283 pissn : , eissn : Symposium J Korean Orthop Assoc 2018; 53: Cur

Transcription

1 283 pissn : , eissn : Symposium J Korean Orthop Assoc 2018; 53: Current Concept: Osteotomy around the Knee 슬관절주위절골술 : 적응증및수술전계획 임승완 류승민 손욱진 영남대학교병원정형외과 Osteotomy around the Knee: Indication and Preoperative Planning Seung Wan Lim, M.D., Seung Min Ryu, M.D., and Oog Jin Shon, M.D. Department of Orthopedic Surgery, Yeungnam University Hospital, Daegu, Korea Osteotomy around the knee is a widely considered surgical procedure for osteoarthritis with lower extremity malalignment. High tibial osteotomy (HTO) is performed for varus deformity, while distal femur osteotomy (DFO) is performed for valgus deformity. However, if the correction is insufficient, double osteotomy can also be considered. This report included the basic principles and current concepts of patient selection and preoperative planning in osteotomy around the knee. Key words: knee joint, osteoarthritis, osteotomy 서론 슬관절은고관절과족관절사이에위치하며정상적으로중력에의한체중부하선이관절의중심을지나가게된다. 만약하지의정렬이정상범위를벗어나게되면슬관절의특정구획에과도한부하를유발하게되어통증과기능저하를유발할뿐아니라결국퇴행성변화를일으키게된다. 1) 교정절골술은하지의정렬이상과슬관절의퇴행성변화를보이는환자에서비정상적인역학적축을교정함으로써병변부에가해지는하중을분산시키는수술방법으로인공관절치환술과는달리수술을통해환자의통증을줄이고퇴행성변화를지연시켜슬관절을보존하여수명을연장시킨다는차이점이있다. 이러한장점때문에나이가비교적젊은환자에서슬관절주위단일구획관절염의치료에근위경골절골술과원위대퇴골절골술이사용되고있고, 좋은결과를보고하고있다. 2-9) Received November 28, 2016 Revised January 12, 2017 Accepted March 22, 2017 Correspondence to: Oog Jin Shon, M.D. Department of Orthopedic Surgery, Yeungnam University Hospital, 170 Hyeonchungro, Nam-gu, Daegu 42415, Korea TEL: FAX: maestro-jin@hanmail.net ORCID: 슬관절변형의대부분을차지하는내반변형의경우근위경골절골술을, 상대적으로드문슬관절외반변형의경우원위대퇴골절골술을선택하여교정을하는것이절골술의기본적인원칙으로알려져있다. 10,11) 하지만교정각이너무크거나경골및대퇴골에모두변형이있어근위경골절골술이나원위대퇴골절골술어느하나만으로는적절한교정을얻지못할경우, 이중절골술역시고려해볼수있다. 12,13) 그러나환자선택및교정각도가적절하지못한절골술을시행할경우, 오히려나쁜결과를초래할수있다. 본종설에서는슬관절주위절골술을올바르게시행하기위한환자의선택및수술전계획의원칙과최신지견등에대해살펴보고자한다. 본론 1. 하지의축하지의역학적축은기립전후면하지전장방사선사진에서대퇴골두의중심점부터거골원개의중심점까지연결한직선으로정상적으로경골의중심점을지나가게된다. 14) 정상슬관절에서는내측구획에 60%-70% 의체중이부하되어내측구획이외측구획보다골관절염의진행이더많다. 15) 양측고관절사이의간격 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.

2 284 Seung Wan Lim, et al. 이슬관절사이의간격보다넓기때문에하지의역학적축은지면에수직인선에대하여 3도내반되어있다 ) 하지의역학적축이슬관절의중심을지나지않고내측으로통과하는경우를역학적내반정렬이라하고, 외측으로통과하는경우를역학적외반정렬이라한다 (Fig. 1). 14) 대퇴골의역학적축은대퇴골두의중심부터과간절흔의중심점까지연결한선이며경골의역학적축은경골고평부의중심부터경골천장부의중심까지연결한선이다. 19) 대퇴골과경골의해부학적축은각각대퇴골과경골간부의축으로평균 6도의외반을이루고있다. 대퇴골의역학적축과해부학적축은평균 6도의각을이루고있으며, 경골의역학적축과해부학적축은거의일치한다. 20) 대퇴골의내과와외과의관절면을이은선과대퇴골의역학적축이이루는각인역학적외측원위대퇴각은평균 88도를이루고있고, 대퇴골의관절면을이은선과대퇴골의해부학적축이이루는각인해부학적외측원위대퇴각은평균 81도를이룬다. 21) 경골의고평부선과경골의역학적축이이루는경골의역학적내측근위경골각은정상적으로평균 87도의각을갖고족관절선과경골이이루는역학적외측원위경골각은평균 89도를이룬다 (Fig. 2). 11,22) 하지의정렬이상에서는이와같은하지의생리적축과생리적각들이정상범위를갖지않고, 정렬이상의종류에따라비정상적인값을갖는다. 수술전방사선사진을통한정확한평가를통해정렬이상의원인을찾아변형이있는부위에서절골술을시행하는것을원칙으로교정부위와교정각도등의술전계획을세울수있다. 12) 2. 