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1 SFWJFX 대한족부족관절학회지 : 제 16 권제 1 호 2012 J Korean Foot Ankle Soc. Vol. 16. No. 1. pp.9-18, 2012 거골의골연골병변 전남대학교의과대학정형외과학교실 Osteochondral Lesions of the Talus Keun-Bae Lee, M.D., Ph.D. Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital, Gwangju, Korea =Abstract= Osteochondral lesions of the talus are isolated cartilage and/or bone lesions that are known cause of chronic ankle pain. They can occur as the result of a single acute ankle injury or from repetitive loading of the talus. Technical development in radiologic imaging and ankle arthroscopy have improved diagnostic capabilities for detecting osteochondral lesions. Characteristics which are important in assessing an osteochondral lesions include: the size, the type (chondral, subchondral, cystic), the stability, the displacement, the location, and the containment of lesion. Nonoperative treatment involving period of casting and non-weightbearing is recommended for acute, non-displaced osteochondral lesions in select pediatric and adolescent patients. Operative treatment is recommended for unstable lesions or failed conservative management. Marrow stimulation techniques (abrasion chondroplasty, multiple drilling, microfracture), osteochondral autograft or allograft, autologous chondrocyte implantation, are frequently employed. The purpose of this article is to review the historical background, etiology, classification systems, diagnostic strategies, and to describe a systematic approach to management of osteochondral lesions of the talus. Key Words: Talus, Osteochondral lesions, Arthroscopy 서 론 거골의골연골병변은족근관절의급성염좌및골절환자에서흔히발생할수있는손상으로, 유병률은전체골절의 0.09%, 모든거골골절의약 1% 로알려져있다. 1,2) 거골 Received: January 15, 2012 Revised: January 30, 2012 Accepted: February 14, 2012 Keun-Bae Lee, M.D., Ph.D. Department of Orthopaedic Surgery, Chonnam National University Hospital, 42 Jebong-ro, Dong-gu, Gwangju , Korea Tel: Fax: kbleeos@chonnam.ac.kr 의골연골병변에대한최초의보고는 1737년 Monro 3) 가족근관절로부터유리체의제거를기술한것이며, 외상에의한병변으로생각하였다. 이후 1888년에 König 4) 가슬관절내의유리체를골연골이괴사되어생긴것이라는의미에서골연골염 (osteochondritis dissecans) 이라는용어를처음사용하였으며, 거골의골연골병변에대해서는거골골연골결손 (talar osteochondral defect), 경연골거골원개골절 (transchondral talar dome fractures), 골연골체 (osteocartilagenous bodies), 관절서 (joint mice) 등의명칭을함께사용하여왔다. 그러나거골의골연골병변이외상뿐만아니라무혈성괴사에의해서도발생할수있다는보고에따라서로다른원인으로발생한병변일가능성이있 - 9 -

