PSJHJOM! SUJMF 대한족부족관절학회지 : 제 15 권제 3 호 2011 J Korean Foot nkle Soc. Vol. 15. No. 3. pp.139-143, 2011 최경진정형외과, 인천힘찬병원정형외과 *, 바른세상병원정형외과 조영아 최경진 송영준 * 서동완 Matrixplasty for the Treatment of Pincer Nail with Nail Growth Plate eformity Young- ho, M.., Kyung Jin hoi, M.., Young Joon Song, M.. *, ong Won Suh, M.. epartment of Surgery, hoi Kyung Jin Orthopedic Hospital, Seoul, Korea epartment of Orthopedic Surgery, Himhan General Hospital, Incheon, Korea * epartment of Orthopedic Surgery arun Sesang Hospital, Seongnam, Korea =bstract= Purpose: The purpose of this study was to introduce the Matrixplasty for the treatment of a severely incurved toenail with growth plate deformity and to report our results treating this disease entity. Materials and Methods: etween January 2010 and May 2010, 48 consecutive patients (62 cases) underwent treatment of symptomatic incurved toenails with the matrixplasty. The mean period of time at last follow-up was 14.0±1.3months. The recurrence rate and complication rate were evaluated. n merican Orthopedic Foot and nkle Society (OFS) forefoot hallux score was assigned and patients were evaluated at pretreatment and the last follow-up meeting. For evaluation of improvement in toenail shape, the center to edge angle of the toenail was measured at pretreatment and last follow-up. Results: ll ingrown toenails healed and the nail deformity was corrected within 3 weeks after the procedure. mong the 62 cases, four cases had recurred by the last follow-up. The mean pretreatment OFS forefoot hallux score was 73.1±12.8, and it improved to 98.7±1.1 by the last follow-up (p<0.01). The mean center to edge angle of the toenail improved from 53.3±12.9 degrees to 18.2±7.4 degrees by the last follow-up (p<0.01). Minor paronychia, which was managed with local wound dressing and oral antibiotics, was identified in eight cases. onclusion: Matrixplasty showed excellent clinical results in the treatment of severe incurved toenail (pincer nail) and this procedure also showed great improvement of the deformed toenail and its growth plate. Key Words: Pincer nail, Incurved toenail, Growth plate deformity, K-, Matrixplasty 서 론 Received: July 10, 2011 Revised: ugust 10, 2011 ccepted: ugust 16, 2011 Young- ho, M.. epartment of Surgery, hoi Kyung Jin Orthopedic Hospital, 116-902, Seokgwan-dong, Seongbuk-gu, Seoul, Korea Tel: +82-2-470-1523 Fax: +82-2-470-1533 E-mail: ninacho@hanmail.net 심하게발톱이안으로말려들어가는내향성발톱은집게발톱또는함입성발톱이라불리며보행시통증, 반복되는염증, 신발선택의제한등의임상증상을유발한다. 1) 집게발톱변형은발톱이안으로말려발톱밑의피부를꼬집는모양을보이며대부분은성장판의변형을동반하고있어 - 139 -
조영아 최경진 송영준 서동완 발톱만을치료하였을경우대부분재발한다 (Fig. 1). 성장판변형이동반된내성발톱은매우치료가힘들다. 발톱전장에걸친심한변형으로부분성장판절제술이나발톱만을펴는치료를시행받은경우에는임상증상이재발하여이러한경우발톱을완전히뽑거나발톱전체를영구적으로자라지못하게하는술식이사용되어왔고심한경우 terminal syme 절단을시행하여치료하였다. 2-6) 이러한치료는임상증상을해결할수있으나치료후환자에게서발톱이자라지않거나발가락의일부가없어지는기형을유 발하게된다. 이에저자들은심하게변형된발톱과성장판변형이있는환자를동일한방법 ( 아래설명 ) 으로치료하고이에대한임상결과를보고하고자한다. 대상및방법 1. 매트릭스플라스티매트릭스플라스티는변형된발톱과발톱성장판을리모델링하는술식으로정의된다. 