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1 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 Suture Technique Hyong-Nyun Kim, M.D., Ki-Hoon Park, M.D., Yong-Wook Park, M.D. Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea =Abstract= Purpose: We try to evaluate the clinical results of the acute Achilles tendon rupture treated with Krackow suture technique. Materials and Methods: We reviewed 27 patients with acute Achilles tendon rupture treated between October 2005 and September There were 26 complete ruptures and 1 incomplete rupture. All were ruptured at tendinous area. There were 21 men and 6 women, and mean age was 38 years. We repaired ruptured Achilles tendon with Krackow suture technique. The results were evaluated with Arner-Lindholm scale for patients satisfaction, strength of calf muscle power, calf circumference, and ankle motion. The average follow-up was 29 months. Results: The patients subjective clinical results was excellent in 25 cases and good in 2 cases. There were 15 cases of less than 1 cm, 6 cases of 1~3 cm, and 1 case of more than 3 cm in the calf circumference difference between the normal and affected leg. There were 20 cases of less than 5 degrees, and 2 cases of more 5 degrees in the difference of range of motion between the normal and affected ankle. We had an experience of postoperative deep infection in one diabetic patient. Conclusion: We had a good clinical result for acute Achilles tendon rupture treated with Krackow suture method. So we recommand Krackow suture technique for acute Achilles tendon rupture. Key Words: Achilles tendon, Acute rupture, Krackow suture 서 론 인체에서가장강력하고큰아킬레스건파열은최근스포츠및여가활동의증가로발생빈도가증가하는추세에있다. 아킬레스건파열에대한치료로는보존적치료 14,15, Address for correspondence Yong-Wook Park, M.D. Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Daerim 1-dong, Yeongdeungpo-gu, Seoul, , Korea Tel: Fax: aofas@chollian.net 24,26) 와수술적치료 2,7-10,25) 로크게구분되나, 파열건에대해봉합술을시행한후파열된건치유를촉진시키고또한파열된건과건막간의유착을방지할목적으로조기에족근관절능동적관절운동과보조기 (walking brace) 착용하에보행을시도하는방법 3,4,18,21,29,32) 이선호되고있다. 파열된아킬레스건봉합술식으로는여러방법들 2,7-10,12,25) 이소개되고있으나, 본교실에서는급성아킬레스건파열에대한봉합술식으로 Krackow 술식 12) 을이용하여좋은결과를얻었기에문헌고찰과함께보고하는바이다

Krackow 봉합술을이용한아킬레스건급성파열의치료 1. 연구대상 대상및방법 2005 년 10월부터 2007 년 9월까지만 24개월동안급성아킬레스건파열로진단받고 Krackow 봉합술식 (Fig. 1) Figure 1. Photograph of the left leg showing Krackow suture with 2.

2 세 ( 범위, 13~63 세 ) 였다. 이중 10대가 2명, 20대가 4명, 30대가 10명, 40대가 9명, 50대이상이 2명으로 30, 40대가전체 27명중에서 19명 (70%) 을차지하였고, 남녀성비는남자가 21예 (78%) 여자가 6예이었다. 좌우측발생빈도는 15:12 로의미있는차이를보이지는않았다.

열상에의해아킬레스건파열이발생한 2예와당뇨가동반되었던 1예를제외한술전 19예에서환부에대해자기공명영상 (Fig. 2) 또는초음파영상 (Fig. 3) 을시행하였으며, 부분파열이 1예였고, 나머지 18예는완전파열이관찰되었다.

