Original Article pissn eissn J Korean Foot Ankle Soc 2017;21(1): 제 1 열전족부절골술을통한평발교정

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1 Original Article pissn eissn J Korean Foot Ankle Soc 2017;21(1): 제 1 열전족부절골술을통한평발교정에있어골이식없이사용한소형쐐기형금속판의치료결과 최준영, 신명진 *, 서진수 * W 병원족부족관절센터, * 인제대학교의과대학일산백병원정형외과학교실 The Results of the First Ray Forefoot Osteotomy Using Low Profile Wedge Plate without a Bone Grafting for Pes Planus Correction Jun Young Choi, Myung Jin Shin*, Jin Soo Suh* W Institute for Foot and Ankle Disease and Trauma, W Hospital, Daegu, *Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea Purpose: We retrospectively analyzed the radiographic and clinical results after the first ray of forefoot osteotomy using low profile wedge plate without additional cancellous bone grafting for pes planus correction. Materials and Methods: Twenty-four patients were enrolled in this study. Medial cuneiform opening wedge osteotomy was performed in 12 patients (Cotton osteotomy, group C) and first metatarsal base osteotomy was performed in 12 patients (group MT). Results: On average, the wedge size was 5.61 mm (5 6 mm). The mean time to radiographic union was 3.18 and 3.27 months in groups C and MT, respectively. Postoperative talonavicular coverage angle, talo-first metatarsal angle (anteroposterior), talo-first metatarsal angle (lateral), talo-calcaneal angle (lateral), medial cuneiform height, and American orthopaedic foot, as well as ankle society midfoot scale were significantly improved in both groups. Nonunion, delayed union or fixation failure was not presented in our series. Conclusion: We have shown that low profile wedge plate was effective in the case of first ray forefoot osteotomy for pes planus correction without any additional cancellous bone grafting. Key Words: Flatfoot, Cotton osteotomy, Low profile wedge plate 서 성인에서발생한편평외반족에대한수술중후족부에대한내측전위종골절골술이후전족부내반이남을경우제 1열에대한교정을시도하게된다. 제 1중족-설상관절의관절염이심하지않을경우, 절골술을행하여교정을시도하게되고, 1,2) 중족-설상관절의관절염이동반되어있을경우, 중족-설상관절유합을고려하게 Received November 8, 2016 Revised December 16, 2016 Accepted January 19, 2017 Corresponding Author: Jin Soo Suh Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University College of Medicine, 170 Juhwa-ro, Ilsanseo-gu, Goyang 10380, Korea Tel: , Fax: , sjs0506@paik.ac.kr Financial support: None. Conflict of interest: None. 론 된다. 3) 전자의경우, 절골은 Cotton 4) 에의해처음으로소개된이후현재에는널리행해지고있는내측설상골족배부에서시행하거나무지외반증이동반되어있는경우함께교정할목적으로제 1중족골에서개방형쐐기절골술의형태로행해질수있다. 수많은저자들에의해제 1열절골술방법이연구, 개선되고골이식유무, 고정에사용되는기기등이변형되어왔으며현재에는개방형절골술부위를유지할수있는쐐기를가진소형금속판 (Arthrex Inc., Naples, FL, USA; Fig. 1) 이많이사용되고있다. 슬관절의내반변형시근위경골에행해지는내측개방형쐐기절골술의경우개방형쐐기부분에추가적인골이식이나골대체물질의삽입이없이도유합에문제가없이좋은결과를얻을수있다는보고들이많이이루어지고있다. 5-7) 이에저자들은성인의편평외반족을 Cotton 절골술, 제 1중족골기저부절골술의두가지의제 1 Copyright c2017 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.

8 Vol. 21 No. 1, March 2017 열전족부절골술을통하여교정할시에소형쐐기형금속판을사용하여추가적인해면골이식없이고정한결과에대해보고하고자한다. 추가적으로해면골을절골공간에채우지않고소형쐐기형금속판만을사용하여고정하더라도방사선학적유합및유합에걸리는시간, 수술전, 후의방사선학적지표들의교정정도에문제가없을것이라가정하였다. 대상및방법 1.

