Original Article J Korean Orthop Assoc 2011; 46: 231-236 doi:10.4055/jkoa.2011.46.3.231 www.jkoa.org 급성후방십자인대경골부견열손상의관혈적내고정 - 임상적결과와술전 3D-CT 의유용성 - Open Repair of Acute Tibial Avulsion Injury of Posterior Cruciate Ligament - Clinical Outcomes and Usefulness of Preoperative 3-D CT - 박종혁 왕성일 이주홍 최희락전북대학교의학전문대학원정형외과학교실 목적 : 후방십자인대경골부견열손상에서후내측도달법에의한관혈적내고정을실시하고임상적결과와술전에시행한 3차원전산화단층촬영 (3D-CT) 의유용성을알아보았다. 대상및방법 : 2004년 7월부터급성후방십자인대경골부견열손상 33예중단독손상이면서 1년이상추시가능한 22예를대상으로후향적으로연구하였다. 후내측도달법을통해골편의크기에따라금속나사, 견인봉합, 또는 staple 을이용하여내고정을시행하고후방전위검사와 Telos 기기를이용한방사선후방부하검사에따른후방안정성, 관절운동범위및 Tegner 점수로임상적결과를평가하였다. 또한견열된골편의크기, 시인성, 분쇄, 전위및관절내연장여부를술전에시행한일반방사선사진과 3D-CT를비교하였다. 결과 : 관절운동범위는건측에비해 10 o 굴곡제한 4예와 10 o 신전제한 1예가있었다. 술후후방안정성은후방전위검사에서 1도의후방전위 2예를제외하고음성을보였고 Telos를이용한방사선부하검사는평균 0.57±0.4 mm였다. Tegner 점수는술전평균 6.7±0.9 이었으나최종추시에서 6.2±0.7로술전상태로회복되었으며 (p>0.05) 한편 3D-CT는일반방사선사진에비해시인성 55.6%, 분쇄정도 50%, 완전전위여부는 44.4% 에서향상된정확도를보였다. 결론 : 급성후방십자인대경골부견열손상에서후내측도달법을통해골편크기에따라적절한수단의내고정을시행하여우수한임상적결과를얻었으며술전에시행한 3D-CT는골절양상을파악하고내고정방법을선택하는데유용하였다. 색인단어 : 후방십자인대, 경골부견열손상, 관혈적내고정, 3 차원전산화단층촬영 서론 후방십자인대의실질부단독손상이나견열골절은슬관절이굴곡된상태에서낙상이되거나자동차사고시 dashboard 에굴곡된경골이가격당하면서발생한다. 수술적치료의필요성에대해상반된의견이존재하는후방십자인대실질부의단독손상에비해후방십자인대경골의견열골절은인대가부착된골편을해부학적으로정복하여인대의길이를회복하고견고한고정 접수일 2010 년 5 월 30 일게재확정일 2011 년 1 월 31 일교신저자이주홍전북전주시덕진구금암동 634-18, 전북대학교병원정형외과 TEL 063-250-1760, FAX 063-271-6538 E-mail jhlee55@chonbuk.ac.kr 을통한조기관절운동을위해조기에견열된골편을고정하는것이일반적이다. 1-3) 경골부견열골절의수술적치료에는관혈적정복술과관절경적봉합술식이있다. 1945년 Abbot 가슬와부에대한직접도달법을기술한이래 Trickey 4) 가후방도달법을이용한관혈적정복술을처음소개하였고 Burks 와 Schaffer 5) 가기존의후방도달법의신경혈관손상문제를해결하기위해보다간편한접근법을제시한바있다. 한편관절경술기의발달로다양한형태의관절경적봉합술식들이발표되고있다. 6-10) 견열된골편고정에는봉합사, 금속나사, 생체흡수성나사등다양한고정방법들이사용되나 11-13) 견열골절의빈도가낮아고정방법들간의비교연구는드물며특히후방십자인대견열골절은동반손상이흔히존재하여일반방사선사진에서간과하기쉽고 14) 골편의크기, 분쇄정도및전위를평가하기어려워술전 대한정형외과학회지 : 제 46권제 3호 2011 Copyright 2011 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
