59 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2019; 54: 59-66 https://doi.org/10.4055/jkoa.2019.54.1.59 www.jkoa.org Ponseti 방법으로치료를시작한선천성만곡족환자에서수술적치료여부를예측할수있는방사선적지표 송광순 연창진 이시욱 이용호 엄상현 권혁준 계명대학교의과대학정형외과학교실 Reliable Radiologic Parameters to Predict Surgical Management for Clubfoot Treated with the Ponseti Method Kwang Soon Song, M.D., Ph.D., Chang Jin Yon, M.D., Si Wook Lee, M.D., Ph.D., Yong Ho Lee, M.D., Sang Hyun Um, M.D., and Hyuk Jun Kwon, M.D. Department of Orthopedic Surgery, Keimyung University School of Medicine, Daegu, Korea Purpose: Several radiologic reference lines have been used to evaluate individuals with a clubfoot but there is no consensus as to which is most reliable. The aim of this study was to identify which radiologic parameters have relevance to the predictability of additional surgery after Ponseti casting on clubfoot and the effect of clubfoot treatments that contain Ponseti casting and additional surgery. Materials and Methods: A total of 102 clubfeet (65 patients, 37 bilateral) were reviewed from 2005 to 2013. The patients were divided into two groups (Group A, those for whom the result of the Ponseti method was successful and did not require additional surgery; and Group B, those for whom the result of the Ponseti method was unsuccessful and required additional surgery), and the following parameters were measured on the plain radiographs: i) talo-calcaneal angle on the anteroposterior and lateral view, ii) talo-1st metatarsal angle on the anteroposterior view, and iii) Tibio-calcaneal angle on the lateral view with the ankle full-dorsiflexion state. Each radiograph was reviewed on two separate occasions by one orthopedic doctor to characterize the intra-observer reliability, and the averages were analyzed. Next, 20 cases were chosen using a random number table, and two orthopedic doctors measured the angle separately to characterize the interobserver reliability. Results: Groups A and B included 73 clubfeet (71.6%) and 29 clubfeet (28.4%), respectively. The initial talo-calcaneal angle and tibiocalcaneal angle in the lateral view were significantly different among the groups. In addition, inter- and intra-observer biases were not detected. The talo-1st metatarsal angle on the anteroposterior view and tibio-calcaneal angle on the lateral view were significantly different after treatment in both groups. Conclusion: Congenital clubfeet treated with the Ponseti method showed successful results in more than 70% of patients. The initial talocalcaneal angle and tibio-calcaneal angle on the lateral view were the radiologic parameters that could predict the need for additional surgical treatments. The talo-1st metatarsal angle on the anteroposterior view and tibio-calcaneal angle on the lateral view could effectively evaluate the changes in clubfoot after treatment. Key words: clubfoot, Ponseti method 서론 Received October 31, 2017 Revised November 2, 2017 Accepted February 26, 2018 Correspondence to: Chang Jin Yon, M.D. Department of Orthopedic Surgery, Keimyung University Dongsan Medical Center, 56 Dalseong-ro, Jung-gu, Daegu 41931, Korea TEL: +82-53-250-7729 FAX: +82-53-250-7205 E-mail: poweryon@nate.com ORCID: https://orcid.org/0000-0003-3580-4175 선천성만곡족은근골격계질환중가장흔한족부질환중하나 이다. 이는족관절의첨족, 후족부내반, 전족부내전, 요족등의 특징적변형을가지며이변형을초기에교정하는것이치료의 The Journal of the Korean Orthopaedic Association Volume 54 Number 1 2019 Copyright 2019 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.
