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1 293 pissn : , eissn : Symposium J Korean Orthop Assoc 2018; 53: Current Concept: Osteotomy around the Knee 개방형경골근위부절골술 오승민 나경욱 한재휘 * 인제대학교일산백병원정형외과, * 대구파티마병원정형외과 Opening Wedge High Tibia Osteotomy Seung Min Oh, M.D., Kyung Wook Nha, M.D., and Jae Hwi Han, M.D.* Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang, *Department of Orthopedic Surgery, Daegu Fatima Hospital, Daegu, Korea Proximal tibial osteotomy is the preferred method for treating medial compartment knee arthritis with varus deformity. The purpose of this treatment is to reduce the weight burden of the lesion by correcting the mechanical axis of the patient with degenerative arthritis of medial tibiofemoral joint and abnormal alignment. In general, the proximal tibial osteotomy provides satisfactory clinical results when suitable patient are selected by considering the extent of cartilaginous injury and the age of the patient and the correct technique is performed. In tibial osteotomy, medial open wedge osteotomy is used widely because of its short operation time and relatively simple technique. This review describes the current knowledge of patient selection, preoperative evaluation and planning, treatment principles, surgical techniques, rehabilitation procedures and complications in open wedge high tibial osteotomy. Key words: knee joint, osteoarthritis, high tibial osteotomy, medial opening wedge 서론 개방형경골근위부절골술 (opening wedge high tibial osteotomy) 은내반변형을동반한내측구획에국한된초기나중기의슬관절골관절염이있는환자에게시행하는수술적치료방법중하나이다. 1951년프랑스의 Debeyre가처음시작한후그제자인 Hernigou가 1987년에추시결과를발표하면서 1) 세상에알려졌으며, 이수술의장점이부각되면서현재전세계적으로널리쓰이고있다. 2) 개방형경골근위부절골술은슬관절의퇴행성변화와하지의정렬이상이있는환자의역학적축을교정함으로써병변부의과도한체중부하를감소시키는수술방법이며임상적으로는절골술후관절내측구획의섬유연골의재생을관찰할수있다. 3) Received June 12, 2017 Revised November 6, 2017 Accepted May 4, 2018 Correspondence to: Jae Hwi Han, M.D. Department of Orthopedic Surgery, Daegu Fatima Hospital, 99 Ayang-ro, Dong-gu, Daegu 41199, Korea TEL: FAX: hjh8434@daum.net ORCID: 개방형경골근위부절골술의목적은첫째, 관절연골의퇴행성변화로인해대퇴골과경골이이루는비정상적인하지정렬을교정하여내측구획의체중부하를외측의건강한관절면으로옮기는데에있다. 둘째, 슬관절내측구획의관절염의진행을늦춤으로써인공관절치환술로의전환을지연시키는데에있다. 4) 최근인공관절치환술의발달로개방형경골근위부절골술의시행은감소추세에있지만적절한환자선택, 정확한수술계획및다양한수술기법을통해절골술이유리한치료결과를제공할수있다는것은명백한사실이다. 2) 따라서성공적인개방형경골근위부절골술을위해서는관절연골의손상범위와환자의연령을고려한환자의선택, 올바른수술전계획그리고정확한수술기법이성공적인결과를위한필수요소이다. 개방형경골근위부절골술은페쇄형에비해상대적으로수술이빠르고수술술기가쉬우며비골절골및하지단축을피할수있는장점이있으나절골부가붕괴될수있고뼈이식이필요한단점이있다. 5,6) 따라서앞서언급한단점을보완하고성공적인개방형경골근위부절골술을시행하기위해서환자의선택및수 The Journal of the Korean Orthopaedic Association Volume 53 Number Copyright 2018 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

294 Seung Min Oh, et al. 술전평가와계획, 수술기법, 재활, 합병증에대한최신경향에대한이해가필요하다. 수술전평가 1. 적응증및금기증적절한환자의선택은절골술의성공에있어서매우중요한요소이다. 개방형경골근위부절골술의적응증은 65세이하의내반변형이동반된내측부에국한된관절염이있는환자로굴곡구축이 15도이하, 굴곡이 90도이상으로관절운동범위가좋아야한다.