232 박종혁 왕성일 이주홍외 1 인 치료계획을세우는데 3차원전산화단층촬영 (3D-CT) 이권장되고있다. 15) 본연구는후방십자인대경골견열골절에대해금속나사, Staple 또는견인봉합술을이용하여관혈적내고정을시행하고임상적결과와술전에시행한 3D-CT 의유용성을평가하였다. 대상및방법 1. 연구대상 2004년 7월부터 2009년 1월까지급성후방십자인대경골부견열골절에대해관혈적도달법에의한골편고정을시행하고 12개월이상추시가가능하였던 33예에서반월상연골판이나전방십자인대파열, 그리고측부인대가손상된경우를제외한 22예의단독손상을대상으로후향적으로연구하였고타부위골절의동반은이에포함시켰다. 수상부터수술하기까지시간은평균 10.2일 ( 범위 : 3-18일 ) 이었고, 손상원인은자동차운전자사고 14예, 보행자사고 2예, 스포츠나낙상으로발생한손상이 6예였다. 평균연령은 39세 ( 범위 : 12-68세 ) 였고 68세환자의경우관절의퇴행성변화가경도이고농사일과같은활동성이높은일에종사하여수술적치료를시행하였다. 추시기간은평균 23.98개월 ( 범위 :12-60 개월 ) 었다. 2. 수술술기모든예는 Burks 와 Schaffer 5) 의후내측도달법을통해견열부위를노출하고골편을정복한다음골절편의크기와분쇄정도에따라골편의크기가최소 3.5 mm 직경의나사고정이가능한크기이면피질골나사와 washer 를이용한내고정, 금속나사고정이어려운크기지만일부골절편의형태가유지되는경우는 staple 내고정, 일부골절편의형태가유지되고있지않으면후방십자인대원위부를 No. 5 ethibond를이용하여 Bunnell 또는 Krackow 방법으로봉합한다음봉합사를경골을통과시켜경골전방에서고정하여정복을유지한채로 staple 고정을시행하였으며골절편의분쇄로크기가너무작으면후방십자인대원위부를봉합하여경골전방으로견인하여고정을시행하였으며피질골나사와 washer 고정은 9예, 견인봉합술 5예, staple 고정 4예, staple 과추가적인견인봉합술은 4예였다. 4. 임상적검사모든환자에서수술전슬관절전후방및측면단순방사선검사를시행하였고 4예를제외하고 3D-CT(Sensation 16, Somatom, Siemens, Germany) 를통해골편의시인성, 건열된골편의크기, 분쇄및전위정도, 그리고견열골절의관절내연장여부등을일반방사선사진과평가하였다. 시인성은견열골편이일반방사선사진의전후및측면사진에서관찰이가능한지여부로정의하였고분쇄는 2개이상의견열골편이존재하는경우, 전위정도는 Meyers와 McKeever 16) 가제시한골절편의분리정도를기준으로하였으며견열골절의관절내연장여부는후방십자인대부착범위이상의골절로정의하였다. 또한자기공명영상을통해동반손상여부를확인하였다. 술후임상적결과는후방전위검사, 관절운동범위, Tegner 점수, Telos를이용한후방부하방사선검사로평가하였으며 Telos 기기를이용한후방부하검사의경우건측과의차이가 5 mm 이상이면불안정성으로간주하였다. 그러나수술전에는골절에의한통증으로정확한계측이어렵고검사로인해골절편의전위를더욱조장할수있어부하검사를시행하지않았다. 한편, 방사선계측에있어서관찰자내변이를나타내는 Intraclass Correlation Coefficients (ICC) 를평가하였으며, 통계학적분석은 SPSS version 12.0 (SPSS Inc., Chicago, IL, USA) 을이용하여 Unpaired t-test를이용하여수술전후 Tegner 점수를비교하고유의수준은 0.05 이하로하였다. 결과 1. 임상적결과최종추시에서의관절운동범위는건측과비교하여 16예에서정상범위의관절운동을보였고 10 o 의신전제한 1예와 10 o 의굴곡제한 4예가관찰되었으나일상적활동에는불편감을호소하지않았다. 술전후방전위검사에서 2도를보인모든환자들은최종추시에서 1도의후방전위 2예를제외하고모두음성이었으며 Telos를이용한방사선후방부하검사는건측과 2 mm 이내차이가 21예와 3 mm 차이 1예로평균 0.57±0.4 mm ( 범위 : 0.5-3 mm) 이었으며방사선계측에있어서관찰자내변이를나타내는 ICC 값은 0.93로우수하였다. 한편, Tegner 점수는술전 6.7±0.9에서최종추시상 6.2±0.7로술전상태로회복되었다. 3. 재활수술후첫 2주간은슬관절을완전신전위로장하지석고고정을실시하였다. 슬개골전위운동, 하지직거상및대퇴사두고근등장성운동을수술후 1일째부터시행하였으며이후석고고정을제거하고복와위상태에서능동및능동보조관절운동을시행하였다. 부분체중부하는 4주이후에허용하였으며가벼운운동은일반적으로골유합이이루어지는 3개월이후에시작하였다. 2. 일반방사선사진과 3D-CT에의한견열골편양상후방십자인대경골견열골절 22예중 18예에서 3D-CT 촬영이가능하였으며이를수상당시촬영한슬관절전후방및측면단순방사선사진과비교하였을때단순방사선사진은 8예 (44.4%) 에서만모든방향에서골편의관찰이가능하였던반면 3D-CT 는모든예에서관찰되었고분쇄정도는 18예중 6예 (33.3%) 에비해 15예 (85%), Meyers와 McKeever 16) 의골절편분리정도에관한분
