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1 358 pissn : , eissn : Original Article J Korean Orthop Assoc 2018; 53: 원위요골골절에서전방금속판나사못의삽입방법에따른고정안정성및신전건손상빈도에대한비교 주민욱 강한빛 유기원 박민식 가톨릭대학교의과대학성빈센트병원정형외과 Comparison of Fixation Stability and Incidence of Extensor Tendon Injury according to the Screw Insertion Method in Volar Plate Fixation for Distal Radius Fractures Min Wook Joo, M.D., Ph.D., Han-Vit Kang, M.D., Kee-Won Rhyu, M.D., Ph.D., and Min-Sik Park, M.D. Department of Orthopaedic Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea Purpose: This retrospective study was aimed to analyze the differences in stability and extensor impairment after two different volar plating procedures to manage unstable distal radius fracture, which were the penetration of only near-cortex followed by screw fixation (Group 1) and perforation of dorsal cortex by drill-bit followed by fixation with the screws downsized after gauging (Group 2). Materials and Methods: We reviewed the medical records of 491 patients with distal radius fracture treated with standard-sized, targeted distal radius plate in two institutions between April 2009 and May Finally, 341 patients with complete demographic data, records of AO classification of fractures, data on the lengths of inserted distal screws, radiologic parameters immediately and at 3 months after operation, as well as extensor impairments, were included in this study. There were 112 patients (98 women and 14 men) in Group 1, and 229 patients (171 women and 58 men) in Group 2. The mean age was 59.8 years for all the patients; 60.3 years in Group 1 and 59.5 years in Group 2. Results: The mean length of the longest screws used in Group 2 was longer than that in Group 1; however, the mean length of the shortest screws used in Group 2 was shorter than that in Group 1. While the differences in changes for radial inclination measured immediately and at 3 months after the operation were statistically significant (p=0.019), the change of radial inclination in Group 2, which showed a greater change, was only 0.5 mm. There were two cases with extensor pollicis longus rupture in Group 1 and 2 respectively, and the difference in frequency according to each Group was not statistically significant (p=0.6). Conclusion: The superiority of one surgical procedure in terms of fracture stability on measured radiological parameters was not fully proven compared with the other one in this study. Therefore, it would be better to selectively use the surgical method of dorsal cortex perforation viadrill-bit followed by fixation only in limited circumstances. Key words: radius, fracture, locking plate, extensor, stability 서론 Received September 29, 2017 Revised October 16, 2017 Accepted October 26, 2017 Correspondence to: Kee-Won Rhyu, M.D., Ph.D. Department of Orthopaedic Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, 93 Jungbu-daero, Paldal-gu, Suwon 16247, Korea TEL: FAX: kwrhyu@catholic.ac.kr ORCID: 정형외과술기의발달로원위요골골절의치료법도달라지고있다. 1) 과거에는원위요골골절에서후방금속판고정술을흔히사용하였는데, 금속판과건이인접하여신전건마찰과파열이흔하였다. 2-4) 이후로후방연조직의침범을피하면서안정적인고정이 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.

359 Screw Insertion Methods in Volar Plating for Distal Radius Fractures 가능한전방금속판고정술에관심을갖게되었고, 5-8) 신전건자극과손상의위험을줄일수있었다. 7,9-11) 그럼에도불구하고여전히그러한합병증이발생하고있으며, 오히려그빈도도증가하고있다.

