Su-Young ae, et al. Surgical Complication of Hallux Valgus 51 Recurrence Insufficient correction Stiff joint 본 1. 관절의강직양호한무지외반증의치료결과를위해서중족족지관절의가동성을유지하

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1 Review rticle pissn eissn J Korean Foot nkle Soc 2017;21(2): 무지외반증교정수술후합병증 배서영, 이의종 인제대학교의과대학상계백병원정형외과학교실 Complications after Surgical Correction of Hallux Valgus Su-Young ae, Oei-Jong Lee Department of Orthopedic Surgery, Sanggye Paik Hospital, Inje University School of Medicine, Seoul, Korea The goal of surgical correction for hallux valgus is to achieve a painless, shoe-wearable, and relatively straight toe with a balanced joint motion that results in aesthetically and functionally satisfactory toe. To date, there has not been a consensus on the ultimate surgical procedure for hallux valgus correction. Unfortunately, such a consensus may be difficult since it is not uncommon to encounter complications after hallux valgus correction. Postoperative soft tissue complications include difficult wound healing, infection, hypertrophy, or pain of the scar, joint stiffness, and tendon or sensory nerve damage. Postoperative bony complications include malunion, nonunion, failure of fixation, failure of angle correction, recurred deformity, osteomyelitis, and failure of balance between the metatarsal heads. Herein, we review common complications after surgical correction of hallux valgus, such as stiff joint, bony complications, recurrence of the deformity, and hallux varus. Key Words: Hallux valgus, Complications 서 무지외반의치료에서교정수술의목표는통증이없고충분히유연하고균형있게움직이면서비교적곧은, 즉기능적이면서도미용적으로만족할만한발을얻는데있다. 오랜세월동안무지외반증의수술적치료에있어다각적치료법들이시도되어왔지만수술술기는다양하고결과의예측은여전히어렵다. 술자마다각각다른수술방법을사용하고있는가장큰이유는수술후합병증이가장적은수술방법에대한합의가아직이루어지지않았기때문이다. 이를바꾸어말하면모든수술방법은여전히어느정도수술후합병증에취약하다고할수있다. 한편환자에게수술적치료를설명함에있어가능한합병증들을가급적모두포함하여설명해야하는국내의료환경의사회적요 Received May 15, 2017 Revised June 8, 2017 ccepted June 8, 2017 Corresponding uthor: Su-Young ae Department of Orthopedic Surgery, Sanggye Paik Hospital, Inje University School of Medicine, 1342 Dongil-ro, Nowon-gu, Seoul 01757, Korea Tel: , Fax: , youngos@paik.ac.kr 구에따라합병증에대한이해와설명및대처는점점중요해지고있다. 수술적치료의모든예상할수있는합병증을빠짐없이설명하거나기술하는것은불가능하지만비교적흔히발생하는합병증에대한수술전후의관심은환자와의사모두에게중요하다. 무지외반증의수술후합병증의빈도는수술전변형의정도, 수술방법등에따라다르게보고되며 10% 50% 에이르기까지매우다양하여일정한합병증의빈도를말하기어렵다. 1,2) 수술후합병증은창상합병증, 감염, 상흔의비후나통증, 관절강직, 괴사, 3) 건손상이나감각신경의손상 4) 과같은연부조직합병증과부정유합이나불유합, 5,6) 변형각교정의실패나고정실패, 7) 골수염, 무혈성괴사, 8) 중족골길이나골두의상하위치의부조화등골성합병증으로나누어볼수있다 (Fig. 1). 