2 Krackow 봉합술을이용한아킬레스건급성파열의치료 1. 연구대상 대상및방법 2005 년 10월부터 2007 년 9월까지만 24개월동안급성아킬레스건파열로진단받고 Krackow 봉합술식 (Fig. 1) Figure 1. Photograph of the left leg showing Krackow suture with 2.0 Ethibond R and circular suture with 3.0 Vicryl R for Achilles tendon rupt ure. 을이용하여건일차봉합술을시행한 38예중추시관찰이가능하였던 27예를대상으로하였다. 파열된아킬레스건에대한치료로 Krackow 봉합술식을이용한일차봉합술을시행할당시의환자의연령은평균 38.2 세 ( 범위, 13~63 세 ) 였다. 이중 10대가 2명, 20대가 4명, 30대가 10명, 40대가 9명, 50대이상이 2명으로 30, 40대가전체 27명중에서 19명 (70%) 을차지하였고, 남녀성비는남자가 21예 (78%) 여자가 6예이었다. 좌우측발생빈도는 15:12 로의미있는차이를보이지는않았다. 급성아킬레스건파열원인으로는운동또는여가활동중발생한경우가 16예 (60%), 발을헛디뎌발생한실족사의경우가 8예 (30%), 열상에의한경우가 2예, 아킬레스건부착부에국소스테로이드주사후발생한경우가 1예이었다. 27명의환자중 1예에서 10년이상당뇨를앓은외에는나머지 26예에서동반질환은없었다. 열상에의해아킬레스건파열이발생한 2예와당뇨가동반되었던 1예를제외한술전 19예에서환부에대해자기공명영상 (Fig. 2) 또는초음파영상 (Fig. 3) 을시행하였으며, 부분파열이 1예였고, 나머지 18예는완전파열이관찰되었다. 부분파열 1예는내원 3달전타병원에서아킬레스건부착부에국소스테로이드주사를맞았던적이있던환자이었고, 이를제외한나머지 18예에서시행한검사에서아킬레스건원위및근위단간격은평균 17 mm( 범위, 4~43 mm) 이었다. 또한 19예에서파열은아킬레스건종골부착부에서평균상방 5.1 cm( 범위, 3.4~7.1 cm) 에서발생하였다. 2. Krackow 봉합술식 아킬레스건파열후일차봉합술을시행하기까지는평균 4일 ( 범위, 1~14 일 ) 이경과하였다. Figure 2. Sagittal T2 weighted MRI image of right leg showing the ruptured Achilles tendon. Figure 3. This US image of right l eg showing the discontinuit y and defect of Achilles tendon

3 김형년 박기훈 박용욱 환자를전신마취또는척추마취후앙와위에두고환측하지를건측하지위에 4자모양을이루게올려놓은후파열부위를중심으로아킬레스건내측을따라약 10 cm 정도종절개를가한후아킬레스건을싸고있는건외막조직 (paratenon) 과건중간막 (mesotenon) 을역시종절개하여파열된아킬레스건을노출시켰다. 파열된아킬레스건단을 11번메스를이용해다듬은후 2.0 Ethibond R (Ethicon Inc, U.K.) 봉합사를이용해봉합을시도하였다. 이때파열된아킬레스건전방에서건외막조직과건중간막에파열이관찰되면아킬레스건을봉합하기전에 3.0 Vicryl R (Ethicon Inc, U.K.) 봉합사를이용해일차봉합을시행하였다. 파열된아킬레스건의근위단과원위단에각각네개에서다섯개의매듭을줬고, 원위및근위파열단이완전히접촉이된상태에서봉합사를파열단내에위치하도록하여철저히묶은후그주변을다시 3.0 Vicryl R 봉합사를이용해봉합을시행하였다. 족근관절을 20 도족배굴곡시켜파열단부위가다시벌어지지않는것을확인하였고이때만일파열단이긴장으로인해벌어질경우에는 3.0 Vicryl R 봉합사를이용해벌어지지않는것이확인될때까지보강을해주었다. 파열된나머지건외막조직과건중간막역시 3.0 Vicryl R 봉합사를이용해봉합해주었다. 술후족근관절을조심스럽게서서히중립위까지족배굴곡시켜이때저항이느껴지지않으면중립위에서단하지부목을시행해주었고만일저항이느껴질경우에는족근관절을약 10도족저굴곡한상태에서단하지부목을시행해주었다. 수술후환부에통증과불편감이해소되고, 환부에염증반응이관찰되지않으면바로보조기 (walking boots) 를착용한상태에서전체중부하보행토록하였다. 이때발뒤꿈치에아킬레스건이긴장하지않을정도의수술용패드 (surgical pad) 를깔아주었다. 보행을하지않을때에는보조기를벗고첫 3주동안은능동적족관절족저운동만허용 하였고, 다음 3주부터는서서히족관절능동적족배운동도같이하도록하였다. 수술후 10~12 주사이에이학적검사를통해파열부위에통증이해소되고족근관절족저및족배굴곡력이양호이상을보이면보조기를제거하였으며, 이때통증및불편감이잔존할경우에는일시적으로힐패드 (heel pad) 를권유하였다. 