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1 ISSN (Print) ISSN (Online) 대한골절학회지제 27 권, 제 4 호, 2014 년 10 월 J Korean Fract Soc 2014;27(4): Original Article Type IIIb 개방성경골골절의치료 임성연 이일재 * 조재호 송형근 아주대학교의과대학정형외과학교실, 성형외과학교실 * Treatment of Type IIIb Open Tibial Fractures Seong Yeon Lim, M.D., Il Jae Lee, M.D.*, Jae Ho Joe, M.D., Hyung Keun Song, M.D. Departments of Orthopedic Surgery, Plastic Surgery*, Ajou University School of Medicine, Suwon, Korea Purpose: The purpose of this study is to evaluate the outcome of treatment for patients with Type IIIb open tibial fractures. Materials and Methods: This study targeted 35 adult patients for whom follow-up was possible over one year after undergoing surgical treatment. There were 29 males and six females with an average age of 45 years. Results: Fracture location was proximal in 10 cases, midshaft in 13 cases, and the distal part of the tibia in 12 cases. An average of 10 days was observed for definitive fixation with soft tissue coverage of the injury. The mean time to radiographic union was 27 weeks. Sixteen cases (45.7%) of complications were observed. Three cases of superficial infection, two cases of deep infection, four cases of partial flap necrosis, three cases of mal-alignment, three cases of joint stiffness, and one case of hardware breakage were observed. The mean lower extremity functional scale score was 68.5 and the factors influencing the clinical results were severity of open wound (p=0.000) and occurrence of complications (p=0.000) according to results of multiple regression analysis. Conclusion: In treatment of Type IIIb open tibial fractures, good clinical results can be expected provided that complications are prevented through proper reduction, firm fixation, early soft tissue reconstruction, and early rehabilitation. Key Words: Tibia, Open fractures, Soft tissue injuries, Negative-pressure wound therapy 서 경골골절은가장흔한장골의골절이며저에너지, 저변위손상부터심각한연부및골조직결손을동반한고에너지손상까지임상양상이매우다양하다. 1) 경골의전내측 론 Received April 4, 2014 Revised May 12, 2014 Accepted July 10, 2014 Address reprint requests to: Hyung Keun Song, M.D. Department of Orthopedic Surgery, Ajou University Hospital, 164 WorldCup-ro, Yeongtong-gu, Suwon , Korea Tel: ㆍFax: ostrauma@ajou.ac.kr Financial support: None. Conflict of interest: None. 부위는피하층에위치하기때문에경골의골절은개방성골절과연관되는경우가많으며이같은골절은심각한연부조직손상, 골결손, 구획증후군, 신경및혈관조직의손상을동반하는경우가많고이로인한감염, 불유합, 창상합병증을동반하기도한다. 발달된연부조직의치료방법및내고정물의다양성에도불구하고개방성경골골절에서좋은결과를얻기는매우어렵다. 2) 개방성경골골절의초기치료목표는손상의범위를명확히파악하고적절한항생제, 변연절제, 창상세척을통해감염을예방하는것이며최종치료의목적은적절한개방창의수복을통하여감염을예방하고다리길이의회복, 올바른정렬및회전, 골절의안정성을획득하여기능을 Copyright c 2014 The Korean Fracture Society. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 267

