ISSN 1225-1682 (Print) ISSN 2287-9293 (Online) 대한골절학회지제 29 권, 제 2 호, 2016 년 4 월 J Korean Fract Soc 2016;29(2):101-106 http://dx.doi.org/10.12671/jkfs.2016.29.2.101 Original Article 정형외과적내고정물제거술전, 후의삶의질비교 고상봉 채승범 대구가톨릭대학교병원정형외과 Comparison of Quality of Life between Before and After Orthopaedic Implant Removal Surgery Sang Bong Ko, M.D., Seung-Bum Chae, M.D. Department of Orthopaedic Surgery, Daegu Catholic University Medical Center, Daegu, Korea Purpose: The purpose of this study is to determine whether or not a patient s results are improved after removal of an internal fixative from a patient with no related symptoms. Materials and Methods: This prospective study included 87 patients who agreed to participate in the study and satisfied the criteria for selection and exclusion of patients who underwent the operation for removal of internal fixative due to broken bones from March 1st, 2004 to December 31st, 2011 at Daegu Catholic University Medical Center. The average replication period was 27 months (12-64 months) and the average age at the time of the operation for removal was 41.5 years (21-75 years) for 55 males and 32 females. The quality of life for all patients was evaluated using Short Form 36 (SF-36) surveys before the operation for removal and after a minimum of one year. Results: After an orthopedic operation for removal of internal fixative, physical health status showed statistically significant improvement (p=0.001); however mental health status did not (p=0.411). A satisfaction test for the subjective surgery written by patients indicated an improvement of subjective health status in 52.9% after the surgery for removal but with no difference in 29.9% compared to preoperation. Conclusion: In case of an operation for removal of internal fixative for patients with no related symptoms with internal fixatives used for treatment of fractures showing agglutination opinions, an improvement was observed in physical health status, not in mental health status. When surgery for removal of internal fixative is performed for patients without related symptoms, consideration that subjective satisfaction of patients shows an improvement only in 52.9% will be helpful. Key Words: Orthopaedic implant, Removal surgery, Quality of life Received May 9, 2015 Revised (1st) June 11, 2015, (2nd) August 24, 2015, (3rd) December 6, 2015, (4th) December 16, 2015, (5th) December 18, 2015, (6th) January 8, 2016 Accepted January 10, 2016 Address reprint requests to: Seung-Bum Chae, M.D. Department of Orthopaedic Surgery, Daegu Catholic University Medical Center, 33 Duryugongwon-ro 17-gil, Nam-gu, Daegu 42472, Korea Tel: 82-53-650-4283ㆍFax: 82-53-626-4272 E-mail: sbchae@cu.ac.kr Financial support: None. Conflict of interest: None. 