근위경골절골술 1) 환자의선택 (1) 나이현재환자나이에따른근위경골절골술의결과에대해합의된결과는없는실정이다. 일부보고들에따르면 65세이상으로나이가많을경우 10년생존율이감소한다고하지만, 23-26) 나이가생존율에영향을미치지않는다는반대되는보고도존재한다 ) 일반적으로술자들이나이많은환자군에서실패율이높을것이라고믿는경향이있기때문에적응증을좀더좁게잡는경향이있는것으로보인다. 9,24) 이처럼저자들에따라결과의차이가있기때문에나이의적응증을잡을때, 실제나이보다는생리학적나이를고려하는것이더중요하다고생각된다. 27) (2) 활동성근위경골절골술은단일구획골관절염이있는환자에서교정후가장높은정도의활동성을보장해준다. 30,31) Fu 등 32) 에따르면, 단일관절치환술을시행한군보다근위경골절골술을시행한군에서술후더빨리걷는것이가능하다고보고하였다. 물론근위경골절골술을시행한군이더오랜재활기간을거쳐야한다는단점이존재한다. 33) 단일관절치환술과근위경골절골술의치환물생존율과인공관절전치환술로의전환에대해서는저자에따라다른결과를보고하고있다. 22,34-36) (3) Osteoarthritis 등급근위경골절골술에서내측구획골관절염의정도는술후결과 CCDA=130 (+6 ) mlpfa=90 (+5 ) ampfa=84 (+3 ) aldfa=81 (+2 ) apdfa=83 (+4 ) mldfa=88 (+2 ) mmpta=87 (+3 ) JLCA=2 (+1 ) appta=81 (+3 ) mldta=89 (+3 ) aadta=80 (+2 ) A B C Figure 1. (A) Normal axis alignment. (B) Varus axis alignment. (C) Valgus axis alignment. Figure 2. Normal physiologic axes and angles of the lower extremities: The physiologic axes and angles have an abnormal value in the malalignment of the lower extremities. CCDA, centrum column diaphyseal angle; ampfa, anatomical medial proximal femoral angle; mlpfa, mechanical lateral proximal femoral angle; aldfa, anatomical lateral distal femoral angle; mldfa, mechanical lateral distal femoral angle; JLCA, joint line congruency angle; mmpta, mechanical medial proximal tibial angle; mldta, mechanical lateral distal tibial angle; apdfa, anatomical posterior distal femoral angle; appta, anatomical posterior proximal tibial angle; aadta, anatomical anterior distal tibial angle.

3 285 Osteotomy around the Knee 에영향을미치는중요한요소중하나이다. 연골손상이내측에국한되어있을때술후좋은결과를기대할수있지만, 심한골관절염에서는수술후에도내측에통증이지속될수있다. 37,38) 특히슬개대퇴관절염이있거나삼중구획골관절염까지진행된경우는절골술의금기증에해당한다. 18,39) Ahlbäck 40) 이제안한골관절염의분류에따르면, 3등급이상인경우결과가좋지않고, 23) 0등급일때보다나은결과를보인다고하였다. 9) 자기공명영상 (magnetic resonance imaging, MRI) 은단일구획관절염의환자에게있어연골손상및동반된다른질환을확인하고외측연골판의손상여부를평가하기위해시행할수있다. 41) (4) 관절운동범위근위경골절골술을시행하기전에관절운동범위를검사해보아야한다. Berman 등 42) 은술전관절운동범위가 90도이하인경우술후결과가좋지않다고보고하였다. Akizuki 등 43) 은술전관절운동범위 100도를술후좋은결과를나타내는기준점으로보고하기도하였다. 많은골관절염을가지고있는환자들은굴곡구축이있으며절골술을통해 10도이하의굴곡구축은교정할수있지만 10도이상의굴곡구축이있는경우는근위경골절골술후후방경골경사의변화로전후방십자인대에나쁜영향을미쳐만족할만한수술결과를기대하기어렵다. 43) (5) 슬관절불안정성슬관절불안정성이동반된정렬이상의경우가있을수있으므로근위경골절골술을시행하기전에인대상태에대한검사가필요하다. 후방경골경사의변화는관절운동범위및전후방십자인대의상태에따라술전계획및술후결과에영향을미칠수있다. 즉내측개방형경골근위부절골술에의한후방경골경사의증가는과신전의감소및후방불안정성의감소 ( 굴곡구축의증가및전방불안정성의증가 ) 효과를가져올수있다. 44) 반대로외측폐쇄형경골근위부절골술에의한후방경골경사의감소는과신전의증가및후방불안정성의증가 ( 굴곡구축의감소및전방불안정성의감소 ) 효과를가져올수있다. 44) 아급성전방십자인대손상과내반변형이동반된경우근위경골절골술과전방십자인대재건술을동시에시행하는것이권장된다. 45,46) 만성전방십자인대손상과내반변형이동반된경우에는근위경골절골술만시행하거나전방십자인대재건술을같이할수있는데, 환자의나이와활동성을고려하여결정한다. 45,46) 후방십자인대손상이나후외측구조물의손상으로만성후외측불안정성이동반된경우에는근위경골절골술만먼저시행하고, 만약불안정성이술후에도지속된다면후방십자인대와후외측구조물재건술을시행하는것을고려한다. 47) (6) 체질량지수 Flecher 등 23) 은체질량지수가 30 kg/m 2 미만인경우, 근위경골절골술후의결과가더좋다고보고하였다. Giagounidis 와 Sell 48) 은체질량지수가정상보다 10% 이상높을경우술후통증이없는 기간이 5년, 체질량지수가정상보다 10% 미만으로높을경우술후통증이없는기간이 7.8년이라고보고하였다. 