2 268 Seong Yeon Lim, et al. 회복하는것이다. 3-5) 이에저자들은 Type IIIb 개방성경골골절의환자를대상으로치료후결과에영향을주는인자들에대하여분석하였다. 1. 연구대상 대상및방법 2011 년 3 월부터 2013 년 3 월까지아주대학교병원에내원한만 18 세이상의성인경골골절환자 214 예가내원하였으며, 그중 Gustilo-Anderson 분류 6) 에의한 Type IIIb 의개방성골절환자중술후 1 년이상추시가가능하였던환자를대상으로의무기록과방사선사진을이용하여후향적분석을실시하였다. 골절의분쇄상및손상정도가심하여초기치료로절단술을시행한환자 (4 예 ), 명확한뇌손상 ( 수상후 21 일째또는퇴원시 Glasgow coma scale 15 점이하 ; 1 예 ), injury severity score 16 점이상의다발성손상환자 (6 예 ), 병적골절 (1 예 ), 인공치환물주위골절환자 (1 예 ), 타병원등의경유를원인으로본원으로이송이수상후 12 시간이상지연된환자 (2 예 ) 는제외하였다. 연구에포함된환자는총 35 명이었고이들중남자 29 예 (82.9%), 여자 6 예 (17.1%) 였으며평균나이는 45 세 (19-80 세 ) 였다. 수상기전은교통사고 14 예 (40%), 압궤손상 7 예 (20%), 추락사고 13 예 (37.1%), 총상 1 예 (2.9%) 였다. 골절위치, 개방창의넓이 (cm 2 ), 초기신경손상유무, 수상일로부터골절내고정까지걸린시간, 일시적외고정장치의사용유무, 내고정물의종류, 연부조직재건방법, 재원기간, 골유합까지걸린기간, 추가수술의유무및합병증의유무를조사하였다. 2. 수술방법및술후처치 수술은응급실도착이후 12 시간이내에시행하는것을원칙으로하였다. 응급실에내원한직후개방창의균주배양검사, 세척술을시행하고 1 세대 cephalosporin 과 aminoglycoside 를병행투여하였고임시석고부목을고정하였다. 수술실로이송하여변연절제술및세척술을시행하고외고정을시행하거나내고정을시행하였다. 모든개방창은진공보조봉합 (vacuum-assisted closure) 을이용한음압창상치료법 (negative-pressure wound therapy) 을 Curavac (Daewoong Pharm. Co. Ltd., Seoul, Korea) 을이용하여시행하였다. 초기고정으로골절의안정성을확보한후개방창의치료를위해 1-2 일간격으로반복적인변연절제술과세척술을시행하였고, 개방창에는음압창상치료법을유지하였다. 항생제는병행투여를수상후 3 일간유지하고그이후에는연부조직상태에따라서 1 세대 cephalosporin 의유지기간을결정하였다. 반복적인상처세척술및음압창상치료법으로연부조직상태가호전되고환자의전신상태가회복된후골절의고정과연부조직재건을동시에시행하고재건한연부조직상태가호전되면관절범위운동및근력운동을시행하였으며, 부분체중부하허용하에목발보행을시행하였다. 3. 평가방법 방사선학적평가는골유합시기및정렬을평가하였다. 골유합시기는추시방사선사진검사상전후면, 측면, 양사선촬영중 3장이상에서가골가교형성을보이며임상적으로골절부의압통이없을때로정하였다. 7) 부정유합은전후면, 측면사진검사상각변형및내반, 외반변형이 10도이상일때로정의하였으며측정은 Milner 8) 의방법에따랐다. 또한건측에비하여 10 mm 이상길이감소가있을때단축으로정의하였다. 9) 임상적기능평가는 lower extremity functional scale (LEFS; 0: unable to perform any activity, 80: excellent function) 10) 을이용하여시행하였으며, 환자의정보를모르는재활치료사가평가하였다. 조사한여러인자가임상점수에미치는영향을분석하기위하여 SAS version 9.1 (SAS Institute Inc., Cary, NC, USA) 을이용하여통계분석 (Mann-Whithney U test, Kruskal- Wallis test, chi-square test, Spearman test) 을시행하였고 p <0.05 일때통계적으로유의하다고판단하였다. 또한위의분석에서임상결과에영향을주는인자를파악하기위하여다변량분석방법 (multiple regression test) 을시행하였다. 결 골절부위는근위부골절 (AO/OTA type 41) 10예 (28.6%), 간부골절 (AO/OTA type 42) 13예 (37.1%), 원위부골절 (AO/OTA type 43) 12예 (34.3%) 였다. 내원당시신경손상이관찰된환자는 11예 (31.4%) 였으며, 구획증후군이발생하여근막절개술을시행한환자가 3예였다. 평균연부조직손상넓이는 49.2 cm 2 (3-220 cm 2 ) 이며, 수상후연부조직재건및내고정까지걸린시간은평균 10일 (3-16일 ) 이었다. 환자의평균재원기간은 45.7일 (16-101일) 이었고평균추시기간은 16개월 (12-24개월) 이었다. 모든환자에서골유합을얻었으며골유합까지기간은평균 27주 (15-63주 ) 였다. 외고정은 31예 (88.6%) 에서시행하였으며, 시행하지않은 4예는수상당일골수정삽입술을시행하였다. 내고정시이용한기구는골수정이 10예 (28.6%), 금속판이 25예 (71.4%) 였다. 연부조직재건은유리피판술 14예 (40%), 천공지피판술또는회전피판술 21예 (60%) 로시행하였다. 과