3. 술후원격추시기간및평가최종추시때환자의임상적결과판정은환자의만족도, 종아리근력정도, 종아리둘레, 족근관절운동범위에근거한 Arner-Lidholm 평가기준 1) (Table 1) 을이용하여우수, 양호, 불량으로판정하였다. 환자의만족도에서는보행시불편감정도를, 보행력 (walking power) 정도를, 발뒤꿈치들기유무와종아리근력정도를살펴보았고, 객관적평가로양측종아리둘레차이와양측족근관절운동범위차이를측정하였다. 평균추시기간은 29개월 ( 범위, 16~44 개월 ) 이었고, 환자가병원을방문해평가를시행한경우가 22예, 전화를통한주관적평가만을시도한경우가 5예였다. 결과환자의주관적만족도는보행시불편감없음이 26 예였고, 당뇨가동반되었던 1예에서가벼운불편감을호소하였다. 또한보행시정상보행력을보인다가 25예였고, 보행능력이다소떨어진다가 2예였고, 여기에는당뇨가동반되었던 1예가속하였다. 당뇨가동반되었던 1예를제외한 26예에서한발뒤꿈치들림이가능하였다. Arner-Lidholm 평가기준에따르면우수 25예, 양호 2예로, 전예에서양호이상의주관적만족을보였다. T a b l e 1. Arner-Lindholm Scale for Evaluation of Acute Achilles Tendon Rupture Excellent Good Poor Free from discomfort and essentially normal function Normal walking power, tip toe, calf muscle power Calf circumference < 1 cm Ankle ROM decrease < 5 degrees (plantar flexion/dorsiflexion) Mild discomfort Slightly decreased walking power, tip toe, calf muscle power Calf circumference < 3 cm Ankle ROM decrease < 15 degrees (plantar flexion/dorsiflexion) Dissatisfied or marked discomfort Limp, inability to tip toe Calf circumference > 3 cm Ankle ROM: dorsiflexion decrease > l0 degrees or plantar flexion decrease > 15 degrees

4 Krackow 봉합술을이용한아킬레스건급성파열의치료 총 27명의환자중 22명에서시행한환측과건측의종아리둘레차이가 1 cm 이하를보인경우가 15예, 1~3 cm 차이를보인경우가 6예, 3 cm 이상차이를보인경우도 1예에서있었으나, 전예에서이로인한근력약화를호소하지는않았다. 총 27명의환자중 22명에서시행한환측과건측의족근관절운동범위의차이가 5도이하를보이는경우가 20예, 2예에서는 7도, 11도의차이를보이고있었으나, 이로인한일상생활에불편은호소하지않았다. 특이하게도 22예중 15예에서건측보다환측에서의족근관절족배굴곡각도가더크게관찰되었고, 그정도는평균 4.3 도 ( 범위, 2~7 도 ) 이었다. 술후합병증으로재파열은없었으나, 당뇨가동반되었던 1예에서절개부심부감염이발생하여장기간치료가요하였고, 창상치유후족근관절의운동범위가감소된외에는환자의주관적만족도는양호를보였다. 고찰 1575년 Pare가아킬레스건파열에대해처음기술한이래이에대한다양한치료방법들 2,7-10,14,15,24-26) 이소개되어져왔다. 지금까지소개된치료방법들은보존적치료방법과수술적치료방법으로크게나눌수가있는데, 보존적치료방법을주장하는학자는수술후많은경우에서수술에따른합병증으로인해종전의활동력을상실한경우때문이라고하였고 30), 수술적치료방법을주장하는학자는수술적치료로수상전의활동력이복구되기때문이라고하였다 27). 최근스포츠와여가활동의증가로아킬레스건파열의발생빈도는점차증가하는추세에있어합병증없이조속한시일내에환자를회복시켜사회에복귀시키는데치료목적이있겠다. 이를위해 Rubin 과 Wilson 28) 은수술적요법이보존적요법보다합병증의빈도는높다하더라도결과의향상을위해서는수슬적요법이시행되어야한다고주장하였다. 지금까지소개된수술방법으로는족저근건을이용하여술식 9,10,25), 대퇴근막을이용하는술식 2), 파열된아킬레스건의근위단의건막 (aponeurosis) 를이용하는술식 8) 등의다양한자가건, 근막또는건막을이용하는방법과파열된아킬레스건을 Bunnell 봉합술식 25,31), Kessler 봉합술식 7), Krackow 봉합술식 12) 또는 pull out 봉합술식 13,25) 을이용해봉합하는방법들이있다. 