REVIEW 대한족부족관절학회지제 17 권제 2 호 2013 J Korean Foot Ankle Soc. Vol. 17. No. 2. pp.79-83, 2013 고려대학교의과대학구로병원정형외과학교실 Calcaneal Fractures-Extended Lateral Approach Sung-Kwang Chun, M.D., Hak Jun Kim, M.D. Department of Orthopedic Surgery, Guro Hospital, Korea University, Seoul, Korea =Abstract= Calcaneus is largest tarsal bone and the fracture of calcaneus is most common tarsal fractures. Calcaneal fractures are divided into extra-articular and intra-articular fractures. Intra-articular calcaneal fractures could be classified as tongue type and joint depression type using simple lateral radiograph (Essex-Lopresti classification), but Sanders suggested new classification according to involving the posterior facet of calcaneus using computed tomography. The involvement of posterior facet was revealed as more complicated than Essex-Lopresti classification. The principle purpose of treatment of calcaneal fractures are restoration of calcaneal height (Böhler angle), width, axis, anatomical reduction of joint and restoration of function through the stable fixation. Good visualization of joint and anatomical reduction could be achieved by extended lateral approach. But, skin problem could be occurred after of extended lateral approach. Key Words: Calcaneus, Fractures, Extended lateral approach 서 론 종골은족근골중가장큰뼈로써거골및입방골과관절을이루고있으며일반적으로종골에서의관절내골절이라함은거골하관절을침범하는것을지칭하며 Received: April 14, 2013 Revised: May 10, 2013 Accepted: May 21, 2013 Corresponding Author: Hak Jun Kim Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul 152-703, Korea Tel: +82-2-2626-3090 Fax: +82-2-2626-1164 E-mail: dakjul@hanmail.net 본논문의요지는 2012 년도대한족부족관절학회추계학술대회에서발표되었음. 70~75% 는관절내골절로발생한다. 종골의관절내골절은축성압력에의한일차골절선이후전단력 (shearing force) 이나압박력 (compressive force) 에의한 2차골절선이발생하여거골하관절의붕괴를가져온다. 1) 단순방사선사진에서 2차골절선의위치에따라서종골골절이분류된다. 2차골절선이종골돌기후방에위치하면설상형종골골절 (tongue type calcaneal fracture) 로종골돌기전방에위치하면관절함몰형종골골절 (joint depression type calcaneal fracture) 로분류한다. 2) 전산화단층사진촬영에서의종골골절의분류는거골하관절을침범한골절선의숫자와위치에따라서 Type II-A, B, C, Type III-A, B, C, Type IV 로나눈다. 3) 종골의관절내골절의치료목표는거골하관절후방소면 (posterior facet) 관절면의회복, 종골높이 - 79 -
(Böhler angle) 의회복, 종골폭의감소, 비골건의움직임이가능하게비골하공간의감압, 종골의축성정열상태회복, 종골주위의관절면의안정적해부학적정복과고정으로기능의향상이다. 그러므로전위가있는관절내골절에서이러한종골골절의치료목표를달성하기위해서는관혈적정복술및내고정술이추천되고있다. 관혈적정복술의방법으로는광범위외측접근법, 내측접근법, 재거돌기접근법 (sustentacular approach), 외측최소절개법 (modified palmer approach) 등이있으며이중광범위외측접근법은가시성이우수하므로종입방관절, 거골하관절및종골돌기의골절편정복에유리하여많이이용되고있다. 4) 본론 광범위외측접근법을시행하기위해서는수상부위 Figure 1. Winkle sign: Surgical approach could be possible when more than 3 wrinkles. Figure 2. Extended lateral approach: Line was drawn at the lateral aspect of calcaneus. Injury of sural nerve should be avoided during approach. Figure 3. Multiple K-wires were used for maintaining reduction of fragments under the fluoroscopic control. - 80 -
