05/004-이재정/29-36

Size: px

Start display at page:

Download "05/004-이재정/29-36"

동훈 양
4 years ago
Views:

1 ORIGINAL ARTICLE pissn eissn J Korean Soc Surg Hand 2012;17(1): JOURNAL OF THE KOREAN SOCIETY FOR SURGERY OF THE HAND 금속판고정술을이용한주두골절의치료 Fixation of Olecranon Fractures Using Plating System 강호정 이원용 김형식고일현 최윤락 이재정 연세대학교의과대학정형외과학교실 접수일 2012 년 1 월 31 일수정일 2012 년 3 월 9 일게재확정일 2012 년 3 월 12 일교신저자이재정서울시서대문구연세로 50 연세대학교의과대학정형외과교실 TEL FAX drjaylee@naver.com * 본논문의요지는 2010 년도대한정형외과학회추계학술대회에서발표되었음. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non- Commercial License ( licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 목적 : 주두골절에대한주치료방법으로금속판고정술을시행한환자들의치료결과에대하여보고하고금속판고정적응증및장점을알아보고자하였다. 대상및방법 : 1995년에서 2008년까지주두골절환자에대하여금속판내고정술로치료한 20예에대하여후향적으로분석하였다. 골절형태로는 Mayo 분류 IIA형이 3 예, IIB형이 7예, IIIB 형이 10예였다. 임상적결과는골유합유무, 최종추시시의평균관절가동범위를통해확인하였고기능적평가를위해 disability of the arm, shoulder and hand (DASH) score 와 Mayo Elbow Performance score (MEPS) 를사용하였다. 결과 : 2예를제외한전예에서골유합이이루어졌였으며평균 5.6개월에골유합을확인하였다. 최종추시시에평균관절가동범위는 123, 평균회전범위는 81 이었다. MEPS에의한평가는 16예에서우수또는양호를보였으며, 평균 DASH score 는 16.3점이었다. 합병증으로는금속판돌출및자극이 3예로가장많았다. 결론 : 주두골골절치료에대한금속판고정술은심한분쇄성골절이나몬테지아양상그리고불유합등에해당하는형태의주두골골절에좋은치료방법이다. 색인단어 : 주두골, 주두골절, 금속판고정, 적응증 서론 성인에서주두골절은주관절골절의약 10% 에해당하는비교적흔한골절로골절양상은전위되지않은단순골절에서탈구가동반된복합골절까지그범위가다양하다. 주관절골절의분류는주로분쇄골절의유무, 그리고전위된정도및안정성에기초한 Mayo 분류방법을따르고있다 1. 주관절주두골절에서가장보편적인수술적치료방법은강선긴장대고정술로알려져있고, 장기추시의결과도만족할만한것으로보고되고있다 2. 그러나분쇄골절, 주관절의불안정성이동반된골절그리고구상돌기부위까지골절선이확장된경우에는강선긴장대고정술만으로는치료가부족한경우가있고, 이때에는다발성나사고정, 이중긴장대나사고정법, 금속판고 정술등을혼합해서치료하는것이가능하다. 현재에는금속판디자인의많은발전이있어문제점이어느정도해결되었으나과거에는금속판에의한자극같은금속판의합병증으로인해이중긴장대고정술같은다른수술법이우선선행되어왔다 3. 본연구에서는일차시도로주두골절에대한주치료방법으로골절양상으로보아긴장대강선고정이어려울것으로보이는환자를대상으로금속판고정술을시행한환자들의치료결과에대하여보고하고금속판고정적응증및장점을알아보고자하였다. 대상및방법 1995 년 1 월부터 2008 년 6 월사이본원에서주관절의주두 Copyright c The Korean Society for Surgery of the Hand 29

J Korean Soc Surg Hand Vol. 17, No. 1, March 2012 골절환자중일차적으로긴장대고정술로안정된고정이어려운경우에대하여금속판내고정술 (synthes reconstruction plate 혹은 acumed congruent olecranon plate) 로수술적치료를받은환자를대상으로하였다.