2 294 Seung Min Oh, et al. 술전평가와계획, 수술기법, 재활, 합병증에대한최신경향에대한이해가필요하다. 수술전평가 1. 적응증및금기증적절한환자의선택은절골술의성공에있어서매우중요한요소이다. 개방형경골근위부절골술의적응증은 65세이하의내반변형이동반된내측부에국한된관절염이있는환자로굴곡구축이 15도이하, 굴곡이 90도이상으로관절운동범위가좋아야한다. 7) 또한내측에골괴사증, 이단성골연골염, 내측반월판의후각부의방사형파열이동반된경우에도좋은결과를보인다. 8) 수술후좋은예후를보이지않는금기증은내측골관절염이심한경우 (Kellgren-Lawrence 분류제4군 ), 교정각이 20 이상필요한경우, 슬관절굴곡구축이 15 이상인경우, 선행된외측구획의골관절염이있는경우, 경골의외측전위, 류마티스관절염같은자가면역질환에의한관절염이있는경우이다. 9-11) Figure 1. Intraoperative C-arm method. Check whether the mechanical axis is located at 62% to 65% of the outer side of the articular surface using iron or steel tape. 2. 수술전고려사항 1) 환자평가수술을결정하기전환자의나이, 증상, 직업, 활동력, 수술과거력및수술결과에대한기대등을문진을통해고려되어야한다. 수술전슬관절에서시행해야하는신체검진으로는슬관절운동범위측정, 신전기전이상으로생긴슬개대퇴관절병변의평가, 골연골손상을시사하는내반부하검사시내측구획의마찰음, 인대손상에의한슬관절불안정성의여부, 하지부동에대한평가등이반드시시행되어야한다. 12) 2) 영상의학적평가방사선검사는기본적으로직립슬관절전후방방사선촬영 (bilateral standing antero-posterior view) 과 45 굴곡양측성체중부하촬영 (Rosenberg view) 을통해내측골관절염및내반변형을정확히평가해야하며측면방사선촬영 (lateral views) 과 Sky line view로슬개-대퇴관절염유무를확인할수있고슬개골의높이를평가함으로써수술전후의슬개골의높이변화를확인할수있다. 13) 또한기립자세로대퇴골두에서슬관절을포함하여족근관절까지촬영할수있는하지전장방사선영상 (scanogram) 을시행해서하지정렬을평가한다. 추가검사로슬관절내반및외반부하검사를시행해서불안정성및전위유무를확인해야한다. 5) 3) 교정각계산개방형경골근위부절골술에서절골후체중부하선을목표범위에위치시키는방법은정확하고세밀해야한다. 이상적인수술후하지정렬은수술후하지전장방사선영상에서역학적축 으로부터 3-5 외반또는 62%-65% 에체중부하선을위치시키는것이임상적으로결과가좋다고알려져있다. 3) 목표범위에위치시키는방법에는여러가지가있다. 먼저기존의고식적인방법으로방사선투시기 (C-arm) 를이용한방법이있고수술시쇠줄이나쇠줄자등을이용하여역학적축이관절면의외측 62%-65% 에위치하는지를확인하는방법이있으며 (Fig. 1) 최근에는컴퓨터항법장치 (navigator) 를이용하여실시간으로하지정렬을확인하는방법이있다. 14) 그러나이들은비체중부하 (non-weight bearing) 방법으로실제환자의체중부하시상황을반영하지못하는단점이있다. 체중부하시교정각을측정하는방법으로 Miniaci 등 15) 과 Dugdale 등 12) 의측정방법이있으며, 먼저 Miniaci 방법은컴퓨터화면에서체중부하하지전장을이용하여측정하는방법으로역학적축 (A) 을그린다음원하는위치를지나는새로운역학적축 (A ) 을그린후경첩부위 (H) 를지나는선 HA와 HA 가이루는각을교정각도로하는방법이다 (Fig. 2A). Dugdale 방법은수술후체중부하선이경골전체의너비를 100으로하였을때내측에서 62.5% 이르도록교정각을만드는것이목표이며고관절의중심과경거골관절의중심에서경골고평부의 62.5% 부위에이르는선을그었을때이두선의사이의각도를교정각도로하는방법이다 (Fig. 2B). 하지만이두방법은컴퓨터화면상측정오차가발생할수있어이를보완하고자체중부하하지전장방사선영상을촬영하여이를 100% 인쇄해교정각을정하는체중부하전장사진 (weight bearing scanogram) 을이용한방법이있으며이는교정할체중부하위치 (Fujisawa point) 를표시후절골술을시행할위치에서가위를이용해가상선을자르고경첩에서돌려서대퇴골두

