202 pissn : 1226-2102, eissn : 2005-8918 Symposium J Korean Orthop ssoc 2015; 50: 202-214 http://dx.doi.org/10.4055/jkoa.2015.50.3.202 www.jkoa.org Proximal Femur Fractures 대퇴전자하부골절 : 골수내정고정술의술기를중심으로 김형진 이태진 오종건 고려대학교의과대학고려대학교구로병원정형외과학교실 Subtrochanteric Fracture: Emphasis on Surgical Techniques in Nailing Hyung Jin Kim, M.D., Tae Jin Lee, M.D., and Jong Keon Oh, M.D., Ph.D. Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea Intramedullary nailing is considered the most biomechanically advantageous therapeutic modality in the treatment of subtrochanteric femoral fractures. Many technical pitfalls and difficulties in nailing are well known. Reduction of the proximal fragment in a flexed, abducted, and externally rotated position should be performed before nailing of subtrochanteric fractures in order to avoid malalignment and nonunion. In this review, various reduction techniques to control the proximal fragment which are useful in nailing will be discussed. Key words: subtrochanteric fracture, intramedullary nailing, cerclage wiring, percutaneous reduction, entry point 해부학및생역학 대퇴골전자하부는소전자의끝단으로부터대략 5 cm 하방까지 를지칭한다. 해부학적특성으로인해외측피질골에는장력, 내 측피질골에는압박력이가해지며골격계에서가장큰부하가가 해지기때문에골절시내고정후부전이빈번하게발생하게된 다 (Fig. 1). 1-4) 골절분류 1. 환자의연령에따른골절양상 전자하부는연령에따라골절의양상이크게둘로나누어지는데 하나는젊은연령에서발생하는고에너지손상에의한전위가 심한분쇄골절이며, 다른하나는골감소증을가진고령의환자 군에서적은외상에의한단순한형태의골절로이중대부분은 나선형 (spiral fracture) 골절양상을보인다. Received June 16, 2015 ccepted June 16, 2015 Correspondence to: Jong Keon Oh, M.D., Ph.D. Department of Orthopaedic Surgery, Korea University Guro Hospital, 148 Gurodongro, Guro-gu, Seoul 152-703, Korea TEL: +82-2-2626-3088 FX: +82-2-2626-1164 E-mail: jkoh@korea.ac.kr 최근고령환자들중골다공증치료를위해장기간 bisphosphonate 복용을하는이유로 stress fracture로인한단순골절의빈도가늘고있어이에대한주의가필요하다. 4-6) 이런 insufficiency fracture는횡혹은약간의사선형골절형태를띠며, 작은분쇄골절을동반하고, 외측피질골이두꺼워지는특징적인방사선특징을보인다. 또한 bisphosphonate와연관된경우양측성으로발생하는경우가많으며이는방사선사진에서반대측소전자의아래외측피질골에 ellipsoid thickening으로나타나므로주의깊게살피는것이중요하다 (Fig. 2). 2. 골절분류전자하부골절에대한분류법은지금까지 16개정도가제시되어있었으나 Russel-Taylor 분류법 (1984) (Fig. 3) 과 Seinsheimer 분류법 (1978) (Fig. 4) 이가장많이이용되어왔으며근래에는타분류법보다서브그룹으로세분화되어분류가쉬워진 O-OT분류법 (Fig. 5) 이점점더많이사용되는추세이다. 5-11) 하지만최근에기존분류법에대하여관찰자마다오차가생기는경우가많아이에대한새로운분류법이필요하다는의견도제시되고있다. 하지만중요한것은전자하부골절의특징적인골절전위양상과기전을이해하는것이다. 일반적으로골절의전위를기술할 The Journal of the Korean Orthopaedic ssociation Volume 50 Number 3 2015 Copyright 2015 by The Korean Orthopaedic ssociation This is an Open ccess article distributed under the terms of the Creative Commons ttribution 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.