60 Kwang Soon Song, et al. 목적이다. 1) 초기치료는 Ponseti 방법을이용하여조기에치료하는것이가장선호되고있다. 2-5) 선천성만곡족의교정평가를위하여방사선적평가가많이이용되고있으나, 6-10) 어떠한방사선적기준선이치료결과의예측및평가에있어서객관적인의미를가는지에대해서는아직논란의여지가있다. 11) 이에본저자들은 Ponseti 방법으로치료한환자들에있어수술적치료의필요성을예측하는데방사선적기준선들의유용성을알아보고치료효과를평가할수있는방사선적기준선을알아보고자하였다. 대상및방법 2005년 2월부터 2013년 5월까지계명대학교동산의료원에서선천성만곡족으로진단받고 Ponseti 방법 12) 으로교정치료한환자중 2년이상추적관찰이가능하였던 65명 (102족) 의환자를대상으로하였다. 37명은양측성만곡족을보였고, 28명은일측성만곡족을보였다. 1) Ponseti 방법후 1주이내에수술적치료를받은환자, 2) 2년미만의추시관찰기간을가지거나추시소실된환자, 3) 선천성만곡족이외의선천성증후군및신경근육이상을보이는환자는연구대상에서제외하였다. 모든환자에서비수술적방법인 Ponseti 방법 12) 을이용한석고붕대교정방법으로치료를시작하였으며, 모든술기는소아정형외과경력이 20년이상되는제1저자에의하여시행되었다. 본연구는계명대학교동산의료원 e-irb에서승인받아진행되었다 (IRB No. 2016-05-011-005). Ponseti 방법 12) 은전족부를회외전시킨후제1 중족골두를밀어올리면서요족을교정하고자하였고족근동의거골경부측에손가락을대어반대로압력을가하면서전족부를외전시켜전족부내전을교정하였다. 이때종골-입방골관절경첩이되지않도록주의하면서장하지석고붕대고정술을시행하였다. 석고고정은 1주일간격으로교체하였고 4-6회시행후교정이만족스럽게이 루어져족배굴곡이 20도이상가능한환아에서외전족배보조기착용을시작하였으며족배굴곡이 20도이하이거나첨족변형이남아있는환아 39명 (63족) 에서는국소마취하에아킬레스건절단술을시행하여족관절을 20도족배굴곡시키고 70도외회전시킨상태로 2주간장하지석고붕대고정술을시행하였다. Ponseti 교정방법의초기성패는추가적인수술여부로결정하였으며수술시행여부로두군 (A군: 초기치료가성공하여수술을시행하지않은군, B군 : 재발혹은잔존변형으로인하여수술을시행한군 ) 으로나누었다. Ponseti 방법에의해초기치료가완료된상태에서결과가만족스럽지못하거나결과가만족스러워도추시기간중재발한환아의경우수술적치료를시행하였다. 수술적치료는평균생후 24개월 (8-56개월) 에시행하였다. 초기치료후결과가만족스럽지못하거나추시기간중재발한환아, 경골염전이동반되어있으며내족지보행이있는환아의경우추가적으로수술적치료를시행하였다. 모든대상환아에대하여전후면족부및최대족배굴곡상태에서족관절을포함하는측면족부단순방사선촬영을시행하였다. 전후면족부방사선촬영은정형외과의사가환아의발을잡은상태에서 X선방사각도가발등에수직이될수있게하여촬영하였고, 측면족부방사선사진은정형외과의사가블록을이용하여환아의발바닥전체를접촉시킨상태에서최대족배굴곡을시킨상태에서촬영하였다. 두군의방사선적인족부변형상태비교는전후면거종간각 (talo-calcaneal angle on anteroposterior view, TCA), 측면거종간각 (talo-calcaneal angle on lateral view, LTCA), TCA 및 LTCA의합 (sum of TCA and LTCA, TCA anteroposterior+laterior [AP+Lat]), 전후면거골-제1중족골간각 (talo-1st metatarsal angle on anteroposterior view, TFMA), 측면경종간각 (tibio-calcaneal angle on lateral view at ankle full-dorsiflexion state, TicalA) 을지표로정하여측정하였다 (Fig. 1). 모든기준선은해당뼈의장축을기준으로선을그렸고그사이의각을측정하여각 A B C D Figure 1. (A) Talo-calcaneal angle on the anteroposterior view. (B) Talo-1st metatarsal angle on the anteroposterior view. (C) Talo-calcaneal angle on the lateral view. (D) Tibio-calcaneal angle on the lateral view.