$fracture.$ system was applied to the open

3 Treatment of Type IIIb Open Tibial Fractures 269 Fig. 1. (A) A 65-year-old man sustained a type IIIb open tibia segmented fracture. (B) The vacuum-assisted closure system was applied to the open wound after debridement and temporary external fixation and provisional plate fixation. (C) An unreamed tibial nail was applied with an antero-lateral thigh free flap at 12 days after injury. (D) No visible callus on the proximal segmented area was observed at two months after surgery. (E) Plate augmentation without bone graft. (F) Clinical photograph shows a successful result 14 months after injury and the fracture was healed without complication.

4 270 Seong Yeon Lim, et al. 골유합까지추가수술을시행한환자는 14 예 (40%) 로심부감염으로내고정제거및변연절제술시행 2 예, 피판의부분괴사로부분층식피술 4 예, 관절강직으로관절유리술 2 예, 내고정물파손으로내고정물교환이 1 예, 골수정삽입후근위부골편의불안정으로금속판추가고정술시행 1 예 (Fig. 1), 골결손부위의자가장골이식술 4 예였다. 합병증은 16 예 (45.7%) 에서발생하였는데, 합병증으로천부감염 3 예 (8.6%), 심부감염 2 예 (5.7%), 피판부피부부분괴사 4 예 (11.4%), 부정정렬 3 예 (8.6%), 관절강직 3 예 (8.6%), 내고정물파손 1 예 (2.9%) 로조사되었다. 이중천부감염은내고정물의제거없이항생제투약만으로회복 되었으며심부감염 2 예중 1 예는골유합이후발생하여내고정물제거, 변연절제술, 항생제투약으로회복되었다. 다른 1 예는내고정물제거후원형외고정장치로교환하고변연절제술및골절골술을통한골이동술로치료하였다. 내고정물이파손된 1 예는골절원위부나사의파손이있었으며골이식없이더긴금속판으로교환하여골유합을얻었다. 관절강직 3 예중 1 예는관절유리술및대퇴사두근성형술을시행하였고 1 예는비관혈적관절수동술을시행하였다 (Table 1). 임상점수인 LEFS 는평균 68.5 점 (43-78 점 ) 으로조사되었다. LEFS 에는다중선형회귀분석 (R 2 =0.694) 상초기연부 Table 1. Factors associated with Complication Following Open Tibial Fractures Factors Complication (n=16) No complication (n=19) p-value Age (yr) Gender Male Female Defect size (cm 2 ) Fracture location Proximal Mid shaft Distal Time between injury and definite surgery (d) Fixation device Nail Pate Soft tissue coverage Free flap Perforator flap Union time (wk) Lower extremity functional scale 39.7± (75) 4 (25) 48.28± (31.3) 7 (43.8) 4 (24.9) 10.06± (25.0) 12 (75.0) 6 (37.5) 10 (62.5) 33.19± ± ± (89.5) 2 (10.5) 50.05± (26.3) 6 (31.6) 8 (42.1) 9.11± (31.6) 13 (68.4) 8 (42.1) 11 (57.9) 22.16± ± * * * * 0.000* Values are presented as mean±standard deviation or number (%). *Mann-Whitney test, Fisher s exact test, Chi-square test. Table 2. Associations of Lower Extremity Functional Scale with Patient Variables Variable Univariate linear regression analysis Multiple linear regression analysis Beta±standard error p-value Beta±standard error p-value Age (yr) Gender Fracture part Nerve injury Defect size Trauma to DS* Device Additional surgery Complication Union time 0.153± ± ± ± ± ± ± ± ± ± ± ± *Time trauma to definitive surgery, Used on definitive surgery (nail or plate).