233 급성후방십자인대경골부견열손상의관혈적내고정 - 임상적결과와술전 3D-CT 의유용성 - 류상제 3형전위여부는 10예 (55.6%) 에비해전예에서확인되어 3D-CT 를통해향상된견열골편양상에대한분석이가능하였다 (Table 2, Fig. 1). 한편, 방사선계측에있어서관찰자내변이를나타내는 ICC 값은단순방사선사진측정은 0.91, 3D-CT 는 0.94로우수하였다. 3. 견열골편과고정방법간의관계고정방법에따른골편양상은금속나사고정한예에서골편크기가가장컸던반면견인봉합술을시행한경우에골절편의크기가가장작고모든예에서분쇄가존재하였으나전위나골절의관절내연장에서의차이는보이지않았다 (Table 2, 3). Table 1. Clinical Outcomes according to Fixation Methods Posterior drawer test Screw Negative:8 GI: 1 Staple Negative: 3 GI: 1 Pull out suture & Staple Range of motion Teger scores SSD using Telos device* 138.3 (125-140) 6.1 0.37 (0.5-2) 135 (130-140) 6.3 1 (1-3) Negative: 4 137.5 (130-140) 6.2 0 Pull out suture Negative: 5 140 6.2 0.5 (0.5-1) *side to side difference using Telos device (mm). Table 2. Comparision of Radiography & CT in Visibility and Patterns of Avulsed Fragment Radiographs 3D-CT Improved by CT Visibility (i.e., all 8/18 (44.4%) 18/18 (100%) 10/18 (55.6%) margins seen) Comminution 6/18 (33.3%) 15/18 (85%) 9/18 (50%) Displacement Type I (minimal) 1/18 (5.5%) Type II (hinged) 7/18 (38.9%) 18/18 (100%) 8/18 (44.4%) Type III (complete) 10/18 (55.6%) Extension 6/18 (33.3%) 10/18 (55.6%) 4/18 (22.2%) 4. 동반손상및합병증후방십자인대견열골절과동반된골절은슬관절주위골절이 8예에서존재하였으며후방십자인대경골견열골절고정에서사용된금속내고정물에의한합병증은물론신경마비나창상에관련된문제점들은관찰되지않았다. 고찰 혈관분포가풍부한후방십자인대는급성손상시중력에따른 Table 3. Characteristics of Avulsed Fragment according to Fixation Methods Bony fragment Comminution Displacement Extension size* Screw ( 9 cases ) Staple ( 4 cases ) 15.7 15.4 8.8 2 Pull out suture & Staple ( 4 cases ) Pull out suture ( 5 cases ) *Bony fragment size, length width depth (mm). 24.6 12.2 8.5 5 All in GIII 6 1 in GII 3 in GII 15.3 9.6 5.2 3 All in GIII 1 11.6 7.0 3.0 5 All in GIII 2 1 Figure 1. A 33-year-old woman with a knee injury sustained during a fall. (A) AP and lateral radiographs of the knee revealed mildly displaced avulsed fragment, but not determined the degree of comminution. (B) A 3D-CT image of the knee definitely showed comminution and displacement of avulsed fragment. (C) Fixation of avulsed tibial fragment of PCL with a pull out suture and staple and lastest follow up stress view using Telos device.