2 J Korean Soc Surg Hand Vol. 17, No. 1, March 2012 골절환자중일차적으로긴장대고정술로안정된고정이어려운경우에대하여금속판내고정술 (synthes reconstruction plate 혹은 acumed congruent olecranon plate) 로수술적치료를받은환자를대상으로하였다. 전체를침범한심한분쇄성골절, 골절선이활차절흔의중간부보다원위부에있는골절, 주두골절과동반된구상돌기의골절이분쇄성인경우나근위부로의사선형골절그리고필요한몬테지아양상의골절등이이에해당하였으며환자들중 1년이상의추시관찰이가능하였던 20예를후향적으로분류하였다. 성별분포는남자가 11예, 여자가 9예였고, 수상당시의나이는평균 48.75세 ( 범위 : 18-73세 ) 였으며평균추시기간은 30.15개월 ( 범위 : 개월 ) 이었다. 수상원인으로교통사고가 8예, 추락사고가 3 예그리고낙상이 9예로고에너지의외력이가해진경우가 11 예였다. 골절형태로는 Mayo 분류 II A형이 3예, II B형이 7 예, III B 형이 10예로대부분의골절이분쇄상골절이었다. 분쇄골절이아닌 II A형의골절은 Schatzker 분류 C형으로사 선형골절이었다. 요골골두의탈구와동반된 Monteggia 양상의골절 (Figs. 1, 2) 은총 8예였고, 불유합으로재수술한예는 2예이었다. 분류는 Bado type IV의불안정성골절이 6예로가장많았다. 구상돌기골절이동반된경우가 10예였고 2 예에서 Regan and Morrey classification type II, 8예에서 type III의골절로전례에서구상돌기골절의고정이필요하였다 (Table 1). 고정방법으로금속판만을이용한경우는 6예, 추가로긴장대고정을같이한경우가 7예, 추가적인소형나사못고정을시행한경우가 2예였으며긴장대고정과나사못고정을모두사용한경우가 5예였다. 사용된금속판으로는재건금속판이 7예, 자가압박금속판 (dynamic compression plate) 가 7예였으며 1/3 관형금속판이 2예잠김압박금속판 (locking compression plate) 가 4예에서사용되었다. 골유합기간은수술후외래에서시행한방사선사진을기초로하였고, 수술후기능적평가는 Mayo Elbow Performance score 와 disability of the arm, shoulder and hand (DASH) score Fig. 1. (A) Lateral radiographs and CT of the elbow of a 49-year-old man show a reverse oblique comminuted olecranon fracture resulting from traffic accident. (B) Before plate fixation, the reverse K-wires heading proximally, was fixed temporally. (C) Immediate postoperative lateral radiograph shows 2 K-wires and plate fixation. (D) At 4 months after surgery, union was achieved. 30

$(A) Preoperative radiographs showed severely comminuted and Monteggia equivalent olecranon fracture resulting from slippage in a 58-year-old man.$

3 Ho-Jung Kang, et al. Fixation of Olecranon Fractures Using Plating System Fig. 2. (A) Preoperative radiographs showed severely comminuted and Monteggia equivalent olecranon fracture resulting from slippage in a 58-year-old man. (B) On CT scans, accompanied coronoid process fracture is seen. (C) At 6 months after surgery, radiographs show union. 를이용하였다 4,5. 결과 2예를제외한전예에서골유합을이루었으며평균 5.6개월에골유합이되었다. 최종추시시에평균관절가동범위는 ±30.1, 평균회전범위는회내전이 41.7 ±10.1, 회 외전이 38.9 ±9.9 이었다. 두예의불유합된예에서는재수술을통하여골이식및금속판고정을시행하였다. 평균 DASH score 는 16.3±18.3점이었고, Mayo score 에의한최종추시시기능적결과는우수 9예, 양호 7예, 보통 1예였고 3 예에서불량한결과를보였다. 불량한결과를보인 2예는치료후불유합을보인고령의환자 (69세, 73 세 ) 였고 (Fig. 3), 다른 1예는수술후감염으로인 Table 1. Causes of injury and fracture pattern Sex/Age Cause Mayo type Radial D/L Bado type Coronoid Fx Regan type 1 M/28 TA Type IIB 2 M/49 Fall down Type IIB 3 M/59 Slip over Type IIB O III 4 F/24 TA Type IIA 5 M/41 Slip over Type IIA 6 M/46 Slip over Type IIB O II 7 M/49 TA Type IIIB O IV 8 F/61 Slip over Type IIIB O IV O III 9 F/40 Slip over Type IIA 10 M/58 Slip over Type IIIB O IV O III 11 M/18 TA Type IIIB O II O III 12 M/35 TA Type IIIB O IV O III 13 F/66 Slip over Type IIB 14 M/49 Fall down Type IIB 15 F/61 Slip over Type IIIB O IV 16 F/64 Slip over Type IIIB O I O II 17 F/73 Fall down Type IIIB O IV O III 18 F/44 TA Type IIIB O III O III 19 M/69 TA Type IIIB O III O III 20 F/41 TA Type IIB DL: dislocation, TA: traffic accident. 31

