bunion pain) 이대표적인증상이며제 1중족-족지관절 (metatarsophalangeal joint) 의외측아탈구 (subluxation), 종자골 (sesamoid) 의외측전위및족무지의회내변형등이동반될수있다. 이외에도제 2중족골두아래의굳은살및통증등도동반되어나타날수있다. 2-4) 치료의가장큰목적은변형을교정하고생역학적으로기능적인족부를만드는것이다. 그러므로다양한원인이있는복잡한변형의교정을위해서는항상변형의근본적인원인을해결하는것이원칙이다. 최근무지외반증은단순히수평면 (transverse plane) 상에서내측으로뻗어있는 (adduction) 평면상에서의변형이아니라관상면 (frontal plane) 에서의외회전 (external rotation), 외반 (valgus), 외번 (eversion), 회내전 (pronation) 이포함된 3차원상의변형 (Fig. 1) 이라는개념이대두되었다. 5,6) 이러한병리생태에대한이해는무지외반증환자를치료하는데중요할것이다. 이에저자들은무지외반증의치료를위해주로사용되는수술적치료에대해기술하고 3차원상의변형을교정하기위한분류및수술법에대해기술하고자한다. Copyright c 2019 Korean Foot and Ankle Society. All rights reserved. CC This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 144 Vol. 23 No. 4, December 2019 본론 1. 현재의수술적치료 (current treatment option) 수많은수술법이소개되었지만기본적으로내측돌출부절제술 (bunionectomy), 외측연부조직유리및내측봉합으로이루어진원위연부조직술식 (distal soft tissue procedure), 제 1중족골절골술 (metatarsal osteotomy) 과제 1근위지골절골술 (Akin procedure) 등이근간을이루고있다. 또한제 1중족지관절염이있을경우유합술 (arthrodesis) 을고려할수있으며제 1족근-중족관절 (tarsometatarsal joint) 의불안정성이있으면제 1족근-중족관절유합술 (Lapidus procedure) 을고려할수있다. Figure 1. Triaxial coordinate plane with Z-axis motion about the 1st ray. 무지외반증환자에서위의많은술기중적절한수술적치료법을선택하기위해가장먼저고려할점은제 1중족-족지관절이상합성 (congruent) 인지비상합성 (uncongruent) 인지혹은관절염은없는지를파악하는것이다. 1) 제 1중족지관절이상합성이라면제 1중족골내측돌출부절제술과함께중족골원위부갈매기형절골술혹은제 1근위지골절골술을통해변형을교정할수있다. 제 1중족-족지관절이비상합성이라면외측으로아탈구된근위지골을중족골두위로옮겨서제 1중족-족지관절을상합성관절로만드는수술법이필요하다. 이경우무지외반증변형정도에따라경증 (mild), 중등도 (moderate), 중증 (severe) 으로구분하여치료계획을수립하는데경증변형은무지외반각이 30도이하, 중족골간각이 13도이하인경우이며증등도변형은무지외반각이 40도이하, 중족골간각이 13 도이상인경우이다. 중증변형은무지외반각이 40도이상, 중족골간각이 20도이상인경우이다. 경증변형인경우에는중족골윈위부절골술 (proximal chevron osteotomy), 중족골간부절골술 (scarf osteotomy) 등을통해변형을교정할수있다. 중등도변형인경우에는중족골근위부절골술을병행한원위연부조직교정술, 중족골간부절골술을시행해볼수있다. 중증변형인경우에는중족골근위부절골술을병행한원위연부조직교정술, 제 1중족-족지관절유합술을고려해볼수있다. 또한제 1중족-족지관절의관절염이심한경우에는제 1중족-족지관절유합술혹은관절치환술이필요할수있다. 제1족근-중족관절의과운동성이동반된무지외반증의치료로제 1족근-중족관절유합술이적절한수술법으로확립되었다. 1,7) 그러나무지외반증과제 1족근-중족관절불안정성사이의인과관계및영향은아직논란의여지가있다. 과거여러논문에서제 1 족근-중족관절불안정성은무지외반증에의해이차적으로나타나는증상이며관절유합술이아닌중족골교정절골술로불안정성 Congruent joint DMO Akin exostectomy Double/triple osteotomy Scarf osteotomy Mild IMA<13 HVA<30 Distal chevron DSTP+PMO Scarf osteotomy Hallux valgus Uncongruent joint Moderate IMA>13 HVA<40 DSTP+PMO Scarf osteotomy Degenerative joint disease Severe IMA>20 HVA>40 Hypermobile first TMT joint Fusion prosthesis DSTP+PMO MTP fusion TMT joint fusion +DSTP Figure 2. Current surgical algorithm for hallux valgus. DMO: distal metatarsal osteotomy, IMA: intermetatarsal angle, HVA: hallux valgus angle, DSTP: distal soft tissue procedure, PMO: proximal metatarsal osteotomy, MPT: metatarsophalangeal, TMT: tasometatarsal.

