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ISSN 1225-1682 (Print) ISSN 2287-9293 (Online) 대한골절학회지제 27 권, 제 4 호, 2014 년 10 월 J Korean Fract Soc 2014;27(4):261-266 http://dx.doi.org/10.12671/jkfs.2014.27.4.261 Original Article 고령에서발생한전자부골절을위한수술적조건 : 전향적연구 정구희 이종서 * 허성근 * 김재도 조현익 고신대학교의과대학정형외과학교실, 기장병원정형외과 * Surgical Fitness for Trochanteric Fracture in Elderly: Prospective Study Gu-Hee Jung, M.D., Jong-Seo Lee, M.D.*, Sung-Gun Heo, M.D.*, Jae-Do Kim, M.D., Ph.D., Hyun-Ik Cho, M.D. Department of Orthopaedic Surgery, Kosin University College of Medicine, Department of Orthopaedic Surgery, Gijang Hospital*, Busan, Korea Purpose: The purpose of this study was to evaluate the risks of undergoing intramedullary nailing with minimum surgical optimization (fast-track) for geriatric trochanter fracture due to fall from a standing height. Materials and Methods: From May 2006 to August 2013, 48 fractures were enrolled in fast-track, and were an average age of patients was 77.6 years (range, 62-97 years). They underwent primary testing for anesthesia, including basic body fluid test, arterial blood, electrocardiography, and chest radiographs. The time from visit to surgery was 28.9 hours (range, 1-96 hours). Results: During hospitalization, there was one case of stress-induced cardiac arrest; however, other complications, infection, and 30-day mortality did not occur. According to preoperative classic test, the average albumin was 3.45 g/dl, blood sugar, 169 mg/dl, blood urea nitrogen, 20.5 mg/dl, Cr, 1.5 mg/dl, Na, 135.3 meq/l, and K, 4.21 meq/l. The average PaCO 2 of arterial blood was 37.6 mmhg. Conclusion: We found that the fast-track for trochanteric fracture due to slip-down was relatively safe, and could be considered as a therapeutic approach. Key Words: Femur, Osteoporotic fractures, Intramedullary nailing 서 노인인구의증가로인하여최근폭발적으로증가되고있는골다공증성골절은정형외과영역에서중요한부분을 론 Received May 27, 2014 Revised June 12, 2014 Accepted September 18, 2014 Address reprint requests to: Gu-Hee Jung, M.D. Department of Orthopaedic Surgery, Kosin University College of Medicine, 262 Gamcheon-ro, Seo-gu, Busan 602-702, Korea Tel: 82-51-990-6785ㆍFax: 82-51-243-0181 E-mail: jyujin2001@kosin.ac.kr Financial support: None. Conflict of interest: None. 차지하고있으며특히고관절주위골절은침상안정및보행제한을야기하면서술후심폐기능및전신상태에영향을미치게되므로아직도수상후 1년내사망률이높을뿐만아니라수상전의상태로회복되는비율도비록이견이있을지라도높지않은것으로알려져있다. 1) 60세이상에서대부분발생하는골다공증성고관절주위골절은 90% 이상에서단순낙상에의해발생하게되므로, 2) 수상으로인한요인보다는고령으로인해동반된내과적질환및전신대사능력의저하가주요합병증의원인으로작용하게될뿐만아니라수술적치료를제한하는이유가되기도한다. Copyright c 2014 The Korean Fracture Society. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 261

