ORIGINAL ARTICLE 대한족부족관절학회지제 17 권제 3 호 2013 J Korean Foot Ankle Soc. Vol. 17. No. 3. pp.220-224, 2013 부산대동병원정형외과 Transarticular Fixation of Akin Osteotomy on Patients with Hallux Valgus after Resection of Medial Protrusion of Base of Proximal Phalanx Seong Jun Ahn, M.D., Bu Hwan Kim, M.D., Moo Ho Song, M.D., Suk Woong Kang, M.D., Kwan Taek Oh, M.D., Seong Ho Yoo, M.D. Department of Orthopaedic Surgery, Daedong Hospital, Busan, Korea =Abstract= Purpose: When medial protrusion in the base of proximal phalanx is severe from removing metatarsal bunion during the hallux valgus surgery, it could lead to skin irritation and medial pain after the surgery. The purpose of this paper was to report our clinical and radiographic results with transarticular fixation of Akin osteotomy for the treatment of patients with hallux valgus after resection of the medial protrusion of base of the proximal phalanx. Materials and Methods: Our study is subject to 34 cases of 30 patients who went through proximal phalanx medial corticectomy among patients undergone both hallux valgus surgery and Akin osteotomy at our institution from March 2006 to March 2012. In all cases, we used absorbable suture material through the articular surface for Akin osteotomy after resection of the medial protrusion in proximal phalanx. Radiographs were reviewed to assess the union and displacement of osteotomy site at the time of postoperative 6 months. The clinical results were assessed by using AOFAS score and complication such as skin irritation and pain. Results: AOFAS score was improved from average 44 points(36-58), before operation and average 87 points(74-96), 12 months after operation. In two cases, partial union was suspected in radiological perspective, however, complete union on the osteotomy site was observed in all cases, 12 months after the operation. No patients was dissatisfied with pain, joint discomfort, skin irritation and inflammation from the knot. Conclusion: When medial protrusion in the base of proximal phalanx is severe from removing metatarsal bunion during the hallux valgus surgery, We have good results by transarticular fixation of Akin osteotomy using absorbable suture material. Key Words: Hallux valgus, Akin osteotomy Received: July 12, 2013 Revised: August 11, 2013 Accepted: August 20, 2013 Corresponding Author: Seong Ho Yoo Department of Orthopaedic Surgery, Daedong Hospital, 530-1 Myungyun 1-Dong, Dongrae-Gu, Busan, Korea Tel: +82-51-554-8996 Fax: +82-51-553-7575 E-mail: 70sh-yoo@hanmail.net 본논문의요지는 2012 년도대한정형외과학회추계학술대회에서발표되었음 서론 무지외반증이란제 1 중족골의내반변형과무지의외반, 제 1 중족골두부의내측비대와하나또는그이상의다른족지의변형이동반되는복합질환을말하며, 1) 그치료는보존적치료와수술적치료가있을수있으나일반적으로수술적적응증이되면수술적치료 - 220 -