그러나족저근건, 대퇴근막, 파열된아킬레스건의근위단건막등과같은다양한자가건, 근막또는건막을이용하는술식은그술식이간단치않아급성아킬레스건파열에서보다는아킬레스건파열이 3~4 주이상경과하여파열된건간의접촉이불가능한경우에서주로이용된다고하겠다. 급성아킬레스건파열에서이용할수있는봉합술식으로는 Bunnell 술식 25,31), Kessler 술식 7), Krackow 술식 12), pull out 술식 13,25) 등다양하게소개되고있지만, 각봉합술식에대한봉합강도는차이를보이는것으로보고하고있다 5,19,22,23). 최근봉합술식의강도가술후조기족근관절운동과조기재활운동을허용할정도로강력하고안정된술식으로많은저자들이 Krackow 술식을사용하고있다. 본연구의경우에도모든예에서파열된건의양단을접촉시켜적당한긴장을유지한상태에서 Krackow 봉합술식을사용하였으며, 이때파열된아킬레스건을보강유지하고유착을줄일목적으로추가하는족저근건을봉합술식은하지않았다 년강등 9) 은 60예의급성아킬레스건파열에대해파열된건의양단을족저근건을이용해단단봉합을시행한결과 54예 (90%) 에서양호이상의결과를보였고, 단지 2예에서절개부피부병변을경험하였다고하였으며, 1997 년강등 8) 은 18예의급성아킬레스건파열에대해파열된근위건단에서길이 7~8 cm, 폭 1.5 cm 정도의건판을만들어이를 180 도이동하여원위건단에봉합해주는술식을시행한결과 3예에서보행및운동시동통을, 1예에서절개부피부병변을경험하였다고하였다. 본교실에서시행한 Krackow 봉합술식을이용한아킬레스건일차봉합술결과전예에서양호이상의결과를보였으며, 조기체중부하및조기족근관절운동으로인한재파열과같은합병증도발생하지않았고, 단지당뇨가동반되었던 1예에서가벼운불편감및절개부심부감염이발생하였다. 일반적으로건손상에대한치유과정은 3단계로나눠진다. 즉염증기 (inflammation), 원섬유생성기 (fibrillogenesis period), 그리고성숙기 (maturing period) 로구성된다 6,20). 손상된건의복원은건초와그주변결합조직의증식에의한외재적치유와건외막및건내막등의건자체조직의증식과이동에의한내재적치유에의해이루어진다. 건의재형성은수상후 2주경에시작하여 4주경에는건섬유가종으로배열되고 17), 성숙과정은 1년까지지속된다. 손상조직의복원과정은고정에의해서변화되어지는데, 육아조직이아킬레스건의절단면사이를연결시켜주지만고정기간이길어지면반흔조직에의해건의주위조직과유착될수있으며정상적인활주작용을방해하게된다 16). 일시적고정을한후에기계적스트레스를가했을때형성된콜라겐섬유의방향이평행한것과는달리장기간고정으로인하여생긴반흔조직의섬유방향은불규칙하며정상적인긴장상태로복귀하는데도더많은시간이소요된다

5 김형년 박기훈 박용욱 또한건수복후에 3주간고정후운동시킨경우가장기간고정한경우보다장력이 3배나강하다고하였다 20). 이런연구결과를바탕으로최근건파열일차봉합술후조기관절운동을시행하는것을원칙으로하고있다. 한편 1977 년 Ketchum 11) 은조기능동적운동은건의활주를향상시키지못하고봉합선을가로지르는장력이증가하여건파열양단사이가벌어지고건경색, 건연화및건파열이생길수있다고하였다 년 Woo 등 33) 에의하면제한된수동적운동이수복한건의장력과활주기능을증가시킨다고하였다. 본교실에서는술후통증이사라지면술후 3주간족근관절능동적족저굴곡운동을, 그리고술후 6주부터는족근관절능동적족배굴곡운동을함께독려하였다. 추시관찰결과 22예중 15예에서건측보다환측에서의족근관절족배굴곡각도가더크게관찰되었으나, 이경우에서양측종아리근력의차이는없었을뿐만아니라둘레역시차이를발견할수없어추후이에대한재평가가필요할것으로사료된다. 결 론 급성아킬레스건파열의수술적치료로 Ethibond 봉합사를이용한 Krackow 봉합술식은조기에체중부하와조기족근관절운동을허용하여환자로하여금만족할만한결과를얻을수있는술식으로사료된다. REFERENCES 1. Arner O and Lindholm A: Subcutaneous rupture of the Achilles tendon; a study of 92 cases. Acta Chir Scand, 116(Supp 239): 1-51, Bae DK, Han JS, Nam GU, Kim JJ and So JK: Reconstruction of Achilles endon using fascia using fascia lata allogrft A case report-. J Korean Orthop Assoc, 29: , Baek GH, Lee HK, Lee SH, Yeo BG and Cho KH: Experimental study on the effects of suture and limited active motion on Achilles tendon healing. J Korean Orthop