241 Locking Screw in Intramedullary Nail of Distal Tibial Metaphyseal Fracture A B C Figure 1. (A) Anteroposterior and lateral radiograph of a 58-year

Size: px

Start display at page:

Download "241 Locking Screw in Intramedullary Nail of Distal Tibial Metaphyseal Fracture A B C Figure 1. (A) Anteroposterior and lateral radiograph of a 58-year"

길수 좌
5 years ago
Views:

1 240 pissn : , eissn : Original Article J Korean Orthop Assoc 2017; 52: 경골원위간단부골절에서골수강내금속정고정시 Blocking Screw 의유용성 조승환 이상홍 이준영 전용철 조선대학교의과대학정형외과학교실 The Usefulness of Blocking Screw in Intramedullary Nail of Distal Tibial Metaphyseal Fracture Suenghwan Jo, M.D., Sang Hong Lee, M.D., Jun Young Lee, M.D., and Yong Cheol Jun, M.D. Department of Orthopedic Surgery, School of Medicine, Chosun University, Gwangju, Korea Purpose: To evaluate the usefulness of blocking screws in distal tibial metaphyseal fractures treated with intramedullary nailing. Materials and Methods: A total of 18 patients with distal tibial metaphyseal fractures, who underwent intramedullary nailing treatment with blocking screws between January 2012 and December 2014 and had a minimum follow-up of 1 year, were retrospectively reviewed for analysis. There were 7 patients with open fracture and 4 patients with intra-articular fracture. The location of the blocking screws was previously determined according to the fracture pattern. Moreover, the preoperative and postoperative angular alignment was measured. Patients received regular postoperative radiographic check-up, and the time-to-bone union and the incidence of nonunion were recorded. The clinical outcome was evaluated using the modified functional Kalstrom-Olerud score. Results: All fractures healed completely without nonunion at an average of 17.7 weeks. The mean coronal/sagittal alignment improved from 6.4/4.8 degrees preoperatively to 2.5/1.9 degrees postoperatively. The alignment was maintained until complete union. There were 3 cases of anterior knee pain but no complications related to the blocking screw and wound infection. Using a modified functional Karlstrom- Olerud score, the outcome was considered good to excellent in 83.4% of the patient cohort. Conclusion: We conclude that the blocking screws may help the maintenance of reduction and alignment in distal tibial metaphyseal fractures treated with intramedullary nailing. Key words: blocking screw, distal tibial metaphyseal fracture, intramedullary nail 서론 경골간부골절의수술적치료에서골수강내금속정고정술은 생역학적으로고정력이우수하고골막과연부조직의보존에유 리하여높은골유합률과빠른기능회복을보이고비교적술기가 어렵지않다는장점을가지고있어널리사용되고있는방법이 Received June 30, 2016 Revised August 19, 2016 Accepted October 23, 2016 Correspondence to: Jun Young Lee, M.D. Department of Orthopedic Surgery, Chosun University Hospital, 365 Pilmun-daero, Dong-gu, Gwangju 61453, Korea TEL: FAX: leejy88@chosun.ac.kr 다. 1,2) 관혈적정복술및내고정술에비해골수강내금속정고정술은골의혈행을보존해주고부하를분담해주며 (load sharing) 과도한연부조직박리를피하게해주는장점이있다. 3) 또한경골골간단부골절에서개방성골절로금속판을사용하여고정하기어려운경우금속정이좋은대안이될수있다. 4) 그러나골수강내금속정고정술로치료한경골원위골간단부골절의환자들에서적절한정복을얻지못하여수술후골절부위의전이등의부정정렬, 지연유합및불유합이발생하는경우가비교적흔하다 (Fig. 1). 1,3,5-9) 이는경골간부골절에비해골수강이넓어져고정력이약해지고교합나사의삽입과정에서도금속정의골수강내이동이가능하기때문에부정정렬의빈도가높아치료에어려움이따르 The Journal of the Korean Orthopaedic Association Volume 52 Number Copyright 2017 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

$(A) Anteroposterior and lateral radiograph of a 58-year-old male showing distal tibial metaphyseal fracture due to motor vehicle accident.$ (B) Postoperative radiographs showing well maintained alignment with intramedullary nailing. (C) Interlocking screw breakage and valgus angulation at 4 months postoperatively.

(B) Postoperative radiographs showing well maintained alignment with intramedullary nailing. (C) Interlocking screw breakage and valgus angulation at 4 months postoperatively.