234 박종혁 왕성일 이주홍외 1 인 경골의후방전위를방지하면자연치유를기대할수있어보존적치료가선택되는실질부단독손상에비해 17,18) 후방십자인대경골견열골절에서전위가있는경우에해부학적정복과내고정을통해인대길이를회복시키고조기관절운동을가능케할것을권장하고있다. 2-4) 저자들이사용한관혈적내고정을위한도달법은 Burks 와 Schaffer 5) 가제시한후내측도달법으로기존의후방도달법에의한신경혈관손상의문제점을피하기위해고안되었다. 이는비복근의내측과반막양건사이로접근하면서비복근내측두를외측으로견인함으로써후내측관절막을노출시키고슬와신경과혈관을보호할수있으며후방십자인대외측면과후외측관절막노출이일부제한되기도하나필요하면비복근내측두의기시부일부를제한적으로유리시키는데슬관절굴곡각도를적절히조절하고족부의족저굴곡으로종아리근육의긴장도를감소시킴으로써전예에서어려움없이골편고정을위한시야확보가가능하였다. 후방십자인대경골부견열손상은다양한형태의동반손상이존재하며수상당시에시행하는단순방사선사진은슬관절주위연부조직손상에의한부종및경골부골편이근위경골과겹쳐보여일부방향에서는골편을관찰하기가어려워간과하기쉬우므로 14) 면밀한관찰이필요하다. 또한견열된골편에대한정확한평가가어려워술전계획을위해 CT 가권장되는데 15) 저자들은슬관절전후방및측면단순방사선사진에비해 3D-CT 는견열된골편의 100% 시인성과전위정도는물론분쇄정도및관절내연장여부를파악할수있어술전계획에도움을얻을수있었다. 후방십자인대경골부견열골절에는여러고정방법들이있으며 Seits 등 12) 은후방십자인대견열골절을후방도달법으로관혈적 K-강선내고정 16예, 금속나사내고정 14예를시행하여두방법간의차이없는좋은결과를보고하였고, Zhang 등 13) 은생체흡수성나사고정을보고하였다. 실제견열된골편의크기및골절양상에따라고정방법의선택은불가피하다. Kim 등 7) 은골절편이작을경우 (<10 mm) 다발성봉합사고정, 중간크기일경우 (10-20 mm) 다발성핀고정, 골절편이클경우 (>20 mm) 금속나사고정을시행할것을제시하였으며 Berg 등 19) 은골절편의크기가금속나사직경의 3배이상되어야효과적인고정이가능하다하였다. 저자들은 3D-CT 상골편의크기와분쇄정도를파악하고수술시야에서내고정방법을선택하였다. 술후임상적평가및 Telos를이용한부하검사에서고정방법간의차이는없었고전예에서수상이전의활동수준으로복귀가가능하였다. 이는기존의결과와유사하며인대실질부손상과달리조기에적극적인수술적내고정으로일관되게우수한임상적결과를보였다. 그러나후방도달법을통한고정술은동반된슬관절내손상이있으면체위변경없이동시에치료하기가어려우며불가피하게근육이나후방관절막을광범위하게노출시켜야하는제한점이 있어 K-강선, staples, 금속나사, 봉합사와같은여러기기들을이용한관절경적고정을통해좋은결과가보고되고있다. 6-8,10,20,21) 그러나관절경적정복술은술기습득이어렵고신경혈관손상이잠재되어있으며경골고평부까지침범한큰크기의골편이면관절경적정복이용이치못해적응증이되지못한다. 10) 또한후방십자인대경골견열골절은수상기전상슬관절주위로심한연부조직손상이동반되는경우가흔하여관절경의관절내시야확보가어려울수있고구획증후군의위험도가존재한다. 또한 Shino 등 9) 이후방십자인대경골부견열골절에대해삽입한금속나사가후방십자인대실질부를자극하여굴곡시통증을유발시킬수있어치유후에금속나사의제거가필요하기도하므로용이한나사못제거를위해서는전방에서후방으로의나사못고정을제안하였으나전방에서후방으로의금속나사고정은견고한압박고정을얻기가어려우며금속나사의삽입동안에골절간격을신연시킴으로써불유합이발생될수있다. 22) 저자들의경우에는관혈적내고정후고정물에의해굴곡시통증을유발하여내고정의제거가필요한경우는없었다. 저자들의연구는후향적이며내고정방법에따른비교가가능할정도의많은증례가아니어서내고정선택기준의일반화을제시할수없다. 그러나동반손상없이단독으로후방십자인대경골부견열골절이존재하는빈도가적어전향적연구를시행하기는어려우나인대손상이면서일종의골손상이므로짧은추시기간에도우수한결과를얻을수있었으며다양한형태의견열골절에도관혈적접근을통해여러내고정방법을이용한내고정이항상가능하여정상수준의후방안정성을회복할수있었다. 결론 급성후방십자인대경골부견열손상에서안전한후내측관혈적도달법을통해골편크기에따라적절한수단의내고정을시행하여우수한임상적결과를얻었으며술전에시행한 3D-CT 는골절양상을정확히파악하고내고정방법을선택하는데유용하였다. 참고문헌 1. Clancy WG, Shelbourne KD, Zoellner GB, Keene JS, Reider B, Rosenberg TD. Treatment of knee joint instability secondary to rupture of the posterior cruciate ligament. Report of a new procedure. J Bone Joint Surg Am. 1983;65:310-22. 2. St Pierre P, Miller MD. Posterior cruciate ligament injuries. Clin Sports Med. 1999;18:199-221. 3. Torisu T. Isolated avulsion fracture of the tibial attachment of the posterior cruciate ligament. J Bone Joint Surg Am.
