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대한골절학회지제 20 권, 제 3 호, 2007 년 7 월 종설 Journal of the Korean Fractrure Society Vol. 20, N o. 3, July, 2007 족근관절경비인대결합손상 (Ankle Syndesmotic Injury) 이근배 전남대학교의과대학정형외과학교실 서 ~ 론 손상기전 해부학및생역학 통신저자 : 이근배 Tel:062-227-1640 Fax:062-225-7794 E-mail:kbleeos@chonnam.ac.kr Fig. 1. Ankle stabilizing structures are medial malleolus and deltoid ligament (1), lateral malleolus and lateral ligament complex (2), anterior syndesmosis and its bony attatchment (3) and posterior syndesmosis and its bony attatchment (4) (Adapted from Tile M. The rationale of operative fracture care, 2nd ed. New York, Springer: 523-561, 2007.). Address reprint requests to:keun-bae Lee, M.D. Department of Orthopedic Surgery, Chonnam National University Hospital, 8, Hak-dong, Dong-gu, Gwangju 501-757, Korea Tel:82-62-227-1640 Fax:82-62-225-7794 E-mail:kbleeos@chonnam.ac.kr 282

족근관절경비인대결합손상 283 Fig. 2. Anterior, posterior, and lateral views of select ligaments of the distal tibiofibular syndesmosis: the anterior-inferior tibiofibular ligament (AITFL); the posterior-inferior tibiofibular ligament (PITFL), of which the inferior transverse ligament (ITL) is part; and the interosseous ligament (IOL), which represents the thickened distal part of the interosseous membrane. The arrows indicate the respective location and point to the cross-sectional view (Adapted from Browner B, Jupiter J, Levine A, eds. Skeletal trauma: fractures, dislocations, and ligamentous injuries, 2nd ed. Philadelphia: WB Saunders, 1997.). ~ 1. 신체검사 진 단 Fig. 3. Sqeeze test is performed by compressing fibula to tibia above midpoint of calf. Test is considered positive if proximal compression produces distal pain in interosseous ligaments or supporting structures (Adapted from Coughlin MJ, Mann RA, Saltzman CL. Surgery of the foot and ankle, 8th ed. Philadelphia: Mosby Elsevier, 2007.). 2. 방사선검사

284 이근배 3. 기타검사 Fig. 4. External rotation test is performed by applying external rotation stress to involved foot and ankle while knee is held in 90 degrees of flexion and ankle is in neutral position. Positive test produces pain over anterior or posterior tibiofibular ligaments and over interosseous membrane (Adapted from Coughlin MJ, Mann RA, Saltzman CL. Surgery of the foot and ankle, 8th ed. Philadelphia: Mosby Elsevier, 2007.). ~ Fig. 5. Normal syndesmotic relationships include a tibiofibular clear space (distance A-B) <6 mm in both the anteroposterior and mortise views, as well as a tibiofibular overlap (distance B-C) >6 mm or >42% of the width of the fibula on the anteroposterior view, or >1 mm on the mortise view. The overlap is measured 1 cm proximal to the plafond (Adapted from Coughlin MJ, Mann RA, Saltzman CL. Surgery of the foot and ankle, 8th ed. Philadelphia: Mosby Elsevier, 2007.).

285 족근 관절 경비 인대 결합 손상 있으므로 관절경에 친숙한 술자에게는 많은 도움이 될 것이 다33) (Fig. 6). 치 행하는 경향이 있었으나, 최근에는 비골 골절을 정확히 정복 하면 거골이 격자 내에 위치하게 되고, 인대 결합도 안정성 4) 을 회복하게 됨이 밝혀짐으로써 점차 줄어드는 추세이다. 료 1. 족근 관절 경비 인대 결합 고정술의 적응증 일반적으로 비골 골절이나 내측 과의 골절을 정확히 고정 하면 경비 인대 결합은 대개 자연 정복되나, 수상 후 수일이 지나거나 인대 결합의 광범위한 손상으로 비골의 불안정성 이 심한 경우에는 인대 결합의 내고정이 필요하다. 인대 결 합 손상에 대한 관통 나사 고정의 빈도는 예전에는 Weber C 형의 비골 골절인 경우 80% 정도까지 고정을 적극적으로 시 경비 인대 결합의 내고정은 그 적응증과 수술방법에 있어 주의를 요한다. 경비 인대 결합 고정은 인대 결합이 치유되 는 동안 일시적인 부목의 역할만 하므로 비골의 정확한 정복 과 인대 결합에서 경-비골의 정상적인 관계를 회복시켜 주는 것이 중요하다. 사체 실험과 임상적 관찰을 통해 연구된 바 Fig. 6. A 23-year-old man slipped and sustained a fracture of the ankle. (A) The initial mortise radiograph shows unstable supination-external rotation stage IV ankle fracture with the widening of medial clear space and increased tibiofibular clear space. (B) The photograph of a medial side of the ankle demonstrates ecchymosis and swelling. (C) Arthroscopic view of medial gutter of the ankle shows tear of the deltoid ligament as seen from the anteromedial portal. Arthroscopic debridement and shrinkage with radiofrequency were performed. (D) Arthroscopic view of the ankle syndesmosis shows diastasis which increased distal tibiofibular joint with arthroscopic shaver. (E) Arthroscopic view shows syndesmotic reduction as seen from the anterolateral portal. (F) Postoperative anteroposterior radiograph shows open reduction and internal fixation of fibula as well as syndesmotic stabilization with two 3.5 mm screws engaging four cortices.