2 8 Vol. 21 No. 1, March 2017 열전족부절골술을통하여교정할시에소형쐐기형금속판을사용하여추가적인해면골이식없이고정한결과에대해보고하고자한다. 추가적으로해면골을절골공간에채우지않고소형쐐기형금속판만을사용하여고정하더라도방사선학적유합및유합에걸리는시간, 수술전, 후의방사선학적지표들의교정정도에문제가없을것이라가정하였다. 대상및방법 1. 연구대상 2013년 6월부터 2015년 6월까지인제대학교일산백병원및 W병원에서성인형편평족으로내측전위종골절골술을이용하여후족부외반을시행한뒤추가적인해면골이식없이소형쐐기형금 속판만을이용한제 1열전족부절골술을통한교정수술을시행받고최소 1년이상추시가가능하였던환자를대상으로후향적인연구를시행하였다. 수술은내측설상골개방형절골술 (Cotton 절골술 ; Cotton osteotomy group, C군 ), 제 1중족골기저부절골술 (1st metatarsal base osteotomy group, MT군 ) 이여기에포함되었으며, 각각 12예였다. C군에서는 10예에서내측전위종골절골술을통한후족부교정이후에전족부교정을실시하였으며 MT군에서는 2예에서만후족부선행교정을실시하였다. 두군의평균나이및추시기간, 남녀성비및수술방향은 Table 1에정리되어있다. 평균나이및추시기간은통계적으로유의한차이가없었다 (p=0.43, 0.57). 2. 수술방법모든군에서앙와위에서장무지신전건의내측에종절개를향하여내측설상골, 혹은제 1중족골기저부의절골부위를노출시켰다. 절골부위및절골방향의확인을위하여족배부에서족저부방향으로가이드핀을삽입한뒤방사선투시촬영장치를이용하여이를확인하였다. 내측설상골절골의경우가이드핀이제 2중족- 설상관절과평행하게놓이도록하였다. 이후절골도를이용하여절골을시행하고 Laminar spreader를이용하여원하는만큼의교정이이루어질때까지절골부위를벌린후에 5 6 mm의쐐기를 Table 1. Patients Demographics in Each Group Variable Group C (n=12) Group MT (n=12) Mean age (yr) 37.1± ±14.25 Follow-up period (mo) 16.22± ±4.27 Male:female 4:8 3:9 Right:left 4:8 8:4 Figure 1. Various types of low profile mini opening wedge plate used for pes planus deformity correction (Arthrex Inc., Naples, FL, USA). Values are presented as mean±standard deviation or number only. Group C: Cotton osteotomy, Group MT: 1st metatarsal base osteotomy. Table 2. Whole Radiologic and Clinical Parameters Related to Each Group Variable Group C (n=12) Group MT (n=12) Preop Postop Preop Postop TNCA ( ) 27.94± ± ± ±5.18 T1MTA ( ) 24.34± ± ± ±4.82 Meary angle ( ) 13.64± ± ± ±2.52 TCA ( ) 60.76± ± ± ±7.81 CPA ( ) 8.13± ± ± ±2.11 MCH (mm) 14.52± ± ± ±2.95 Time to radiographic union (mo) 3.18± ±0.72 AOFAS score 61.76± ± ± ±2.45 Values are presented as mean±standard deviation. Group C: Cotton osteotomy, Group MT: 1st metatarsal base osteotomy, Preop: preoperative, Postop: postoperative, TNCA: talo-navicular coverage angle on anteroposterior (AP) radiograph, T1MTA: talo-1st metatarsal angle on AP radiograph, TCA: talo-calcaneal angle on lateral radiograph, CPA: calcaneal pitch angle on lateral radiograph, MCH: medial cuneiform height on lateral radiograph, AOFAS: American Orthopaedic Foot and Ankle Society.

Jun Young Choi, et al. The First Ray Forefoot Osteotomy Using Wedge Plate 9 가진소형금속판을이용하여절골부위를고정하였다 ( 평균 5.61 mm). 후족부교정을함께시행한경우, 술후 6주째까지는단하지석고붕대를고정하고체중부하를금지시켰으며, 석고붕대제거이후부분체중부하를시작하였다.

