J Korean Hip Soc 22(2): 116-121, 2010 Review Article Treatment for the Acetabular Fracture Weon-Yoo Kim, MD Department of Orthopedic Surgery, Daejeon St. Mary s Hospital, The Catholic University of Korea, Daejeon, Korea The acetabulum is the socket of the hip joint and incongruence of the joint surface caused by fracture causes hip pain and posttraumatic arthritis. The usual choice of treatment for displaced acetabular fracture is operative treatment, which entails a challenging, stiff learning curve. The principle of treatment is restoring the stable and congruent hip joint for early mobilization to prevent local and systemic complications. Key Words: Acetabular fracture, Treatment 비구란고관절의소켓부위를말하는것으로해부학적으로관절연골, 비구벽 (anterior & posterior wall), 골지주 (anterior & posteror colum), 관절순 (lablum) 등으로구성되어있다. 사춘기에서부터골화가일어나는삼방연골 (triradiate cartilage) 이비구의중심이며, 전하방 1/5 는치골, 상방 2/5 는좌골, 후하방 2/5 는좌골에의하여구성되어있다. 비구의골절은단독으로일어나기보다는골반골의골절, 근위대퇴골의골절등과동반되어일어나며골절이일어날시에는교통사고나추락등의큰외력손상에의한경우가대부분이며다른장기의손상이동반되어있을수도있으므로초기에세심한전신상태를점검하고서골절부위의치료에임하는것은당연하지만간과될수있으므로특히주의를기우려야한다. 골반골절이동반된경우에는비구골절이라하는데그만큼비구부위의손상은고관절의예후에중요하기때문이라고할수있다. 비구의골절을정복하지못할경우고관절의관절면이매끄럽게되지못하여고관절의파괴가진행되어외상성관절염이속발하므로비구골절의치료는정확한관절면의정복이선행되어야한다. Submitted: April 15, 2010 1st revision: June 15, 2010 2nd revision: June 18, 2010 3nd revision: June 21, 2010 4nd revision: June 22, 2010 Final acceptance: June 22, 2010 Address reprint request to Weon-Yoo Kim, MD Department of Orthopedic Surgery, Daejeon St. Mary s Hospital, 520-2 Daeheung-dong, Jung-gu, Daejeon 301-723, Korea TEL: +82-42-220-9530 FAX: +82-42-221-0429 E-mail: weonkim@hotmail.com 1. 역사적배경 비구골절의치료에있어서는이미고인이되어버린프랑스사람들인 Robert Judet 과그의 resident 이었던 Emil Letournel 의공적을상기하여야한다. 그들에의한골절의분류가아직도가장유용하게이용되고있으며이들의골절분류는그들의비구골절치료에대한열정과수많은경험례 (1,000 예이상 ) 에서파급되었으며 Judet 의 sketch 를보게되면이미 1956 년수술한 T-shaped and posterior wall 골절의경우 Ollier 도달법을시행하여강선고정술을시도한기록이전해지고있다 1). 이들에의하여비구골절의치료가개발되었으며특히이들의골절분류는골절수술의전략적도달법및내고정에필수조건이된다고할수있다. 또무엇보다이들의비구골절에대한공헌으로는비광범위도달법인 Kocher- Langenbeck 도달법과 ilioinguinal 도달법의개발이라고도할수있다. 이들의문하생으로연수한미국인들인 Joel Mata, Jeffrey Mast, Eric Johnson 등이미국으로돌아와서현재 AO group 의북미 counter part 인 OTA (Orthopedic Trauma Association) 의중심인물로서활동하고있는중이며그외 AO group 에서비구골절의치료와연구및교육을진행하고있어비구골절에대한적극적인치료가보편화되고있는실정이다. 2. 골절의분류 수술도달법및내고정의방법등을결정하는전략에이용될수있는 Judet & Letournel 의골절분류가가장많이 116
