대한족부족관절학회지 : 제 13 권제 2 호 2009 J Korean Foot Ankle Soc. Vol. 13. No. 2. pp.118-123, 2009 전북대학교의학전문대학원정형외과학교실, 임상의학연구소, 제주대학교의과대학정형외과학교실 * 김정렬 김영신 신성진 * 김상림 * 서규범 * Analysis of the Deformities of the Foot after Tibial Fracture and Outcome of the Surgical Treatment Jung-Ryul Kim, M.D., Ph.D., Young-Sin Kim, M.D., Sung-Jin Shin, M.D.*, Sang-Rim Kim, M.D., Ph.D.*, Kyu-Bum Seo* Department of Orthopaedic Surgery, Chonbuk National University Medical School, Research Institute of Clinical Medicine, Jeonju, Korea Department of Orthopaedic Surgery, Jeju National University College of Medicine, Jeju, Korea* =Abstract= Purpose: We wanted to evaluate the relating factors for deformities of the foot after tibial fracture and the outcome of respective surgical treatment. Materials and Methods: We studied thirty-two patients (thirty-five feet) who had foot deformities after tibia fracture. The age, gender, shape, location, concurrent soft tissue injury and operative treatment of tibial fracture were analysed and outcome of the surgical treatment was investigated. Results: Deformities of the foot mostly occurred in open fractures of Gustilo type 3 or closed fracture with severe soft tissue injury. Variable surgical treatments such as simple release, lengthening, Z-plasty and osteotomy were performed. The AOFAS ankle-hind foot scale was improved from average of 37.3 points preoperatively to an average of 77.2 points at the last follow up. The Maryland foot score was from 42.9 to 90.2 and AOFAS Lesser Toe Metatarso-phalangeal interphalangeal scale was from 42.9 to 90.5. Radiological correction was also improved from 21.9 degrees to 7.9 degrees (Meary angle), from 112.2 to 138.5 (Hibb s angle) and from 33.8 to 25.9 (Calcaneal pitch). Conclusion: We proposed that great care should be taken of treatment for the tibial fracture and early detection and proper management of the foot deformities are crucial. Key Words: Tibia fracture, Foot deformity 서 론 경골골절후에주로발생하는합병증으로는지연유합이나불유합또는각변형등이다양하게발생하게되나, 드 Address for correspondence Sung Jin Shin M.D. Department of Orthopaedic Surgery, Jeju National University College of Medicine, Jeju, 690-120, Jeju, 690-756 Korea Tel: +82-64-717-1295 Fax: +82-64-757-8276 E-mail: ggeep@naver.com 물게 checkrein 변형, 요족변형, 갈퀴족지, 그리고작은족지변형등의족부및족지변형도발생한다 3,21). 이러한변형은하퇴부심부후방구획내의근육들이골절의유합부위에서유착되거나, 또는골절시동반된후방구획의직접적인손상및허혈에의해서나타나게되며 14) 이러한합병증은경골골절의치료결과를악화시킨다. 치료는보조기나스트레칭과같은보존적인방법보다는수술적치료가더좋은결과를보이고있으며 16) 이러한수술적방법으로는여러문헌에서다양한치료법들이소개되고있으며다양한결과들이보고되고있다 1,18). 이에저자들은경골골절후발 - 118 -