203 Subtrochanteric Fracture 때는근위골편을기준으로원위골편의전위방향을이용한다. 하지만전자하부골절에서는근위골편인대퇴골두-경부골편의전위를기술하게되는데이는변형 ( 전위 ) 을일으키는주요인이근위골편에부착된근육의견인력이기때문이다 (Fig. 6). 12) 또한근위골편의특징적전위를이해하고이를정복하는것이수술적치료를성공적으로하는데매우중요하므로이를잘숙지해야한다. 특징적으로근위골편은소전자에부착하는장요근건 (iliopsoas tendon) 의견인에의해굴곡 (flexion), 고관절의외회전근 (short external rotators) 에의해외회전 (external rotation) 그리고중 둔근 (gluteus medius) 에외전 (abduction) 된다 (Fig. 7). 수술적치료 1. 적응증골절부의강력한변형력을감안하여적극적인수술적치료가권장되며골수정을포함한골수내고정방법과활강압박고나사 (dynamic hip screw), 역동적과상나사 (dynamic condylar screw), 대퇴근위부잠김금속판 (proximal femur locking plate), 이분굴곡날금속판 (angled blade plate) 등의골수외고정방법으로나눌수있 Stress Concentration on SubTorc area Tensile force Compressive force Figure 1. Koch s diagram showing the magnitude of the compressive stresses medially and the tensile stresses laterally. Figure 2. () Unique configuration of alendronate-associated subtrochanteric fractures: transverse or slight obliquity; minimal comminution; and lateral cortical thickening with splaying of cortices suggesting a pre-existing structural abnormality. () Ellipsoid thickening in the lateral cortex of the subtrochanteric femur (arrow) preceded fracture in patients on long-term alendronate. I- I- II- II- Figure 3. Russell-Taylor classification of subtrochanteric fractures. Note the emphasis on lesser trochanteric integrity and piriformis fossa extension.
204 Hyung Jin Kim, et al. Grade 1 ny fracture with less than 2 mm displacement Grade 2a Two part transverse Grade 2b Two part spiral with lesser trochanter in proximal fragment Grade 2c Two part spiral with lesser trochanter in distal fragment Grade 3a Three part spiral. Third fragment is lesser trochanter Grade 3b Three part. Third fragment is a butterfly fragment Grade 4 Four or more fragments Grade 5 ny fracture with extension into greater trochanter Figure 4. Seinsheimer classification of subtrochanteric fractures. Note the emphasis on fracture obliquity, comminution, and proximal extension. 다. 골수내정은생역학적으로골수외고정방식에비해 bending moment의레버암이짧으며강성과경도가더크고, 대퇴골전장에걸쳐있어효과적으로힘이분산되며, 변형력, 특히내전력에대하여강하게저항할수있는장점이있어일차적인치료방법으로선택되어왔다. 13) 최근발표된 meta-analysis에도골수정이정복소실, 고정실패, 재수술률이골수외고정보다낮은것으로보고하였다 (Fig 8). 가골형성을촉진하고골편의 vascularity를보존가능한 biological fixation으로치료원칙이바뀌면서최소침습금속판고정술의좋은결과가일부보고되었으나아직까지금속정이주된치료방법으로사용되고있어골수내정고정방법을주로논하고자한다. 2. 골수내정고정술의문제점골수내고정방법은수술시간이짧고, 출혈량이적으며, 불유합비율이골수외고정방법보다낮은장점이있다. 또한도수정복으로골절주위의골막및근육에추가손상을최소화하여골유합가능성을높일수있고생역학적으로 bending lever arm이짧아금 속판고정술에비해금속파손 (metal failure) 가능성이적은것을들수있다. 하지만짧은근위골편의전위로인해도수정복을시행하기가기술적으로어려워부정유합의빈도가높은것이문제로지적되어왔다 (Fig. 9). 