Original Article pissn eissn J Korean Foot Ankle Soc 2019;23(1): 단일족지절단환자의상처치유위험인

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1 Original Article pissn eissn J Korean Foot Ankle Soc 2019;23(1): 단일족지절단환자의상처치유위험인자에대한통계적분석 정형진, 배서영, 신우진 a, 이준호 인제대학교의과대학정형외과학교실 Statistical Analysis of the Risk Factors for Single Toe Amputation Patients in Wound Healing Hyung-Jin Chung, Su-Young Bae, Woo-Jin Shin a, Jun-Ho Lee Department of Orthopedic Surgery, Inje University College of Medicine, Seoul, Korea Purpose: This study compared and analyzed the risk factors that affect a wound healing group and healing failure group. Materials and Methods: From 2010 to 2018, 39 patients who had suffered a single toe amputation were evaluated retrospectively. The patients were divided into two groups (wound healing group and healing failure group - within at least 3 months following the amputation). Regarding the possible risk factors, age, gender, Wagner and Brodsky classifications, duration of diabetes mellitus, whether the patient had peripheral arterial occlusive disease (PAOD) or cardiovascular disease, body mass index, HbA1c, total cholesterol, estimated glomerular filtration rate (egfr), blood urea nitrogen (BUN), smoking, and alcohol were investigated. Results: The mean duration of diabetes mellitus was 140 months in the healing group and 227 months in the healing failure group, and the duration of diabetes was significantly longer in the failure group (p=0.009). A significant difference in egfr was observed between the two groups (59.17 ml/min/1.73 m 2 in the healing group and 31.1 ml/min/1.73 m 2 in the failure group) (p=0.022). Sixteen patients with PAOD were found, all 10 patients in the healing failure group were PAOD patients. Conclusion: To reduce the additional complications in single toe amputation patients, the underlying disease and appropriate treatment are the most important factors. In addition, a more proximal level of amputation also should be considered in cases of patients with PAOD, high BUN and low egfr, and patients with long-term diabetes. Key Words: Toe amputation, Diabetes mellitus, Arterial occlusive disease 서 론 당뇨발환자를치료함에있어서절단은감염혹은괴사조직의 광범위제거를시행하는치료의마지막수단이지만절단시행후 Received February 1, 2019 Revised March 6, 2019 Accepted March 6, 2019 Corresponding Author: Hyung-Jin Chung Department of Orthopedic Surgery, Inje University Sanggye Paik Hospital, 1342 Dongil-ro, Nowon-gu, Seoul 01757, Korea Tel: , Fax: , orthoman@paik.ac.kr ORCID: a Current affiliation: Department of Orthopedic Surgery, Gwangju Veterans Hospital, Gwangju, Korea Financial support: None. Conflict of interest: None. 환자에게기능적, 미용적, 정신적장애를남길수있어절단범위의결정은신중하게해야한다. 