서 정형외과적내고정물의발전과더불어골절에대한치료로써내고정물을이용한수술적치료는점점늘어나고있고, 1,2) 이에따라정형외과적내고정물제거술도역시증가하는추세이다. 1-3) Böstman과 Pihlajamäki 4) 의 Finnish study 에따르면정형외과적내고정물제거술은대부분정규수술의 30% 에해당하고전체정형외과수술의 15% 를차지해 론 Copyright c 2016 The Korean Fracture Society. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 101
102 Sang Bong Ko and Seung-Bum Chae 서뼈와관절수술에서가장흔한수술중하나이다. 일반적으로소아에서는성장장애와골의과성장으로인한지연제거의어려움등으로내고정물을제거해야하는경우가많지만성인에서는내고정물제거술이과연꼭필요한지에대한논란이많다. 3,5) 성인환자에서는정형외과적내고정물이통증을유발하거나연부조직의자극과같은국소적영향, 전신적영향및심리적인원인등으로정형외과적내고정물제거술을시행하는경우가많고, 3) Hanson 등 5) 은설명하기어려운통증이나국소증상이내고정물제거술후호전되는증례들도보고한바있다. 하지만많은저자들은정형외과적내고정물제거술후생길수있는반흔조직및신경손상이나재골절과같은합병증에대해서도보고하며제거술이꼭필요한수술이아니라고주장하기도한다. 2,6-14) 또한정형외과적내고정물제거술이반드시통증을완화시키는것이아니라증가시킨다는주장도있다. 15,16) Hanson 등 5) 은정형외과의사들이정형외과적내고정물제거에대해어떻게생각하는지에대한설문조사로체내내고정물로인해중요한부작용이없기때문에내고정물제거술이꼭필요한것도아니라고주장하면서의사중심결과가아닌환자중심의결과에대한연구가더필요하다고주장하였다. 물론내고정물에의한증상이있는경우에는제거술이필요하지만, Hanson 등 5) 의연구에따르면젊은, 증상이없는환자에서정형외과적내고정물이일상적으로필요하다는의견도 37.1% 정도로증상이없는환자에서도비록대다수는아니지만정형외과적내고정물제거술이필요하다고주장하였다. 이에저자들은내고정물과관련된증상이없는환자에서골절유합후정형외과적내고정물을제거하고난뒤환자 중심의결과가호전되는여부를판단하고자이연구를시작하였다. 1. 대상 대상및방법 2004 년 3 월 1 일부터 2011 년 12 월 31 일까지대구가톨릭대학교병원에서골절로인해내고정물수술후내고정물제거술을시행받은환자 87 명을대상으로전향적인연구를진행하였다. 모든환자는연구에동의하였고술전감염, 내고정물에의한통증, 내고정물과관련된연부조직자극증상등의여러가지이유로인하여내고정물을제거하여야하는환자들은모두제외하였다. 환자에서내고정물제거를위해입원할당시환자의삶의질을평가하였고, 같은환자를내고정물제거술최소 1 년후외래방문시에삶의질을평가하였다. 골절수술과내고정물제거수술은숙련된동일한정형외과의사에의해시행되었다. 선정기준에불편감이없는무증상의환자란환자자신이내고정물에의한불편감을호소하여내고정물제거술을위해내원한환자가아닌정기적인추시중인환자를대상으로하였다. 제거수술후평균추시기간은 27 개월 (12-64 개월 ) 이었으며, 환자들의내고정물제거술당시평균나이는 41.5 세 (21-75 세 ), 남자가 55 명, 여자가 32 명이었다. 외상력은교통사고가 40 명, 보행자교통사고 9 명, 낙상 12 명, 그밖의원인이 26 명이었다. 각환자의인구학적특징, 제거술후추시기간, 진단명, 치료방법, 골절양상및골절의특징은 Table 1 에나타내었다. Table 1. Characteristics of Populations Diagnosis Treatment No. of patient Mean age (yr) Mean F/U period (mo) Clavicle fracture ORIF with plate 2 25 25 Distal radius fracture ORIF with plate 8 62.63 18.25 Femur shaft fracture CRIF with IM nail 13 33.69 18.54 Femur condyle fracture ORIF with plate 5 33.2 21 Forearm fracture ORIF with plate 13 44.69 24.15 Olecranon fracture ORIF with wire 2 53.5 28 Humerus shaft fracture CRIF with IM nail 4 31 16.25 Humerus distal shaft fracture ORIF with plate 5 25.8 21.4 Patellar fracture ORIF with wire 9 44.11 17.67 Tibia shaft fracture CRIF with IM nail 15 41.73 18.27 Tibia shaft fracture ORIF with plate 11 47.73 26.91 Total 87 40.28 21.40 F/U: Follow-up, ORIF: Open reduction and internal fixation, CRIF: Closed reduction and internal fixation, IM nail: Intramedullary nail.
