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세나 묘
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1 대한정형외과학회지 : 제 44 권제 5 호 2009 J Korean Orthop Assoc 2009; 44: DOI: /jkoa CAS 를이용한개방형과폐쇄형경골근위부절골술에서네비게이션장치와방사선사진상계측치의비교분석 배대경ㆍ송상준ㆍ윤경호ㆍ곽상준 경희대학교의과대학정형외과학교실 A Comparative Study of the Navigated and Radiographic Measurements in Open and Closed Wedge High Tibial Osteotomy with Computer Assisted Surgery Dae Kyung Bae, M.D., Sang Jun Song, M.D., Kyung Ho Yoon, M.D., and Sang Joon Kwak, M.D. Department of Orthopedic Surgery, School of Medicine, Kyung Hee University, Seoul, Korea Purpose: We wanted to identify the difference of the measured values between a navigation system and radiographs when performing open and closed wedge high tibial osteotomy (HTO) under the control of a navigation system. Materials and Methods: Thirty-two open wedge HTOs and 51 closed wedge HTOs were performed using a navigation system. The postoperative mechanical axis percent, which was planned on the navigation system, was 62%. The mechanical axis (MA) was measured before osteotomy and after fixation on the navigation system, and these were compared with the measured values from the radiographs. The difference of the postoperative MA between the navigation system and the radiographs was compared according to the type of HTO. The alteration of the tibial posterior slope angle was also compared. Results: For the open wedge HTO, the mean MA after fixation was valgus 2.7 o on the navigation system and the postoperative MA was valgus 4.0 o on the radiograph. For the closed wedge HTO, the mean MA after fixation was valgus 3.5 o on the navigation system and the postoperative MA was valgus 1.6 o on the radiograph (p=0.000). The mean tibial posterior slope angle was increased by 5.3 o after the open wedge HTO and it was decreased by 1.8 o after closed wedge HTO (p=0.000). Conclusion: Performing HTO with a navigation system could increase the surgical accuracy because the navigation system checked the intraoperative correction angle in real time. Weight bearing makes a difference for the postoperative MA between the navigation system and radiographs. This should be taken into account, according to the type of HTO. Key Words: Knee, Osteoarthritis, Open wedge and closed wedge high tibial osteotomy, Navigation system 서론성공적인경골근위부절골술을위해서는적절한환자의선택, 정확한교정각을위한술전계획과수술술기, 재활치료의중요성이강조된다. 1-7) 교정각의크기를정하는고식적인방법으로술전방사선사진상교정각과 쐐기 (wedge) 의크기를계측하는방법, 절골지침자 (jig system) 를사용하는방법, 수술중고관절중심과족근관절중심을잇는 cable 선을이용하는방법등이있지만, 방사선사진상하지의회전에의한교정각측정의부정확성, 방사선사진계측시영상시차 (image paral- 접수일 :2008 년 11 월 20 일, 게재확정일 :2009 년 7 월 7 일교신저자 : 송상준서울시동대문구회기동 1 경희대학교의과대학정형외과학교실 TEL: ㆍ FAX: songsjun@khmc.or.kr Correspondence to Sang Jun Song, M.D. Department of Orthopedic Surgery, School of Medicine, Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul , Korea Tel: , Fax: songsjun@khmc.or.kr 499