262 Gu-Hee Jung, et al. 골다공증성전자부골절 ( 이하전자부골절 ) 에서수상전능력의회복을위해서많은노력이이루어지고있으며, 최근널리시행되고있는전자부골수강내금속정고정술 ( 이하전자부금속정 ) 은생역학적장점과함께견고한고정으로인해술후침상안정기간을줄임으로써임상적결과가많이호전되고있는것으로보고되고있다. 3) 그러나그수술적시기결정에있어서많은이견이있는상태이며, 몇몇저자들 4-11) 에의해조기수술의유용성이알려졌으나아직도명확한기준은없는상태이다. 이는수술적시기의결정및조기수술의유용성을증명하기위한무작위성전향적연구는윤리적인문제로인하여시행할수없다는점이주요한원인이될것으로저자들은판단하였다. 이에마취과의협조하에단순낙상으로인한전자부골절에서전자부금속정이시행되기로결정된환자들을대상으로별도의일괄승인절차 ( 이하 fast-track) 을작성하여수술적치료를전향적으로실시하였으며그결과에대해보고하고자한다. 대상및방법 2006 년 5 월부터 2013 년 8 월까지자동차사고및낙상에의한고에너지성골절및다른부위의골절이동반된경우를제외한저에너지성전자부골절 117 예를일차대상으로하여환자보호자에의해수술이연기된경우, 타의료기관입원중전원된경우, 그리고헤파린및기타약물복용으로인해수술적연기가불가피한경우를제외한나머지골절들을 fast-track 에잠정적으로포함시켰다. Fasttrack 이라함은수술및마취를위한일차적인검사로서체액검사 ( 소변, 정맥혈, 동맥혈 ), 심전도및단순흉부방사선촬영만을시행하게되며무조건적인폐기능검사및심초음파검사를시행하지않게된다. 그리고골절수술에의한합병증의위험성평가는전문의에의한심전도판독결과및기본검사결과를이용하여마취전문의와협진을통해일괄처리절차를진행함으로써전체과정을간소화시켜검사등을위한시간적인소요및업무부담을줄일수있는절차이다. 잠정적으로 fast-track 에포함되었으며추가적인검사가필요없는것으로판단되어금속정내고정술이시행된경우는총 48 예였으며, 평균나이는 77.6 세 ( 범위 62-97 세 ) 이고내원에서수술까지소요된시간은평균 28.9 시간 ( 범위, 1-96 시간 ) 이었다. 마취위험등급 12) (American Society of Anesthesiologists [ASA] score) 은제 1 군 1 예, 제 2 군 18 예, 제 3 군 28 예, 제 4 군은 1 예로마취과에의해평가되었다. 동반된내과질환으로는당뇨 16 예, 뇌졸중 4 예, 심장질환 6 예 ( 혈관성형술 2 예, 협심증에의한혈관성형술 2 예, 승 모판협착증 1 예, 심방세동 1 예 ), 치매 5 예, 만성신부전증 4 예, 타부위악성종양 2 예였고심장전문의에의해판독된심전도에서이상소견은 13 예였다. 혈전예방을위해스타킹착용및항혈전제주사 (low molecular weight heparin) 는응급실내원즉시시행되었으며, 내고정술후 8 시간이후부터앉는것을허용하였으며다음날부터휠체어보행을시작하도록격려하였다. Table 1. Summary of Fast-Tracker Total case 결 Fast-track 에포함되어금속정내고정술를시행한 48 예에서 30 일이내사망은술후 2 일째스트레스성심정지가발생한 1 예였으며, 폐렴및폐부종과같은호흡기관련합병증은발생하지않았다. 그리고기타감염및욕창과같은추가적인합병증은발생하지않았다. Fast-track 에포함된환자들의응급실내원시초기수축기혈압이평균 139 mmhg ( 범위, 70-190 mmhg) 이었으며, 기본혈액검사에서혈중 albumin 은평균 3.6 g/dl ( 범위, 2.7-4.1 g/dl) 로써 36.7% 에서비정상수치를나타내었고, 혈당은평균 169 mg/dl ( 범위, 111-349 mg/dl) 이며 140 mg/dl 를넘는환자는 52.1% 였다. 신장기능평가를위한혈중요소질소 (blood urea nitrogen, BUN) 는평균 19.8 mg/dl ( 범위, 7-42 mg/dl) 로 28.6% 에서비정상적인수치를보였고, 혈중크레아티닌 (Cr) 은평균 1.3 mg/dl ( 범위, 0.5-6.1 mg/dl) 로 14.3% 에서비정상적이었다. 체내전해질 과 48 Fractures by slip-down Age (yr) 77.6 (62-97) Time to surgery (h)* 28.9 (1-96) Systolic BP at ER (mmhg) 139 (70-190) Albumin (g/dl) 3.6 (2.7-4.1) Blood sugar (mg/dl) 169 (111-349) BUN (mg/dl) 19.8 (7-42) Cr (mg/dl) 1.3 (0.5-6.1) Na (meq/l) 136.0 (110-146) K (meq/l) 4.2 (3.1-5.7) PaCO 2 (mmhg) 34.3 (23-47) Cardio-thoracic ratio 0.52 (0.37-0.72) Comorbid disease Diabetes mellitus 16, cerebrovascular stroke 4, cardiac disease 6, chronic renal failure 4 Values are presented as median (range) or number only. *The time from hospital visit to surgery. Systolic blood pressure at hospital visit. Serum level. Analysis of arterial blood. Cardiothoracic ratio on chest radiographs. BP: Blood pressure, ER: Emergency room, BUN: Blood urea nitrogen.