$(A) A 73-year-old woman sustained a right comminuted olecranon and radial head fracture (Mayo type IIIB and Schatzker type F olecranon fracture).$

4 J Korean Soc Surg Hand Vol. 17, No. 1, March 2012 Fig. 3. (A) A 73-year-old woman sustained a right comminuted olecranon and radial head fracture (Mayo type IIIB and Schatzker type F olecranon fracture). (B) The fracture was fixed internally using plate, screw and Kirshner s wires. (C) At 6 months after operation, radiograph shows nonunion. Re-plating and auto iliac bone graft were performed. (D) At 9 months after second operation, radiograph shows union. 해굴곡운동의시기가늦어 2차적인주관절부분강직의증세를보이는환자이었다 (Table 2). 수술후합병증으로는주두골근위부의금속판돌출및자극을호소한환자가 3예로가장많았고, 감염이 1예불유합이 2예였다. 금속판자극을호소하는환자는전례에서골유합까지기다린후제거하였고, 불유합환자는각각 6개월, 9개월에금속판재고정및골이식술로치료하여추후골유합을얻었다. 이외에중등도의주관절부분강직을호소한환자가 2예였다. 강직을보인예중 1예는이소성골화를동반하였다. 주관절부분강직환자에대해서는골유합후금속판을제거하면서관절유리술을시행하여기능적 인관절운동범위를회복하였다. 고찰 주두골절의치료의목표는주관절의안정성회복, 관절강내의적합성과고정강도의유지, 기능과통증의회복에있다. 단순횡골절의경우주된수술적치료방법으로알려진긴장대고정술만으로도충분히좋은결과를기대할수있겠지만, 복합적인양상의골절의경우에는긴장대고정술만으로는만족할만한결과를기대하기힘들어다른고정술이나추가적인 32

