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1 대한골절학회지제 22 권, 제 4 호, 2009년 10월 Journal of the Korean Fractrure Society Vol. 22, No. 4, October, 2009 종설 원위경골골절 : 금속판고정술 (Distal Tibia Fracture: Plate Osteosynthesis) 이근배 전남대학교의과대학정형외과학교실 서 원위경골골절은고에너지에의한굴곡력과회전력에의해주로발생하므로분쇄정도가심하고수포, 종창, 압궤손상및구획증후군, 혈관손상등의연부조직손상이동반되는경우가많다 12). 또한골절의약 10 30% 가개방성골절이고 10), 경골내측부위의얇은연부조직은내부의골절편에의해쉽게손상을받을수있으며골절편의정복후에도피부괴사및감염등이잘발생하여그에따른지연유합, 불유합및골수염등의합병증이흔하다. 따라서이러한합병증을줄이고자하는방향으로많은치료방법들이사용되어왔으나성공적인수술결과를얻기에는여전히치료가어려운골절로알려져있다 10). 수술방법으로는외고정장치를이용한방법과금속판내고정술또는골수강내금속정고정술등이있다. 외고정장치를이용한치료법의경우심한연부조직손상을동반한개방성골절에서사용할수있으나, 잦은나사못주위감염및부정정렬, 족관절강직등의한계를지니고있다. 골수강내금속정고정술은일반적으로연부조직손상이적고견고한고정으로조기재활이가능하다는장점이있으나, 원위경골부위는특징적인모래시계형태의골수강을가지고있어금속정을이용한견고한고정이어려우므로부정정렬이나불유합등이생길수있고금속정삽입부의전방슬관절동통이나타나는단점이있다 2). 금속판내고정술은고식적인금속판을사용하는경우정확한골절편의정복을통한견고한고정이가능하나, 외상에의한골절부의연부조직손상부위에수술로인한광범위한피부절개및골막의박리로미세순환손상이추가되어감염및지연유합, 불유합의발생률이높다 1,5). 론 이러한합병증을줄이고자하는노력으로대두된최소침습적금속판고정술 (MIPO) 은생물학적고정및간접정복의기법을이용함으로써연부조직손상을최소화하고골절부위혈류손상을줄임으로써기존술식으로인한감염, 골유합지연등의합병증을크게줄이고높은골유합률을얻는것으로보고되고있다 15). 최근에는잠김압박금속판을사용하여골절부위에압박력을최소화하고골막의혈액순환을보존할수있으며, 이를해부학적형태로가공한금속판의사용으로해당골절부위에보다쉽게위치시킬수있고고정력을증대시킴으로써합병증을줄이고높은골유합률을얻을수있는것으로알려져있다. 이에본종설에서는원위경골골절에대하여해부학적잠김압박금속판을이용한최소침습적금속판고정술의수술술기와주의점및결과, 합병증등에대하여기술하고자한다. 수술술기 1. 초기처치및치료방법결정 원위경골골절의경우, 연부조직손상을동반할때일차적인골고정술이매우중요하다. 단순골절인경우즉각적인내고정술이가능하지만, 심한연부조직손상을동반한경우에는환자의전신상태및동반손상의정도에따라일차적으로외고정기혹은골견인술을통하여골절의정렬및일시적고정을유지하고 (Fig. 1) 수상후약 7 14 일이경과하여종창의감소 (wrinkle sign) 및연부조직손상이회복되면이차적으로최소침습적금속판고정술을시행하는것이필요하다 10). 통신저자 : 이근배광주시동구학동 8 번지전남대학교의과대학정형외과학교실 Tel: ㆍ Fax: kbleeos@chonnam.ac.kr Address reprint requests to:keun Bae Lee, M.D., Ph.D. Department of Orthopedic Surgery, Chonnam National University Medical School and Hospital, 8, Hak-dong, Dong-gu, Gwangju , Korea Tel: ㆍ Fax: kbleeos@chonnam.ac.kr 306

$(A) A man was sustained distal tibia fracture with severe soft tissue swelling and blister.$ $(B) A temporary external fixator was applied to reduce the fracture and to maintain the length and$ Fig. 2. (A) Medial and (B) anterolateral distal tibia locking plate (Synthes R, Zimmer R ).