여기서는비교적흔히발생하는합병증에대한예방및가능한대처방법들을관절의강직, 골유합에관련된합병증, 변형의재발, 무지내반증 9-11) 등으로나누어살펴보고자한다. Financial support: None. Conflict of interest: None. Copyright c2017 Korean Foot and nkle Society. ll rights reserved. CC This is an Open ccess article distributed under the terms of the Creative Commons ttribution 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 Su-Young ae, et al. Surgical Complication of Hallux Valgus 51 Recurrence Insufficient correction Stiff joint 본 1. 관절의강직양호한무지외반증의치료결과를위해서중족족지관절의가동성을유지하는것은매우중요하다. 수술후관절의강직을일으키는관절연부조직의섬유화 (arthrofibrosis) 는단순히관절침습적수술후발생하는반흔조직외에도기존의중족지간관절퇴행성변화나이미변형된골두와상합하지않는종자골, 술후통증이나부종으로관절가동지연, 감염, 수술후관절낭을너무단단히중첩시켜봉합하는경우등다양한요인이작용한다. 관절의유연성을유지하기위해서는부종을빨리완화시키고, 통증을잘조절하며, 조기에관절운동을시작해야하며수술중과도한관절낭의절제나과한중첩봉합을지양하고자연스러운수동운동이가능한범위에서관절낭을봉합하는것이중요하다. 중족골의길이가길어지면관절에과도한압력이가해져운동범위가줄수있으므로중족골의길이변화에주의하여야한다. 중족골두가족저혹은족배측으로전위되면그또한통증이나수동및능동관절운동범위가줄어드는원인이되므로주의해야한다. 즉관절의가동성에는연부조직과골조직모두가관여한다. 관절낭의과도한중첩이나관절유착에의한관절운동제한은유착조직의유리술과관절수동조작등으로어느정도호전될수있지만 12) 중족골두의삼차원적부정위나종자골의상합성문제등 13) 골의구조적요인이동반되어있다면연부조직유리술만으로는충분하지않고골두의적정위치를얻기위해재절골술을시행하는등관절감압을위한추가의조치가필요할수있다. 2. 골조직합병증 Hallux varus Hallux valgus correction 1) 불유합과지연유합골구조에의한합병증중부정유합은변형의재발혹은불충분한교정과연관되므로순수한골합병증은불유합과골수염, 골의무혈성괴사 8) 라고할수있다. 불유합은무지외반증의수술적교정에서그리흔하지않은합병증이다. 대부분은절골후고정력이 Transfer metatarsalgia Nonunion, delayed union, VN Tendon injury, infection Figure 1. Several soft tissue and bony complications after hallux valgus correction surgery. VN: avascular necrosis. 충분하지않거나너무일찍체중부하를시도한경우, 절골의모양이나전위가부적절하여접촉면이너무작은경우등에발생하는데대부분은불유합이라기보다는지연유합에가깝다. 일단불유합이발생하면교정의실패가어느정도동반되므로무지외반잔존변형의정도가받아들일수있는정도라면체중부하및보행의제한만으로대개충분한치료가된다. 그러나수술적치료가요구될정도의변형과유합실패가동반되어있다면변형의재교정과골유합을동시에얻기위해처음시행했던수술방법보다더견고한고정물을선택하고필요시골이식을주저하지말아야한다. 불유합혹은지연유합이관찰되는경우감염이혼재되어있는지살펴야하며이경우모든치료목적에앞서감염에대한치료가우선되어야하므로환자와충분한논의를거쳐적극적으로대처하도록해야한다. 2) 골괴사골괴사가발생하는원인은중족골의원위절골술, 감염, 중족족지관절외측의연부조직유리술등이다. 8) 종족골두의혈류공급은관절족배측과외측에위치하는족배동맥의망상구조에의한골외분포및중족골원위외측으로들어가는영양동맥에의하는데앞서나열한모든술기는이혈류를차단시킬수있기때문에골괴사의위험요인으로생각된다. 원위중족골절골중가장흔히사용하는갈매기형 (chevron) 절골술에서무혈성괴사의빈도는그리흔하지않고기존의연구들에서는 0% 10% 로일정하지않게보고되고있는데 1985년 Meier 와 Kenzora 14) 가원위절골술만시행하는경우에 20%, 외측연부조직유리술을함께시행하는경우에 40% 라고보고하면서그위험성에대한염려가다소과장된바있다. 또한대부분의경우에중족골두의골괴사는외측골두의일부만을침범하고골두전체의함몰로발전하지않기때문에변형의진행이나증상을반드시동반한다고는할수없다. 골괴사가관찰되는경우라도골두의침범이광범위하지않고관절이안정적이라면조심스럽게골두의변화를관찰하는것으로충분하고염증반응에의한관절증상이동반되는동안만활동을제한시키면된다. 드물지만골두전체의함몰이나변형, 이차적관절염의진행이일어날수있는데이때는골두절제나중족지간관절의유합술을고려해야한다. 일단골괴사가일어나관절유합술을시행해야하는경우에는무지의길이유지를위하여지주골이식 (strut bone graft) 을시행해야하는경우가대부분이며고정도용이하지않아관절유합술에따른이차적합병증, 즉가관절 (pseudarthrosis) 에도유의해야한다. 15) 골괴사가한번발생하면비록유의한증상이동반되지않더라도진행여부에대해서는근접추시가필요한것은사실이므로위험요인으로작용할수있는술기들은주의를기울일필요가있다. 즉외측연부조직의조작은최소로하고원위절골술을시행할때톱날이외측으로깊이전진하지않도

