PSJHJOBM! BSUJDMF 대한족부족관절학회지 : 제 15 권제 1 호 2011 J Korean Foot Ankle Soc. Vol. 15. No. 1. pp.13-17, 2011 인제대학교의과대학상계백병원정형외과 Treatment of Anteroinferior Tibiofibular Ligament Avulsion Fracture Accompanied with Ankle Fracture Hyung-Jin Chung, M.D., Su-Young Bae, M.D., Man-Young Kim, M.D. Foot and Ankle Center, Department of Orthopedic Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea =Abstract= Purpose: To evaluate the clinical results of anteroinferior tibiofibular ligament avulsion fracture accompanied ankle fractures treated with anatomical reduction and internal fixation. Materials and Methods: From January 2007 to April 2010, 30 cases with anteroinferior tibiofibular ligament avulsion fracture that treated with anatomical reduction and internal fixation were analyzed. The average follow-up period was 26 months (minimum 6 months). We have reviewed the bony union, complication and subjective satisfaction according to the fracture classification and method of internal fixation. Results: Among 30 cases, 28 cases were occurred in Lauge-Hansen classification supination-external rotation type, one case was fracture-dislocation and one case was Maisonneuve fracture. We have performed internal fixation with Mini screw in 11 cases, K-wire in 10 cases, repair in six cases and Mini screw & K-wire in three cases. In all cases bony union was completed. two cases in Mini screw, one case in K-wire, two cases in repair and one case in Mini screw & K-wire revealed LOM of ankle joint. Skin irritation and superficial peroneal nerve irritation happened in one case each. Other cases show good subjective satisfaction. Conclusion: Anteroinferior tibiofibular ligament avulsion fracture accompanied with ankle fracture is a good clinical outcome with internal fixation. So we should not miss out the anteroinferior tibiofibular ligament avulsion fracture in radiologic evaluation or operation room. Key Words: Ankle, Anteroinferior tibiofibular ligament avulsion fracture, Internal fixation Received : January 24, 2011 Revised : February 16, 2011 Accepted : February 22, 2011 Hyung-Jin Chung, M.D. Department of Orthopedic Surgery, Sanggye Paik Hospital, Inje University College of Medicine, 761-1 Sanggye-dong, Nowon-gu, Seoul 139-707, Korea Tel: +82-2-950-1026 Fax: +82-2-934-6342 E-mail: chunghj@dreamwiz.com * 본논문의요지는 2010 년도대한족부족관절학회추계학술대회에서발표되었음. * 본논문은 2008 년도인제대학교학술연구조성비보조에의한것임. 서론족관절의안정성과기능은격자상의골구조와주변인대들에의해유지된다. 족관절골절은인대손상을포함한주변연부조직손상과동반되는경우가많으므로 1) 족관절골절시골손상에대한정확한해부학적정복과내고정외에주변인대손상에대한정확한평가와치료가필요하다. 전하경비인대견열골절은족관절골절시동반되어원위경비인대결합부의이개등족관절안정성에영향을줄수 - 13 -