의연부조직이안정화되어야시행할수있다. 그러므로종골골절환자에서족부의주름징후 (wrinkle sign) 가 3개이상나타날때까지부목고정, 하지거상및얼음찜질을이용하여연부조직의부종을안정화시켜야한다 (Fig. 1). 수술방법은환자를측앙와위 (lateral decubitus position) 로눕힌뒤종골의외측에 L 자모양의피부절개선을가한후골막하박리를통하여거골하관절까지접근한다 (Fig. 2). 절개선을가할때원위부와근위에비복신경 (sural nerve) 이지나가므로손상되지않게주의를하여야한다. 수술에방해가되지않게들어올린피판은잦은조작에의한피판괴사방지및가시성을유지하기위해 K-강선을거골부위에삽입하여유지시켜준다. 거골하관절이노출되면후방소면 (posterior facet) 의골절을정복한다. 재거돌기를거골의관절에일차적으로정복한후 K-강선으로거골과재거돌기를임시로연결시킨다. 정복된재거돌기골편에차례로관절골절편을정복하여임시로 K-강선고정을시행한다. 후방소면이정복된후종골결절 (calcaneal tuberosity) 을정복하고전방돌기 (anterior process) 를정복하여 K-강선으로임시고정한다. 골편의정확한정복을위해영상증폭장치를이용하여수시로정복의정도를확인하여야한다. 해부학적정복이완성된후외측벽에종골금속판을댄후금속나사를이용하여고정을시행한다. 금속나사의삽입위치는일반적으로재거돌기방향으로 2 개, 종골결절골편방향으로 2개, 전방돌기골편방향으로종입방관절가까운곳에 2개를반드시고정하여 Figure 4. Half-buried horizontal mattress suture was done after fixation. 야한다 (Fig. 3). 절개선의봉합은피판의괴사를방지하기위한봉합을시행하여야한다 (Fig. 4). 고찰 종골골절은관절내골절과관절외골절로구분되며관절내골절의분류는 Essex-Lopresti 분류 2) 와 Sanders 분류 3) 를가장널리사용한다. 관절내골절의분류중예후와의연관성이높은분류는 Sanders 분류로알려져있으며수술적방법의결정에많은도움을준다. 과거에는 Essex-Lopresti 분류상설상형골절의경우에는도수정복및축성핀고정술로좋은결과를보고하였으나, 2) Tornetta 5) 는 Sanders 분류 IIC형에서만제한된적응증으로만족할만한결과를가지고있다고보고하였다. 많은연구결과에서관절내종골골절에서는도수정복보다는관혈적정복을시행한경우종골높이 (Böhler angle) 의회복, 후방소면의관절면회복과돌출된외측골편의정복으로임상적결과가우수한것으로보고하고있다. 4,6-13) 또한단순방사선사진상설상형골절로분류된경우에서도전산화단층사진촬영상 Sanders 제3형, 4형골절로판명되는경우가많으며 Sanders 제3형, 4형골절에서의관혈적정복술및내고정술이골절편의추가전위및정복소실이적은것으로보고되고있다. 13-15) 또한생역학적연구결과 1~2 mm 의거골하관절함몰에의해접촉면의압력이증가한다는보고도있다. 16) 그러므로, 관절면의정확한해부학적정복과정복소실을막아좋은임상적결과를얻기위해서는제한된접근법보다는광범위접근법을이용하는것이후방소면, 종골전방돌기및종골돌기에발생한골절편의정복및고정에유리하다고할수있다. 금속판을이용한견고한내고정으로조기에관절운동을시행할수있어서불유합이나부정유합, 거골하관절강직등의합병증의빈도를줄일수있을것이다. 종골의관절내골절수술에사용하는금속판은다양하게알려져있다. 골절의양상에따라서사용하는금속판은잠김종골금속판 (locking calcaneal plate, Synthes, Bochum, Germany), 1/3 금속판 (Synthes, Bochum, Germany), F 금속판 (Solco, Pyeongtaeksi, Korea), Y 금속판 (Solco, Pyeongtaeksi, Korea) 등이있으며임상적으로우수한결과가보고되고있다. 4,7,12- - 81 -
14,17,18) 설상형종골골절에서도금속판을이용한술식이핀고정술보다우수하다는보고 15) 가있으며, 생역학적연구결과에서는잠김금속나사를사용한금속판에서더욱안정성이증가한다. 19) 광범위외측접근법은외측피판을완전히박리하는술식으로합병증으로창상부위의피부괴사및비복신경손상이발생할수있다. 4,11,12,20,21) 피부괴사는술자의경험에반비례한다는보고가있으며, 22) Abidi 등은광범위외측접근법에서피부괴사의위험요인으로체질량지수, 흡연과수상후수술까지의긴시간이관계가있으나, 나이, 당뇨등의내과적원인은관계가적은것이라고보고하였다. 20) 비복신경의외측종골분지의손상은약 6% 에서보고되고있으며 11) 비복신경의손상방지를위해광범위외측접근법시행시주의하여야한다. 그러므로족부의부종이일정정도가라앉는주름징후 3개이상의적당한시기를고려하여광범위외측접근법을시행하여야하며수술중시간을줄이기위해노력하여야하며수술후창상의봉합은봉합부위에과도한긴장이되지않게반매몰수평매트리스봉합 (half-buried horizontal mattress suture) 을시행하는것이추천된다. 