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1 대한골절학회지제 23 권, 제 2 호, 2010 년 4 월 Journal of the Korean Fracture Society Vol. 23, No. 2, April, 2010 고관절주위골절후에골다공증치료의결과 임수재ㆍ이영구ㆍ김정관ㆍ송현석ㆍ강희경 순천향대학교부천병원정형외과 목적 : 고관절주위골절수술을받은환자들에서지속적인관리와약물치료로골다공증의경과를좋게함으로서일반골다공증환자들에비해순응도가차이가나는지와다른동반골절의이환율이감소하는지알고자한다. 대상및방법 : 2006 년 7 월부터 2007 년 7 월까지본원정형외과에서대퇴골경부골절과대퇴골전자간골절로수술받은연속된 60 명을실험군으로하였으며, 같은기간에골다공증진단하에골다공증의약물치료받은 61 명을대조군으로하였다. 실험군의평균연령은 73.8 (±6.7) 세였으며, 대조군은평균연령은 66.6 (±7.46) 세였다. 두군모두최소 1 년간약물치료와함께외래추적관찰하였으며최소 1 년후골밀도검사를추시하였다. 결과 : 실험군에서골밀도검사는수술전 3.05 (±1.35) 에서 2.74 (±1.50) 으로호전된소견보였으며 (p=0.0002) 대조군에서골밀도검사는첫내원시 3.55 (±0.52) 에서마지막추시시 3.10 (±0.87) 로역시호전된소견보였다 (p<0.0001). 결론 : 고관절주위골절환자들에서골다공증약물의순응도는지속적인관리와교육을통해일반골다공증환자들에비해비슷한정도를보였으며, 또한동반골절율도낮출수있었다. 색인단어 : 고관절주위골절, 골다공증, 순응도 Results of Osteoporotic Treatment Drug after Periarticular Fracture of Hip Soo Jae Yim, M.D., Young Koo Lee, M.D., Cheong Kwan Kim, M.D., Hyun Seok Song, M.D., Hee Kyung Kang, R.N. Department of Orthopedic Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea Purpose: The Purpose of the study is to know patients compliance of drug treatment of osteoporosis after operation of fracture and to compare of accompanying fractures between patients who diagnosed with osteoporosis itself and had the drug treatment of osteoporosis after surgery of periarticular fracture of hip. Materials and Methods: In experimental group, consecutive 60 patients who had fracture of femoral neck and trochanter. And in control group, 61 patients diagnosed osteoporosis with drug treatment within the same period in orthopedic department from July 2006 to July The average age is 73.8 (±6.7) year in experimental group, and 66.6 (±7.46) year in control group. Both groups had at least a year follow-up with drug treatment and had BMD again at least a year later. Results: BMD test in experimental group showed 3.05 (±1.35) preoperatively and 2.74 (±1.50) in last follow-up. BMD test in control group showed 3.55 (±0.52) in initial administration and 3.10 (±0.87) in last follow-up. The results showed a significant improvement in statistical analysis (p=0.0002, p<0.0001). Conclusion: The compliance of drug treatment of osteoporosis after operation of periarticular fracture of hip is the same as in patients diagnosed osteoporosis. Key Words: Periarticular fracture of hip, Osteoporosis, Compliance 통신저자 : 임수재부천시원미구중동 4 순천향대학교부천병원정형외과 Tel: ㆍ Fax: yimsj@chol.com 접수 : 심사 ( 수정 ): 게재확정 : Address reprint requests to:soo Jae Yim, M.D. Department of Orthopedic Surgery, Soonchunhyang University Bucheon Hospital, 4, Jung-dong, Wonmi-gu, Bucheon , Korea Tel: ㆍ Fax: yimsj@chol.com 167