5 Ho-Jung Kang, et al. Fixation of Olecranon Fractures Using Plating System Table 2. Functional and radiologic result Follow-up Function Function Mayo score Radiologic Pain Motion Stability dur (mo) Score1* Score2 Score union (mo) 1 35 None Stable (E) None Stable (E) Mild Stable (G) None Stable (E) Mild Stable (G) None Stable (E) Mild Stable (G) Mild Stable (G) Mild Stable (F) None Stable (E) None Stable (E) None Stable (G) None Stable (E) None Stable (E) Moderate Stable (P) Mild Stable (G) Moderate Moderate (P) Nonunion Unstable None Stable (E) Moderate Stable (P) Nonunion Mild Stable (G) 16 Mean E: excellent, G: good, F: fair, P: poor. *Mayo Elbow Performance function score. Disabilties of the Arm, Shoulder, and Hand score. Total Mayo Elbow Performance score. 고정술을이용하여야한다. 긴장대고정술은가장널리사용되는방법이고, 장기추시결과가좋은것으로알려져있다. Karlsson 등 6 은긴장대고정술을시행한 67명의환자에대해 18년간의추시경과를통해, 환자들이임상적주관적결과모두 96% 이상에서우수한결과를보였음을보고한바있다. 비록방사선학적소견상 50% 이상에서이차적퇴행성관절변화가보였지만이는외상후장기추시에의한것이지수술방법의문제가아니라고결론짓고있다. 이러한우수한결과의전제조건은골절의틈 (gap) 없이해부학적정복이이루어져야하고, 견고한고정이이루어져야한다는것이다 7-9. 하지만, 분쇄골절특히구상돌기를침범한골절인경우나주두를통한주관절의골절및탈구가있는경우에는긴장대고정술만으로는견고하고해부학적인정복이힘들기때문에수술후빠른관절운동이지연되어좋은결과를기대하기힘들다. 기존의연구에의하면, 수술후 3주이후에관절운동을시킨경우에기능적으로관절운동의범위가감소하였다보고하고있는데이를통해견고한고정을통한빠른관절운동이수술후기능에직접적인영향을준다는것을알수있다 8,10. 또한척골의근위부가운동시극단 적인휨압력 (bending stress) 이작용하기때문에금속판고정이분쇄상골절에서내고정물실패에서더안전할것을기대할수있다 11,12. Hak 과 Golladay 13 는문헌고찰을통해서금속판고정에대한다양한결과를보고한바있다. 그이후로적절한적응증에해당하는분쇄성주두골절에서금속판고정이정형화된치료로인정되고있다. 분쇄가심한골편의경우 K-강선만으로는여러개의골편을고정하는데제한이있으며 K-강선을삽입하는부위에골절이있을수있으며, 활차절흔의중간부원위부에골절선이있는경우에는 K-강선이골절선에수직으로삽입되면서동시에관절면과가깝게삽입되기힘들기때문에관절면부위에서골절틈이벌어질수있다. 구상돌기의골절이있는경우에는긴장대고정술로고정후에도구상돌기부위의안정성이유지되지않으며, 사선형골절의경우전완부굴곡건에의해골편의전위가일어나는힘이커더강한고정력이필요하다 14. Monteggia 유사골절과불유합골절의경우에는주관절의안정력을위해긴장대고정술의고정력이부족하며골절후불유합의경우골이식이필요한경우가대부분이며이경우골이식편이안정적으로유지되기위해서는금속 33