5 Treatment of Type IIIb Open Tibial Fractures 271 조직손상넓이 (β±standard error = 0.059±0.015, p=0.000) 와합병증의발생유무 (β±stndard error = ±1.479, p=0.000) 가영향을주는것으로조사되었다 (Table 2). 고 광범위한연부조직손상을동반한개방성경골골절 (Type IIIb) 의치료는연부조직의재건및하지구제를위하여많은발전이이뤄져왔다. 이같은손상을치료하기위하여가장중요한목표는골의안정성과연부조직의재건이며, 이를위하여변연절제, 개방창의관리, 골절의고정방법, 적절한항생제의사용, 연부조직재건의시기등고려가필요한사항이많다. 5,11-14) Godina 15) 는수상후 72 시간내에피판술을시행하는것이감염방지에효과적이라고보고하였으며, Gopal 등 16) 도 72 시간내에피판성형술을시행하여골감염률을 3% 정도로줄이는효과를보고하였다. 그러나대부분의환자들이고에너지및다발성손상으로초기에피판술이라는장시간의수술및마취는위험성이있으며, 응급피판성형술을위하여는경험이많은의료진과시설이필요하므로여러가지제한점이있다. 연부조직복원을위한피판술을언제해야하는지아직논란이있다. 많은논문들이연부조직의조기복원이결과에중요한영향을준다고보고하고있으며, 최근발표된 D Alleyrand 등 17) 의논문에서도 7 일이내의피판술시행은큰위험도의차이는없으나그이후로는하루에감염등합병의위험도가 16% 씩증가한다고보고하였다. 본연구에서피판의실패는없었으나부분괴사로부분층식피술을시행한경우가 4 예였는데모두수상후피판술시행까지 14 일이상지연된환자에서발생하였다. DeFranzo 등 2) 이제안한음압상처치료는지속적인음압이창상의경계부위에고르게장력을가하여점진적으로창상의크기를줄여주며, 창상의부종을줄이고, 혈관생성을촉진하며, 균의수를줄이고육아조직의생성속도를높이는장점이있다. 또한개방성상처를폐쇄성상처로전환시켜상처의습윤성을유지하여대기에노출된상처보다치유효과가큰것으로알려져있다. Dedmond 등 18) 은 Gustilo-Anderson 3 형의개방성골절에서연부조직결손에대한초기처치로음압상처치료법을시행하였는데추후피판술의시행빈도가낮아졌거나이식크기가줄어들었으나감염과불유합의발생빈도는크게차이가없다고보고하였다. 저자들은본논문에포함된모든환자에서음압상처치료를적용하였는데고식적인컴퓨터조절진공펌프대신변형된방법인벽흡인기를이용하였다. DeFranzo 등 2) 의보고에서는급성창상에는 125 mmhg 의음압을, 만성창상에는 175 mmhg 의음압적용을권장하였다. 기존 찰 의 V.A.C. Therapy (vacuum assisted closure, advanced therapy system; KCI Whitney, Oxon, UK) 의경우유닛 (unit) 과부가물품의고비용및이동시무게로인한불편이있으나, Curavac 의경우는벽설치흡입기 (wall suction unit) 가있어벽흡인기를이용할수있다는장점이있으며이로인하여상대적으로비용절감의효과가있다. 그러나벽흡인기의경우컴퓨터조절진공펌프처럼흡인압력을정확히유지하기어렵고환자가임의로압력을줄이거나늘리는경우가생길수있으며, 간헐흡인과지속흡인의차이에대한연구가충분하지않다는문제점이있다. Type IIIb 경골골절의감염률은저자에따라차이가있으나 8.5%-52.0% 로보고되고있으며 14,16,19,20) 저자들의경우감염이 5예 (14.3%) 발생하였다. 심부감염이발생한 2예중 1예는내원당시나비골편이몸밖으로노출이되어있었으며골막이벗겨져있는상태였다. 후향적으로판단할때이나비골편을제거하는것이옳았다고생각하나수술당시환자의나이가젊고골편이커서지연나사를통한압박고정을시행하였고결국골괴사로이어져수상후 3개월에농양형성을동반한골감염이발생하게되었다. 재수술은피판을들어올린후내고정물및괴사된골조직을제거하고변연절제술을시행하였으며, 원형외고정장치를이용하여고정하였다. 경골원위부에서골절골술을시행후점진적골이동술을시행하였으며골이식을통해골유합을얻을수있었으나치유기간이길어지고관절범위운동이제한되는등합병증이발생하게되었다. 개방성골절의최초변연절제술시오염된조직및괴사된조직의철저한변연절제술이매우중요하다고생각된다. 외고정을시행하지않고초기에골수정으로내고정을시행한경우가 4예있었다. 4예모두경골간부의골절이었으며, 연부조직손상부위가경골의외측부 (8-25 cm 2 ) 로경골의노출없이근육부위의노출이있는환자였다. 이들모두골수내정을이용하여고정하였으며음압상처치료를적용하여손상부위의무균소독 (aseptic dressing) 을유지하였다. 