52 Vol. 21 No. 2, June 2017 록항상주의하여야한다. 이와는별개로통풍성관절염을가지고있는환자의무지외반수술후에는통풍결절의침착에의한골침식으로관절면일부가무혈성골괴사처럼보일수있으므로통풍성관절염증상이반복되지않도록관리하는것도중요하다. 3.

다만불충분한교정은애초에변형이큰경우, 연소기무지외반증, 중족골내전이동반되거나관절의과도한유연성혹은경직등여러요인과도연관되므로수술후발생하는변형의재발을술자가완벽하게제어하는것은거의불가능하다. 원위갈매기형절골술후중족골간각이 15도이상이거나무지외반변형각이 35도이상이면약 10% 에서변형이재발된다는보고가있고수술방법에무관하게변형의재발은 2.

일단무지외반변형이재발하면일차수술보다좀더섬세한수술전략이요구된다. 재발한변형을구성하는가장중요한요소가 무엇인지얼마만큼의교정이필요한지숙고하고일차적수술전략외에도만일수술중충분히교정되지않으면어떤술식을추가로시행할것인가에이르기까지치밀한계획을필요로한다.

변형의재교정을위해서는관절의진행된관절염여부, 중족족지관절의상합성, 이전의술기, 근위지골의형태, 중족골간각의정도, 무지외반변형의각변형정도외에도진행성여부와연부조직의문제가동반되어있는가를모두고려하여이차술기를결정하여야한다.