12-14) Bock 등 12) 은중족골간부절골술 (scarf osteotomy) 후 10년추시연구에서 30% 의재발률을보고하였다. Chong 등 13) 은무지외반증수술후 5.2년의중기추시관찰연구에서 25.9% 의환자들이불편감을호소했다고보고하였으며 Jeuken 등 14) 은중족골간절골술시행후장기추시결과에서 75% 의재발률을보고하였다.

3 Sung-Hyun Lee, et al. Approach for the Treatment on Hallux Valgus 145 이호전됨을보고하기도하였다 (Fig. 2). 8-10) 2. 무지외반증의 3차원상의변형과치료 1) 무지외반증의관상면에서의회전변형현재통용되는분류는무지외반각과중족골간각의크기에기초한치료알고리즘 (severity-based system) 이다. 1,11) 이치료알고리즘은수평면상에서의무지외반각과중족골간각의교정에중점을두고있으나이에따른수술후중기및장기추시관찰연구에서예상보다높은재발률이보고되고있다 ) Bock 등 12) 은중족골간부절골술 (scarf osteotomy) 후 10년추시연구에서 30% 의재발률을보고하였다. Chong 등 13) 은무지외반증수술후 5.2년의중기추시관찰연구에서 25.9% 의환자들이불편감을호소했다고보고하였으며 Jeuken 등 14) 은중족골간절골술시행후장기추시결과에서 75% 의재발률을보고하였다. 여러연구들은방사선적계측후재발률이 25%~78% 까지높다고보고했으며이는현재시행되는무지외반증수술방법이여전히개선의여지가있음을시사한다 ) 무지외반증수술후다시변형이재발하는이유에대해서많은연구가이루어졌다. 그중 Okuda 등 16) 은종자골정복 (reduction) 여부를무지외반증수술후재발의주요위험인자로보고하였다. 또한후속논문에서관상면에서의회전변형을의미하는전후방단순방사선촬영상에서중족골두의외측이타원형으로보이는 round sign을보고하였으며이러한외회전을교정한절골술을시행하여 4% 재발률의좋은결과를보고하였다 (Fig. 3). 17,18) 1980년에 Scranton과 Rutkowski 19) 는사체등을대상으로건막류 (bunion) 변형여부에따른회내정도를측정하였다. 변형이있 는경우의회내정도는 14.5도, 변형이동반되지않은경우는 3.1도였다. 또한 Kim 등 20) 은컴퓨터단층촬영 (computed tomography) 을통한 3차원영상분석에서무지외반증환자의 87.3% 에서제 1중족골의외회전변형이증가됨을발표하였다. 또한중족골의회전변형과종자골의아탈구여부에따라무지외반증의회전변형을 4군으로분류하였으며실제로종자골이아탈구되지않았으나중족골의회전에의해아탈구된것처럼보이는가성종자골아탈구가 25.9% 에서관찰된다고하였다. 20) Dayton 등 21) 은외반을관상면상에서의외회전으로정의하며용어자체에무지와중족골의 3차원상의변형을내포하기위한 hallux abducto valgus with metatarsus primus adducto valgus 라는용어를제안하였다. 이를종합해볼때, 무지외반증을단순히수평면상의변형으로접근해치료한다면관상면상에서의회전변형을교정하기힘들며재발등의좋지않은결과로이어질수있다. 2) Triplane hallux abducto valgus classification 최근무지외반증의관상면에서의회전변형에대한연구가이루어지면서 Hatch 등 5) 은이에대한분류를제시했다. 기존의무지외반각및중족골간각으로무지외반증을진단후족부전후방방사선사진및체중부하종자골방사선사진 (weight bearing sesamoid axial view) 을통해중족골의외회전및종자골의아탈구여부를분류의기준으로삼았다. 이에따라중족골이외회전되지않은 class 1 과중곡골의외회전이관찰되는 class 2로분류하였으며 class 2는다시종자골의아탈구여부에따라 class 2A와 class 2B로세분화했다. 중족골내전각이 20도이상인경우를 class 3, 중족지관절의퇴행성변화가있는환자는 class 4로분류했다 (Fig. 4). A B Figure 3. Radiographs illustrating for the shape of the lateral edge of the first metatarsal head. (A) In case of metatarsal external rotation, the shape of lateral edge is a round shape (arrows). (B) When there is no metatarsal rotation, the shape of lateral edge had an angular shape (arrows).