6 J Korean Soc Surg Hand Vol. 17, No. 1, March 2012 판고정이필요하다. 이러한이유에서이런골절의경우긴장대고정술보다는금속판고정을선호하게된다. 저자들의기관에서는과거금속판보다는긴장대고정술을선호하였으나다발성긴장대고정술을사용한다하더라도고정력이부족하거나골유합이지연되는경우를경험하였다. 따라서현재저자들은 1) 전체를침범한심한분쇄성골절, 2) 골절선이활차절흔의중간부보다원위부에있는경우, 3) 주두골절과동반된구상돌기의골절이분쇄성인경우나근위부로의사선형골절인경우 (Fig. 1), 4) 주관절의불안정성으로강한고정이필요한몬테지아양상의골절, 5) 불유합골절에서는일차치료로금속판고정술을사용하고있다. 주두골골절의금속판고정에다양한금속판이이용되고있는데, 우선전형적인금속판으로자가압박금속판, 1/3 관상금속판, 근위부가얇게처리된윤곽변형금속판이있으며, 나사못들은양측피질을고정해야하고가장근위부의나사못은 home-run 나사못이라고불리며나사못방향이구상돌기를향해있어야되는것으로알려져있다 15. 이를사용하여 Anderson 을비롯하여다양한저자들이좋은결과를보고하고있다 11, 이에반해잠김압박금속판은금속판의특징상근위부피질만고정해도되기때문에근위부나사못을골수강내로고정하여골수정의효과를기대할수있어좀더견고한고정력을얻을수있다고보고되었다 19. 견고한고정력을위해후방금속판이아닌내외측양측금속판고정을하여좋은결과를보고한바있는데 20, 이에대한생역학적실험결과에서각각의금속판이갖는휨모멘트가큰차이를보이지않았고, 오히려잠김압박금속판에서골수강내나사못을추가했을경우가오히려양측금속판보다통계학적으로유의미한큰휨모멘트를보고한바있다 8,15,20. 이는내외측금속판이직접적으로삼두근의작용에저항하지못하고양측금속판을적용한다고공간적으로작은근위부골편에나사못을추가할수없기때문일것이다. 본연구에서는 1예에서양측금속판을적용하였는데, 이는작은근위부골편에단일금속판보다는양측금속판을이용하였을때더많은나사못을추가할수있다고판단되었기때문이었다. 기존의보고에서, 금속판고정술후관절운동범위는굴곡범위를 107 에서 130 까지그리고신전제한을 9 에서 14 까지보고하였는데, 본연구결과에서는좀더나은굴곡범위를보여줬다 11,12,19. 또한기존의보고에서는 30 이상의신전제한을보여서기능적으로많은제한을준증례를 26% 정도로보고한바에비해서본연구에서는단 1 예에서만 (5%) 그러한신전장애를보였다. 합병증에있어서는금속삽입물에의한자극으로추후금속판제거술을계획하는환자가 3예 (16%) 로가장많았는데, 이 는기존에긴장대고정술에서보고한 80% 보다는적은수치이고금속판고정술에서보고한 0%-20% 와는유사한결과를보였다 2,6,8,11,12,17,19,21,22. 긴장대고정술에서금속삽입물에의한자극이많은이유로는금속판고정에서는나사못주변으로금속판이위치하는데반해긴장대고정술에서는핀이주변연부조직에둘러싸여지기때문에붓기가빠지면서자극이일어난다고생각된다. 하지만금속판고정에서도주두근위부첨단부위에연부조직이얇기때문에금속판돌출이여전히합병증으로보고되는있는데, 이는금속나사고정시에주두골모양에맞게성형하는것이기술적으로힘들기때문에돌출로인한합병증은여전히해결과제로남아있다. 최근에개발되고사용되는주두골에대한금속판들은근위부가얇게윤곽이성형되어금속판자극합병증을최소화하려하고있다. 불량한결과를보인 2예는수술후불유합을보인경우였다. 두명모두고령이었고결과적으로불유합으로두번의수술을시행하였다. 두명모두에서수술후시행한골밀도검사에서 T score-2.5 이하로골다공증에해당되었고각각의분류는 Mayo 분류상 IIIB로분쇄형의골절이었다. 두군모두수술후 1년경과후수술부위의통증이있어내고정물제거를계획하였는데수술장소견상불유합및골결손이관찰되어추가적으로자가골이식을시행하였다. 한예에서는골이식과동반하여금속판재고정술을시행하였고, 다른한예에서는골이식만을시행한후에지속적으로불유합소견보여이차로수술후 8개월에골이식과금속판재고정술을시행하였다. 이렇듯고령의골다공증이있는환자의분쇄가심한주두골절에서는상지골절이기때문에더나은골유합을기대할수있다하더라도, 골결손부위에대해서처음수술시부터골이식술을추가적으로하는것이추천된다. 추후에주두골절수술후불유합된환자를대상으로연구가필요할것으로생각된다. 결론 주두골골절치료에대한금속판고정술은심한분쇄성골절이나몬테지아양상그리고불유합등에해당하는형태의주두골골절에좋은치료방법이다. 고령의골다공증환자에서는술후불유합의가능성이높기때문에처음수술부터골이식을추가로하는것이추천된다. 참고문헌 1. Veillette CJ, Steinmann SP. Olecranon fractures. Orthop 34