2 500 배대경ㆍ송상준ㆍ윤경호외 1 인 lax), 절골면의위치, 경골직경의차이등으로고식적방법의한계에대해보고되고있다. 8-15) 최근수술의정확성, 정밀성, 재현성을높이기위해네비게이션장치를이용하고있으며, 네비게이션장치를이용한개방형경골근위부절골술의보고는비교적많으나, 13,16,17) 네비게이션장치를이용한폐쇄형경골근위부절골술에대한보고는드물었고, 18) 네비게이션장치를이용한개방형과폐쇄형경골근위부절골술을비교한연구는없었다. 본연구의목적은네비게이션장치를이용한개방형또는폐쇄형경골근위부절골술후역학적축의방사선사진상계측치와네비게이션장치상계측치차이및수술전, 후후방경사각의변화를비교하여네비게이션시술의정확도를분석하고그에따른문제점을보고하고자함이다. 대상및방법 1. 연구대상 2005년 7월부터 2007년 11월까지내반변형을동반한내측구획의퇴행성슬관절염에서 CT-free navigation system (Vector Vision R version 1.1, BrainLAB, Heimstetten, Germany) 을이용하여개방형경골근위부절골술을시행한 32명과폐쇄형경골근위부절골술을시행한 51명의환자를대상으로전향적으로분석하였다. 수술방법은환자의연령, 술전방사선사진상의내반변형의정도등을고려하여, 연령이젊고술전방사선사진상내반변형이심해폐쇄형절골술을시행할경우경골결절의손상가능성이있을만큼큰교정각이필요하였던경우개방형절골술을시행하였다. 절골면의고정을위해개방형절골술시 Puddu plate 8,19) 를, 폐쇄형절골술시 miniplate staple 20) 을사용하였다. 개방형절골술시전례에서동종골이식을시행하였다. 환자의평균연령은개방형절골술에서 56.7±7.5세, 폐쇄형절골술에서 60.3±7.1세이었다. 성비는개방형절골술에서여자 30예, 남자 2예였으며, 폐쇄형절골술에서여자 47예, 남자 4예이었다. 환자의평균 body mass index 는개방형절골술에서 25.4±2.8, 폐쇄형절골술에서 24.9 ±2.6 이었다 (p=0.481). 2. 수술방법과네비게이션장치상계측경골간부와대퇴골원위부에 dynamic reference base를부착시킨후해부학적표식자를등록하였다. 경 피적등록시슬관절주위해부학구조를충분히고려하여등록전미리해부학적경계표 (landmark) 를표시해둔상태에서정확히등록하고자노력하였다. 관절면 cm 아래에표시해두었던지침핀삽입위치에서절골면의시작점과종결점을등록하였다. 방사선사진상경골후방경사각계측치를입력하였고, 교정각은역학적축의경골고평부통과점이내측으로부터 62% 가되도록계획하였다. 네비게이션장치에의한변형평가, 절골면위치, 역학적축, 쐐기크기에대한정보를확인하였고, 절골후쐐기의개방또는폐쇄가용이하게끔회전중심 (center of rotation) 을보정하였다. 개방형또는폐쇄형절골술후네비게이션장치를이용하여교정각을실시간확인하며목표한교정각으로 Puddu plate 또는 Miniplate staple을고정하였다. 절골전역학적축과절골면고정후역학적축또는역학적축백분율을조사하였다. 3. 방사선사진상계측방사선사진상수술전, 후하지의역학적축, 역학적축백분율과경골후방경사각을계측하였다. 수술전과수술 일째전체중부하하지전장사진 (Orthoreontgenogram) 21) 과경골측면사진을촬영하였다. 하지의역학적축은전체중부하하지전장사진상대퇴골역학적축과경골역학적축사이의각으로정의하였고, 역학적축백분율은전체중부하하지전장사진상하지의역학적축이경골고평부를통과하는점의고평부내측으로부터의길이백분율 (%) 로정의하였다 (Fig. 1). 경골후방경사각은경골측면사진상경골내측고평부관절면과경골의해부학적축사이의각을 Oswald 법 22) 으로계측하였다. 방사선사진상수술전, 후역학적축의차이를교정각이라정의하였고, 수술전, 후경골후방경사각의차이를후방경사변화각이라정의하였다. 방사선학적계측은네비게이션장치를이용한계측치를모르는두명의관측자가영상저장전송시스템 (picture acquiring communication system, PACS) 을이용하여각각계측하였고, 두관측자간계측치의상관관계를확인하였다 (r>0.8, p=0.000).