Comparison of Quality of Life between Before and After Orthopaedic Implant Removal Surgery 103 Table 2. Results of Functional Outcome Variable Pre-removal value Post-removal value p-value PCS 61.3±18.2 64.4±17.1 0.001* PF 50.2±21.2 56.3±20.5 0.000* RP 72.0±24.1 77.2±21.6 0.000* BP 73.6±23.8 73.3±19.0 0.545 GH 51.2±21.2 57.3±18.4 0.000* MCS 69.1±21.9 68.4±21.6 0.411 VT 59.2±20.3 60.9±20.0 0.010 SF 76.6±24.6 77.0±23.2 0.783 RE 73.2±32.3 67.4±35.9 0.011* MH 67.3±18.9 68.3±19.7 0.076 Values are presented as mean±standard deviation. *p<0.05. Wilcoxon sighed rank test was used for statistical analysis. PCS: Physical component score in Short Form 36 (SF-36), PF: Physical functioning, RP: Role limitation due to physical health problem, BP: Bodily pain, GH: General health, MCS: Mental component score in SF-36, VT: Vitality, SF: Social-functioning, RE: Role limitation due to emotional problems, MH: Mental health. 2. 평가 Table 3. Result of Item 2 Questionnaire Variable Number (%) Much better 12 (13.8) Somewhat better 34 (39.1) About the same 26 (29.9) Somewhat worse 11 (12.6) Much worse 4 (4.6) Total 87 (100) 항목에서는정형외과적내고정물제거술전, 후에서통계적유의한차이를보이지않았다 (p=0.545). 전반적인 PCS 는내고정물제거술전 61.3±18.2 점에서내고정물제거술후 64.4±17.1 점으로정형외과적내고정물제거술후통계적으로의의있는향상된결과를보였다 (p=0.001) (Table 2). MCS 중 VT 항목은증가하였으나 (p=0.010), RE 항목은내고정물제거술후에악화되었고 (p=0.011), 기타 SF, MH 항목은통계적으로의의가없었다. 전반적인 MCS 는내고정물제거술전 69.1±21.9 점에서내고정물제거술후 68.4± 21.6 점으로감소된듯보이지만통계적인유의한차이를보이지는않았다 (p=0.411) (Table 2). 환자관점의결과즉환자의삶의질의평가는 Short Form 36 (SF-36) 설문지를사용하였다. SF-36 설문지내의신체건강상태 (physical component score, PCS), 정신건강상태 (mental component score, MCS) 항목이이연구에서이용되었으며, PCS 는신체기능 (physical functioning, PF), 신체역할제한 (role limitation due to physical health problems, RP), 통증 (bodily pain, BP), 일반건강 (general health perception, GH) 으로각각나누어분석하였으며, MCS 는정신건강 (mental health, MH), 감정역할제한 (role limitation due to emotional problems, RE), 사회기능 (social functioning, SF), 활력 (vitality, VT) 으로각각나누어분석하였다. 또한 SF-36 설문지의두번째내용인 (Item 2 Questionnaire) 1 년전과비교하여전반적으로당신의건강상태는어떻습니까 는 내고정물제거술이전과비교하여현재당신의건강은어떻습니까? 로바꾸어질문하였다. 