전후면상에서는거주상피복각 (talo-navicular coverage angle), 거골-제 1중족골간각 (talo-1st metatarsal angle) 을측정하였고, 측면상에서는거골-제 1중족골간각 (Meary angle), 거골-종골간각 (talo-calcaneal angle), 종골피치각 (calcaneal pitch angle) 및내측설상골

Mean Correctional Power to Radiologic Parameters of Each Osteotomy Variable Group C (n=12) Group MT (n=12) p-value Δ TNCA ( ) 9.94±1.26 8.78±1.25 0.211 Δ T1MTA ( ) 6.29±3.16 6.63±2.39 0.

76 Values are presented as mean±standard deviation.

3 Jun Young Choi, et al. The First Ray Forefoot Osteotomy Using Wedge Plate 9 가진소형금속판을이용하여절골부위를고정하였다 ( 평균 5.61 mm). 후족부교정을함께시행한경우, 술후 6주째까지는단하지석고붕대를고정하고체중부하를금지시켰으며, 석고붕대제거이후부분체중부하를시작하였다. 술후 6 8주사이에체중부하시통증을느끼지않을때임상적유합이이루어지고있다고판단하고전체중부하를시작하였다. 후족부교정이없이전족부단독교정일경우수술직후부터딱딱한바닥을가지도록고안된특수신발을신기고뒷꿈치보행을시킨이후에술후 6주째부터부분체중부하로이행하도록하였다. 3. 평가방법수술전및최종추시시점에서기립한상태에서의전후면방사선을측정하였다. 전후면상에서는거주상피복각 (talo-navicular coverage angle), 거골-제 1중족골간각 (talo-1st metatarsal angle) 을측정하였고, 측면상에서는거골-제 1중족골간각 (Meary angle), 거골-종골간각 (talo-calcaneal angle), 종골피치각 (calcaneal pitch angle) 및내측설상골 (medial cuneiform height) 의높이를측정하 였다. 또한전체예에서방사선사진상에서보이는골유합시기를측 정하였으며, 수술전과최종추시에서의임상적분석은 American Table 3. Mean Correctional Power to Radiologic Parameters of Each Osteotomy Variable Group C (n=12) Group MT (n=12) p-value Δ TNCA ( ) 9.94± ± Δ T1MTA ( ) 6.29± ± Δ Meary angle ( ) 15.47± ± Δ TCA ( ) 14.12± ± Δ CPA ( ) 8.12± ± Δ MCH (mm) 3.60± ± Values are presented as mean±standard deviation. Group C: Cotton osteotomy, Group MT: 1st metatarsal base osteotomy, Δ: delta, an increment of a variable, TNCA: talo-navicular coverage angle on anteroposterior (AP) radiograph, T1MTA: talo-1st metatarsal angle on AP radiograph, TCA: talo-calcaneal angle on lateral radiograph, CPA: calcaneal pitch angle on lateral radiograph, MCH: medial cuneiform height on lateral radiograph. A B C D E F Figure 2. Preoperative weightbearing foot anteroposterior (A) and lateral (B) radiographs of a 37-year-old male patient with pes planus. (C, D) Immediate postoperative radiographs shows the correction of radiographic parameters. Note that the opening wedge gap in the medial cuneiform bone was remained empty without additional cancellous bone graft. (E, F) Radiographs at the final follow-up (1.5 years) show a stable maintenance with a radiographic union.

수술은모두한명의외과의에의해진행되었으며, 본연구는인제대학교일산백병원윤리위원회의심의를통과하였다. 두군간의통계적검증은 PASW Statistics ver. 18 통계프로그램 (IBM Co.

방사선학적유합을얻은시기의경우 C군에서 3.18±0.99개월, MT군에서 3.27±0.72개월로두군간통계적으로유의한차이가없었으며 (p=0.43), AOFAS midfoot scale은수술후두군모두에서 유의한증가를보였다 (C군: p=0.

각각의방사선학적지표들에대한교정력 ( 술후수치에서술전수치를뺀값 ) 을각군에따라서비교해보면 (Table 3), 체중부하족부전후면및측면상에서측정가능한지표모두에서두군간통계적으로유의한차이를보이지않았다.