295 Opening Wedge High Tibial Osteotomy 의중심, Fujisawa point, 거골중심이일직선이되도록맞춘후고정을하는방법이다 (Fig. 3).

슬개건의내측면과경골후방경계의중간부위에약 5-6 cm의종절개를가한후거위발건을노출시켜확인한다음부착부에서 ㄱ 형태로절개를가한후후내측으로견인시킨다 (Fig. 4).

16) 천부내측측부인대 (superficial medial collateral ligament) 를부분박리하는방법은 2가지가있으며, 첫째는내측측부인대를확 Proximal Patella tendon 2 3 X A Figure 2.

A new mechanical axis Line 1 passing through the desired position is drawn and the angle formed by line 2 and 3 passing through the hinge section (X) is defined as the correcting

3 295 Opening Wedge High Tibial Osteotomy 의중심, Fujisawa point, 거골중심이일직선이되도록맞춘후고정을하는방법이다 (Fig. 3). 5) 그후절골간격을자 (ruler) 로측정하여절골간격확인및골이식여부를결정하며최근에는체중부하하지전장방사선영상을이용한방법과방사선투시기를이용하는방법을함께사용하는경향이있다 수술기법 1) 접근법먼저수술부위를표기한다. 슬개건의내측면과경골후방경계의중간부위에약 5-6 cm의종절개를가한후거위발건을노출시켜확인한다음부착부에서 ㄱ 형태로절개를가한후후내측으로견인시킨다 (Fig. 4). 거위발건은보존하고수술할수있으나금속판의고정후이를봉합하면금속판과의마찰로인한건염 (tendinitis) 및굴곡구축 (flexion contracture) 을유발할수있으므로떼어내는것이좋다. 16) 천부내측측부인대 (superficial medial collateral ligament) 를부분박리하는방법은 2가지가있으며, 첫째는내측측부인대를확 Proximal Patella tendon 2 3 X A Figure 2. Bilateral weight bearing anteroposterior whole lower limb X-ray. (A) Miniaci method. A new mechanical axis Line 1 passing through the desired position is drawn and the angle formed by line 2 and 3 passing through the hinge section (X) is defined as the correcting angle. (B) Dugdale method. Line 1 is drawn formo the center of the femoral head to the 62.5% of the tibial width. Line 2 is drawn from the center of the talus to the 62.5%. The angle formed by line 1 and 2 is the correcting angle. 2 B X Anterior MCL Hamstrings Posterior Figure 4. Pes anserinus was detached from the attachment and then pulled inward. The metaphyseal flare could be identified. MCL, medial collateral ligament. Ruler 62.5% WBL Figure 3. Weight-bearing scanography measure method: a template was cut through the osteotomy site and the tibia was rotated until the weight bearing line (WBL) through the 62.5% coordinate.

296 Seung Min Oh, et al. 인한후절골위치에서관절면과평행하게횡절단 (transection) 하는방법이고둘째는내측측부인대를절골위치에서박리하여관절면의압력을줄여주는방법이다. 이중인대를횡절단하는방법이수술시시야가좋다. 16) 2) 가이드핀삽입가이드핀 2개를삽입해야하는데이때핀의삽입위치가가장중요하다.

골간단이행부는슬개건부착부위와일치하며관절선과평행하게형성되어있어이곳을촉지하여절골술을시행한다. 먼저전방 K-wire (ø 2.0-2.4 mm) 를 safe zone 을향해삽입한다. Safe zone 은비골의 tip과비골두의 circumference line 사이의공간으로외측에는관절막이있어외측피질골골절로인한전위를막을수있다 (Fig. 5).

