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1 대한족부족관절학회지 : 제 13 권제 2 호 2009 J Korean Foot Ankle Soc. Vol. 13. No. 2. pp , 2009 변형된장족무지굴건이전술을이용한진구성아킬레스건파열의치료 한림대학교강남성심병원정형외과학교실 김형년 서일우 박용욱 Treatment of Old Achilles Tendon Rupture using Modified Flexor Hallucis Longus Tendon Transfer Hyong-Nyun Kim, M.D., Il-Woo Suh, M.D., Yong-Wook Park, M.D. Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea =Abstract= Purpose: The purpose of this study was to evaluate the clinical results of the old Achilles tendon rupture treated with modified flexor hallucis longus (FHL) tendon transfer. Materials and Methods: Seventeen patients with old Achilles tendon rupture treated with modified FHL tendon transfer between March 2004 and February 2008 were enrolled in this study. Technically FHL was pass through the distal portion of the ruptured tendon instead of the drilled hole made on the calcaneus. The mean age of the patients was 37 years (range, 22~67 years), mean follow-up period was 28 months (range, 12~30 months). Patients' subjective satisfaction, calf circumferential diameter, range of motion of ankle and AOFAS ankle-hind foot score and Arner-Lidholm score was evaluated. Results: The average gap between the ruptured tendon was 52 mm (range, 47~56 mm). The AOFAS score improved from 47 pre-operatively to 91 points at the last follow-up. Sixteen patients were satisfied with the result free from discomfort, a patient had mild discomfort who had DM. fourteen patients had decreased range of motion less than 5 degrees while 2 patients had more than 7 degrees decrease compared to the intact side but had no discomfort in daily activities. Nine patients had less than 1 cm calf circumferential diameter difference and 7 patients had 1 to 3 cm diameter difference compared to the intact side. One who had more than 3 cm diameter difference had deteriorated muscle strength. Conclusion: Modified FHL tendon transfer can be a useful technique for the treatment of old Achilles tendon rupture when the gap is with large gap placed too proximal. Key Words: Achilles tendon, Old Achilles tendon rupture, Modified FHL tendon transfer 서 론 Address for correspondence Yong-Wook Park, M.D. Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Dalim-1dong, Youngdeungpo-gu, Seoul, , Korea Tel: Fax: aofas@chollian.net 아킬레스건급성파열은대개 30~40 대의연령에서스포츠와관련하여발생하는데최근스포츠및여가활동의증가로발생빈도가증가하는추세에있다 13). 급성아킬레스건파열을치료하지않고방치하거나보존적치료가실패한경우파열단사이에반흔조직이채워지고파열된건은수축, 위축되며결국족저굴곡력이약화되어보행에지