2 168 임수재, 이영구, 김정관, 송현석, 강희경 서 고관절주위골절은높은사망률과이환율을가진골절이며특히고연령군에서는아주위험한골절이다. 많은고관절주위골절을가진환자들에게서단독보행이불가능해지고, 골절의결과로사망하게되며연속된다른부분의골절이동반되게된다 17,21,23,26). 결과적으로고관절주위골절후효과적인관리와골다공증에대한적당한약물치료가동반골절이나사망률및이환율을낮추는데상당히중요하다. 약물치료는다양한방법으로사용되며가장잘알려져있는방법으로 Bisphosphonates 와선택적에스트로겐수용체조절체 (Selective estrogen receptor modulator, SERMs), 부갑상선호르몬제 (Parathyroid hormone, PTH), Strontium ranelate 등이있다. 하지만, 대부분의관절주위골절환자들은고령인데다가단독보행등이용이하지않기때문에약물복용등의관리가용이하지않고다시골절이발생할가능성이높아진다. 따라서이러한환자들에게서약물복용의순응도를높여재골절의가능성을줄이는과정이중요하다. 이논문의목적은고관절주위골절로수술을받은환자들을대상으로골다공증의치료를하는과정에서지속적인약물복용의교육과필요성에대한지속적인관리를통해일반골다공증환자들에비해순응도가차이가나는지와다른동반골절의이환율이감소하는지를알고자한다. 론 대상및방법 2006 년 7 월부터 2007 년 7 월까지본원정형외과에서이학적검사및방사선소견에서대퇴골경부골절과대퇴골전자간골절로진단되어수술받은연속된 60 명을실험군으로하였으며, 같은기간에본원정형외과에내원하여대퇴골경부골절이나대퇴골전자간골절로진단된전력이없는사람중골다공증진단하에골다공증의약물치료받은 61 명을대조군으로하였다. 실험군의평균연령은 73.8 (±6.7) 세였으며, 여자가 48 명남자가 12 명이었고, 평균추시기간은 개월이었다. 대조군은평균연령은 66.6 (±7.46) 세였고, 여자가 57 명남자가 4 명이었으며, 평균추시기간은 개월이었으며실험군과추시시간의차이는없었다. 연구시작시두군사이의변화된정도를평가하는연구이므로대조군의나이나성별에대해서는서로비교하지않았다. 하지만두군사이의나이는이전의다른연구에서진행한결과 15) 에근거하여편견 (bias) 이발생하지않는같은나이군에존재하기때문에연구의결과에영향을미치지않을것으로생각되었다. 실험군은골절후수술직전에골절이된고관절의반대편의대퇴경부에서 골밀도검사 (DXA, Dual-energy X-ray absorptiometry) 를시행받았으며, 반대편대퇴경부에도골절이발생한경우에는척추에서골밀도검사를시행하였다. 실험군에대해서는실험시작전척추나고관절등의외상력은염두에두지않았으며연구시작후부터의경과를관찰하였다. 실험군에대해서는전향적으로연구를진행하였으며, 실험군모두에게연구의진행에대해설명하였고, 1 달에 1 회씩외래추적관찰하면서약물복용에대해교육을진행하였으며고령의환자의경우가많아같이내원한환자의보호자와환자에게약물의복용방법에대해자세히설명하였으며, 반드시복용해야함을설명하였다. 대조군은내원후골밀도검사를시행받고골다공증이진단된사람들을대상으로하였다. 대조군에대해서도모두 1 달에 1 회씩외래추적관찰과교육을진행하였으며, 그중 1 년이상추시가가능했던대상을후향적으로분석하였다. 두군모두최소 1 년후골밀도검사를추시하였다. 약물은 Fosamax plus tab 1T/week (Frosst Iberica S.A. Korea MSD, Spain) 를사용하였으며, 일주일중적당한요일을선택하여약물을복용하게하였고아침식전에다른약물을복용하기전에물한컵과함께약물을복용케하였다. 또한약물복용후약 30 분간은눕는자세를피하게하여소화장애등을피하게하였다. 다른연구에서는다양하게칼슘제재를동시에사용하는보고가있으나, 본연구에서는 Fosamax plus 만을복용케하였으며그결과를정리하였다. 모든통계분석은 SAS 프로그램 (version 9.1, SAS Institute Inc., Cary, North Carolina) 을이용하여분석하였다. 두그룹에대한환자의임상적특징은범주형변수는 Pearson s chi-squared test 으로, 연속형변수는 Student s t-test 로분석하였다. 골밀도검사에대한각그룹별변화정도는 paired t-test 로분석하였다. 그리고각그룹간의골밀도검사의변화정도차이에대한비교는 Student s t-test 로분석하였다. 모든통계분석은 p 값이 α=0.05 미만인경우를통계적으로유의성이있는것으로판단하였다. 결 실험군에서골밀도검사는수술전 3.05 (±1.35) 에서 2.74 (±1.50) 으로호전된소견보였으며 (p=0.0002), 대조군에서골밀도검사는첫내원시 3.55 (±0.52) 에서마지막추시시 3.10 (±0.87) 로역시호전된소견보였다 (p<0.0001). 하지만실험군의골밀도검사의변화의정도와대조군에서의골밀도검사의변화의정도는통계적으로차이가없었다 (Table 1). 수상후추적관찰시다른부위의골절이되었던환자는 5 명으로 4 명에서는반대측고관절주위골절로인공관절 과