매트릭스플라스티의주요한술기는발톱의성장판과조갑상을지골에서분리하고발톱을펴는기구를이용하여펴진상태를유지하는것이다 (Fig. 2). Figure 1. Severely incurved toenail-the nail growth plate is also deformed. In such a case, matrixplasty of the incurved toenail can be indicated. Figure 2. Illustration of matrixplasty of an incurved toenail -The partial separation of the nail growth plate from the phalangeal bone and application of a nail flattening device. Figure 3. adaver study: (, ) The matrix located within 7 mm proximal to and 5 mm distal from the ungual fold. (, ) The thickness of the matrix is 4~6 mm at the lateral portion. - 140 -
2. 해부학적연구및매트릭스구조매트릭스플라스티를시행하기전에성인 8개의냉동사체의엄지발가락을해부하여매트릭스의두께와위치를기록하였다. 매트릭스는발톱성장이일어나는 germinal matrix와발톱이올려져있는기능을하는 sterile matrix (nail bed) 로나누어지며이위로발톱이올려져있는구조로발톱과매트릭스, 지골이서로붙어있게된다. 카데바 연구상발톱의매트릭스는발가락의지골에붙어있으며두께는주변부 (4~6 mm) 가중심부 (2~4 mm) 보다두껍다 (Fig. 3, 3). 그러므로시술시발톱의외측만을지골과분리하면발톱이나성장판의손상을피할수있다. 발톱의성장판은 ungular fold를중심으로근위부로 7 mm 원위부로 5 mm 내에위치한다 (Fig. 3, 3). 3. 수술술기 Figure 4. The K- can supply a corrective force on the entire width of the nail plate because the two hook sections hold each lateral edge of the nail. The central point of the nail acts as a fulcrum to the lever created by the hook sections. 환자를앙와위로위치시킨상태에서제1 족지의지간신경차단술을시행한다. 이때리도카인과부피바카인을 1:1 로섞어서사용하면수술후통증을 6~8시간동안완화시킬수있다. 전족부를소독하고소독포로덮어서수술준비를시행한다. 매트릭스플라스티는경피적으로시행함으로지혈대가필요없지만다른술기 ( 피부절제술 ) 를시행할경우는발가락지혈대를설치할수가있다. 먼저발톱과피부경계부에서발가락의측면중앙에 15번 blade를이용하여피부를찌르고약 5 mm 길이의피부절개를시행하고그대로밀어넣어지골에칼날이닿는것을느낄수있다. 이상태에서칼날의방향을상향으로바꾸어밀면칼날끝이지골에닿아저항이느껴지다가상부로칼날을더움직이면지골의족배면에서칼날에저항이없어지는점을찾는다이곳에서칼날을지골에접촉하면서매트릭스를지골에서분리시킨다. 칼날의방향을바꾸어원위부도약 5~7 mm 정도지골과매트릭스를분리시킨다. 이후피부를봉합한다. 이후발톱의넓이를측정하여케이디기구를 lunula 레벨과발톱의원위부에각각걸어준다. 저자들은발톱의매트릭스와지골사이를절개하여분리시키고발톱을일시적으로들어주기위해케이디 (K-; S& iotech, Seoul, South Korea) 를사용하였다 (Fig. 4). 7) 이후압박드레싱을시행한다 (Fig. 5). 4. 수술후관리 2일후드레싱을교체해주고꼭끼이는신발이아니면특별하게제한을두지않는다. 3주후발사를하고동시에기구를제거한다. Figure 5. These serial photographs show how the matrixplasty is performed. Severe incurved toenail (, ). Percutaneous elevation of matrix (). fter application of K- (). 5. 대상및방법 2010년 1월부터동년 5월까지발톱의성장판변형을동반한심한함입성발톱또는집게발톱변형으로내원한환자중매트릭스플라스티를시행하여치료한환자 49명 (62-141 -
조영아 최경진 송영준 서동완 Figure 6. enter to edge angle of toenail - On the greater toe clinical photograph anterior-posterior view, a point was first marked on the center and both tips of the lateral edge of the nail plate, then a line was drawn from the tip of the lateral edge to the opposite side tip of the lateral edge. nother line was drawn from the center of the nail plate to one tip of the lateral edge. The angle made by the two lines was measured. (13~88) 세였으며평균추시기간은 14.0±1.3개월이었다. 발톱을펴기위해형상기억합금소재의의료용클램프 (K-) 를사용하였으며 3주후발사를하고동시에기구를제거한다. 술전과술후임상증상의개선여부를알기위해미국족부족관절학회무지점수 8) 를술전과마지막추시에조사하였으며발톱모양의개선을알기위해임상전후면사진에서중심- 주변각 (Fig. 6) 을술전과최종추시시조사하였다. 술후환자의미용상만족도를매우만족, 만족, 보통, 불만족으로나누어조사하였고합병증발생여부를조사하였다. 통계적인유의성을확인하기위해 student t-test를이용하여술전과술후의결과를비교하였다. 결과임상증상은전례에서 3주이내치료되었다 (Fig. 7). 최종추시기간동안 62예의환자중 4예에서증상의재발이있었다. 술전조사한미국족부족관절학회무지점수 73.1±12.8에서술후 98.7±1.1점으로증가하였다 (p<0.01). 술전발톱중심- 변연각은 53.3±12.9에서 18.2±7.4도로증가되었다 (p<0.01). 재발한환자 4예를포함하여모든환자에서미용상만족또는매우만족의결과를보였다. 