Surgical Fitness for Trochanteric Fracture in Elderly: Prospective Study 263 에서혈중나트륨 (Na) 및혈중칼륨 (K) 은각각평균 136.0 meq/l ( 범위, 110-146 meq/l), 4.2 meq/l ( 범위, 3.1-5.7 meq/l) 로 25.0%, 20.4% 에서정상을벗어난수치였다. 동맥혈검사에서는혈중이산화탄소농도 (PaCO 2 ) 는평균 34.3 mmhg ( 범위, 23-47 mmhg) 으로측정되어 46.9% 에서정상범위가아니었으며, 단순흉부방사선을통해측정된심흉비는평균 0.52 ( 범위, 0.37-0.72) 로 0.5 이상인경우는 57.1% 였다 (Table 1). 고 고령에서발생하는전자부골절은대부분 1 m 정도의환자높이에서넘어지면서발생하게되는바수상자체의요인보다는동반된비외상성내과적질환및복용중인약과환자의전신상태등이수술적치료의예후를결정하게될뿐만아니라수술적시기의결정에서도많은영향을미치게되며, 마취및수술조건개선을위해지연되는것이일반적이다. 13) 그러나최근전자부골절에서조기수술의유용성이몇몇저자들 4-8,10,11) 에의해보고되면서어느정도시도되고있으나그명확한기준에대해서는알수없는실정이다. 이에저자들은전자부골절에대해관례적으로시행되어온수술적조건개선을위한정규수술을문헌고찰및마취과의협조를통해 fast-track 이라는별도의일괄승인절차를만들어 2006년 5월부터본연구를전향적으로실시하게되었다. Fast-track 에의한수술계획으로조정함에있어서수술관련위험성에대해많은우려가있으면서초기에는그대상선정이조심스러워적었으나진행을통해경험이누적되면서대부분의전자부골절이포함되며증가되는경향이있었다. 본연구기간동안 fast-track 에포함된환자에서 30일이내사망은단 1예에서만발생하였고, 포함되지않은환자들에서는발생하지않아 fast-track 에대한위험성을객관적으로평가할수는없었다. 그러나 Hu 등 14) 에의한메타분석을통해고관절주위골절환자의술후 30 일이내사망률은 13.3% 로보고되었던것을비교하였을때추가적인위험성은없을것으로예상할수있었다. 그리고그위험성을수술적조건개선을통한정규수술과직접적으로비교할수없을지라도금속정의생역학적인장점으로인한조기보행과현저히줄어든수술전침상안정기간을통해전체예에서정맥혈전증및욕창과같은합병증들이발생하지않았다는점에서그이론적인장점을모두경험할수있었다. 그러나 3차의료기관의특성상조기전원되는특징으로인하여입원기간의단축에대해서는평가할수가없었다. 본연구에포함된환자들의수술대기시간이평균 28.9 찰 시간 ( 범위, 1-96시간 ) 으로후향적분석을통해실제적으로비교적짧지않았음을알수있었으며그원인들로는 fast-track 자체의요인과수술방관련요인들로구분할수있었다. Fast-track 이가동되어수술을시행하기로결정되었다할지라도기존정규수술들로인하여수술방확보가힘들어수술대기시간이비교적늘어났으며, 또한수술관련응급상황에대한효과적인조치를위하여야간수술을시행하지않고정규수술시간에응급수술을시행하고자하는 fast-track 의운영지침도많이반영되었음을알수있었다. 특히주말에환자가내원한경우에는월요일에수술을시행하게되어대기시간의현저한증가가있었음을알수있었다. 따라서노인성손상에대한여러전문분야가포함된팀구성을통해원활한수술이이루어진다면대기시간을보다줄일수있을것으로저자들은예상할수있었다. Fast-track 운영을위한전제조건인고령환자는그명확한기준은없을지라도손상및수술과관련된생리학적변화에대한예비정도가낮아젊은성인에비해합병증및사망률이비교적높은것으로알려져있는바수술전에그위험성을미리파악하는것이아주중요한부분이된다. 특히고관절주위골절에관한위험인자로는나이, 성별, 치매여부, 주거환경, 보행능력, ASA sore, 12) 그리고동반된내과적질환이영향을미치는것으로널리알려져있다. 