Review Article pissn 1738-3757 eissn 2288-8551 J Korean Foot Ankle Soc 2017;21(3):83-87 https://doi.org/10.14193/jkfas.2017.21.3.83 중족골통에서의소족지중족절골술 이승열, 정진화 가톨릭대학교의과대학부천성모병원정형외과학교실 Lesser Metatarsal Osteotomies for Metatarsalgia Seung-Yeol Lee, Jin-Wha Chung Department of Orthopedic Surgery, Bucheon St. Mary s Hospital, The Catholic University of Korea, Seoul, Korea Metatarsalgia means the pain under the lesser metatarsal heads. The many causes of can be categorized into three groups: local disease in the region, altered forefoot biomechanics, and systemic disease affecting the region. Surgical options need to be considered if nonsurgical treatment fails. The metatarsal osteotomies are designed primarily to reduce the weightbearing forces on the metatarsal head by elevating or shortening the metatarsal. Many lesser metatarsal osteotomies have been described, and their success depends on many factors. Regardless of the method employed, it is important to maintain or restore the metatarsal cascade to maintain an even pressure under the lesser metatarsal heads and prevent transfer lesions. The surgeon must understand the effects of the metatarsal osteotomy on the forefoot patho-biomechanics and decide, using a combination of clinical examinations and imaging, whether the desired effect of the osteotomy is to shorten or elevate the metatarsal head or both. Key Words: Lesser metatarsal, Metatarsalgia, Metatarsal osteotomy 서 중족골통 () 또는중추중족골통 (central ) 은단일한진단명이라기보다는전신적또는국소적인원인들에의해전족부의통증이두번째, 세번째또는네번째중족골두근처에서발생하게되는포괄적인증상을지칭하는용어이다. 통증의원인으로는중족골두와관절낭을포함하는주위연부조직에병적상태를유발하는전신적질환뿐만아니라지간신경종이나 Freiberg 병증과같은국소적문제와함께생역학적으로보행과정중전족부의모든부위가체중을골고루나눠갖지못하고일부분에반복적으로집중되는문제가단순히중족골길이들간의상호불균형이나해당중족골두의낮은위치에기인하기도하지만, 이와더불어무지외반증, 소족지의갈퀴족지변형, 요족으로인한 Received August 8, 2017 Revised September 9, 2017 Accepted September 11, 2017 Corresponding Author: Jin-Wha Chung Department of Orthopedic Surgery, The Catholic University of Korea, Bucheon St. Mary s Hospital, 327 Sosa-ro, Wonmi-gu, Bucheon 14647, Korea Tel: 82-32-340-7035, E-mail: koreafoot@gmail.com 전족부의과도한회내 (pronation), 아킬레스건의단축으로인한족관절의운동범위감소등과같은족부족관절의다양한원인들에의해중족골통이발생하게된다. 