7-10) 또한급성호흡곤란증후군 (adult respiratory distress syndrome) 이나지방색전, 폐색전등전신적인문제에서부터외전근위축을일으키는상둔신경 (superior gluteal nerve) 손상, 이소성골형성등의국소적합병증도보고되고있다. 14) 이로인해집도의들이전자하골절에서골절부위를개방하여관혈적정복후쐐기골편들을 Cerclage wiring으로고정한후골수내정을고정하는방법도적지않게사용하고있다. 하지만 wiring 과정에서쐐기골편의골막을손상하여 (stripping) 불유합을초래하는문제점들이지적되어왔다 (Fig. 10). 또한골막의혈류공급이대퇴골의종방향으로이루어지기때문에 wiring을하게되면이를방해하여 biologic fixation을저해한다는원칙이주를이루고있다. 반면다른장골과달리대퇴골은횡방향의환상형태로여러개의근골막혈관으로부터혈류공급이이루어진다
205 Subtrochanteric Fracture 1. Simple oblique 2. Simple transverse 3. Simple fragmentary 1. Wedge fracture Spiral wedge 2. Wedge fracture ending wedge 3. Wedge fracture Fragmented wedge 313 Trochanteric fracture intertrochanteric 32 Wedge fracture 1. Two part spiral 2. Two part oblique 3. Two part transverse 32 Simple fracture 1. Spiral 2. Semental 3. Irregular 32C Complex fracture Figure 5. Orthopedic Trauma ssociation classification of subtrochanteric fractures. 는동물연구가있었으며한두개의 wiring은골막의혈류공급에큰지장을초래하지않기때문에골절편의골막을잘보존하여 wiring을이용한정복후골수내정을삽입하게되면오히려안정적인술기가될수있다는주장도제기되고있다 (Fig. 11). 15) 따라서 wiring 후발생하는불유합의원인은 wiring 자체의문제라기보다는수술중쐐기골편에부착된골막및근육을박리하여골유합에필요한혈액공급을파괴하는것이주된요인으로생각한다. 따라서 wiring을이용한골편정복후골수내정고정술을시행할때는 wire passer를이용하여쐐기골편의골막박리를강선이지나가는부위로최소화하여시행하는것이중요하다. Figure 6. The illustration depicts the subtrochanteric region of the femur (between double arrows), most commonly demarcated by the lesser trochanter as its superior margin and 5-cm distal as its inferior margin. m., muscle. 3. 골수내정고정술의수술술기 1) 기본원칙골수내정고정술의기술적어려움을해결하기위해다양한경피적혹은최소침습적정복방법 (percutaneous or minimally invasive reduction technique) 들이소개되어있어이를소개하고자한다. 어
206 Hyung Jin Kim, et al. Figure 7. The typical deforming muscular forces cause the proximal fragment to be flexed by the iliopsoas, externally rotated by the short rotators, and abducted by the abductors. The femoral shaft is shortened and adducted by the adductors and quadriceps. C D Figure 10. () Initial X-ray shows a segmental fracture (O-OT 32) with subtrochanteric involvement. () Postoperative X-ray after open wiring and nailing. (C, D) X-ray taken 3 months after operation shows nonunion (arrow). Figure 8. Intramedullary nail has a shorter bending lever arm than plate. Figure 9. Malreduction after unsuccessful nailing of a subtrochanteric fracture. Flexion, abduction, and external rotation of the proximal fragment was not reduced at all. Figure 11. () Satisfactory alignment was achieved postoperatively. () Follow-up radiograph after 7 months showed solid union of the fracture.