146 Vol. 23 No. 4, December 2019 Type 1 Type 2 Type 3 Type 4 A Type 2A B Type 2B C D E Figure 4.

(A) Radiographs showing class 1 hallux abducto valgus, with no rotation observed on the axial view.

frontal/coronal plane rotation seen on sesamoid axial view.

또한분류에따라중족골외회전이있는 class 2에서는 3차원적변형을교정할수있는절골술을권고하였으며종자골아탈구가없는가성종자골탈구인 class 2A에서는과도한원위연부조직유리술을하지않을것을권고했다 (Table 1).

(validation) 조사가되지않았으므로더많은후속연구가필요하다고생각된다.

17,22,23) 이를바탕으로여러저자들은 3차원변형을위한절골술을시행할때제 1중족골의 CORA를교정하는것이바람직하며변형 Lapidus 술식을통해교정할수있다고주장하였다.

11,24) Dayton 등 22) 은원위중족골관절각을측정하는데검사자사이에낮은신뢰도를보인이유는중족골의관상면상에서외회전으로인해중족골관절면의내측 Table 1.

Pronation ( ) MT OT or TMT correction Sesamoid release 2A MT Pronation Sesamoid subluxation ( ) Triplane

4 146 Vol. 23 No. 4, December 2019 Type 1 Type 2 Type 3 Type 4 A Type 2A B Type 2B C D E Figure 4. Radiologic findings of Triplane hallux valgus classification. (A) Radiographs showing class 1 hallux abducto valgus, with no rotation observed on the axial view. (B) Radiographs of class 2A hallux abducto valgus showing eversion of the first metatarsal and the sesamoid still in the groove with intact crista. (C) Radiographs of class 2B hallux abducto valgus showing rotation of the first metatarsal with subluxation of the sesamoid complex. (D) Radiographs of class 3 hallux abducto valgus associated with metatarsus adductus, with no first metatarsal frontal/coronal plane rotation seen on sesamoid axial view. (E) Radiographs of class 4 hallux abducto valgus showing arthrosis of the first metatarsal phalangeal sesamoid complex. 또한분류에따라중족골외회전이있는 class 2에서는 3차원적변형을교정할수있는절골술을권고하였으며종자골아탈구가없는가성종자골탈구인 class 2A에서는과도한원위연부조직유리술을하지않을것을권고했다 (Table 1). 그러나 Hatch 등 5) 에의한 3차원적분류는현재통용되는무지외반각과중족골간각의정도및족근-중족관절과운동성에대해고려하지않아 Lapidus 외에다른술식을고려할경우적용이어려울수있으며아직이분류에대해타당성 (validation) 조사가되지않았으므로더많은후속연구가필요하다고생각된다. 3) 3차원적변형교정을위한절골술여러문헌에서무지외반증은 3차원상의변형이며해부학적인회전각의중심 (center of rotation angulation, CORA) 이제1 족근- 중족관절에있음을제시하였다. 17,22,23) 이를바탕으로여러저자들은 3차원변형을위한절골술을시행할때제 1중족골의 CORA를교정하는것이바람직하며변형 Lapidus 술식을통해교정할수있다고주장하였다. 5,22,23) 과거논문들에서는원위중족골관절각이측정자간에불일치성을보인다고보고하였다. 11,24) Dayton 등 22) 은원위중족골관절각을측정하는데검사자사이에낮은신뢰도를보인이유는중족골의관상면상에서외회전으로인해중족골관절면의내측 Table 1. Triplane Hallux Valgus Classification and Treatment Algorithm* Class Anatomic finding Treatment recommendation 1 MT Pronation ( ) MT OT or TMT correction Sesamoid release 2A MT Pronation Sesamoid subluxation ( ) Triplane correction±lateral capsulotomy 2B MT Pronation Sesamoid subluxation (+) Triplane correction+latereal capsular release 3 >20 MTA MT OT or triplane correction 2, 3 MT correction 4 Degenerative arthritis MTP arthrodesis MT: metatarsal, OT: osteotomy, TMT: tarsometatarsal, MTA: metatarsus adductus, MTP: metatarsophalangeal. *Radiologic findings of hallux valgus in all classification were increased hallux valgus angle and intermetatarsal angle. 및외측경계를명확히구분하기힘들기때문이라고주장하였다. 또 한원위중족골관절각에대한교정술식없이변형 Lapidus 술식만 으로수술후예후를평가하는중요한요소인원위중족골관절각이 호전되었음을보고하였다. 22) 그러나이러한변형 Lapidus 술식은기술적으로어려우며제 1 족 지열 (1st ray) 의단축이유발될수있으므로제 1 족지열이족배굴곡 이되지않도록유의해야한다. Yi 와 Lee 는 25) 3 차원적변형교정을