절단후창상합병증, 재수술이나절단범위의확장없이단일수술만으로성공적인치료를시행하는것역시쉽지않아절단범위결정과절단창상의치유율은족부정형외과의사에게는항상고민의대상이다. 기존연구결과들에따르면, 혈류의개선이나연부조직치료를위한여러재료들이개발되고있고기능적인사지보존의원칙하에소절단의비율이높아지고있으며 1-3) 소절단후재수술률은 10% 정도로낮게보고되고있어가능하면소절단을일차적으로고려해야하며, 방사선소견, 검사의학적소견, 임상경험및수술소견을고려해서절단부위를정해야하는것이중요하다. 1) 소절단중에서도족지절단은환자의잔여하지를보존해서활동을유지할수 Copyright c2019 Korean Foot and Ankle Society. All rights reserved. CC This is an Open Access article distributed under the terms of the Creative Commons Attribution 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 Hyung-Jin Chung, et al. Risk Factor Analysis for Toe Amputation Patients in Wound Healing 19 있게하고보조기없이보행이가능하며기능적인사회구성원으로서삶을영위하도록하는장점이있지만국내외여러연구들중족지절단이후창상치유에영향을미치는인자들에대한연구는찾아보기힘들었다. 이에본저자들은족지절단수술후창상치유에영향을줄수있는여러요인들을분석하여유의한인자들을찾아보고자하였다. 대상및방법 1. 연구대상 2010년 3월부터 2018년 7월까지당뇨병성족부궤양으로인제대학교상계백병원에내원하여단일족지절단술을시행받고 3개월이상추적조사가가능하였던총 39명 (39예) 의환자들을대상으로하였다. 이중근위족지에서의절단은 22예, 중위족지에서의절단은 14예, 원위족지에서의절단은 3예였다. 본연구는연구진행의생명윤리및안전을확보하기위하여인제대학교상계백병원연구윤리심의위원회승인하에의무기록및임상사진등을후향적으로분석하여이루어졌다. 2. 연구방법 동맥질환은말초혈관조영술과족배동맥과후경골동맥촉지여부, 그리고만성호흡기질환은폐기능검사를이용하여조사하였다. (3) 검사의학적지표족지절단수술직전의검사의학적결과중혈색소 (hemoglobin), 백혈구수 (white blood cell count), 중성구수 (neutrophil count), C-반응성단백 (C-reactive protein), 총단백 (total protein), 알부민 (albumin), 총콜레스테롤 (total cholesterol), 혈액요소질소 (blood urea nitrogen, BUN) 를조사하였다. 또한크레아티닌 (creatinine) 을조사하여연령, 성별및인종에근거한신질환수정요법 (Modification of Diet in Renal Disease study) 으로산출한추정사구체여과율 [estimated glomerular filtration rate (egfr)=1.86 (serum creatinine) (age) 0.203, multiply by for female, ml/min/1.73 m 2 ] 로변환하여기록하였다. (4) 창상관련지표먼저감염여부와균배양검사결과를조사및기록하였으며, 족지궤양에대해 Wagner 분류 4) 와 Brodsky 깊이-허혈분류 5) 를이용하여조사및기록하였다. 1) 군의분류환자들을절단수술후창상치유성공군 (wound healing group) 과창상치유실패군 (healing failure group) 의두군으로구분하였다. 창상치유성공군은단일족지절단수술이후창상의치유를얻고 3개월추시기간내에창상의재발이없었던경우로정의하였으며, 창상치유실패군은수술후 3개월이내에절단단성형술 (stump revision) 이나근위부에서의재절단을필요로했거나창상감염, 창상열개 (dehiscence) 등의합병증으로지속적인창상관리가필요로했던경우로정의하였다. 2) 창상치유에영향을줄수있는지표의조사 (1) 인구학적지표나이, 성별, 흡연및음주여부, 체질량지수의인구학적지표들에대한의무기록을통해조사및기록하였다. (2) 당뇨및동반질환관련지표당뇨관련지표로써당뇨유병기간과당화혈색소 (HbA1c), 경구혈당강하제와인슐린주사의혈당조절방법으로나누어조사하였으며당뇨와동반된질환들을심혈관질환, 말초동맥질환유무, 만성호흡기질환, 간질환, 만성콩팥병 (chronic kidney disease) 및투석여부로나누어조사및기록하였다. 이중심혈관질환은고혈압, 심근경색, 협심증등의과거력을바탕으로조사하였으며, 말초 3) 통계분석각지표의군간유의성검정을위해인구학적지표, 혈당조절방법을제외한당뇨관련지표, 검사의학적지표는독립 t-test를이용하여분석하였으며, 혈당조절방법과창상관련지표는 Pearson χ 2 검정 (chi-square test) 을이용하여분석하였고, 유의수준은 0.05 이하로하였다 (SPSS for Windows ver. 10.0; SPSS Inc., Chicago, IL, USA). 결과 1. 군의분류창상치유성공군에해당되는환자들은총 29예 (29명) 로모든예에서족지절단술후 2주이내에발사를시행하였고, 창상치유실패군에해당되는환자들은총 10예 (10명) 로근위부에서의재절단을필요로했던경우가 3예, 절단단성형술을필요로했던경우가 2예, 감염이나창상치유지연으로 3개월이상창상치료를지속하여야했던경우가 5예로확인되었다 (Table 1). 2. 각지표의분석결과 1) 인구학적지표족지절단환자들의평균연령은 65세였으며, 창상치유성공군은평균 63.37세, 창상치유실패군은평균 70.09세였다 (p=0.123).