5,10-12) 이에저자들은경골원위골간단부골절에서골수강내금속정고정시 blocking screw를사용한환자들을대상으로결과를분석하여이의유용성을알아보고자한다. 대상및방법 1. 연구대상본연구는조선대학교병원기관생명윤리위원회의승인을받고이루어졌다 (IRB No. 2016-06-019-001).

$2012년 1월부터 2014년 12월까지 20세이상성인에서경골원위골간단부골절이발생하여본원에서수술적치료를시행한경우는총 46예로이중경골천정골절 (pilon fracture) 22예와 Gustilo와 Anderson 분류에서 grade IIIb, IIIc에해당하는개방성골절 6예는연구대상에서제외하였으며남은 18 예는모두골수강내금속정및$ 비골의간부에골절이동반된경우는 10예였으며, 개방성골절이 7예였고개방성골절의양상은 Gustilo와 Anderson 분류법에의해서 I이 1예, II가 5예였고 IIIa는 1예였다. 수상원인으로는교통사고가가장많았다. 골절선이족관절면으로연장되어관절면을침범한경우가 4예, 관절면을침범하지않은경우가 14예였다.

비골의간부에골절이동반된경우는 10예였으며, 개방성골절이 7예였고개방성골절의양상은 Gustilo와 Anderson 분류법에의해서 I이 1예, II가 5예였고 IIIa는 1예였다. 수상원인으로는교통사고가가장많았다. 골절선이족관절면으로연장되어관절면을침범한경우가 4예, 관절면을침범하지않은경우가 14예였다.

2 241 Locking Screw in Intramedullary Nail of Distal Tibial Metaphyseal Fracture A B C Figure 1. (A) Anteroposterior and lateral radiograph of a 58-year-old male showing distal tibial metaphyseal fracture due to motor vehicle accident. (B) Postoperative radiographs showing well maintained alignment with intramedullary nailing. (C) Interlocking screw breakage and valgus angulation at 4 months postoperatively. 고금속정삽입시관절면으로골절선의연장및골절부위에충분한안정성을줄수없어발생하는것으로알려져있다. 6) 최근에는이를극복하기위해고식적인골수강내금속정고정술을보완한여러방법으로서좋은결과들이보고되고있으며, 3) 추가적인 blocking screw를이용하는것이하나의방법으로제시되고있다. 5,10-12) 이에저자들은경골원위골간단부골절에서골수강내금속정고정시 blocking screw를사용한환자들을대상으로결과를분석하여이의유용성을알아보고자한다. 대상및방법 1. 연구대상본연구는조선대학교병원기관생명윤리위원회의승인을받고이루어졌다 (IRB No ). 본연구에서경골원위골간단부골절은골절선이족관절면에서근위 7 cm 안에포함된경우로정의하였다. 2012년 1월부터 2014년 12월까지 20세이상성인에서경골원위골간단부골절이발생하여본원에서수술적치료를시행한경우는총 46예로이중경골천정골절 (pilon fracture) 22예와 Gustilo와 Anderson 분류에서 grade IIIb, IIIc에해당하는개방성골절 6예는연구대상에서제외하였으며남은 18 예는모두골수강내금속정및 blocking screw를이용하여골절부고정을시행하였다. 후향적분석을시행하였으며남자가 10예, 여자가 8예였고평균연령은 51.1세 (25-73세) 였으며평균추시기간은 21개월 (13-34개월) 이었다. 모든환자는수술전해당하지에수상및수술과거력이없었으며보행및일상생활에지장이없는환자였다. 비골의간부에골절이동반된경우는 10예였으며, 개방성골절이 7예였고개방성골절의양상은 Gustilo와 Anderson 분류법에의해서 I이 1예, II가 5예였고 IIIa는 1예였다. 수상원인으로는교통사고가가장많았다. 골절선이족관절면으로연장되어관절면을침범한경우가 4예, 관절면을침범하지않은경우가 14예였다. 주골절선과족관절면과평균거리는 50 mm (29-63 mm) 였고이는족관절면이침범한경우에도동일하게측정하였다 (Table 1). 방사선적평가는잠재적오류를줄이기위해 2명의정형외과전문의가술전, 술후방사선사진에서각변형, 지연유합및불유합등을각각평가하였고두값의평균값을구하였다. 2. 수술방법모든수술은한명의술자에의해시행되었으며전예에서 Sirus Intramedullary Tibial Nail System (Zimmer, Warsaw, IN, USA) 을이용하여골수강내내고정을시행하였다. 술전에미리골절면을경계로전후면, 시상면에서 alignment를측정한후골수강이넓어지는골간단부에장축을따라직선을그리고주골절선을따라직선을그려두직선이만나는지점에서골간단부의예각에해당하는지점을 blocking screw의삽입점으로정하였고 (Fig. 2), 11) 단순방사선사진상저명하게보이지않은감춰진골절을확인하기위하여수술전 3차원컴퓨터단층촬영을시행하여수술계획을세우는데이용하였다. 환자를방사선투과수술대에앙와위로위치시키고근위대퇴부에지혈대를감은후근위대퇴후방에수술포를받쳐서슬관절을최대한굴곡시킨상태에서슬개건종절개법을이용하여삽입구 (entry portal) 를확보하였다. 경골조면의근위부에서외측경골극의바로내측부를시작점 (starting point) 으로하여영상증폭장치하에골절의정복을시행하였고