2 359 Screw Insertion Methods in Volar Plating for Distal Radius Fractures 가능한전방금속판고정술에관심을갖게되었고, 5-8) 신전건자극과손상의위험을줄일수있었다. 7,9-11) 그럼에도불구하고여전히그러한합병증이발생하고있으며, 오히려그빈도도증가하고있다 ) 신전건손상의기전은돌출된나사못에의한마모나 drill bit에의한손상으로생각한다. 9,12,13,17-22) 신전건손상을피하기위해인접피질골만을통과하는나사못을사용하면후방연조직손상은줄일수있지만나사못이너무짧으면골절지지구조의기계적안정성을저해할수있다. 양측피질골 (bicortical) 나사못고정을하게되면후방피질골을뚫어야하며, 다양한방사선촬영법으로수술중에나사못의돌출여부를확인하고있지만, 정확히판단하기가쉽지않다. 13,23,24) 이에어떤술자들은측정된나사못길이보다 2 mm만큼짧은나사못을사용할것을제안한다. 9,25) 불안정성원위요골골절에서 drill bit로인접피질골만뚫은후나사못으로고정한경우 (1군) 와후방피질골까지뚫은후측정한길이보다짧은나사못으로고정한경우 (2군) 에수술후안정성및신전건손상에차이가있는지알아보고자후향적연구를시행하였다. 대상및방법 2009년 4월부터 2014년 5월까지전방요골금속판 (Acu-Loc VDR Plate; Acumed, Hillsboro, OR, USA) 으로수술받은원위요골골절환자 491명에대한의무기록을검토하였다. 인구학적특징, AO 분류법, 원위나사못의길이, 수술직후및 3개월후의방사선적지표, 신전건손상에대한자료를분석하였으며, K-강선, 또는골편간나사못으로추가고정한증례는제외하였다. 최소 20년의임상경험을가진 2명의수부외과전문의가각각의수술을시행하였다. 수술시지혈대를사용하였으며, extended flexor carpi radialis approach 10) 로수술을시행하였다. 골절을정복한뒤영상증폭기로위치를확인하며가이드 (guide) 를끼운금속판을적절한위치에놓았다. 피질골을뚫는동안천공침이후방골편을밀어내는것을방지하기위해가이드와원위골편을전후방으로압박하였다. 한술자는 drill bit에의한후방피질골의천공이없는나사못고정을시행하였고 (1군), 다른술자의는후방피질골을천공한뒤측정된길이보다짧은나사못으로고정하였다 (2군). 후방분쇄로후방피질골을뚫을수없는경우라도깊이측정기를이용하여길이를측정한후 2 mm 짧은나사못을사용한경우는 2군에포함하였다. 나사못길이를측정하는중에도가이드와골편에압박을유지하였다. 원위요골의후방에는경사면이있기때문에금속판의가장요측에있는 2개의구멍에서는실제보다나사못길이가길게측정되지않도록깊이측정기의갈고리를후외방으로향하여길이를측정하였다 (Fig. 1). 수술후 4주동안단상지부목 (Cock-up splint) 으로고정하였고, 수술 3개월이후 에는모든활동을허용하였다. 최종적으로 341명의환자를분석하였다. 두군모두에서여성이더많았고, 1군에는 112명의환자 ( 여성 98명과남성 14명 ), 2군에는 229명의환자 ( 여성 171명과남성 58명 ) 가속하였다. 전체평균연령은 59.8세 (17-87세) 이며, 1군은 60.3세 (25-80세), 2군은 59.5 세 (17-87세) 였다. 두군모두에서 C형골절이가장많았다. 1군에서 14명은 AO 분류 A3, 2명은 B3, 6명은 C1, 70명은 C2, 20명은 C3 였고, 2군에서 18명은 A2, 13명은 A3, 1명은 B3, 11명은 C1, 78명은 C2, 108명은 C3였다. 원위나사못의수와길이를검토하고, 가장긴나사못과가장짧은나사못의길이차이및나사못의평균길이를분석하였다. 영상프로그램을사용하여단순방사선사진에서요측길이, 경사및전방경사를측정하여골절고정의안정도를평가했다. 세명의서로다른정형외과의사가측정하여측정값들의평균을사용하였다. 신전건파열과건막염의발생유무를확인하고, 각군에따른신전건손상의빈도를분석하였다. 나사못길이에대해서는비대응표본 t-검정, 방사선적지표의측정값에대해서는 ANCOVA ( 공변량분석 ), 신전건손상의빈도에대해서는 Fisher의정확한검정으로통계분석하였고, p값이 0.05 미만인경우통계적으로유의한것으로정의하였다. 결과 모든환자에서 4개의원위나사못을삽입하였다. 나사못의평균길이는 1군에서 17.43±1.20 mm, 2군에서 17.71±1.64 mm였고, 통계적으로유의한차이는없었다 (p=0.071, 95% 신뢰구간, ). 가장긴나사못의평균길이는 1군에서 18.75±1.11 mm, 2군 Figure 1. According to the direction of the gauge hook, measurements can be different.

