8 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2015; 50: 8-17 http://dx.doi.org/10.4055/jkoa.2015.50.1.8 www.jkoa.org 고관절골수정을이용하여안정된원위부고정을얻은대퇴전자간골절에서원위잠금이항상필요한가? 윤호현 윤정로 서효성 유중진 중앙보훈병원정형외과 Is Distal Locking Constantly Necessary When Intertrochanteric Femur Fracture Is Stably Fixed in the Distal Area with Intramedullary Hip Nail? Ho Hyun Yun, M.D., Jung Ro Yoon, M.D., Hyo Seong Seo, M.D., and Jung Jin Yu, M.D. Department of Orthopedic Surgery, VHS Medical Center, Seoul, Korea Purpose: The purpose of this study is to investigate the constant necessity of distal locking when intertrochanteric fracture was treated with an intramedullary hip nail. Materials and Methods: From April 2010 to June 2013, 47 stable intertrochanteric fractures (AO/OTA 31-A1) were treated with second generation intramedullary hip nailing. They were followed-up for more than 12 months. In the first group of 18 cases distal locking was used, and in the second group of 29 cases, distal locking was not used. We compared the radiologic and clinical results of the two groups. Results: Comparison of the two groups of patients showed no difference in terms of radiological and functional results. Postoperative thigh pain developed in eight cases (17%). A statistically difference was observed between isthmic diameter and used nail diameter (Fisher exact test, p=0.01) for postoperative thigh pain. In logistic regression analysis, the difference between isthmic diameter and used nail diameter was the most statistically significant factor in development of postoperative thigh pain (p=0.04, odd ratio=27.75). Conclusion: Our results suggested that the second generation intramedullary hip nail may be successfully implanted without distal interlocking in 31-A1 intertrochanteric femur fracture when the reduction status was satisfactory and stable fixation of the distal area was estimated by less than 3 mm difference between isthmic diameter and used nail diameter. Key words: femur, intertrochanteric fractures, intramedullary hip nail, distal locking 서론 전세계적인고령화현상으로인하여대표적인노인성골절인 고관절골절의발생률은해마다증가하고있어서고관절골절 은 2050 년에는전세계적으로연간약 6,260 만명에서발생하며 Received July 16, 2014 Revised August 12, 2014 Accepted September 26, 2014 Correspondence to: Ho Hyun Yun, M.D. Department of Orthopaedic Surgery, VHS Medical Center, 53 Jinhwangdo-ro 61-gil, Gangdong-gu, Seoul, Korea TEL: +82-2-2225-4172 FAX: +82-2-2225-1910 E-mail: 3188yun@naver.com 그중 52%, 약 3,250만명이우리나라를포함한아시아에서발생할것으로예상되고있다. 1) 고관절골절들중대퇴전자간골절은 Orthopaedic Trauma Association (OTA) 분류상 2) 31-A에해당하며, 주골절선방향, 골편위치, 분쇄유무에따라서 A1, A2 및 A3 골절로소분류되어있다. 