Hirose와 Johnson 9) 은 16예에서임상적, 방사선학적으로좋은결과를얻었다고보고한바있으며, 술후평균 12주에서방사선학적 A B C E D F Figure 3.

4 10 Vol. 21 No. 1, March 2017 Orthopaedic Foot and Ankle Society (AOFAS) 에서통증 40점, 기능 45점, 정렬 15점인총점 100점을기준으로평가한중족부평가법 8) 을이용하여평가하였고, 합병증발생의유무를확인하였다. 수술은모두한명의외과의에의해진행되었으며, 본연구는인제대학교일산백병원윤리위원회의심의를통과하였다. 두군간의통계적검증은 PASW Statistics ver. 18 통계프로그램 (IBM Co., Armonk, NY, USA) 을이용하였고, Mann-Whitney test를시행하여 p-value가 0.05 미만이었을경우통계적으로의미가있는것으로정의하였다. 결과 술전, 후측정한방사선학적지표및임상적지표는 Table 2에정리되어있다. 방사선학적유합을얻은시기의경우 C군에서 3.18±0.99개월, MT군에서 3.27±0.72개월로두군간통계적으로유의한차이가없었으며 (p=0.43), AOFAS midfoot scale은수술후두군모두에서 유의한증가를보였다 (C군: p=0.005; MT군 : p=0.005). 술후 AO- FAS midfoot scale 수치에있어서두군간의유의한차이는없었다 (p=0.58). 각각의방사선학적지표들에대한교정력 ( 술후수치에서술전수치를뺀값 ) 을각군에따라서비교해보면 (Table 3), 체중부하족부전후면및측면상에서측정가능한지표모두에서두군간통계적으로유의한차이를보이지않았다. 두군에속하는전체예에서절골부위의술후감염은없었으며, 불유합이나지연유합혹은삽입된금속고정물의파손을보인예역시없었다. 고찰 성인의편평외반족을교정함에있어서시행하는내측설상골절골술의결과에대해서는그동안여러저자들이보고하여왔다. Hirose와 Johnson 9) 은 16예에서임상적, 방사선학적으로좋은결과를얻었다고보고한바있으며, 술후평균 12주에서방사선학적 A B C E D F Figure 3. Preoperative weightbearing foot anteroposterior (A) and lateral (B) radiographs of a 47-year-old female patient with pes planus and hallux valgus deformity. (C, D) Immediate postoperative radiographs shows the correction of radiographic parameters. Note that the opening wedge gap in the 1st metatarsal bone was remained empty without additional cancellous bone graft. (E, F) Radiographs at the final follow-up (1 year) show a stable maintenance with a radiographic union.