술후 8예에서발톱주위염이관찰되었으나 5예는경구용항생제와드레싱으로치료되었다. 3예는과도하게펴진발톱이주위살을자극하여발생하였으며피부를자극하는약간의발톱을제거한후증상이없어졌다. 발톱성장중발톱모양의변화는전례에서관찰되지않았고기구와관련된특별한합병증도관찰되지않았다. 4예의재발한환자는시술초기에시행하였던환자로성장판이완전히분리되지않아증상이발생한것으로사료되며증상은주로좁은신발을신을때나타났고재발한환자의중심- 변연각은 13도이상으로전례에서증가됨이관찰되었다. 고 찰 Figure 7. These preoperative and final follow-up clinical photographs show that the severely incurved toenail with growth plate deformity was transformed into a toenail that appears almost normal (Previous procedure photographs: (, ) and last follow-up photographs: (, )). 예 ) 을대상으로하여연구를진행하였다. 남자 16명, 여자 33명이었으며우측 19예좌측 17예, 양측 13예였다. 환자중 2명이당뇨환자였다. 환자의평균나이는 39.5±18.9 내성발톱은그정도와형태가다양하다. 발톱만변형 ( 휘어 ) 이있는단순내성발톱의경우부분성장판절제술이나휘어진발톱만을펴는방법을이용하여치료할수가있다. 1-3,9,10) 그러나발톱성장판의변형이동반된경우발톱을완전히제거후다시자라지않도록하거나 terminal syme amputation을시행하여치료하였다. 1) 그러나이러한치료는환자에게심한정신적인충격과미용상불만족을주었다. 4-6) 매트릭스플라스티후발톱성장판손상이관찰되지않았 - 142 -
던이유는발톱의양끝으로갈수록두꺼워지는매트릭스와매트릭스아래연부조직때문인것으로보인다. Fig. 3에서와같이발톱의중심부 matrix는약 2~4 mm이나주변부의두께는 4~6 mm로충분히두꺼워성장판의손상이잘발생하지않는것으로사료된다. 발톱을펴기위해케이디를사용한이유는일반적으로성장판변형이동반된발톱의변형은심한경우가많고심하게말려있어이것을펴고유지시키는기구가필요한데이기구는발톱전장에걸쳐펴는힘이전달되어야하고충분한교정력을가져야한다. 케이디는양끝의훅이발톱양끝을잡아주기때문에발톱의전장에걸쳐교정을위해발톱에걸리는힘을골고루전달할수있다. 양훅부와발톱의윗부분이이루는삼각점에교정력이가해져발톱의전장에힘을전달한다. 일반적으로탄성력이약한경우발톱에기구를끼우기가용이하지만교정력이떨어지며탄성력이강한경우교정력은뛰어나지만발톱에기구를걸기가매우어렵다. 하지만, 케이디는섭씨 23~25도이하에서매우부드럽고탄성이적은성질을나타내어발톱에기구를걸기가용이하고섭씨 25도부터현저하게강도가증가하여발톱에충분한교정력을발휘하는상태로바뀌며발체온에의해지속적인교정력을가진다. 또한기구의두께가 1 mm 이하로가늘고발톱에밀착되어있어신발을제한할필요가없어환자의기구에대한거부감이적다. 일반적으로내성발톱은통증과이로이한신발의선택의제한이문제가되는질병으로변형이심할수록증상이심해지는경향이있다. 본연구에서발톱의모양을교정한후통증이완화되고신발의선택이넓어지는효과가있었다. 술전과술후조사된미국족부족관절학회무지점수의증가도이러한결과를반영한다. 기존발톱만을펴는치료방법이소개되고결과가보고되어왔다. 9) 이론상으로는발톱을펴면발톱이펴서자랄수가있다. 그러나성장판자체가변형된경우라면발톱만을펴도다시발톱이변형되 어자라게된다. 매트릭스플라스티는발톱의성장판모양을변형시킬수있다는측면에서과거문헌검색에서볼수가없었던새로운개념의치료방법으로사료된다. 결 론 저자들은발톱성장판변형이동반된심한내향성발톱치료에있어매트릭스플라스티시술은효과적이며미용상으로도만족감을주는치료방법으로생각한다. REFERENES 1. eorio JK, oughlin MJ. Toenail abnormalities. In: oughlin MJ, Mann R, Saltzman L, ed. Surgery of the foot and ankle. 8th ed. St. Louis, MO: Mosby; 2006. 737-89. 2. ixon GL Jr. Treatment of ingrown toenail. Foot nkle. 1983;3:254-60. 3. Grieg J, nderson JH, Ireland J, nderson JR. The surgical treatment of ingrowing toenails. J one Joint Surg r. 1991;73:131-3. 4. Murray WR. Onychocryptosis: principles of non-operative and operative care. lin Orthop Relat Res. 1979;(142):96-102. 5. Thompson T, Terwelliger. The terminal syme operation for ingrown toenail. Surg lin North m. 1950;31:575-84. 6. Zadik FR. Obliteration of the nail bed of the great toe without shortening the terminal phalanx. J one Joint Surg. r. 1950; 32:66-7. 7. Kim JY, Park JS. Treatment of symptomatic incurved toenail with a new device. Foot nkle Int. 2009;30:1083-7. 8. Kitaoka H, lexander IJ, delaar RS, Nunley J, Myerson MS, Sanders M. linical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot nkle Int. 1994;15:349-53. 9. Ishibashi M, Tabata N, Suetake T, et al. simple method to treat an ingrowing toenail with a shape-memory alloy device. J ermatolog Treat. 2008;19:291-2. 10. Lathrop RG. Ingrowing toenails: causes and treatment. utis. 1977;20:119-22. - 143 -