CAS 를이용한개방형과폐쇄형경골근위부절골술에서네비게이션장치와방사선사진상계측치의비교분석 501 4. 네비게이션장치상계측치와방사선학적계측치의비교네비게이션장치에서절골전하지의역학적축과절골면고정후역학적축과역학적축백분율계측치를두관측자에의한방사선학적계측평균치와비교하였다 (Pearson s correlation analysis). 5. 개방형과폐쇄형절골술에따른비교개방형과폐쇄형절골술에따른술후역학적축의방사선사진상계측치와절골면고정후역학적축의네비게 이션장치상계측치의차이를비교하였다 (Student t test).

개방형과폐쇄형절골술에따른수술전, 후후방경사각과후방경사변화각을비교하였다. Fig. 1. (A) The mechanical axis % (MA%) shown on the preoperative ortho-roentgenogram is evaluated by percentile denotation [(b/a) 100].

3 CAS 를이용한개방형과폐쇄형경골근위부절골술에서네비게이션장치와방사선사진상계측치의비교분석 네비게이션장치상계측치와방사선학적계측치의비교네비게이션장치에서절골전하지의역학적축과절골면고정후역학적축과역학적축백분율계측치를두관측자에의한방사선학적계측평균치와비교하였다 (Pearson s correlation analysis). 5. 개방형과폐쇄형절골술에따른비교개방형과폐쇄형절골술에따른술후역학적축의방사선사진상계측치와절골면고정후역학적축의네비게 이션장치상계측치의차이를비교하였다 (Student t test). 술후역학적축의방사선사진상계측치가절골면고정후역학적축의네비게이션장치상계측치보다 2 o 이상작은경우 I군, 차이가 2 o 미만인경우 II군, 방사선상계측치가네비게이션장치상계측치보다 2 o 이상큰경우 III군으로분류하였고, 개방형또는폐쇄형절골술에따른분포를비교하였다 (Chi-square test). 개방형과폐쇄형절골술에따른수술전, 후후방경사각과후방경사변화각을비교하였다. Fig. 1. (A) The mechanical axis % (MA%) shown on the preoperative ortho-roentgenogram is evaluated by percentile denotation [(b/a) 100]. a is the width of tibia plateau and b is the distance from the medial border of the medial tibial condyle to the point at which the mechanical axis intersects the knee joint line. It shows medial deviation of the mechanical axis. (B) The mechanical axis % (MA%) shown on the postoperative ortho-roentgenogram is evaluated by percentile denotation [(b /a ) 100]. a is the width of tibia plateau and b is the distance from the medial border of the medial tibial condyle to the point at which the mechanical axis intersects the knee joint line. It shows lateral deviation of the mechanical axis. Table 1. Radiological Measurements and Measurements using Navigation System Navigation X-ray r p Open wedge HTO Preoperative MA* ( o ) 8.8± ± Postoperative MA* ( o ) 2.7± ± MA% (%) 57.7± ± Closed wedge HTO Preoperative MA* ( o ) 8.3± ± Postoperative MA* ( o ) 3.5± ± MA% (%) 62.0± ± *MA, angle between the femoral and tibial mechanical axis; MA%, percentile denotation ((b/a) 100) of the point at which the mechanical axis of the low extremity intersects the line extending from the medial border to the lateral border of the tibial plateau on orthoroentgenogram; -, negative values mean varus angles.

502 배대경ㆍ송상준ㆍ윤경호외 1 인 결과개방형절골술시 Puddu plate 고정후네비게이션장치상목표교정각외반 3 o 의 ±2 o 이내의오차를보인 경우가 87.

폐쇄형절골술시 miniplate staple 고정후네비게이션장치상목표교정각외반 3 o 의 ±2 o 이 Fig. 2.

(A) A 64-year-old woman have the open wedge high tibial osteotomy under navigation control.

4 o and the mechanical axis % (MA%) is 9.2%. The posterior slope angle of tibia is 8.0 o.

(B) In the navigation system, the post-osteotomy MA is valgus 3.5 o and the MA% is 57.7%.

