379 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2015; 50: 379-386 http://dx.doi.org/10.4055/jkoa.2015.50.5.379 www.jkoa.org 슬관절내측구획골관절염에서개방형경골근위절골술의고정기기에따른임상적결과 : 잠김나사금속판과삽입형금속판의비교 이주홍 박혁 고종현 전북대학교의학전문대학원정형외과학교실, 전북대학교병원임상시험센터 Clinical Results after Medial Opening Wedge High Tibial Osteotomy in Medial Compartment Osteoarthritis of the Knee: TomoFix versus Aescula Plates Ju Hong Lee, M.D., Hyuk Park, M.D., and Jong Hyun Ko, M.D. Department of Orthopedic Surgery, Chonbuk National University Medical School, Chonbuk National University Hospital Clinical Trial Center, Jeonju, Korea Purpose: The purpose of this study was to compare the clinical and radiologic results of medial open wedge high tibial osteotomy (HTO) using either TomoFix plate (group A) or Aescula plate (group B) in patients with medial compartment osteoarthritis. Materials and Methods: Sixty-four consecutive patients who underwent HTO for medial compartmental osteoarthritis from 2008 were included. Mean follow-up duration was 37.1 months. Twenty men and 44 women with a mean age of 50 years (range, 41 to 62 years) were divided into group A (locking plate, n=20) and group B (spacer plate, n=44). Clinical results were evaluated using knee society rating system (KSS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Radiological results were obtained by measuring the mechanical axis, posterior tibial slope, and medial joint space width preoperatively, 3 months postoperatively, and at the final follow-up. Results: In overall patients, the mechanical axis was corrected from 7.8 ±2.4 of varus preoperatively to 1.9 ±2.2 of valgus 3 months after HTO. At the final follow-up, the mechanical axis was to 2.1 ±3.1 of valgus which showed no statistical difference in group A. However, loss of correction was observed at the final follow-up, at 0.1 ±3.1 of valgus angulation in group B. The increase of the posterior tibial slope was significantly greater in group A than group B. The joint space width in both groups was improved at last follow-up. All clinical results showed improvement after HTO, with significantly improved KSS and WOMAC scores (p<0.001). Conclusion: The overall clinical results after HTO for medial compartment osteoarthritis were satisfactory. A group of spacer plates needed for prolonged protective weight bearing and locking plate was effective in maintenance of correction. Key words: knee, medial compartment osteoarthritis, open wedge high tibial osteotomy, spacer plate, locking plate 서론 