2 으므로현재는거골의관절면이나연골하부위유래의병변에대하여 ' 거골의골연골병변 (osteochondral lesions of the talus)' 이라는넓은의미의명칭이널리사용되고있다. 최근에는거골골연골병변의특징을크게여섯가지로나누어분류하고있다 (Table 1). 일반적으로거골의골연골병변은대부분내측에발생하며, 주로후방에발생하고모양이컵형태로깊은반면, 외측의경우는외상과관련이많고전방에주로발생하며흔히전위되어보다심한증상을보인다 (Table 2). 2,5-7) 원 인 거골의골연골병변의가장흔한원인은외상이며족근 관절염좌후자주발생한다. 1955년에 Bosien 등 8) 은전체족근관절염좌의 6.5% 에서골연골병변이관찰되었으며대부분 10대부터 30대에서발생한다고보고하였다. 하지만최근엔스포츠손상이증가함에따라거골의골연골병변의유병률도크게증가하고있으며발생연령대도더다양해지는추세이다. 9,10) 1959년 Berndt 와 Harty 2) 는거골골연골병변의내측과외측부위손상의기전을밝히고내측손상은내번및족저굴곡에의하여생기며, 외측손상은내번및족배굴곡에의해발생한다고보고하였다. 그외의선행원인으로는국소무혈성괴사, 만성미세손상, 내분비계 ( 부갑상선기능저하증또는항진증 ) 나대사성질환, 퇴행성관절병변, 관절의부정렬및유전적인원인등이알려져있다. Table 1. Characteristics of Osteochondral Lesion of the Talus 71) 1. Type of lesion A. Chondral (cartilage only) B. Chondral/subchondral (cartilage and underlying bone) C. Subchondral (intact overlying cartilage) D. Cystic (>5 mm deep) 2. Stability of lesion A. Stable B. Unstable 3. Displacement of lesion A. Displaced B. Non-displaced 4. Location A. Medial (anterior, central, or posterior) B. Lateral (anterior, central, or posterior) C. Central (anterior, central, or posterior) 5. Containment A. Contained B. Uncontained (shoulder lesion) 6. Size of lesion A. Small (area<1.5 cm 2 or greatest diameter<15 mm) B. Large (area>1.5 cm 2 or greatest diameter>15 mm) 분류거골의골연골병변은단순방사선소견, 전산화단층촬영 (CT), 자기공명영상 (MRI) 및관절경적소견에따라분류할수있다. 1959년 Berndt와 Harty 2) 는단순방사선소견에따라병변의정도를 4단계로분류하였으며, 이분류법은지금까지도이용되고있다 (Table 3, Fig. 1). 하지만단순방사선소견으로병변의단계를정확히구분하기에는한계가있다. Loomer 등 11) 은 92명을대상으로한연구에서골연골병변의 50% 정도는단순방사선소견상발견되지않았다고하였다. 따라서보다정확한진단을위하여전산화단층촬영이나자기공명영상촬영등이필요하며관절경시야에서직접골연골병변의상태를검사할수도있다. 현재는전산화단층촬영이나자기공명영상, 관절경등의새로운영상기술이발전, 도입됨에따라다양한분류법들이제시되어사용되고있다. 전산화단층촬영은단순방사선촬영에비해우수하고연골하낭종을관찰할수있다는장점이있다. 1990년 Ferkel 등 12) 은전 Table 2. Characteristics of Osteochondral Lesion of the Talus by Location Medial Lateral Frequency More frequent Less frequent Injury mechanism Inversion/plantarflexion Inversion/dorsiflexion Trauma history Less frequent More frequent Location Mid to posterior Anterior Shape of lesion Deep cup shaped Thin, wafer shaped Displacement Less More Degenerative change Rare Frequent Symptom Mild & late onset Severe & early onset Cystic lesion Frequent Rare Treatment Conservative treatment Early surgical treatment