2 김형년 서일우 박용욱 장을주게된다 1,9,13,17). 진구성아킬레스건파열의수술적치료시파열단사이에채워진반흔조직을제거하고나서생기는결손부위는파열단사이의단단봉합이어려워급성아킬레스건파열의수술적치료보다더복잡하고어렵다. 결손부위가클경우장족무지굴근건이전술을통한치료로좋은결과들이보고되고있는데 14,15,20,22-24) 파열부위가근위부이거나결손부위가커서장족무지굴근건을충분하게이전, 보강하지못하는경우를경험하게된다. 이에저자들은장족무지굴근건을아킬레스건부착부종골을통과시키지않고파열원위단아킬레스건을통과시키는변형된장족무지굴근건이전술을이용하여만족할만한결과를얻었기에문헌고찰과함께보고하는바이다대상및방법 2004 년 3월부터 2008 년 2월까지본교실에내원한 28예의진구성아킬레스건파열환자중변형된장족무지굴근건이전술을통해치료하였으며추시가가능하였던 17예를대상으로후향적연구를하였다. 평균나이는 37세 ( 범위, 22~67 세 ) 이였으며환자중당뇨가있던환자는 5예, 아킬레스건부착부위에스테로이드주사를맞은기왕력이있는환자가 1예가있었으며아킬레스건손상후진단하기까지는평균 4.5 개월 ( 범위, 4주 ~14 개월 ) 이었다. 파열부위는아킬레스건의종골부착부위에서부터평균 53 mm( 범위, 44~65 mm) 상방이었으며파열단사이의결손간격은평균 52 mm( 범위, 47~56 mm) 이었다. 최종추시관찰까지는평균 28개월 ( 범위, 12~30 개월 ) 이었으며. 최종추시때환 자의임상적결과판정은미국정형외과족부족관절학회의족관절-후족부평가와환자의만족도, 종아리근력정도, 종아리둘레, 족근관절운동범위에근거한 Arner- Lidholm 평가기준을이용하여우수, 양호, 불량으로판정하였다 2). 환자의만족도에서는보행시불편감정도, 보행력, 발뒤꿈치들기유무와종아리근력정도를보았고객관적평가로양측종아리둘레차이와양측족근관절운동범위차이를측정하였다. 수술방법은환자를전신마취또는척추마취후앙와위에두고환측하지를건측하지위에 4자모양을이루게올려놓은후중족부내측에주상골에서부터중족골두에이르는종절개를가한다. 족무지외전근과단족무지굴근을족저부로도수견인하여중족부심부를노출시키면장족무지굴근건과장족지굴근건이나타나며장족무지굴근건을장족지굴근과봉합할정도를남겨둔채최대한원위부에서절개하여충분한길이의이식건을얻는다 (Fig. 3A). 장족무지굴근건과장족지굴근건을 5개의족지가모두중립위인상태에서봉합을한다. 다음후족부에종골의아킬레스건부착부 1.0 cm 내측에서건의내측을따라약 10 cm 정도종절개를가한후아킬레스건을노출시켰다. 파열부위의반흔조직을신선건이나타날때까지제거한후슬관절굴곡 30도족관절중립위에서단단간의결손간격을측정하였다. 하퇴의후방구획의근막을종절개하여장족무지굴근을노출시키고중족부에서절개하였던이식건을후방절개부위로도수견인하여얻는다. 파열부위가근위부이거나결손부위가커서이식건의길이가충분하지못할때족근관절족저굴곡 10도의상태에서아킬레스건의파열원위단부착부에서 1 cm 근위부에절개를가하여내측에서외측으로이식건을통과시킨후 2.0 Ethibond R (Ethicon Figure 1. Pre-operative T1-weighted MRI shows a chronic Achilles tendon ruptured with retracted tendon ends and the fibrous scar tissue filled between the tendon stumps. Figure 2. Diagram of modified FHL tendon transfer showing FHL tendon passing through the distal portion of the ruptured tendon instead of the drilled hole made on the calcaneus

) 로아킬레스건통과부위과이식건을봉합하였다. 이식건은결손부위를건너아킬레스건에지그재그형태를이루도록통과시킨후봉합하였다. 또한장족무지굴근을아킬레스건의내측에봉합하여보강하고혈류개선을도왔다 (Fig. 2, 3B). 환자는 2주간의단하지석고고정후봉합사의제거와함께단하지보조기 (walking boots) 를착용하여체중부하를허용하였다.