이와는반대로 Naudie 등 25) 은체질량지수가 25 kg/m 2 미만인환자에서근위경골절골술후더나쁜결과를보인다고보고하였는데, 이는가벼운사람이더활동적이어서절골술부위에더많은부하가걸리기때문이라고주장하였다. 이처럼체중과골관절염발생에대한논쟁은아직까지진행중이며보통비만환자의경우슬관절에더욱부하가가해지는것은사실이다. 2) 수술전계획과소한혹은과다한교정을피하기위해서수술전계획을바르게세우는일이필요하다. (1) 방사선검사술전방사선적평가를위해여러촬영이필요한데, 슬관절을완전히신전한상태에서하지정렬평가를위한양측장하지체중부하전후방촬영이반드시포함되어야한다. 이때하지의정렬이중요하며일반적으로양하지체중부하된상태로발의위치는약간내회전, 슬개골은대퇴골과의중심에위치해야한다. 49,50) 또관절염의평가를위해양측체중부하전후방및진성외측촬영, 45도골곡양측체중부하촬영인 Rosenberg view와 sky line view를촬영하여야한다. 51) 내측구획골관절염의정도및슬개골의높이는전후방촬영에서 Insall-Salvati, Blackburne-Peel, Carton-Deschamps index 52) 를이용하여평가할수있고, 슬개골고위가있는경우경골결절절골술을동반하기도한다. MRI는연골손상, 인대손상, 골연골결손, 골괴사, 연골하부종등을확인하는데도움을준다. (2) 고위경골절골술의목표내반변형의교정목표및수술전계획방법은저자에따라다양하다. Coventry 53) 는해부학적대퇴경골각을 8도외반으로과교정할것을주장하였고, Hernigou 등 54) 은역학적축을 3-6도외반으로교정할것을주장하였다. Fujisawa 등 18) 은술후역학적축이경골고평부의내측에서부터 60%-70% 지점을지나야한다고보고하였다. Miniaci 등 55) 은경골고평부의 30%-40% 지점을, Dugdale 등 56) 은경골고평부의 62.5% 를지나야한다고보고하였으며 Fujisawa 등 18) 이언급한방법에따라위치를계산하였다. 최근 Jakob과 Jacobi 57) 는내측구획의연골두께에따라교정정도를조절하여야한다고주장하였다. 만약내측연골의 1/3이손상되었다면역학적축은경골고평부중심에서외측으로 10%-15% 지점을지나야하고, 내측연골의 2/3가손상되었다면 20%-25% 지점을, 내측연골이모두손상되었다면 30%-35% 지점을지나야한다고보고하였다. (3) 관상면에서술전교정계획 1 Miniaci 방법 : 수술후교정선이대퇴골두의중심에서술자가원하는체중부하위치로경골고평부를지나면서족관절까지가도록선을그린다 (Line A). 근위경골절골술의경첩점에서족관절의중심까지선을그리고 (Line B), 경첩점에서 Line A가교차하

4 286 Seung Wan Lim, et al. A A x B C B Figure 3. Bilateral weight bearing anteroposterior whole lower limb x-ray in full extension for planning the Miniaci method. Line A represents the planned weight bearing line for the postoperative correction extending from the center of the hip to about 60% to 70% of the tibial plateau width past the ankle. Line B connects the osteotomy hinge point with the center of the ankle. Line C connects the osteotomy hinge point with the arc intersection of Line A. The angle formed by Lines B and C is the planned correction angle. Figure 4. Bilateral weight bearing anteroposterior whole lower limb x-ray in full extension for planning the Dugdale method. Line A is drawn from the center of the femoral head to 62.5% of the tibial width. Line B is drawn from the center of the tibiotalar joint to the 62.5% coordinate. The angle formed by these two lines is the correction angle. 는선을그린다 (Line C). Line B와 Line C가이루는각도가 Miniaci 방법으로계획된교정각이다 (Fig. 3). 55) 2 Dugdale 방법 : 대퇴골두의중심에서경골고평부의 62.5% 지점까지선을그린다 (Line A). 다음으로족관절의중심에서경골고평부의 62.5% 까지선을그린다 (Line B). Line A와 Line B가이루는각도가 Dugdale 방법으로계획된교정각이다 (Fig. 4). 56) 3 체중부하단속촬영법 (weight bearing scanography) 을이용한방법 : 체중부하단속촬영을한후, 이를실제크기로출력한다. 절골술을시행할부분을자른후 62%-65% 사이로체중부하목표점이지나도록선을그리고회전시킨다. 절골술부분의크기를자를이용하여직접측정을하여교정정도를계획할수있다 (Fig. 5). 58) 4 수술중하지정렬을확인하는방법 : 수술을하는도중에수술전계획에맞게하지정렬교정이되는지를확인하는것이필요하다. 수술중하지정렬을확인하기위해 cable이나 rod를이용하는방법이고전적으로사용되고있으나정확도및재현성에문제점이있다. 최근사용되고있는항법장치시스템 (navigation system) 은수술중실시간으로해부학적위치에대한정보를제공하여원하고자하는교정각을보다정확하게얻을수있고, 오차범위및이상치를줄이며교정의정밀도를향상시킬수있는장점이있다 ) 하지만임상적인결과에대해서는추가적인연구및장기추시가필요하다. 