3 52 Vol. 21 No. 2, June 2017 록항상주의하여야한다. 이와는별개로통풍성관절염을가지고있는환자의무지외반수술후에는통풍결절의침착에의한골침식으로관절면일부가무혈성골괴사처럼보일수있으므로통풍성관절염증상이반복되지않도록관리하는것도중요하다. 3. 무지외반변형의재발혹은불충분한교정변형의재발은엄밀하게말하자면변형이수술에의해충분히교정된뒤일정시간이경과된후재발하는것을의미하지만대부분의재발은변형의교정과정중에술자의예측가능여부에상관없이, 변형의하나이상의요인이불충분하게교정되고외반변형이다시발생하는원인이되어발생한다. 따라서변형의재발은불충분한교정과항상연관되어있다. 다만불충분한교정은애초에변형이큰경우, 연소기무지외반증, 중족골내전이동반되거나관절의과도한유연성혹은경직등여러요인과도연관되므로수술후발생하는변형의재발을술자가완벽하게제어하는것은거의불가능하다. 원위갈매기형절골술후중족골간각이 15도이상이거나무지외반변형각이 35도이상이면약 10% 에서변형이재발된다는보고가있고수술방법에무관하게변형의재발은 2.7% 에서 16% 까지다양하게보고되며, 재발에의한재교정수술이필요한빈도역시원위절골술, 근위절골술, 중족족근관절유합술 (Lapidus procedure) 간에유의한차이가없다고보고되고있다. 1,2,16-20) 이를보면심한변형을가진무지외반증에서재발의위험이크지만어떤수술방법을선택하는지에대해서는상대적으로덜영향을받는다고할수있다. 일단무지외반변형이재발하면일차수술보다좀더섬세한수술전략이요구된다. 재발한변형을구성하는가장중요한요소가 무엇인지얼마만큼의교정이필요한지숙고하고일차적수술전략외에도만일수술중충분히교정되지않으면어떤술식을추가로시행할것인가에이르기까지치밀한계획을필요로한다. 환자의현재변형정도, 진행여부, 교정목표, 증상의정도, 환자가원하는교정의정도를파악하고수술방법을선택해야하며수술방법및교정목표를정할때뿐만아니라수술후관리에도환자를적극적으로동참시키는것이바람직하다. 방사선적소견만을기준으로재수술을결정하는것보다환자가불편을느끼는증상여부와정도에따라재교정술이정말필요한지를판단하는것이우선되어야한다. 변형의재교정을위해서는관절의진행된관절염여부, 중족족지관절의상합성, 이전의술기, 근위지골의형태, 중족골간각의정도, 무지외반변형의각변형정도외에도진행성여부와연부조직의문제가동반되어있는가를모두고려하여이차술기를결정하여야한다. 이차교정술의방법으로는일차수술방법에동원가능한모든술기를포함하며, 중족족지관절의유합술이나중족족근관절의유합술과같은관절제거수술 (joint sacrificing procedure) 들도고려되며관절의재정렬을유도하는절골술및연부조직의유리술이동반되어시행되기도한다. 모든이차교정술의구체적방법은각증례마다철저하게개별적으로구상되어야한다 (Fig. 2, 3). 최근들어변형의재발의한위험요소로중족골의원위관절면이이루는각도 (distal metatarsal articular angle, DM) 가주목되고있고이의적절한교정을위해중족골의절골중에원위골편을회전전위시키거나두곳에서절골을시행하여중족골간각과원위중족골관절면각을동시에교정하는 이중절골술 (double osteotomy) 을시행하기도한다. 하지만이런방법이재발한무지외반증의치료에항상필요하다고하기어렵고, 모든무지외반증 Figure 2. Insufficient correction of hallux valgus deformity () in a 75-year-old female patient was treated with metatarsophalangeal joint arthrodesis (). Figure 3. Recurred hallux valgus deformity (middle) after proximal osteotomy () was treated with proximal arthrodesis ().

Su-Young ae, et al. Surgical Complication of Hallux Valgus 53 의재발에 DM의증가가원인으로작용하는것도아니어서일괄적적용은여전히어렵다.

그러나많은무지외반변형재발의경우여러가지원인과문제점들을동시에가지고있는경우가많다. 예를들어근위관절의불안정이있으면서 DM도증가되어있고근위지골의형태는외측으로편향되어있고평편족이면서어느정도의중족지간관절의관절염을가지고있다면재절골을시행할것인지, 관절유합술을시행할것인지, 관절유합술을어디에서시행할것인지등여전히쉽지않은고민이남게된다.

dditional proximal metatarsal and kin osteotomies and combined lesser toe correction procedures were performed () to correct recurred hallux valgus (). 4. 무지내반변형무지내반변형은무지외반의수술적치료후그리드물지않은합병증중하나다.

경험이많은족부정형외과전문의들중에는무지내반증보다는차라리경도의무지외반변형을남기는것을수용하겠다고하는이들이많은데이는무지내반증이한번발생하면그만큼교정이쉽지않기때문이다.