A B C D Figur e 1. A 14-year-old girl with a cavus foot deformity after open type IIIA tibia fracture. (A) Pre-operative radiograph at initial injury and (B) photograph of t he def ormed feet aft er 12mont hs. (C) Pre- operative radiographs showing Meary angle 20, Hibb s angle 114 and calcaneal pitch 35. (D) Radiographs 3 years postoperatively showing Meary angle 5, Hibb s angle 136, and calcaneal pitch 24. 생하는족부및족지변형들을유형별로분석해보고각각에대한치료의결과를문헌고찰과함께보고하고자한다. 대상및방법 1. 연구대상 1999년 12월부터 2008 년 5월까지경골골절이후에발생한족부및족지변형을대상으로하였으며요족, 첨족, 갈퀴지, 망치족지, 추지, checkrein 변형으로나누어분류하고이에대해본원에서수술적치료를시행하고 1년이상추시가가능했던 32명 (35예 ) 를후향적으로조사하였다. 수술당시평균연령은 30세 ( 범위, 8~58 세 ) 였으며, 남자가 26 명, 여자가 6명이였다. 초기수상당시경골골절의위치는 AO/OTA 분류로 AO/OTA 41이 8예, 42는 18예, 43이 5예, 44는 4예였다. 골절의형태는횡형 9예, 사상골절 4예, 나선상골절 7예, 분쇄골절 15예였다. 개방성골절은총 22예였고 Gustilo-Anderson 분류로 II형이 3예, IIIA형이 4예, IIIB 형이 7예, IIIC 형이 8예였다. 폐쇄성골절은총 13예로연부조직손상은 Tscherne 및 modified Tscherne 분류를사용하였고 II단계 7예, III단계 6예였으며구획증후군은폐 쇄성골절에서만 2예였다. 초기경골골절의수술방법으로골수강내금속정을이용한고정술 10예, 금속판과나사못을이용한관혈적정복술이 10예, 외고정장치를이용한고정술이 15예였다. 족부변형에대한수술은수상후평균 7.2 개월 ( 범위, 3~14 개월 ) 에시행되었으며환자의전신상태와창상의조건에따라수술시기를정하였다. 족부및족지변형의양상은첨족 14예, 요족 7예, checkrein 변형 5예, 갈퀴지 3예, 망치족 3예, 추지변형 3예였으며 (Table 1), 첨족의경우 7예에서아킬레스건연장술, 7예에서일리자로프외고정장치를이용하여교정을하였고, 요족에대한치료는전례에서절골술및골유합술을포함한건, 인대연장술을사용하였다 (Fig. 1). Checkrein 변형은 5예전부에서장무지, 장족지연장술을시행하였고 (Fig. 2) 갈퀴지변형과망치족변형은근위족지절제성형술과장족지신전건연장술시행후경피적 K-강선고정술로치료하였으며추지변형은중위족지절제성형술과굴곡건절제술후경피적 K-강선고정술을이용하여치료하였다. 수술후재활치료는환자의상태에따라서다르게시행하였으나기본적으로수술후가능한조기에족부및족관절의수동, 능동운동을실시하여재유착을방지하였다. Table 1. Summary of Cases Equinus Cavus Checkrein Claw toe Hammer toe Mallet toe Number of case 14 7 5 3 3 3-119 -
김정렬 김영신 신성진 김상림 서규범 A B C Figur e 2. A 28-year-old man with a checkrein deformity. (A) Pre- operative radiograph showing a ankle f racture with Tscherne grade 3. ( B) The checkrein def ormit y was observed when the ankle was passively dorsiflexed and (C) correction after a Z-plasty lengthening of the flexor hallucis longus and flexor digitorum longus tendon at the distal portion of fracture site. 2. 