5 최근소개되고있는방법들 : 최근의료영상저장전송시스템 Figure 5. Weight bearing scanography. A template was cut through the osteotomy site, and the tibia was rotated until the weight-bearing line passed through the 62% to 65% coordinate. (picture archiving and communication system, PACS) software나 Photoshop을이용하여 Miniaci 방법으로교정각을계산하는방법들이소개되고있다. PACS software나 Photoshop이널리보급되어쉽게접근이가능하고, 앞의방법들과는달리실제크기의출력물이필요하지않다는장점이있다 ) (4) 시상면에서술전교정계획후방경골경사가증가하면굴곡구축이발생하고경골의전방

5 287 Osteotomy around the Knee 전위및전방십자인대의인장력을증가시켜후방십자인대결손시나타나는경골의후방아탈구가감소하게된다. 반대로후방경골경사가감소하면과신전이발생하고후방전위및후방십자인대의인장력을증가시켜전방십자인대결손시나타나는경골의전방아탈구가감소하게된다. 64,65) 즉후방경골경사를조정하여굴곡구축및과신전과같은슬관절변형을교정할수있다는것을고려해야하겠다. 하지만후방경골경사가 10도이상증가하게되면전방십자인대에가해지는힘이 3배이상증가하므로주의해야한다. 66) 개방형근위경골절골술의경우후방경골경사가 3도정도증가하는경향을보인다. 이러한상황을피하기위해절골술부위의전후간격을 2:3 정도로벌려주는것이좋다. 67,68) 하지만만성후방십자인대손상이있는경우전후간격을비슷하게하는것이더좋은결과를기대할수있다. 이와는반대로폐쇄형근위경골절골술에서는후방경골경사가 3도정도감소하는경향이있고, 69) 만성십자인대손상이있는경우더좋은결과를기대할수있겠다. line view를찍어야한다. 또슬관절을완전히신전한상태에서하지정렬평가를위한양측장하지체중부하전후방촬영을반드시시행해야한다. 만약인대불안정성이의심되면스트레스촬영을시행할수있고, 교정각결정시인대이완을고려해야한다. (2) 원위대퇴골내반절골술의목표원위대퇴골절골술의교정각을결정하는방법에대해아직일치된의견은없다. 역학적대퇴경골각이 1-3도혹은해부학적대퇴경골각이 6-10도로역학적축이슬관절의내측을지날것을권장하거나하지의역학적축이슬관절의중심을지나는것이좋다는보고도있다. 22,77-81) 원위대퇴골절골술이생역학적으로신전상태를교정하는수술이기때문에, 굴곡상태에서증상호전을기대하기어렵다. 90도굴곡상태에서는대퇴골후방과에부하가걸리고, 이부분은대퇴원위절골술로교정되는부분이아니므로환자에게이에대한설명을미리하는것이좋다. (3) 술전교정계획원위대퇴골절골술의교정각은양측장하지체중부하전후방 3. 원위대퇴골내반절골술 1) 환자의선택원위대퇴골내반절골술의주된적응증은슬관절의외측구획에만국한된골관절염이외반변형과동반된경우이다 ) 또다른적응증으로는만성내측측부인대부전으로인한인대불안정성으로외반견인을감소하기위한경우가있고, 46) 외반변형으로인한슬개대퇴부정정렬을교정하기위해시행하는경우가있다. 73) 그외에도구루병, 신성이영양증, 소아마비, 기타외상이나근육신경질환에의한외반변형등에서고려해볼수있다. 22,74) 원위대퇴골내반절골술의 1차적응증은퇴행성관절염과외반변형이동반되어심한통증을호소하는경우지만최근에는인대재건술, 연골이식이나반월연골판동종이식등의수술에서수술후최상의결과를얻기위해함께시행되기도한다. 75) 환자는나이가 60세이하이고, 술전운동범위가 90도이상의굴곡이가능하고, 굴곡구축이 15도이하일때, 슬관절의불안정성이없는상태일때결과가좋다. 76) 통증의원인이슬개대퇴관절에있는경우, 외측구획뿐아니라내측구획에도관절염이있는경우, 내측구획반월연골판에손상이있는경우, 슬관절에감염성질환이있는경우, 수술후재활에협조가불가능할경우에는수술을시행하면좋은결과를기대하기어렵다. 76,77) 2) 수술전계획 (1) 방사선검사술전방사선적평가를위해여러촬영이필요하다. 먼저기본적인슬관절의진성전후면과측면촬영을시행하며, 슬관절양측구획의퇴행성변화를평가하기위해슬관절을 45도굴곡하여체중부하한상태에서후방에서전방으로촬영하는 Rogenberg view와 sky A B C A D B Figure 6. Bilateral weight bearing anteroposterior whole lower limb x-ray in full extension to plan the medial close-wedge distal femoral osteotomy. (A) The present mechanical axis is drawn from A, which is the center of the femoral head, to B, which is the center of the ankle joint. Line B C is of equal length as Line A B and passes the knee, just medial to the medial eminence, representing the desired postoperative mechanical axis. (B) The hinge point of the osteotomy D is marked just proximal to the upper border of the lateral condyle and cm within the lateral cortex. The angle of correction (α) is defined by Line A D between the present femoral head center and the hinge point and Line C D connecting the new femoral head center position and the hinge point. (C) Correction angle α is projected at the distal femur using two oblique, down-sloping lines of equal length converging at the hinge point. The distance measured between those two lines at the level of the medial cortex represents the osteotomy wedge base length, which is to be removed during surgery. C