현재까지대퇴전자간골절은골수강외 3) 나골수강내 4) 기구들을이용하여치료하고있다. 그중골수정은활강압박고나사보다지렛대간격이짧아서내고정물에가해지는굴곡응력이작고내측에위치하여대퇴거를통한효율적인하중전달이가능하다는생역학적인장점이있어서, 특히불안정형대퇴전자간골절 The Journal of the Korean Orthopaedic Association Volume 50 Number 1 2015 Copyright 2015 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/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
9 Intramedullary Hip Nail without Distal Locking 에서골수강외기구들보다우수하다고알려져있다. 4) 초기 1 세대 골수정인감마정에서대퇴골골절, 대퇴골두천공, 대퇴부동통 이주요합병증으로보고되었으며, 5) 그중원위잠금 (distal locking) 으로인한합병증이가장흔해서발생률이 15% 에이르기도 하였다. 6) 이후향상된디자인 ( 골수정길이단축, 골수정원위직 경감소, 골수정근위외반경사감소, 원위잠금나사직경감소, 동적구멍 ) 및개선된수술기법 ( 확공없이골수정삽입, 골절압 박장치 ) 을가진 2 세대골수정을사용하면서전반적인합병증발 생률은매우감소하였으나원위잠금으로인한합병증은여전히 발생하고있어서 7) 저자에따라서는원위잠금의적응증을줄이거 나 8,9) 전혀사용하지않기도한다. 10-12) 하지만저자들의문헌검색 상이에대한국내연구보고는없는실정이다. 저자들은모든대퇴전자간골절에서골수정으로치료시원위 잠금이항상필요한지에대한의문을가졌으며골절형태에따라 서는원위잠금유무가치료결과에영향을주지않아서항상원 위잠금을사용할필요는없다는연구가설을설정하였다. 본연 구의목적은 2 세대골수정으로치료한안정형대퇴전자간골절 들 (31-A1) 을원위잠금을사용한군과원위잠금을사용하지않 은군으로분류하여두군간의방사선적및임상적치료결과들 을후향적으로분석하여안정형대퇴전자간골절을 2 세대골수 정으로치료시원위잠금이항상필요한지에대해서알아보고자 함이다. 1. 연구대상 대상및방법 2010 년 4 월부터 2013 년 6 월까지본원에서대퇴전자간골절을 2 세대골수정으로치료후최소 1 년이상방사선및임상추시가 가능하였던 92 예중 OTA 분류상 2) 31-A1 에해당하였던 47 예에 대해서원위잠금을사용한 18 예 (1 군 ) 와원위잠금을사용하지않 Table 1. Comparison of Groups of Patients with and without Distal Locking Group 1 Group 2 p-value Age (yr) 75.1±11.7 77.8±7.8 0.38 Sex (male/female) 11/7 21/8 0.87 Type (A1-1/A1-2) 5/13 13/16 0.20 Body mass index (kg/m 2 ) 21.8±4.0 22.5±3.1 0.27 Bone mineral density (t-score) -2.7±1.3-2.4±1.0 0.19 Osteoporosis/non-osteoporosis 9/9 13/16 0.21 Follow-up (mo) 17.8±10.6 12.8±2.6 0.02 Values are presented as mean±standard deviation or number only. Group 1: group of patients with distal locking, Group 2: group of patients without distal locking. 은 29예 (2군) 로각각분류하여연구대상으로설정하여후향적연구를시행하였다. 저자들은 31-A2 대퇴전자간골절의경우에는원위잠금이골절안정성을확보하는데필요하다고판단하여 31-A2 대퇴전자간골절은연구대상에서제외시켰다. 2011년 6월까지는연구대상에대하여원위잠금을항상사용하였으며, 이후로연구기간종료시점까지는원위잠금을사용하지않았다. 원위잠금사용유무에대한양군의적응기준에차이는없었으며, 두군은추시기간에서만통계적으로유의한차이 (p<0.05) 가관찰되었다 (Table 1). 사용한 2세대골수정은 Gamma3 (Stryker, Mahwah, NJ, USA), ITST (Zimmer, Warsaw, IN, USA), PFNA (DeuPeySynthes, Oberdorf, Swizerland) 였으며, 디자인 ( 골수정길이, 근위부직경, 근위부외반상태, 구금나사직경, 원위잠금나사직경 ) 및골절압박장치를포함한수술기법은유사하였다. 1 군에서 Gamma3 6예, ITST 9예, PFNA 3예를사용하였고, 2군에서 Gamma3 24예, ITST 5예를사용하였다. 삽입된구금나사의각도는 125 o 나 130 o 였으며, 1군에서 125 o 4예, 130 o 14예를사용하였고, 2군에서는 125 o 3예, 130 o 26예를사용하였다. 본연구는중앙보훈병원 Institutional Review Board (IRB) 의승인을받아진행하였다 (IRB file No. 201408009). 2. 수술방법단일집도의에의해서수술이시행되었다. 