3 360 Min Wook Joo, et al. 에서 21.01±1.93 mm로 2군에서더길었으며, 이는통계적으로유의하였다 (p<0.001, 95% 신뢰구간, ). 가장짧은나사못의평균길이는 1군에서 15.39±1.25 mm, 2군에서 14.28±1.86 mm 였고, 그차이는통계적으로유의하였다 (p<0.001, 95% 신뢰구간, ). 수술직후및 3개월후에측정된방사선적지표에서요측길이및전방경사의변화차이는통계적으로유의하지않았지만 (p=0.134 and p=0.490), 요측경사의변화의차이는통계적으로유의하였으며 (p=0.019), 2 군에서그값이더많이감소하였다 (Table 1). 최소 9개월추시동안신전건의건막염은관찰되지않았다. 장무지신전건 (extensor pollicis longus, EPL) 파열의경우 1군에서 2 명 (1.8%), 2군에서 2명 (0.9%) 발생하였으며, 그빈도의차이는통계적으로유의하지않았다 (p=0.6). 고찰 이연구에서사용된원위요골금속판 (Acu-Loc VDR Plate; Acumed) 은일종의고정각수장측잠김금속판 (fixed angle volar locking plate) 이다. 전방금속판고정술에서원위요골금속판은원위연골하골에작용하여중화금속판으로서기능을한다. 또이금속판은잠김-나사 (locking-screw) 구조로서골절의고정을유지하기위해직접적으로골질에의존할필요가없으므로양측피질골나사못고정또는불필요하게긴나사못고정은필요하지않다. 하지만전방피질골만천공하고나사길이를경험적으로결정하면너무짧은나사를사용하여구조의안정성이떨어질가능성이있다. 수술후요측길이, 경사및전방경사각, 요수근관절의일치성, 원위요골의 S자형절흔관절면일치성을기준으로골절정복상태를평가할수있다. 22) 본연구에서수술후 3개월째두군간 요측길이와전방경사의변화차이는통계적으로유의하지않았지만요측경사는 1군에서더잘유지되었으며통계적으로유의한차이를보였고, 서로다른골질, 서로다른집도의의다른수술기법, 골절전원위요골의형태와크기, 최초골절의형태, 고정된금속판의 3차원적형태의차이가그원인일수있다. 하지만수술후 3개월째 2군의요골경사도수술직후에비해크게달라지지는않았다. 두군간수술후안정성의차이를명확히알기위해기타잠재요인들을확인해야하며, 미세변화를측정하기위한추가적인방사선적검사도고려할수있다. 신전건손상의원인에는수술기법과기구관련합병증 ( 예를들어, 돌출된후방나사못이나 drill bit에의한원위요골후방피질골천공 ) 뿐아니라골절발생으로인한건의기계적압박및혈관손상 ( 예를들어, 골편, 돌기, 골절부위의후방틈새, 혈종압박 ) 도있다 ,17-19) EPL은요골에서 Lister s 결절의척측에서요골구에둘러싸여좁고고정된경로를따라주행하며, 비교적혈액공급이부족하여신전건구획의직접손상이없더라도파열에취약하다. 26) 전방고정각금속판으로수술을한후약 2%-4% 에서 EPL 파열과건막염을포함한신전건손상이발생한다. 4,9,21) 따라서, 후방피질골을뚫었던 2군에서신전건손상의빈도가더높을것으로예상하였으나신전건손상중가장흔한 EPL 파열 12,13,15,17) 이각군에서 2명씩발생하였고, 군에따른빈도의차이는통계적으로유의하지않았다. 파열이발생한환자들은시지신건 (extensor indicis proprius) 건이전술로치료받았으며, 수술소견상돌출된나사나빈드릴구멍은관찰할수없었다. 두군모두에서신전건손상은골절자체에의한것일수있다. 본연구에서가장긴나사못의평균길이는 2군에서더길었으나예상과달리가장짧은나사의평균길이는 1군에서더길었다. 2군에서나사못길이를결정할때기본적으로깊이측정기가눈금의사이를가리킬경우더작은값을먼저선택하고그값에 Table 1. Mean Values of Radiologic Parameters with p-values Variable Group 1 Group 2 p-value* Radial length (mm) Immediately after operation 12.1 ( ) 12.0 ( ) Three months after operation 12.0 ( ) 11.7 ( ) Radial inclination ( ) Immediately after operation 23.2 ( ) 22.7 ( ) Three months after operation 23.2 ( ) 22.2 ( ) Volar tilt ( ) Immediately after operation 10.4 ( ) 11.7 ( ) Three months after operation 10.5 ( ) 11.0 ( ) Values are presented as median (range). Group 1 included the cases operated with penetration of only near-cortex followed by screw fixation. Group 2 included the cases operated with perforation of dorsal cortex by drill-bit followed by fixation with the screws downsized after gauging. *Comparison of changes in radiologic parameters between Group 1 and 2.