통계방법은 paired t-test, Wilcoxon signed rank test 를사용하였고, 유의성은 0.05 이하로정의하였다. 결 과 1. SF-36 을사용한환자삶의질결과 PCS 중 PF 와 RP 항목및 GH 에서정형외과적내고정물제거술을시행한환자군에서향상되었고 (all p<0.05), BP 2. 제 2 항목설문결과 제 2 항목설문의결과는내고정물제거술후내고정물제거술전과비교해서주관적인건강상태가 12 명 (13.8%) 에서훨씬좋아졌으며, 34 명 (39.1%) 에서조금나아졌고, 26 명 (29.9%) 은큰차이가없다고하였다. 11 명 (12.6%) 에서건강상태가나빠졌다고하였고, 4 명 (4.6%) 은매우나빠졌다고하였다. 종합해보면 52.9% 의환자가내고정물제거술전과비교해내고정물제거술후주관적인건강상태가나아졌다고하였으며, 29.9% 의환자는내고정물제거술전, 후큰차이가없었지만, 17.2% 에서의환자에서는내고정물제거술후전반적인건강상태가악화되었다고하였다 (Table 3). 고 정형외과적내고정물은골절의안정화및골유합의촉진을위해많이이용되지만일단골절부유합후에는생체내의내고정물은어떠한역할도하지않고심지어는감염혹은응력방패효과 (stress shielding effect) 로골다공증을유발하여내고정물주위골절을일으키기도한다. Hanson 등 5) 의연구에서비록의사중심의설문조사이긴하지만 57.8% 의정형외과의사가 40 세이하의젊은환자에서증상이없다면정형외과적내고정물제거술을동의하지는않 찰
104 Sang Bong Ko and Seung-Bum Chae 는다고보고하였지만정형외과적내고정물제거술을 37% 에서는동의하였다. 정형외과적내고정물을골절유합후제거할것인가그대로둘것인가에대한판단은전적으로정형외과의사의판단에맡겨지는경우가많고이는나라마다차이를보인다. Sanderson 등 6) 은내고정물은골절이유합된다음제거해야하며, 특히체중부하골의내고정물제거의필요성에대해주장하였고, 65% 의환자에서내고정물제거술을시행하였다. Raman 등 17) 은비록치골결합 (symphysis pubis) 의내고정물이긴하지만내고정물제거술을해야하는사유에대한서술없이하나의일반적으로행해지는술기로설명하기도한다. 내고정물제거술은반흔조직위의재수술을요하므로, 신경손상이나재골절의위험을안고있다. 6,10,13,14) Hanson 등 5) 은설명할수없는통증에대해내고정물제거술이도움을줄수있다고주장하기도하지만그효과에대해서는확신하지못한다고도하였으며제거술후악화된다는주장도있다. Gösling 등 15) 은 109예의대퇴골수강내정제거술후통증과불편감증가가전체환자의 7% 에서, 그리고술전무증상환자군의 20% 에서발생했다고보고하였다. 개방적정복및내고정을시행한뒤내고정물을제거한발목골절환자들에게서도비슷한보고가있다. 16) Townend와 Parker 18) 는내고정물제거술후 50% 의경우에서통증이지속된다는연구결과를보고하였지만, Hanson 등 5) 은내고정물제거에대한환자의요구와는별개로정형외과적내고정물을제거하지않아생기는부작용은임상적으로유의하지않다고도하였다. Evers 등 19) 은관련된 14개의연구에대한전반적인고찰을통해내고정물제거술후합병증발생률은 20%-40% 로신경손상이 2%-29%, 재골절이 2%-26%, 감염이 5%-12% 에이른다고보고하였다. 문헌에따르면부작용이발생할위험도도다양하게나타나는데술후출혈이 1%, 상처감염이 0%-14%, 신경손상이 1%-29%, 재골절이 1%-30%, 만족스럽지못한흉터가 9% 로보고되고있다. 2,6,8-10,12,20-22) 현재의내고정물제거수술에대한술기와태도는나라와문화에따라다양하게나타난다. 핀란드에서는내고정물제거술이 80% 에이르는데, 4) 노르웨이에서는비록환자가원하는경우시행하지만 50%, 영국에서는 20% 에불과하다. 1) 이러한정형외과적내고정물제거술이시행되는비율의차이는정형외과적내고정물제거술이실제의기능적결과에기초한지식보다의사개개인의경험에의한혹은문화적요소에의해결정된다는것을알수있다. 23) 또한환자들의심리적인원인도내고정물제거술의주요한이유중하나로몇몇환자들은남아있게된내고정물로인한심리적, 정신적인고통으로내고정물을제거하기위 해수술을위한마취와수술의위험및합병증을감수할뿐아니라비용을부담하기도한다. 24) Minkowitz 등 25) 은저자들과비슷하게내고정물제거술후 short musculoskeletal function assessment 및 SF-36 의 PCS 가향상되고통증의호전도보고하였다. 