환자를골절대에앙와위로눕힌후원활한골수정삽입을도모하기위해서환측팔은가슴에걸치고환측반대편으로최대한상체외전및환측하지내전 (10 o -15 o ) 을시행하였으며영상증폭장치하에골절을정복하였다. 대전자부첨부 3-5 cm 상방에서대퇴장축에평행하게 5-6 cm 피부절개후피부절개선을따라서근막및중둔근을분리하여대전자부첨부를노출시켰다. 수술전방사선사진으로예측하였던삽입구에 4 o -5 o 외반각을유지하면서유도핀을 11 cm 깊이까지삽입후근위확공기를이용하여삽입구를넓이고수조작으로골수정을삽입하였다. 골수정삽입시유도조립기구의부피로인하여발생할수있는원위골편의내측전위를예방하고자골수정이골절부위를지나면외반력을주었으며, 구금나사의삽입위치를고려하여원위부까지삽입하였다. 대퇴골협부직경이사용할골수정직경과비교하여좁다고판단된경우에서만유연확공기 (flexible reamer) 를이용하여사용할골수정직경보다 1 mm 크게추가적인골수강내확공을시행후골수정을삽입하였으며나머지경우에서는골수정을확공없이삽입하였다. 유도핀을이용하여구금나사가대퇴골두전후면및측면상중심 1/3 지점에위치할것으로예상되는지점을구금나사의삽입위치로설정하였고, 대퇴골두연골하 10 mm 지점까지구금나사가충분히삽입되도록노력하였다. 구금나사삽입후골절대의견인을풀고, 정복소실에유의하면서골절압박장치를통해서골절간격을최대한줄였다. 충분한근막절개후원위잠금나사
10 Ho Hyun Yun, et al 를삽입하였으며, 원위잠금나사를과도하게조이지않도록주의하였다. 수술후 2-3일경부터능동적관절운동및휠체어거동을허용하였으며수술후 1주일경부터환자의전신상태및추시방사선소견에따라서 standing, parallel bar exercise, walker를이용한체중부하운동을통증이없는한점진적으로시행하였다. 3. 연구방법마취위험도 (American Society of Anesthesiologists [ASA] classification), 마취종류, 수술시간, 출혈량은입원당시진료기록부를참고하여측정하였다. 수술후방사선적및임상적평가는수술후 1개월, 2개월, 3개월, 6개월, 1년및매 1년마다환자가외래에내원할때시행하였다. 수술직후및최종추시단순고관절방사선영상을이용하여대퇴경간각의변화, 지연나사의활강거리, 13) Tip-apex distance (TAD), 14) 구금나사의골두내위치, 15) 정복상태, 16) 골유합기간, 대퇴골협부직경, 대퇴골협부직경과사용한골수정직경간차이를측정하여방사선적평가를시행하였다. 단순고관절방사선영상은치골결합부를중심으로양측고관절이포함되도록촬영되었으며촬영시골반이수직축상이나수평축상에서회전이나경사가발생하지않도록주의하였다. 수술에참여하지않은 2명 의정형외과전공의가관찰자간오차를줄이기위해서합의하에방사선적측정을시행하였으며서로간에심각한불일치가발생한경우는없었다. Parker 와 Palmer 17) 의 mobility score 와 Jensen index 18) 가임상적평가에사용되었으며수상전과최종추시측정결과를통해서보행능력및일상생활능력을평가하였다. 또한수술후합병증및대퇴부동통의발생유무도확인하였다. 두군간자료및방사선적및임상적치료결과를분석하고자 independent t-test 및 chi-square test를시행하였다. 두군간대퇴부동통결과를분석하고자 Fisher exact test를시행하였으며대퇴부동통에영향을미치는위험인자를알아보고자 logistic regression analysis를시행하였다. 통계처리는 SPSS Software version 11.0 (SPSS Inc., Chicago, IL, USA) 을사용하였으며 p값이 0.05 미만인경우를통계적으로유의한차이가있다고간주하였다. 결과 수술전마취위험도는모든예에서 ASA 2등급이었고 1예를제외한모든예에서척추마취가시행되었다. 수술시간은 1군에서평균 71.1±21.4분 ( 범위, 30-110분 ), 2군에서평균 61.7±19.1분 ( 범위, 30-100분 ) 이었으며통계적으로유의한차이가없었다 (p=0.13). 출 Figure 1. (A) Preoperative antero-posterior hip radiograph of a 65-year-old male with a 31A1-2 fracture of his left proximal femur. (B) Postoperative radiograph of the patient four weeks after treatment with the intramedullary hip nail with two distal locking. (C) Postoperative radiograph of the patient 24 months after treatment showing union. (D) Preoperative antero-posterior hip radiograph of an 87-year-old male with a 31A1-2 fracture of his left proximal femur. (E) Postoperative radiograph of the patient four weeks after treatment with the intramedullary hip nail without distal locking. (F) Postoperative radiograph of the patient 12 months after treatment showing union.