Received November 6, 2013 Revised February 24, 2014 Accepted May 30, 2015 Correspondence to: Hyuk Park, M.D. Department of Orthopedic Surgery, Chonbuk National University Medical School, 20 Geonji-ro, Deokjin-gu, Jeonju 54907, Korea TEL: +82-63-250-1760 FAX: +82-63-271-6538 E-mail: hyukpark@jbnu.ac.kr 근위경골절골술은비교적젊고활동적인환자에있어서슬관절의내측구획에국한된퇴행성관절염의중요한치료수단으로서역학적축을병변이존재하는내측구획에서관절염에이환되지않은외측구획으로이동시켜체중부하의재분배를통해동통 The Journal of the Korean Orthopaedic Association Volume 50 Number 5 2015 Copyright 2015 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/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
380 Ju Hong Lee, et al. 완화와관절염진행의지연을목표로한다. 1,2) 근위경골절골술은적절한환자의선택, 정확한교정각의성취, 그리고고정기기및수술술기의발전으로임상적결과가향상되고있으며, 3,4) 절골술후관절연골병변이연골양조직으로치유되기도한다. 5) 또한근위경골절골술의 10년이상장기추시에서만족스러운임상적결과들을보이고있다. 6) 개방형근위경골절골술은정확한교정각을얻고비골절골술이나근위경비골관절의해리에따른합병증이없으며향후관절염진행으로슬관절전치환술로의전환이용이하다고알려져많이시행되고있지만 7,8) 지연유합, 불유합또는교정소실등의합병증들이보고되고있다. 9) 근위경골절골술의합병증을줄이고임상적결과를높이기위해절골부에대한여러가지고정기기가소개되고있으며최근사용되는금속판들의생역학적연구는 10,11) 물론그와관련된임상적결과들이보고되고있다. 12,13) 본연구에서는잠김나사금속판 (TomoFix ; Mathys, Bettlach, Switzerland) 과삽입형금속판 (Aescula ; B. Braun Korea, Seoul, Korea) 사용에따른임상적결과및교정각유지에차이가없다는가설하에두고정기기간의방사선및임상적결과를비교하였다. 대상및방법 2008년부터 2011년까지내반변형이있는내측구획퇴행성슬관절염 (degenerative osteoarthritis) 에대해개방형경골근위절골술을실시하고최소 2년이상추시가가능했던 64예를대상으로한후향적연구로, Aescula plate을사용한환자는 44예 (B군), Tomo- Fix 를사용한환자는 20예 (A군) 였다. 남자가 20예 (31.3%), 여자가 44예 (68.8%) 였고, 평균나이는 50세 (41-62세) 였으며, 평균추시기간은 37.1±6.8개월이었다. 두군간의나이, 성별, 그리고체질량지수 (body mass index, BMI) 에서유의한차이는없었다 (Table 1). 술전교정각측정은체중부하장하지방사선사진에서경골고평부의내측으로부터경골너비의약 62% 에해당하는점을기준으로대퇴골두중심을연결하는선과경골-거골관절의중심을연결한두선이이루는각을교정각으로한 Dugdale의방법 14) 으로하였다 (Fig. 1). 수술중교정각의확인은주로과교정을방지하기위해시행하였고, 육안과영상증폭장치 (C-arm) 하에금속지침자를이용하였다. 대부분수술전에계측한교정각에따라 교정하였으나육안상전상장골극 (anterior superior iliac spine) 과발목의중심을연결한선을기준으로과도한외반교정이면교정각을조정하였는데, 이때외측경골극의바로외측에금속지침자가위치하는지 C-arm으로확인하였고교정각을줄이는경우비체중부하상태인점을고려하여경골너비의최소 50% 보다는외측에위치하도록하였다. 일반적으로경골너비의약 62% 는외측경골극의바로외측이며 3 o -5 o 외반의역학적축, 그리고 8 o - 10 o 외반의대퇴-경골각에해당한다. 모든환자에서절골술시행전관절경으로관절내병변을확인하였고, 관절연골상태는 Outerbridge classification을따랐다. 15) 관절경상에서 Outerbridge grade IV인경우미세절골술을시행하였다. 경골극과경골의후방경계의중간부위에종절개후내측측부인대를노출시키고원위부까지골막하에서들어올려 (periosteal elevation) 이완 (release) 을시행하였다. 