Assoc, 29: 36-43, Carter TR, Fowler PJ and Blokker C: Functional postoperative treatment of Achilles tendon repair. Am J Sports Med, 20: , Cetti R, Henriksen LO and Jacobsen KS: A new treatment of ruptured Achilles tendons. A prospective randomized study. Clin Orthop Relat Res, 308: , Gelberman RH, Vande Berg JS, Lundborg GN and Akeson WH: Flexor tendon healing and restoration of the gliding surface. An ultrastructural study in dogs. J Bone Joint Surg, 65-A: 70-80, Ihn JC, Park BC, Kyung HS, Kim SY and Shin SH: Surgical treatment of the closed complete rupture of Achilles tendon. J Korean Orthop Assoc, 32: , Kang CN, Kim JH, Kim DW, Koh YD, Go SH and Kim SM: Surgical repair of Achilles tendon ruptures-modified Lindholm method-. J Korean Orthop Assoc, 32: , Kang JD, Kim KY, Kim HC, Kim JH and Choi SK: Surgical treatment of Achilles tendon rupture using modified Lynn method. J Korean Soc Foot Surg, 7: , Kang JD, You MK, Yoo HJ and Ha PS: Reapir of the torn Achilles tendon, using the Plantaris tendon. J Korean Orthop Assoc, 20: , Ketchum LD: Primary tendon healing: a review. J Hand Surg, 2-A: , Krackow KA, Thomas SC and Jones LC: A new stitch for ligament-tendon fixation. Brief note. J Bone Joint Surg, 68-A: , Lavine LS, Karas S and Warren RF: Two-pin technique for Achilles tendon repair. Clin Orthop Relat Res, 40: , Lea RB and Smith L: Nonsurgical treatment of tendo-achilles rupturr. J Bone Joint Surg, 54-A: , Lee EW, Kang KS, Kang SY and Jin WJ: Comparison of conservative and operative treatment of Achilles tendon rupture. J Korean Orthop Assoc, 31: , Lehto M, Duance VC and Restall D: Collagen and fibronectin in a healing skeletal muscle injury. An immunohistological study of the effects of physical activity on the repair of injured gastrocnemius muscle in the rat. J Bone Joint Surg, 67-B: , Levy M, Velkes S, Goldstein J and Rosner M: A method of repair for Achilles tendon ruptures without cast immobilization. Preliminary report. Clin Orthop Relat Res, 187: , Mandelbaum BR, Myerson MS and Forster R: Achilles tendon ruptures. A new method of repair, early range of motion, and functional rehabilitation. Am J Sports Med, 23: , Marti R and Weber BG: Rupture of the achilles tendon - functional after