11 Intramedullary Hip Nail without Distal Locking 혈량은 1군에서평균 260±203.1 ml ( 범위, 50-700 ml), 2군에서평균 174±76.3 ml ( 범위, 50-350 ml) 였다. 1군에서만 500 ml 이상의출혈량을보인경우가 3예있었으며출혈량간에는통계적으로유의한차이가있었다 (p=0.049). 전후면단순고관절방사선사진상구금나사의골두내위치는 1군에서대퇴골두중심부 18예, 2군에서는대퇴골두중심부 28예, 대퇴골두하단부 1예였으며측면단순방사선사진상구금나사의골두내위치는 1군에서대퇴골두중심부 18예, 2군에서는대퇴골두중심부 26예, 후방부 1예, 전방부 2예였다. 구금나사가대퇴골두상단부및후방부에동시에위치한경우는없었다. 정복상태는모든예에서우수 (good) 하였다. TAD 측정값은 1군에서평균 12.0±2.3 mm ( 범위, 8.8-16.1 mm), 2군에서평균 11.8± 3.4 mm ( 범위, 6.4-19.3 mm) 였으며통계적으로유의한차이가없 었다 (p=0.17). 구금나사의활강거리는 1군에서평균 1.4±2.0 mm ( 범위, 0.0-7.1 mm), 2군에서평균1.4±2.3 mm ( 범위, 0.0-8.6 mm) 였으며통계적으로유의한차이가없었다 (p=0.76). 대퇴골협부직경은 1군에서평균 14.0±2.6 mm ( 범위, 10.2-19.4 mm), 2군에서평균 13.2±2.0 mm ( 범위, 10.2-17.2 mm) 였으며통계적으로유의한차이가없었다 (p=0.19). 수술직후전후면단순방사선사진상대퇴경간각은 1군에서평균 128.9 o ±9.5 o ( 범위, 121 o -150 o ), 2군에서평균 127.6 o ±5.8 o ( 범위, 126 o -140 o ) 였으며통계적으로유의한차이가없었다 (p=0.85). 최종추시전후면단순고관절방사선사진상대퇴경간각은 1군에서평균 126.7 o ±9.5 o ( 범위, 121 o -150 o ), 2 군에서평균 126.0 o ±5.8 o ( 범위, 127 o -139 o ) 였으며통계적으로유의한차이가없었다 (p=0.10). 사용한골수정직경과대퇴골협부직경간차이가 1군에서평균 2.7±2.3 mm ( 범위, 0.2-7.4 mm), 2 Figure 2. (A) Preoperative anteroposterior hip radiograph of a 79-year-old male with a 31A1-2 fracture of his left proximal femur. (B) Postoperative radiograph of the patient four weeks after treatment with the intramedullary hip nail without distal locking. (C) Postoperative radiograph of the patient three months after treatment showing a visible fracture gap with migration of the nail. (D) Postoperative radiograph of the patient six months after treatment showing a persistent fracture gap. (E) Postoperative radiograph of the patient nine months after treatment showing disappearance of the fracture gap. (F) Postoperative radiograph of the patient 12 months after treatment showing union.
12 Ho Hyun Yun, et al 군에서평균 1.7±1.6 mm ( 범위, 0-5.8 mm) 였으며통계적으로유 의한차이가없었다 (p=0.08). 대퇴골협부직경과사용한골수정 직경간차이가 5.8 mm 였던 2 군 1 예를제외한나머지모든예에 서수술후 16 주이내에골유합이관찰되었다 (Fig. 1). 수상전 mobility score 는 1 군에서평균 5.8±2.3 점, 2 군에서평균 5.9±1.6 점이었으며통계적으로유의한차이가없었다 (p=0.23). 최 종추시상 mobility score 는 1 군에서평균 4.7±2.9 점, 2 군에서평 균 4.8±1.4 점이었으며통계적으로유의한차이가없었다 (p=0.31). 수상전 Jensen index 는 1 군에서평균 2.0±0.9 점, 2 군에서평균 1.8 ±0.7 점이었으며통계적으로유의한차이가없었다 (p=0.40). 최종 추시상 Jensen index 는 1 군에서평균 2.5±1.1 점, 2 군에서평균 2.4 ±0.7 점이었으며통계적으로유의한차이가없었다 (p=0.47). 최종추시시점까지정복소실이나구금나사의골두관통이 발생한경우는없었다. 원위잠금나사를사용한 1 예에서원위잠 금나사주위로선상골절이수술중발생하여수술후 3 개월간 Table 2. Thigh Pain with and without Distal Locking Gap (mm) No. of thigh pain/no. of group (%) Group 1 Group 2 Total <1 1/6 (17) 1/14 (7) 2/20 (10) 1 3 0/4 (0) 0/6 (0) 0/10 (0) >3 2/8 (25) 4/9 (44) 6/17 (35) Group 1: group of patients with distal locking, Group 2: group of patients without distal locking. 체중부하를제한하였다. 원위잠금나사를사용하지않은 1 예에 서지연유합소견이있었으나보존적치료를시행하여수술후 9 개월째골유합을얻었다 (Fig. 2). 수술후대퇴부동통이 1 군에서 3 예, 2 군에서 5 예총 8 예 (17%) 에서발생하였으며 6 예에서대퇴골 협부직경과사용한골수정직경간차이가 3 mm 초과였다 (Table 2). 대퇴부동통발생은두군간에서통계적으로유의한차이가 없었고 (Fisher exact test, p=0.38), 대퇴골협부직경과사용한골수 정직경간차이가많았을때 (3 mm 초과 ) 통계적으로유의한차 이가있었다 (Fisher exact test; p=0.01; Table 2). Logistic regression analysis 결과상대퇴골협부직경과사용한골수정직경간차이 Table 3. Results of Logistic Regression Analysis for Thigh Pain p-value Odd ratio Age 0.08 0.82 Sex 0.22 0.13 Type of fracture 0.74 1.60 Body mass index 0.10 0.72 Tip-apex distance 0.43 0.84 Isthmic diameter 0.07 0.12 Locking screw 0.08 33.04 Gap 0.04 27.75 Sliding distance 0.04 2.32 Group 1: group of patients with distal locking, Group 2: group of patients without distal locking. Figure 3. (A) Postoperative antero-posterior hip radiograph of a 65-year-old male with a 31A1-1 fracture of his left proximal femur four weeks after treatment with the intramedullary hip nail with two distal locking. (B) Postoperative radiograph of the patient 12 months after treatment showing distal cortical hypertrophy around the locking screw. (C) Postoperative radiograph of the patient four weeks after removal of the nail showing persistent distal cortical hypertrophy. (D) Postoperative radiograph of the patient 24 months after removal of the nail showing decreased distal cortical hypertrophy.