전체예에서내측측부인대가완전박리 (detach) 된환자는없었으며, 슬괵건은상부약 1/2 이절제되었고, 수술후봉합하였다. B군에서는경골건부착부의근위부로 C-arm하에관절면에서약 2.5 cm 원위부에한면 (uniplane) 절골술을시행하였다. A군에서는 B군에비해절골부근위부에보다많은나사고정을시행하기위해 C-arm하에관절면에서약 3 cm 원위부에절골을시행하였고, 슬개건부착부보존을목적으로두면 (biplane) 절골술을시행했다. A군과 B군전체예에서절골부에동측장골로부터피질-해면질골을후내측과전내측 Table 1. Demographic Data of the Two Groups Variable Group A (n=20) Group B (n=44) p-value Age (yr) 52.4±6.9 51.2±6.0 0.79 BMI (kg/m 2 ) 29.0±3.8 27.1±3.6 0.65 Sex (female case) 15 (0.75) 29 (0.66) 0.57 Values are presented as mean±standard deviation or number (%). Group A, TomoFix group; Group B, Aescula group; BMI, body mass index. Figure 1. (A) The angle (*) formed by lines drawn from this coordinate to the center of the femoral head and talar dome is corrected. (B) The limb alignment was corrected by high tibial osteotomy with locking plate. A B
381 TomoFix versus Aescula Plates A B C Figure 2. Long locking plate (A) and short spacer plate (B) were used for high tibial osteotomy. The locking plate used at least four proximal and distal screws. The spacer plate used 2 plates for anteromedial and posteromedial support. (C) Posterior tibial slope ( ) formed by axis of tibia and tibial plateau. A B Figure 3. (A) Cartilage lesion (Outerbridge grade IV) was shown at initial arthroscopy. (B) Cartilage lesion was completely healed on second-look arthroscopy. 에삽입하였고, 술전과동일한경골후방경사도를유지하기위해전내측과후내측이식골의높이의비를 0.68이되게하였으며, 나머지빈공간은자가또는동종해면골, tri-calcium phosphate (choronos wedge, semicircular; Synthes, Solothurn, Switzerland) 로충전했다. 술후처치는수술직후부터관절운동과하지직거상운동을시행하였으며, 절골술시행시내측반월연골판후각부방사형파열로봉합술을시행한경우에한해서는술후 3주부터관절운동을시행하였다. 체중부하는술후 3주가경과하면신전위로슬관절보조기착용하에허용하였으나관절연골결손부에대한미세골절술시행과반월연골판봉합술을시행받은환자는술후 6주부터부분체중부하를시작하였다. 완전체중부하의가능시기는 B 군에서술후 3개월전후에가능하였고, A군에서대부분술후 2 개월에가능하였다. 양군의임상적결과는최종추시에서 knee society rating system (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) 를비교하였다. 수술중발생한경골외측피질골중첩부골절은 C-arm을통해확인하였고 Takeuchi 분류 16) 에따라 I형은골절선이외측피질골로연장된경우, II형은골절 선이하부피질골로연장된경우, 그리고 III형은골절선이경골고평부로연장된경우로하였다. 수술후합병증은의무기록를통해감염, 심부정맥혈전, 외측구획관절염, 슬관절전치환술로의전환등을확인하였고술후 3개월방사선사진에서골유합소견이없으면지연유합, 6개월째방사선사진에서골유합이없으면불유합이라고정의하였다. 방사선적평가는술전, 술후 3개월, 6개월및마지막추시에서시행한체중부하장하지방사선사진, 체중부하슬관절전후방및측면방사선사진을통해골유합까지의기간, 경골후방경사도 (Fig. 2), 내측구획관절간격, Insall-Salvati 비율을확인하였으며역학적축을기준으로술후및최종추시에서의교정각차이를교정소실각으로하였다. 금속판의종류, 성별, 나이, BMI, 흡연및술전내반각과교정소실각사이의연관성을분석하였다. 고정기기를제거하면서총 36예 (56.3%; B군 25예, A군 11예 ) 에서이차관절경이가능하였으며이중 B군 17예, A군 6예로전체 23예 (63.9%) 에서절골술당시미세천공술을시행하였다. 이차관절경시야에서내측구획의관절연골이회복된정도를완전치유, 불완전치유및치유실패로나누어평가하였다 (Fig. 3). 연구자료의통계분석은 SPSS ver. 12.0 (SPSS Inc., Chicago, IL,