3 20 Vol. 23 No. 1, March 2019 Table 1. Status Table of 39 Toe Amputation Patients Patient no. Sex Age (yr) Cardiovascular Wound healing PAOD disease Pulmonary disease Liver disease Renal disease Dialysis Smoking Alcohol Wagner Brodsky classification (depth) Brodsky (ischemia) Amputation level 1 M 51 Y N Y N N N N Y N 4 1 C 2nd MP 2 M 75 N Y N N N N N Y Y 2 2 B 1st PP 3 M 60 N Y Y N N N N N N 4 1 C 4th DP 4 M 66 N N Y N N N N Y Y 2 1 C 1st PP 5 M 63 Y Y Y N Y Y Y N N 4 3 C 1st MP 6 F 63 Y N Y N N Y N N N 4 3 C 1st MP 7 M 70 Y N N N N N N Y Y 4 3 C 4th MP 8 M 48 Y N N N N N N Y Y 3 3 B 1st DP 9 M 73 Y N Y N N N N N N 2 2 B 2nd PP 10 F 72 Y N N N N N N Y N 4 3 C 4th PP 11 F 64 Y N Y N N Y Y N N 4 3 C 4th PP 12 M 64 Y Y N N N N N Y N 3 3 C 4th PP 13 M 48 Y N Y N N N N N N 3 3 C 1st PP 14 M 51 Y N N N N N N Y N 4 3 C 1st PP 15 M 68 Y N Y N N N N N N 3 3 B 5th PP 16 M 64 Y N N N N N N N N 2 2 B 3rd PP 17 M 74 N Y Y N N Y N N N 4 3 C 1st PP 18 M 58 Y N N N N N N N N 4 3 C 1st PP 19 M 87 N Y Y N N Y Y N N 4 3 C 3rd PP 20 F 77 N Y Y N N Y Y N N 3 2 B 1st PP 21 F 47 Y N N N N N N N N 3 3 B 2nd MP 22 F 52 Y Y N N N N N Y Y 4 3 C 1st PP 23 M 43 Y Y N N N N N N N 4 3 C 1st PP 24 M 88 Y Y N N N Y Y N N 4 3 C 2nd MP 25 M 76 N N Y N N Y Y N N 3 2 B 4th MP 26 M 69 Y Y N N N N N Y Y 4 3 C 3rd MP 27 M 84 Y N N N N N N N N 4 3 B 1st MP 28 F 66 N N Y Y N N N N N 2 3 B 2nd PP 29 M 80 Y N N N N Y N N N 2 2 B 1st PP 30 M 70 N N Y N N N Y N N 2 2 B 4th MP 31 M 56 Y N N N N N N N N 4 3 C 2nd PP 32 F 85 Y N N N N N N N N 3 3 B 4th MP 33 M 82 Y N N N N N N N N 4 3 B 2nd DIP 34 M 57 N Y N N N N N Y Y 2 2 B 2nd MP 35 M 58 Y Y Y N Y Y N Y Y 3 3 C 4th MP 36 M 58 Y Y N N N Y N Y Y 3 3 C 4th PP 37 F 78 Y Y N N N Y Y N N 3 3 C 2nd MP 38 F 57 Y Y N N N N Y N N 2 2 B 3rd PP 39 M 84 Y N N N N N N N N 2 2 B 2nd PP PAOD: peripheral arterial occlusive disease, M: male, F: female, Y: yes, N: no, MP: metatarsophalaneal joint, PP: proximal phalanx, DP: distal phalanx, DIP: distal interphalangeal joint. 남녀비율은창상치유성공군은 20:9, 창상치유실패군은 9:1로 (p=0.189) 두군의차이에통계적의의는없었다. 흡연 (p=0.195) 과음주 (p=0.363) 의경우에서도두군간의통계적차이가없었다. 체질량지수는창상치유성공군 kg/m 2, 창상치유실패군 kg/m 2 로통계적유의성은확인되지않았다 (p=0.161) (Table 2). 2) 당뇨및동반질환관련지표당뇨병의유병기간은창상치유성공군 140개월, 창상치유실패군 227개월로창상치유실패군에서이환기간이길었으며, 통계 적으로도유의하여의미있는인자로확인되었다 (p=0.009). 당화혈색소수치는창상치유성공군 8.17%, 창상치유실패군 7.04% 로, 통계적인유의성은확인되지않았다 (p=0.206). 인슐린및경구혈당강하제복용등의혈당조절방법에서도통계적으로유의성은없었다 (Table 3). 동반질환관련지표에대한결과에서는말초동맥질환동반여부에따른두군의차이에서통계적으로유의한인자로확인되었으나 (p=0.0001), 심혈관질환동반여부및만성호흡기질환, 간질환, 만성콩팥병유무에서두군간에통계적유의성은없었다 (Table 4).