있다. 이에대해 1875년 Wagstaffe 2) 가최초로 2예를보고한이후 1979년 Pankovich 3) 가 Wagstaffe의분류를수정하여보고하였고, 국내에서는 2002년 Park 등 4) 에의해기술되었지만이후이에대한보고가드문상태이다. 본연구는족관절골절과동반된전하경비인대견열골절의발생빈도, 분류, 족관절골절분류와의상관관계및치료후임상적, 방사선학적결과에대해알아보고자하였다. 대상및방법 1. 연구대상 모든예에서단하지석고고정을하였으며, 평균 4주경에관절운동및부분체중부하를시작하였으며이후점진적인체중부하를통해평균 7주경에전체중부하를하였다. 3. 평가방법방사선학적결과의판정은최종추시단순방사선사진을통해골절의정복상태, 유합정도및원위경비관절의이개및내측관절간격에대해분석하였고, 임상적결과의판정은미국정형외과족부족관절학회의족관절 -후족부점수와합병증여부에대해평가하였다. 2007년부터 2010년사이본원에서수술한 249예의족관절골절환자중전하경비인대견열골절환자 30예를대상으로하였다. 환자의성별은남자 10예, 여자 20예였고, 평균연령은 53세 (20~81세) 였으며, 평균추시기간은 26개월 (6~44개월) 이었다. 수술전족관절전후방, 측면및격자단순방사선사진을통해골절을진단하였으며, 족관절골절의양상은 Lauge-Hansen 분류법 5) 으로, 전하경비인대견열골절의양상은변형 Wagstaffe 분류법 3,4) 으로분류하였다. 단순방사선사진을통한전하경비인대견열골절이의심되지만확진이어려운경우에는컴퓨터단층촬영검사를시행하였고, 수술중소견을통해서도전하경비인대견열골절을진단할수있었다. 족관절외과골절외에원위경비관절의이개에대해외과내측면과경골후과외측사이의간격, 외과내측면과경골전방결절과의중첩을단순방사선사진에서측정하였으며, 6-8) 내측관절의간격에대해서도측정하였다. 2. 수술방법족관절의외과및동반된내과또는후과골절에대해관혈적정복과내고정을시행하였고, 1 mm 이상의전위를보였던전하경비인대견열골절에대해 11예에서 mini screw, 10예에서 K-강선을이용하여고정하였고, 골편이 3 mm 미만으로작거나분쇄상으로내고정이어려웠던 6예에서전하경비인대를흡수성봉합사를이용하여봉합하였다. 3 예에서 Miniscrew 와 K-강선모두를이용하여고정하였다. 이후원위경비인대결합의손상이의심되는경우수술중부하검사 (Cotton test) 를시행하였으며, 이를통해원위경비인대결합부손상이진단된 3예에대해서는유관나사를이용하여원위경비인대결합부를고정하였다. 9,10) 수술후 결과 1. 방사선학적결과전체족관절골절 249예중전하경비인대견열골절은 30예 (12%) 에서진단되었으며, 이중 Lauge-Hansen 분류법회외- 외회전형과동반된경우가 28예로대부분을차지하였고, Lauge-Hansen 분류법회내-외회전형과족관절골절 -탈구에동반된경우가 1예씩있었다. 회내- 외회전형 1예는 Masionneuve 골절이었다. 전하경비인대견열골절의변형 Wagstaffe 분류상 2형이 23예 (77%) 로가장많았고, 1형이 1예 (3%), 3형이 4예 (13%), 4형이 2예 (6%) 였다. 최종추시시전예에서골절부위동통없었으며, 단순방사선검사상족관절골절및전하경비인대견열골절부위의골연속성확인되었다. 경골- 비골간격은평균 2.5 mm (1.2~6.4 mm) 에서 2.4 mm (1.2~3.8 mm) 로내측관절간격은평균 4.0 mm (2.3~10.7 mm) 에서 3.2 mm (2.0~5.0 mm) 로, 경골- 비골중복은평균 6.3 mm (2.8~12.7 mm) 에서 6.8 mm (5.0~11.5 mm) 로변화를보여원위경비관절이개의호전을확인하였다. 2. 임상적결과임상적결과는미국정형외과족부족관절학회의족관절- 후족부점수상 90점이상을우수, 80~89점을양호, 70~79 점보통, 60점이하불량으로판단하였고, 11) 23예에서우수, 6예에서양호의결과를보였으며, 족관절초기수상정도가심했던삼과골절 1예에서보통의결과를보였다. 6예에서족관절의신전제한 ( 평균 9.2도 ) 의운동범위의감소소견을보였고, 천비골신경및내고정물의자극에의한동통이각각 1예있었다. - 14 -