가시행되고있다. 무지외반증에대한수술적치료는최근일반인들의발의노출및레저활동등의증가에따른인식의변화와족부전문의들의증가및술기의발전등으로인하여계속늘어나고있는추세이다. 이에따라환자들의수술결과에대한기대감이점점높아지는데주로여성들에게서수술이행해지는이유로단순히술전의통증감소에만만족하지않고오히려각교정의정도에따른미용적인만족감과술후얼마나원하는형태의신발을신을수있는가에따라수술후만족도가정해진다고할수있다. 그래서많은술자들이기존의무지외반증수술에 Akin 절골술을병행하여무지외반각을감소시키며무지의회내변형으로인한족저부내측면의각화증을치료하고있다. 2,3) 그런데무지외반증수술중중족골두의내측돌출부 (medial eminence) 절제후근위지골의기저부내측돌출이상 대적으로심해지는경우 (Fig. 1A) 술후신발과의접촉에의해피부자극및내측통증의원인이될수있어이를제거하는데, 이러한경우에는근위부골편의내측피질골이제거되어있는상태로기존의 K-강선이나나사못고정또는봉합사고정등 4-7) 으로는충분한고정력을얻기힘들다. 이처럼내측피질골이제거되어기존의고정법을이용한 Akin 절골술로는충분한고정력을얻기힘들다고판단되는경우저자들은흡수성봉합사를이용하여관절면을통한고정으로좋은결과를얻었기에이를보고하고자한다. 대상및방법 2006년 3월부터 2012년 3월까지본원에서폭이좁은신발을신을가능성이많은비교적젊은여성에게서 A B C D Figure 1. (A) At the postopeative, anteroposterior radiograph shows a medial protrusion of base of proximal phalanx. (B) Intraoperative view of the medial protrusion of the proximal phalanx (C) Intraoperative view of the proximal phalanx after resection of medial protrusion. (D)The intraoperative photograph shows transarticular fixation of akin osteotomy with absorbable suture material after resection of medial bony protrusion of proximal phalanx. - 221 -
무지외반증치료를위해원위갈매기형절골술을시행후중족골두내측면에비해상대적으로근위지골원위부의돌출이 3 mm 이상인경우 Akin 절골술을시행한후근위지골내측피질골의돌출부절제술을시행하였던환자중 12개월이상방사선적추시관찰이가능하였던 30명 34례를대상으로하였다 (Fig. 1A). 전예에서여자였으며평균나이는 38.6세 (28~48세) 였다. 평균추시기간은 12.8개월 (12~17개월) 이었다. 전례에서흡수성봉합사 (coated vicryl plus 2, ETHICON, Somerville, New Jersey, US) 를사용하였고수술후방사선학적으로절골부위의전위발생및유합정도를관찰하고임상적으로피부자극이나통증등의합병증발생을조사하였다. 수술방법은무지근위지골기저부 5~6 mm 원위부에서전동톱을이용하여제 1 중족족지관절과평행하게근위절골면을만들고, 중족골절골술후잔존하는무지외반의정도에따라 2~4 mm 크기의내측폐쇄성쐐기절골술을시행한후, 무지의회내변형의정도에따라회외감염 (derotation) 하였다. 이후근위지골기저부의내측돌출면과절제된중족골두내측면과의균일한정도를판단하여 2~3 mm 이상돌출된경우근위지골의내 측돌출면을절제하였다 (Fig. 1B). 이후 1.6 mm의 K-강선을이용하여제 1 중족지절관절의근위지골관절면을통하여근위에서원위방향으로구멍을뚫고원위골편은절골면으로부터 3~4 mm 떨어진곳에구멍을뚫어원위부에서근위부로봉합사의바늘을이용하여직접통과시킨후단단하게봉합하였다 (Fig 1C). 술후처치는전족부에체중이가해지지않는술후신발을착용하고발뒤꿈치나외측으로부분체중부하를시작하였으며술후 2주부터능동적관절운동을, 6주부터는신발을착용한상태로전체중부하를시작하였다. 방사선학적결과판단은술후방사선사진상에서보이는절단면의방사선투과성음영선의길이가 2/3이상골경화성음영으로바뀌는시점을골유합으로판단하여술전, 술후충분히골유합이이루어졌을거라고예상되는 6개월시점에서전후면방사선촬영하여절골면이벌어지거나유합소견이보이지않으면실패라고생각하였고, 전위발생유무는술후방사선사진상에서절골면의벌어짐이나각도의소실등을관찰하여평가하였다. 임상적으로는 Paired t-test로수술전후의 VAS 통증척도및술전과술후 12개월시점에서전족부 AOFAS score를비교하였으며, 절골술이이루어진무지근위지골부위의피부자극이나관절부위통증등의합병증을조사하였다. 