4 296 Seung Min Oh, et al. 인한후절골위치에서관절면과평행하게횡절단 (transection) 하는방법이고둘째는내측측부인대를절골위치에서박리하여관절면의압력을줄여주는방법이다. 이중인대를횡절단하는방법이수술시시야가좋다. 16) 2) 가이드핀삽입가이드핀 2개를삽입해야하는데이때핀의삽입위치가가장중요하다. 핀삽입전슬관절을약간굴곡해야방사선투시기로슬관절을평행하게관찰할수있다. 가이드핀삽입은단층절골술 (uniplanar osteotomy) 의경우는관절면하방 3 cm에서부근인골간단이행부 (metaphyseal flare) 에서, 이중절골술 (biplanar osteotomy) 인경우는관절면의하방약 4 cm에서시작한다. 골간단이행부는슬개건부착부위와일치하며관절선과평행하게형성되어있어이곳을촉지하여절골술을시행한다. 먼저전방 K-wire (ø mm) 를 safe zone 을향해삽입한다. Safe zone 은비골의 tip과비골두의 circumference line 사이의공간으로외측에는관절막이있어외측피질골골절로인한전위를막을수있다 (Fig. 5). 17) 후방 K-wire (ø mm) 는첫번째 K-wire와평행하게, 후방경사각과평행하게삽입하고 2개의 K-wire를연결하는면이절골술을위한절개면이된다. 3) 단일평면절골술절골술을시작하기전에절골용견인기 (long tongue retractor) 를이용하여신경혈관을보호해야한다. 전기톱 (oscillating saw) 을이용하여삽입된두개의가이드핀하방에서절골을시행하며절골면의 50%-60% 이상부터는절골도 (osteotome) 를이용하여조심스럽게절골술을시행한다. 이때외측피질에서약 5-10 mm 전 까지충분히절골술을시행한다. 후방피질이두꺼우므로충분히절골을시행하고이후절개면을 3 or 4 chisel을이용하여완성시킨다 (Fig. 6). 3 chisel 기법이용시첫번째 chisel은외측피질골의끝부분에서 5-10 mm까지삽입시키고두번째 chisel을첫번째를따라삽입시킨후두개사이로세번째 chisel을삽입한다. 이후조심스럽게외반력을가해절골면을열어주고신연기 (bone spreader) 를절골면깊이삽입한다. 신연기에드라이버를삽입하여천천히시계방향으로돌려주고방사선투시기를이용하여하지정렬과교정정도를확인한다. 절골면을유지하는방법에는여러방법이있으며첫째는금속블록 (metal block) 을사용하는방법, 둘째는신연기를이용하는방법, 셋째는자가골 (tricortical iliac bone graft) 을사용하는방법, 마지막으로인공뼈 (synthetic bone block) 를이용하는방법이있다. 이들은금속판을삽입하기전절골간격을유지하는데유용한방법이며신연기는계획된수치보다 1-2 mm 더열어주어야하며 10 mm 이상개방시에는조심스럽게열어야골절을예방할수있고금속블록또는뼈블록의고정이용이하다 (Fig. 7). 4) 이중평면절골술절골술을시작하기전에절골용견인기를이용하여신경혈관을보호해야한다. 전기톱을이용하여삽입된두개의가이드핀하방에서절골을시행하며절골면의 50%-60% 이상부터는절골도를이용하여조심스럽게절골술을시행한다. 이중절골술에서경골결절을보존하기위한추가적인경골결절의절골은첫번째절개된면에대하여약 경사가되도록작은전기톱을이용해절골을시행한후단일평면절골술과마찬가지로 3 or mm A B Figure 5. Anteroposterior fluoroscopy view of the knee showing the safe zone. A, tip of the fibular head; B, circumference line of the fibular head. Figure 6. An osteotomy should be performed until only 5 to 10 mm of the lateral cortex is left.

297 Opening Wedge High Tibial Osteotomy Figure 7.

During uniplanar osteotomy, a metal block is fixed to the plate using screw. A B Figure 8.

(B) The 3 or 4 chisel technique is used to open the site of osteotomy.

5) 금속판의삽입및고정단일평면절골술은절골위치상절골근위부에 3개의금속나사를고정할수있고이로인해약한고정력을금속블록또는뼈블록을사용하여축성압박을견딜수있게할수있다.