6 288 Seung Wan Lim, et al. 촬영사진을통해결정할수있다. 대퇴골두의중심 A에서족관절의중심 B로역학적축을그린다 (Line A-B). 족관절의중심 B 에서술후원하는역학적축이경골과간융기바로내측지점을지나도록 Line B-C를그린다. 이때 Line A-B와 Line B-C의길이는동일해야한다. 대퇴골과상부외측인절골술의경첩점 D에서그린 Line A-D와 Line C-D가이루는각도가교정각 α가된다. 교정각 α를원위대퇴골에적용하였을때내측피질골위치에서두선이이루는사이간격이절골술에서제거되는쐐기기저부의길이가된다 (Fig. 6). 22,77) 4. 이중절골술관상면에서하지의축을교정할때단일절골술만시행하는경우, 과도한관절선경사를만들어관절면에전단부하를증가시킬수있다. 또한교정각도가 15도이상으로크고경골및대퇴골에모두변형이있는경우단일절골술만으로는좋은결과를기대하기어렵다. 82) 이러한경우고려할수있는이중절골술은근위경골절골술과원위대퇴골절골술을모두시행하는것으로 Benjamin 83) 이처음으로제안하였다. 수술전교정계획을위해체중부하단속촬영이필요하다. 체중부하단속촬영사진을실제크기로출력하고대퇴골과경골의변형을고려하여절골술을대퇴골과경골에서각각개방형으로할것인지혹은폐쇄형으로할것인지를결정한다. 84) 절골술을시행할부분을잘라대퇴골과경골의변형이교정되고하지정렬이회복되도록회전하여교정정도를결정할수있다 (Fig. 7). 또다 Figure 7. Double level osteotomy. A template was cut through each osteotomy site, and the femur and tibia were rotated until the weightbearing line passed through the 62% to 65% coordinate (Courtesy of Professor Dr. Seung-Beom Han, Department of Orthopaedic Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea). 른방법으로는 osteotomy analysis and simulation software (OASIS; Mayo Medical Ventures, Rochester, MN, USA) 를이용하여수술전계획을세우는방법도소개되고있다. 85) 결론 인공관절치환술은진행된슬관절의퇴행성관절염에서환자의증상을호전시키고술후빠른통증감소와짧은재활기간등의장점이있는우수한수술방법이다. 하지만모든환자를대상으로시행하기에는무리가있고특히젊고활동적이고슬관절의기능적요구가많은환자인경우더욱그러하다. 하지정렬이상을동반한단일구획관절염의치료에근위경골절골술과원위대퇴골절골술이좋은결과를보여주고있다. 3,5,77,86,87) 또단일절골술만으로만족할만한결과를얻기힘든경우이중절골술을고려해볼수도있다. 82) 물론이러한절골술을시행할때, 적절한환자의선택과철저한수술전계획이수술의성공을결정하는중요한요소라고할수있겠다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Nakagawa Y, Mukai S, Yabumoto H, Tarumi E, Nakamura T. Cartilage degeneration and alignment in severe varus knee osteoarthritis. Cartilage. 2015;6: Aglietti P, Rinonapoli E, Stringa G, Taviani A. Tibial osteotomy for the varus osteoarthritic knee. Clin Orthop Relat Res. 1983;176: Coventry MB. Proximal tibial varus osteotomy for osteoarthritis of the lateral compartment of the knee. J Bone Joint Surg Am. 1987;69: Insall JN, Joseph DM, Msika C. High tibial osteotomy for varus gonarthrosis. A long-term follow-up study. J Bone Joint Surg Am. 1984;66: McDermott AG, Finklestein JA, Farine I, Boynton EL, MacIntosh DL, Gross A. Distal femoral varus osteotomy for valgus deformity of the knee. J Bone Joint Surg Am. 1988;70: Morrey BF. Upper tibial osteotomy for secondary osteoarthritis of the knee. J Bone Joint Surg Br. 1989;71: Morrey BF, Edgerton BC. Distal femoral osteotomy for lateral gonarthrosis. Instr Course Lect. 1992;41:77-85.