Fig. 2. (A) Medial and (B) anterolateral distal tibia locking plate (Synthes R, Zimmer R ).

금속판의준비 술전계획으로건측하지의단순방사선영상을토대로골절부위에사용할금속판의크기, 길이, 위치및곡률 (curvature) 을결정하는것이중요하다.

최근에는원위경골의해부학적구조에맞게제작된잠김압박금속판 (LCP-DTP) 의사용이보편화되고있다 (Fig. 2).

금속판의길이는골절부를충분히수용할수있는길이의것을사용하며, 보통골절부길이의 2 3

2 원위경골골절 : 금속판고정술 307 Fig. 1. (A) A man was sustained distal tibia fracture with severe soft tissue swelling and blister. (B) A temporary external fixator was applied to reduce the fracture and to maintain the length and alignment of the limb. (C) A skeletal traction with calcaneal Steinmann pin was applied temporarily. Fig. 2. (A) Medial and (B) anterolateral distal tibia locking plate (Synthes R, Zimmer R ). (C) Application of periarticular distal tibia locking plate system (from Synthes R ). 2. 금속판의준비 술전계획으로건측하지의단순방사선영상을토대로골절부위에사용할금속판의크기, 길이, 위치및곡률 (curvature) 을결정하는것이중요하다. 금속판의곡률은과상부의해부학적형태복원, 내 / 외반및삽입물과골의불일치로인한회전부정배열을방지하는데중요하다 2). 최근에는원위경골의해부학적구조에맞게제작된잠김압박금속판 (LCP-DTP) 의사용이보편화되고있다 (Fig. 2). LCP-DTP 를이용하기어려운상황이라면기존의잠김압박금속판을굽힘기를이용하여미리해부학적형태로맞추어사용할수있다. 금속판의길이는골절부를충분히수용할수있는길이의것을사용하며, 보통골절부길이의 2 3 배길이를선택한다. 3. 환자의위치 동반손상의종류에따라약간의차이가있을수있으나 일반적으로원위경골골절의경우엔환자를방사선투영이가능한수술대에앙와위로위치시킨다음환측의둔부밑에쿠션을놓아하지의슬관절과족관절이중립위치가되게정렬하는것이중요하다. 소독전에영상증폭기를이용하여슬관절을포함하는하지의정렬상태를수술중확인가능한지체크한후, 환측의전체하지를소독한다. 지혈대는보통 300 mmhg 까지사용한다 9,10). 4. 골절의정복 골절의분쇄가심하고광범위하여바른정렬이어렵거나단축이심한경우에는일시적으로대퇴견인장치를이용하면보다쉽게수술이가능해진다. 그리고원위경골골절의대부분에서비골골절이동반되는데이경우에는 1/3 관상금속판을이용한비골고정술을먼저시행하는것이외측안정성유지와경골의정확한길이회복및골절부위의과도한신연을방지할수있다는점에서중요하다 10). 만약골절이골간단부에서골간부로확장되어전위된경

(B) First, fix the fibula taking care to

$stability of the ankle fracture.$ (C) Directly reduce the fragment using

(D) Holding the fragment by pointed forcep,

through limited approaches to buttress a

$fracture.$ (C) Minimal skin incisions were shown

invasive percutaneous insertion of the LCP

$reduced fracture site was verified by$ fluoroscopy.

3 308 이근배 Fig. 3. (A) Apply femoral distractor to correct axial malalignment and to maintain the length. (B) First, fix the fibula taking care to restore length, alignment and rotation. Also, the fibula is fixed to increase the stability of the ankle fracture. (C) Directly reduce the fragment using pointed forcep. (D) Holding the fragment by pointed forcep, insert interfragmenary lag screw before plating. (E) An additional T-plate was applied through limited approaches to buttress a large metaphyseal defect. Fig. 4. (A, B) A 47 year-old man had distal tibia fracture. (C) Minimal skin incisions were shown proximally and distally on the medial side of tibia. (from AO surgery reference) (D, E) Minimally invasive percutaneous insertion of the LCP using drill sleeve on distal tibia. The location and size of plate, and the reduced fracture site was verified by fluoroscopy. (F) The compression screw can be used through the conventional hole for plate adjustment. (G) Interfragmentory lag screw was inserted under fluoroscopic guidance. (H) Skin incisions were determined minimally under fluoroscopic guidance for screw fixation. (I, J) 4 months after operation, the distal tibia fracture was achieved adequate reduction and bony union.