3 거골의골연골병변 Table 3. Berndt and Harty Classification System 2) Stage I II III IV Feature Focal compression of the subchondral bone (bone beneath the cartilage) Focal compression of the subchondral bone with partial detachment of a fragment of cartilage Focal compression of the subchondral bone with a fully detached fragment of cartilage still situated in place at the site of injury Focal compression of the subchondral bone with a fully detached fragment of cartilage detached from the site of injury and floating in the joint space Table 4. CT Classification of Osteochondral Lesion of the Talus 12) Type Characterisctics I Cystic lesion within the talar dome IIA Cystic lesion with communication to the talar dome IIB Open articular surface lesion with overlying non-displaced fragment III Non-displaced lesion with lucency IV Displaced fragment Stage I Stage IIA Stage IIB Figure 1. Berndt and Harty classification system. 2,72) 산화단층촬영에서관절면의상태와연골하낭종의유무에따라 4단계로분류하고 (Table 4, Fig. 2), 제I, II기는보존적치료를, 제III기와 IV기그리고보존적치료에실패한경우에서는수술을필요로한다고하였다. 거골의골연골병변의진단및분류에가장널리쓰이는자기공명영상촬영은병변의범위를파악하는데매우유용하다. 1989년 Anderson 등 13) 이 MRI를이용한분류를처음제시하였으며, 1999년에 Taranow 등 14) 이 MRI에의한분류법을발표하였고, 같은해에 Hepple 등 15) 도주변부의부종유무에따라 IIa기와 IIb기를세분하는 MRI 분류법을보고하였으며현재널리이용되고있다 (Table 5, Fig. 3). 관절경적소견을이용한분류법도등장하였는데, 1986년 Pritsch 등 16) 은관절경적소견을기초로하여제I기는연골표면이딱딱하며빛나는경우, 제II기는연속성은있으나부드러운경우, 제III기는연속성이파괴되어연골이너덜거리는 (frayed) 경우로기술하였다. 그후 1999년에 Ferkel과 Cheng 17) 은다음과같은구체적인관절경적분류법을제시하였다 (Table 6). Stage III Stage IV Figure 2. CT classification of osteochondral lesion of the talus. 12,73) 임상증상및진단 1. 임상증상거골의골연골병변의평균발생연령은 대이며, 남성에서 70% 정도호발하고, 양측성으로보고되는경우도 10% 정도된다. 18) 대부분의환자가족근관절부위외상의과거력을가지며, 19) 증상으로족근관절의부종, 동통, 잠김현상등을보인다. 어느순간족근관절의심한통증이있다가자연적으로좋아지는증상이반복되는것이특징적이

4 Table 5. MRI Staging of Osteochondral Lesion of the Talus 15) Stage Description I Articular cartilage damage only IIa Cartilage injury with underlying fracture and surrounding bony edema IIb Stage IIa without surrounding bony edema III Detached but undisplaced fragment IV Detached and displaced fragment V Subchondral cyst formation Table 6. Arthroscopic Staging of Osteochondral Lesion of the Talus 17) Stage A B C D E F Description Smooth/intact cartilage Rough cartilage Fibrillations/fissures Cartilage flap present or bone exposed Loose, undisplaced osteochondral fragment Displaced osteochondral fragment I IIb IV IIa III V 경사 ) 을시행하여골절유무를확인하여야한다. 