361 Screw Insertion Methods in Volar Plating for Distal Radius Fractures 되어수술직후및 3개월후의지표만을비교하였으며, 장기추시자료는포함하지않았다. 대부분신전건파열은골절후 1-3개월사이에발생하기때문에, 12) 최소 9개월간의추적검사기간은충분하다고생각한다.

4 361 Screw Insertion Methods in Volar Plating for Distal Radius Fractures 되어수술직후및 3개월후의지표만을비교하였으며, 장기추시자료는포함하지않았다. 대부분신전건파열은골절후 1-3개월사이에발생하기때문에, 12) 최소 9개월간의추적검사기간은충분하다고생각한다. 결론 방사선적지표상두수술법에따른수술후안정성의차이는확연하지않았다. 신전건손상의합병증도어느한경우에더많이발생하지않았다. 그러므로제한된경우에한하여선택적으로후방피질골을천공하는나사못삽입방법을사용하는것이바람직할것으로생각된다. Figure 2. Because of the inconsistent morphology of the distal radius dorsal cortex, the direction of the gauge hook can impact on the measurements. Especially, screw lengths can be measured longer around the stiff slope of Lister s tubercle. 서 2 mm 짧은길이를선택하였다. 측정기눈금의간격은 20 mm 이하길이에서는 2 mm, 20 mm 이상에서는 2.5 mm였다. 그러므로, 예를들어측정기가가리킨값이 20 mm 이상이면서눈금사이에위치할경우에는최대약 4 mm 정도짧은길이의나사못을선택할수도있다. 이로인해가장짧은나사못의평균길이가 2 군에서더짧았을수있다. 또한가장긴나사못은 Lister s 결절을향해삽입되고가장짧은나사는비교적더평평한후방피질을향해삽입되는데, Lister s 결절주변후방피질골을천공한뒤깊이를측정하면측정기가결절의경사면에걸리기때문에측정값은피질에서피질까지의정확한실제길이보다더길수있다 (Fig. 2). 신전건손상의예방을위해가장중요한점은적절한수술적방법의선택보다궁극적으로세심한수술술기에있다고생각한다. 만약술자가후방피질골을과격하게뚫지않는다면양측피질골 (bicortical) 고정을시행하여도 drill-bit에의한신전건구획의손상을줄일수있다. 어떤술자들은적절한굵기의 K-강선이드릴의절삭연 (cutting flute of drill) 에비해손상을덜준다고주장한다. 27) 최근연구와본연구에서일반적으로사용되는전방잠금금속판의 고위험 구멍을알수있으며, 1) 해당구멍을사용할시더주의해야할것이다. 본연구의제한점으로방사선사진촬영각의미세한차이와각수술에사용된나사의총개수가일정하지않은점 ( 범위, 6-8개 ), 수술기법의차이가있을수있는두술자의결과를비교하였다는점, 나사못이요골관절면과얼마나가깝게위치하느냐가골절고정의안정성에영향을줄수있다는점을생각할수있고, 향후연구에서는더정교한통제가필요할것이다. 수술기법수술후 3개월이후에는방사선적지표에큰변화가없을것으로예상 CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Perry DC, Machin DM, Casaletto JA, Brown DJ. Minimising the risk of extensor pollicis longus rupture following volar plate fixation of distal radius fractures: a cadaveric study. Ann R Coll Surg Engl. 2011;93: Jakob M, Rikli DA, Regazzoni P. Fractures of the distal radius treated by internal fixation and early function. A prospective study of 73 consecutive patients. J Bone Joint Surg Br. 2000;82: Ring D, Jupiter JB, Brennwald J, Büchler U, Hastings H 2nd. Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures. J Hand Surg Am. 1997;22: Rozental TD, Beredjiklian PK, Bozentka DJ. Functional outcome and complications following two types of dorsal plating for unstable fractures of the distal part of the radius. J Bone Joint Surg Am. 2003;85: Kamano M, Honda Y, Kazuki K, Yasuda M. Palmar plating for dorsally displaced fractures of the distal radius. Clin Orthop Relat Res. 2002;397: Liporace FA, Gupta S, Jeong GK, et al. A biomechanical comparison of a dorsal 3.5-mm T-plate and a volar fixed-angle plate in a model of dorsally unstable distal radius fractures. J Orthop Trauma. 2005;19: Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand

5 362 Min Wook Joo, et al. Surg Am. 2002;27: Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg Am. 2004;29: Arora R, Lutz M, Hennerbichler A, Krappinger D, Espen D, Gabl M. Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate. J Orthop Trauma. 2007;21: Orbay JL. The treatment of unstable distal radius fractures with volar fixation. Hand Surg. 2000;5: Smith DW, Henry MH. Volar fixed-angle plating of the distal radius. J Am Acad Orthop Surg. 2005;13: Al-Rashid M, Theivendran K, Craigen MA. Delayed ruptures of the extensor tendon secondary to the use of volar locking compression plates for distal radial fractures. J Bone Joint Surg Br. 2006;88: Benson EC, DeCarvalho A, Mikola EA, Veitch JM, Moneim MS. Two potential causes of EPL rupture after distal radius volar plate fixation. Clin Orthop Relat Res. 2006;451: Engkvist O, Lundborg G. Rupture of the extensor pollicis longus tendon after fracture of the lower end of the radius: a clinical and microangiographic study. Hand. 1979;11: Failla JM, Koniuch MP, Moed BR. Extensor pollicis longus rupture at the tip of a prominent fixation screw: report of three cases. J Hand Surg Am. 1993;18: McKay SD, MacDermid JC, Roth JH, Richards RS. Assessment of complications of distal radius fractures and development of a complication checklist. J Hand Surg Am. 2001;26: Wong-Chung J, Quinlan W. Rupture of extensor pollicis longus following fixation of a distal radius fracture. Injury 1989;20: De Maeseneer M, Marcelis S, Osteaux M, Jager T, Machiels F, Van Roy P. Sonography of a rupture of the tendon of the extensor pollicis longus muscle: initial clinical experience and correlation with findings at cadaveric dissection. AJR Am J Roentgenol. 2005;184: Lee HC, Wong YS, Chan BK, Low CO. Fixation of distal radius fractures using AO titanium volar distal radius plate. Hand Surg. 2003;8: Ruch DS, Papadonikolakis A. Volar versus dorsal plating in the management of intra-articular distal radius fractures. J Hand Surg Am. 2006;31: Drobetz H, Kutscha-Lissberg E. Osteosynthesis of distal radial fractures with a volar locking screw plate system. Int Orthop. 