결 과 Figure 2. At the postoperative 12 months, anteroposterior radiograph shows a radiolucent line of the osteotomy site. 방사선소견상 2례에서불완전골유합으로보이는절골면의방사선투과성음영이발견되었으나이는절골면의내측 1/3정도에만걸쳐있었으며, 술후 3개월시점부터절골면의동통이나압통은존재하지않는상태로부분적인골유합으로생각하였다 (Fig. 2). 그외전례에서완전골유합을보였으며, 단 1례에서도고정력약화로인한절골면의벌어짐이나각도의소실은없었다. 술전 VAS 동통점수가 6.5점 (4~8점) 에서술후 0.6점 (0~3점) 으로유의하게감소하였으며 (p<0.05), AOFAS 척도는술전평균44.6에서술후12개월시점에서평균 87.6으로향상되었다 (Table 1). 피부자극및염증소견등의합병증은관찰할수없었고봉합사가통과한중족지절관절부위에서도어떠한불편감이나통증도발생하지않았다. - 222 -
고찰 무지외반증에대한수술적치료에는원위부연부조직재건술, 중족골절골술, 중족족지관절유합술, 중족족지관절성형술등무지의외반, 제 1 중족골의내반정도및중족족지관절의상합성여부에따라다양한수술적방법들이사용되고있다. 수술적치료의목적은무지의외반변형과제 1 중족골의내반변형을교정하여제 1 중족족지관절의생역학을회복시켜제 1 중족족지관절의통증을덜어주는데그주된목적이있 었으나 8,9) 최근에는발을노출해야할기회가많아지며 이수술이주로여성들에게서행해지므로단순히술전의통증감소에만만족하지않고무지외반각을감소시키고수술후발생할수있는족저부내측면의각화증을완화하여원하는형태의신발을신을수있는가로관심이옮겨가고있다. 이러한이유로많은술자들이기존의무지외반증수술에더하여 Akin 절골술을시행하고있다. Akin 절골술은 1925년처음소개되었는데이는제1 중족골두의내측융기 (medial eminence) 및근위지골의기저부절제와족무지의곧은정렬을위한근위지골의내측폐쇄성쇄기절제술로이루어져있는데 10) 이를단독으로사용시제 1 중족족지관절의중심이제1 열의축에대해조금더외측으로이동하게되므로결과적으로제 1 중족족지관절의외측탈구내지아탈구를유발하여재발가능성이높아지므로단독으로는거의사용하지않으며주로다른연부조직수술이나다른중족골수술에병행하여시행되는것이일반적이다. 11) 그런데본연구에서처럼무지외반증수술중중족골두의내측융기 (bunion) 제거후상대적으로근위지골의내측돌출이심하게되는경우에는술후신발과의접촉에의한동통및불편감을야기할가능성이높다. 이와유사하게무지외반증교정을위한과도한 Akin 절골술후무지원위지골의내측부돌출에의한동통과불편감으로절제술을시행한증례는보고되어있다. 12) 이는주로폭이좁은신발을즐겨신는비교적젊은연령의여성에게서일어날가능성이높은데실제로저자의경우에도무지외반증수술을시행한 2명의 20대여성에게서비교적폭이좁은신발을신었을때발생한무지내측부통증으로인하여추가적인근위지골돌출부절제술후증세의호전을경험한예가있다. 이러한이유로무지외반증수술중중족골두의내측융기절제후 Akin 절골술을시행하려할때근위지골의내측돌출부절제술을병행하는경우내측피질골이없어지거나상대적으로얇아지게되므로일반적으로사용되어지는나사못 7) 이나금속강선, staple 13,14) 과같은고정방법으로는골유합에필요한안정성을얻기가힘들어진다. 이러한경우에저자들은흡수성봉합사를이용하여관절면을통한고정방법을선택함으로써근위지골내측돌출부제거술로인하여 Akin 절골술의절골면근위부에서내측피질골이없어지거나상대적으로얇아지게되더라도나사못고정보다상대적으로더욱견고한안정성을확보할수있었으며, 골유합후고정물을제거할필요가없었고, 또한매듭이일정시간지난후흡수됨으로써비흡수성봉합사를사용할때일어날수있는피부자극도예방할수있었다. 물론관절면을통한직접적봉합은관절면의손상을초래하게되나그범위가봉합사의바늘 (needle) 크기정도이고완전한체중부하관절이아니기때문에큰문제를야기하진않을것으로예상하였고저자들이경험한 34례에서도이와관련된관절증세는발생하지않았다. 흡수성봉합사를이용한고정시발생할수있는문제점은일정기간골유합에필요한고정력이유지되는가 Table 1. Summary of AOFAS Scores AOFAS score Mean (±SD) Preoperative Postoperative 12 months Improvement Pain 20.0 (±3.8) 35.4 (±4.6) 15.4 (±4.4) Function 22.6 (±5.0) 36.8 (±4.8) 14.2 (±5.0) Alignment 02.0 (±2.4) 15.4 (±2.4) 13.4 (±2.4) Total (p=0.02) 44.6 (±6.8) 87.6 (±5.8) 43.0 (±6.2) The statistic analysis using t-test. - 223 -