207 Subtrochanteric Fracture 10 15 Figure 12. Supine position on a fracture table with the torso tilted toward the opposite side. Figure 13. Intraoperative images show use of a Steinmann pin as a joystick to control the external rotation of the proximal fragment. 떠한방법을사용하든지지켜야할두가지원칙은 1) 근위골편의전위즉굴곡, 외전, 외회전변형을교정하여골절부위를정복한후유도핀 (guide pin) 을삽입하기시작해야한다는것과 2) 근위골편을정복할때골절부위의골막손상을최소화해야한다는것이다. 2) 환자의자세골절대 (fracture table) 에서앙와위 (supine position) 로시술하는것이흔히사용되는데이때는상체를반대쪽으로충분히기울여서유도핀을삽입할때골반이방해하는문제를최소화해야한다 (Fig. 12). 측와위에서골수내정을삽입할수도있는데굴곡된근위골편에맞춰서간부골편을정복한상태로골수내정을삽입하므로근위골편의외회전및외전변형만교정하면비교적용이하게정복을얻을수있으며, 환자가고도비만일때도사용할수있는장점이있다. 하지만조수가정복상태를유지하기위해견인을해야하는단점이있다. 술자의선호도에따라체위를정할수있다. 3) 정복방법근위골편에대해서는매우다양한정복방법이알려져있는데골절형태와술자의경험에따라적절한방법을선택한다. (1) Joy stick technique: 근위골편에핀을고정하여이를 joy stick 으로사용하는방법이있다. Steinmann pin을흔히사용하는데강한변형력을이겨야하므로두께가적어도 3.2 mm 이상인것을사용하며골수정이들어갈길을피해서앞쪽으로치우쳐서삽입한다 (Fig. 13). Tonsil clamp를이용하여뼈를뚫지않고쉽게근위골편의변형을교정하는방법도유용하다. 10) Intramedullary joy stick technique도간부골절의골수내정고정술에흔히사용되는방법이나전자하부골절에서는근위골편의길이가짧고골수강의직경이넓어효과적이지않은경우가많으므로주의가필요하며이때 blocking pin을사용하여교정하는것도좋은방법이다 (Fig. 14). Insufficiency fracture에는골절선이소전자직하방에있어일반적인방법으로는적절한정복을얻을수없으며, 위에기술된외측면에서 joy stick을삽입하는방법으로도정복이어려울수있다. 이런경우에 calcar에 anteroposterior 방향으로 joystick을삽입
208 Hyung Jin Kim, et al. C D Figure 14. (, ) Intraoperative lateral images show that malalignment persists even after nail passed mainly due to the wire medullary canal at the proximal fragment. (C, D) The blocking pin (arrows) neutralizes the deforming force and in turn the deformity was corrected as the nail passed. C D E F Figure 15. (, ) Intraoperative anteroposterior (P) and lateral images of an insufficiency fracture. (C, D) Joystick inserted from the lateral side does not neutralize the deforming force. (E, F) The calcar joystick neutralizes the external rotation on P view but flexion force on lateral view is not ideally controlled.
209 Subtrochanteric Fracture C D Figure 16. (, ) Failed attempt of reduction using the intramedullary joystick tech nique due to a wide medullary ca nal at the proximal fragment. (C, D) restoration of alignment with a bone hook placed percutaneously through a 2 cm incision (arrow). C D Figure 17. (, ) Intraoperative traction views show a simple spiral subtrochanteric fracture. (C, D) Near anatomical reduction was achieved by minimally invasive direct reduction of the fracture.
210 Hyung Jin Kim, et al. C D Figure 18. (, ) Intraoperative traction views show a long oblique fracture involving the subtrochanteric area. (C, D) Near anatomical reduction was achieved by percutaneous direct reduction with reduction forcep and compression by forcep of the fracture. Figure 19. () Intraoperative compression view by forcep at inferior incision. () The picuture shows compression at mid line incision makes more rotational error than inferior incision. White and black arrow indicate greater and lesser trochanter rotation.