4 Su-Young ae, et al. Surgical Complication of Hallux Valgus 53 의재발에 DM의증가가원인으로작용하는것도아니어서일괄적적용은여전히어렵다. 21) Raikin 등 7) 은 2014년제시한재수술의알고리듬 (algorithm) 을통해재수술을위해중족지간관절의관절염유무, DM의증가여부, 근위관절인족근중족관절의불안정성, 족지골의형태, 중족골간각의교정불충분여부등을고려하여관절유합술을시행할것인지, 재절골술을시행할것인지, 어느위치의절골술을선택할것인지등에대한지침을제시하고있다. 그러나많은무지외반변형재발의경우여러가지원인과문제점들을동시에가지고있는경우가많다. 예를들어근위관절의불안정이있으면서 DM도증가되어있고근위지골의형태는외측으로편향되어있고평편족이면서어느정도의중족지간관절의관절염을가지고있다면재절골을시행할것인지, 관절유합술을시행할것인지, 관절유합술을어디에서시행할것인지등여전히쉽지않은고민이남게된다. 따라서실제로는대부분의재수술에서여러술기를병합하는것을고려해야한다 (Fig. 4). Figure 4. dditional proximal metatarsal and kin osteotomies and combined lesser toe correction procedures were performed () to correct recurred hallux valgus (). 4. 무지내반변형무지내반변형은무지외반의수술적치료후그리드물지않은합병증중하나다. Mcride 술기시행후약 5% 에서무지내반변형이보고되었고이후다양한수술술기를통해 2% 에서 17% 까지발생하는것으로알려져있다. 1,2,9-11) 무지내반증발생역시수술후무지외반증의재발만큼이나그원인을찾아내기가쉽지않다. 경험이많은족부정형외과전문의들중에는무지내반증보다는차라리경도의무지외반변형을남기는것을수용하겠다고하는이들이많은데이는무지내반증이한번발생하면그만큼교정이쉽지않기때문이다. 보편적으로지목되는무지내반변형과연관된원인인자로는외측종자골의절제에의한내측종자골과건의내측편위, 내측중족골두융기부의과도한절제, 내측연부조직의과도한봉합, 외측연부조직의과도한유리, 중족골간각의과도한교정, 수술후중족족지관절을내전시켜드레싱한경우등을들수있다. 앞서말한것처럼무지내반의교정수술은쉽지않다. 내측연부조직의유리술, 외측관절낭의겹침봉합, 무지신전건의이전술등연부조직에대한수술과중족골간각을다시넓히기위한각종중족골의역교정절골술과근위지골의역절골술등을병합하여 22) 술기를결정해야한다 (Fig. 5). 무지내반변형은여러원인이병합되어발생하는것과마찬가지로수술방법역시어느하나로특정될수없다. 한번무지내반변형이발생하면외반변형의재발보다다시재발하는위험이크다. 또한심하지않은경도의내반변형은환자가별다른불편을호소하지않는경우가많아방사선학적각도가내반이라고하더라도추가수술을섣불리결정하는것은바람직하지않다. 내반변형은변형각도보다도변형이진행하는지혹은정체된변형인지, 환자의불편을초래하는정도의변형인지고려하여수술적치료여부를판단하는것이중요하다. Crawford 등 9) 은 2014년무지내반증의치료알고리듬을제안했는데내반변형이이미고정된변형인지유연한변형인지가중요한결정지표가된다. 또한수술후 6주이내에생긴변형은일반적 Figure 5. Hallux varus deformity () was corrected by reverse chevron osteotomy and lateral sliding osteotomy of proximal phalanx at a same time ().