3 변형된장족무지굴건이전술을이용한진구성아킬레스건파열의치료 A B Figure 3. Intra-operative photograph shows (A) harvested FHL tendon from the midfoot, (B) recontructed Achilles tendon with FHL passing through the distal stump and woven through the proximal stump. Inc, U.K.) 로아킬레스건통과부위과이식건을봉합하였다. 이식건은결손부위를건너아킬레스건에지그재그형태를이루도록통과시킨후봉합하였다. 또한장족무지굴근을아킬레스건의내측에봉합하여보강하고혈류개선을도왔다 (Fig. 2, 3B). 환자는 2주간의단하지석고고정후봉합사의제거와함께단하지보조기 (walking boots) 를착용하여체중부하를허용하였다. 결과환자의주관적만족도는보행시불편감없음이 16예였고당뇨가동반되었던 1예에서가벼운불편감을호소하였다. 또한보행시정상보행력을보인다가 15예였고보행능력이다소떨어진다가 2예였고, 여기에는당뇨가동반되었던 1예가속하였다. 당뇨가동반되었던 1예를제외한 16예에서한발뒤꿈치들림이가능하였다. 미국정형외과족부족관절학회의족관절후족부평가점수는수술전평균 47점에서수술후최종추시에서평균 91점으로향상되었다. Arner-Lidholm 평가기준에따르면우수가 15예, 양호 2 예로전예에서양호이상의주관적만족을보였다. 총 17명의환자중시행한환측과건측의종아리둘레차이가 1 cm 이하를보인경우가 9예, 1~3 cm 차이를보인경우가 7예, 3 cm 이상의차이를보인예가 1예에서있었으며 1예에서이로인한근력약화를호소하였다. 환측과건측의족근관절운동범위의차이가 5도이하를보이는경우가 14예, 2예에서는 7도이상의차이를보이고있었으나이로인한일상생활에불편을호소하지않았다. 수술후재파열이나심부감염등의합병증은없었다. 고 찰 진구성아킬레스건파열은급성손상을진단하지못하였거나치료하지않고방치된경우, 잘못진단되었던경우또는급성손상의보존적치료가실패한경우를포함하며손상후 4주이상이경과한경우를말한다 9). 파열후 10일이지나면서부터파열단사이에반흔조직이채워지고파열된건은수축, 위축되며결국족저굴곡력이약화되어보행에지장을주게된다 1,17). 급성아킬레스건파열은문진과이학적검사만으로도진단이비교적용이하지만 Ballas 등 3) 은전체손상의 5분의 1에서진단을놓칠수있다고보고하였고 Boyden 등 4) 은 25% 에서진단을놓칠수있다고보고하였다. Nestorson 등 18) 은 25명의고령환자에서진단이늦어지거나이뤄지지못하여치료가 1주일이상지연되었던경우가 9건 (36%) 이었다고보고하였다. 급성파열의진단과치료가이루어지지않을경우통증과부종은가라앉으며결손부위는반흔조직으로채워져이학적검사에서결손부위가촉지되지않는경우도있고후경골근과장족무지굴근등족저굴근에의해족근관절의굴곡운동이가능한경우가있어주의깊은문진과이학적검사가필요하다 13). 진구성아킬레스건파열의경우장족지굴근및장족무지굴근이하퇴삼두근의기능을대신하며강화되어갈퀴족지변형이나타나거나내측종아치가높아지기도하며또한하퇴삼두근의기능약화로환측하지만으로뒤꿈치를들지못하는경우가많다. 정확한진단과치료방법의결정을위하여자기공명염상검사가도움이되며정상의아킬레스건이 T1과 T2 강조영상모두에서저신호강도를보이는반면파열부위는 T1 강조영상에서저신호강도를 T2 강조영상에서비연속성의변화된신호를보인다 10). 진구성아킬레스건의수술적치료는파열단사이에채워진반흔조직

4 김형년 서일우 박용욱 을제거하고나서생기는결손부위의단단봉합이어려워급성아킬레스건파열의수술적치료보다더복잡하고어렵다. 수술적방법은크게단단봉합 (end-to-end repair), 아킬레스건전진술및건판을이용한재건술 (tendo-achilles advancement or flap reconstruction), 국소건이전술 (lcoal tendon transfer), 건이식술 (autograft, allograft or synthetic) 로나눌수있다 9,11,13,17). 여러가지방법들중 Myerson 17) 은파열단단간결손간격과환자의나이및활동정도, 손상후경과한기간등으로수술방법을결정할것을제안하고진구성아킬레스건파열을결손간격정도에따라치료방법을제시하였다. 결손간격이 1~2 cm 이하인경우는단단봉합 (end-to-end repair) 및후방구획의근막절개술을, 간격이 2~5 cm인경우는 V-Y 건판전진술을건이전술과함께혹은단독으로시행할것을제안하였고간격이 5 cm 보다큰경우는장족무지굴근건을이용한건이전술을 V-Y 건판전진술과함께혹은단독으로시행할것을제안하였다. 한편 Kuwada 12) 는 Type I은부분파열의경우로보존적치료를, Type II는결손간격이 3 cm 이하의완전파열로단단봉합을, Type III는결손간격이 3~6 cm으로건이식술을인조건보강술 (synthetic graft augmentation) 과함께혹은단독으로할것을제안하였다. Type IV는결손간격이 6 cm 이상이경우로하퇴삼두근의전진술이나유리건이전술, 인조건이전술을제안하였다. V-Y 건판전진술은 Abraham 과 Pankovich 1) 에의해처음소개되었는데건판을 5 cm 이상전진시켰을때근단위 (muscle unit) 에약화를가져올가능성이많아큰결손간격을갖는진구성아킬레스건파열에서는사용에제한이있고비복근근막젖혀내림피판술의경우절개부위가크다는단점이있다 8,17). 