Weon-Yoo Kim: Treatment for the Acetabular Fracture 이용되고있으며이들은기본골절 (elementary fracture) 로서후벽골절 (posterior wall fracture), 후방골주골절 (posterior column fracture), 전벽골절 (anterior wall fracture). 전방골주골절 (anterior column fracture). 횡형돌절 (transverse fracture) 의 5 가지골절을분류하였으며, 이들은모든골절에서기본적으로일어나며골절이더욱심하게진행될시에는이들기본골절의조합인복합골절 (assocciate fracture) 이일어난다고하였다. 이들복합골절은여러가지가추가될수있지만각조합의치료방침으로도달법및내고정방법의공통점이있는것들은서로통합하여그중대표적인것으로 post. wall plus post. column fracture, post. wall with transverse fracture, T-shaped fracture, ant. column or wall with post. hemitransverse fracture, both column fracture 등 5 가지를제시하여도합 10 가지로분류하였다. 또, Tile, Helfet 등에의하여기존의 AO 골절분류를이용한 comprehensive classification 이이용되기도하는데이는기존 AO 골절분류의기본개념인문자화, 숫자화하여전산적인 data base 를얻기위하여골절을 type A (partial articular fracture, one column involved) type B (partial articular fracture, two column involved) type C (both column fracture, floating acetabulum) 로분류하여사용하고있다 2). 비구골절치료의첫단계는정확한분류에있으며이는수술도달법및정복고정의방침을정하는데있어서전략적인측면에서매우중요하다. 그러나비구골절에서똑같은골절은있을수없으며완벽한비구골절분류방법은아직도존재하지는않다고도말할수있다고한다. 비구골절의분류에있어그근간을이루는것은 Judet 와 Letournel 의많은치료예를분석하여이루어진 Judet 와 Letournel 의분류법이며이는해부학적분류를근간으로하고있으므로수술도달과내고정방법등을전략적으 로결정하는데필수적인방법이다. 그러나이방법의단점으로는같은골절, 예를들어 T-shaped fracture 라도전위가있는경우와없는경우, 대퇴골두의탈구가동반된경우의유무, 심한분쇄골절이동반된 high energy trauma 또는노인에서경우와같이 low energy trauma 로일어나는경우등의여러가지예후에관한인자가있을수있으므로같은골절이라도분명히같을수는없는단점이있다. AO group 에서는모든골절을 same language 로표현하고전산화하기위하여 Alphanumeric coding 을시작하였는데이를 Universal Classification 이라고명명하였으며요약하면골절을손상정도에비례하여 A, B, C 의세 group 으로분류하는것이다. A 가가장약하고 C 가가장심한골절손상이다. 각 Group 은다시손상정도와수상부위에따라 1, 2, 3 으로 subtype 을나누었다. 비구골절에서도기존상지와하지의모든골절에이용되던 AO Universal classification 이 Letournel, Helfet, Tile 등의학자들이동의하여 Letournel 의골절분류를응용하여탄생되었으며골절에관한각학회및유관기관 (SICOT, AO, OTA 등 ) 에서도이것을채택하여현재 AO comprehensive classification 이라고불린다 (Tile s AO modification of Letournel s classification) 3). 그러나 AO 골절분류법역시단점으로는골절의분쇄및전위정도, 골절방향, 체중부하지점의골절정도, 탈구등치료의예후에직접영향을끼치는요소들은표현할수없으며중요한것은모든골절은같지않으므로수술자의경험에의한주관적판단도중요한인자가될수있다는점이다 (Fig. 1). A B C Fig. 1. AO comprehensive classification. 117
J Korean Hip Soc 22(2): 116-121, 2010 1) Judet and Letournel classification Elementary fracture Posterior wall Posterior column Anterior wall Anterior column Transverse Associated fracture: at least 2 elementary fractures T-shaped Posterior column and posterior wall Transverse and posterior wall Anterior column and posterior hemitransverse Both columns Type A: Partial articular, involving only one of the two columns. A1; Posterior wall fracture A2; Posterior column fracture A3; Anterior column or wall Type B: Partial articular, involving a transverse component. B1; Pure transverse B2; T-shaped B3; Anterior column and posterior hemitransverse Type C: Complete articular, both column. C1; High variety, extending to the