원위경골골절 : 금속판고정술 309 우라면끝이뾰쪽한집게 (pointed focep)

4 원위경골골절 : 금속판고정술 309 우라면끝이뾰쪽한집게 (pointed focep) 를이용하여골절을직접정복한상태에서지연나사를이용하여고정하면금속판고정이훨씬쉬워진다. 관절내골절편이있을경우에는연부조직손상을최소화하는방법으로관혈적정복을시행하고골절편은지연나사를사용하여고정해준다. 원위경골부의골결손및분쇄정도가심할경우엔추가적으로 T 형금속판및기타금속판을사용함으로써지지대역할을해주는것이필요하다 (Fig. 3) 10). 5. 금속판의고정 내측금속판을사용할경우경골내과의근위부에약 2 3 cm 의피부절개를가한후, 이곳을통하여드릴슬리브 (drill sleeve) 가부착된금속판을피하조직과골막사이로밀어넣은후위치시킨다. 금속판의양끝이위치하는부 Fig. 5. Partial weight-bearing was permitted by applying Ankle-Foot-Orthosis. Fig. 6. (A, B) A 26 year-old man was stained distal tibia and fibular open fractures. (C, D) A temporary external fixator was applied immediately to maintain the alignment due to severe soft tissue injury. (E) The Vacuum Assisted Closure (VAC) device was used to facilitate wound healing by converting an open wound to a closed wound. 4 weeks after applying Wound VAC, granulation tissue was formed and wound was closed. (F) Immediate postoperative x-ray, the distal tibia and fibular fracture achieved adequate reduction. (G, H, I, J) The patient had a good bony union and clinical outcomes.

310 이근배 위에동시에피부절개를가하여드릴슬리브를부착시켜금속판을조정하면정렬하기가용이하다.

5 310 이근배 위에동시에피부절개를가하여드릴슬리브를부착시켜금속판을조정하면정렬하기가용이하다. 임상적으로는절개부위를통해볼수있는금속판의앞쪽가장자리가경골간부의전방피질골에서약 5 10 mm 뒤쪽에위치토록하면바른정열이되어있음을의미한다. 외측금속판을사용할경우족관절전외측접근법으로족관절에서 1 cm 상방에서근위부로 2 3 cm 가량의종절개를가하고족무지신전건외측에서신전지대를절개한후이를내측으로견인하여경골을노출시킨후금속판을삽입한다. 영상증 폭기를통하여골절의정복상태, 금속판의위치및길이, 전반적인정렬상태등을점검한후에순서에따라작은절개를통하여나사못을삽입한다. 일반적으로는원위부와근위부에먼저나사못을위치시킨후정렬상태를확인하면서순차적으로나사못을고정한다. 보통골절근위부와원위부에각각최소한 3 개이상의나사못을고정하여 6 개의피질골을잡는것이안정성및골유합을위해권장된다. 골편의정복이부족한경우에는금속판을통한지연나사나골편간나사를이용하면만족스런정복이가능해진다 (Fig. 4). Fig. 7. (A, B) A 40 year-old man was sustained distal tibia comminuted fracture combined with distal tibiofibular joint comminution caused by falling down. (C, D) Immediate operation was impossible due to medical comorbidity, so calcaneal traction was applied temporarily. (E, F) The fracture was treated with percutaneous plating using LCP-MP on medial side at 2 weeks after injury. (G) Clinical photo showed multiple minimal incisions intraoperatively. (H, I, J) A successful union was achieved with a good functional outcome.