2003;27: Nana AD, Joshi A, Lichtman DM. Plating of the distal radius. J Am Acad Orthop Surg. 2005;13: Maschke SD, Evans PJ, Schub D, Drake R, Lawton JN. Radiographic evaluation of dorsal screw penetration after volar fixed-angle plating of the distal radius: a cadaveric study. Hand (N Y). 2007;2: Ozer K, Wolf JM, Watkins B, Hak DJ. Comparison of 4 fluoroscopic views for dorsal cortex screw penetration after volar plating of the distal radius. J Hand Surg Am. 2012;37: Musgrave DS, Idler RS. Volar fixation of dorsally displaced distal radius fractures using the 2.4-mm locking compression plates. J Hand Surg Am. 2005;30: Hirasawa Y, Katsumi Y, Akiyoshi T, Tamai K, Tokioka T. Clinical and microangiographic studies on rupture of the E.P.L. tendon after distal radial fractures. J Hand Surg Br. 1990;15: McCann PA. Comment on: minimising the risk of extensor pollicis longus rupture following volar plate fixation of distal radius fractures: a cadaveric study. Ann R Coll Surg Engl. 2011;93:494.

6 363 pissn : , eissn : Original Article J Korean Orthop Assoc 2018; 53: 원위요골골절에서전방금속판나사못의삽입방법에따른고정안정성및신전건손상빈도에대한비교 주민욱 강한빛 유기원 박민식 가톨릭대학교의과대학성빈센트병원정형외과 목적 : 불안정성원위요골골절에서 drill bit 로인접피질골만뚫은후나사못으로고정한경우 (1 군 ) 와후방피질골까지뚫은후측정 한길이보다짧은나사못으로고정한경우 (2군) 에수술후안정성및신전건손상에차이가있는지알아보고자후향적연구를시행하였다. 대상및방법 : 2009년 4월부터 2014년 5월까지전방요골금속판으로수술받은원위요골골절환자 491명에대한의무기록을검토하였으며, 최종적으로 341명에대해인구학적특징, AO 분류법, 원위나사못의길이, 수술직후및 3개월후의방사선적지표, 신전건손상에대한자료를분석하였다. 1군에는 112명의환자 ( 여성 98명과남성 14명 ), 2군에는 229명의환자 ( 여성 171명과남성 58 명 ) 가속하였으며, 평균연령은 59.8세, 1군에서는 60.3세, 2군에서는 59.5세였다. 결과 : 가장긴나사못길이의평균은 2군에서더길었으나가장짧은나사못길이의평균은 1군에서더길었다. 수술직후및 3개월후에측정한요측경사의차이는통계적으로유의하였으나 (p=0.019), 더큰변화를보인 2군에서그변화는 0.5 mm에불과하였다. 1, 2군에서장무지신전건파열은각각 2예였으며, 각군에따른빈도의차이는통계적으로유의하지않았다 (p=0.6). 결론 : 방사선적지표상두수술법에따른수술후안정성의차이는확연하지않았다. 신전건손상의합병증도어느한경우에더많이발생하지않았다. 그러므로제한된경우에한하여선택적으로후방피질골을천공하는나사못삽입방법을사용하는것이바람직할것으로생각된다. 색인단어 : 요골, 골절, 잠김금속판, 신전건, 안정성 접수일 2017 년 9 월 29 일수정일 2017 년 10 월 16 일게재확정일 2017 년 10 월 26 일책임저자유기원 16247, 수원시팔달구중부대로 93, 가톨릭대학교의과대학성빈센트병원정형외과 TEL , FAX , kwrhyu@catholic.ac.kr, 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.

황지웅

황지웅 Comparison of Laparoscopy and Exploration in the Distal Pancreatectomy BACKGROUND: To determine the benefits of laparoscopic surgery compared with exploration, the clinical outcomes of open and laparoscopic