내측병변은후방에위치하는경우가많으므로족근관절을족저굴곡한상태에서전후면촬영을하면더잘보이며, 외측병변은전방에위치하는경우가많으므로족배굴곡한상태에서 mortise 사진을촬영하면병변을더잘관찰할수있다. 그러나단순방사선검사는약 50% 정도에서골연골병변을발견할수없으며, 12) 골연골의상태를알기어려우므로추가적인검사가필요하다. 전산화단층촬영은병변의위치, 크기, 형태, 그리고골연골의전위정도를진단하는데유용한검사이지만, 관절연골, 골타박, 비전위성병변을관찰하는데는한계가있다. 20) 골주사검사는단순방사선사진에서병변을확인할수없는경우선별검사로이용할수있으며음성예측치가 94% 로보고되어, 21) 골주사검사상음성일때골연골병변을배제할수있는장점이있다. 자기공명영상은병변의위치와크기, 낭종의유무, 안정성을평가하는데큰도움이되며, 관절연골및연골하골병변모두를확인할수있고, 주변연부조직의이상소견까지도확인할수있다는장점이있으나, 18) 골병변의정도를과대평가할가능성이있다. 수술전평가및계획 Figure 3. MRI staging of osteochondral lesion of the talus. 15) 다. 또한증상은오랜보행이나달리기, 점프같은충격량이많은운동으로악화된다. 신체검사상병변부위에압통을관찰할수있으며, 이외에도족근관절운동범위의감소, 관절내삼출액증가, 연발음, 불안정성등을관찰할수있다. 2. 영상학적검사족근관절의단순방사선사진 ( 체중부하전후방, 측면, 관절연골은손상된경우에복원력이매우약하므로손상받은관절연골은제거후연골결손부위를복구하여야한다. 골연골병변의상태에따라서수술적치료의목표는유리체를제거할것인지, 해부학적으로큰골편을보전할것인지, 섬유연골의재생을유도할것인지또는초자연골편치환술을시행할것인지가결정된다. 어떤수술방법을선택하던지수술결과에영향을미치는요소들로는병변의위치및크기, 전위정도, 체중, 연령, 술후처치등이중요한것으로알려져있다. 22) 또한수술방법을결정하는데있어족근관절의불안정성및퇴행성변화유무, 관절의부정정렬등을사전에평가해추가술식이필요한지를결정해야한다. 단순방사선사진상골연골병변이보이고환자

5 거골의골연골병변 의증상과일치하면컴퓨터단층촬영이나자기공명영상촬영이권장되며이는삼차원적으로병변의위치와크기, 낭종의유무, 안정성등을평가하는데큰도움을준다. 1. 비수술적치료 치 료 무증상이거나우연히발견된병변일경우에는비수술적치료를시행하여볼수있다. 일반적인방법은석고고정후물리치료를시행하는것이며, 연골치유를목적으로경구또는주사용연골영양제재 (chondroprotective agents) 를사용할수있다. 경구연골영양제재로는 glucosamine hydrochloride, chondrotin sulfate, vitamin 등이있으나이들제재들은국소연골병변에는효과가없는것으로알려져있다. 23) 주사용제재로는 hyaluronate 유도체가있으며초기증상이있는퇴행성슬관절염에서효과를보고하고있으나거골에발생한국소연골병변에대한치료효과는보고된바가없다. Berndt와 Harty 2) 는비수술적치료를시행하였을때 75% 에서좋지않은결과를보인다고하였고 Flick과 Gould 6) 도비슷한결과를보고하였다. Canale과 Belding 24) 은 I기와 II 기의병변은비수술적으로치료해야하며, III기는수술적치료전석고고정을시도해야하고, III기중외측병변및모든 IV기의환자는수술적치료를권장하였다. 그러나최근에는관절경을이용한치료가발전하면서조기에좀더적극적인치료가시도되고있다. 방사선소견으로는 II기로분류되더라도관절경하에서는불안정한경우도있는데이러한경우에는 III기에준하여치료하여야한다. 또한방사선사진에서는발견되지않고자기공명영상에서신호강도의변화만보이는병변이라도통증이지속될경우엔좀더적극적인관절경검사가필요할수있다. 2. 수술적치료 급성골절에서전위된작은골연골편은절제하고, 큰골연골편은정복후고정하는방법으로치료한다. 만성적인병변은증세가있는경우에치료를한다. 이경우수술적치료의목적은혈관이없어재생능력이떨어지는관절연골을제거하고골연골결손부위에재혈관화를시켜주어치료를도모하는것이다. 22,25) 외측병변인경우주로외상에의해발생하며자연치유되는경우가드물고, 증세를유발하는경우가많으므로조 Table 7. Surgical Treatment Options for Osteochondral Lesion of the Talus Marrow stimulstion A. Abrasion chondroplasty B. Curettage C. Debridement and microfracture D. Drilling: antegrade or retrograde Osteochondral autograft A. Single cylinder B. Multiple cylinders (mosaicplasty) Osteochondral allograft Autologous chondrocyte implantation (ACI) Concomitant procedures (i.e. lateral ligament reconstruction, hindfoot realignment) 기에수술적치료를하는것이좋다. 