하는점인데, 저자들이사용한흡수성봉합사의경우봉합사강도의유지정도가술후 28일째 25% 정도유지되는것으로알려져있다. 15) 이는 K-강선을제거하고수동적관절운동을시작하는술후 4주시점의강도로서는충분한것으로저자들은판단하였고본연구에서도고정력약화로인한점진적인골절편의전위나불유합은단한건도발생하지않았다. 특히 2례에서방사선사진상보이는내측절골면의투과성음영이경과관찰중증가하지않고유합에이른것은초기절골술시양측절골면의불일치에의한것이지봉합사의고정력약화로인한점진적인변화가아니라고저자들은판단하였다. 본연구의제한점으로는첫째무지외반증수술환자에있어서근위지골내측돌출부의존재가술후임상증세에어떠한영향을미치는가에대한비교연구가이루어지지않았다는것이다. 내측돌기를제거한군과제거하지않는군에서발생한임상증세를각각조사하여술전과술후상태를비교해본다면더많은결과를얻을수있을것이다. 둘째본연구는단기간의추시에기초한임상결과로서부분적인관절면손상에대한장기추시임상결과가필요할것으로생각한다. 결론 무지외반증수술중근위지골의기저부내측면이돌출되어이를제거후내측피질골이없는상태에서 Akin 절골술을시행하는경우, 흡수성봉합사를이용한관절면을통한고정으로골유합과정에서교정각이소실되지않았으며, 성공적인골유합소견을얻을수있었다. REFERENCES 01. Mann RA, Coughlin MJ. Adult hallux valgus. In: Surgery of the Foot and Ankle, 6 th ed. St.Louis: Mosby-Year book; 1993.167-296. 02. Young KW, Lee KT, Kim JY, Cha SD, Kim ES. Fixation with suture material in akin osteotomy. J Korean Foot Ankle Soc. 2004;8:138-41. 03. Silberman FS. Proximal phalangeal osteotomy for the correction of hallux valgus. Clin Orthop. 1972;85:98-100. 04. William ED, William ED Jr. The proximal phalangeal osteotomy: A technically advanced approach. Clinic Podiatry. 1985;2:449-55. 05. Melamed E, Eli P, Zinman C. Technique tip: Suture fixation of wedge osteotomies in the foot. Foot Ankle Int. 2005;26: 1096-8. 06. Green AH, Bosta SD. Akin osteotomy of the hallux valgus proximal phalanx utilizing richard mini-staple fixation. J Foot Surg. 1986;25:386-9. 07. Levitsky DR, DiGilio J, Kander R, Rubin B. Rigid compression screw fixation of first proximal phalanx osteotomy for hallux abducto valgus. J Foot Surg. 1982;21: 65-9. 08. Klosol JK, Pring DJ, Jessop JH, Maffulli N. Chevron or Wilson metatarsal osteotomy for hallux valgus. A prospective randomized trial. J Bone Joint Surg Br. 1993;75:825-9. 09. Ocuda R, Kinoshita M, Morikawa J. Distal soft tissue procedure and proximal metatarsal osteotomy in hallux valgus. Clin orthop. 2000;37:209-17. 10. Akin OF. The treatment of hallux valgus: a new operative procedure and its results. Med Sentinel. 1925;33:678. 11. Springer KR. The role of the akin osteotomy in the surgical management of hallux abductio valgus. Clin Podiatr Med Surg. 1989;6:115-31. 12. Carlos V, Javier DR, Andres V, Matias A. Symptomatic medial exostosis of the great toe distal phalanx: A complication due to over-correction following akin osteotomy for hallux valgus repair. J Foot Ankle Surg. 2009;48:47-51. 13. Tollison ME, Baxter DE. Combination chevron plus akin osteotomy for hallux valgus. should age be a limiting factor? Foot Ankle Int. 1997;8:477-81. 14. McGarvey SR. Internal fixation of the akin osteotomy. Foot Ankle Int. 1995;16:172-3. 15. Song MH, Kim BH, Ahn SJ, Yoo SH, Lee DJ. Fixation with absorbable suture material in Akin osteotomy. J Korean Foot Ankle Soc. 2011;3:149-52. - 224 -