$Age (yr) Sex Injury mechanism AO classification Open fracture* Distance from joint to fracture line (mm) Intraarticular fracture 1 53 Male Fall down B2-47.8 X O 2 38 Male Slip down A3-29.$ 3 X O 3 73 Female MVA B1 IIIA 54.3 X O 4 25 Female Fall down A1 II 40.0 X O 5 58 Male MVA A1 II 62.3 X X 6 56 Female MVA C1-31.0 O X 7 48 Male Fall down B2-33.7 X X 8 42 Male Fall down B1-43.

3 X O 3 73 Female MVA B1 IIIA 54.3 X O 4 25 Female Fall down A1 II 40.0 X O 5 58 Male MVA A1 II 62.3 X X 6 56 Female MVA C1-31.0 O X 7 48 Male Fall down B2-33.7 X X 8 42 Male Fall down B1-43.

3 242 Suenghwan Jo, et al. Table 1. Demographic Data of the Patients Case No. Age (yr) Sex Injury mechanism AO classification Open fracture* Distance from joint to fracture line (mm) Intraarticular fracture 1 53 Male Fall down B X O 2 38 Male Slip down A X O 3 73 Female MVA B1 IIIA 54.3 X O 4 25 Female Fall down A1 II 40.0 X O 5 58 Male MVA A1 II 62.3 X X 6 56 Female MVA C O X 7 48 Male Fall down B X X 8 42 Male Fall down B X O 9 55 Female MVA A2 II 57.4 X O Female MVA B X X Male Fall down C1 II 49.6 O O Male MVA B3 I 61.3 X O Male Fall down A X O Male Fall down B X X Female MVA C O O Male Slip down B O X Female Slip down C1 II 63.2 X X Female Slip down C X X *Gustilo and Anderson Classification. MVA, motor vehicle accident. Fibular fracture 2nd line 1st line A Distal tibia Flared segment Obliquity of the fracture Blocking screw Long axis of the bone Direction of fracture displacement Acute angles Desired direction of reduction Figure 2. (A) To determine the position of the blocking screw, a line is drawn along the long axis of the distal fragment. Bisecting the first line, a second line is drawn along the plane of the main fracture line. The blocking screw (circle) is placed in the acute angle of the metaphyseal segment. (B) Three-dimensional reconstruction image of distal tibial metaphyseal fracture for positioning the blocking screw. Cited from the article of Hannah et al. (Injury. 2014;45:1011-4). 11) B 유도강선을삽입하고확공을시행한후금속정을삽입하기이전에경골원위골간단부의예각에해당하는부분에 blocking screw 를삽입하였다. 이후조심스럽게금속정을전진하면서점진적으로골절면이정복되도록유도하였다. Gustilo와 Anderson 분류에서 IIIA의 1예를제외하고사전측정된경골협부직경보다 1 mm 과확공을시행한후금속정을삽입하였다. Blocking screw 는골수정의고정시사용하는교합나사 (interlocking screw, sirus intramedullary tibial nail system; Zimmer) 를사용하였다. Blocking screw의방향과위치는내반또는외반변형을방지하기위해원위골편에골수정이지나갈중심선의외측또는내측의전면에서고정하였고그위치는앞서기술한대로원위골편의장축과주골절선이만나는지점에서골간단부의예각에해당하는부위를삽입점으로정하였다 (Fig. 3). 이후모든예에서각각 2개씩원위및근위교합나사를삽입하였으며, 삽입한후영상증폭장치로골절부위의안정성을확인하였고골절부위의안정성이떨어지는경우나정렬이양호하지않을경우추가적인 blocking screw를삽입하였다. 족관절관절면으로골절선이연장된 4예골절의경우모두전이가 2 mm 이내였으나관절면의침범정도가 25% 이상이어서골수정의삽입시골편의전이가생기지않도록 4.0 mm 유관나사 (4CIS cannulated screw system; Solco, Pyeongtaek, Korea) 를

243 Locking Screw in Intramedullary Nail of Distal Tibial

7예모두에서창상세척술및변연절제술시행후단일수술 (single stage operation) 을시행하였다.