연구방법 수상당시연령, 골절부위, 골절의형태, 개방성및폐쇄성골절여부, 연부조직손상의정도, 그리고경골골절의수술방법에따른족부및족지변형의종류와각각의치료결과에대하여분석하였다. 초기수상당시경골골절의위치는 AO/OTA 분류로, 개방성골절은 Gustilo-Anderson 분류로, 연부조직손상은폐쇄성골절에서 Tscherne 및 modified Tscherne 분류로나누었으며각각의분류에대하여족부및족지변형과의상관관계를분석하였다. 수술후임상적결과에대한판정은족부변형과족지변형을나누어서평가하였는데족부변형은변형의교정도 ( 정렬정도 ), 보행, 수술부위및족관절운동범위를포함한기능적측면, 미용적측면과통증의유무등을포함하는미국정형외과족부족관절학회 (American Orthopaedic Foot and Ankle Society) 의족관절-후족부평가법 12) 과 Maryland foot score 19) 를이용하여평가하였으며족지변형에대하여미국정형외과족부족관절학회의소족지중족족지-지간관절평가법 12) 을이용하였다. 방사선학적결과에대한판정은특히, 요족변형에대해서는단순방사선사진을통하여제1 중족 -거골간각 (Meary angle), 제1 중족 -종골간각 (Hibb s angle), 종골경사각 (calcaneal pitch angle) 을측정하여비교하였고모든예에서각각의결과를분석한후이러한인자들이족부및족지변형의양상과치료에어떠한영향을주는지에대해 Pearson Chi-Square test, Wilcoxon signed rank test 를이용하여 p<0.05 에서통계적으로유의하다고판단하였다. Figur e 3. Histogram showing the relationship between deformities of the foot and location of the facture in tibia(pearson Chi-Square test, p=0.049). 결 과 본연구에포함된총 35예중에서경골골절은주로 20~40 대에주로발생하였으며 (65.7%) 그외연령대에서의모수가작아통계처리는불가능하였지만 40대이상에서는총 7예중 7예 (100%) 에서모두첨족변형을보였다. 골절부위는 AO/OTA 분류에따라나누어족부변형과의상관관계를조사하였으며근위부에서원위부보다첨족및요족변형의발생이통계적으로유의하게많았고원위부에서는 checkrein 변형의발생이통계적으로유의하게많았다 (Pearson Chi-Square test, p=0.049) (Fig. 3). 골절의형태는횡형골절 9예, 사상골절 4예, 나선상골절 7예, 분쇄골절 15예였으며첨족변형의경우횡형골절에서 6예 (67%), 분쇄골절에서 7예 (47%) 로골절의형태와첨족변형발생과의상관관계는통계적으로유의하지않았다 (Pearson Chi-Square test, p=0.42). 폐쇄성골절에서 - 120 -
첨족변형이 4예 (29%), 요족변형이 6예 (43%) 였고, 개방성골절에서는첨족변형이 10예 (48%) checkrein 변형, 갈퀴지, 추지가각각 3예 (14%) 였다. 폐쇄성과개방성골절과족부변형과의상관관계는통계적으로유의하지않았다 (Pearson Chi-Square test, p=0.58). 폐쇄성골절의경우 Tscherne 및 modified Tscherne 분류 II등급이상에서만족부및족지변형이발생하였으며개방성골절의경우 Gustilo-Anderson IIIB 형이상에서 15예 (71%) 의변형이발생하였다. 모든족부와족지변형들의발생은폐쇄성분류 II등급이상, 개방성분류 IIIB 형이상의연부조직손상과통계적으로유의한상관관계를가지고있었다 (Pearson Chi-Square test, p=0.00) (Fig. 4A, B). 첨족및요족변형의임상적결과는 AOFAS ankle-hindfoot rating score 를기준으로수술전평균 37.3 점 ( 범위, 28~ 57점 ) 에서수술후최종추시에서평균 77.2 점 ( 범위, 69~ 85 점 ) 으로통계적으로유의하게향상되었다 (Wilcoxon signed rank test, p=0.00). 또한 Maryland Foot Score 기준으로수술전평균 42.9 점 ( 범위, 34~64 점 ) 에서수술후최종추시에서평균 90.2 점 ( 범위, 79~94 점 ) 으로통계적으로유의하게향상되었다 (Wilcoxon signed rank test, p=0.00). Checkrein, 갈퀴지, 망치족지, 추지변형의임상적결과는미국정형외과족부족관절학회의소족지중족족지-지간관절평가법을기준으로수술전평균 42.7 점 ( 범위, 37~52 점 ) 에서수술후평균 90.5 점 ( 범위, 88~95 점 ) 으로통계적으로유의하게향상되었다 (Wilcoxon signed rank test, p= 0.00) (Table 2). 