382 Ju Hong Lee, et al. Table 2. Factors Associated with Correction Loss after Open Wedge High Tibial Osteotomy USA) 프로그램을이용하였으며, 통계적방법으로금속판의종 류, 성별, 나이, BMI 와흡연에대해 Student t-test 를사용하여양 군간의차이를분석하였고, 술전내반각에대해 Pearson correlation test 를사용하여교정소실각과의연관성을분석하였다. 관찰 자간및관찰자내의신뢰도를확인하기위해방사선결과를 3 명 의검사자가 2 주간격으로 3 회측정하였고, 급간상관계수 (intraclass correlation coefficient, ICC) 를확인하였다. 본연구는전북대학교병원생명의학연구윤리심의위원회 (Institutional Review Board) 의승인을받고시행되었다. 결과 KSS 슬관절점수는술전 54.0±11.7 점에서 94.4±5.6 점으로, 기능 점수는 53.1±14.3 점에서 86.3±8.1 점으로향상되었고 (p<0.001), WOMAC 점수는술전 77.2±15.0 점에서 5.5±3.4 점으로호전되었 으며 (p<0.001) 두군간의임상적결과는유의한차이가없었다 (p=0.573). Factor Correction loss p-value Plate <0.01 Group A 0.8±0.6 Group B 2.1±2.1 Sex 0.86 Male 1.8±2.5 Female 1.3±1.7 Age (yr) 0.40 50 1.6±1.9 <50 1.4±2.1 BMI 0.65 30 1.7±2.3 <30 1.4±2.3 Smoking 0.71 Yes 1.5±1.6 No 1.4±2.8 Values are presented as mean±standard deviation. Group A, TomoFix group; Group B, Aescula group. BMI, body mass index. 방사선적결과에서전체환자의수술전역학적축은내반 7.8 o ±2.4 o 에서술후 3 개월째외반 1.9 o ±2.2 o 로교정되었고, 평균교정 각은외반 9.7 o ±2.1 o 였다. B 군에서역학적축은술전내반 7.7 o ± 2.3 o 에서술후 3 개월은외반 2.0 o ±2.1 o 로교정되었으나최종추시 에서외반 0.1 o ±3.1 o 로교정소실이있었다 (p<0.001). A 군에서역 학적축은술전내반 8.2 o ±2.7 o 에서술후 3 개월째외반 2.1 o ±4.4 o Table 3. Radiological Results after High Tibial Osteotomy Variable Group A Group B p-value Correction angle (º) 9.8±2.8 9.6±2.7 0.82 Correction loss angle (º) 0.1±0.6 2.1±2.1 <0.01 Increased posterior tibial slope (º) 5.9±1.8 3.6±2.3 <0.02 Insall-Salvati ratio 0.96±0.12 0.98±0.16 0.686 Bony union (mo) 6.4±1.9 6.6±1.9 0.57 Group A, TomoFix group; Group B, Aescula group. 로교정되었고최종추시에서외반 2.1 o ±3.1 o 를보였다 (p=0.40). 교정소실정도와성별, 나이, BMI 및흡연과의연관성분석에서통계적유의성은없었고 (Table 2) 교정소실정도와술전내반각과의연관성분석에서도유의한차이는보이지않았다 (p=0.23). 후방경사도는 A군에서술전 8.0 o ±1.8 o 에서술후 13.9 o ±4.3 o 로, B군은술전 8.7 o ±2.3 o 에서술후 12.3 o ±3.9 o 로 (p<0.001) 두군모두증가하였으나 (p<0.001) A군에서 B군에비해후방경사도의유의한증가를보였다 (p=0.02) (Table 3). 내측관절간격은 A군에서평균 3.1±0.9 mm에서 3.7±0.9 mm로, B군은술전평균 3.2±0.9 mm에서평균 3.7±1.2 mm로 (p=0.02) 호전되었고두군간의유의한차이는없었다 (p=0.03). 슬개골의위치를평가한 Insall-Salvati 비율은 A군에서술전 0.99±0.13에서술후에 0.96±0.12, B군은술전 0.99±0.16에서술후 0.98±0.16으로두군간의유의한차이는없었다 (p=0.686). 골유합까지기간은 A군은 6.4±1.9개월, B 군은 6.6±1.9개월로두군간의유의한차이는없었다 (p=0.57) (Table 3). 이차관절경검사에서관절연골의치유결과는 A군에서완전한치유가 6예 (54.5%), 불완전치유 3예 (27.3%), 치유가없었던 2예 (18.2%) 가관찰되었고, B군에서완전한치유가 14예 (56.0%), 불완전치유 7예 (28.0%), 치유가없었던 4예 (16.0%) 가관찰되어, 양군간의유의한차이는보이지않았다 (p=0.47). 또한미세골절술을시행했던 23예에서는완전한치유가 12예 (52.2%), 불완전치유 7 예 (30.4%), 치유실패 4예 (17.4%) 가관찰되었다. 합병증으로경골피질골중첩부골절은 Takeuchi 분류상 A군에서 I형이 2예 (10%), B군에서 I형이 3예 (6.8%), III형이 2예 (4.5%) 관찰되었다. A, B군에서표재성연부조직감염이 1예씩발생하여변연절제술을시행하였다. B군에서불유합에따른붕괴가 1예있어골이식시행후잠김나사금속판으로고정하였고, A군에서불유합에따른붕괴 (collapse) 는없었다. 그외에신경이나혈관손상, 심부정맥혈전증과관절염의진행으로인한슬관절인공관절전치환술로의전환은없었다. 전반적인합병증발생률에양군간의유의한차이는없었다 (p=0.46). 방사선적결과에대한관찰자내신뢰도는 ICC가 0.991, 관찰자간신뢰도는 ICC가 0.994로높은신뢰도를보였다.
383 TomoFix versus Aescula Plates 고찰 본연구에서개방형근위경골절골술시행후 3개월째역학적축의교정각은 9.7 o ±2.1 o 였다. 목표교정각을수술후역학적축외반 3 o 로했을경우목표교정각과의차이는 1.2 o ±2.2 o 였다. Hankemeier 등 17) 은개방형절골술이절골후개방정도에따라교정각을미세하게조절할수있어폐쇄형절골술보다목표교정각을얻을수있다고보고하였으며, 개방형절골술에서목표교정각과실제교정각이 1.7 o ±1.6 o 차이를보였고, 폐쇄형절골술은 2.6 o ± 1.8 o 차이를보였다. 본연구에서는 Hankemeier 등 17) 의보고와유사한목표교정각과의일치를보였다. 본연구에서는긴잠김나사금속판 (long locking plate) 을사용한군에서 0.1 o ±0.6 o 교정각소실을보였고, 짧은삽입형금속판 (short spacer plate) 을사용했을때 2.1 o ±2.1 o 교정각소실과비교하여높은안정성을보였다 (p<0.01). 현재개방형근위경골절골술에사용되는금속판의종류는잠김나사의사용유무, 금속판의길이및삽입물의유무에따라서다양하게존재한다. 10,11) 절골부를고정하는고정기기가개방형근위경골절골술의임상적결과에영향을미칠것으로생각되지만이에대한생역학연구는많지않다. Agneskirchner 등 10) 은개방형절골술에사용되는네가지의금속판비교에서긴잠김나사금속판을사용했을때가장안정적이었고, 짧은삽입형금속판에비해 2배이상의부하를견딜수있으며절골부의불안정성이가장적고, 외측피질골골절도가장적었다. 삽입형금속판인 Puddu plate (Arthrex Inc., Naples, FL, USA) 와 TomoFix (Mathys) 를비교한논문에서긴잠김나사금속판의안정성이가장높았다. 18) 본연구에서잠김나사금속판이삽입형금속판에비해서최종추시에서교정각소실이유의하게적었다. 교정각소실이적었던이유는긴잠김나사금속판을사용하여보다안정적인절골부의고정의결과라고생각되며기존의대부분의생역학연구를동일한결과였다. Miller 등 6) 은개방형절골술의합병증을분석한결과교정소실이 15.2% 로가장많았고, 교정소실은 BMI와연관성이높다고했으며, Niinimäki 등 19) 은성별 ( 여성 ) 과고령 (>50세) 이근위경골절골술의생존율에부정적인영향을준다고했다. 이에본연구에서도교정소실과성별, 나이, BMI와흡연과의연관성을분석하였으나통계적의미는없었다 (Table 2). A군과 B군모두경골후방경사도는증가하였으나 B군은 A군과비교했을때유의하게후방경사도증가가적었다 (p=0.02). 최근경골후방경사도는술자의의도에따라조절할수있는술기로받아들여지는경향이있으나 20) Rodner 등 21) 은경골후방경사도증가가전방십자인대에긴장을높게하며슬관절에접촉압력 (contact pressure) 를높일수있다고하였고, 여전히개방형절골술시후방경사도를줄이려는노력은계속되고있다. Chae 등 22) 은전내측과후내측이식골의높이의비를 0.68로하여술후의경골 후방경사도의증가가없었다. 본연구에서도이와유사하게전내측과후내측이식골의높이의차이를두었고, A군과 B군에서같은술기를적용하였다. 그러나기존보고와다르게본연구에서는 B군에서후방경사도의증가가높아금속판에의한차이라고생각이된다. Asada 등 23) 은후방경사도증가를최소화하기위해서는절골술후삽입형금속판의삽입시전방과후방에각각의금속판을삽입할것을권유하였고, 본연구에서도 B군도 2개의금속판을이용하여전방과후방의교정각도를조절하여후방경사도조절에긍정적인영향을주었을것으로생각된다. 개방형절골술에서수술중에발생하는외측경골고평부골절은기존의보고에따르면 11.7%-19.0% 에서발생하였다. 24) 고평부골절을최소화하기위해서는경골관절면을따라서삽입한 K-강선을기준으로하여약 35 mm 이하에서 oscillating saw를이용하여절골을시작하고, 외측피질골약 5-10 mm를보존하는것을권유한다. 또한납작한정 (chisels) 을절골면을따라삽입하고두번째정은첫번째정보다약간깊게들어가도록하며, 두개의정사이에정을추가로삽입하여순차적으로교정각을얻는방법이권유되고있다. 25) 본연구에서는 B군에서외측고평부골절 (III형) 이수술중에인지되어 1예에대해서추가적인나사고정을하였고 3예의외측피질골골절 (I형) 에대해서는 1예에서 staple 고정, 나머지는 2주정도하지고정을연장하거나체중부하를지연시켰다. A군에서는 2예에서외측피질골골절 (I형) 이있었으나추가적인처치는필요하지않았다. B군에서발생한외측고평부골절 (III형) 2예는금속판에따른차이가아닌수술시행초기에절골선이 safe zone을향하고있음에도불구하고적절한절골전무리한개방을시도하였던술기의문제로생각된다. Jung 등 13) 은본연구와같은두금속판을비교한연구에서삽입형금속판을사용했을경우금속판관련합병증인불유합, 수술후외측피질골골절과교정소실이유의하게높았다고보고하였다. 본연구에서는전체적인합병증은양군간의차이를보이지않았고, 불유합과교정소실이 B군에서많이보였으나상대적으로적은환자에대한연구로추가적인연구가필요할것으로생각된다. Sterett 등 26) 은슬관절내측의연골병변과내반변형을가진환자에서개방형근위경골절골술과미세천공술을동시에시행하여 7년에 91% 의생존율을보고하였으나 Matsunaga 등 27) 은절골술만시행한환자와절골술과미세천공술을같이시행한환자에대해관절경으로확인했을때두군간의차이가없다고하면서골수자극술식의임상적유용성이명확하지않다고하였다. 본연구에서는 35 명의이차관절경소견에서 57.1% 의완전치유를보여미세천공술이관절연골치유에긍정적인영향을예상할수있지만개방형절골술에따른효과와구분할수없어이에대한후속연구가필요할것으로생각된다. 본논문의제한점은대조군연구의진행시비확률표본추출