내측병변인경우에는외상과관계없는경우가많고, 증세를유발하는경우가적으며, 퇴행성관절염을일으키는경우도적으므로증세를일으킬때까지기다려수술하는것이좋다. 수술적치료방법으로는관절경을이용한소파술, 연마, 변연절제술및다발성천공, 미세골절술등의골수자극요법이있으며연골결손부위를초자연골대신섬유연골로복원시키는방법들이다. 관절면의초자연골을복원시키기위한방법으로는자가골연골편또는동종골연골편이식법이나자가연골세포이식법등이있다 (Table 7). 1) 관절경적수술방법어떠한수술방법을시행할것인지를결정하는데있어서관절경적소견이매우중요하며, 관절경적수술법은수술합병증이적고기능적회복이매우빠르다는장점이있다. 일반적으로전내방, 전외방삽입구를이용하며경우에따라서후내방및후외방삽입구를추가적으로사용할수있다. 가 ) 연골안정화 / 고정술전위되지않은외상성골연골편은고정술을시행하기에적합한경우로, 골편이크면서불안정성을보이는경우변연절제술을시행하는것보다고정술을시행하는것이좋다. 26) 최근에는 polyglycolic acid (PGA) 나 polylactic acid (PLLA) 같은생체흡수성재료를이용한고정물을사용하기때문에금속고정물의제거를위한수술을할필요가없으며좋은결과가보고되고있다. 27) 나 ) 역행성천공술 (retrograde drilling) 연골부위손상없이연골하병변만존재하는경우에는연골의손상을줄이기위해순행성천공술보다는역행성천공술을시행하는것이좋다. 14) 이때주의할점은병변의

6 골절술을 시행한 결과에서 79%에서 우수, 21%에서 양호 의 결과를 얻었으며 불량의 결과는 없었다고 보고하였다. 32) 또한 Chuckpaiwong 등 은 미세 골절술을 시행한 105예 중 15 mm 미만의 병변 73예는 모두 결과가 좋았으나, 15 mm 이상의 32예에서는 1예만 결과가 좋았음을 보고하였 으며, 고령, 높은 체질량 지수, 외상의 과거력, 골극을 동반 한 경우 등에서 더 나쁜 결과를 보였다고 보고하였다. 연 33) 골하 다발성 천공술에 대해서는 Angermann과 Jensen 이 20명에서 유리된 골편을 제거하고 천공술을 시행하여 좋 은 결과를 얻었다고 보고하였다. 하지만 연골하골의 낭종 을 가진 만성 골연골 결손에서는 천공술이 덜 효과적이었 34) 다는 보고도 있다. Second-look 관절경술은 연골 손상이 어느 정도 복구되어 있는지를 확인할 수 있는 방법으로, 29) Lee 등 은 미세 골절술 후 12개월에 시행한 second-look 관절경 소견상 약 40%에서 불완전한 연골 재생 상태를 보였 으나, 대부분의 환자에서 양호한 임상 결과를 보였다고 보고 하였다. 감압도 중요하지만 관절 부위의 붕괴를 막기 위하여 골이 식술 또는 골이식 대체물(surgical-grade calcium sulfate 28) 등)을 이용한 시술이 필요하다. 다) 변연 절제술(debridement), 소파술(curettage), 연마 (abrasion), 연골하 천공술(subchondral drilling), 미 세 골절술(microfracture) 골수 자극 치료방법은 골의 출혈을 일으켜 섬유 연골로 의 치유를 유도하는 방법으로 초자 연골이 아닌 섬유 연골 로 치유되어 역학적인 질은 떨어지지만 족근 관절로 통하 29) 는 무게를 견디는 데는 충분한 것으로 보고되고 있다. 다 발성 천공술과 미세 골절술 중 어느 방법이 더 좋은가에 대 해서는 아직 논란이 있지만 천공술 시 발생하는 열에 의한 골세포의 손상과 병변에 수직으로 천공하기 위해서는 정상 내측과를 통해야 하는 등의 단점이 제기되어 미세 골절술 25,30,31) 이 좀 더 선호되고 있는 추세이다(Fig. 4). 6) Flick과 Gould 는 21명의 환자에서 변연절제술 및 미세 A B Figure 4. (A) Arthroscopic photographs showing that microfractures were performed using arthroscopic awl. (B) Adequate bleeding occurred from the microfracture holes after tourniquet 30) release. A B Figure 5. (A) T2-weighted coronal MR images showing medial osteochondral lesion with subchondral cyst. (B) Two osteochondral autograft cylinders were 74) transplanted into the lesion