7 289 Osteotomy around the Knee 8. Rinonapoli E, Mancini GB, Corvaglia A, Musiello S. Tibial osteotomy for varus gonarthrosis. A 10- to 21-year followup study. Clin Orthop Relat Res. 1998;353: Bonasia DE, Dettoni F, Sito G, et al. Medial opening wedge high tibial osteotomy for medial compartment overload/ arthritis in the varus knee: prognostic factors. Am J Sports Med. 2014;42: 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: Hunter DJ, Sharma L, Skaife T. Alignment and osteoarthritis of the knee. J Bone Joint Surg Am. 2009;91 Suppl 1: Amis AA. Biomechanics of high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2013;21: Leonardi F, Rivera F, Zorzan A, Ali SM. Bilateral double osteotomy in severe torsional malalignment syndrome: 16 years follow-up. J Orthop Traumatol. 2014;15: Yoo JD, Kim NK. Distal femoral varization osteotomy. J Korean Orthop Assoc. 2014;49: Hsu RW, Himeno S, Coventry MB, Chao EY. Normal axial alignment of the lower extremity and load-bearing distribution at the knee. Clin Orthop Relat Res. 1990;255: Moreland JR, Bassett LW, Hanker GJ. Radiographic analysis of the axial alignment of the lower extremity. J Bone Joint Surg Am. 1987;69: Tetsworth K, Paley D. Malalignment and degenerative arthropathy. Orthop Clin North Am. 1994;25: Fujisawa Y, Masuhara K, Shiomi S. The effect of high tibial osteotomy on osteoarthritis of the knee. An arthroscopic study of 54 knee joints. Orthop Clin North Am. 1979;10: Moore J, Mychaltchouk L, Lavoie F. Applicability of a modified angular correction measurement method for openwedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2017;25: Pape D, Rupp S. Preoperative planning for high tibial osteotomies. Oper Tech Orthop. 2007;17: Brown GA, Amendola A. Radiographic evaluation and preoperative planning for high tibial osteotomies. Oper Tech Sports Med. 2012;20: Brinkman JM, Lobenhoffer P, Agneskirchner JD, Staubli AE, Wymenga AB, van Heerwaarden RJ. Osteotomies around the knee: patient selection, stability of fixation and bone healing in high tibial osteotomies. J Bone Joint Surg Br. 2008;90: Flecher X, Parratte S, Aubaniac JM, Argenson JN. A year followup study of closing wedge high tibial osteotomy. Clin Orthop Relat Res. 2006;452: Khoshbin A, Sheth U, Ogilvie-Harris D, et al. The effect of patient, provider and surgical factors on survivorship of high tibial osteotomy to total knee arthroplasty: a population-based study. Knee Surg Sports Traumatol Arthrosc. 2017;25: Naudie D, Bourne RB, Rorabeck CH, Bourne TJ. The Install Award. Survivorship of the high tibial valgus osteotomy. A 10- to -22-year followup study. Clin Orthop Relat Res. 1999;367: Trieb K, Grohs J, Hanslik-Schnabel B, Stulnig T, Panotopoulos J, Wanivenhaus A. Age predicts outcome of high-tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2006;14: Goshima K, Sawaguchi T, Sakagoshi D, Shigemoto K, Hatsuchi Y, Akahane M. Age does not affect the clinical and radiological outcomes after open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2017;25: Odenbring S, Egund N, Knutson K, Lindstrand A, Larsen ST. Revision after osteotomy for gonarthrosis. A year follow-up of 314 cases. Acta Orthop Scand. 1990;61: van Raaij T, Reijman M, Brouwer RW, Jakma TS, Verhaar JN. Survival of closing-wedge high tibial osteotomy: good outcome in men with low-grade osteoarthritis after years. Acta Orthop. 2008;79: Shin YS, Lee DH, Lee SH, Kim MJ, Han SB. Basic principles and current trends of medial opening-wedge high tibial osteotomy. J Korean Orthop Assoc. 2014;49: Nwachukwu BU, McCormick FM, Schairer WW, Frank RM, Provencher MT, Roche MW. Unicompartmental knee arthroplasty versus high tibial osteotomy: United States practice patterns for the surgical treatment of unicompartmental arthritis. J Arthroplasty. 2014;29: Fu D, Li G, Chen K, Zhao Y, Hua Y, Cai Z. Comparison of high tibial osteotomy and unicompartmental knee arthroplasty in the treatment of unicompartmental osteoarthritis: a meta-analysis. J Arthroplasty. 2013;28: W-Dahl A, Toksvig-Larsen S, Lindstrand A. Ten-year results of physical activity after high tibial osteotomy in patients with knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc. 2017;25: W-Dahl A, Robertsson O, Lidgren L. Surgery for knee osteoarthritis in younger patients. Acta Orthop. 2010;81: Börjesson M, Weidenhielm L, Mattsson E, Olsson E. Gait

