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1 대한족부족관절학회지 : 제 8 권제 호 4 J Korean Foot Ankle Soc. Vol 8. No.. pp.86-9, 4 한전의료재단한일병원정형외과 라종득 박현수 임창석 장영수 박상원 정태원 전용수 Comparison of the Results after the Surgical Treatments of the Trimalleolar Ankle Fractures Jong-Deuk Rha, M.D., Hyun-Soo Park, M.D., Chang-Suk Lim, M.D., Yeung-Soo Jang, M.D., Sang-Won Park, M.D., Tae-Won Chung, M.D., Yong-Soo Jeon, M.D. Department of Orthopaedic Surgery, Hanil General Hospital, Seoul, Korea =Abstract= Purpose: To evaluate the methods and results of the surgical treatment in the trimalleolar fracture of the ankle. Materials and Methods: We analysed the results of the ankle trimalleolar fracture which were treated with open reduction and internal fixation from January 999 till September 3. There were 45 patients who had at least six months follow up, 6 men, and 9 women. We have analysed the mechanism of injury, methods of operation and postoperative complications. Results: The results were assessed on ankle AP, lateral and mortise X-rays and retrospective chart review. There were 3 supination-external rotation, 3 pronation-external rotation, pronation-abduction in the mechanism of injury by Lauge-Hansen classification. Cases of the posterior malleolar fracture which involved more than 5% of the weight bearing surface were 7 (5.6%). Medial malleolar mono-fixation was done in 5 cases, fibular mono-fixation in cases, bimalleolar fixation in 3 cases, trimalleolar fixation in 6 cases. 38 cases (84.4%) were good or excellent in clincal assessment and 39 cases (86.7%) were good or excellent in radiological assessment according to the criteria of the Meyer. There was no difference of results among the surgical treatment methods. Conclusion: The results of our study indicate that the rigid fixation with early ankle motion and weight bearing is needed in ankle trimalleolar fracture. But minimal fixation is not bad in slight displaced fracture. Both anterior approach and posterior approach were useful methods to stabilization the posterior malleolar fracture. And pre-operative evaluation to detect the hidden soft tissue injuries and fracture mechanism is very important to avoid the failure. Key Words: Trimalleolar fracture, Posterior malleolar fracture, Surgical treatment Address for correspondence Chang-Suk Lim, M.D Ssangmoon-3-dong, Dobong-gu, Seoul, 3-33, Korea Department of Orthopaedic Surgery, Hanil General Hospital Tel: Fax: internetmind@hanmail.net * 본논문의요지는 4 대한족부외과학회춘계학술대회에서구연발표되었음. 서론족관절은기립및보행에중요한역할을담당하는복잡한해부학적구조의하지관절로수상시골절에의한해부학적구조의변형뿐만아니라주위인대및연부조직의손상이동반되기때문에수술전족관절골절의손상기전을

2 명확히이해하는것이정확한진단과치료방향을결정하는데중요하다. 특히경골후과까지침범하는족관절삼과골절은대부분의경우, 불안정골절로관혈적정복술이필요한경우가많다. 저자들은 999년 월부터 3년 9월까지족관절삼과골절로수술적치료를받은환자중 6개월이상추시가가능하였던 45예를대상으로손상의원인및분류, 여러가지관혈적정복술및내고정술방법에대한결과를문헌고찰과함께보고하는바이다. 대상및방법 999년 월부터 3년 9월까지족관절삼과골절로수술적치료를받은환자중 6개월이상추시가가능하였던 45예를대상으로술후치료결과를관찰하였다. 총 45예중남자가 6명 (35.6%), 여자가 9명 (64.4%) 이었으며, 연령분포는 세부터 83세까지로이들의평균연령은 47.3세였고, 그중 6대와 대가각각 예와 예로가장많았다. 골절의분류는 Lange-Hansen 분류법을적용하였으며, 수술시기는조기에시행함을원칙으로하였는데, 손상부위의부종및피부상태에따라 주이내에관혈적정복및내고정을시행하였고, 수술중사용한내고정방법으로는 K- 강선, 긴장대기법 (tension band wiring), 금속나사, 금속판및금속나사등이다. 족관절삼과골절에서수술중내고정해야할위치는골절부위의손상및전위정도에따라정하였는데, 한곳의고정만으로도족관절의해부학적정복이가능한경우에서는경골의내과또는외과 ( 비골 ) 만단독으로고정하였고, 곳모두필요한경우는양과를동시에고정하였으며, 경골후과의체중부하관절면골절정도가 5% 이상인경우는조기관절운동과체중부하를위해삼과모두고정을원칙으로하였다. 여기에서고정이필요하다고생각했던골절부전이의기준은내과및후과는 mm, 외과는 mm를경계선으로잡았다. 수술도달법은내과인경우는전내측도달법을, 외과인경우는외측도달법을, 후과인경우는전방도달법또는후외방도달법을이용하였고, 원위경비관절이개 (distal tibiofibular diastasis) 가있는경우엔관통고정나사 (syndesmotic screw) 로추가고정을시행하였다. 수술후처치는골절부위의손상정도와고정방법등에따라, 먼저술후 4주간장하지석고고정을시행한다음, 추가로 4내지 8주간슬개건체중부하석고나단하지석고고정을시행하였다. 그리고체중부하는수술 -주후부터 Table. Mechanism of Injury (Lause-Hansen Classification) Mechanism of injury Supination-external rotation Pronation-external rotation Pronation-abduction Total Number of cases 발끝접촉보행을하다가 3주후부터부분체중부하를허용하였으며, 전체중부하는내고정정도나골유합정도에따라 8주에서 주사이에시작하였다. 치료결과는수술전후및추시과정에서나타나는방사선소견및통증의정도와족관절운동의범위에따라판정하는 Meyer 평가법을이용하여, 수술방법에따른결과를비교하였다 (Table ). 결 과 손상의원인으로는실족이 7예, 교통사고가 예, 운동중손상이 5예, 추락인경우가 예였다. Lauge-Hansen 골절분류상회외-외회전에의한골절이 3예로가장많았고, 회내-외회전에의한골절이 3예, 회내-내전에의한골절이 예였다 (Table ). 수술적치료는경골의내과만관혈적정복술및내고정을시행한경우가 5예, 비골만고정한경우가 예, 양과를동시에수술한경우가 3예, 경골의후연부까지포함하여삼과를동시에수술한경우가모두 6예였다. 경골후과의관절면골절이 5% 이상인경우는 7예 (5.6%) 였으며, 그중전위가전혀없으며피부상태가좋지않았던 예를제외한 6예에서모두관혈적정복및내고정을시행하였는데, 전방도달법통한수술이 4예 (Fig. ), 후외방도달법통한관혈적정복및내고정이 예였다. 그리고 예에서원위경비관절이개교정을위하여관통고정나사의고정이필요하였다 (Fig. ). 전체 45예중 Meyer의평가방법을이용하였을때, 임상적으로관절운동의제한이 5도미만이면서일상생활에서통증을느끼지못하는양호이상의결과를보인경우는모두 38예 (84.4%) 였으며 (Table 3), 방사선학적으로정상이거나주변인대의석회화만보이는양호이상의결과는 39예 (86.7%) 였다 (Table 4). 골절부위의고정부위에따른임상적결과는경골의내과만고정을시행한경우가 5예중 4예 (8%) 에서양호이상이었으며, 비골만고정한경우는 예 (%) 모두양호이상, 양과를동시에수술한경우가 3예중 9예 (9%) 에서

motion Pain after strenuous activity 5 loss of motion Pain with normal activity 5 loss of motion Constant pain over 3 loss of motion

Radiographs show anterior approach procedure using counter pushing technique.

3 라종득 박현수 임창석 장영수 박상원 정태원 전용수 Table. Criteria Used in Assessment of Result (by Meyer) Result Clinical Radiological Excellent Good Fair Poor No pain with full range of motion Pain after strenuous activity 5 loss of motion Pain with normal activity 5 loss of motion Constant pain over 3 loss of motion Normal X-ray Calcification of interosseous lig. or deltoid lig. Malunion or nonunion Joint narrowing or marginal osteophytes Figure. Radiographs show anterior approach procedure using counter pushing technique. 양호이상, 경골의후연부까지포함하여삼과를동시에수술한경우가 6예중 3예 (5%) 에서양호이상의결과를보여전이가적은경우에있어서는내과또는외과한곳만시행한경우에도양과모두고정한것과비슷한결과를보였다 (Table 3). 고찰 족관절골절의치료목적은관절면을포함한골절부위의정확한해부학적정복은물론인대손상의유무를파악하고복원시켜주어조기에관절운동과체중부하를가능하게함으로써합병증을예방하고정상적인관절기능을회복하는데있다,6,7,4,5). Cooper 5) 는경골후과를침범하는족관절골절을처음기술하였고 Henderson 9) 은방사선소견에따라일과, 양

$(A, B) Preoperative anteroposterior and lateral radiographs of trimalleolar fracture with distal tibiofibular$ diastasis.

4 Figure. (A, B) Preoperative anteroposterior and lateral radiographs of trimalleolar fracture with distal tibiofibular diastasis. (C, D) Postoperative anteroposterior and lateral radiographs show bimalleolar fixation with syndesmotic screw transfixation. Table 3. Clinical Assessment of Result (by Meyer) Position of fixation Excellent Good Fair Poor Total Medial malleolar mono-fixation Fibular mono-fixation Bimalleolar fixation Trimalleolar fixation Total Table 4. Radiological Assessment of Result (by Meyer) Position of fixation Excellent Good Fair Poor Total Medial malleolar mono-fixation Fibular mono-fixation Bimalleolar fixation Trimalleolar fixation Total

5 라종득 박현수 임창석 장영수 박상원 정태원 전용수 과, 삼과골절로족관절골절을간단하게분류하였다. 그후 Ashurst와 Bromer ) 에의해손상기전에따른분류가처음체계화되었고, 948년 Lange-Hansen 7,8) 이사체실험과임상및방사선관찰로그체계가정립되어져현재까지치료를위한지침으로널리쓰이고있다. Lange-Hansen 및 Burwell과 Charnley 3) 는회외-외회전손상이가장많았다고보고하였는데, 저자들의경우에있어서도회외-외회전이 3예로 (67%) 가장많았다. 치료방법은보존적요법과수술적방법으로크게분류되며많은학자들이수술적방법에의한관혈적정복및내고정이더좋은결과를얻었다고보고하고있다,,,3,,5,6). 그이유는수술적방법은해부학적정복및이의유지가용이하고조기운동으로외상성삼출액의섬유화를방지하여주위조직의유착을방지할수있을뿐만아니라부정유합과불유합의발생빈도를감소시킬수있기때문이라고알려져있다 6,4). 저자들은전위된족관절삼과골절의치료는대부분수술적치료를원칙으로하였는데, mm 이상전이된외과골절에는금속나사또는금속판및금속나사를이용하여고정하였고, mm 이상전이된내과골절고정에는한개또는두개의금속나사, K-강선, 또는 K-강선과긴장대기법을병행하는방법등을사용하였으며, 골절편의크기가관절면의 5% 이상이면서 mm 이상전이된경골후과골절인경우는전방도달법이나직접적인후방도달법을사용하여나사못으로고정하였다. 수술중자세는수술시간의단축과준비의편리성을위해앙와위한자세로삼과모두를고정시키는것을원칙으로하였으며, 양과를고정시키고나서후과고정을위해족관절에외력이가해질경우, 수술중고정된양과의정복실패가발생할수있기에, 경골후과골절을먼저정복하여고정시키는것을원칙으로하였다. 그리고외과골절정복후에도원위경비인대결합불안정성이있는경우엔관통고정나사로추가고정을시행하였다. Yablon과 Heller 7) 는사체및임상연구를통하여양과골절시전위된거골은외과를따라움직이기때문에거골의정복을위해서는외과의정확한해부학적정복이선행되어야하며, 원위경비인대결합하부의외과골절이내과의골절보다족관절의안정성에더중요하다고하였다. 저자들역시외과의정확한해부학적정복의중요성을인지하고외과골절에대해서대부분관혈적정복및금속판혹은나사를사용하여내고정하였는데, 이는외과의견고한내고정과원위경비인대결합부의손상여부도확인하기쉽고관통고정나사를함께고정하는데도용이했기때문이다. 원위경비골간에횡으로삽입고정한금속나사는금속나사의파손을방지하기위하여,4,,4,6) 전체중부하전에제거하였다. Burwell과 Charnley 3), Lindsj 9) 저자의경우등은족관절골절탈구는정확한정복과견고한내고정술후조기관절운동및체중부하가좋은결과를얻는데필수적이라고하였고, McDaniel 과 Wison ) 은관절면의 5% 이상을침범한경골후과골절을동반하는삼과골절의경우비관혈적정복후거골아탈구가남게되어후외상성관절염빈도가관혈적정복의경우보다높다고하였다. 저자들역시족관절의정확한해부학적정복을위해서는족관절의내과및외과모두안정적으로고정시켜주는경우가대부분필요하였으며, 경골후과골절편의크기가관절면의 5% 이상이며 mm 이상전이된골절에서는거골의아탈구를정복시키기위해, 반드시전방도달법이나후외방도달법을이용한나사못고정이필요하였다. 결 론 족관절의정확한해부학적정복을위해서는많은경우에있어서족관절의내과및외과모두를안정적으로고정시켜주는것이필요하였다. 하지만전위가심하지않는골절에서는최소한의고정으로도비슷한결과를얻을수가있었다. 경골후과의관절면골절이 5% 이상인경우엔조기관절운동과체중부하를위해서내고정을시행하는데, 후과의전위가심하지않는경우엔후방에서지지를해주면서 (counter pushing) 전방에서고정을시도하는전방도달법이유용하였고, 후과의전위가심한경우엔후외방도달법이더유용하였다. REFERENCES. Ashhurst APC and Bromer RS: Classification and mechanism of the leg bone involving the ankle. Arch Surg, 4: 5, 99.. Burgess E: Fractures of the ankle. J Bone Joint Surg, 6: 7-73, Burwell HN and Chanley AD: The treatment of displaced fractures at the ankle by rigid internal fixation and early joint movement. J Bone Joint Surg, 47-B: , Close JR: Some application of the functional anatomy of the ankle joint. J Bone and Joint Surg, 38-A: 76-78, Cooper AP: Treatise on dislocation and fractures of the joint

6 6. Ha KI, Hahn SH, Chung MY, Kim HJ and Chung JY: A Clinical study of ankle fractures. J of Korean Orthop Assoc, 4: 7-77, Ha SH, Lee SH, Shin DM, Chung YJ and Park KH: Operative treatment of ankle fractures. J of Korean Society of Fractures, 3: 34-39, Han CD, Park BM and Jahng JS: A Clinical study of ankle fracture. J of Korean Orthop Assoc, 7: 9-, Henderson MS: Trimalleolar fracture of the ankle. Surg Clin North Am, : , 93.. Hughes JL,Weber H, Willenger H and Kuner EH: Evalation of ankle fractures. Clin Orthop, 38: -9, Jergesen F: Open reduction of fracture and dislocation of the ankle. Am J Surg, 98: 36-5, Jung HG, Yoo MJ, You SJ, et al.: The Evaluation of clinical prognostic factors for the surgically treated unstable ankle fractures. J of Korean Society of Foot Surg, 5: -9,. 3. Kim ID, Lee SY, Kim PT, Park BC and Choi YD: A clinical study of ankle fracture. J of Korean Orthop Assoc, : 3-39, Kim KH, Cho JL, Kim TS and Song JM: A clinical study of the ankle fracture. J of Korean Orthop Assoc, (3): 589-6, Kim SJ, Choi IY and Ahn TK: A clinical study of the trimalleolar fractures of the ankle. J of Korean Society of Fractures, : 45-54, Klossner O: Late results of operative and nonoperative treatment of severe ankle fractures, Acta Chir Scand, 93-36, Lauge-Hanson N: Fractures of the ankle. Analytic historic surgery as the basis of new experimental, roentgenologic and clinical investigarions. Arch Surg, 56: 59-37, Lauge-Hanson N: Fracture of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg, 6: , Lindsjoe U: Operatifve treatment of ankle fracturedislocatioins. Acta Orthop Scand, 89: -3, 98.. Malka JA and Taillard W: Results of nonoperative and operative treatment of fractures of the ankle. Clin Orthop, 67: 59-68, McDaniel WJ and Wilson FC: Trimalleolar fractures of the ankle. Clin Orthop, : 37-45, Meyer TL Jr and Kumler KW: A.S.I.F. technique and ankle fractures. Clin Orthop, 5: -6, Pankovich A: Fracture of the fibular at the distal tibiofibular syndesmosis. Clin Orthop, 43: 38, Park MS and Song KJ: A clinical study of the ankle fracture. J of Korean Orthop Assoc, 9: , Phillips WA, Schwarts HS, Keller CS, et al.: A prospective, randomized study of the management of severe ankle fractures. J Bone Joint Surg, 67-A: 67-78, Roberts RS: Surgical treatment of displacement ankle fractures. Clin Orthop, 7: 64-7, Yablon IG, Heller FG and Shouse L: The key role of the lateral malleolus in displaced fractures of the ankle. J Bone Joint Surg, 59-A: 69-73,

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