관절면으로골절선이연장된 4예는술후 6주후부터부분체중부하보행을시켰으며나머지 14예는술후

개방성골절 7 예모두에서창상의일차봉합 (primary closure) 이가능했기때문

골유합이된것을확인하고전체중부하시골절부위통증이없음을확인한이후에전체중부하보행을시작하였다. 3.

임상적으로는골절부압통이없고통증이없이전체중부하보행이가능한경우를골유합으로인정하였다.

(A) Fluoroscopic view showing blocking screw placement in the

Satisfactory reduction obtained after nail insertion,

4 243 Locking Screw in Intramedullary Nail of Distal Tibial Metaphyseal Fracture 이용한현위치내고정 (in situ fixation) 을시행하여관절면을먼저고정한후골수강내금속정고정술을시행하였다. 비골간부에골절이동반된경우가 10예였는데근위 1/3, 중간, 원위 1/3는각각 3예, 4예, 3예였으며 10예모두에서족관절격자 (ankle mortise) 및원위경비인대결합의손상이보이지않아비골에대한고정은시행하지않았고개방성골절인 7예모두에서창상세척술및변연절제술시행후단일수술 (single stage operation) 을시행하였다. 술후바로하지거상운동을권장하였고통증이호전된이후부터조기관절운동을권유하였다. 관절면으로골절선이연장된 4예는술후 6주후부터부분체중부하보행을시켰으며나머지 14예는술후 2주후부터부분체중부하보행을시켰다. 개방성골절 7 예모두에서창상의일차봉합 (primary closure) 이가능했기때문 에체중부하시기를정하는데창상은고려하지않았다. 골유합이된것을확인하고전체중부하시골절부위통증이없음을확인한이후에전체중부하보행을시작하였다. 3. 평가방법술후방사선사진에서정렬을평가하기위하여, 부정정렬은전후면혹은시상면에서 5도이상의각형성이있는경우로정의하였다. 3) 골유합의판정은방사선적으로정면과측면및양측사면촬영에서최소 3개이상의사진상골절부에분명한가골형성이된경우로정의하였고, 임상적으로는골절부압통이없고통증이없이전체중부하보행이가능한경우를골유합으로인정하였다. 3) 또한수술후 3개월이후에도유합이덜된경우를지연 A B C D E Figure 3. (A) Fluoroscopic view showing blocking screw placement in the preselected position after guidewire insertion. Satisfactory reduction obtained after nail insertion, anteroposterior view (B), and lateral view (C). Posteoperative anteroposterior (D) and lateral view (E). A B C Figure 4. (A) Radiograph showing distal tibial metaphyseal fracture with intraarticular extension in a 56-year-old female due to a car accident. (B) After in situ fixation of intraarticular fracture, blocking screw assisted interlocking nailing was performed. (C) Healed fracture 5 months postoperatively.