내고정후 2예는 3일, 2예는 4일에피판술로연부조직복원을시행하였고 4예중 1예에서외회전부정유합의합병이있었으나감염은발생하지않았으며평균 LEFS 는 73점 (70-77점) 이었다. Oh 등 12) 은외고정을하지않고수상직후비확공성골수정으로고정한개방성경골간부골절환자 19명에서감염이 2예 (1예는천부, 1예는심부 ) 였고교합나사파손이 1예있었다고발표하였다. 저자들의경우교합나사의파손은없었으나 1예에서외회전부정유합이발생하였고 1예에서는지연유합이발생하여골이식술을시행하였다. 증례가적어감염발생에대한논의를하기는어려우나 4예중감염이없었던것은조기에초기에철저한변연절제를시행하고연부조직복원을비교적

6 272 Seong Yeon Lim, et al. 조기에시행한것이도움이되었을것이라생각한다. 임상결과에미치는요인을평가하기위하여다변량분석방법을이용하였는데조사된요인중초기연부조직손상의정도 (p=0.000) 와합병증의유무 (p=0.000) 가영향을주는것으로평가되었다. 연부조직손상의정도는의사가조절할수없는부분이므로합병증을예방하기위하여노력을한다면좋은임상결과를얻을수있다는것으로해석할수있다. 결 초기연부조직손상넓이및합병증의발생이 Type IIIb 개방성경골골절환자의임상결과에영향을주는요인으로, 초기연부조직의치료및연부조직의재건, 합병증발생예방으로좋은임상결과를얻을수있을것으로생각된다. 론 References 1) Court-Brown CM, Rimmer S, Prakash U, McQueen MM: The epidemiology of open long bone fractures. Injury, 29: , ) DeFranzo AJ, Argenta LC, Marks MW, et al: The use of vacuum-assisted closure therapy for the treatment of lower-extremity wounds with exposed bone. Plast Reconstr Surg, 108: , ) Melvin JS, Dombroski DG, Torbert JT, Kovach SJ, Esterhai JL, Mehta S: Open tibial shaft fractures: I. Evaluation and initial wound management. J Am Acad Orthop Surg, 18: 10-19, ) Melvin JS, Dombroski DG, Torbert JT, Kovach SJ, Esterhai JL, Mehta S: Open tibial shaft fractures: II. Definitive management and limb salvage. J Am Acad Orthop Surg, 18: , ) Olson SA, Schemitsch EH: Open fractures of the tibial shaft: an update. Instr Course Lect, 52: , ) Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am, 58: , ) Sarmiento A, Sobol PA, Sew Hoy AL, Ross SD, Racette WL, Tarr RR: Prefabricated functional braces for the treatment of fractures of the tibial diaphysis. J Bone Joint Surg Am, 66: , ) Milner SA: A more accurate method of measurement of angulation after fractures of the tibia. J Bone Joint Surg Br, 79: , ) Sohn OJ, Kang DH: Staged protocol in treatment of open distal tibia fracture: using lateral MIPO. Clin Orthop Surg, 3: 69-76, ) Binkley JM, Stratford PW, Lott SA, Riddle DL: The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Phys Ther, 79: , ) Kang CN, Kim JO, Kim DW, et al: Treatment of type IIIB open tibial shaft fractures. J Korean Soc Fract, 