7 Ho-Jung Kang, et al. Fixation of Olecranon Fractures Using Plating System Clin North Am. 2008;39: Chalidis BE, Sachinis NC, Samoladas EP, Dimitriou CG, Pournaras JD. Is tension band wiring technique the gold standard for the treatment of olecranon fractures? A long term functional outcome study. J Orthop Surg Res. 2008;3:9. 3. Kang S, Hwang CS, Chung PH, Kim YS, Chung JW, Kim JP. Double tension band wiring for olecranon fractures. J Korean Fracture Soc. 2008;21: Morrey BF, An KN, Chao EY. Functional evaluation of the elbow. In: Morrey BF, editor. The elbow and its disorders. 2nd ed. Philadelphia: W.B. Saunders; p Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29: Karlsson MK, Hasserius R, Besjakov J, Karlsson C, Josefsson PO. Comparison of tension-band and figureof-eight wiring techniques for treatment of olecranon fractures. J Shoulder Elbow Surg. 2002;11: Murphy DF, Greene WB, Dameron TB Jr. Displaced olecranon fractures in adults. Clinical evaluation. Clin Orthop Relat Res. 1987;(244): Scharplatz D, Allgower M. Fracture-dislocations of the elbow. Injury. 1975;7: Lee JM, Park JH. Fractures of the olecranon of ulna treated by plating and tension band wiring technique. J Korean Soc Fracture. 1996;9: Macko D, Szabo RM. Complications of tension-band wiring of olecranon fractures. J Bone Joint Surg Am. 1985;67: Anderson ML, Larson AN, Merten SM, Steinmann SP. Congruent elbow plate fixation of olecranon fractures. J Orthop Trauma. 2007;21: Simpson NS, Goodman LA, Jupiter JB. Contoured LCDC plating of the proximal ulna. Injury. 1996;27: Hak DJ, Golladay GJ. Olecranon fractures: treatment options. J Am Acad Orthop Surg. 2000;8: Horner SR, Sadasivan KK, Lipka JM, Saha S. Analysis of mechanical factors affecting fixation of olecranon fractures. Orthopedics. 1989;12: Gordon MJ, Budoff JE, Yeh ML, Luo ZP, Noble PC. Comminuted olecranon fractures: a comparison of plating methods. J Shoulder Elbow Surg. 2006;15: Hume MC, Wiss DA. Olecranon fractures. A clinical and radiographic comparison of tension band wiring and plate fixation. Clin Orthop Relat Res. 1992;(285): Spivak JM, Chen D, Kummer FJ. The effect of locking fixation screws on the stability of anterior cervical plating. Spine (Phila Pa 1976). 1999;24: Waddell G, Howat TW. A technique of plating severe olecranon fractures. Injury. 1973;5: Bailey CS, MacDermid J, Patterson SD, King GJ. Outcome of plate fixation of olecranon fractures. J Orthop Trauma. 2001;15: Shin HD, Yang JH, Kim PS. Internal fixation using double plates for comminuted olecranon fractures in adults. J Korean Fract Soc. 2009;22: Buijze G, Kloen P. Clinical evaluation of locking compression plate fixation for comminuted olecranon fractures. J Bone Joint Surg Am. 2009;91: Tejwani NC, Garnham IR, Wolinsky PR, Kummer FJ, Koval KJ. Posterior olecranon plating: biomechanical and clinical evaluation of a new operative technique. Bull Hosp Jt Dis. 2002;61:

8 J Korean Soc Surg Hand Vol. 17, No. 1, March 2012 Fixation of Olecranon Fractures Using Plating System Ho-Jung Kang MD, Won-Yong Lee MD, Hyoung-Sik Kim, Il-hyun Koh MD, Yun-Rak Choi MD, Jae-Jeong Lee MD Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea Purpose: To evaluate the clinical and radiological outcomes of plate fixation for olecranon fractures which was difficult to be fixed firmly with tension band wiring alone. Materials and Methods: From 1995 through 2008, 20 patients who underwent plate fixation of an olecranon fracture were included in this retrospective study. According to the Mayo classification, there were 3 type IIA fracture, 7 type IIB, and 10 type IIIB fractures. Clinical evaluation was done based on radiographic union of olecranon and measurements of range of motion at last follow-up. Disability of the arm, shoulder and hand (DASH) score and Mayo Elbow Performance score was used for evaluation of functional recovery. Results: Union was achieved in 18 (90%) at an average of 5.6 months. The mean arc of elbow motion was 123 and the mean rotation arc was 81. According to the MEPS, sixteen of twenty patients had a good or excellent outcome. The mean DASH score was Most common complication was hardware irritation in 3 patients. Conclusion: Plate fixation is an effective treatment option for severe olecranon fracture pattern like comminuted fractures, Monteggia equivalent with unstable elbows and nonunions. Keywords: Olecranon, Olecranon fracture, Plate fixation, Indication Received: January 31, 2012 Revised: March 9, 2012 Accepted: March 12, 2012 Correspondence to: Jae-Jeong Lee MD Department of Orthopedic Surgery, Youngdong Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul , Korea TEL: FAX: drjaylee@naver.com 36

The Journal of the Korean Society of Fractures Vol.11, No.3, July, 1998 Department of Orthopaedic Surgery, College of Medicine Chungnam National Unive

The Journal of the Korean Society of Fractures Vol11, No3, July, 1998 Department of Orthopaedic Surgery, College of Medicine Chungnam National University Hospital, Taejon, Korea and Taejon Sungshim General