3 고관절주위골절후에골다공증치료의결과 169 Table 1. Difference between initial BMD and follow up BMD in experimental group and control group Initial Follow up Difference Experimental group Control group p-value ±1.35 ±1.50 ± ±0.52 ±0.87 ± p-value is for student's t-test. Difference: Follow up BMD - Initial BMD. Table 2. The cases of accompanied fracture during follow up period Case Age/Sex Preop. BMD Postop. BMD Fracture site Case 1 Case 2 Case 3 Case 4 Case 5 F/79 F/81 F/72 F/81 F/ Hip Rt L1 Vertebra 반치환술치료를받았으며한명은척추골절로척추성형술을시행받았으며추시기간중사망자는없었다 (Table 2). 고 고관절주위골절을당한환자들의사망률은그에의한합병증등으로수상후 1 년이내의사망률이평균 15 25% 로상당이높다 1,9,12,23). 더군다나이는삶의질에오랜기간동안상당한악영향을끼치게된다 27). Boonen 등의보고에의하면수상후기능적회복이와도수상전에비해삶의질이심각하게나빠졌다고한다 3). 많은골다공증의치료는고관절주위골절의발생률을줄여주는중요한요소라는것을널리알려져있다 5). 또한심한골다공증을가진환자군에서금속내고정물이나양극성반치환술을이용한치료모두고정실패나불유합군등이비교적많이발생한다고보고되어있다 14,16). 골다공증의치료제로서여러호르몬제등다양한약물들이보고되고있지만, 정형외과에서는호르몬제제보다는 Bisphosphonates 제제를이용한치료요법이가장대중화되어있다. 하지만이러한다양하고좋은장점을가진약물들이있어도이런고관절주위골절을가진사람들은대부분고령이며수상후정상보행이잘안되는고령의환자들이대부분이어서약물에대한순응도는상당히감소할것으로여겨졌다 6). 약물치료의순응도에영향을미치는인자로약물사용의빈도 (dosage frequency) 가가장중요한인자로알려져있으며, 다음으로나이가 75 세까지는점차적으 찰 로순응도가증가하며 75 세이상이되면순응도가감소한다는나이요소 (age factor) 와사회경제적지위의정도 (social economic status) 와보험의여부 (insurance) 등도중요한요소라고하였다 4,10,20). 따라서이러한요소에의한약물의순응도가약물복용시에결과에가장중요한역할을하며 2,11), 약물의비순응도를보인환자에서재골절이 16 50% 까지증가하였다고보고하고있다 7,13,18,19,22,25). 여러논문에서도언급하였듯이약물사용의빈도가가장중요한요소로이에대한빈도가 BMD 의결과에영향을미치고또한재골절률이증가한다고하지만지금까지알려진연구는환자들에게교육을충분히하였는지의여부와그교육을통해골절이있었던환자와그렇지않은환자사이의순응도를비교한논문은없었다. 더군다나 BMD 를비교하여그순응도의여부를후향적으로평가한논문은알려져있지않다. 본연구는약물의순응도에영향을미치는인자에대해실험군과대조군에대해동등한조건을가지게한후 BMD 의변화를측정하여비교함으로써고관절주위골절후발생할수있는순응도의감소를줄일수있는지를알고자하였다. 1 달에 1 회씩지속적으로외래에서관찰하며복용의필요성과당위성에대해보호자와환자에게설명하였고복용이잘되지않았을경우발생할수있는골절의위험성등을교육하였으며, 그후에도전담간호사가 1 대 1 식교육과정을진행하여결과를측정할수있었다. 하지만최종적으로약물을얼마만큼복용하였는지에대해서는조사하지않고 BMD 의결과를통해비교를하여, 그순응도를측정하였고, 결과에서실험군과대조군에대해비슷한결과를가진다는것을알수있었다 (p=0.22). 이결과로만보게되면고관절주위골절환자들에게서지속적인약물치료시지속적인교육과전담간호사에의한약물의복용과사용의격려는환자의순응도를좋게할것이라여겨지면이렇게진행할경우 BMD 또한증가됨을알수있었다. 하지만이결과는몇가지문제점이있다. 우선이연구의진행시연속된환자들을대상으로하였지만, 우선골절환자중외래로추시가능한환자를대상으로하였기때문에순응도가좀더높았을것으로생각되며, 또한본연구에의해지속적으로관리되어왔기때문에보통의고령환자에서의순응도에비해좋게나타날수있었다. 두번째로본원의약물치료과정에서 bisphosphonate 만을사용하였기때문에다른약물을혼합복용하였거나다른약물만을사용하였을때와다른결과를가져올수있는편견 (bias) 이있을수있었다. 하지만이부분에서같은약물을사용한두군을비교한내용이기때문에편견이있을수있었음에도이연구에의의가있었을것으로생각된다. 이번연구기간동안총 60 명의고관절주위골절환자들

4 170 임수재, 이영구, 김정관, 송현석, 강희경 에게서골밀도검사를시행하였으며, 추시기간동안 5 명의환자에서동반된골절이생겼다 (Table 2). 4 명의환자들은골절된반대측에고관절주위골절이발생하였고, 한명의환자에서는척추에압박골절이생겼다. Colón-Emeric 등의보고에의하면 8), 골다공증에의한고관절주위골절이생긴후동반되는골절이생기는비율을평균 100 명당 10.4 명이생긴다고하였으며, 이는같은나이에서고관절주위골절이생기지않은사람들에비해 2.5 배높은비율을보였다고한다. 또한 Van Helden 등은그들의연구에서고관절주위골절이생긴사람들에서 2 년이상추시한결과약 11% 에서동반골절이생겼다고하였다 24). 본연구의결과에서도추시기간동안약 8.2% 정도의발생빈도를보였다. Colón-Emeric 등및 Van Helden 등의보고에비해다소낮은결과를보인것은추시기간이좀더짧아서생겼을수있으며, 지속적인관리에의한편견에의할수도있겠으나, 지속적인관리에의한좋은순응도는골절의가능성을낮출수있는방법이라는결과를얻을수있었다. 결과적으로골다공증에의한고관절주위골절환자들에게술후가장중요한과정중에하나는골다공증검사및환자와의지속적인추적관찰을통해골다공증약물을지속적으로사용하게하는것이중요하다고여겨졌으며, 이는수술의결과만을중요시하는정형외과의사의관점을넘어지속적인관리를위한코디네이터의역할과약물사용을조절해주는약사와수술후운동을통한골다공증의예방을관리하는물리치료사등의팀관리 (Team approach) 가동반손상의예방이나, 더나아가서삶의질의향상에도움이될것으로생각된다. 