286 이근배 ~ ~ 2. 골절의동반여부에따른경비인대결합손상의치료 ~ ~ Fig. 7. A 54-year-old woman sustained an inversion injury of ankle. (A) Anteroposterior radiograph shows pronation-abduction stage III ankle fracture. (B) Lateral radiograph shows posterior malleolar fracture. (C) Postoperative anteroposterior radiograph shows accurate anatomical reduction and fixation of fracture. Syndesmotic transfixation screws were unnecessary because intraoperative evidence of syndesmotic disastasis is absent after fixation.

족근관절경비인대결합손상 287 3. 경비인대결합고정에있어서논란점 Fig. 8. (A) Anteroposterior radiograph demonstrates Weber type B supination-external rotation ankle fracture associated with disruption of the syndesmosis. (B) Syndesmosis fixation with a single 4.5 mm screw was performed (Adapted from Zalavras C, Thordarson D: Ankle syndesmotic injury. J Am Acad Orthop Surg, 15:330-339, 2007.). Fig. 9. (A) Anteroposterior and lateral radiograph show the proximal fibula fracture (Maissonneuve) that was not stabilized. (B) Syndesmosis fixation with two 4.5 mm screws was performed (Adapted from Zalavras C, Thordarson D: Ankle syndesmotic injury. J Am Acad Orthop Surg, 15:330-339, 2007.).

288 합 고정 방법은 비골 골절을 고정한 경우에는 1개의 금속 나 사못만을 사용해도 안정적 고정이 가능하며, 고정하지 않는 근위부나 중간부위의 비골 골절이 있는 경우에는 2개의 금속 37) 나사못을 사용할 것을 권장한다. 예를 들어, 회외-외회전 손상에서는 비골 골절을 금속판으로 고정하고 1개의 3.5 mm 또는 4.5 mm 나사못으로 3개 피질골을 고정하고, 회내- 이근배 외회전 손상에 의한 Maisonneuve 골절에서는 비골 골절은 고정하지 않고, 2개의 3.5 mm 혹은 4.5 mm 나사못으로 4개 피질골을 고정한다. 하지만 환자에 따라 여러 상황이 달라질 수 있으므로 경비 인대 결합의 불안정 정도와 비골의 크기에 따라 고정하는 피질골의 수와 나사못의 크기를 결정하는 것 이 필요하다 (Fig. 8-10). Fig. 10. A 48-year-old man slipped and sustained a fracture of the ankle. (A) Anteroposterior radiograph shows unstable pronation-external rotation stage IV ankle fracture with widening of medial clear space and increased tibiofibular clear space. (B) Lateral radiograph demonstrates posterior malleolar fracture. (C) Postoperative anteroposterior radiograph shows open reduction and internal fixation of fibula as well as syndesmotic stabilization with two 3.5 mm screws. Fig. 11. Proper placement of a syndesmotic screw. (A) Incorrect angle for insertion of syndesmotic transfixation screw. (B) In the transverse plane, the screw should follow a 30 degrees oblique direction from posterolateral to anteromedial. (C) The fibula should be held reduced during screw placement. The screw may be inserted through a fibular plate or outside of the plate (From Heim U, Pfeiffer KM: Small fragment set manual: Technique recommended by the ASIF group, 2nd ed. Berlin, Springer-Verlag, 1975.).

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