11: , ) Oh JK, Oh CW, Roh KJ, Chung DM: Treatment of open tibial shaft fractures using unreamed nailing. J Korean Fract Soc, 18: 22-28, ) Park KC: Acute management of soft tissue defect in open fracture. J Korean Fract Soc, 23: , ) Templeman DC, Gulli B, Tsukayama DT, Gustilo RB: Update on the management of open fractures of the tibial shaft. Clin Orthop Relat Res, (350): 18-25, ) Godina M: Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg, 78: , ) Gopal S, Majumder S, Batchelor AG, Knight SL, De Boer P, Smith RM: Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br, 82: , ) D'Alleyrand JC, Manson TT, Dancy L, et al: Is time to flap coverage of open tibial fractures an independent predictor of flap-related complications? J Orthop Trauma, 28: , ) Dedmond BT, Kortesis B, Punger K, et al: The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibial shaft fractures. J Orthop Trauma, 21: 11-17, ) Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma, 24: , ) Naique SB, Pearse M, Nanchahal J: Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres. J Bone Joint Surg Br, 88: , 2006.

7 ISSN (Print) ISSN (Online) 대한골절학회지제 27 권, 제 4 호, 2014 년 10 월 J Korean Fract Soc 2014;27(4): Original Article Type IIIb 개방성경골골절의치료 임성연 이일재 * 조재호 송형근 아주대학교의과대학정형외과학교실, 성형외과학교실 * 목적 : 경골의 Type IIIb 개방성골절에서임상결과에영향을주는요인을파악하고자하였다. 대상및방법 : Type IIIb 개방성경골골절로치료받은 35명을대상으로하였다. 남자 29예, 여자 6예였으며, 평균나이는 45세 (19-80세) 였다. 결과 : 골절부위는근위부골절 10예, 간부골절 13예, 원위부골절 12예였다. 평균연부조직손상넓이는 49.2 cm 2 (3-220 cm 2 ) 이며, 수상후연부조직재건및내고정까지걸린시간은평균 10일 (3-16일) 이었다. 골유합까지기간은평균 27주였다. 합병증은 16예 (45.7%) 에서발생하였는데, 합병증으로천부감염 3예, 심부감염 2예, 피판부피부부분괴사 4예, 부정정렬 3예, 관절강직 3예, 내고정물파손 1예로조사되었다. 임상결과로 lower extremity functional scale 점수는평균 68.5점이었고초기연부조직손상넓이 (p=0.000) 및합병증의유무 (p=0.000) 가영향을주는것으로조사되었다. 결론 : 개방성경골골절의치료에서연부조직의손상넓이및합병증의유무가임상결과에영향을주기때문에적절한연부조직의치료및내고정을통하여합병증을예방하는것이중요할것으로생각된다. 색인단어 : 경골, 개방성골절, 연부조직손상, 음압상처치료 접수일 수정일 게재확정 교신저자송형근경기도수원시영통구월드컵로 164, 아주대학교병원정형외과 Tel , Fax , ostrauma@ajou.ac.kr Copyright c 2014 The Korean Fracture Society. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 273

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar