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1 대한족부족관절학회지 : 제 12 권제 1 호 2008 J Korean Foot Ankle Soc. Vol. 12. No. 1. pp.9-13, 2008 부산의료원정형외과학교실 Consideration of Various Medial Capsulorrhaphy Methods in Hallux Valgus Surgery Sung Jong Choi, M.D., Byung Cheol Kim, M.D., Il Soo Eun, M.D., Jung Wook Huh, M.D. Department of Orthopaedic Surgery, Busan Medical Center, Busan, Korea =Abstract= Purpose: Medial capsulorrhaphy is additional hallux reduction method following various hallux reduction procedures and we are going to report author s opinion about several methods of medial capsulorrhaphy. Materials and Methods: We performed three kinds of medial capsulotomy and imbricatory capsulorrhaphy in hallux valgus surgery. Through 8 cadavar study, we compared the easiness of sesamoid reduction and hallux valgus angle reduction. Also, we measured thickness of capsule in various portions. Results: Longitudinal capsule incision and imbrication was useful in sesamoid reduction and vertical procedures was useful in hallux valgus angle reduction. The capsule thickness was measured thickest in dorsal and distal portioin. Conclusion: The methods of medial capsulorrhaphy should be planned preoperatively considering individual hallux deformities. These selected medial capsulorrhaphy can help the reduction of hallux valgus deformity correction and its maintenance. Key Words: Hallux valgus, Medial capsulorrhaphy 서 론 무지외반증의다양한수술방법중내측관절낭봉합술 (medial capsulorrhaphy) 는족무지를정복된상태로유지 Address for correspondence Byung Cheol Kim, M.D. Department of Orthopaedic Surgery, Busan Medical center, 1330, Geoje-dong, Yeonje-gu, Busan, , Korea Tel: Fax: kbcos@yahoo.co.kr 하기위한보조수단이다. 현재까지무지외반증에대한수술방법중중족골절골술 (metatarsal osteotomy) 의위치및방법에대한언급은흔하지만내측관절낭봉합술에대한술기는교과서마다다르다. 변형종류와정도가다른환자에적합한내측관절낭봉합술에대한고민이많았으며어떻게관절낭을절개하여중첩봉합할것인가에대한이론적근거에대한언급을찾기어려웠다. 이에내측관절낭봉합술에대한저자의경험및의견을기술하고자한다

2 A B C Figure 1. (A) L-shape incision of which apex located in dorsal and proximal portion of capsule. (B) L-shape incision of which apex located in dorsal and distal portion of capsule. (C) T-shape incision of wh ic h lon gitudin al in c is ion loc at ed th rough met ata rsop ha lan geal joint and vertica l inc is ion l oca ted in p roxim al portion of c ap sule. T a bl e 1. Correction of Hallux Valgus Angle and Intermetatarsal Angle Shape of incision No. of cases Pre OP HVA ( ) Pre OP IMA ( ) Post OP HVA ( ) Post OP IMA ( ) Correction of HVA ( ) Correction of IMA ( ) DP* (26~35) (12~19) 5.91 (0~25) 9.82 (5~11) (1~10) 5.00 (2~10) DD (26~35) (12~19) 9.63 (0~25) 9.13 (5~11) (1~29) 6.00 (2~10) T (10~17) (10~17) 9.83 (0~20) 8.92 (5~11) (7~35) 5.00 (2~7) *DP, group of L-shape incision of which apex located in dorsal and proximal portion of capsule; DD, group of L-shape incision of which apex located in dorsal and proximal portion of capsule; T, group of T-shape incision of which longitudinal incision located through metatarsophalangeal joint and vertical incision located in proximal portion of capsule; HVA, hallux valgus angle; IMA, intermetatarsal angle. 대상및방법 1. 연구대상 2005 년 8월부터 2006 년 7월까지본원에서무지외반증에대하여수술을시행한환자중추후관찰이가능했던 28명 (25명은편측, 3명은양측 ), 총 31예의임상경험및사체 8구의중족족지관절에서사체실습을시행하였다. 2. 술전분석단순방사선검사로무지외반각과중족골간각을측정하였고, 술전이학적검사로관절낭절개술시무지를정복된상태로유지하기위한관절낭절개방법과중첩봉합술의방법을계획하였다. 3. 수술방법원위연부조직교정술로수축된조직인족무지내전근, 외측관절낭, 횡중족인대 (transverse metatarsal ligament) 를풀어주고다양한방법의근위중족골절골술혹은원위중족골절골술을시행하였다. 일부환자에서추가로근위지골에대한 Akin 절골술을추가하였다. 이러한연부조직교정술과절골술후내측관절낭절개술후관절낭중첩 봉합술을시행하였다. 3가지방법으로관절막의절개술을시행하였다. 1) 첨점 (apex) 이배부와근위부 (dorsal and proximal) 에있는 L자모양의절개 2) 첨점이배부와원위부 (dorsal and distal) 에있는 L자모양의절개, 3) T자모양의절개, 즉종적인절개부위가중족족지관절에걸쳐있고이에수직인횡절개가중족족지관절의근위부에수직으로있는절개법을시행하였다 (Fig. 1). 또한, 이러한저자의임상경험을염두에두고 8구의사체실습을통하여각각의장단점을알아보려하였다. 4. 평가및분석관절막절개방향즉종절개및횡절개에따른무지변형교정의용이정도를환자수술시와사체에서경험해보았다. 또한, 사체실습에서중족골지관절내측에서근위약 2 cm 에서원위부를향해길이약 3.5 cm, 폭약 2 cm의장방형으로관절낭을체취하여내측관절낭의두께를부위별로측정하였다 (Fig. 2). 결과세가지의내측관절낭봉합술은모두회내전및외반된무지를중립상태로정복된위치로유지하는데도움이되었다 (Table 1). 8구의사체실습상내측관절낭의두께는대부