6 원위경골골절 : 금속판고정술 수술후처치및재활 수술후발생하는종창을줄이기위해서는, 술후약 7 10 일동안은압박붕대고정과석고부목고정, 하지거상및얼음마사지가필요하다 4). 골절이관절을침범하지않은경우에는통증이없는한술후가능한빨리족관절관절운동을시작하며, 술후약 2 3 주후부터는석고부목을제거하고족관절족부보장구 (Ankle-Foot-Orthosis) 를착용하면서부분체중부하를시작한다 (Fig. 5). 술후약 8 주정도경과하여골유합소견이관찰되는시기가되면, 보장구착용하에전체중부하를허용한다 14). 관절내골절이있는경우는수술부위상처가치유된후, 약 2 3 주간추가적으로단하지석고붕대고정을시행하고, 부분체중부하는술후약 4 6 주후부터보장구를착용한상태에서시작한다 14). 결 최근 10 년동안원위경골골절에대하여최소침습적금속판고정술을시행한경우의문헌들을분석한결과, 총 213 예중 89.7% (80 100%) 에서일차골유합을보였다 (Fig. 6, 7). 모두경골내측금속판을이용하여치료한결과들로서, 합병증으로는지연유합, 불유합, 부정정렬, 각변형, 가관절증, 금속판변형및불편감등이보고되었다 (Table 1). 합병증 원위경골골절의치료후합병증으로는피부괴사와감염, 부정유합, 지연유합및불유합등이있다. 그중가 과 장심각한합병증중하나가술후감염으로, Lau 등 12) 은 48 명의원위경골골절환자를대상으로잠김압박금속판을이용한최소침습적금속판고정술을시행후 1 예의초기감염과 7 예의후기감염을보고하였는데, 환자에따라절개및변연절제술과항생제투여를시행하여모든환자에서적절한골유합을얻은후금속판을제거하였다고보고하였다. 또한 Arens 등 1) 은토끼를대상으로금속판고정술후다양한농도의포도상구균을투여하여감염의발생에대해연구하였는데, 관혈적고정술을시행한경우전체의 38.5% 에서술후감염을보인데반해 MIPO 술식을이용한경우에서는 25.0% 로현저히낮은감염률을보였다고보고하였다. 이들은최소침습적금속판고정술이연부조직의손상을줄이고골절부위조직의연속성을유지하여골막혈액순환을보존함으로써감염에대해저항성을갖게된것이원인인것으로해석하였다 (Fig. 8) 12). Hazarika 등 8) 은술후빠른체중부하로인하여 10% 의불유합및 5% 의금속판파손을보고하고있으며, 부정확한비골정복은경골의내 / 외반변형을일으킬수있다고하였다. 과거약 10% 의술후금속판자극증상에의한불편감이보고되고있으나, 최근금속판재질의꾸준한개발로얇은금속판의사용이가능해져이러한합병증은줄어들었다 3). 요 원위경골골절에서고식적금속판고정술은골수강내금속정고정술에비하여견고한고정이가능하며부정유합등의합병증이적으나골절편의정복및금속판삽입을위한광범위한절개로인하여감염및골유합장애등의심각한합병증이보고되어왔다. 하지만해부학적잠김압박 약 Table 1. Literature reviews on outcomes and complications of MIPO for distal tibia fractures Studies Cases Approach & Implant Outcomes Complications Oh et al, ) Francois et al, ) Borg et al, ) Maffulli et al, ) Redfern el al, ) Krackhardt et al, ) Hazarika et al, ) Hasenboehle et al, ) Medial, Precontoured LC-DCP Medial, AO LCP-DT Medial, Precontoured LC-DCP Medial, AO LCP-DT Medial, Precontoured LC-DCP Medial, Precontoured LC-DCP or titanum T-plate Medial, AO LCP-DT Medial, AO LCP-DT Primary union (21) Primary union (10) Primary union (17) Primary union (19) Primary union (20) Primary union (69) Primary union (16) Primary union (29) 1 rotational malunion 2 required bone grafting 2 malreductions required revision 2 metal irritation 7 of angular deformity of 7 10 o 1 varus malunion 2 malunion with instability 2 nonunions, 2 required bone grafting, 1 metal breakage required revision 2 pseudoarthrosis required revision, 1 metal bending required revision Total (89.7%)

$(A) A 53 year-old man was sustained proximal and distal tibia open comminuted fractures by traffic$ $(D) The fractures were treated with MIPO using LCP- DTP on medial side at 3 weeks after injury.$ (E) Delayed infection was developed at primary open site and plate was exposed at 2 months

(E) Delayed infection was developed at primary open site and plate was exposed at 2 months

(G, H, I) A successful union was achieved at 9 months postoperatively, with a good functional outcome.

연부조직의손상을최소화하고골절편으로의혈류를보존하며금속판과나사못의고정력이향상됨으로써골유합률을높이고기존의술식으로인한합병증을줄일수있는효과적인수술방법이라생각한다.

infection in biological internal fixation.