5 Sung-Hyun Lee, et al. Approach for the Treatment on Hallux Valgus 147 위한절골술을시행할때중족골전이통 (transfer metatarsalgia) 을 예방하기위해제 1 족지열시상면 (sagittal plane) 상에서의길이가 유지되어야하며또한절골면이관상면에평행할수록고정후안정 성이적기때문에금속판등의추가적인고정이필요하다고보고하 였다. Wagner 와 Wagner 26) 는근위중족골회전절골술 (proximal metatarsal rotational osteotomy, PROMO) 을 25 명의무지외반 증의환자에서시행하여좋은결과를발표하였다. 그러나 PROMO 술식은절골면의각도에의해교정정도가결정되므로수술전환자 의변형에대한정확한계산이필요하며이를통해정확한절골술을 할수있는특정기구가필요하다는단점이있다. 또한 Swanton 등 27) 은 중족골간부절골술 (scarf osteotomy) 을시행하면서절골면이족저 방향을향함으로서중족골의회전변형에대해교정효과를기대할수 있다고주장하였다. 또한중족지관절유합술은관절염이있거나변 형이심한무지외반증환자에서 3 차원적변형을같이교정할수있 는치료방법이다. 결 현재통용되고있는알고리즘에의한무지외반각및중족골간각 의정도에따른수술적치료는무지외반증의 3 차원적인변형을고 려하지않아개선의여지가있다. 단순히수평면상에서발생한무지 외반변형은고식적인수평면상에서의변형교정으로호전될수있 다. 그러나고도의무지외반변형은 3 차원상의변형을포함하는경 우가많다. 따라서무지외반증환자를치료하기위해 3 차원상에서 의변형을교정할수있는수술적치료방법을고려해야하며환자의 론 좋은예후에긍정적인영향을미칠것으로기대된다. REFERENCES 1. Coughlin MJ, Saltzman CL, Anderson RB, Mann RA. Mann's surgery of the foot and ankle. 9th ed. Philadelphia: Saunders Elsevier; p Menz HB, Lord SR. Gait instability in older people with hallux valgus. Foot Ankle Int. 2005;26: doi: / Coughlin MJ, Jones CP. Hallux valgus: demographics, etiology, and radiographic assessment. Foot Ankle Int. 2007;28: doi: / FAI Jang KS, Kim TW, Kim HJ. Diagnosis and pathophysiology of hallux valgus. J Korean Foot Ankle Soc. 2014;18:43-7. doi: / jkfas Hatch DJ, Santrock RD, Smith B, Dayton P, Weil L Jr. Triplane hallux abducto valgus classification. J Foot Ankle Surg. 2018;57: doi: /j.jfas Ko KR, Sung KS. Corrective osteotomies in hallux valgus. J Korean Foot Ankle Soc. 2017;21:43-9. doi: /jkfas Bednarz PA, Manoli A 2nd. Modified lapidus procedure for the treatment of hypermobile hallux valgus. Foot Ankle Int. 2000;21: doi: / Kim JY, Park JS, Hwang SK, Young KW, Sung IH. Mobility changes of the first ray after hallux valgus surgery: clinical results after proximal metatarsal chevron osteotomy and distal soft tissue procedure. Foot Ankle Int. 2008;29: doi: /FAI Coughlin MJ, Jones CP. Hallux valgus and first ray mobility. A prospective study. J Bone Joint Surg Am. 2007;89: doi: / JBJS.F Coughlin MJ, Shurnas PS. Hallux valgus in men. Part II: first ray mobility after bunionectomy and factors associated with hallux valgus deformity. Foot Ankle Int. 2003;24:73-8. doi: / Coughlin MJ, Freund E. Roger A. Mann Award. The reliability of angular measurements