개방형경골근위부절골술시행시후방경사 (posterior slope) 의증가및슬개골의높이증가는알려진사실이다.

5 297 Opening Wedge High Tibial Osteotomy Figure 7. Space can be maintained by inserting the metal block into the osteotomy surface. Figure 9. During uniplanar osteotomy, a metal block is fixed to the plate using screw. A B Figure 8. (A) Second osteotomy was performed with a tilt to the first osteotomy site. (B) The 3 or 4 chisel technique is used to open the site of osteotomy. chisel 을이용하여절골간격을개방한다 (Fig. 8). 5) 금속판의삽입및고정단일평면절골술은절골위치상절골근위부에 3개의금속나사를고정할수있고이로인해약한고정력을금속블록또는뼈블록을사용하여축성압박을견딜수있게할수있다. 먼저방사선투시기를이용하여금속판의위치를확인하고필요에따라금속판의위치를조절한다. 개방형경골근위부절골술시행시후방경사 (posterior slope) 의증가및슬개골의높이증가는알려진사실이다. 6) 금속판을뼈에고정하는경우절골근위부에금속나사를삽입하여먼저고정하고이후무릎을과신전및발목을내회전하여절골원위부의금속나사를고정해하지의외회전및슬관절의후방경사의증가를막을수있다. 마지막으로금속블록을사용한경우는금속블록과연결된금속나사를고정한다 (Fig. 9). 단일평면절골술시견고한고정을위해서근위부금속나사를고정후원위부의가장밑에있는홀에 drill bit로근위피질골 Figure 10. After screw fixation of the proximal part, hyperextension and internal rotation of knee, fix the distal part.