61 Radiological Parameters in Clubfoot 도를기록하였다. 각방사선사진은관찰자내신뢰도를평가하 기위해한정형외과의사가 2 회씩검토한후평균을분석하였으 며, 관찰자간신뢰도를평가하기위해난수표를통해 20 족을선 정하여각도를측정하여급내상관변수 (intra-class correlation) 를 통하여분석하였다. 두그룹간의초기족부변형상태를비교하고자최초방문시 각방사선적지표를측정하여통계적으로비교하였다. Ponseti 방 법을시행후족부변형의호전정도의차이를확인하기위해 A 군에서는최초방문시와 Ponseti 방법으로치료후최종추시시 방사선적지표들을측정하였으며 B 군에서는최초방문시와수 술적치료직전, 최종추시시의방사선적지표들을측정하여각 시기별로호전정도를평가하였다. 모든결과는 IBM SPSS package ver. 21.0.1 (IBM Co., Armonk, NY, USA) 을이용하여분석하였다. 정규성가정을만족하는항 목에대해서는 paired t-test 를시행하였고, 정규성가정을만족하 지못하는항목에대해서는 Mann-Whitney 및 chi square 검사, Wilcoxon 부호순위검정을시행하였다. 95% 의신뢰구간을기준 으로분석하였으며, p-value 0.05 미만에서통계적의의를지닌다 고해석하였다. 결과 Ponseti 방법으로치료를시작할당시의환아들의평균연령은생 후 1.63 주 (A 군 : 1.45 주, B 군 : 2.07 주 ) 였고, 최종추시시의평균연 령은 6.67 세 (A 군 : 6.16 세, B 군 : 7.86 세 ) 였다. 환자들의추시기간은 평균 3.95 년 (2.0-8.3 년 ) 이었다. 73 족 (71.6%: A 군 ) 에서 Ponseti 방법 으로치료후추가적인수술없이성공적인결과를얻었고, 29 족 (28.4%: B 군 ) 에서 Ponseti 방법으로치료후결과가만족스럽지못 Table 1. Surgical Treatments after the Ponseti Method Surgical treatment For recurred foot deformity 1st surgery (no. of feet) 2nd surgery (no. of feet) Tibio-calcaneal lengthening 9 - T ibio-navicular release+cuboid wedge osteotomy P osterior tibialis release+tibionavicular release±cuboid wedge osteotomy For residual foot deformity 2-14 5 Metatarsal corrective osteotomy 1 3 Tibia derotational osteotomy 3 6 Etc.* - 4 *Supramalleolar derotational osteotomy 1 case, subtalar posterior capsular release 2 cases, tibialis anterior tendon partial transposition 1 case. 하여추가적인수술을요하였다. 재발하는족부변형에대하여 pie-crusting 술식을이용한경골 - 종골간연장술 (tibio-calcaneal lengthening) 9 예, 입방골설상절골술을포함한거골 - 주상골관 절유리술 (tibio-navicular release+cuboid wedge osteotomy) 2 예, 후 경골근유리술과입방골설상절골술을포함혹은포함하지않은 거골 - 주상골관절유리술 (posterior tibialis release+tibionavicular release±cuboid wedge osteotomy) 14 예를시행하였으며, Ponseti 교정에도불구하고잔존하는족부변형에대하여중족골교정 절골술 (metatarsal corrective osteotomy) 1 예및경골회전절골술 (tibia derotational osteotomy) 3 예를시행하였다. 추가적인수술은 평균나이 25.8 개월 (3-64 개월 ) 에시행하였다. 추후 18 족 (17.6%) 에 대해서는추가적 2 차수술을시행하였다 (Table 1). Ponseti 치료시 아킬레스건절단술은 63 족 (61.8%) 에서시행하였고, A 군에서 39 족 (53.4%), B 군에서 24 족 (82.8%) 에서시행하였고, 아킬레스건시행 여부에따른통계적유의한차이는없었다. 두명의정형외과의사가무작위로선택한 20 족의방사선사진 Table 2. Inter-Observer Reliability of the Radiologic Parameter Evalua tion in Randomized 20 Cases Radiologic reference line Initial talo-1st metatarsal Initial tibio-calcaneal Last f/u talo-1st metatarsal Last f/u tibio-calcaneal Measurer Mean±SD Single measure p-value 1 20.58±18.06 0.978 0.000 2 21.28±20.42 1 33.56±29.14 0.968 0.000 2 35.48±27.45 1 24.69±11.40 0.962 0.000 2 26.44±11.50 1 86.63±32.10 0.995 0.000 2 85.63±32.43 1 45.27±26.52 0.984 0.000 2 47.71±28.18 1 30.45±8.61 0.911 0.000 2 30.83±8.58 1 6.53±5.83 0.876 0.000 2 6.85±6.62 1 24.31±11.52 0.973 0.000 2 24.63±11.78 1 71.58±14.27 0.991 0.000 2 71.5±14.33 1 54.76±16.08 0.971 0.000 2 55.45±17.58 SD, standard deviation; AP, on anteroposterior view; Lat, on lateral view with ankle full-dorsiflexion; Talo-calcaneal angle (AP+Lat), sum of talocalcaneal angle AP and talo-calcaneal angle Lat; f/u, follow-up.