이렇게중족골두로의과도한압력의집중은전족부발바닥피부에굳은살을만들어내어난치성족저각화증 (intractable plantar keratosis, IPK) 이란진단명으로분류되고, 통증과부종, 발적등의증상을유발한다. 이러한병적원인들에대한깊은이해와평가를바탕으로보존적치료를우선적으로시행하였음에도증상의호전이없는환자들에대하여수술적치료를시행하게되며, 해당중족골두로의과도한압력집중을회피하기위한목적으로중족골에대한절골술을시행하는술기들이주를이룬다. 절골을시행하는해부학적위치에따라중족골의경부또는골간단 (metaphysis) 에서시행하는원위절골술과간부에서시행하는절골술로나눌수있으며, 절골의모양에따라폐쇄쐐기절골술 (closing wedge osteotomy), 횡절골술 (transverse osteotomy), 사형절골술 (oblique osteotomy) 또는계단절골술 (step-cut osteotomy) 등의방법들이있다. 1,2) Financial support: None. Conflict of interest: None. Copyright c2017 Korean Foot and Ankle Society. All rights reserved. CC This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
84 Vol. 21 No. 3, September 2017 본 1. 생역학적문제해부학적구조상전족부의제 1열및 4, 5열은시상면에서의굴신운동이일부가능하지만, 제 2열과 3열의경우해당중족골의기저부는설상골과안정적인관절을형성함으로써이러한굴신운동이상대적으로허용되지않아족저로부터가해지는과도한압력으로인한충격에취약하다. 체중부하보행과정중각각의시기를구분하여이해하는것이중족골통의생역학적원인파악에도움이된다. 만약, 보행과정중뒤꿈치가땅에닿은후발바닥전체가지면에닿는시기 (midstance 또는 second-rocker phase) 에하나또는그이상의중족골에해부학적으로과도하게족저굴곡된변형이있는경우, 해당골두의위치가다른골두들에비하여시상면에서낮게위치하게됨으로써이곳으로압력이과도하게집중된다. 한편, 뒤꿈치가들리면서 (heel rise) 제 1족지를포함한전족부가땅을박차고나가는시기 (third-rocker phase) 에다른중족골들에비해지나치게긴중족골이있다면이곳으로과도한압력이가해질것이다. 또한, 아킬레스건단축에의해족관절의족배굴곡이제한된경우에도이시기에전족부로의과도한압력증가를유발하게된다. 이렇게중족골두가위치하는족저부는보행과정중체중을지탱하면서땅을디디거나박차고나가는과정에서지면또는신발에의한압력을받게되므로, 통증의병리학적원인과함께생역학적인문제를함께고려해야올바른진단과적절한치료가가능하다. 2. 분류 Espinosa 등 2) 은중족골통을일차성, 이차성및의인성의세가지 Table 1. Different Types of Metatarsalgia Category Primary Secondary Iatrogenic Cause Insufficiency of the first ray Excess of metatarsal plantar slope or plantar flexed metatarsal bone Metatarsal length discrepancy Equinus (pes cavus, contracture of gastrocsoleus complex) Metabolic disorders (gout) Systemic disorders (rheumatoid arthritis) Arthritis of MP joint Trauma Neurologic disorders (Morton's neuroma, tarsal tunnel syndrome) Freiberg's disease Failed hallux valgus surgery Failed MP joint fusion Failed corrective metatarsal osteotomies Data from the article of Espinosa et al. (Foot Ankle Int. 2008;29:871-9). 