The posterior slope angle of tibia is 12.1 o.

4 502 배대경ㆍ송상준ㆍ윤경호외 1 인 결과개방형절골술시 Puddu plate 고정후네비게이션장치상목표교정각외반 3 o 의 ±2 o 이내의오차를보인 경우가 87.5% (28 예 /32예 ), ±3 o 이내의오차를보인경우는 100% 였다. 폐쇄형절골술시 miniplate staple 고정후네비게이션장치상목표교정각외반 3 o 의 ±2 o 이 Fig. 2. Change of mechanical axis after the open wedge high tibial osteotomy using navigation system. (A) A 64-year-old woman have the open wedge high tibial osteotomy under navigation control. In the preoperative roentgenogram, the mechanical axis (MA) is varus 9.4 o and the mechanical axis % (MA%) is 9.2%. The posterior slope angle of tibia is 8.0 o. In the navigation system, the MA is varus 7.4 o and the MA% is 22%. (B) In the navigation system, the post-osteotomy MA is valgus 3.5 o and the MA% is 57.7%. In the postoperative 2 week roentgenogram, the MA is valgus 5.2 o and the MA% is 72.9%. The posterior slope angle of tibia is 12.1 o. The postoperative MA and MA% in roentgenogram is larger than the postosteotomy MA and MA% in navigation system. (C) In the postoperative 4 month roentgenogram, the MA is varus 1.2 o and the MA% is 37.4%. There are two proximal screws breakage of Puddu plate and loss of correction angle.