3) 이중예후증진을위한수술적조건개선에서의사가조절가능한부분은동반된내과적질환이유일한위험인자가된다. 따라서수술전에당뇨, 심혈관계및신장기능의수술관련위험성이평가되어야하고, 15) 전해질불균형또한중요한위험요소이므로반드시사전에확인되어야한다. 16,17) 저자들은 fast-track 을가동함에있어서심근경색및심정지와같은치명적인합병증으로인하여즉각적인조치가필요한심혈관계의실제적위험성을평가에많은어려움을경험할수있었다. 따라서심장전문의와의협진을통해내원당시시행된심전도및자세한병력을통해활동성심장질환 15) 및헤파린과같은혈액응고기전에직접적인영향을미치는약물복용여부를파악하여 fast-track 가동 / 비가동을결정하게되었다. 즉내원당시활동성질환은없으나과거에심혈관질환이있어서치료받은경력이있다면환자및보호자와의충분한상담을통해그위험성을이해하고동의한경우 fast-track 을통해수술을시행하였다. 본연구에서는관상동맥성형술 (2 예 ) 및뇌경색 (2예) 으로인한치료중인환자들도포함되었으며활동성심장질환및과거병력이없는경우에도치료적과정에대한충분한협조가확보된상태에서 fast-track 을통해치료를시행하였고추가적인합병증은발생하지않았다. 그러나수술후조기사망한 1예에서는

264 Gu-Hee Jung, et al. 추가적인심혈관계위험성은없었으나스트레스성심근병증에의한심정지가발생하여심폐소생술및중환자실치료를시행하였으며회복후퇴원하였으나귀가후 48 시간에사망하였다. 따라서본연구에포함된환자가적은관계로 fast-track 으로위한추가적인심장위험성에대해서는평가할수없었으나즉각적인조치를위한대비가항상필요함을알수있었다. 다른위험인자로서호흡기계위험성에대해평가하기위해서앉을수없는자세에서부적절한협조에의한폐기능검사는그해석에제한점이있으므로시행하지않고동맥혈검사만시행하였다. 그러나호흡기관련합병증은전체예에서발생하지않았다. 이는금속정을사용할경우비교적덜침습적인고정술이가능하여비교적짧은수술시간에출혈량이많지않아수분섭취를가능한한조기에시행할수있었을뿐만아니라술후 1 일째부터휠체어보행을권장함으로써가능하였다고저자들은판단한다. 그리고전자부골절로내원한고령의환자에서, 특히활동력이떨어지거나적절한보살핌을받지못한경우에는만성적인전해질불균형이드물지않았으며, Lewis 등 18) 도실제적으로 20% 의환자에서중 Na 이낮은것으로보고하면서입원시 BUN 이높았을경우합병증발생률이높다고하였다. 본연구에서도내원시혈중 Na 이 135 meq/l 보다낮은경우는총 12 예 (25%) 였으나대부분 130 meq/l 이상이었으며저나트륨혈증증상을야기하는 120 meq/l 이하는단 1 예였고, 대부분 127 meq/l 이상이었다. 저나트륨혈증으로진단된 1 예는목요일밤에응급실로내원하여금요일에수술적치료를시행하려했으나수술방사정으로불가능하여월요일에시행함으로써전해질공급을통해 130 meq/l 으로수술적치료를시행하였다. 그리고 BUN 이높은 14 예 (23 mg/dl 이상, 만성신부전 4 예포함 ) 에서도 fast-track 을통해추가적인합병증없이치료할수있었다. 저자들은단순낙상에의한전자부골절이발생한고령의환자에서 fast-track 을이용한치료적경험을통해수술적조건의개선및추가적인검사를위한연기는반드시필요하지않았음을경험할수있었다. 특히활동성심장병변이없으면서치료적계획에대해협조적이라면비교적덜침습적인금속정고정술을시행할경우 fast- track 이수술전, 후침상안정기간을줄임으로써추가적인합병증을예방할수있을것으로판단하였다. 그러나본연구에포함된대상환자들이적을뿐만아니라조기사망증례및합병증이많지않아통계적방법을통한위험요인을구별할수없었다. 따라서향후다기관연구및지속적인연구등을통해충분한치료적경험이누적됨으로써그 fast-track 의유용성에대한평가가시도되어야할것으로저자들은생각한다. 