2) MP: metatarso-phalangeal. 로분류하였으며, 이러한원인에따른분류는치료의계획을세우는데도움을준다 (Table 1). 일차성중족골통은환자에게내재한중족골의이상, 즉과도한족저굴곡또는길이의부조화뿐만아니라첫째열의과운동성 (hypermobile first ray), 족저패드 (plantar pad) 의위축, 전족부의과도한회내등으로이환된중족골에과도한압력이집중될때발생한다. 중족골의과도한족저굴곡은해당족지의갈퀴족지변형을동반하는경우가흔하며, 이때 IPK는중족골두바로아래에위치한다. 반면에, 중족골들간의길이부조화로발생하는중족골통의경우 IPK는해당중족골두보다원위부에위치하게되며이곳에가해지는전단력으로인해흔히둥글고넓은모양을가진다. 또한, 무지외반증환자는보행과정의마지막단계인엄지발가락이땅을박차고나가는과정이불완전하며이에대한보상으로제 2중족골두또는제 3중족골두부위로과도한힘이집중된다. 여기에외반된제 1족지가제 2족지를위로들어올려제 2중족지간관절의아탈구나완전탈구를유발하기도하여통증을더욱악화시킨다. 이차성중족골통은흔하게는중족골골절후회전또는각형성부정유합으로인한부정렬 (malalignment) 이원인이다. 다른원인으로는류마티스관절염, 통풍등의질환에서중족지간관절의불안정성이유발되며, 이는이차적으로중족지간관절의과도한족배굴곡변형이발생하고족저지방패드 (fat pad) 가위축되거나원위로이동하게되어중족골두가더욱압박을받게된다. 여기에중족골두들사이로지나가는지간신경또한눌리게되어신경증상을유발하기도한다. 이외에도 Morton 족지, 족근관증후군및 Freiberg 질환에서도중족골통을유발한다. 의인성중족골통들중에서는전이성중족골통이가장흔하며, 이는무지외반증에대한절골술후제 1중족골두가거상되거나소족지중족골들에대한절골술이후과도한단축이나중족골두의거상이발생하여이차적으로유발되는경우가많다. 3. 평가환자의과거력청취를통해외상또는수술에대한기왕력과전신적인병증을알아보는것이중요하다. 특히, 당뇨환자의경우신경의당화 (glycation) 가진행되는당뇨신경증에의해족부의이상감각및통증이유발될뿐만아니라결합조직역시당화에의한변성으로인해아킬레스건이나족저근막의신축성이감소되어족부족관절의운동범위를감소시키기도한다. 신체검사에서환자를서게하고걷게하여특정동작에서의통증악화여부를알아보아야하며, 평소에신는신발과의관계를파악하는것도도움이된다. 또한, 족관절을각각족저굴곡및족배굴곡시킨상태뿐만아니라뒤꿈치를내번및외번시켜중족-족근관절의잠김과풀림이유발된상태에서의족지의운동범위를관찰하여신전건및굴곡건의단축을검사한다. 족관절의족배굴곡에있어운동범위제한을보일때, 비복근 (gastrocnemius) 단독
Seung-Yeol Lee, et al. Lesser Metatarsal Osteotomies for Metatarsalgia 85 A B C D E F Figure 1. Schematic figures of variable metatarsal osteotomies: Distal oblique metatarsal neck osteotomy by Weil (A), distal metatarsal metaphyseal osteotomy (DMMO) by Redfern (B), distal oblique osteotomy by Helal (C), distal metatarsal wedge out osteotomy by Leventen and Pearson (D), proximal metatarsal wedge out osteotomy by Fleischli (E), and distal chevron osteotomy by Kitaoka and Patzer (F). 또는가자미근 (soleus) 과병합된단축을구별하기위하여 Silfverskiöld 검사를시행하기도하며, 지간신경에대한압박을포함한신경및혈관의상태를파악한다. 3,4) 방사선검사는체중을부하한상태에서양측족부의전후면과측면을촬영하여중족골들간의상대적길이와측면경사의정도를파악한다. 또한, 내사면 (internal oblique) 촬영을추가하여중족지간관절의아탈구나탈구를확인한다. 4. 