5 244 Suenghwan Jo, et al. 유합으로, 6개월이후에도골유합의진행소견이없는경우를불유합으로정의하였다. 3,13-16) 합병증으로금속정삽입에의한전방슬부통증, 금속정의파손및 blocking screw의파손, 그리고창상감염이나창상벌어짐등창상관련합병증을확인하였다. 최종외래방문시신체검사와설문조사를통한 modified functional Karlstrom-Olerud score를이용하여임상적결과를측정하였고, 17) 점수에따라우수 (excellent, 33점 ), 양호 (good, 30-32점 ), 만족 (satisfactory, 27-29점 ) 및중간 (moderate, 24-26점 ), 불량 (poor, 점 ) 으로분류하였다. 결과 총 18예의골절중지연유합이나불유합은없었고모든예에서 Table 2. Frontal Plane/Sagittal Plane Mean Malalignment Alignment Frontal plane ( o ) Sagittal plane ( o ) Preoperative Postoperative Last follow-up 일차적인골유합을얻었으며 (Fig. 4), 평균골유합기간은 17.7주 (14-24주) 였다. 술전부정정렬에해당하는경우는총 18예의골절중 14예였으며술전전후면에서평균 6.4도 ( 도), 시상면에서평균 4.8도 ( 도) 의각형성을보였고이는술후전후면에서평균 2.5도 ( 도), 시상면에서평균 1.9도 ( 도) 로교정되었으며최종방사선검사에서부정정렬로나타나는경우는없었다 (Table 2). 금속정고정후에도정렬이만족스럽지않은 5예에서 blocking screw 한개를추가로고정하였다. 관절면을침범하여 4.0 유관나사로현위치내고정 (in situ fixation) 후골수강내금속정고정술을한 4예모두평균 16주에골유합을이뤘으며최종추시에서시행한단순방사선촬영에서골편의전이가관찰되지않았고정렬도양호하였다. 최종추시에서 modified functional Karlstrom-Olerud score를이용하여임상적결과를측정한결과평균 30.3점이었으며우수가 1예 (5.6%), 양호가 14예 (77.8%), 만족 2예 (11.1%), 중간 1예 (5.6%) 로 83.4% 에서양호이상의결과를얻었다 (Table 3). 모든예에서창상벌어짐이나창상감염없이창상양호하였으며특히개방성골절 7예에서우려하던창상감염등은보이지않았다. 금속정및 blocking screw의파손, blocking screw 삽입에의한새로운골절의발생등같은 blocking screw의 Table 3. Postoperative Radiographic and Clinical Results Case No. Bone union (wk) Blocking screw (n) Alignment ( o ) Preoperative Postoperative Last F/U Frontal Saggital Frontal Saggital Frontal Saggital K-O score Complications Anterior knee pain Anterior knee pain Anterior knee pain F/U, follow-up; K-O score, modified functional Karlstrom-Olerud score.