13 Intramedullary Hip Nail without Distal Locking 가대퇴부동통발생에가장큰영향을미치는통계적으로유의한인자였다 (p=0.04, odd ratio=27.75; Table 3). 8예의대퇴부동통중 6예는골유합이진행됨에따라서동통이감소하여수술후 4 개월이전에모두소실되었다. 지연유합소견이관찰된 1예에서는수술후 9개월째골유합후대퇴부동통이소실되었고 (Fig. 2), 원위잠금을사용하였던1예에서는수술후 1년경과시점에서골수정제거술후대퇴부동통이소실되었다 (Fig. 3). 고찰 저자들이 2세대골수정으로치료한안정형대퇴전자간골절들을원위잠금을사용한군과원위잠금을사용하지않은군으로분류하여두군간의방사선적및임상적치료결과들에대한분석결과를근거로정복상태가만족스럽고수술술기상대퇴골협부직경과골수정직경차이를최소화하여 (3 mm 이하 ) 안정된원위부고정을얻었다고예상된경우에한해서원위잠금을사용하지않아도임상결과에차이가없었다. 하지만대퇴골협부직경과사용한골수정직경간차이가큰경우들에서 (3 mm 초과 ) 실패율차이는없었으나골수정움직임에따른수술후대퇴부동통이통계적으로유의하게발생함을확인하였다. 따라서내경차이가클수록또는불안정형골절인경우에는원위잠금이대퇴부동통을예방하기위해서반드시필요하다고생각된다. 2세대골수정은 1세대골수정인감마정의합병증들을향상된 디자인및개선된수술기법을통해서예방하고자하였다. 하지만원위잠금으로인한합병증은 2세대골수정을사용하여도여전히발생하고있다. 7) 그동안원위잠금과관련된문제점들은불충분한근막절개로발생한잘못된구멍뚫기 (additional drilling) 로인한부정확한원위잠금나사위치, 원위잠금나사의과도한조임, targeting device와골수정간의불충분한조임등의부적절한수술기법에서주로기인하는것으로알려져있다. 6,19) 또한원위잠금나사를삽입하는과정에서혈관손상이발생할수있으며, 20-22) Yang 등 23) 은 color-flow duplex scanning 연구결과를근거로중립위상태에서원위잠금나사를삽입하여야혈관손상을줄일수있다고보고하였다. 저자들의경우에서도 1예에서불충분한근막절개로잘못된구멍뚫기가발생하여수술중잠금나사를재삽입하였으며 (Fig. 4), 1예에서원위잠금나사주위로선상골절이수술중발생하여수술후 3개월간체중부하를제한하였다. 또한혈관조영술등을시행하여객관적으로혈관손상을저자들이확인하지는않았으나두군간출혈량에서통계적으로유의한차이가있었고 (p=0.049), 500 ml 이상의과다한출혈량을보였던 3예가모두원위잠금나사를사용한 1군에서발생했던점을고려해본다면저자들의증례에서도원위잠금나사삽입과정에서발생한혈관손상의가능성을완전히배제할수는없다고생각한다. 현재저자들은혈관손상을예방하고자중립위상태에서원위잠금나사를삽입하고있다. 골수정원위부주위에발생하는응력집중현상 9,24) 도원위잠금과관련되어발생하는 Figure 4. (A) Preoperative antero-posterior hip radiograph of an 85-year-old male with a 31A1-1 fracture of his right proximal femur. (B) Intraoperative radiograph of the patient showing inappropriate position of the distal locking screw. (C) Repeated drilling was performed. (D) Postoperative radiograph of the patient 12 months after treatment showing union.