첨족변형에서의방사선학적결과는제1 중족-거골간각은수술전평균 21.9 도 ( 범위, 18~26 도 ) 에서수술후최종추시에서평균 7.9 도 ( 범위, 5~11 도 ) 로, 제1 중족-종골간각은평균 112.2 도 ( 범위, 101~122 도 ) 에서평균 138.5 도 ( 범위, 134~145 도 ) 로, 종골경사각은평균 33.8 도 ( 범위, 29 Table 2. Clinical Result of the Foot and Ankle Deformities Score Pre-Op Last F/U AOFAS* ankle-hind foot 37.38±6.41 77.24±5.49 rating score Maryland foot score 49.95±9.44 90.24±3.40 AOFAS* Lesser Toe Metatarso-phalangeal interphalangeal scale 42.79±5.10 90.50±3.16 *AOFAS, American Orthopedic Foot and Ankle Society; Pre-op, Preoperative; F/U, Follow up. Table 3. R adio logical Res ult of An kle Defo rmities Pre-op* Last F/U Meary s angle 21.93±2.30 7.92±1.68 Hibb s angle 112.21±6.18 138.50±2.82 Calcaneal pitch 33.86±3.70 25.93±1.85 *Pre-op, Preoperative; F/U, Follow up. ~42 도 ) 에서평균 25.9 도 ( 범위, 23~29 도 ) 로향상되었으며통계적으로유의하였다 (Wilcoxon signed rank test, p= 0.001) (Table 3). 고 찰 첨족및요족변형은족관절의족저굴곡과발의종아치가비정상적으로높아지는것으로약 80% 에서원인이밝혀져있으며대부분신경근육성질환에서외, 내재근의불균형으로발생되나 7,22), 하지의구획증후군이나압궤상또는골절과같은외상에의해서도나타날수있다 10). Checkrein 변형은발목을족저굴곡한상태에서발가락이신전되지만, 발목을족배굴곡할수록발가락의굴곡변형이나타나는것으로주로경골골절부위에서장무지, 장족지굴곡건의유착에의해서발생한다 13). 갈퀴지, 추지및망치지변형은원 A 6 4 2 0 Closed Fx. Grade 0 Grade 1 Grade 2 Grade 3 B Open Fx. I II IIIA IIIB IIIC (Pearson Chi-Square test, p=0.049) equinous cavus checkrein claw hammer mallet Figure 4. Histogram showing the relationship between deformities of the foot and severity of the soft tissue in tibial fracture(pearson Chi-Square test, p=0.00). - 121 -
김정렬 김영신 신성진 김상림 서규범 인은잘알수는없으나요족변형과동반된신경근육성질환이나관절염, 대사질환, 그리고하지외상에의해서발생한다 3,21). 그러나일반적으로경골골절후구획증후군이약 1~6% 정도로드물고 6) 신경근육성질환에비하여외상에의해나타나는족부변형의발병률이낮다. 그러나경골골절의빈도가높아지고또한최근산업재해와교통사고와같은고에너지손상으로인한연부조직손상을동반한형태로증가하고있어이로인한족부및족지변형등의합병증이중요시되고있다. 이에저자들은경골골절후발생하는합병증중족부및족지변형의빈도및양상에영향을미치는인자들을세분화하여이러한인자들이족부변형에어떤관계를갖는지를통계적으로분석하고각각의변형에대한수술의결과를조사하여연부조직손상을동반한경골골절의치료시고려할점들을알아보고자하였다. 경골골절의부위에따른족부변형양상은첨족과요족, 그리고 checkrein 변형에서상관관계를확인할수있었다. 첨족및요족의경우, 경골의근위간부골절로인한후방심부구획손상이나이로인한구획증후군으로후방경골근, 장족지및장무지굴곡건의구축에의하여발생하며 4,9,11,15), 본연구에서도근위부와간부손상시첨족과요족의발생이원위부에서보다유의하게많았다. Checkrein 변형은경골또는비골의원위부골절로인한장족지, 장무지굴곡건의유착에의해발생하며 14,18) 저자의경우도 5예전례에서원위부골절시에 checkrein 변형을관찰할수있었다. 폐쇄성골절과개방성골절에서연부조직손상이중등도이상 (Tscherne 및 modified Tscherne 분류 II등급이상, Gustilo-Anderson IIIB 형이상 ) 에서만통계적으로유의하게족부및족지변형이발생하였다. 여러다른저자들은그들의논문 5,9,15) 에서주로경골골절후의급성구획증후군에의해서발생된족부및족지변형에대하여언급하고있다. 그러나본연구의경우에서는수상혹은수술후급성구획증후군의발생은많지않았기때문에이것과의연관성을알순없었다. 