portion. 분배부와원위부에서가장두껍게측정되었으며평균은 4.5 mm였다 (Fig. 2). 관절낭의종절개후중첩봉합술은종자골의정복의교정및유지즉무지의회내전변형의교정에중요한역할을하였고관절낭의횡절개후중첩봉합술은무지외반각의교정및정복의유지에도움이되었다.

3 A B Figure 2. (A) In cadavar study, quadriangular capsule was obtained. (B) Mean capsule thickness of quadriangular capsule were measured separa tel y in dors al an d dis ta l p ortion, d orsa l a nd prox ima l p ortion, plantar and dorsal and plantar and proximal portion. 분배부와원위부에서가장두껍게측정되었으며평균은 4.5 mm였다 (Fig. 2). 관절낭의종절개후중첩봉합술은종자골의정복의교정및유지즉무지의회내전변형의교정에중요한역할을하였고관절낭의횡절개후중첩봉합술은무지외반각의교정및정복의유지에도움이되었다. 또한, 통계학적으로유의하지는않았으나, 첨점 (apex) 이배부 (dorsal) 와근위부 (proximal) 에있는 L자모양의절개가종자골의정복및무지회내전변형의교정에가장효과적인방법으로사료되었다 (Table 1, Fig. 3). Figure 3. In cadavar trials, L-shape incision of which apex l o c a t ed in dorsal and proximal portion of capsule was most useful for correction of both hallux valgus angle and hallux pronation. 고찰무지외반증은꽉조이는신발이나하이힐사용등으로인한내측중족족지관절연부조직의약화, 중족골두의내측및외측종자골사이의융기 (ridge) 의미란 (erosion) 에서발단된다고한다 4,7,9,10). 이후내측연부조직약화및중족골두하방종자골사이의융기의미란이진행됨에따라중족족지관절주위의족무지내전건의외측종자골및근위지골의견인효과에의하여중족족지관절의외반및족무지의회내전정도가점차적으로심해진다 4,7,9,10). 무지외반증의수술적치료방법은대부분원위연부조직교정술은주로중족족지관절의외측에대해수축된조직인족무지내전근, 외측관절낭, 횡중족인대를풀어주고 2,8), 중족골두의내측융기부를제거하며, 심한변형이있는경우에는연부조직교정술과아울러중족골절골술을시행할수있다. 이러한술기가마친후내측관절낭을겹쳐서봉합하는술식 3,4,7-9,11) 으로구성된다. 환자의연령, 변형의정도, 중족족지관절의상합성 (congruency) 유무, 퇴행성유무등을고려한후적절한연부조직교정술, 제1 중족골원위부절골술, 제1 중족골근위부절골술, 제1 근위지골절골술, 절개관절성형술, 관절고정술등의다양한방법을술전에계획한다 12). 결국무지외반증에대한수술의목적은동통완화, 변형교정을하여궁극적으로보행시불편을없애는데있다 1). 이중무지외반증의수술방법중변형의경중 (severity) 에

4 따른절골술부위의위치에대한방법의기술에대한언급은흔히찾아볼수있으나원위연부조직교정술인내측관절낭의절개및봉합방법은다양하다. 또한, 이에대한장단점의언급은찾기어렵다. 일반적으로내측연부조직재건술의주목적은중족족지관절외측내전근의구축제거및중족골절골술이후중족족지관절및무지를부가적으로중립상태로유지하는것이다 5,6). 실제수술에서는중족골의장축에대해족무지가중립상태를유지한상태에서관절낭을비흡수성봉합사로중첩봉합한다 5,6). 중첩봉합은술자의개인적선호에따라서관절낭의절개방법이달라진다. 저자들은교과서에기술되어있는내측관절낭봉합술에대한장단점을수술, 문헌고찰및해부학적인실험을통하여알아보았다. 사체에서내측관절낭의채취시 15번매스를이용하였으며중족골두에부착된관절낭의훼손으로두께측정에오차가생기지않도록노력하였다. 다만, 사체의보존상태가양호하지않은점, 사체의나이를정확히알수없는점등많은혼란요인 (bias) 이있어서객관적자료로는보기어려울것으로사료된다. 첨점이배부및근위부에위치한 L자모양의관절낭절개술의장점은회내전된무지를적절한장력하에중첩봉합하기에역학적으로좋은위치라는점이다. 단점으로이부위는관절낭의두께가얇아서중첩봉합술시연부조직의부족으로인한정복소실이우려된다. 첨점이배부및원위부에위치한 L자모양의관절낭절개술의장점은연부조직이비교적두꺼워중첩봉합술의강도가좋으며내측융기의노출정도가양호한것이라하겠다. 그러나, 첨점이배부및근위부에있는절개술보다는무지의변형교정위치가좋지못한면이있다고하겠다. 마지막으로저자가선호하는 T자모양의관절낭절개봉합술, 즉종적인절개부위가관절낭의배측및족저부측부착부의중간지점에서중족족지관절에걸쳐있으며중족족지관절의근위부에이에수직인횡절개가수직으로있는방법이다. 이는관절낭을중족족지관절에평행하게절개하여중첩봉합함으로종자골의정복이용이하고관절낭을수직절개하여중첩봉합함으로외반각의교정도용이하다고사료된다. 상기기술한어떤방법을사용하거나관절낭중첩봉합술만으로무지외반각을유지하는것은어렵다고생각된다. 특히내측연부조직의중첩을무리하게많이하여무지외반각을교정시교정각감소를외래추시시경험하였다. 교정각의감소원인은수술후고정을오래하지않고바로엄지발가락을움직이게하는경우에봉합부위의파열로인한것이주원인으로사료된다. 따라서절골술에의하여얻 어진교정각을유지하는정도의장력으로봉합하는것이내측관절낭이파열될가능성이낮고무지운동범위감소에미치는영향도적다고사료된다. 결 론 무지외반증의다양한수술방법중내측관절낭봉합술은족무지를정복된상태로유지하기위한보조수단이다. 저자는 T자모양의절개를가장선호하며이는관절낭을종절개를함으로종자골의정복이용이하며관절낭을수직절개를함으로외반각의교정에도용이한것으로사료된다. 이러한관절낭절개술의다양한방법에대한장단점이있음을고려하여술전계획과술중관절낭의보존정도에따라서각각의무지의변형의교정및유지에가장적합한술식을선택하는것이좋은예후에도움을주리라고사료된다. REFERENCES 1. Agoropoulos Z, Efstathopoulos N, Mataliotakis J, et al: Long-term results of first metatarsophalangeal joint fusion for severe hallux valgus deformity, Foot Ankle Surg, 7: 9-13, Basile A, Battaglia A and Campi A: Comparison of Chevron- Akin osteotomy and distal soft tissue reconstruction-akin osteotomy for correction of mild hallux valgus, Foot Ankle Surg, 6: , Cohen MM: The oblique proximal phalangeal ostetotomy in the correction of hallux valgus, J Foot Ankle Surg, 42: , Coughlin MJ and Mann RA: Hallux valgus, Surgery of the foot and ankle, 8th ed. Philadelphia, Mosby Inc: , Goldberger M and Conti SF: Distal soft tissue release, Operative techniques in Orthopaedics, 9: 2-7, Honkamp NJ and Rongstad KM: A technique for proximal first metatarsal osteotomy for hallux valgus repair, J Foot Ankle Surg, 43: , Mann RA and Mann JA: Hallux valgus, In: Michael W. Chapman ed. Chapman s orthopaedic surgery. 3rd ed. Philadelphia, Lippincott Williams & Wilkins: , Mann RA, Rudicel S and Graves SC: Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy. A long term follow-up, J Bone Joint Surg, 74-A: , Richardson EG: Disorders of the Hallux. In: S. Terry Canale, James H. Beaty ed. Campbell s operative orthopaedics. 11th ed. Philadelphia, Mosby Elsevier: ,

5 10. Robinson AH and Limbers JP: Modern concepts in the treatment of hallux valgus, J Bone Joint Surg, 87-B: , Steinbock G: Review Chevron-osteotomy for the treatment of Hallux Valgus, Foot Ankle Surg, 9: , Zettl R, Tmka HJ, Easley M, Salzer M and Ritschl P: Moderate to severe hallux valgus deformity: correction with proximal crescentic osteotomy and distal soft-tissue release, Arch Orthop Trauma Surg, 120: ,

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07 이호승( ).hwp 대한족부족관절학회지 : 제 권제 호 6 J Korean Foot Ankle Soc. Vol.. No.. pp.56-6, 6 무지외반증에서외측연부조직유리술을함께시행한원위갈매기형절골술의치료결과 울산대학교의과대학정형외과학교실, 한일병원정형외과 * 이호승 지형철 이성우 김종민 * The Results of Distal Chevron Osteotomy with Lateral