5 Jun Young Choi, et al. The First Ray Forefoot Osteotomy Using Wedge Plate 11 유합을얻었다고언급하였다. Castaneda 등 10) 은 23예에서내측설상골절골술을시행하여전체예에서내측설상골의근위및원위관절면이이루는각도가유의하게개선됨을확인하기도하였다. 절골술사용하는쐐기의두께에대해서는많은저자들이 4 6 mm 의교정이필요하다고소개하였는데, 1,11-13) 초기에는자가골을채취하여족배부쪽이족저부쪽보다넓은형태의사다리꼴내지는삼각형모양으로다듬은뒤사용하는방법을사용하였으나 9,14) 장골능의이식골채취부위에서의합병증발생이보고되면서동종골을이식하는방법이소개되기도하였다. 9) 최근에는두께를선택할수있는쐐기가부착된소형금속판을고정하는방법이널리선택되고있다. 저자들의예에서도 5 6 mm의쐐기를 ( 평균 5.61 mm) 사용하여고정하였으며이전의보고들과큰차이를보이지는않았다 (Fig. 2). League 등 15) 은사체연구를통해대퇴골동종골및소형쐐기형금속판을이용한내측설상골절골술뒤, 두군에서족부의외측주로가는압력이통계적으로유의한차이없이줄어듦을확인하였다. 이들의연구는생역학적인연구로서실제로생체내에쐐기형금속판이사용되었을때, 쐐기형으로만들어진동종혹은자가이식골과어떠한임상적결과의차이를만들어내는지를증명해내지는못하였다는한계가있다. 본저자들은소형쐐기형금속판만을성인편평외반족환자에게고정하여실제임상적으로좋은결과를얻을수있음을확인하였으며, 이는쐐기를삽입한뒤남아있는개방형절골공간에해면골이식조차없이얻은결과이기때문에임상적인의의가있을것으로판단한다. 편평외반족의평가에주로사용되는각종방사선학적지표에대해서, 이번연구에서는전족부교정과관계되는모든지표에대해서두종류의수술방법이큰교정력의차이를보이지는않았다. 제 1중족골기저부절골술의경우에는 Cotton 절골술보다 lever arm 이짧아서교정에불리한점은있지만제 1중족골에서생긴무지외반증등의변형을동시에교정할수있는장점이있어서해당예에서사용되었다 (Fig. 3). 두군모두에서임상적, 방사선학적유합에걸리는시기에있어서도큰차이를보이지않았으므로두수술방법모두절골술이필요한경우선택지로사용될수있을것이다. 본연구의한계점으로는 2년미만의비교적짧은기간의추시였다는점과각군에속하는예의숫자가적었다는점, 그리고후향적인연구디자인이었다는점이있다. 또한쐐기형소형금속판을사용하면서해면골이식을함께시행한경우나금속내고정물없이쐐기형골편삽입만으로고정을시행한군들과의직접적인비교가이루어지지못했다는점역시또다른한계점이라고할수있겠다. 결론 부절골술의제 1열전족부절골술을통하여성인형편평족을교정할시에, 쐐기삽입후남게되는개방형절골공간에추가적인해면골이식없이도효과적으로골유합이이루어지고임상적, 방사선학적으로좋은결과를얻을수있음을확인하였기에이를보고하는바이다. REFERENCES 111 Cohen BE, Ogden F. Medial column procedures in the acquired flatfoot deformity. Foot Ankle Clin. 2007;12: Mosier-LaClair S, Pomeroy G, Manoli A 2nd. Operative treatment of the difficult stage 2 adult acquired flatfoot deformity. Foot Ankle Clin. 2001;6: Sizensky JA, Marks RM. Medial-sided bony procedures: why, what, and how? Foot Ankle Clin. 2003;8: Cotton FJ. Foot statics and surgery. N Engl J Med. 1936;214: Han JH, Kim HJ, Song JG, Yang JH, Bhandare NN, Fernandez AR, et al. Is bone grafting necessary in opening wedge high tibial osteotomy? A meta-analysis of radiological outcomes. Knee Surg Relat Res. 2015;27: El-Assal MA, Khalifa YE, Abdel-Hamid MM, Said HG, Bakr HM. Opening-wedge high tibial osteotomy without bone graft. Knee Surg Sports Traumatol Arthrosc. 2010;18: Zorzi AR, da Silva HG, Muszkat C, Marques LC, Cliquet A Jr, de Miranda JB. Opening-wedge high tibial osteotomy with and without bone graft. Artif Organs. 2011;35: Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994;15: Hirose CB, Johnson JE. Plantarflexion opening wedge medial cuneiform osteotomy for correction of fixed forefoot varus associated with flatfoot deformity. Foot Ankle Int. 2004;25: Castaneda D, Thordarson DB, Charlton TP. Radiographic assessment of medial cuneiform opening wedge osteotomy for flatfoot correction. Foot Ankle Int. 2012;33: Tankson CJ. The Cotton osteotomy: indications and techniques. Foot Ankle Clin. 2007;12: Yarmel D, Mote G, Treaster A. The cotton osteotomy: a technical guide. J Foot Ankle Surg. 2009;48: Van Gestel L, Van Bouwel S, Somville J. Surgical treatment of the adult acquired flexible flatfoot. Acta Orthop Belg. 2015;81: Needleman RL. A surgical approach for flexible flatfeet in adults including a subtalar arthroereisis with the MBA sinus tarsi implant. Foot Ankle Int. 2006;27: League AC, Parks BG, Schon LC. Radiographic and pedobarographic comparison of femoral head allograft versus block plate with dorsal opening wedge medial cuneiform osteotomy: a biomechanical study. Foot Ankle Int. 2008;29: 소형쐐기형금속판을이용하여 Cotton 절골술, 제 1 중족골기저

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