$2) Bedi A, Le TT, Karunakar MA: Surgical treatment of nonarticular distal tibia fractures.$ $3) Borg T, Larsson S, Lindsjö U: Percutaneous plating of distal tibial fractures.$ $4) Collinge C, Sanders R, DiPasquale T: Treatment of complex tibial periarticular fractures using$

7 312 이근배 Fig. 8. (A) A 53 year-old man was sustained proximal and distal tibia open comminuted fractures by traffic accident. (B, C) Spanning external fixator was applied immediately to maintain the alignment. (D) The fractures were treated with MIPO using LCP- DTP on medial side at 3 weeks after injury. (E) Delayed infection was developed at primary open site and plate was exposed at 2 months postoperatively. (F) Patient underwent curettage and antibiotic bead insertion without plate removal. (G, H, I) A successful union was achieved at 9 months postoperatively, with a good functional outcome. 금속판을이용한최소침습적술식을적용하면골, 연부조직의손상을최소화하고골절편으로의혈류를보존하며금속판과나사못의고정력이향상됨으로써골유합률을높이고기존의술식으로인한합병증을줄일수있는효과적인수술방법이라생각한다. 참고문헌 1) Arens S, Kraft C, Schleqel U, Printzen G, Perren SM, Hansis M: Susceptibility to local infection in biological internal fixation. Experimental study of open vs minimally plate osteosynthesis in rabbits. Arch Orthop Trauma Surg, 119: 82-85, ) Bedi A, Le TT, Karunakar MA: Surgical treatment of nonarticular distal tibia fractures. J Am Acad Orthop Surg, 14: , ) Borg T, Larsson S, Lindsjö U: Percutaneous plating of distal tibial fractures. Preliminary results in 21 patients. Injury, 6: , ) Collinge C, Sanders R, DiPasquale T: Treatment of complex tibial periarticular fractures using percutaneous techniques. Clin Orthop Relat Res, 375: 69-77, ) Foux A, Yeadon AJ, Uhthoff HK: Improved fracture healing with less rigid plates. A biomechanical study in dogs. Clin Orthop Relat Res, 339: , ) Francois J, Vandeputte G, Verheyden F, Nelen G: Percutaneous plate fixation of fractures of the distal tibia. Acta Orthop Belg, 70: , ) Hasenboehler E, Rikli D, Babst R: Locking compression plate with minimally invasive plate osteosynthesis in dia-

8 원위경골골절 : 금속판고정술 313 physeal and distal tibial fracture: a retrospective study of 32 patients. Injury, 3: , ) Hazarika S, Chakravarthy J, Cooper J: Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients. Injury, 9: , ) Helfet DL, Shonnard PY, Levine D, Borrelli J Jr: Minimally invasive plate osteosynthesis of distal fractures of the tibia. Injury, 28: A42-47, ) Helfet DL, Suk M: Minimally invasive percutaneous plate osteosynthesis of fractures of the distal tibia. Instr Course Lect, 53: , ) Krackhardt T, Dilger J, Flesch I, Höntzsch D, Eingartner C, Weise K: Fractures of the distal tibia treated with closed reduction and minimally invasive plating. Arch Orthop Trauma Surg, 125: 87-94, ) Lau TW, Leung F, Chan CF, Chow SP: Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures. Int Orthop, 32: , ) Maffulli N, Toms AD, McMurtie A, Olive F: Percutaneous plating of distal tibial fractures. Int Orthop, 3: , ) Oh CW, Kyung HS, Park IH, Kim PT, Ihn JC: Distal tibia metaphyseal fractures treated by percutaneous plate osteosynthesis. Clin Orthop Relat Res, 408: , ) Redfern DJ, Syed SU, Davies SJ: Fractures of the distal tibia: minimally invasive plate osteosynthesis. Injury, 6: , 2004.

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untitled 대한골절학회지제 23 권, 제 1 호, 2010 년 1 월 Journal of the Korean Fractrure Society Vol. 23,. 1, January, 2010 원위경골골절에서외측금속판을이용한최소침습적경피적금속판골유합술 손욱진ㆍ김대성 영남대학교의학대학정형외과학교실 목적 : 원위관절면에서 3 cm 내에위치하고내측연부조직의손상이동반된원위경골골절에서외측금속판