4 Hyung-Jin Chung, et al. Risk Factor Analysis for Toe Amputation Patients in Wound Healing 21 Table 2. Comparison between Wound Healing Group (HG) and Healing Failure Group (FG) in Patients Factors Variable Age (yr) (43~88) (56~87) Male:female 20:9 9: Smoker/non-smoker 8 (27.6) 5 (50.0) Drinker/non-drinker 6 (20.7) 3 (30.0) BMI (kg/m 2 ) 23.22± ± Values are presented as mean (range), number only, number (%), or mean±standard deviation. BMI: body mass index. Table 3. Comparison between Wound Healing Group (HG) and Healing Failure Group (FG) in Diabetes Mellitus (DM) Factors DM duration (yr) 11.68± ± HbA1c (%) 8.17± ± Treatment of DM PO Insulin 5 1 Values are presented as mean±standard deviation or number only. Table 4. Comparison between Wound Healing Group (HG) and Healing Failure Group (FG) in Comorbidity Factors Cardiovascular disease 14 (93.3) 5 (50) PAOD 6 (26.1) 10 (100) Pulmonary disease 0 (0) 1 (11.1) Liver disease 2 (6.8) 0 (0) Renal disease 8 (27.6) 4 (40) Dialysis 6 (26.1) 3 (30) Values are presented as number (%). PAOD: peripheral arterial occlusive disease. Table 5. Comparison between Wound Healing Group (HG) and Healing Failure Group (FG) in Laboratory Factors Hemoglobin (g/dl) 11.31± ± White blood cell (10 3 /μl) 10.26± ± Neutrophil count (10 3 /μl) 6.30± ± C-reactive protein (mg/dl) 4.33± ± Protein (g/dl) 7.10± ± Albumin (g/dl) 3.56± ± Total cholesterol (mg/dl) ± ± BUN (mg/dl) 25.78± ± egfr (ml/min/1.73 m 2 ) 59.17± ± Values are presented as mean±standard deviation. BUN: blood urea nitrogen, egfr: estimated glomerular filtration rate. Table 6. Comparison between Wound Healing Group (HG) and Healing Failure Group (FG) in Wound-related Factors; Infection and Wound Culture Infection 26 (89.7) 10 (100) Wound culture Staphylococcus group 8 (27.6) 5 (50.0) Streptococcus group 2 (6.9) 1 (10.0) Pseudomonas group 2 (6.9) 2 (20.0) Others 11 (37.9) 2 (20.0) Values are presented as number (%). Table 7. Comparison between Wound Healing Group (HG) and Healing Failure Group (FG) in Wound-related Factors; Wound Classification Wagner (2+3/4+5) 14/15 7/ Brodsky Depth (1+2/3) 6/23 7/ Ischemia (A+B/C+D) 11/18 6/ ) 검사의학적지표수술전혈색소는창상치유성공군에서 g/dl, 창상치유실패군에서 g/dl였으며통계적유의성은없었고, 백혈구수 (p=0.151), 중성구수 (p=0.896), C-반응성단백 (p=0.707) 은모두창상치유실패군에서높았으나통계적으로유의하지않았다. 총단백질량 (p=0.258) 과알부민 (p=0.220), 콜레스테롤 (p=0.678) 에서는두군간의통계적유의성은없었지만, 신장기능과관련된검사지표인 BUN (p=0.0001) 은창상치유실패군에서 mg/ dl로창상치유성공군 mg/dl보다유의하게높았고 egfr (p=0.022) 은창상치유성공군에서 ml/min/1.73 m 2 로창상치유실패군 31.1 ml/min/1.73 m 2 보다유의하게높았으며두지표모두유의한인자로확인되었다 (Table 5). 4) 창상관련지표감염여부가두군에미치는영향을조사하였으나통계적유의성은없었다 (p=0.051). 균배양검사에서는창상치유성공군 39 예중 23예에서균이동정되었으며, 창상치유실패군에서는 10 예모두에서균이동정되었으나창상치유에영향을미치는데에는통계적유의성이확인되지않았다 (p=0.263) (Table 6). 상처분류에서 Wagner 분류의경우창상치유성공군에서절단의위험성이높은 4, 5 등급이많았지만통계적유의성은없었다 (p=0.240). Brodsky 깊이-허혈분류에서깊이는창상치유성공군에서절단의위험성이높은 3등급이많았고 (p=0.281) 허혈의정도도창상치유성공군에서절단의위험성이높은 C, D등급이많았으며 (p=0.230) 두분류에서통계적유의성은없었다 (Table 7). 고찰 성공적인절단술이이루어지기위해서는절단하고자하는부위의치유가능성을정확히파악하고가능한한말단부위에서절단하며수술후초기에재활교육을시행하여야한다. 6) 하지절단술시행후예후를예측하기위한여러연구중 Dickhaut 등 7) 은혈