본연구에서는술전에촬영한자기공명영상검사를통해단단간결손간격을측정하여 Myerson 의기준에따라수술을계획하였고실제수술장에서반흔조직을제거한후측정하였을경우 5 cm 보다컸던경우모두장족무지굴근건이전술을통해아킬레스건을재건하였다. 장족무지굴근건은다른이식건보다길고내구성이강하며수축의축이아킬레스건과같고하퇴삼두근과같은자극에수축하며해부학적으로인접하여접근이쉽다. 또한족저굴근에서족저굴근에이식하므로다른근육간의균형을유지할수있고중족부에서채취하는경우 10~12 cm의긴이식건을얻을수있는장점이있다 14,22). 장족무지굴근의근육부위를아킬레스건의파열부위에함께봉합하면아킬레스건의혈액공급및순환에도움이된다 5). 하지만장족무지굴근의이식으로무지지간관절의능동적굴곡이불가능하게되지만이것으로인한보행의불 편을호소하는경우는없었다. Coull 등 6) 은족저압력분석검사 (pedobarography) 에서보행시족무지원위지골의최대압력지수가저하되었지만통계학적으로유의하지않았으며기능적으로이상이없음을보고하였다. Wapner 등 22) 이처음소개한장족무지굴근건이전술의경우파열된부위가하퇴 1/3 이상근위부이거나결손부위가커서이식건의길이가짧을경우충분하게결손부위에이식하기가어렵다. 본연구에서는변형된장족무지굴근건이전술을시행하여만족할만한결과를얻었기에문헌고찰과함께보고하는바이다. 결 론 진구성아킬레스건파열의수술적치료로변형된장족무지굴근건이전술은파열된부위가근위부이거나결손부위가크고이식건의길이가짧아충분하게결손부위에이식하기가어려운경우사용할수있는유용한술식으로사료된다. REFERENCES 1. Abraham E and Pankovich AM: Neglected rupture of the achilles tendon. treatment by V-Y tendinous flap. J Bone Joint Surg, 57-A: , Arner O and Lindholm A: Subcutaneous rupture of the achilles tendon; a study of 92 cases. Acta Chir Scand Suppl, 116: 1-51, Ballas MT, Tytko J and Mannarino F: Commonly missed orthopedic problems. Am Fam Physician, 57: , Boyden EM, Kitaoka HB, Cahalan TD and An KN: Late versus early repair of Achilles tendon rupture. Clinical and biomechanical evaluation. Clin Orthop Relat Res, 317: , Carr AJ and Norris SH: The blood supply of the calcaneal tendon. J Bone Joint Surg, 71-B: , Coull R, Flavin R and Stephens MM: Flexor hallucis longus tendon transfer: Evaluation of postoperative morbidity. Foot Ankle Int, 24: , Den Hartog BD: Flexor hallucis longus transfer for chronic achilles tendonosis. Foot Ankle Int, 24: , Elias I, Besser M, Nazarian LN and Raikin SM: Reconstruction for missed or neglected achilles tendon rupture with V-Y lengthening and flexor hallucis longus tendon transfer through one incision. Foot Ankle Int, 28: , Gabel S and Manoli A 2nd: Neglected rupture of the achilles tendon. Foot Ankle Int, 15: , Hahn F, Meyer P, Maiwald C, Zanetti M and Vienne P:

5 변형된장족무지굴건이전술을이용한진구성아킬레스건파열의치료 Treatment of chronic achilles tendinopathy and ruptures with flexor hallucis tendon transfer: Clinical outcome and MRI findings. Foot Ankle Int, 29: , Kissel CG, Blacklidge DK and Crowley DL: Repair of neglected achilles tendon ruptures--procedure and functional results. J Foot Ankle Surg, 33: 46-52, Kuwada GT: Classification of tendo-achilles rupture with consideration of surgical repair techniques. J Foot Surg, 29: , Maffulli N and Ajis A: Management of chronic ruptures of the achilles tendon. J Bone Joint Surg, 90-A: , Mann RA, Holmes GB,Jr, Seale KS and Collins DN: Chronic rupture of the achilles tendon: A new technique of repair. J Bone Joint Surg, 73-A: , Martin RL, Manning CM, Carcia CR and Conti SF: An outcome study of chronic achilles tendinosis after excision of the achilles tendon and flexor hallucis longus tendon transfer. Foot Ankle Int, 26: , Mulier T, Rummens E and Dereymaeker G: Risk of neurovascular injuries in flexor hallucis longus tendon transfers: An anatomic cadaver study. Foot Ankle Int, 28: , Myerson MS: Achilles tendon ruptures. Instr Course Lect, 48: , Nestorson J, Movin T, Möller M and Karisson J: Funcion after Achilles tendon rupture in the elderly: 25 patients older than 65 years followed for 3 years. Act Orthop Scan, 71: 64-68, Reddy SS, Pedowitz DI, Parekh SG, Omar IM and Wapner KL: Surgical treatment for chronic disease and disorders of the achilles tendon. J Am Acad Orthop Surg, 17: 3-14, Tashjian RZ, Hur J, Sullivan RJ, Campbell JT and DiGiovanni CW: Flexor hallucis longus transfer for repair of chronic achilles tendinopathy. Foot Ankle Int, 24: , Us AK, Bilgin SS, Aydin T and Mergen E: Repair of neglected achilles tendon ruptures: Procedures and functional results. Arch Orthop Trauma Surg, 116: , Wapner KL, Pavlock GS, Hecht PJ, Naselli F and Walther R: Repair of chronic achilles tendon rupture with flexor hallucis longus tendon transfer. Foot Ankle, 14: , Wegrzyn J, Luciani JF, Philippot R, Brunet-Guedj E, Moyen B and Besse JL: Chronic achilles tendon rupture reconstruction using a modified flexor hallucis longus transfer. Int Orthop, Wilcox DK, Bohay DR and Anderson JG: Treatment of chronic achilles tendon disorders with flexor hallucis longus tendon transfer/augmentation. Foot Ankle Int, 21: ,

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< D D28B9DABFEBBFED2DB1E8C7FCB3E2292D33342E687770> 대한족부족관절학회지 : 제 13 권제 1 호 2009 J Korean Foot Ankle Soc. Vol. 13. No. 1. pp.34-39, 2009 Krackow 봉합술을이용한아킬레스건급성파열의치료 한림대학교강남성심병원정형외과학교실 김형년 박기훈 박용욱 Treatment of Acute Achilles Tendon Rupture Using Krackow