iliac crest C2; Low variety, extending to the anterior or the ilium C3; Extension into the sacroiliac joint 2) AO comprehensive classification A B Fig. 2. (A) A 71 year-old male with a T-shaped acetabular fracture and severe impaction due to osteoporosis was performed primary total hip arthroplasty with a flanged acetabular cup after fixation of posterior column and (B) reinforcement with mesh cage and autogenous bone graft from own femoral head. Fig. 3. This picture shows the interfragmental fixation with a columnar screw, posterior columnar or ilioischial screw. Fig. 4. This picture shows an anterior columnar or iliopubic screw. 118
Weon-Yoo Kim: Treatment for the Acetabular Fracture AO 분류법의특징은각분류에따라수술도달법을선택할수있다. A1 : Kocher-Langenbeck approach A2 : Kocher-Langenbeck approach A3 : Ilioinguinal approach B1 : 주전위골절방향에따라선택하나주로 Kocher-Langenbeck approach B2 : Kocher-Langenbeck or Ilioinguinal approach B3 : Ilioinguinal approach C1/C2 : Ilioinguinal approach C3 : Extended iliofemoral approach 그러나이러한권장되는도달법외에도손상이심한경우에는전후방연합도달법 (anterior and posterior combined approach) 가권장되기도한다. 실제적으로 AO 골절분류법을비구골절의분류에적용할시에는 AO 분류법의정의와는달리 type B 가 C 보다고에너지손상인모순이있는점을인지하여야하며 Type C 는관절부가 axial skeleton 과따로떨어져있는 floating acetabulum 으로 Letournel classification 에따르면양주골절이다 4). 3. 치료 치료의목적은고관절의안정성과관절면의정확한정복 (stable & congruent joint) 이다. 전신상태가수술에적합하지않는경우를제외하고는현재대부분의 A B Fig. 5. (A) Postoperative radiograph and (B) CT scan of 31 Year-old male patient with an anterior column & posterior hemitransverse acetabular fracture show an anatomical reduction and fixation by a posterior plate and percutaneous anterior columnar screw with Kocher-Langenbeck approach. A B C Fig. 6. (A) A simple radiograph of a 16-year-old male with T-shaped acetabular fracture. (B) 3D CT shows pattern of the fracture and (C) a postoperative film shows an anatomical reduction and plate fixation with a combined anterior and posterior approach. 119
J Korean Hip Soc 22(2): 116-121, 2010 Surgeon 들은조기거동이가능할수있고관절면의정확한정복이가능할수있는수술을선호하는추세이다. 1) 비수술적치료전위가없거나경미한골절은침상안정가료후 4~6 주후목발보행을허용하며체중부하는 8~12 주에시행한다. 비수술적치료를시행하는데있어 Mata 는 roof arc angle 의개념을소개하였는데대퇴골두의중심에서부터중요한체중부하천정부 (weight bearing dome) 인비구천장 (roof) 의상부 10 mm 은대퇴골두중심에서그어볼때 45 이내에위치하므로견인을제거한상태에서 internal & external rotation 3/4 view 에서이각도 ( 대퇴골두의중심부에서수직으로그은선과골절선이이루는각도 ) 가모두 450 이상일때에는보존적요법으로치료가가능하다는점이다. 이개념은 T- 형골절에서만적용될수있으며양주골절에서는골절면의양상이 coronal plane 이므로적용이될수없다 5). 양주골절에서는골절이일어나게되면대퇴골두를중심으로비구골절편이재조합되게되는데이것을 secondary congruence 라하며이러한 secondary congruence 가적당히이루어질경우에는골견인을유지시켜골유합을이룰수도있다. 