5 CAS 를이용한개방형과폐쇄형경골근위부절골술에서네비게이션장치와방사선사진상계측치의비교분석 503 내의오차를보인경우가 90.2% (46 예 /51예 ) 이었고, ±3 o 이내의오차를보인경우는 100% 였다. 개방형절골술시네비게이션장치에서절골전하지의역학적축은내반 8.8±2.6 o 였고, Puddu plate 고정후하지의역학적축은외반 2.7±2.2 o, 역학적축백분율은 57.7±8.9% 이었다. 방사선사진상역학적축과역학적축백분율은술전평균내반 9.5±3.4 o, 10.2 ±13.6% 였으며, 술후평균외반 4.0±2.8 o, 64.7± 11.2% 였다. 네비게이션장치와방사선사진에서계측한술전하지의역학적축, 술후하지의역학적축과역학적축백분율은통계적으로유의한상관관계를보였다 (r>0.5, p<0.001)(table 1). 폐쇄형절골술시네비게이션장치에서절골전하지의역학적축은내반 8.3 ±2.6 o 였고, Miniplate staple 고정후하지의역학적축은외반 3.5±1.4 o, 역학적축백분율은 62.0±5.9% 이었다. 방사선사진상하지의역학적축과역학적축백분율은술전평균내반 7.6±2.8 o, 16.0±11.5% 였으며, 술후평균외반 1.6±2.7 o, 56.7±11.8% 였다. 네비게이션장치와방사선사진에서계측한술전하지의역학적축, 술후하지의역학적축과역학적축백분율은통계적으로유의한상관관계를보였다 (r>0.3, p<0.02) (Table 1). 개방형절골술에서방사선사진상술후역학적축계측치와네비게이션장치상절골면고정후역학적축계측치의차이는 1.3±2.0 o 로방사선사진상크게계측되는경향이있었다 (Fig. 2). 폐쇄형절골술에서술후역학적축의방사선사진상계측치와절골면고정후역학적축의네비게이션장치상계측치의차이는 1.9± 2.6 o 로방사선사진상작게계측되는경향이있었다 (p=0.000). 방사선사진상술후역학적축계측치를네비게이션장치상절골면고정후역학적축계측치와비교했을때개방형절골술은 34.4% (11예/32예 ) 가과대계측되었고, 폐쇄형절골술은 41.2% (21 예 /51예 ) 가과소계측되었다 (p=0.000)(table 2). 개방형절골술에서경골의후방경사각은술전평균 11.0±4.7 o 였고, 술후평균 16.3±4.5 o 로증가하였다. 폐쇄형절골술에서경골의후방경사각은술전평균 11.0±2.7 o 였고, 술후평균 9.1±2.8 o 로감소하였다. 경골의후방경사각은개방형절골술후평균 5.3± 3.3 o 증가하였고, 폐쇄형절골술후 1.8±1.9 o 감소하였다 Table 2. Difference between the Post-osteotomy Mechanical Axis in Navigation System and Postoperative Mechanical Axis in Radiograph (Number of Cases) Group Open wedge HTO Closed wedge HTO I* 2 21 II III 11 3 Total *Group I, Group of cases in which the postoperative mechanical axis on radiograph is 2 o smaller than the post-osteotomy mechanical axis on navigation; Group II, Group of cases in which the difference between the postoperative mechanical axis on radiograph and post-osteotomy mechanical axis on navigation is within 2 o ; Group III, Group of cases in which the postoperative mechanical axis on radiograph is 2 o more than the post-osteotomy mechanical axis on navigation. (p=0.000). 합병증으로개방형절골술에서 Puddu plate의고정나사못의절단 4예와이로인한교정각의소실이 3예있었고 (Fig. 2), 폐쇄형절골술에서교정각의소실 1예있었다. 고찰고식적방법의경골근위부절골술의정확도는만족스럽지못하며, 2,6,14) Saragaglia 와 Roberts 23) 는목표한교정각의 ±2 o 이내의하지정렬을보인예가고식적방법의경우 71%, 네비게이션장치를이용한경우 96% 였다고보고하였다. 저자들의경우네비게이션장치상술후하지의역학적축백분율이 62% 가되도록계획하였으며, Puddu plate 또는 miniplate staple 고정후네비게이션장치상목표교정각 3 o 의 ±2 o 이내의오차를보인경우가개방형절골술에서 87.5%, 폐쇄형절골술에서 90.2% 이었다. 저자들은방사선계측을두관측자에의해독립적으로시행하여두관측자의계측치간에강한상관관계를입증하였고 (r>0.8, p=0.000), 네비게이션장치와방사선사진에서계측한술전하지의역학적축, 술후하지의역학적축과역학적축백분율은개방형또는폐쇄형절골술에서모두통계적으로유의한상관관계를보였다 (r>0.543, p<0.001)(r>0.334, p<0.017). 경골근위부절골술에서경첩축 (hinge axis) 위치와쐐기크기결정은쐐기개방 (wedge opening) 또는쐐기폐쇄 (wedge closing) 를위한중요한과정이다. 경첩축이과도하