3. 증례보고 1) 증례 1 58세남자로 Lauge-Hansen 분류법회외- 외회전형족관절골절 (stage 4) 에동반된변형 Wagstaffe 분류 2형의전하경비인대견열골절소견으로수술전단순방사선검사를방사선진단하였다 (Fig. 1). 전하경비인대견열골절에대해 mini screw를이용하여고정하였고, 미국정형외과족부족관절학회의족관절- 후족부점수 93점의우수한결과를보였다 (Fig. 2). 2) 증례 2 54세남자로 Lauge-Hasen 분류법회외 -외회전형족관절골절 (stage 4) 에동반된변형 Wagstaffe 분류 4형의전하 경비인대견열골절소견으로수술전단순방사선검사및컴퓨터단층촬영소견및수술소견을통해진단하였다 (Fig. 3, 4). 전하경비인대견열골절에대해 mini screw 를이용하여고정하였고, 미국정형외과족부족관절학회의족관절-후족부점수 91점의우수한결과를보였다 (Fig. 5). 고찰원위경비인대결합은전하경비인대, 후하경비인대, 골간인대, 하횡인대로이루어지며, 원위경비인대결합의손상은비골의전위, 회전, 근위로의이동을유발할수있다. 12) 전하경비인대는경골과비골의전방결절을연결하고, 원위경비인대결합의안정성유지에 35% 를담당한다. 13) 전하경비인대는족관절의기능과안정성에중요한역할을하므로, 손상유무는족관절손상치료와예후에 Figure 1. Ankle fracture with an avulsion fragment by the anterior inferior tibiofibular ligament (X-ray). Figure 2. AITFL avulsion fragment was fixed with mini screw. Figure 3. Ankle fracture with an avulsion fragment by the anterior inferior tibiofibular ligament (x-ray, CT). - 15 -
Type I Type II Type III Type IV Figure 6. A modified Wagstaffe classification of anterior inferior tibiofibular ligament avulsion fracture. Figure 4. Operative finding of the type III anterior inferior tibiofibular ligament avulsion fracture (F: fibula, W: Wagstaffe fragment). Figure 5. Anterior inferior tibiofibular ligament avulsion fragment was fixed with mini screw. 중요한영향을미친다. 4,14) 원위경비인대결합의손상은주로외회전력에의해발생되는데, Lauge-Hansen 족관절분류법회외-외회전형, 회내-외회전형, 회내-외전형의골절에서원위경비인대결합의손상이동반된다고하였다. 5,15,16) 전하경비인대견열골절은 1875년 Wagstaffe 2) 가원위비골전방피질골의수직골절에대하여최초로기술함으로써알려졌고, 이는회외-외회전형족관절골절과관계가있다고하였다. 전하경비인대견열골절에대한 Pankovich의분류 ( 변형 Wagstaffe 분류 ) 는비골측에견열골절이발생하는 I형, 비골골절에동반된견열골절을 II형, 경골측의견열골절을 III형, 경골, 비골양측에견열골절이발생하는 IV형으로분류되며, 주로 II형의골절이많이발생한다 (Fig. 6). 3,4) Park 등 4) 에의하면전하경비인대견열골절은 93예중 13예로 14% 의발생빈도를보였고, 전예가 Weber B형 17,18) 의골절에서발생하였으며, 변형 Wagstaffe 분류상모두 2형이었고, Pankovich도 9예의보고중 8예가 2형으로대부분을차지했다. 본연구에서전하경비인대견열골절은전체족관절골절의 12% 에서발생하였고, 93% 가족관절 Lauge-Hansen 분류법상회외- 외회전형에서발생하였으며, 변형 Wagstaffe 분류상 II형이대부분 (76%) 이었다. 일반방사선검사상전하경비인대견열골절의경우경비골의중첩으로인해진단이어려운경우가있으며, Park 등 4) 은 45도내회전방사선검사가진단에유용하다고하였다. 본연구에서는전후면또는측면사진상의심이되는경우에는컴퓨터단층촬영검사를통하여진단하였고, 수술중진단이된경우도있었다. 족관절골절에동반된전하경비인대견열골절의치료는족관절골절의해부학적정복및견고한내고정뿐만아니라전하경비인대의정확한복원또한치료에중요하다. 4,15,19) 전하경비인대의정확한복원이되지않을경우원위경비관절의이개에의한원위경비관절부위만성적인통증과거골의만성적인전위로인한외상성관절염, 골절편의감입에의한동통등이발생할수있다. 20,21) Park 등 4) 은전한경비인대견열골절의불유합으로인해 1예의보통의결과를보였으나, 전하경비인대견열골절에대한정확한진단과정복, 동반된족관절골절에대한적절한치료를할경우좋은결과를보였다. 결 론 동반된족관절골절의초기수상정도가심하였던경우를제외하고, 전하경비인대견열골절의치료결과는대부분우수한결과를보였다. 단순방사선검사, 컴퓨터단층촬영혹은수술중소견으로전하경비인대견열골절을발견하여정확한내고정을시행한다면, 이를간과하여발생하는추가적인합병증을예방할수있을것으로생각된다. REFERENCES 1. Kannus P, Palvanen M, Niemi S, Parkkari J, Järvinen M. Increasing number and incidence of low-trauma ankle - 16 -
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