2) 수술적치료골절의양상이매우분쇄가심하거나골다공증이동반된노인등에서수술로골유합을시도하였을때예후가불량할것으로예견될때에는일차적으로인공관절치환술을시행하여좋은결과를얻을수있다고한다 6-8) (Fig. 2). 또, 골절이관절연골의함입, 분쇄등이없으며전위가적은경우에는작은수술절개창으로피하나사못내고정술 (percutaneous screw fixation) 을시행할수도있다 9) (Fig. 3, 4, 5). 그러나비구골절의정복수술을시행함에있어서는가파른학습곡선과많은임상경험이필요하며 Mata 는초기 100 예의수술을분석하였을때 60 예를지나야만불만족스러운정복이없어졌다고하는 learning curve 를제시하기도할정도로수술의의숙련도가필요한수술이기도하다. 수술도달법으로는크게광범위도달법 (extensile approach) 과비광범위도달법 (non-extensile approach) 으로대별되며광범위도달법으로는 ilioischaiol, iliofemoral, triradiate approach 등이있으며비광범위도달법은후방으로는 Kocher-Langenbeck approach, 전방으로는 Ilioinguinal approach 가있다. 비광범위도달범의장점으로는출혈, ectopic ossification, 창상감염등의합병증이현저히낮은반면대부분의골절이이러한도달법으로써정복이가능하고그렇지못할경우에는비광범위도달법을모두이용한 전후방연합도달법 (combined anterior and posterior approach) 10) 으로도가능해지므로대부분의수술의가선호하는실정이다. 간혹이러한도달법외에도일부에서는비뇨기과에서이용하고있는 Stoppa 도달법을선호하여골반골절의정복과더불어이용되기도한다 (Fig. 6). REFERENCES 01. Letournel E, Judet R. Fracture of the acetabulum. 2nd ed. Berlin: Springer-Verlag; 1993. 02. Rüedi TP, Murphy WM. AO principles of fracture management. New York: Thieme; 2000. 03. Tile M, Helfet D, Kellam J. Fracture of the pelvis and acetabulum. 3rd ed. Philadelpia: Lippincott Willams & Wilkins; 2003. 04. Smith WR, Ziran BH, Morgan SJ. Factures of the pelvis and acetabulm. New York: Informa healthcare; 2007 05. Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures:value of plain radiography in early assessement and management. Radiogoly.1986;160:445-51. 06. Mears DC, Velyvis JH. Acute total hip arthroplasty for selected displaced acetabular fractures: two to twelveyear results. J Bone Joint Surg Am. 2002;84:1-9. 07. Mears DC, Velyvis JH. Primary total hip arthroplasty after acetabular fracture. Instr Course Lect. 2001;50:335-54. 08. Boraiah S, Ragsdale M, Achor T, Zelicof S, Asprinio DE. Open reduction internal fixation and primary total hip arthroplasty of selected acetabular fractures. J Orthop Trauma. 2009;23:243-8. 09. Starr AJ, Jones AL, Reinert CM, Borer DS. Preliminary results and complications following limited open reduction and percutaneous screw fixation of displaced fractures of the acetabulum. Injury. 2001;32 Suppl:45-50. 10. Kim WY, Sung JH, Han CH, Cheon JS, Hwang HJ. Combined anterior and posterior approach in operating on complex acetabular fractures. J Korean Ortho Assoc. 2001;36:287-92. 120
Weon-Yoo Kim: Treatment for the Acetabular Fracture 국문초록 비구골절의치료 김원유 가톨릭대학교대전성모병원정형외과 비구는고관절의소켓에해당되는부위로골절로인한관절면의불일치는고관절의동통과외상후관절염을일으킬수있다. 대부분의전위된비구골절의치료로는수술적정복이며이는도전적이고학습도가가파른행위이다. 치료의원칙은국소및전신적인합병증을예방하기위한조기관절운동을가능하게하는안정적이고일치된관절면복원이다. 색인단어 : 비구골절, 치료 121