384 Ju Hong Lee, et al. (non-probability sampling) 로특정기간동안대상자를표본으로추출 (consecutive sampling) 하였고, B군은초기에, A군은후기에추출되어비록 2년이상추시기간이있는환자를대상으로했지만, 연구결과에영향을미쳤을것으로보여향후무작위표본추출 (random sampling) 을통한보다많은수의환자를대상으로전향적인연구가필요할것으로보인다. 본연구에서두군의절골방법으로금속판의특성상 B군에서는한면절골을시행했고, A군에서는두면절골을시행하였다. A군에서근위부나사못사용을늘리기위해 B군보다원위부에절골이필요했고, 경골건을보존하기위해두면절골을시행했으나수직절골면 (vertical plane) 은횡절골면 (transverse plane) 에비해보조적으로사용되어절골면의안정성에미치는영향이작을것으로생각되나보다많은생역학적, 임상적연구가필요할것으로생각된다. 결론 개방형경골근위절골술의임상적결과는우수하였으며, 삽입형금속판은오랜기간의부분체중부하가필요하며, 잠김나사금속판이삽입형금속판보다변형교정유지에효과적이었다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Agneskirchner JD, Hurschler C, Wrann CD, Lobenhoffer P. The effects of valgus medial opening wedge high tibial osteotomy on articular cartilage pressure of the knee: a biomechanical study. Arthroscopy. 2007;23:852-61. 2. Floerkemeier S, Staubli AE, Schroeter S, Goldhahn S, Lobenhoffer P. Outcome after high tibial open-wedge osteotomy: a retrospective evaluation of 533 patients. Knee Surg Sports Traumatol Arthrosc. 2013;21:170-80. 3. Akizuki S, Shibakawa A, Takizawa T, Yamazaki I, Horiuchi H. The long-term outcome of high tibial osteotomy: a ten- to 20-year follow-up. J Bone Joint Surg Br. 2008;90:592-6. 4. Flecher X, Parratte S, Aubaniac JM, Argenson JN. A 12-28- year followup study of closing wedge high tibial osteotomy. Clin Orthop Relat Res. 2006;452:91-6. 5. Akizuki S, Yasukawa Y, Takizawa T. Does arthroscopic abrasion arthroplasty promote cartilage regeneration in osteoarthritic knees with eburnation? A prospective study of high tibial osteotomy with abrasion arthroplasty versus high tibial osteotomy alone. Arthroscopy. 1997;13:9-17. 6. Miller BS, Downie B, McDonough EB, Wojtys EM. Complications after medial opening wedge high tibial osteotomy. Arthroscopy. 2009;25:639-46. 7. Smith TO, Sexton D, Mitchell P, Hing CB. Opening- or closing-wedged high tibial osteotomy: a meta-analysis of clinical and radiological outcomes. Knee. 2011;18:361-8. 8. Benzakour T, Hefti A, Lemseffer M, El Ahmadi JD, Bouyarmane H, Benzakour A. High tibial osteotomy for medial osteoarthritis of the knee: 15 years follow-up. Int Orthop. 2010;34:209-15. 9. Warden SJ, Morris HG, Crossley KM, Brukner PD, Bennell KL. Delayed- and non-union following opening wedge high tibial osteotomy: surgeons' results from 182 completed cases. Knee Surg Sports Traumatol Arthrosc. 2005;13:34-7. 10. Agneskirchner JD, Freiling D, Hurschler C, Lobenhoffer P. Primary stability of four different implants for opening wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2006;14:291-300. 