235 급성후방십자인대경골부견열손상의관혈적내고정 - 임상적결과와술전 3D-CT 의유용성 - 1977;59:68-72. 4. Trickey EL. Rupture of the posterior cruciate ligament of the knee. J Bone Joint Surg Br. 1968;50:334-41. 5. Burks RT, Schaffer JJ. A simplified approach to the tibial attachment of the posterior cruciate ligament. Clin Orthop Relat Res. 1990;254:216-9. 6. Deehan DJ, Pinczewski LA. Arthroscopic reattachment of an avulsion fracture of the tibial insertion of the posterior cruciate ligament. Arthroscopy. 2001;17:422-5. 7. Kim SJ, Shin SJ, Choi NH, Cho SK. Arthroscopically assisted treatment of avulsion fractures of the posterior cruciate ligament form the tibia. J Bone Joint Surg Am. 2001;83:698-708. 8. Martinez-Moreno JL, Blanco-Blanco E. Avulsion fractures of the posterior cruciate ligament of the knee. An experimental percutaneous rigid fixation technique under arthroscopic control. Clin Orthop Rel Res. 1988;237:204-8. 9. Shino K, Nakata K, Mae T, Yamada Y, Shiozaki Y, Toritsuka Y. Arthroscopic fixation of tibial bony avulsion of the posterior cruciate ligament. Arthroscopy. 2003;19:E12. 10. Zhao J, He Y, Wang J. Arthroscopic treatment of acute tibial avulsion fracture of the posterior cruciate ligament with suture fixation technique through Y-shaped bone tunnels. Arthroscopy. 2006;22:172-81. 11. Jazayeri SM, Esmaili Jah AA, Karami M. A safe postero-medial approach to posterior cruciate ligament avulsion fracture. Knee Surg Sports Traumatol Arthrosc. 2009;17:244-7. 12. Seits H, Schlenz I, Pajenda G and Vecsei V. Tibial avulsion fracture of the posterior cruciate ligament: K-wire or screw fixation? A retrospective study of 26 patients. Arch Orthop Trauma Surg. 1997;116:275-8. 13. Zhang CL, Xu H, Li MQ. Posteromedial approach of gastrocnemius for reduction and internal fixation of avulsed tibial attachment of posterior cruciate ligament. Chin J Traumatol. 2006;9:25-8. 14. Meyers MH. Isolated avulsion of the tibial attachment of the posterior cruciate ligament of the knee. J Bone Joint Surg Am. 1975;57:669-72. 15. Griffith JF, Antonio GE, Tong CW, Ming CK. Cruciate ligament avulsion fractures. Arthroscopy. 2004;20:803-12. 16. Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am. 1970;52:1677-84. 17. Jung YB, Kim JS, Jung HJ, Jeong PH. Conservative treatment of acute isolated injuries to the posterior cruciate ligament - prospective study-. J Korean Knee Soc. 2002;14:193-9. 18. Peterson CA 2nd, Warren RF. Management of acute and chronic cruciate ligament injuries. Am J Knee Surg. 1996;9:172-84. 19. Berg EE. Comminuted tibial eminence anterior cruciate ligament avulsion fracture: failure of arthroscopic treatment. Arthroscopy. 1993;9:446-50. 20. Choi NH, Kim SJ. Arthroscopic reduction and fixation of bony avulsion of the posterior cruciate ligament of the tibia. Arthroscopy. 1997;13:759-62. 21. Littlejohn SG, Geissler WB. Arthroscopic repair of a posterior cruciate ligament avulsion. Arthroscopy. 1995;11:235-8. 22. Nicandri GT, Klineberg EO, Wahl CJ, Mills WJ. Treatment of posterior cruciate ligament tibial avulsion fractures through a modified open posterior approach: operative technique and 12- to 48-month outcomes. J Orthop Trauma. 2008;22:317-24.