8 290 Seung Wan Lim, et al. and clinical measurements in patients with knee osteoarthritis after surgery: a prospective 5-year follow-up study. Knee. 2005;12: Stukenborg-Colsman C, Wirth CJ, Lazovic D, Wefer A. High tibial osteotomy versus unicompartmental joint replacement in unicompartmental knee joint osteoarthritis: 7-10-year follow-up prospective randomised study. Knee. 2001;8: Bonnin M, Chambat P. Current status of valgus angle, tibial head closing wedge osteotomy in media gonarthrosis. Orthopade. 2004;33: Kumagai K, Akamatsu Y, Kobayashi H, Kusayama Y, Koshino T, Saito T. Factors affecting cartilage repair after medial opening-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2017;25: Pape D, Seil R, Adam F, Rupp S, Kohn D, Lobenhoffer P. Imaging and preoperative planning of osteotomy of tibial head osteotomy. Orthopade. 2004;33: Ahlbäck S. Osteoarthrosis of the knee. A radiographic investigation. Acta Radiol Diagn (Stockh). 1968;Suppl 277: Murphy SB. Tibial osteotomy for genu varum. Indications, preoperative planning, and technique. Orthop Clin North Am. 1994;25: Berman AT, Bosacco SJ, Kirshner S, Avolio A Jr. Factors influencing long-term results in high tibial osteotomy. Clin Orthop Relat Res. 1991;272: Akizuki S, Shibakawa A, Takizawa T, Yamazaki I, Horiuchi H. The long-term outcome of high tibial osteotomy: a ten- to 20-year follow-up. J Bone Joint Surg Br. 2008;90: Nha KW, Kim HJ, Ahn HS, Lee DH. Change in posterior tibial slope after open-wedge and closed-wedge high tibial osteotomy: a meta-analysis. Am J Sports Med. 2016;44: Naudie DD, Amendola A, Fowler PJ. Opening wedge high tibial osteotomy for symptomatic hyperextension-varus thrust. Am J Sports Med. 2004;32: Phisitkul P, Wolf BR, Amendola A. Role of high tibial and distal femoral osteotomies in the treatment of lateral-posterolateral and medial instabilities of the knee. Sports Med Arthrosc. 2006;14: Arthur A, LaPrade RF, Agel J. Proximal tibial opening wedge osteotomy as the initial treatment for chronic posterolateral corner deficiency in the varus knee: a prospective clinical study. Am J Sports Med. 2007;35: Giagounidis EM, Sell S. High tibial osteotomy: factors influencing the duration of satisfactory function. Arch Orthop Trauma Surg. 1999;119: Lee YS, Lee BK, Lee SH, Park HG, Jun DS, Moon DH. Effect of foot rotation on the mechanical axis and correlation between knee and whole leg radiographs. Knee Surg Sports Traumatol Arthrosc. 2013;21: Lee YS, Lee BK, Kwon JH, et al. Serial assessment of weight-bearing lower extremity alignment radiographs after open-wedge high tibial osteotomy. Arthroscopy. 2014;30: Sancheti P, Patil K, Gugale S, Shyam A. How can preoperative planning prevent occurrence of a painful total knee replacement? In: Hirschmann MT, Becker R, ed. The unhappy total knee replacement. Cham: Springer; Phillips CL, Silver DA, Schranz PJ, Mandalia V. The measurement of patellar height: a review of the methods of imaging. J Bone Joint Surg Br. 2010;92: Coventry MB. Upper tibial osteotomy for osteoarthritis. J Bone Joint Surg Am. 1985;67: Hernigou P, Medevielle D, Debeyre J, Goutallier D. Proximal tibial osteotomy for osteoarthritis with varus deformity. A ten to thirteen-year follow-up study. J Bone Joint Surg Am. 1987;69: Miniaci A, Ballmer FT, Ballmer PM, Jakob RP. Proximal tibial osteotomy. A new fixation device. Clin Orthop Relat Res. 1989;246: Dugdale TW, Noyes FR, Styer D. Preoperative planning for high tibial osteotomy. The effect of lateral tibiofemoral separation and tibiofemoral length. Clin Orthop Relat Res. 1992;274: Jakob RP, Jacobi M. Closing wedge osteotomy of the tibial head in treatment of single compartment arthrosis. Orthopade. 2004;33: Lee DH, Han SB, Oh KJ, et al. The weight-bearing scanogram technique provides better coronal limb alignment than the navigation technique in open high tibial osteotomy. Knee. 2014;21: Akamatsu Y, Mitsugi N, Mochida Y, et al. Navigated opening wedge high tibial osteotomy improves intraoperative correction angle compared with conventional method. Knee Surg Sports Traumatol Arthrosc. 2012;20: Reising K, Strohm PC, Hauschild O, et al. Computer-assisted navigation for the intraoperative assessment of lower limb alignment in high tibial osteotomy can avoid outliers compared with the conventional technique. Knee Surg Sports