11. Spahn G, Mückley T, Kahl E, Hofmann GO. Biomechanical investigation of different internal fixations in medial opening-wedge high tibial osteotomy. Clin Biomech (Bristol, Avon). 2006;21:272-8. 12. Lee SC, Jung KA, Nam CH, Jung SH, Hwang SH. The shortterm follow-up results of open wedge high tibial osteotomy with using an Aescula open wedge plate and an allogenic bone graft: the minimum 1-year follow-up results. Clin Orthop Surg. 2010;2:47-54. 13. Jung WH, Chun CW, Lee JH, Ha JH, Kim JH, Jeong JH. Comparative study of medial opening-wedge high tibial osteotomy using 2 different implants. Arthroscopy. 2013;29:1063-71. 14. Dugdale TW, Noyes FR, Styer D. Preoperative planning for high tibial osteotomy. The effect of lateral tibiofemoral separation and tibiofemoral length. Clin Orthop Relat Res. 1992;(274):248-64. 15. Outerbridge RE. The etiology of chondromalacia patellae. J Bone Joint Surg Br. 1961;43-B:752-7. 16. Takeuchi R, Ishikawa H, Kumagai K, et al. Fractures around the lateral cortical hinge after a medial opening-wedge high tibial osteotomy: a new classification of lateral hinge fracture. Arthroscopy. 2012;28:85-94. 17. Hankemeier S, Mommsen P, Krettek C, et al. Accuracy
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386 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2015; 50: 379-386 http://dx.doi.org/10.4055/jkoa.2015.50.5.379 www.jkoa.org Ju Hong Lee, et al. 슬관절내측구획골관절염에서개방형경골근위절골술의고정기기에따른임상적결과 : 잠김나사금속판과삽입형금속판의비교 이주홍 박혁 고종현 전북대학교의학전문대학원정형외과학교실, 전북대학교병원임상시험센터 목적 : TomoFix (A 군 ) 와 Aescula plate (B 군 ) 에따른개방형경골근위절골술 (high tibial osteotomy, HTO) 의임상및방사선적검 사결과를평가하였다. 대상및방법 : 2008 년부터 HTO 를실시하여평균 37.1 개월간추시한 64 예를대상으로하였고, A 군은 20 예, B 군은 44 예였다. 평균 나이는 50 세 (41-62 세 ) 였고, 남성이 20 예 (31.3%), 여성이 44 예 (68.7%) 였다. 임상결과는 knee society rating system (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) 를비교하였고, 방사선결과는역학적축, 후방경사도, 그리고 내측관절간격을측정했다. 결과 : 전체환자의술전역학적축은내반 7.8 o ±2.4 o, 술후 3 개월역학적축은외반 1.9 o ±2.2 o 였다. 최종추시상 A 군은외반 2.1 o ± 3.1 o 로교정이유지됐지만 B 군은외반 0.1 o ±3.1 o 로교정소실을보였다. 후방경사도는 A 군에서보다유의한증가를보였다. 내측관 절간격은두군에서모두호전을보였다. KSS 와 WOMAC 점수도의미있는호전을보였다 (p<0.001). 결론 : HTO 의임상결과는우수하였으며, 삽입형금속판은오랜기간의부분체중부하가필요하며, 잠김나사금속판이삽입형금속 판보다교정유지에효과적이었다. 색인단어 : 슬관절, 내측구획관절염, 개방형경골근위절골술, 삽입형금속판, 잠김나사금속판 접수일 2013 년 11 월 6 일수정일 2014 년 2 월 24 일게재확정일 2015 년 5 월 30 일책임저자박혁 54907, 전주시덕진구건지로 20, 전북대학교의학전문대학원정형외과학교실 TEL 063-250-1760, FAX 063-271-6538, E-mail hyukpark@jbnu.ac.kr 대한정형외과학회지 : 제 50 권제 5 호 2015 Copyright 2015 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/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.