7 거골의골연골병변 2) 조직이식술거골에골연골을이식하기위하여, 병변부위에수직으로접근함이필요하며, 이를위해다양한내과절골술의방법들이보고되어있으며, 35-37) 거골체대부분의부위에서외과절골술은필요하지않다. Muir 등 38) 은대부분의거골원개는절골술이없이도수직으로접근할수있다고하였으나, 내측거골원개의 17%, 외측거골원개의 20% 에서는절골술없이는접근할수없다고하였다. 가 ) 자가골연골이식술 (autologous osteochondral graft, mosaicplasty) 자가골연골이식술은동측의슬관절에서골연골을떼어내어거골의연골결손부위에이식하는방법으로골수자극치료를시행한경우에서초자연골이아닌섬유연골로치유되어생역학적특성이떨어지는단점을극복할수있는방법으로고안되었다 (Fig. 5). 일반적으로병변의크기가 1.5 cm 2 이상으로큰경우나, 이전의수술에실패한경우, 또는큰연골하골낭종을가진경우등에서시행된다. 하지만건강한슬관절에서골연골편을채취하여야한다는점, 절골술을필요로하는복잡한술식, 슬관절과족근관절의연골두께의차이가나는점등의단점이있다. Scranton 등 39) 은직경 8-20 mm의병변을가진 50명의환자에대하여자가골연골이식후 90% 에서술후양호한결과를보고하였고, Al-Shaikh 등 40) 도평균직경 mm의병변을가진 19명에서술후 AOFAS 88점의우수한결과를보고하였다. 1993년 Draper와 Fallet 41) 은무릎의연골병변에대해여러개의작은이식을하는새로운방법 (mosaicplasty) 을보고하였으며, 이방법은결손부의모양에맞추기가쉽고공여부의합병증을줄일수있다는장점이있으나이식골연골편사이가섬유성조직으로치유된다는단점이있다. Hangody 등 42) 은직경 10 mm 이상의거골골연골병변을가진 36명의환자에대하여대퇴골내, 외측과의골연골편을이용한 mosaicplasty 시행후 2-7년추시상 94% (34명) 에서양호한결과를보고하였으며, 공여부의합병증도관찰되지않았다고하였다. 43) 다른방법으로 Sammarco와 Makwana 44) 는병변이있는거골자체에서골연골을채취하여이식하는방법을보고하기도하였다. 나 ) 동종골연골이식술 (osteochondral allograft transplantation) 동종골연골이식술은동종골로부터큰골연골편을이식하는방법으로골연골병변이매우클때고려할수있다. 장점으로는관절표면을복구할수있고, 공여부를필요로하지않으며, 여러개의이식물대신하나의골연골편을사용함으로써이식골연골편사이의섬유연골로의치유를최소화할수있다는점등이있으나, 면역거부반응및연골세포의생존율에서제한점을가지고있다. Raikin 45) 은 6예의심한골연골결손에대하여동종골연골이식술을시행후 AOFAS 족관절 -후족부점수가술전 42점에서술후 86 점으로향상되었음을보고하였다. Gross 등 46) 도거골의골연골병변을가진 9명의환자에대해서동종골연골이식술을시행하여추시상 6명의환자에서평균 11년의생존을보였고 3명의환자는유합술을시행하였다고보고하였다. 다 ) 자가연골세포이식 (autologous chondrocyte transplantation) 자가연골세포이식술은슬관절의연골을일부채취하여시험관내에서연골세포를분리한후 3주간배양증폭한다음거골의골연골결손부에이식하는방법으로초자연골로재생시켜줄수있는방법으로각광받고있다. Giannini 등 47) 은거골의골연골병변에대하여자가연골세포이식술을시행하여건강한주변연골을닮은새로운초자연골이형성되는것을관찰하였다고하였다. 자가연골세포이식술은작은연골표본을가지고연골을배양할수있으므로공여부의크기나상태에제한을받지않는다는장점이있으나 2번의수술이필요하고술기가복잡하며비용이많이들고, 장기간의추시결과가없다는단점이있다. 3. 부가적인치료 / 향후치료방향 거골의골연골병변에대한치료로는물리치료를포함한비수술적치료, 또는병변의크기, 환자의성별, 나이등을고려한수술적치료가널리이용되고있으나, 최근새로운치료법들이소개되고있다. 1) 점성관절액보충치료 (viscosupplementation therapy) 점성관절액보조물로알려진히알루론산 (hyaluronic acid) 의관절내주사는관절염이나다른관절내에발생하는다양한병변에치료를위하여그사용이증가하고있는추세이다. 다양한연구에서관절내연골병변에대하여점성관절액주사치료는좋은결과를보고하고있으며, 또한족근관절골관절염환자에서도안정성과좋은효과를나타내고있다 )

8 2) 전기 / 전자기자극치료 (electrical/electromagnetic stimulation) 연골손상의치유에있어서전기또는전자기자극치료의효용성에대해서는아직논란이있으나, 일부연구에서는이러한치료가형질전환성장인자- 베타 (TGF-β) 나다양한골형성단백질 (BMPs) 의분화에기여한다고보고되고있다 ) 펄스전자기장이연골세포의분화를유도한다는것이다. Benazzo 등 56) 은동물모델을이용한연구에서자가골연골이식후펄스전자기치료를병행한경우골형성및이식물의안정성이향상되었다고보고하였다. 3) 초음파자극치료 (ultrasound stimualtion) 저강도의초음파는골과연골의치유를촉진하고유도하는것으로알려져있다 ) 최근동물모델을이용한연구에서양측슬관절의골연골병변에대하여초음파치료를시행한병변이반대측에비하여더우수한결과를보였다는보고가있다. 61) 그러나이러한초음파치료의효용성에대해서는더많은연구가필요하다. 