하지만, 본연구에서연부조직손상과관찰된통계적유의성은심부구획내의직접적인근육손상이나압궤상으로인한급성손상과이로인하여발생된근육의구축에의한것 11,17) 으로추론할수있었으며연부손상의정도가심할수록변형의발생이많았던것으로생각된다. 본연구에서첨족의경우 7예에서아킬레스건연장술을시행하였고 7예에서는연부조직의심한구축이동반되어일리자로프외고정장치를이용하여교정을하였다. 연부조직의구축이심한경우에아킬레스건연장술만을이용한급속한변형의교정은피부괴사및주변혈관과신경손상의 위험성이많기때문에 8) 이러한경우엔일리자로프외고정장치를이용하여점진적인변형교정을얻을수있었다. 저자들의경우요족의발생은후방심부근육손상에의한것으로전족부요족 (anterior cavus) 이대부분이었다. 치료의궁극적목표는체중부하시에바닥과발바닥이평편하고안정되게붙게 (plantigrade) 하는것이며수많은치료방법들이제시되고있으나족저근막절제술, 내과주변에서의후방심부구획근육연장술, 중족골기저부절골술을기본으로하였다 11,16,23). Checkrein 변형은골절부위에서유착을박리하는술식보다는골절부위원위부에서장무지, 장족지연장술을시행하였는데 20), 술식자체가간편하고이전의유착된부위를피함으로써재유착의위험성을막을수있었기때문이다. 갈퀴지변형과망치족변형은근위족지절제성형술과장족지신전건연장술시행후경피적 K-강선고정술로치료하였으며추지변형은중위족지절제성형술과굴곡건절제술후경피적 K-강선고정술을이용하여치료하였다. 수술후재활치료는환자의상태에따라서다르게시행하였으나기본적으로술후가능한조기에족부및족관절의수동, 능동운동을실시하여재유착을방지하였다 2,19). 첨족및요족의경우방사선학적평가에서수술직후와최종추시에서통계학적으로유의한교정을얻을수있었다. 임상적평가는미국정형외과족부족관절학회의족관절-후족부및소족지중족족지-지간관절평가기준과 Maryland Foot Score 평가기준에서도통계학적으로유의한향상을보였다. 술후감염이나교정의소실등의합병증은발견되지않았으나이연구는증례수가 35예로많지않으며많은변수에대한통계적분석이필요함에따라증례수가적은경우에있어그통계적처리가비모수적검정법을사용한경우가있었던점, 이로인해통계적결과에대한해석의수준이다소애매한경우가있어서명확한결론을내리는데조심스러울수밖에없는점이있었으며그대안으로장기추시기간및많은증례가필요하리라생각된다. 결론경골골절후다양한족부및족지변형이발생하는것을알수있었으며특히, 첨족과요족변형과같은중증의변형은 Gustilo-Anderson IIIB형이상의심한개방성골절이나심한연부조직손상이동반된폐쇄성골절후에대부분발생하였다. 이를통하여연부조직손상이동반된경골골절후발생할수있는족부변형을예견할수있었으며, 치료시세심한주의와각각의변형에적합한치료가필요할 - 122 -
것으로생각된다. REFERENCES 1. Clawson DK: Claw toes following tibial fracture. Clin Orthop, 103: 47-48, 1974. 2. Coughlin MJ: Lesser toe abnormalities. Inst Course Lect, 52: 421-444, 2003. 3. Coughlin MJ: Operative repair of the mallet toe deformity. Foot Ankle Int, 16: 109-116, 1995. 4. Curry EE, O Brien TS and Johnson JE: Fibular nonunion and equinovarus deformity secondary to posterior tibial tendon incarceration in the syndesmosis: a case report after a bimalleolar fracture-dislocation. Foot Ankle Int, 20: 527-531, 1999. 5. Dávid A, Tiemann A, Richter J and Muhr G: Corrective soft tissue interventions for equinovarus deformity. Foot deformities after tibial compartment syndrome. Unfallchirurg, 100: 371-374, 1997. 6. DeLee JC and Stiehl JB: Open tibia fracture with compartment syndrome. Clin Orthop Relat Res, 160: 175 184, 1981. 7. Duchenne GB: Physiologie des mouvements. Baillaire, Paris, 1867. 8. Hahn SB, Park HJ, Park HW, Kang HJ and Cho JH: Treatment of severe equines deformity associated with extensive scarring of the leg, Clin Orthop, 393: 250-257, 2001. 