6 245 Locking Screw in Intramedullary Nail of Distal Tibial Metaphyseal Fracture 사용에따른합병증은없었으나금속정삽입에따른전방슬부통증이 3예에서관찰되었다. 고찰 경골골절은가장흔한정형외과적외상중하나이며원위경골골절은전체경골골절중 37.8% 에해당한다. 18) 원위경골골절의치료는부정유합, 불유합, 그리고창상감염같은높은합병증및기술적어려움으로아직논란이있다. 19) 원위경골골절의수술적치료방법으로흔히사용하는방법은금속판또는금속정을이용한내고정인데이에대해 Im과 Tae 20) 는경골원위골간단부골절에서두수술법을비교한결과금속정으로고정한 34예에서부정유합이 11.7% 발생한반면금속판으로고정한 30예에서부정유합은 0% 로금속정을사용한경우부정유합이의미있게높았으나감염에관련된합병증은금속판을사용한경우가의미있게높게나타났다고발표하였다. 비슷하게 Iqbal과 Pidikiti 19) 와 Vallier 등 16) 도경골원위골간단부골절에서금속정을이용한군은 5도이상의각변형으로정의되는부정유합의빈도가높다고발표하였는데이러한문제로경골원위골간단부골절에서금속정사용은그동안제한되어왔으며널리받아들여지지않고있었다. 그러나최근원위부에교합나사를경골천장 (tibia plafond) 가까이삽입가능하며 3개이상삽입가능한교합성골수정디자인의발전으로경골원위골간단부골절에도안정성및정렬을유지할수있어금속정의사용이점차확대되고있다. Chan 등 21) 은금속정의원위부에교합나사를 3개고정하는방법은 blocking screw의사용에관계없이 2개교합나사를사용한경우보다편측부하에대해축성강성이더높고골편의내반움직임 (varus motion) 을줄여준다고하였다. 그러나이러한경우원위교합나사의가장원위부교합나사삽입구는나사산 (thread) 이있거나폴리에틸렌끼움재 (polyethylene bushing) 등이있어야하고 saw bone을대상으로한연구이기때문에임상적연구가필요하다고하였다. 반면 Agathangelidis 등 22) 은경골원위부불안정골절에서골수강내금속정을이용한고정시평행하게삽입한 2개의원위부교합나사만으로충분한안정성을얻을수있으며 2개의원위교합나사를교차시켜삽입하거나 3개혹은 4개의원위교합나사를삽입하는것은불필요하다고하였다. 하지만이러한 saw bone을이용한생역학적연구는임상에적용하기에는한계가있으며실제임상에서골절부정렬을유지한상태에서원위부교합나사수를늘려경골원위골간단부골절의정렬및안정을얻는방법은술기상의어려움이있으므로아직논란이있다고하겠다. 이러한이유로경골원위골간단부골절에서금속정고정시골절의정렬및안정을얻는다른방법중하나인 blocking screw를이용한고정방법이제시되었다. Krettek 등 10) 은경골원위골간단부골절의금속정고정시부정유합을예방하기위해 blocking screw를사용하는 것을추천하였으며 blocking screw를사용함으로써경골원위골간단부의넓은골수강을좁혀주어생역학적으로골절부위의안정성을증가시키는효과가있다고하였다. Stedtfeld 등 12) 은골편이연부조직에걸리는장력이더많은곳에서더적은곳으로틀어지기때문에 3-point fixation이유지되지않아부정정렬이유발된다고하였고 blocking screw를통해 3-point fixation을유지하여부정정렬을회복할수있다고하였다. 원위교합나사의수를늘려골절의정렬및안정을얻는방법은특수한디자인의골수정이필요하나 blocking screw를이용한방법은교합나사로가능하여특수한디자인의골수정이나다른기구가필요하지않기때문에본연구에서는경골원위골간단부골절에서 blocking screw를이용하였으며골절의정렬및안정을유지하는데만족스러운결과를얻을수있었다. 경골근위골간단부골절및대퇴원위부골절에서골수강내금속정고정시 blocking screw 사용에대한연구및논문은많이발표된바있으나경골원위골간단부골절에서골수강내금속정고정시 blocking screw 사용에대한연구및논문은많이시도되지않았다. 본연구에서는경골원위골간단부골절의치료에서골수강내금속정고정시 blocking screw를사용하여부정정렬없이좋은결과를얻을수있었다. 이는술전에미리 3-point fixation을위한 blocking screw의위치를정하였고금속정이전진하기이전에경골원위골편의예각에해당하는부분에 blocking screw를삽입하여금속정이전진하면서점진적으로정복이되도록유도하였을것으로생각된다. 또한정렬이양호하지않을경우에는추가적으로 blocking screw를삽입하여정렬를회복할수있었다. 또한본연구에서는원위교합나사를 2개만사용하였음에도골절부위의안정성을확보하여부정유합없이골유합을얻을수있었는데이는앞에서언급한것처럼 blocking screw가골수강을좁혀주어안정성을높여주었기때문으로생각된다. 더불어 blocking screw의파손이나 blocking screw에의한새로운골절의유발등우려하던부작용도관찰되지않았고개방성골절에서창상의벌어짐, 괴사및창상감염등의합병증도보이지않았으며전예모두임상적평가를위해시행한 modified functional Karlostrom-Olerud score에서만족할만한좋은결과를얻었다. 본연구에서는비골간부골절이동반된 10예모두에대해서고정을시행하지않았다. 원위경골과동반된비골골절고정의여부는여러저자들에의해연구되었는데, Helfet과 Suk 23) 은원위경골골절에서경골골절과동반된비골골절의고정이중요하다고하였고, Robinson 등 24) 은경골원위골간단부골절의금속정고정시비골의전이가심하거나족관절격자를저해하는경우비골을고정해야한다고하였다. 그러나 Williams 등 25) 은비골골절의관혈적정복및금속판고정술이원위경골에긴장을주어원위경골의불유합에영향을미친다고하였고 Attal 등 26) 은경골원위골간단부골절에서원위부에교합나사를 3개이상다방향으