6 504 배대경ㆍ송상준ㆍ윤경호외 1 인 게골수강측일경우무리한쐐기개방이나폐쇄시경골고평부골절이발생할수있다. 과도하게피질골측일경우피질골의손상으로내고정물을사용한고정력이부족하거나, 교정각의소실이발생할수있다. 1,8,24) 쐐기의 3 차원적위치를잘못선정하면절골술후후방경사각의변화나경골회전변형을초래할수있으므로주의를요한다. 3,12) 네비게이션장치를이용한경골근위부절골술은쐐기의크기와경첩축을조절하고, 쐐기의 3차원적위치를예측하여보다정확한절골술을시행할수있는장점이있다. 13,25) 저자들의경우쐐기개방또는폐쇄를위한회전중심 (center of rotation) 을네비게이션장치를이용하여조정하여쉽고안전하게쐐기개방또는폐쇄를하였으며, 고평부골절이나, 피질골손상이발생한예는없었다. 개방형절골술에서술후방사선사진에서계측한하지의역학적축과역학적축백분율은네비게이션장치계측치보다평균 1.3±2.0 o, 7.0±9.9% 크게계측되었다. 그러나, 폐쇄형절골술에서술후방사선사진에서계측한하지의역학적축과역학적축백분율은네비게이션장치계측치보다평균 1.9±2.6 o, 4.6±10.2% 작게계측되었다. Kendoff 등 25) 은개방형경골근위부절골술의사체연구를통해절골면고정후네비게이션장치상역학적축을외력을가하기전과전체중부하외력을가한후비교하여전체중부하외력을가할시 o 정도계측치증가를관찰하였고, 가해진외력과교정각이크고, 내측측부인대유리가광범위할수록더크게증가한다고보고하였다. 이는개방형절골술시경첩축이경골외측피질골에위치하고보존된비골은경첩축의밖에위치하여쐐기개방시외측측부인대는기능적으로이완되므로, 외력이가해지지않는앙와위에서는외측구획 (lateral joint compartment) 이벌어지고, 전체중부하시외측구획이좁아지게되어체중부하시교정각이증가한다고설명하였다. Kendoff 등 25) 은폐쇄형경골근위부절골술시엔그반대의상황을추론하였고, Shaw 등 24) 은사체연구를통해폐쇄형경골근위부절골술후 5 pound 의외반외력을가할시교정각의감소를보고하였고, 수술중네비게이션장치상체중부하모의실험 (weight bearing simulation) 이필요하다고주장하였다. 경골근위부절골술후교정각은체중부하, 인대의이완과내고정물의위치에영향을받을수있을것으로사료되 며, 폐쇄형또는개방형절골술에따른체중부하시역학적축의변화가능성을이해해야한다. 저자들은네비게이션장치에절골전최초하지정렬의등록을위하여내반된하지를입력할때, 하지정렬을유지하는 (holding) 방법에따라역학적축계측치가영향을받음을관찰하였다. 개방형절골술에서최초하지정렬이실제보다내반되어등록된다면술후역학적축은과교정되고, 폐쇄형절골술에서최초하지정렬이실제보다외반되어등록된다면술후역학적축은부족하게교정된다. 술후역학적축의방사선사진상계측치가절골면고정후역학적축의네비게이션장치상계측치에비해개방형절골술에서크고, 폐쇄형절골술에서작게계측되는경향을고려하여, 절골전최초하지정렬의등록시개방형절골술에서는실제변형보다내반되지않도록하지의정렬을중립위치에서유지하고, 폐쇄형절골술에서는체중부하외력을주어 24) 외반되어등록되지않도록주의하여야한다. 경골근위부절골술전, 후경골후방경사각의변화에대한보고가많으며일반적으로개방형절골술에서증가하고, 6,19,26) 돔형과폐쇄형절골술에서감소하는경향이있다. 3,20) Giffin 등 2) 은개방형절골술후평균 4 o 의경골후방경사각의증가를보고하였고, Hohmann 등 3) 은폐쇄형절골술후경골후방경사각의평균 4.9 o 감소를보고하였다. 개방형절골술시후방경사각의증가를피하기위해신연기나고정금속판을후방에위치시키는방법, 충분한후방연부조직박리를시행하는방법과후방쐐기의비정방형추가확장 (asymmetrical opening) 등이소개되어있다. 14,27) 저자들의경우개방형절골술후후방경사각의증가는평균 5.3 o 였으며, 그원인으로써교정각의크기가컸고, 직사각형형태의블록을가진 Puddu plate 를사용하여 Noyes 등이추천한것처럼 27) 전, 후방개방간격을차이있게할수없었다. 그리고, 충분한고정력을얻기위해연구초기에금속나사못삽입위치를경골근위부내측면의전방으로하였던것등이원인이었을것으로생각하였다. 전향적인연구도중개방형경골근위부절골술후경골후방경사각증가경향을관찰하였으며이를고려하여고정금속판을후방에위치시켰고, 완전한후방피질골의절골과충분한후방연부조직박리술을시행하여후방경사변화각을감소시켰다. 저자들의경우폐쇄형절골술후후방경사각은평균 1.8 o 의감소를보였으며, 개방형절골술에비해변화