9. Horne G: Pes cavovarus following ankle fracture. A case report. Clin Orthop Relat Res, 184: 249-250, 1984. 10. Ibrahim K: Pes cavus. In: Evarts CM ed. Surgery of the Musculoskeletal System. New York, Churchill Livingstone: 4015-4034, 1990. 11. Karlström G, Lönnerholm T and Olerud S: Cavus deformity of the foot after fracture of the tibial shaft. J Bone Joint Surg Am, 57: 893-900, 1975. 12. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS and Sanders M: Clinical rating systems for the ankle- hindfoot, midfoot, hallux and lesser toes. Foot Ankle Int, 15: 349 353, 1994. 13. Lee HS, Kim JS, Park SS, Lee DH, Park JM and Wapner KL: Treatment of checkrein deformity of the hallux. J Bone Joint Surg Br, 90: 1055-1058, 2008. 14. Leitschuh PH, Zimmerman JP, Uhorchak JM, Arciero RA and Bowser L: Hallux flexion deformity secondary to entrapment of the flexor hallucis longus tendon after fibular fracture. Foot Ankle Int, 16: 232-235, 1995. 15. Manoli A 2nd, Smith DG and Hansen ST Jr: Scarred muscle excision for the treatment of established ischemic contracture of the lower extremity. Clin Orthop Relat Res, 292: 309-314, 1993. 16. Paulos L, Coleman S and Samuelson K: Pes cavovarus: Review of a surgical approach using selective soft-tissue procedures. J Bone Joint Surg, 62-A: 942 953, 1980. 17. Przybyszewski J and Rozwadowska-Wróblińska A: Foot deformity as a late consequence of tibial shaft fracture. Chir Narzadow Ruchu Ortop Pol, 60: 47-49, 1995. 18. Rosenberg GA and Sferra JJ: Checkrein deformity: an unusual complication associated with a closed Salter-Harris Type II ankle fracture: a case report. Foot Ankle Int, 20: 591-594, 1999. 19. 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, 290: 87 95, 1993. 20. Sanhudo JA and Lompa PA: Checkrein deformity: flexor hallucis tethering: two case reports. Foot Ankle Int, 23: 799-800, 2002. 21. Schnepp KH: Hammer toe and claw foot. Am J Surg, 36: 351-359, 1933. 22. Schwend R and Drennan JC: Cavus foot deformity in children. J Am Acad Orthop Surg, 11: 201 211, 2003. 23. Sraj SA, Saghieh S, Abdulmassih S and Abdelnoor J: Medium to long-term follow-up following correction of pes cavus deformity. J Foot Ankle Surg, 47: 527-532, 2008. - 123 -