4) 중간엽줄기세포 (mesenchymal stem cells) 현재까지골수에서기원하는중간엽줄기세포를이용한연골치료는초기단계에있으나, 최근동물모델연구들에서골연골결손부위에지지체를이용한중간엽줄기세포이식의성공적인결과가보고되고있다 ) 5) 혈소판풍부혈장 (platelet-rich plasma) 혈소판에는다양한성장인자및형질전환성장인자- 베타 (TGF-ß) 와같은외인성인자가함유되어있어조직재생및골치유과정에관여하는것으로알려져있다. 65,66) 따라서연골손상이외에도주관절의상과염, 슬개건염및인대손상, 근육손상등에도이용되고있다. 최근자가연골세포이식과혈소판풍부혈장을함께사용하여더성공적인효과를얻고자하는연구들이진행되고있다. 67,68) 6) 네비게이션과로봇의이용 (computer-aided navigation and robot-assisted surgery) 정형외과영역에서네비게이션또는로봇을이용한수술이점차증가하고있으며, 최근에는족관절영역에서도네비게이션및로봇을이용한수술적치료가시도되고있다. 특히병변이작은거골의골연골병변에서는정확한위치파악과최소침습적절개및술후결과를극대화하기위하여이러한기술적접근은매우유용해지고있다. 69,70) 요약및결론 거골골연골병변의정확한원인은아직불분명하지만대부분족근관절의외상후에이차적으로발생한다. 거골골연골병변이족근관절염좌후에발생시간과되는경우가많으며, 증상이없는병변의경우도우연히방사선적검사에서발견된다. 최근자기공명영상검사와관절경술의발달로골연골병변에대한진단은더욱정확해지고있으며, 치료방법또한계속해서진화하고있다. 치료방법을결정하는데있어서는병변의크기와위치, 병변의안정성및전위정도, 연골하낭종유무, 환자의나이와활동정도등을고려해야한다. 지금까지시행되고있는치료방법들의전체적인성공률은양호한편이지만, 지속적인효과및안정성을가지고시행할수있는방법의확립을위해서는꾸준한연구와더많은증례의결과들이필요하다. REFERENCES 1. Saxena A, Eakin C. Articular talar injuries in athletes: results of microfracture and autogenous bone graft. Am J Sports Med. 2007;35: Berndt AL, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg Am. 1959;41-A: Monro A. Part of the cartilage of the joint separated and ossified. In: Medical essays and observations, 2nd ed. Edinburgh: Ruddimans; König F. Uber freie Korper in den Gelenken [On the presence of loose bodies in joints]. Dtsch Z f Chir. 1888;27: Clanton TO, DeLee JC. Osteochondritis dissecans. History, pathophysiology and current treatment concepts. Clin Orthop Relat Res. 1982;(167): Flick AB, Gould N. Osteochondritis dissecans of the talus (transchondral fractures of the talus): review of the literature and new surgical approach for medial dome lesions. Foot Ankle. 1985;5: Thompson JP, Loomer RL. Osteochondral lesions of the talus in a sports medicine clinic. A new radiographic technique and surgical approach. Am J Sports Med. 1984;12: Bosien WR, Staples OS, Russell SW. Residual disability following acute ankle sprains. J Bone Joint Surg Am. 1955;37: Schenck RC Jr, Goodnight JM. Osteochondritis dissecans. J Bone Joint Surg Am. 1996;78: Tol JL, Struijs PA, Bossuyt PM, Verhagen RA, van Dijk CN. Treatment strategies in osteochondral defects of the talar dome: a systematic review. Foot Ankle Int. 2000;21: Loomer R, Fisher C, Lloyd-Smith R, Sisler J, Cooner T. Osteochondral lesions of the talus. Am J Sports Med. 1993;21:

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