14 Ho Hyun Yun, et al 문제이다. Rosenblum 등 9) 은생역학적연구를통해서원위잠금이근위대퇴골에서는응력차페현상을유발시키고골수정원위부주위에서는응력집중현상을발생시키므로회전불안정성이나단축이염려되는불안정형대퇴전자간골절에서만원위잠금이필요하다고하였다. Robinson 등 25) 은단순방사선상골수정원위부주위피질골에서관찰되는골성비후 (distal cortical hypertrophy) 가근위대퇴부응력차페및골수정원위부주위로응력집중이발생했음을암시하는방사선적 hall marker라고하였다. 저자들의경우에서도잠금나사를사용한 1예에서수술후대퇴부동통및추시방사선상골수정원위부주위피질골비후가관찰되었고수술후 1년시점에서골수정제거술을시행후대퇴부동통이소실된바있다 (Fig. 3). 원위잠금은대퇴전자간골절의불안정성 ( 축성, 회전성 ) 을방지하는데중요한역할을하나기본적으로불안정성은골절형태에따라서결정된다. 11) A1 및 A2 대퇴전자간골절에서는주골절선이대퇴경부와전자부사이에서사상형으로주행하며 vastus ridge를포함한대전자기저부로구성된원위골편이근위외측방향으로돌출된다. 이런경우에는구금나사가원위골편의외측피질골을통해서근위골편까지삽입되므로지연나사가골편을안정화시키고골편들간의상호회전및골수정을따라서발생하는축성압박을예방할수있다. 또한골절압박장치를통해서수술중골절간격을최대한줄이는작업이유효하여골편을안정화시키는데도움이된다. 역사상대퇴전자간골절 (A3) 에서는근위골편에 vastus ridge를포함한대전자기저부가대부분포함되어있어서구금나사가근위골편의외측피질골을통해서삽입되므로대퇴축을따른축성압박이발생한다. 또한골절압박장치를통해서수술중골절간격을최대한줄이는작업이유효하지못하여골편을안정화시키는데도움이되지않는다. 따라서원위잠금을사용하지않으면대부분의골절들은불안정한상태에도달한다. 상기이론적근거를바탕으로그동안 A1 및 A2 대퇴전자간골절들에대하여원위잠금을사용하지않은채로골수정으로치료하여만족스러운결과를얻었다는보고들이있었다. 11,12) 본연구결과상원위잠금사용유무가방사선및임상결과에영향을미치지않았고원위잠금이혈관손상, 20-22) 연부조직자극, 12) 응력집중현상, 9,24) 부적절한수술기법 8,19) 등을유발할수있다는점을고려해본다면안정형 A1 대퇴전자간골절을골수정으로치료할때골절정복상태가만족스럽고, 수술술기상대퇴골협부직경과골수정직경차이를최소화하여 (3 mm 이하 ) 안정된고정을얻었다고판단된경우에한해서원위잠금을사용할필요는없다고생각한다. 1세대골수정인감마정의합병증들중하나인수술후대퇴부동통을줄이고자하는노력들이그동안꾸준히있어왔다. Rosenblum 등 9) 은골수정이근위대퇴골에정상부하를전달하지못하며, 골수정의원위부주위에서발생한응력집중현상으 로인하여대퇴부동통이발생한다고하였다. 이에따라서원위잠금나사를한개만사용하거나정적고정을통해서응력집중을줄이고자하였다. 26) 또한 Baumgaertner 등 27) 은전방피질골에대한충돌도대퇴부동통의원인이어서이를예방하기위해서는대퇴골직경보다작은직경의골수정을사용해야한다고보고하였다. 저자들의연구에서수술후대퇴부동통이 8예 (17%) 에서발생하였으며, 1군에서 3예, 2군에서 5예가각각발생하였다. 두군간에서대퇴부동통발생이통계적으로유의한차이는없었으나대퇴골협부직경과사용한골수정직경간차이에서는통계적으로유의한차이가있었다 (Fisher exact test, p=0.01). 또한 logistic regression analysis 결과상대퇴골협부직경과사용한골수정직경간차이가대퇴부동통발생에가장큰영향을주는인자였으며 (odd ratio=27.75), 통계적으로도유의하였다 (p=0.04) (Table 3). 현재사용할수있는골수정의원위직경이제한적이어서대퇴골협부직경이사용할수있는골수정직경보다과도하게넓은경우가발생할수있다. 이런경우에서는내경편차로인해발생하는골수정의움직임이대퇴부동통을유발할수있으며증례사진 (Fig. 2) 에서도골수정의움직임이추시방사선상관찰된바있다. 저자들은본연구결과에근거하여원위부확공을시행하여골수정을고정한경우를포함한대퇴골협부직경과골수정직경차이가 3 mm 이하인경우들에서골수정원위부움직임으로인한대퇴부동통이발생하지않는안정고정상태로판단하였고, 이런경우들에한해서원위잠금은불필요할수도있다라고생각하였다. 또한대퇴골협부직경이골수정직경보다 3 mm 초과하는경우는대퇴부동통을유발하는제일중요한위험인자라고평가하였다. 2세대골수정을사용하여안정형대퇴전자간골절을치료시수술전가늠술상대퇴골협부직경과사용할골수정직경간차이가커서 (3 mm 초과 ) 대퇴부동통발생이예상되는경우에는원위잠금을시행하거나골수강외고정술을고려하는것이골수정의움직임으로발생할수있는대퇴부동통을예방하기위해서필요하다고생각한다. 또한노인에서골다공증으로인하여대퇴골직경이넓어지는현상및현재사용할수있는골수정의직경이제한되어있음을고려해본다면향후좀더다양한직경의골수정이필요하다고생각한다. 본연구의제한점들로는우선후향적연구이어서단일골수정으로연구대상을조절할수없었다. 하지만본연구에사용된골수정들은모두 2세대골수정으로서디자인및수술기법이서로간에큰차이가없고, 합병증발생여부는골수정의종류보다는술자나골절형태에따라서주로관련이있는것으로알려져있다. 28-30) 또한대상환자군이적고, 추시기간이짧아서좀더객관적인결과분석을위해서는향후 meta-analysis 및장기추시결과가필요하다. 마지막으로본연구대상의과반수이상에서수술전평가상골다공증이없었고, 안정형대퇴전자간골절들만을대상으로본연구가진행된점을고려해볼때모든대퇴전자간