하지만저자들의연구에서는정형외과적내고정물제거술후 PCS 중 BP 는제거술후에도호전되지않았으나다른 PF, RP, GH 는모두호전되는양상을보였으며 PCS 도호전되는양상을보였다. MCS 는 VT 는호전되었지만 RE 에는오히려악화된결과를보였으며그이외의항목에서는큰차이가없었다. 이결과정형외과적내고정물제거술의경우 PCS 는호전되는양상을보이지만 MCS 의호전은기대할수없다고볼수있다. 그러나정형외과적내고정물제거술을시행한경우수술전보다 52.9% 에서주관적인환자의건강상태의호전을보였지만제거술후 17.2% 에서는전반적으로나쁜건강상태를보이기도하였으며모든환자에서제거술시행중혈관손상이나신경손상과같은수술과관련된문제는없었다. 나쁜건강상태를보이는 15 명의환자중 9 명은자살을위해추락한환자들이고 5 명은 65 세이상환자들이지만증례가부족하여통계적분석은시행하지않았다. 저자들은다양한임상상황을극복하기위해한환자에서조사하였다는장점은있지만내고정물의다양성을조사하진못하였다. 또한제거술을시행한환자들에게최소 1 년후설문조사를시행하였으므로환자의내고정물제거술후발생하는심리적은부분을반영하지는못하였다. 또한 SF-36 의각항목에대한세부분석을하기에는환자의증례가부족한단점은있다. 또한제거술시행시발생하는경제적관점및본연구에서제외조건인제거술시발생할수있는합병증, 재골절의문제등에대한관점등도충분히고려되어제거술이시행되어야한다. 결 골절로인한정형외과적내고정물을시행후골절부의유합후내고정물과관련된증상이없는환자에게서정형외과적내고정물제거술을시행하면 PCS 는호전되지만 MCS 의호전을기대할수는없었다. 그렇지만제거술후 52.9% 의환자에서주관적인건강상태가호전되었지만 29.9% 의환자에서는큰차이가없었고심지어 17.2% 의환자에서는내고정물제거술후전반적인건강상태가악화되었다. 내고정물과관련된증상이없는환자의내고정물제거술을시행할때이러한결과를참고하는것이도움이될것으로생각한다. 론
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ISSN 1225-1682 (Print) ISSN 2287-9293 (Online) 대한골절학회지제 29 권, 제 2 호, 2016 년 4 월 J Korean Fract Soc 2016;29(2):101-106 http://dx.doi.org/10.12671/jkfs.2016.29.2.101 Original Article 정형외과적내고정물제거술전, 후의삶의질비교 고상봉 채승범 대구가톨릭대학교병원정형외과 목적 : 내고정물과관련된증상이없는환자에서내고정물을제거하고난뒤환자중심의결과가호전되는지를판단하고자하였다. 대상및방법 : 2004년 3월 1일부터 2011년 12월 31일까지골절로인해내고정물수술후내고정물제거술을시행한환자 87명의환자를대상으로전향적연구를시행하였다. 평균추시기간은 27개월 (12-64개월), 제거술당시평균나이는 41.5세 (21-75세) 였다. 삶의질은모든환자에게서제거술직전과최소 1년후에 Short Form 36 (SF-36) 설문지를사용하여평가하였다. 결과 : 내고정물제거술후신체건강상태는통계적으로의의있게호전되었으며 (p=0.001), 정신건강상태의호전은없었다 (p=0.411). 환자의주관적인수술에대한만족는내고정물제거술후 52.9% 에서주관적인건강상태의호전을보였으며, 29.9% 에서는제거술전과큰차이가없다고하였다. 결론 : 골절의치유로사용된내고정물을내고정물과관련된증상이없는환자에게서제거술을시행하는경우신체건강상태는호전을보이지만정신건강상태의호전은없었다. 또한제거술을시행할때환자의주관적인만족도는 52.9% 에서만호전을보인다는점을고려하는것이도움이될것으로생각한다. 색인단어 : 내고정물, 제거술, 삶의질 접수일 2015. 5. 9 수정일 1 차 2015. 6. 11, 2 차 2015. 8. 24, 3 차 2015. 12. 6, 4 차 2015. 12. 16, 5 차 2015. 12. 18, 6 차 2016. 1. 8 게재확정 2016. 1. 10 교신저자채승범 42472, 대구시남구두류공원로 17 길 33, 대구가톨릭대학교병원정형외과 Tel 053-650-4283, Fax 053-626-4272, E-mail sbchae@cu.ac.kr Copyright c 2016 The Korean Fracture Society. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 106