62 Kwang Soon Song, et al. 을통해각각각도를측정하여관찰자간신뢰도를평가하였으며, 신뢰성점수는모든각도에서 85% 이상이었다. 모든각도는한명의정형외과의사가두차례에걸쳐검토하였으며, 관찰자내신뢰도점수는모든각도에서 95% 이상이었다. 치료전후및초기변형각도를평가하기위해각측정값의평균값을구하여 통계적분석을시행하였다 (Table 2, 3). 초기방사선소견상 LTCA 및 TicalA에서두군간에의미있는차이가있었다. LTCA는 A군에서 33.99 ±15.24, B군에서 24.78 ± 15.25, TicalA는 A군에서 79.03 ±28.72, B군에서 94.83 ±24.13 로초기변형이심할수록수술비율이높게나타났다 (p=0.007, 0.010) Table 3. Intra-Observer Reliability of a Radiologic Parameter Evaluation Radiologic reference line Initial talo-1st meta tarsal Initial tibio-calcaneal Pre-op talo-calcaneal Pre-op talo-1st metatarsal Pre-op talo-calcaneal Pre-op tibio-calcaneal Pre-op talo-calcaneal Last f/u talo-1st metatarsal Last f/u tibio-calcaneal Measure time Mean±SD Group A (n=73) Single measure p-value Mean±SD Group B (n=29) Single measure p-value 1st 23.45±14.99 0.998 0.000 26.50±15.33 0.996 0.000 2nd 23.67±14.85 27.27±15.85 1st 33.77±15.44 0.995 0.000 24.63±14.96 0.997 0.000 2nd 34.20±15.08 24.94±15.58 1st 32.39±23.85 0.993 0.000 28.64±27.22 1.000 0.000 2nd 33.16±23.70 29.67±27.53 1st 78.87±28.78 0.999 0.000 93.73±24.04 0.998 0.000 2nd 79.19±28.70 95.92±24.26 1st 57.23±24.01 0.998 0.000 51.13±21.08 0.996 0.000 2nd 57.87±23.49 52.20±21.71 1st - - - 27.51±16.30 0.998 0.000 2nd 28.54±16.87 1st - - - 24.11±12.99 0.994 0.000 2nd 25.20±13.82 1st - - - 17.02±20.80 0.999 0.000 2nd 17.76±20.94 1st - - - 81.37±20.83 0.999 0.000 2nd 82.89±21.40 1st - - - 51.63±25.94 0.997 0.000 2nd 53.74±27.53 1st 30.20±9.73 0.995 0.000 29.09±12.16 0.997 0.000 2nd 31.54±9.69 30.58±12.60 1st 36.13±13.62 0.995 0.000 27.15±12.32 0.998 0.000 2nd 36.40±13.64 27.98±12.65 1st 11.11±8.71 0.996 0.000 12.61±14.54 0.999 0.000 2nd 12.20±9.01 13.57±15.23 1st 62.83±18.42 0.998 0.000 75.44±18.51 0.997 0.000 2nd 63.74±18.44 75.19±17.85 1st 66.34±17.84 0.995 0.000 55.96±19.28 0.996 0.000 2nd 67.94±18.03 58.56±19.47 Group A, those for whom the result of the Ponseti method was successful and did not require additional surgery; Group B, those for whom the result of the Ponseti method was unsuccessful and required additional surgery; SD, standard deviation; AP, on anteroposterior view; Lat, on lateral view with ankle full-dorsiflexion; Talo-calcaneal angle (AP+Lat), sum of talo-calcaneal angle AP and TALO-calcaneal angle Lat; Pre-op, preoperative; f/u, followup.