9 291 Osteotomy around the Knee Traumatol Arthrosc. 2013;21: Elson DW, Petheram TG, Dawson MJ. High reliability in digital planning of medial opening wedge high tibial osteotomy, using Miniaci's method. Knee Surg Sports Traumatol Arthrosc. 2015;23: Lee DH, Nha KW, Park SJ, Han SB. Preoperative and postoperative comparisons of navigation and radiologic limb alignment measurements after high tibial osteotomy. Arthroscopy. 2012;28: Yoon SD, Zhang G, Kim HJ, Lee BJ, Kyung HS. Comparison of cable method and miniaci method using picture archiving and communication system in preoperative planning for open wedge high tibial osteotomy. Knee Surg Relat Res. 2016;28: 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: Dean CS, Liechti DJ, Chahla J, Moatshe G, LaPrade RF. Clinical outcomes of high tibial osteotomy for knee instability: a systematic review. Orthop J Sports Med. 2016;4: Dejour H, Bonnin M. Tibial translation after anterior cruciate ligament rupture. Two radiological tests compared. J Bone Joint Surg Br. 1994;76: Chae DJ, Shetty GM, Lee DB, Choi HW, Han SB, Nha KW. Tibial slope and patellar height after opening wedge high tibia osteotomy using autologous tricortical iliac bone graft. Knee. 2008;15: Ogawa H, Matsumoto K, Ogawa T, Takeuchi K, Akiyama H. Effect of wedge insertion angle on posterior tibial slope in medial opening wedge high tibial osteotomy. Orthop J Sports Med. 2016;4: Bae DK, Ko YW, Kim SJ, Baek JH, Song SJ. Computer-assisted navigation decreases the change in the tibial posterior slope angle after closed-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2016;24: Sharma L, Song J, Felson DT, Cahue S, Shamiyeh E, Dunlop DD. The role of knee alignment in disease progression and functional decline in knee osteoarthritis. JAMA. 2001;286: Stähelin T, Hardegger F, Ward JC. Supracondylar osteotomy of the femur with use of compression. Osteosynthesis with a malleable implant. J Bone Joint Surg Am. 2000;82: Chahla J, Mitchell JJ, Liechti DJ, et al. Opening- and closing-wedge distal femoral osteotomy: a systematic review of outcomes for isolated lateral compartment osteoarthritis. Orthop J Sports Med. 2016;4: Hinterwimmer S, Rosenstiel N, Lenich A, Waldt S, Imhoff AB. Femoral osteotomy for patellofemoral instability. Unfallchirurg. 2012;115: Niklasch M, Dreher T, Döderlein L, et al. Superior functional outcome after femoral derotation osteotomy according to gait analysis in cerebral palsy. Gait posture. 2015;41: Kazi HA, Abdel-Rahman W, Brady PA, Cameron JC. Meniscal allograft with or without osteotomy: a 15-year follow-up study. Knee Surg Sports Traumatol Arthrosc. 2015;23: Wang JW, Hsu CC. Distal femoral varus osteotomy for osteoarthritis of the knee. J Bone Joint Surg Am. 2005;87: Thein R, Bronak S, Thein R, Haviv B. Distal femoral osteotomy for valgus arthritic knees. J Orthop Sci. 2012;17: Backstein D, Morag G, Hanna S, Safir O, Gross A. Long-term follow-up of distal femoral varus osteotomy of the knee. J Arthroplasty. 2007;22:S Finkelstein JA, Gross AE, Davis A. Varus osteotomy of the distal part of the femur. A survivorship analysis. J Bone Joint Surg Am. 1996;78: Franco V, Cipolla M, Gerullo G, Gianni E, Puddu G. Open wedge osteotomy of the distal femur in the valgus knee. Orthopade. 2004;33: Mathews J, Cobb AG, Richardson S, Bentley G. Distal femoral osteotomy for lateral compartment osteoarthritis of the knee. Orthopedics. 1998;21: Paley D, Pfeil J. Principles of deformity correction around the knee. Orthopade. 2000;29: Benjamin A. Double osteotomy for the painful knee in rheumatoid arthritis and osteoarthritis. J Bone Joint Surg Br. 1969;51: Archbold P, Verdonk P, Servien E. Surgical technique for a double osteotomy. In: Neyret P, Demey G, ed. Surgery of the Knee. London: Springer; Babis GC, An KN, Chao EY, Rand JA, Sim FH. Double level osteotomy of the knee: a method to retain joint-line obliquity. Clinical results. J Bone Joint Surg Am. 2002;84: Magyar G, Toksvig-Larsen S, Alkstedt J, et al. Frequent complications in distal femoral osteotomy: a retrospective 8 year multicenter follow-up. Chir Organi Mov. 1999;84: Terry GC, Cimino PM. Distal femoral osteotomy for valgus deformity of the knee. Orthopedics. 1992;15:1283-9; discussion

10 292 pissn : , eissn : Symposium J Korean Orthop Assoc 2018; 53: 슬관절주위절골술의최신지견 슬관절주위절골술 : 적응증및수술전계획 임승완 류승민 손욱진 영남대학교병원정형외과 슬관절골관절염과하지정렬이상이동반된경우슬관절주위절골술을고려할수있다. 슬관절내반변형의경우근위경골절골술을, 슬관절외반변형의경우원위대퇴골절골술을선택하여교정을하는것이절골술의기본적인원칙으로알려져있다. 그러나단일절골술만으로불가능할경우이중절골술도고려해볼수있다. 본종설에서는슬관절주위절골술을시행함에있어환자의선택및수술전계획의원칙과최신지견에대해살펴보고자한다. 색인단어 : 슬관절, 관절염, 절골술 접수일 2016 년 11 월 28 일수정일 2017 년 1 월 12 일게재확정일 2017 년 3 월 22 일책임저자손욱진 42415, 대구시남구현충로 170, 영남대학교병원정형외과 TEL , FAX , maestro-jin@hanmail.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.