결 단순낙상에의한전자부골절이발생한고령의환자에서활동성심장병변및복용중인약물에의한제한이없는경우수술적조건개선및추가적인검사를위한지연없는 fast-track 을통한금속정고정술은비교적안전하므로치료적접근시고려되어야할것으로판단된다. 론 References 1) Clement ND, Aitken SA, Duckworth AD, McQueen MM, Court-Brown CM: The outcome of fractures in very elderly patients. J Bone Joint Surg Br, 93: 806-810, 2011. 2) Hayes WC, Myers ER, Robinovitch SN, Van Den Kroonenberg A, Courtney AC, McMahon TA: Etiology and prevention of age-related hip fractures. Bone, 18: 77S-86S, 1996. 3) Khan SK, Kalra S, Khanna A, Thiruvengada MM, Parker MJ: Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury, 40: 692-697, 2009. 4) Davis TR, Sher JL, Porter BB, Checketts RG: The timing of surgery for intertrochanteric femoral fractures. Injury, 19: 244-246, 1988. 5) Dorotka R, Schoechtner H, Buchinger W: The influence of immediate surgical treatment of proximal femoral fractures on mortality and quality of life. Operation within six hours of the fracture versus later than six hours. J Bone Joint Surg Br, 85: 1107-1113, 2003. 6) Kenzora JE, McCarthy RE, Lowell JD, Sledge CB: Hip fracture mortality. Relation to age, treatment, preoperative illness, time of surgery, and complications. Clin Orthop Relat Res, (186): 45-56, 1984. 7) Orosz GM, Magaziner J, Hannan EL, et al: Association of timing of surgery for hip fracture and patient outcomes. JAMA, 291: 1738-1743, 2004. 8) Parker MJ, Pryor GA: The timing of surgery for proximal femoral fractures. J Bone Joint Surg Br, 74: 203-205. 1992. 9) Rogers FB, Shackford SR, Keller MS: Early fixation reduces morbidity and mortality in elderly patients with hip fractures from low-impact falls. J Trauma, 39: 261-265, 1995. 10) Siegmeth AW, Gurusamy K, Parker MJ: Delay to sur-

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