63 Radiological Parameters in Clubfoot (Table 4). A 군에서평균 13.93 주간 Ponseti 방법으로치료후 TCA 가평균 7.31, TCA 와 TCA 의합 (TCA AP+Lat) 이평균 9.59, TFMA 가평 균 21.12, TicalA 이평균 15.75 만큼의호전 (p=0.000) 을보였으며, LTCA 에서는통계적으로의미있는변화가없었다 (p=0.179). B 군에서평균 22.17 주간 Ponseti 방법으로치료후 TFMA 가평 균 11.77 만큼호전 (p=0.014) 을보였으며, TicalA 이평균 12.71 만큼 의호전 (p=0.012) 을보였다. 그외방사선적지표에서는통계적으 Table 4. Initial Radiologic Findings of Groups A and B Initial radiologic parameter Group A (n=73) Group B (n=29) p-value Talo-calcaneal angle AP ( ) 23.56±14.90 26.88±15.56 0.318 Talo-calcaneal angle Lat ( ) 33.99±15.24 24.78±15.25 0.007 Talo-calcaneal angle AP+Lat ( ) 57.55±23.73 51.67±21.36 0.249 Talo-1st metatarsal angle AP ( ) 32.78±21.36 29.16±27.83 0.507 Tibio-calcaneal angle Lat ( ) 79.03±28.72 94.83±24.13 0.010 Values are presented as mean±standard deviation. Group A, those for whom the result of the Ponseti method was successful and did not require additional surgery; Group B, those for whom the result of the Ponseti method was unsuccessful and required additional surgery; AP, on anteroposterior view; Lat, on lateral view with ankle full-dorsiflexion; Talo-calcaneal angle AP+Lat, sum of talo-calcaneal angle AP and talocalcaneal angle Lat. 로의미있는변화가없었다 (TCA, p=0.770; LTCA, p=0.973; TCA AP+Lat, p=0.865). TFMA, TicalA은 A군과 B군모두에서초기평가와비교하였을때, 최종추시상의미있는호전이있었다 (Table 5). 고찰 지금까지유 소아의족부변형에있어서단순방사선사진을이용한방사선적측정을통한평가는완전히신뢰하기는어려운것으로회자되어왔다. 13-16) Simons 17) 는 1978년유 소아에서는단순방사선사진상골화중심이없거나매우작아서선천성만곡족의평가에있어서방사선적측정을사용하는것은논란의여지가있을수있다고기술하였다. 하지만동시에유 소아의족부위치의오류로인한각도의변화량은매우미미하다고도기술하고있다. 방사선적평가의질을높이기위해서는첫째, 단순방사선사진촬영시의올바른발의위치와모양이중요하며둘째, 골화중심의축을해부학적인축과최대한일치하게하여오차를줄이는데있다. 특히후자의경우대상환아의나이가어릴수록골화중심이둥글기때문에각도를잴때더큰오차가생길수있으므로주의해야한다. 실제로본연구에서는 A군과 B군의초기방사선적지표를비교분석했고 A군과 B군에서각각 Ponseti cast를통한초기치료결과에대해분석했으며 B군에서는초기치료후수 Table 5. Statistical Value of the Change in Radiologic Findings after the Treatment of Clubfoot Radiologic parameter Group Treatment Mean change p-value Talo-calcaneal angle AP ( ) A Ponseti cast 23.56 30.87 0.000 B Ponseti cast 26.88 28.03 0.770 Ponseti cast with additional surgery 26.88 29.83 0.345 Talo-calcaneal angle Lat ( ) A Ponseti cast 33.99 36.27 0.199 B Ponseti cast 24.78 24.66 0.973 Ponseti cast with additional surgery 24.78 27.58 0.390 Talo-calcaneal angle AP+Lat ( ) A Ponseti cast 57.55 67.14 0.000 B Ponseti cast 51.67 52.69 0.865 Ponseti cast with additional surgery 51.67 57.26 0.203 Talo-1st metatarsal angle AP ( ) A Ponseti cast 32.78 11.66 0.000 B Ponseti cast 29.16 17.39 0.014 Ponseti cast with additional surgery 29.16 13.09 0.002 Tibio-calcaneal angle Lat ( ) A Ponseti cast 79.03 63.28 0.000 B Ponseti cast 94.83 82.12 0.012 Ponseti cast with additional surgery 94.83 75.31 0.000 Group A, those for whom the result of the Ponseti method was successful and did not require additional surgery; Group B, those for whom the result of the Ponseti method was unsuccessful and required additional surgery; AP, on anteroposterior view; Lat, on lateral view with ankle full-dorsiflexion; Talo-calcaneal angle AP+Lat, sum of talo-calcaneal angle AP and talo-calcaneal angle Lat.