소족지중족절골술절골술의목적은중족골의족배굴곡또는단축을시행하여중족골통을유발하는중족골두를상방또는근위부로이동시키는것이다. 5-7) 이때중족골두의적절한이동이필수적인데, 부족할경우에는중족골통의재발이, 과할경우에는전이성중족골통의결과를초래할수도있다. 중족골통을동반한 IPK가하나의중족골에기인하여발생하였을때, 전이성중족골통을방지하기위하여다른중족골에대한절골술을수술과정에포함시켜야하는지에대하여는확실히정해진바는없다. 예를들어, 제 3중족골두의절골술시행시제 2중족골또는제 4중족골에대한절골술을시행할지여부는저자들마다다르다. 1,8,9) 또한, 무지외반증환자들일부에서무지를포함한제 1열의통증보다는동반된소족지중족골통을주소로병원을방문하기도한다. 이에대한치료에있어무지외반증에대해서만단독으로수술적치료를시행하더라도, 수술후체중부하보행시무지를포함한제 1열의생역학적운동이회복됨으로써소족지로의압력이감소하여시간이지나면서소족지중족골통이자연적으로소실되는지에대하여는논란이있다. 10) 절골을시행하는해부학적위치에따라중족골경부및골간에서시행하는원위절골술과이보다근위부에서시행하는간부절골술로나누어설명한다 (Fig. 1). 1) 원위절골술 (1) Weil 절골술 Weil과 Barouk에의해시작된원위사형절골술의일종인 Weil 절골술은중족골의단축으로인한내재근의긴장을감소시킬수있 Figure 2. When the angle of the Weil osteotomy is more vertical than the weightbearing surface of the foot, plantar displacement of the metatarsal head during the shortening of the metatarsal will coincide. 으며, 절골부의넓은접촉면을가지는내재적안정성과함께절골부를 2.0 mm twist-off screw와같은나사못을이용하여고정함으로써수술후부정유합이나불유합의위험성이감소되고조기재활이가능하다는장점으로근래에많이시행되고있다. 하지만절골후중족골두가근위부로이동하게되므로수술전해당중족골의길이가길지않았을경우에는중족골의단축으로인해부유 (floating) 족지를유발하거나주변중족골두로의과도한압력을유발함으로써전이성중족골통을초래하는등의문제가발생할수있다. 11,12) 또한, 이적으로절골을시상면에서지면과평행하게시행을하여야절골원위부가근위이동을할때중족골두의하방전위가발생하지않으며, 이를위하여절골의각도가제 2중족골일경우간부에대하여약 30도이내의각도를유지하여야한다. 하지만이러한각도로절골을시행할경우원치않게중족골의근위부까지도달할정도로길어지는절골을피할수없으며, 이에따른연부조직및혈관의손상을유발하기도한다. 이러한술기상의어려움으로실제로는절골의각도가이보다커지게되는경우가많으며, 이러한수직에가까운절골로인해중족골두의근위부이동시의도치않게중족골두의하방으로의전위가동반됨으로써중족지간관절의내재근들이결과적으로중족골두의상방에위치하게되어신전근으로의역할을하게된다. 이는추후 15% 에서많게는 50% 의환자들에게서중족지간관절이족배굴곡된상태로구축되어이로인한강
86 Vol. 21 No. 3, September 2017 직과부유족지등을유발한다고보고되었다 (Fig. 2). 13,14) 이에일부저자들은 Weil 절골의각도가커지는것을허용하는동시에배부 (dorsal) 폐쇄쐐기를추가함으로써지나치게긴절골과중족골두의하방전위를방지하려는목적의술기를고안하기도하였다. 15) 또한, Weil 절골술은관절낭의종적절개를통하여골두연골의상방일부를포함하게되는관절내절골술로서다른절골술들에비하여족배부반흔조직의과도한형성에기인한족배굴곡으로의구축을유발할수있어수술을마칠시관절낭의봉합을하지않거나필요시신전건연장술과족저판 (plantar plate) 단축술을시행하기도하며, 술후일정기간해당족지를족저굴곡시킨상태에서핀고정을유지하는등의방법들을사용하기도한다. 13) (2) 원위중족골간단절골술 (distal metatarsal metaphyseal osteotomies, DMMO) Weil 절골술을시행함에있어전후면상의중족골길이는 Maestro 등 9) 이제시한바와같이주변중족골들과의조화를이룰수있도록방사선영상검사를통하여적정한단축을의도할수있다. 