in hallux valgus deformities. Foot Ankle Int. 2001;22: doi: / Bock P, Kluger R, Kristen KH, Mittlböck M, Schuh R, Trnka HJ. The scarf osteotomy with minimally invasive lateral release for treatment of hallux valgus deformity: intermediate and long-term results. J Bone Joint Surg Am. 2015;97: doi: /JBJS.N Chong A, Nazarian N, Chandrananth J, Tacey M, Shepherd D, Tran P. Surgery for the correction of hallux valgus: minimum five-year results with a validated patient-reported outcome tool and regression analysis. Bone Joint J. 2015;97-B: doi: / X.97B Jeuken RM, Schotanus MG, Kort NP, Deenik A, Jong B, Hendrickx RP. Long-term follow-up of a randomized controlled trial comparing scarf to chevron osteotomy in hallux valgus correction. Foot Ankle Int. 2016;37: doi: / Iyer S, Demetracopoulos CA, Sofka CM, Ellis SJ. High rate of recurrence following proximal medial opening wedge osteotomy for correction of moderate hallux valgus. Foot Ankle Int. 2015;36: doi: / Okuda R, Kinoshita M, Yasuda T, Jotoku T, Kitano N, Shima H. Postoperative incomplete reduction of the sesamoids as a risk factor for recurrence of hallux valgus. J Bone Joint Surg Am. 2009;91: doi: /JBJS.H Okuda R, Kinoshita M, Yasuda T, Jotoku T, Kitano N, Shima H. The shape of the lateral edge of the first metatarsal head as a risk factor for recurrence of hallux valgus. J Bone Joint Surg Am. 2007;89: doi: /JBJS.F Yasuda T, Okuda R, Jotoku T, Shima H, Hida T, Neo M. Proximal supination osteotomy of the first metatarsal for hallux valgus. Foot Ankle Int. 2015;36: doi: / Scranton PE Jr, Rutkowski R. Anatomic variations in the first ray: Part I. Anatomic aspects related to bunion surgery. Clin Orthop Relat Res. 1980;(151): Kim Y, Kim JS, Young KW, Naraghi R, Cho HK, Lee SY. A new measure of tibial sesamoid position in hallux valgus in relation to the coronal rotation of the first metatarsal in CT scans. Foot Ankle Int. 2015;36: doi: / Dayton P, Kauwe M, Feilmeier M. Clarification of the anatomic definition of the bunion deformity. J Foot Ankle Surg. 2014;53: doi: /j.jfas

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07 이호승( ).hwp 대한족부족관절학회지 : 제 권제 호 6 J Korean Foot Ankle Soc. Vol.. No.. pp.56-6, 6 무지외반증에서외측연부조직유리술을함께시행한원위갈매기형절골술의치료결과 울산대학교의과대학정형외과학교실, 한일병원정형외과 * 이호승 지형철 이성우 김종민 * The Results of Distal Chevron Osteotomy with Lateral