5 22 Vol. 23 No. 1, March 2019 중알부민과같은영양지표나총림프구수와같은면역요인들이정상수치일때하지절단술후성공적인결과를예측할수있다고하였고, Wagner 8) 는하지절단술후당뇨발환자의창상치유에있어조직에영양을줄수있는충분한수준을혈중알부민 2.5 g/dl, 총림프구수 1,500 mm 3 이상인경우등으로제시하였다 9). 이처럼당뇨족부궤양환자들에서여러위험인자들에대한연구는많았으나창상치유에영향을주는인자들에대한연구는찾기힘들었다. 이에연구자들은본원에서당뇨족부궤양으로단일족지절단술을시행한환자들을대상으로연구를시행하였고, 총 39명중 10 명 (25.6%) 의경우에서창상치유실패를경험하였으며, 심지어이중 5명의환자들은창상치유를얻는데평균 4.6개월간지속적으로창상에대한치료가필요하였다. 따라서본연구에서는족지절단술후여러합병증을미리예측하고예방하기위해족지절단술후창상치유에영향을끼치는여러인자에대해분석해보았다. 여러가지지표들중긴당뇨병이환기간과말초동맥질환의동반여부그리고낮은 egfr, 높은 BUN의신장기능저하가통계적으로유의하게창상치유에악영향을주는위험인자로분석되었다. 말초동맥질환은대동맥이나사지동맥에협착이나폐쇄가존재하는경우로정의된다. 10) 말초동맥질환에의한충분하지않은혈류공급은창상을유발할뿐아니라이미발생된창상을악화시키기때문에말초동맥질환을치료하는것이족부창상치료의가장중요한치료적목표이며, 11) 기존의연구들에서말초동맥질환과절단과의높은상관관계를보고하였다. 12,13) 본연구에서도창상치유에실패한환자들은전원말초동맥질환을동반하여절단단성형술이나근위부에서재절단을필요로하였다. 따라서말초동맥질환의조기진단과내과적치료가정형외과적치료와동반될때, 절단술을시행한환자에서근위부재절단을포함한추가합병증을줄일수있는방법이될수있을것으로생각된다. 당뇨이환기간이절단율과유의한상관관계를가진다는연구들은있었으나 14-17) 이환기간과창상치유의관계에대한연구는찾아보기힘들었다. 본연구에서창상치유실패군의당뇨이환기간은 227개월로창상치유성공군의약 1.6배로유의하게길었는데, 이는유병기간이길수록만성콩팥병및말초혈관질환등의합병증의동반가능성이높아지기때문일것으로생각된다. 본연구결과와이러한사실들을근거로이환기간이긴당뇨환자에서절단술을시행함에있어신중한절단위치선정과합병증에대한동반치료가중요하다고생각된다. 또한, 본연구에서 BUN이높은환자와 egfr이낮은환자에서창상치유에실패할위험이큰것으로확인되었다. 만성콩팥병은콩팥손상의증거가있거나 egfr 이 60 ml/min/1.73 m 2 미만일때로정의하며, 그중에신장기능이 50% 이하로떨어진상태가 3개월이상지속될경우로정의하고있다. 18) 본연구에서확인된바두군모두평균 egfr 수치는 60 ml/ min/1.73 m 2 미만으로만성콩팥병환자에해당되는수치를나타 내었으나창상치유실패군에서는유의하게 egfr 수치가낮음을 확인할수있었다. Miyajima 등 19) 은당뇨발환자에서여러인자들과절단율과의관 계를분석한연구에서투석환자들이투석하지않는환자들에비 해절단율이높은것을확인하였으나본연구에서는이와관련해 서는투석과상처치유와의통계적유의성은없었다. 본연구는후향적연구디자인으로써환자의의무기록을바탕으 로하였기때문에부정확한정보획득의가능성이있으며, 단일연 구기관에서시행한연구로술자들의선택편재가있을수있다는 점, 본원에서족지절단만시행하였던환자의수가적다는것을제 한점으로볼수있겠으나기존에족지절단술시행후창상치유에 영향을미치는인자들에대한조사가없었다는점에서가치가있 다. 결 론 본연구에서확인되었듯이당뇨병을오래앓아왔던환자들이나 신장기능이저하된환자들, 말초동맥질환을지니고있는환자들 에게하지의상처여부를자주관찰하게하는교육과더불어상처 발생시병원에조기방문하여치료할것을주지시켜주는것이매 우중요하다. 또한, 절단술의적응에해당되는환자들중본연구 에서확인된위험인자를지닌환자들에서는여러연구결과와마찬 가지로신중한절단위치를선정하여야하며, 20,21) 창상치유가능 성이낮을것을예측하여족지절단술시행후발생할수있는창 상합병증과추가적인수술가능성에대해미리충분한설명을시 행하여야할것이다. REFERENCES 1. Bae JI, Won JH, Han SH, Lim SH, Hong YS, Kim JY, et al. Endovascular revascularization for patients with critical limb ischemia: impact on wound healing and long term clinical results in 189 limbs. Korean J Radiol. 2013;14: Myerson MS, Bowker JH, Brodsky JW, Trevino S. Symposium: partial foot amputations. Contemp Orthop. 1994;29:139-42, Canaud L, Alric P, Berthet JP, Marty-Ané C, Mercier G, Branchereau P. Infrainguinal cutting balloon angioplasty in de novo arterial lesions. J Vasc Surg. 2008;48: Sharp CS, Bessman AN, Wagner FW Jr, Garland D. Microbiology of deep tissue in diabetic gangrene. Diabetes Care. 1978;1: Brodsky JW. Evaluation of the diabetic foot. Instr Course Lect. 1999;48: Roon AJ, Moore WS, Goldstone J. Below-knee amputation: a modern approach. Am J Surg. 1977;134: Dickhaut SC, DeLee JC, Page CP. Nutritional status: importance in predicting wound-healing after amputation. J Bone Joint Surg