7 CAS 를이용한개방형과폐쇄형경골근위부절골술에서네비게이션장치와방사선사진상계측치의비교분석 505 정도는크지않았다. 수술전, 후후방경사각의유지를위하여근위부및원위부절골면의입력시관절면에평행이되도록하고, 두절골면이평행하도록절제하는것이중요하며, 네비게이션장치를이용한 4 pin technique으로폐쇄형절골술을평행하게할수있었다. 결론네비게이션장치를이용한개방형과폐쇄형경골근위부절골술은수술중교정각을확인함으로써정확성을기할수있다. 술후역학적축의네비게이션계측치와방사선학적계측치의차이는체중부하라는외력에의해영향을받게되며, 네비게이션을이용한개방형및폐쇄형절골술시이를고려해야한다. 참고문헌 1. Coventry MB, Ilstrup DM, Wallrichs SL. Proximal tibial osteotomy. A critical long-term study of eighty-seven cases. J Bone Joint Surg Am. 1993;75: Giffin JR, Vogrin TM, Zantop T, Woo SL, Harner CD. Effects of increasing tibial slope on the biomechanics of the knee. Am J Sports Med. 2004;32: Hohmann E, Bryant A, Imhoff AB. The effect of closed wedge high tibial osteotomy on tibial slope: a radiographic study. Knee Surg Sports Traumatol Arthrosc. 2006;14: Kazakos KJ, Chatzipapas C, Verettas D, Galanis V, Xarchas KC, Psillakis I. Mid-term results of total knee arthroplasty after high tibial osteotomy. Arch Orthop Trauma Surg. 2008;128: Lee JY, Seon JK, Song EK, Yoon TR, Cheon SY, Lim KY. Comparison of high tibial osteotomy: Opening versus closing wedge osteotomy. J Korean Orthop Assoc. 2004;39: Nakamura E, Mizuta H, Kudo S, Takagi K, Sakamoto K. Open-wedge osteotomy of the proximal tibia hemicallotasis. J Bone Joint Surg Br. 2001;83: Naudie DD, Amendola A, Fowler PJ. Opening wedge high tibial osteotomy for symptomatic hyperextension-varus thrust. Am J Sports Med. 2004;32: Brouwer RW, Bierma-Zeinstra SM, van Raaij TM, Verhaar JA. Osteotomy for medial compartment arthritis of the knee using a closing wedge or an opening wedge controlled by a Puddu plate. A one-year randomised controlled study. J Bone Joint Surg Br. 2006;88: Dahl MT. Preoperative planning in deformity correction and limb lengthening surgery. Instr Course Lect. 2000;49: Ellis RE, Tso CY, Rudan JF, Harrison MM. A surgical planning and guidance system for high tibial osteotomy. Comput Aided Surg. 1999;4: Hanssen AD. Osteotomy about the knee. In: Insall JN, Scott WN, ed. Surgery of the knee. 3rd ed. New York: Churchill Livingstone; Kawakami H, Sugano N, Yonenobuk, et al. Effects of rotation on measurement of lower limb alignment for knee osteotomy. J Orthop Res. 2004;22: Keppler P, Gebhard F, Grützner PA, et al. Computer aided high tibial open wedge osteotomy. Injury. 2004;35 Suppl 1: Marti CB, Gautier E, Wachtl SW, Jakob RP. Accuracy of frontal and sagittal plane correction in open-wedge high tibial osteotomy. Arthroscopy. 2004;20: Moreland JR, Bassett LW, Hanker GJ. Radiographic analysis of the axial alignment of the lower extremity. J Bone Joint Surg Am. 1987;69: Hankemeier S, Hufner T, Wang G, et al. Navigated open-wedge high tibial osteotomy: advantages and disadvantages compared to the conventional technique in a cadaver study. Knee Surg Sports Traumatol Arthrosc. 2006;14: Wang G, Zheng G, Keppler P, et al. Implementation, accuracy evaluation, and preliminary clinical trial of a CT-free navigation system for high tibial opening wedge osteotomy. Comput Aided Surg. 2005;10: Bäthis H, Perlick L, Tingart M, Lüring C, Perlick C, Grifka J. Flexion gap configuration in total knee arthroplasty following high tibial osteotomy. Int Orthop. 2004;28: Puddu G, Franco V. Femoral antivalgus opening wedge osteotomy. Oper Tech Sport Med. 2000;8: Bae DK, Mun MS, Kwon OS. A newly designed miniplate staple for high tibial osteotomy. Bull Hosp Jt Dis. 1997;56: Wright JG, Treble N, Feinstein AR. Measurement of lower