6 298 Seung Min Oh, et al. 만고정하거나또는 K-wire를이용하여임시고정후절골부바로아래에압박나사 (compression screw) 를삽입, 고정하여금속판과뼈의간격을좁힐수있다. 이후나머지잠김나사구멍에잠김나사를원위피질골까지고정후이전에삽입한압박나사도잠김나사로다시고정한다. 이중평면절골술은근위부에 4개의금속나사를삽입할수있는술식이므로충분한고정력을얻을수있는장점이있다. 금속판의형태는잠김-압박금속판의형태가견고하며이는압박고정을할수있도록고안됐다. 하지만압박고정은외측피질골절 Takeuch type 1이있는경우에유용하며, 골절선이 safe zone 에위치한경우는압박나사를꼭사용하지않아도된다. 18) 골절선이관찰되지않은경우금속판과뼈의간격이 4 mm 이상큰경우에압박고정을시행하면외측피질골절 Takeuchi type 2가발생할수있다. 이중평면절골술시견고한고정을위해서근위부금속나사를고정한후원위부의가장밑에있는홀에 drill bit로근위피질골만임시고정후절골부바로아래에압박나사를고정한다. 이후소파기구 (curette) 등을이용하여금속블록을망치로때려서아래로빼낸다. 원위부의 drill bit를제거하여잠김나사를근위피질골만삽입하고나머지구멍에잠김나사를모두삽입한다 (Fig. 10). 최근개발된금속판의경우는해부학으로디자인된금속판으로서후방경사를주고측면에서보았을때조금더구부림이가능하게제작되어뼈에가깝게부착될수있도록만들어지고있다. 현재한국에서많이쓰이는금속판으로는 Tomofix plate (Mathys Inc., Bettlach, Switzerland), Puddu plate (Arthrex Inc., Naples, FL, USA), Ohtofix plate (OhtoMedical Company, Goyang, Korea) 등이있으며 Tomofix plate는기존의 T-plate에비해견고한고정을위해고안되어빠른체중부하가가능하며, Puddu plate 는 metal block이있어내측지지가좋은장점이있고 Otofix plate 는 plate가좌우구분이되어있어경골의후방경사에맞춰금속판을고정할수있는특징이있다. 19) 금속판이견고하게고정되어있으면절골술공간이 mm 정도되어도뼈의이식은필요하지않다. 이보다절골간격이큰경우는기계적지지및골유합을촉진하기위해서절골간격으로자가골이식을시행할수있으며동종해면골및인공뼈등을이용할수도있다. 20) 금속판과금속나사를모두삽입하면마지막으로압박대를감압하여혈관손상유무를수술장에서꼭확인한후배액관을삽입하도록한다. 재활 개방형경골근위부절골술에서고정이적절히되었다면조기관절운동을시행할수있으며일반적으로수술후 1주일뒤경첩보조기를이용하여 0-90 관절운동및부분체중부하를시작하고점진적으로향후 4-6주간에걸쳐완전체중부하까지진행한 다. 이후 12주까지는보조기없이체중부하를증가시키며환자개개인에따라수술경과가다를수있으므로수술후 6개월까지는교정이잘유지되고있는지기본방사선검사와하지전장방사선영상을촬영하여평가해야한다. 7) 만일수술중외측피질골절이발생하였다면체중부하를늦추어야한다. 합병증 수술후가장중요한것은재발의방지이며재발의가장흔한원인은경첩역할을하는외측피질골의골절이다. 이는 Takeuchi 분류에의해그예후를예측할수있으며이를예방하기위해 safe zone 에절골술을시행하는것이중요한수술방법이다. 17,18) 개방형경골근위부절골술시가장위험한합병증은후방슬와동맥및신경의손상이다. 이것을예방하기위해서는앞서설명한것처럼전기톱의사용은절골면의 50%-60% 까지만시행한후절골도를이용하고후외방피질골절골시에는반드시절골용견인기를이용하여동맥과신경을보호해야한다. 수술후구획압증가에따른구획증후군이발생할수있고하지의부종, 감각의이상, 심한통증등의임박증상을보이면서이완기혈압과구획압의혈압차이가 30 mmhg 이하일때강력하게의심할수있으며응급근막절개술의적응이된다. 개방형경골근위부절골술후지연유합및불유합등의합병증이약 0.7%-4.4% 정도보고되고있다. 21) 자가골이식시불유합의가능성이줄어드므로교정각이큰경우 (14 mm 이상 ) 에는자가골이식을고려해야한다. 결론 개방형경골근위부절골술은 65세이하의비교적젊은환자의내반변형이동반된슬관절의내측구획관절염의치료로널리사용되고있으며좋은임상결과를보여주고있다. 술기가비교적간단하며수술시간이짧은장점이있는수술로서환자의적응증을잘선택하고술전계획을잘세우며기본적인수술의원칙을지킨다면내측구획관절염으로고통받는환자의인공관절치환술을지연시킬수있는좋은치료법이다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Hernigou P, Medevielle D, Debeyre J, Goutallier D. Proximal tibial osteotomy for osteoarthritis with varus deformity. A ten

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8 300 pissn : , eissn : Symposium J Korean Orthop Assoc 2018; 53: 슬관절주위절골술의최신지견 개방형경골근위부절골술 오승민 나경욱 한재휘 * 인제대학교일산백병원정형외과, * 대구파티마병원정형외과 개방형경골근위부절골술은무릎의내반변형을동반한내측구획의슬관절관절염을치료하는데선호되는수술방법이다. 이치료법은내측대퇴경골관절의퇴행성변화및하지정렬의이상을동반한환자의역학적축을교정하여병변부의체중부하를감소시키는데에목적이있다. 일반적으로개방형경골근위부절골술은관절연골의손상범위와환자의연령을고려하여적절히환자를선택하고정확한술기로수술을시행하였을때만족스러운임상결과를보인다. 경골절골술중내측개방형근위경골절골술은폐쇄형에비하여수술시간이짧고비교적술기가쉬운장점이있어최근널리사용되고있다. 이종설에서는개방형경골근위부절골술에서환자의선택, 수술전평가및계획, 치료원칙과수술술기, 재활과정및합병증에대한최신지견을다루고자한다. 색인단어 : 슬관절, 골관절염, 고위경골절골술, 내측개방형쐐기절골술 접수일 2017 년 6 월 12 일수정일 2017 년 11 월 6 일게재확정일 2018 년 5 월 4 일책임저자한재휘 41199, 대구시동구아양로 99, 대구파티마병원정형외과 TEL , FAX , hjh8434@daum.net, ORCID 대한정형외과학회지 : 제 53권제 4호 2018 Copyright 2018 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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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