반면에 Weil 절골의각도를조정하거나폐쇄쐐기를추가함으로써중족골의높낮이, 즉중족골의경사를어느정도는조정할수있지만, 이에대한술전계획을세울때나수술중에방사선영상검사를통하여정확한계측과평가가어려울뿐만아니라, 수술과정중에나사못을이용하여골두의높낮이를인위적으로고정함으로써절골부의안정성을얻는장점대신에술후보행시족부아치의문제또는아킬레스건의단축등에의한동적영향을받게되더라도추가적인중족골두의높낮이변동이불가능하여예상치못한중족골통의재발이나전이성중족골통이발생할수도있다. 16) Vernois 등 17) 은최소침습도달법을통하여직경이작은 Shannon burr로중족골경부중앙에서시작하여약 45도를유지한채로중족골간부로절골을진행하는술식을시행하였으며, 이에대한양호한결과를보고하였다. 이러한술식은 Weil 절골술과달리관절외절골술이므로술후강직에의한관절운동제한이적게발생하며, 절골부에대한고정을시행하지않음으로써절골부의완전유합이전에보행을시행하여중족골두의높낮이가생역학적으로자연스럽게위치하는장점이있겠으나, 오히려절골부의불유합과함께과도한골두의상방전위를가져오는부정유합등이문제가되기도한다. 18) 한편, Leventen과 Pearson 8) 은중족골경부에 rongeur를이용하여약 5 mm의피질골을제거한후골두에상방으로의도수압박을가하여결과적으로 V자모양의배측폐쇄쐐기절골술을유도하는술식을시행하였다. 이때, 술후전이성중족골통의속발을방지하기위해제 2중족골두또는제 4중족골두부위에발생한 IPK의경우제 3중족골에대한절골술을같이시행하였고, 제 3중족골두부위에발생한 IPK에대하여는제 2중족골및제 4중족골에대하여절골술을동시에시행하여양호한결과를보고하였다. 이러한술 식의절골부는부전골절 (greenstick fracture) 의양상을취하므로원칙적으로내고정을요하지않지만, 부정유합또는불유합이우려되어 K강선으로한시적고정을시행하기도한다. 또한, Kitaoka와 Patzer 19) 는중족골골두와경부의경계를정점으로종적원위갈매기 (vertical distal chevron) 절골을시행하여중족골두를수직으로 2 3 mm 정도거상시킨후절골부위를밀착시키는술식을시행하였으며, 이또한절골부자체에내재하는안정성은어느정도있지만환자의체중부하보행에따른골두의거상이과도하게발생할수있어, K강선을이용하여절골부를한시적으로고정하는것을권장하였다. 15,19) 2) 간부절골술 Wolf 21) 는 V자모양의배측폐쇄쐐기절골술을원위간부에서시행하였고, Helal은원위간부로부터시작하여약 45도의각도로중족골골두의결절 (tubercle) 에손상이가지않는범위내에서원위족저간부로향하는사형절골술을시행한후내고정을시행하지않은채로체중부하보행을허용하여원위절골편의자연스러운거상및근위부로의이동을유도하였다. 20,21) 이들술기에대한양호한결과들이보고되었지만, 반대로절골부의부정유합이나불유합의발생빈도가높아전이성중족골통의합병이많고임상적만족도역시높지않다는보고들도있다. 22) 한편, Fleischli 등 23) 은 V자모양의배측폐쇄쐐기절골술을중족- 설상골간관절로부터약 1 cm 원위부인근위간부에서치밀골을약 2 5 mm가량절제하는방법으로시행하였으며, 당뇨족의전족부궤양및지간신경종을가지는환자들에게서좋은결과를보고하였다. 결 중족골통에시행하는소족지중족절골술은해당중족골두로의과도한압력집중을회피하기위한목적으로중족골두를상방또는근위부로이동시키는술기로, 술후발생할수있는중족골통의재발이나전이성중족골통의속발등을방지하기위하여전족으로의과도한압력을유발할수있는보행을포함한족부의생역학및병변의해부학적이해가요구된다. REFERENCES 111 Feibel JB, Tisdel CL, Donley BG. Lesser metatarsal osteotomies. A biomechanical approach to. Foot Ankle Clin. 2001;6:473-89. 222 Espinosa N, Maceira E, Myerson MS. Current concept review:. Foot Ankle Int. 2008;29:871-9. 333 Aronow MS, Diaz-Doran V, Sullivan RJ, Adams DJ. The effect of triceps surae contracture force on plantar foot pressure distri-
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