8 506 배대경ㆍ송상준ㆍ윤경호외 1 인 limb alignment using long radiographs. J Bone Joint Surg Br. 1991;73: Oswald MH, Jakob RP, Schneider E, Hoogewoud HM. Radiological analysis of normal axial alignment of femur and tibia in view of total knee arthroplasty. J Arthroplasty. 1993;8: Saragaglia D, Roberts J. Navigated osteotomies around the knee in 170 patients with osteoarthritis secondary to genu varum. Orthopedics. 2005;28 Suppl: Shaw JA, Dungy DS, Arsht SS. Recurrent varus angulation after high tibial osteotomy: an anatomic analysis. Clin Orthop Relat Res. 2004;420: Kendoff D, Citak M, Pearle A, et al. Influence of lower limb rotation in navigated alignment anaylsis: implications for high tibial osteotomies. Knee Surg Sports Traumatol Arthrosc. 2007;15: Rodner CM, Adams DJ, Diaz-Doran V, et al. Medial opening wedge tibial osteotomy and the sagittal plane: the effect of increasing tibial slope on tibiofemoral contact pressure. Am J Sports Med. 2006;34: Noyes FR, Goebel SX, West J. Opening wedge tibial osteotomy: the 3-triangle method to correct axial alignment and tibial slope. Am J Sports Med. 2005;33: = 국문초록 = 목적 : 네비게이션장치를이용한경골근위부절골술에서개방형과폐쇄형에따른네비게이션장치와방사선사진상계측치의차이를비교하고자한다. 대상및방법 : 네비게이션장치를이용하여개방형절골술을시행한 32 예와폐쇄형절골술을시행한 51 예를대상으로하였다. 교정각은역학적축백분율이 62% 가되도록계획하였다. 절골전, 후역학적축을계측하고, 방사선사진상계측치와비교하였다. 개방형과폐쇄형절골술에따른술후역학적축의방사선사진상계측치와네비게이션장치상계측치의차이와술후후방경사각의변화를비교하였다. 결과 : 개방형절골술에서의술후평균역학적축은네비게이션장치상외반 2.7 o, 방사선사진상외반 4.0 o 이었고, 폐쇄형절골술에서의술후평균역학적축은네비게이션장치상외반 3.5 o, 방사선사진상 1.6 o 이었다 (p=0.000). 술후후방경사각의변화는개방형절골술에서 5.3 o 증가하였고, 폐쇄형절골술에서 1.8 o 감소하였다 (p=0.000). 결론 : 네비게이션장치를이용한절골술은수술중교정각을확인함으로써정확성을기할수있다. 술후역학적축의네비게이션계측치와방사선학적계측치의차이는체중부하라는외력에의해영향을받게되므로이를고려해야한다. 색인단어 : 슬관절, 퇴행성관절염, 개방형과폐쇄형경골근위부절골술, 네비게이션장치

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untitled 대한정형외과학회지 : 제 43 권제 3 호 2008 J Korean Orthop Assoc 2008; 43: 391-395 폐쇄형경골근위부절골술후발생한심한전반슬 - 증례보고 - 안재민ㆍ서정탁 부산대학교의과대학정형외과학교실 Severe Genu Recurvatum after a Closing-wedge High Tibial Osteotomy - A Case Report