236 박종혁 왕성일 이주홍외 1 인 Open Repair of Acute Tibial Avulsion Injury of Posterior Cruciate Ligament - Clinical Outcomes and Usefulness of Preoperative 3-D CT - Jong-Hyuk Park, M.D., Sung-Il Wang, M.D., Ju-Hong Lee, M.D., and Hee Rack Choi, M.D. Department of Orthopedic Surgery, Chonbuk National University Medical School, Jeonju, Korea Purpose: To evaluate the clinical outcome of open repair of acute tibial posterior cruciate ligament (PCL) tibial avulsion injury using the posteromedial approach, and to examine the usefulness of pre-operative 3D-computed tomography (CT) imaging. Materials and Methods: From July 2004 onwards, among the 33 patients with acute tibial avulsion injury of the PCL, 22 patients were available for a 1-year follow-up. Patients underwent internal fixation using screws, pullout sutures or staples through the posteromedial approach. Clinical evaluations were performed using the posterior drawer test, posterior drawer stress x-ray, range of motion and Tegner score. In addition, size of the fragment, visibility, comminution, displacement and presence of extension were studied and were compared to the pre-operative X-ray and 3D-CT imaging. Results: Four cases demonstrated 10-degree restriction in flexion and 1 case demonstrated 10-degree restriction in extension compared to the unaffected side. Except for the 2 cases which had Grade I posterior instability on the posterior drawer test, the results of the post-operative joint stability were negative and the posterior drawer stress X-ray using the Telos device showed an average of 0.57±0.4 mm. Like the average pre-operative Tegner score of 6.7±0.9, the Tegner score was restored to 6.2±0.7 (p>0.05) at the last follow-up. 3D-CT showed an improved accuracy in visibility (55.6%), comminution (50%) and displacement (44.4%) compared to the simple X-ray. Conclusion: The acute tibial avulsion injury treated with the appropriate internal fixation through the posteromedial approach based on the fracture size demonstrated exellent outcomes. The pre-operative 3D-CT was useful for identifying the fracture pattern and choosing the appropriate internal fixation. Key words: posterior cruciate ligament, tibial avulsion injury, open repair, 3D-CT Received May 30, 2010 Accepted January 31, 2011 Correspondence to: Ju-Hong Lee, M.D. Department of Orthopedic Surgery, Chonbuk National University Medical School, 634-18, Keumam-dong, Duckjin-gu Jeonju 561-712, Korea TEL: +82-63-250-1760 FAX: +82-63-271-6538 E-mail: jhlee55@chonbuk.ac.kr