7 246 Suenghwan Jo, et al. 로삽입한경우동반된비골골절의금속판을이용한고정은안정성에아무도움이되지않고오히려연부조직에손상을줘감염에취약하게할수있으며골유합을저해할수있다고하였다. 본연구에서는비골의고정없이비골의골유합을얻었고비골길이가유지되는등좋은결과를얻었다. Blocking screw를이용한경골부의고정이충분히안정성이있었고정복이양호하였으며비골골절이동반된 10예모두원위경비인대결합이나족관절격자에손상이없었기때문에좋은결과를얻을수있었던것으로생각된다. 본연구에포함된환자수가적어추후동반된비골골절에대해고정한군과고정하지않은군간에비교연구가필요할것으로생각된다. 본연구에서는 blocking screw를너무주골절선과근접하게위치시킨경우골수정삽입후정렬이더틀어져 blocking screw를제거후좀더원위부에삽입하여정렬을얻은경우가 1예가있었다. 기존연구에서는주골절선에서어느정도떨어진거리에 blocking screw를위치시켜야하는지에대해구체적으로명시되지않았는데이에대해향후생역학적연구가필요할것으로생각된다. 또한본연구에서는골다공증의정도는고려하지않았는데골밀도가낮을수록 blocking screw가충분한고정력을얻지못해부정정렬이발생할수있을수있다고생각되나골밀도가낮은골다공증환자에서골간단부의골수강이상대적으로더넓어 blocking screw가더유용하다는보고도있으므로 27) 이에대한연구도향후필요할것으로생각된다. 본연구는대조군이없고후향적으로짧은추시기간동안 18 명의비교적적은수의환자를대상으로한연구라는점과한종류의금속정을사용한점에서한계가있으며, 이를보완하기위해다수의환자를대상으로여러금속정을사용한연구및장기간의추시가필요하며추후이에대한대규모의전향적연구가필요할것으로생각된다. 결론 부정정렬이나부정유합등의우려로금속판내고정술이주된술식인경골원위골간단부골절에대해 blocking screw 를이용한골수강내금속정고정술은연부조직손상을최소화하고골수내강의너비를줄여주어정복의손실을막아주고골절의안정성을높일수있는효과적인방법으로생각된다. 또한경골원위골간단부골절에서개방성창상이동반되거나연부조직의손상이심하여금속판고정이어려운경우좋은대안이될수있으며전이및분쇄가심하지않은족관절면을침범한경골원위부골절에대해서도사용해볼수있는좋은술식으로생각된다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Ahlers J, von Issendorff WD. Incidence and causes of malalignment following tibial intramedullary nailing. Unfallchirurgie. 1992;18: Coles CP, Gross M. Closed tibial shaft fractures: management and treatment complications. A review of the prospective literature. Can J Surg. 2000;43: Nork SE, Schwartz AK, Agel J, Holt SK, Schrick JL, Winquist RA. Intramedullary nailing of distal metaphyseal tibial fractures. J Bone Joint Surg Am. 2005;87: Rajasekaran S, Devendra A, Perumal R, Dheenadhayalan J, Sundararajan SR. Initial management of open fractures. In: Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta P III, ed. Rockwood and green s fractures in adults. 8th ed. Philadelphia: Wolters Kluwer Health; Buehler KC, Green J, Woll TS, Duwelius PJ. A technique for intramedullary nailing of proximal third tibia fractures. J Orthop Trauma. 1997;11: Freedman EL, Johnson EE. Radiographic analysis of tibial fracture malalignment following intramedullary nailing. Clin Orthop Relat Res. 1995;315: Henley MB, Meier M, Tencer AF. Influences of some design parameters on the biomechanics of the unreamed tibial intramedullary nail. J Orthop Trauma. 1993;7: Lang GJ, Cohen BE, Bosse MJ, Kellam JF. Proximal third tibial shaft fractures. Should they be nailed? Clin Orthop Relat Res. 1995;315: Tornetta P 3rd, Collins E. Semiextended position of intramedullary nailing of the proximal tibia. Clin Orthop Relat Res. 1996;328: Krettek C, Rudolf J, Schandelmaier P, Guy P, Könemann B, Tscherne H. Unreamed intramedullary nailing of femoral shaft fractures: operative technique and early clinical experience with the standard locking option. Injury. 1996;27: Hannah A, Aboelmagd T, Yip G, Hull P. A novel technique for accurate Poller (blocking) screw placement. Injury. 2014;45: Stedtfeld HW, Mittlmeier T, Landgraf P, Ewert A. The logic and clinical applications of blocking screws. J Bone Joint Surg Am. 2004;86 Suppl 2:17-25.