6 Hyung-Jin Chung, et al. Risk Factor Analysis for Toe Amputation Patients in Wound Healing 23 Am. 1984;66: Wagner FW Jr. Management of the diabetic neurotrophic foot part II. A classification and treatment program for diabetic, neuropathic, and dysvascular foot problems. In: The American Academy of Orthopaedic Surgeons, editor. Instructional course lectures. St. Louis: C.V. Mosby; p Creager MA, Loscalzo J. Vascular diseases of the extremities. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, editors. Harrison's principles of internal medicine. 18th ed. New York: McGraw-Hill Medical; p Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293: Swaminathan A, Vemulapalli S, Patel MR, Jones WS. Lower extremity amputation in peripheral artery disease: improving patient outcomes. Vasc Health Risk Manag. 2014;10: Adler AI, Boyko EJ, Ahroni JH, Smith DG. Lower-extremity amputation in diabetes. The independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers. Diabetes Care. 1999;22: Maser RE, Steenkiste AR, Dorman JS, Nielsen VK, Bass EB, Manjoo Q, et al. Epidemiological correlates of diabetic neuropathy. Report from Pittsburgh Epidemiology of Diabetes Complications Study. Diabetes. 1989;38: The DCCT Research Group. Factors in development of diabetic neuropathy. Baseline analysis of neuropathy in feasibility phase of Diabetes Control and Complications Trial (DCCT). Diabetes. 1988;37: Lee WC, Park HS, Kim HC, Kim CS, Choi DS, Rha JD. Influence of neuropathy and ischemia in the development and treatment of the diabetic foot. J Korean Orthop Assoc. 1999;34: Mayfield JA, Reiber GE, Nelson RG, Greene T. A foot risk classification system to predict diabetic amputation in Pima Indians. Diabetes Care. 1996;19: National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2 Suppl 1):S Kwon SH, Han DC. Diagnosis and screening of chronic kidney disease. Korean J Med. 2009;76: Miyajima S, Shirai A, Yamamoto S, Okada N, Matsushita T. Risk factors for major limb amputations in diabetic foot gangrene patients. Diabetes Res Clin Pract. 2006;71: Armstrong DG, Frykberg RG. Classifying diabetic foot surgery: toward a rational definition. Diabet Med. 2003;20: Nehler MR, Whitehill TA, Bowers SP, Jones DN, Hiatt WR, Rutherford RB, et al. Intermediate-term outcome of primary digit amputations in patients with diabetes mellitus who have forefoot sepsis requiring hospitalization and presumed adequate circulatory status. J Vasc Surg. 1999;30:

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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