15 Intramedullary Hip Nail without Distal Locking 골절들을대상으로본연구결과를확대적용하기에는무리가따른다는점이다. 결론 안정형대퇴전자간골절들을 2세대골수정으로치료시정복상태가만족스럽고수술술기상대퇴골협부직경과골수정직경차이를최소화하여 (3 mm 이하 ) 안정된원위부고정을얻을수있다고예상된경우에한해서원위잠금은불필요할수있다. 하지만대퇴골협부직경과사용한골수정직경간차이가크거나불안정형골절인경우에서는원위잠금이반드시필요하다고판단된다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Cooper C, Campion G, Melton LJ 3rd. Hip fractures in the elderly: a world-wide projection. Osteoporos Int. 1992;2:285-9. 2. Kregor PJ, Obremskey WT, Kreder HJ, Swiontkowski MF; Evidence-Based Orthopaedic Trauma Working Group. Unstable pertrochanteric femoral fractures. J Orthop Trauma. 2005;19:63-6. 3. Cheng T, Zhang G, Zhang X. Review: minimally invasive versus conventional dynamic hip screw fixation in elderly patients with intertrochanteric fractures: a systematic review and meta-analysis. Surg Innov. 2011;18:99-105. 4. Saudan M, Lübbeke A, Sadowski C, Riand N, Stern R, Hoffmeyer P. Pertrochanteric fractures: is there an advantage to an intramedullary nail?: a randomized, prospective study of 206 patients comparing the dynamic hip screw and proximal femoral nail. J Orthop Trauma. 2002;16:386-93. 5. Leung KS, So WS, Shen WY, Hui PW. Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomised prospective study in elderly patients. J Bone Joint Surg Br. 1992;74:345-51. 6. Lacroix H, Arwert H, Snijders CJ, Fontijne WP. Prevention of fracture at the distal locking site of the gamma nail. A biomechanical study. J Bone Joint Surg Br. 1995;77:274-6. 7. Gadegone WM, Salphale YS. Proximal femoral nail: an analysis of 100 cases of proximal femoral fractures with an average follow up of 1 year. Int Orthop. 2007;31:403-8. 8. Radford PJ, Needoff M, Webb JK. A prospective randomised comparison of the dynamic hip screw and the gamma locking nail. J Bone Joint Surg Br. 1993;75:789-93. 9. Rosenblum SF, Zuckerman JD, Kummer FJ, Tam BS. A biomechanical evaluation of the Gamma nail. J Bone Joint Surg Br. 1992;74:352-7. 10. Bridle SH, Patel AD, Bircher M, Calvert PT. Fixation of intertrochanteric fractures of the femur. A randomised prospective comparison of the gamma nail and the dynamic hip screw. J Bone Joint Surg Br. 1991;73:330-4. 11. Skála-Rosenbaum J, Bartonícek J, Bartoska R. Is distal locking with IMHN necessary in every pertrochanteric fracture? Int Orthop. 2010;34:1041-7. 12. Ozkan K, Unay K, Demircay C, Cakir M, Eceviz E. Distal unlocked proximal femoral intramedullary nailing for intertrochanteric femur fractures. Int Orthop. 2009;33:1397-400. 