64 Kwang Soon Song, et al. 술적치료까지마친후의치료결과도분석하였다. 본연구의결과에따르면 LTCA 및 TicalA가수술적치료의필요성을예측할수있는중요한지표가될수있을것이다. 또한 TFMA, TicalA는선천성만곡족의치료후치료효과를평가하는데있어유용한것으로평가되었다. 이에서종골과거골이모두재태 26주경에골화중심형성을시작하나종골의경우거골에비해장축의형성이빠르기때문에 18,19) 경골과종골의장축을비교하는경종간각및제1중족골의장축을측정하는데오차가제일적었을것임을짐작할수있다. 본연구의제한점으로는첫째, 본연구는후향적으로이루어진연구이며두그룹간치료전초기족부변형상태를 Diméglio score 20) 등을통하여임상적으로평가하지못하여방사선적족부상태의평가와임상적인환아의족부상태의평가가실제로연관성을가지는지확인하지못하였다는점이다. 둘째, 많은연구에서보조기착용순응도가예후에큰영향을끼친다는보고 21) 가있었음에도불구하고보조기착용순응도를나타내는객관적인기준이모호 22) 하여본연구에포함하지못하였다. 마지막으로측정각들의표준편차가커서임상적으로수술적치료여부를결정하는데적용할수있는기준치를정하지못하였다. 이들제한점은추후환자군에대한지속적인추시및추가적인환자군의포함을통하여파악할수있을것으로생각한다. 결론 선천성만곡족의치료에서방사선적으로초기 LTCA 및 TicalA 를통해서수술적치료여부를예측할수있었으며, 초기 LTCA가작을수록, 초기 TicalA가클수록수술적치료를요하는경우가더많았다. TFMA 및 TicalA가선천성만곡족의치료에서전족부내전및요족변형의호전정도를평가하는데가장객관적인지표로확인되었다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Dobbs MB, Rudzki JR, Purcell DB, Walton T, Porter KR, Gurnett CA. Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet. J Bone Joint Surg Am. 2004;86:22-7. 2. Herzenberg JE, Radler C, Bor N. Ponseti versus traditional methods of casting for idiopathic clubfoot. J Pediatr Orthop. 2002;22:517-21. 3. Cooper DM, Dietz FR. Treatment of idiopathic clubfoot. A thirty-year follow-up note. J Bone Joint Surg Am. 1995;77: 1477-89. 4. Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital club foot. J Bone Joint Surg Am. 1980;62:23-31. 5. Ponseti IV, Smoley EN. The classic: congenital club foot: the results of treatment. 1963. Clin Orthop Relat Res. 2009;467: 1133-45. 6. Radler C, Manner HM, Suda R, et al. Radiographic evaluation of idiopathic clubfeet undergoing Ponseti treatment. J Bone Joint Surg Am. 2007;89:1177-83. 7. Kite JH. Principles involved in the treatment of congenital club-foot. 1939. J Bone Joint Surg Am. 2003;85:1847; discussion 1847. 8. Kite JH. The clubfoot. New York: Grune & Stratton; 1964. 232. 9. Kite JH. Conservative treatment of the resistant recurrent clubfoot. Clin Orthop Relat Res. 1970;70:93-110. 10. Kite JH. Nonoperative treatment of congenital clubfoot. Clin Orthop Relat Res. 1972;84:29-38. 11. Park SS, Kim SW, Jung BS, Lee HS, Kim JS. Selective soft-tissue release for recurrent or residual deformity after conservative treatment of idiopathic clubfoot. J Bone Joint Surg Br. 2009;91:1526-30. 12. Ponseti IV. Congenital clubfoot: fundamentals of treatment. Oxford: Oxford University Press; 1996. 