5 54 Vol. 21 No. 2, June 2017 으로수동조작이나붕대감기의조정, 보조기등으로치료하면서관찰하여진행하는지볼수있고, 유연한내반변형이면서진행성이더라도초기에는연부조직유리술과같은간단한수술후주의깊게관찰할수있다. 하지만변형의정도가크고진행성이라면보다적극적으로재절골술을고려할필요가있다고하겠다. 최근에는무지외반증에절개를최소로하고경피적절골술후고정하는교정수술방법들이소개되어사용되기도하고중족골간각의교정을절골술이아닌고정장치 (tightrope) 를사용하여수술하는방법들이소개되기도하며중족골의절골술을시행하더라도다양한금속판을사용하는경우가많아지고있는데 23,24) 이러한새로운수술방법들은새로운합병증을만들기도한다. 따라서새로운수술술기를적용하는경우이에따를수있는합병증및합병증에대한치료방법까지심사숙고하는자세가필요하다. 결 무지외반증의수술적교정후합병증은여전히다양하고드물지않지만각합병증에대한심도깊은연구들이이루어지고있는만큼수술후발생하는합병증에대해서과거보다잘이해하고대처하는것이가능해졌다. 다만수술전혹은수술중에합병증의발생을예측하는것은아직도거의불가능하기때문에수술적치료에앞서다양한합병증에대해충분히설명하고발생한합병증에대해서는적극적으로대처하는자세가필요하다. REFERENCES 111 Sammarco GJ, Idusuyi O. Complications after surgery of the hallux. Clin Orthop Relat Res. 2001;(391): Schuh R, Willegger M, Holinka J, Ristl R, Windhager R, Wanivenhaus H. ngular correction and complications of proximal first metatarsal osteotomies for hallux valgus deformity. Int Orthop. 2013;37: Goforth WD, Kruse D, rantigan CO, Stone P. cute ischemia after revision hallux valgus surgery leading to amputation. J Foot nkle Surg. 2013;52: Jastifer JR, Coughlin MJ, Doty JF, Stevens FR, Hirose C, Kemp TJ. Sensory nerve dysfunction and hallux valgus correction: a prospective study. Foot nkle Int. 2014;35: Goldberg, Singh D. Treatment of shortening following hallux valgus surgery. Foot nkle Clin. 2014;19: Roukis TS. Nonunion after arthrodesis of the first metatarsalphalangeal joint: a systematic review. J Foot nkle Surg. 2011;50: Raikin SM, Miller G, Daniel J. Recurrence of hallux valgus: a review. Foot nkle Clin. 2014;19: Rothwell M, Pickard J. The chevron osteotomy and avascular necrosis. Foot (Edinb). 2013;23: Crawford MD, Patel J, Giza E. Iatrogenic hallux varus treatment algorithm. Foot nkle Clin. 2014;19: Kannegieter E, Kilmartin TE. The combined reverse scarf and opening wedge osteotomy of the proximal phalanx for the treatment of iatrogenic hallux varus. Foot (Edinb). 2011;21: Plovanich EJ, Donnenwerth MP, bicht P, orkosky SL, Jacobs PM, Roukis TS. Failure after soft-tissue release with tendon transfer for flexible iatrogenic hallux varus: a systematic review. J Foot nkle Surg. 2012;51: Feuerstein C, Weil L Jr, Weil LS Sr, Klein EE, rgerakis N, Fleischer E. Joint manipulation under anesthesia for arthrofibrosis after hallux valgus surgery. J Foot nkle Surg. 2016;55: Woo K, Yu IS, Kim JH, Sung KS. Effect of lateral soft tissue release on sesamoid position in hallux valgus surgery. Foot nkle Int. 2015;36: Meier PJ, Kenzora JE. The risks and benefits of distal first metatarsal osteotomies. Foot nkle. 1985;6: Easley ME, Kelly IP. vascular necrosis of the hallux metatarsal head. Foot nkle Clin. 2000;5: Gutteck N, Wohlrab D, Zeh, Radetzki F, Delank KS, Lebek S. Immediate fullweightbearing after tarsometatarsal arthrodesis for hallux valgus correction: does it increase the complication rate? Foot nkle Surg. 2015;21: Pentikäinen I, Piippo J, Ohtonen P, Junila J, Leppilahti J. Role of fixation and postoperative regimens in the long-term outcomes of distal chevron osteotomy: a randomized controlled two-by-two factorial trial of 100 patients. J Foot nkle Surg. 2015;54: Rink-rüne O. Lapidus arthrodesis for management of hallux valgus: a retrospective review of 106 cases. J Foot nkle Surg. 2004;43: Willegger M, Holinka J, Ristl R, Wanivenhaus H, Windhager R, Schuh R. Correction power and complications of first tarsometatarsal joint arthrodesis for hallux valgus deformity. Int Orthop. 2015;39: Wood EV, Walker CR, Hennessy MS. First metatarsophalangeal arthrodesis for hallux valgus. Foot nkle Clin. 2014;19: Park CH, Cho JH, Moon JJ, Lee WC. Can double osteotomy be a solution for adult hallux valgus deformity with an increased distal metatarsal articular angle? J Foot nkle Surg. 2016;55: Choi KJ, Lee HS, Yoon YS, Park SS, Kim JS, Jeong JJ, et al. Distal metatarsal osteotomy for hallux varus following surgery for hallux valgus. J one Joint Surg r. 2011;93: Dayton P, Sedberry S, Feilmeier M. Complications of metatarsal suture techniques for bunion correction: a systematic review of the literature. J Foot nkle Surg. 2015;54: Iannò, Familiari F, De Gori M, Galasso O, Ranuccio F, Gasparini G. Midterm results and complications after minimally invasive distal metatarsal osteotomy for treatment of hallux valgus. Foot nkle Int. 2013;34:

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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