13. Doppelt SH. The sliding compression screw: today's best answer for stabilization of intertrochanteric hip fractures. Orthop Clin North Am. 1980;11:507-23. 14. Lindskog DM, Baumgaertner MR. Unstable intertrochanteric hip fractures in the elderly. J Am Acad Orthop Surg. 2004;12: 179-90. 15. Cleveland M, Bosworth DM, Thompson FR, Wilson HJ Jr, Ishizuka T. A ten-year analysis of intertrochanteric fractures of the femur. J Bone Joint Surg Am. 1959;41:1399-408. 16. Fogagnolo F, Kfuri M Jr, Paccola CA. Intramedullary fixation of pertrochanteric hip fractures with the short AO-ASIF proximal femoral nail. Arch Orthop Trauma Surg. 2004;124:31-7. 17. Parker MJ, Palmer CR. A new mobility score for predicting mortality after hip fracture. J Bone Joint Surg Br. 1993;75:797-8. 18. Jensen JS. Determining factors for the mortality following hip fractures. Injury. 1984;15:411-4. 19. Hesse B, Gächter A. Complications following the treatment of trochanteric fractures with the gamma nail. Arch Orthop Trauma Surg. 2004;124:692-8. 20. Grimaldi M, Courvoisier A, Tonetti J, Vouaillat H, Merloz P. Superficial femoral artery injury resulting from intertrochanteric hip fracture fixation by a locked intramedullary nail. Orthop Traumatol Surg Res. 2009;95:380-2. 21. Rajaesparan K, Amin A, Arora S, Walton NP. Pseudoaneurysm of a branch of the profunda femoris artery following distal locking of an intramedullary hip nail: an unusual ana-
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17 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2015; 50: 8-17 http://dx.doi.org/10.4055/jkoa.2015.50.1.8 www.jkoa.org Intramedullary Hip Nail without Distal Locking 고관절골수정을이용하여안정된원위부고정을얻은대퇴전자간골절에서원위잠금이항상필요한가? 윤호현 윤정로 서효성 유중진 중앙보훈병원정형외과 목적 : 대퇴전자간골절을골수정으로치료시원위잠금이항상필요한지에대해서알아보고자하였다. 대상및방법 : 2010년 4월부터 2013년 6월까지 2세대골수정으로안정형대퇴전자간골절들 (AO/OTA 31-A1) 을치료하고, 최소 1 년이상방사선및임상추시가가능하였던 47예의방사선적및임상적치료결과들을원위잠금을사용한군과원위잠금을사용하지않은군으로분류하여비교분석하였다. 결과 : 두군의방사선적및임상적치료결과간에서통계적으로유의한차이는없었다. 수술후대퇴부동통이 8예 (17%) 에서발생하였다. 대퇴골협부직경과사용한골수정직경간차이는대퇴부동통발생에통계적으로유의하였다 (Fisher s exact test, p=0.01). Logistic regression analysis 결과상대퇴골협부직경과사용한골수정직경간차이가대퇴부동통발생에가장큰영향을미치는통계적으로유의한인자였다 (p=0.04, odd ratio=27.75). 결론 : 2세대골수정으로안정형대퇴전자간골절을치료시정복상태가만족스럽고대퇴골협부직경과골수정직경차이가작아서안정된원위부고정을얻었다고예상된경우에한해서원위잠금은불필요할수있다. 색인단어 : 대퇴골, 전자간골절, 골수정, 원위잠금 접수일 2014 년 7 월 16 일수정일 2014 년 8 월 12 일게재확정일 2014 년 9 월 26 일책임저자윤호현서울시강동구진황도로 61 길 53, 중앙보훈병원정형외과 TEL 02-2225-4172, FAX 02-2225-1910, E-mail 3188yun@naver.com 대한정형외과학회지 : 제 50 권제 1 호 2015 Copyright 2015 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/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.