결론 종골의관절내골절은다른관절의관절내골절의치료목적과같이관절의해부학적정복과고정이필요하므로광범위외측도달법을이용한관혈적정복술및내고정술이추천된다. REFERENCES 01. Cave EF. Fracture of the os calcis--the problem in general. Clin Orthop Relat Res. 1963:64-6. 02. Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis, 1951-52. Clin Orthop Relat Res. 1993:3-16. 03. Sanders R, Fortin P, DiPasquale T and Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res. 1993:87-95. 04. Zwipp H, Rammelt S and Barthel S. Calcaneal fractures-- open reduction and internal fixation (ORIF). Injury. 2004;35 Suppl 2:46-54. 05. Tornetta P, 3rd. Percutaneous treatment of calcaneal fractures. Clin Orthop Relat Res. 2000:91-6. 06. Buckley R, Tough S, McCormack R, et al. Operative compared with nonoperative treatment of displaced intraarticular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002;84- A:1733-44. 07. Guerado E, Bertrand ML and Cano JR. Management of calcaneal fractures: what have we learnt over the years? Injury. 2012;43:1640-50. 08. Miller WE. Pain and impairment considerations following treatment of disruptive os calcis fractures. Clin Orthop Relat Res. 1983:82-6. 09. Richards PJ and Bridgman S. Review of the radiology in randomised controlled trials in open reduction and internal fixation (ORIF) of displaced intraarticular calcaneal fractures. Injury. 2001;32:633-6. 10. Stromsoe K, Mork E and Hem ES. Open reduction and internal fixation in 46 displaced intraarticular calcaneal fractures. Injury. 1998;29:313-6. 11. Byun YS, Cho YH, Park JW, Lee JS and Kim JH. Early Postoperative Complications of Calcaneal Fractures Following Operative Treatment by a Lateral Extensile Approach. Journal of the korean society of fractures. 2004;17:323-7. 12. Chung HJ, Ahn JK, Bae SY and Jung H. Operative Treatment of Intraarticular Calcaneal Fractures using Extensile Lateral Approach. J Korean Foot Ankle Soc. 2009;13:60-7. 13. Lee MJ, Sohn SK, Lee KY, et al. Open Reduction and Internal Fixation with AO Calcaneal Plate for Displaced Intra-articular Calcaneal Fracture. Journal of the korean society of fractures. 2010;23:303-9. 14. Kim HJ, Ha KI, Yoon JR, et al. Usefulness of CT Scan in Treatment of Calcaneal Fracture. Journal of the korean society of fractures. 2003;16:526-33. 15. Shin DE, Yoon HK, Han SH, Choi WJ, Ahn CS and Ok HS. Operative Treatment of Tongue Type Intra-articular Calcaneal Fractures: Comparison of the Open Reduction and Essex-Lopresti Technique. J Korean Foot Ankle Soc. 2010;14:151-6. 16. Mulcahy DM, McCormack DM and Stephens MM. Intra- - 82 -
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