결 본연구에서고관절주위골절환자들에서골다공증약물의순응도는일반골다공증환자들에비해비슷한정도를보였으며, 지속적인관리를통해동반골절을낮출수있었으며, 또한단순골절에대한수술뿐만아니라골다공증예방및운동에대한팀관리를통해고령환자들에게서삶의질을향상시킬수있을것으로생각된다. 론 참고문헌 1) Autier P, Haentjens P, Bentin J, et al: Costs induced by hip fractures: a prospective controlled study in Belgium. Belgian Hip Fracture Study Group. Osteoporos Int, 11: , ) Blouin J, Dragomir A, Ste-Marie LG, Fernandes JC, Perreault S: Discontinuation of antiresorptive therapies: a comparison between and among osteoporotic women. J Clin Endocrinol Metab, 92: , ) Boonen S, Autier P, Barette M, Vanderschueren D, Lips P, Haentjens P: Functional outcome and quality of life following hip fracture in elderly women: a prospective controlled study. Osteoporos Int, 15: 87-94, ) Brankin E, Walker M, Lynch N, Aspray T, Lis Y, Cowell W: The impact of dosing frequency on compliance and persistence with bisphosphonates among postmenopausal women in the UK: evidence from three databases. Curr Med Res Opin, 22: , ) Bruyere O, Brandi ML, Burlet N, et al: Post-fracture management of patients with hip fracture: a perspective. Curr Med Res Opin, 24: , ) Cadarette SM, Katz JN, Brookhart MA, et al: Trends in drug prescribing for osteoporosis after hip fracture, J Rheumatol, 35: , ) Caro JJ, Ishak KJ, Huybrechts KF, Raggio G, Naujoks C: The impact of compliance with osteoporosis therapy on fracture rates in actual practice. Osteoporos Int, 15: , ) Colón-Emeric C, Kuchibhatla M, Pieper C, et al: The contribution of hip fracture to risk of subsequent fractures: data from two longitudinal studies. Osteoporos Int, 14: , ) Cooper C, Atkinson EJ, Jacobsen SJ, O'Fallon WM, Melton LJ 3rd: Population-based study of survival after osteoporotic fractures. Am J Epidemiol, 137: , ) Cramer JA, Amonkar MM, Hebborn A, Altman R: Compliance and persistence with bisphosphonate dosing regimens among women with postmenopausal osteoporosis. Curr Med Res Opin, 21: , ) Cramer JA, Gold DT, Silverman SL, Lewiecki EM: A systematic review of persistence and compliance with bisphosphonates for osteoporosis. Osteoporos Int, 18: , ) Haentjens P, Autier P, Barette M, Boonen S; Belgian Hip Fracture Study Group: The economic cost of hip fractures among elderly women. A one-year, prospective, observational cohort study with matched-pair analysis. Belgian Hip Fracture Study Group. J Bone Joint Surg Am, 83: , 2001.

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386-390.hwp 386 HANYANG MEDICAL REVIEWS Vol. 29 No. 4, 2009 우리나라 미숙아의 통계와 의료비용 Statistics and Medical Cost of Preterm in Korea 윤혜선 을지대학교 노원을지병원 소아청소년과학교실 Hye Sun Yoon, M.D., Ph.D., Department of Pediatrics, Nowon