8 247 Locking Screw in Intramedullary Nail of Distal Tibial Metaphyseal Fracture 13. Moghaddam A, Zimmermann G, Hammer K, Bruckner T, Grützner PA, von Recum J. Cigarette smoking influences the clinical and occupational outcome of patients with tibial shaft fractures. Injury. 2011;42: Puno RM, Teynor JT, Nagano J, Gustilo RB. Critical analysis of results of treatment of 201 tibial shaft fractures. Clin Orthop Relat Res. 1986;212: Nork SE, Barei DP, Schildhauer TA, et al. Intramedullary nailing of proximal quarter tibial fractures. J Orthop Trauma. 2006;20: Vallier HA, Cureton BA, Patterson BM. Randomized, prospective comparison of plate versus intramedullary nail fixation for distal tibia shaft fractures. J Orthop Trauma. 2011;25: Karlström G, Olerud S. Percutaneous pin fixation of open tibial fractures. Double-frame anchorage using the Vidal- Adrey method. J Bone Joint Surg Am. 1975;57: Court-Brown CM, Rimmer S, Prakash U, McQueen MM. The epidemiology of open long bone fractures. Injury. 1998;29: Iqbal HJ, Pidikiti P. Treatment of distal tibia metaphyseal fractures; plating versus intramedullary nailing: a systematic review of recent evidence. Foot Ankle Surg. 2013;19: Im GI, Tae SK. Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plate and screws fixation. J Trauma. 2005;59: ; discussion Chan DS, Nayak AN, Blaisdell G, et al. Effect of distal interlocking screw number and position after intramedullary nailing of distal tibial fractures: a biomechanical study simulating immediate weight-bearing. J Orthop Trauma. 2015;29: Agathangelidis F, Petsatodis G, Kirkos J, Papadopoulos P, Karataglis D, Christodoulou A. Distal locking screws for intramedullary nailing of tibial fractures. Orthopedics. 2016;39:e Helfet DL, Suk M. Minimally invasive percutaneous plate osteosynthesis of fractures of the distal tibia. Instr Course Lect. 2004;53: Robinson CM, McLauchlan GJ, McLean IP, Court-Brown CM. Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classification and treatment by locked intramedullary nailing. J Bone Joint Surg Br. 1995;77: Williams TM, Marsh JL, Nepola JV, DeCoster TA, Hurwitz SR, Bonar SB. External fixation of tibial plafond fractures: is routine plating of the fibula necessary? J Orthop Trauma. 1998;12: Attal R, Maestri V, Doshi HK, et al. The influence of distal locking on the need for fibular plating in intramedullary nailing of distal metaphyseal tibiofibular fractures. Bone Joint J. 2014;96: Larsson S. Treatment of osteoporotic fractures. Scand J Surg. 2002;91:140-6.

9 248 pissn : , eissn : Original Article J Korean Orthop Assoc 2017; 52: 경골원위간단부골절에서골수강내금속정고정시 Blocking Screw 의유용성 조승환 이상홍 이준영 전용철 조선대학교의과대학정형외과학교실 목적 : 경골원위골간단부골절에서골수강내금속정고정시 blocking screw 의유용성에관하여알아보고자하였다. 대상및방법 : 2012년 1월부터 2014년 12월까지원위경골골간단부골절환자로골수강내금속정고정과 blocking screw 를사용한환자중최소 1년이상추시한 18예를대상으로하였으며, 후향적연구를시행하였다. 개방성골절은 7예가있었으며, 족관절면까지골절선이연장된경우는 4예가있었다. Blocking screw 의위치는술전골절의형태에따라미리정하였고술전및술후정렬을측정하였다. 술후주기적인영상학적검사를시행하였으며, 골유합이된시기와불유합의빈도를기록하였다. 임상적결과는 modified functional Kalstrom-Olerud score 를이용하여분석하였다. 결과 : 모든예에서불유합없이골유합을얻었고평균골유합시기는 17.7주였다. 술전 alignment 는관상면상평균 6.4도, 시상면상평균 alignment 4.8도였으며, 술후 2.5도, 1.9도로좋아졌으며, 골유합시까지유지되었다. 합병증으로 anterior knee pain은 3 예였으며, blocking screw 에의한합병증및감염등의창상관련합병증은없었다. Modified functional Kalstrom-Olerud score 에서 good에서 excellent 까지는 83.4% 였다. 결론 : Blocking screw 는경골원위골간단부골절에서골수강내금속정고정시정복및정렬에도움이된다. 색인단어 : blocking screw, 경골원위골간단부골절, 골수강내금속정 접수일 2016 년 6 월 30 일수정일 2016 년 8 월 19 일게재확정일 2016 년 10 월 23 일책임저자이준영 61453, 광주시동구필문대로 365, 조선대학교병원정형외과 TEL , FAX , leejy88@chosun.ac.kr 대한정형외과학회지 : 제 52 권제 3 호 2017 Copyright 2017 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

untitled

untitled ISSN 1225-1682 (Print) ISSN 2287-9293 (Online) 대한골절학회지제 26 권, 제 4 호, 2013 년 10 월 J Korean Fract Soc 2013;26(4):275-283 http://dx.doi.org/10.12671/jkfs.2013.26.4.275 원 저 경골분절골절에서교합성골수강내금속정내고정술후결과및골유합에영향을미치는인자분석