care. Helv Chir Acta, 41: , Mason ML and Allen HS: The rate of healing of tendons: An experimental study of tensile strength. Ann Surg, 113: , Mortensen HM, Skov O and Jensen PE: Early motion of the ankle after operative treatment of a rupture of the Achilles tendon. A prospective, randomized clinical and radiographic study. J Bone Joint Surg, 81-A: , Mortensen NH and Saether J: Achilles tendon repair: a new method of Achilles tendon repair tested on cadaverous materials. J Trauma, 31: , Mortensen NH, Saether J, Steinke MS, Staehr H and Mikkelsen SS: Separation of tendon ends after Achilles tendon repair: a prospective, randomized, multicenter study

6 Krackow 봉합술을이용한아킬레스건급성파열의치료 Orthopedics, 15: , Nistor L: Surgical and non-surgical treatment of Achilles tendon rupture. J Bone Joint Surg, 63-A: , Park IH, Lee KB, Song KW, Lee JY and Song YS: Surgical repair of Achilles tendon ruptures-3 tissue bundle technique-. J Korean Orthop Assoc, 25: , Persson A and Wredmark T: The treatment of total rupture of the Achilles tendon by plaster immobilization. Int Orthop, 3: , Ralston EL and Schmidt ER Jr: Repair of the ruptured Achilles tendon. J Trauma, 11: 15-21, Rubin BD and Wilson HJ Jr: Surgical repair of the interrupted Achilles tendon. J Trauma, 20: , Speck M and Klaue K: Early full weightbearing and functional treatment after surgical repair of acute Achilles tendon rupture. Am J Sports Med, 26: , Stein SR and Luekens CA Jr: Closed treatment of Achilles tendon ruptures. Orthop Clin North Am, 7: , Thompson TC: A test for rupture of the tendo achillis. Acta Orthop Scand, 32: , Troop RL, Losse GM, Lane JG, Robertson DB, Hastings PS and Howard ME: Early motion after repair of Achilles tendon ruptures. Foot Ankle Int, 16: , Woo SL, Gelberman RH, Cobb NG, Amiel D, Lothringer K and Akeson WH: The importance of controlled passive mobilization on flexor tendon healing. A biomechanical study. Acta Orthop Scand, 52: ,

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< D D28B9DABFEBBFED2DB1E8C7FCB3E2292E687770> 대한족부족관절학회지 : 제 13 권제 2 호 2009 J Korean Foot Ankle Soc. Vol. 13. No. 2. pp.133-137, 2009 변형된장족무지굴건이전술을이용한진구성아킬레스건파열의치료 한림대학교강남성심병원정형외과학교실 김형년 서일우 박용욱 Treatment of Old Achilles Tendon Rupture using Modified