140. 13. Simons GW. Analytical radiography of club feet. J Bone Joint Surg Br. 1977;59:485-9. 14. Colburn M, Williams M. Evaluation of the treatment of idiopathic clubfoot by using the Ponseti method. J Foot Ankle Surg. 2003;42:259-67. 15. Frick SL. The Ponseti method of treatment for congenital clubfoot: importance of maximal forefoot supination in initial casting. Orthopedics. 2005;28:63-5. 16. Hamel J, Becker W. Sonographic assessment of clubfoot deformity in young children. J Pediatr Orthop B. 1996;5:279-86. 17. Simons GW. A standardized method for the radiographic evaluation of clubfeet. Clin Orthop Relat Res. 1978:107-18. 18. Shapiro F, Glimcher MJ. Gross and histological abnormalities of the talus in congenital club foot. J Bone Joint Surg Am. 1979;61:522-30. 19. Fritsch H, Eggers R. Ossification of the calcaneus in the normal fetal foot and in clubfoot. J Pediatr Orthop. 1999;19:22-6. 20. Diméglio A, Bonnet F, Mazeau P, De Rosa V. Orthopaedic
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66 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2019; 54: 59-66 https://doi.org/10.4055/jkoa.2019.54.1.59 www.jkoa.org Ponseti 방법으로치료를시작한선천성만곡족환자에서수술적치료여부를예측할수있는방사선적지표 송광순 연창진 이시욱 이용호 엄상현 권혁준 계명대학교의과대학정형외과학교실 목적 : 선천성만곡족환자에서 Ponseti 방법으로치료한환자들에서잔여혹은재발변형에대한수술적치료의필요성을예측하고치료결과를평가하는데있어어떤방사선적기준선이유용할지에대하여연구하고자하였다. 대상및방법 : 2005년부터 2013년까지 Ponseti 방법으로치료를시작한환자 102족 (65명, 양측성 37명 ) 을연구대상으로했다. 환자는수술여부에따라두군 (A군: Ponseti 방법의결과가성공적이어서추가수술을시행하지않은군, B군 : Ponseti 방법의결과가만족스럽지않아수술을시행한군 ) 으로나누었고, 두군의방사선적족부변형상태비교를위해전후면및측면거종간각, 전후면거골-제1중족골간각, 발목완전배굴상태에서의측면경종간각을측정하였다. 각방사선사진은관찰자내신뢰도를평가하기위해한정형외과의사가두번씩검토한후평균을분석하였으며관찰자간신뢰도를평가하기위해난수표를통해 20족을선정하여각도를측정하였다. 결과 : A군은 73족 (71.6 %) 이었고, B군은 29족 (28.4%) 이었다. 초기방사선소견상측면거종간각및측면경종간각에서두군간의미있는차이가있었고, 관찰자간및관찰자내신뢰도의편향은관찰되지않았다. 전후면거골-제1중족골간각및측면경종간각은양군에서모두치료전후로유의한차이가있었다. 결론 : 선천성만곡족의치료에서 Ponseti 방법으로치료한후 70% 이상의환자에서만족스러운결과를보였다. 방사선적으로초기측면거종간각및측면경종간각을통해수술적치료여부를예측할수있었고, 전후면거골-제1중족골간각및측면경종간각을통해치료후선천성만곡족의변화정도를평가할수있었다. 색인단어 : 선천성만곡족, Ponseti 방법 접수일 2017 년 10 월 31 일수정일 2017 년 11 월 2 일게재확정일 2018 년 2 월 26 일책임저자연창진 41931, 대구시중구달성로 56, 계명대학교동산의료원정형외과 TEL 053-250-7729, FAX 053-250-7205, E-mail poweryon@nate.com, ORCID https://orcid.org/0000-0003-3580-4175 대한정형외과학회지 : 제 54 권제 1 호 2019 Copyright 2019 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.