211 Subtrochanteric Fracture 하여시도한다면더좋은결과를얻을수있다 (Fig. 15). (2) 갈고리 (bone hook) 등을이용한경피적정복방법 (percutaneous reduction with bone hook, Homann retractor, all spike pusher): 근위골수강이큰경우에 joystick으로적절한정복이이루어지지않으므로갈고리등을근위골편부위에사용해정복을시도해볼수있다 (Fig. 16). (3) 정복겸자를이용한경피적직접정복 (percutaneous direct reduction with reduction forceps): 전자하부의단순골절 (simple fracture) 중에서사선골절이나나선형골절은비관혈적인방법시행시완전한해부학적정복이되거나아니면골절편사이의공간이벌어지는 all or none phenomenon 이나타나수술이힘들뿐만아니라추후지연유합, 부정유합등이발생하게된다. 4) 그러므로 3 cm 내외의작은절개를통해골절정복용겸자를골절부위에넣고골편을직접정복한후골수내정고정을시도하는것도좋은방법이다 (Fig. 17). 이때절개는추후골두에교합나사를삽입할때사용할위치에시행하게되면추가의절개없이교합나사를삽입할수있는장점이있다. 대개소전자 (lesser trochanter) 부위에 3 cm 길이의절개를하면충분하다. 대전자까지골절선이길게있는경우에도견인후정복겸자를사용하여경피적직접정복을시행할수있다 (Fig. 18). 추후골두에교합나사를삽입할때는대퇴염전 (femoral anteversion) 을고려하여 targeting device를바닥 (floor) 쪽으로눌러야하므로축면의정중앙보다는다소후면 (floor 방향 ) 에절개를하는것이좋다 (Fig. 19). (4) Entry portal과 nail의불일치 (mismatch) 에의한내반부정선열발생의이해 : 전자하부골절은근위골편의크기가작으므로근위교합나사 (interlocking screw) 를대퇴골두에삽입하는골두-골수강금속정 (cephalomedullary nail) 이주로사용된다. 초기골두-골수강금속정들은 entry를이상와 (piriformis fossa) 로사용하며버팀테응력 (hoop stress) 을최소화하며 single curvature의형태를가진일직선인소위 straight shot 구조였다. 이금속정사용시부적절한 entry point는부정교합및골절부위의분쇄정도를증가시킬수있으며, 너무앞쪽으로치우친 entry point 는골절부위의증가된버팀테응력때문에 entry site 로의대퇴골의 bursting fracture를초래하게된다. 13) Grechenig 등 16) 이시행한 100구의사체연구에서 1/3의경우대전자의모양이 piriformis fossa를덮고있는형태로나타나는것으로보고하였으며이럴경우 entry point가내측으로이동하게되는등적절한 entry point를찾기가쉽지않다 (Fig. 20). 근래에사용되는 cephalomedullary nail들은대전자에서시작하는소위전자골수정 (trochanteric nail) 들이많이사용되고있다. 대전자골수정의근위부는내반변형을막기위해서 double valgus curvature (orbending) 의형태이며, 삽입부의중둔근을포함한연부조직손상을줄이기위하여체부의크기를감소시켰다. C D Figure 20. (, ) The entry point could be reached without problems in two-thirds of the specimens. (C, D) The entry point is often covered by parts of the greater trochanteric one-third of the specimens. 하지만전자골수정의시작점이너무외측으로치우치게되면 근위골절편의내반변형이발생하게되므로결국골두 - 골수강 금속정과마찬가지로완벽한삽입위치를찾는것이매우중요하 다. 17) 골절이 reaming 하는동안해부학적으로정복된상태라도골 수정의모양이대전자의옵셋의및경간각차이등환자의해부 학적구조와일치할수없기때문에골수정을완전히삽입한후 에부정유합이발생할수있음을기억해야만하고한가지시작 점이모든환자에게적용될수있다는생각은버려야한다. 18) 전자골수정으로전자하골절을고정할때는 entry 를 greater tip
212 Hyung Jin Kim, et al. Proximal bending 5 18 C E D Figure 21. () n illustration shows 5 degrees of proximal bending in a cephalomedullary nail. () Intraoperative anteroposterior image shows that the angle between the entry portal and the axis of the medullary canal is much larger (18 o ) than proximal bending (5 o ) of a nail used. (C) s the proximal part of the nail passes the nail pushes the head fragment into varus, resulting in primary reduction loss. (D) Entry was corrected using a cannulated cutter. Now the angle between the entry portal and the axis of the proximal femur has decreased. (E) Compared to C, varus, tilt and the resulting gap on the lateral cortex was reduced. 에서약간내측 (just medial) 에서시작하라고권하는데이때전자하골절에서허용되는약간의외반변형도발생할수있으나이는 entry portal과 nail bending 사이의불일치 (mismatch) 로인한내반변형을막을수있는조치이다 (Fig. 21-21C). 엄밀하게이야기하면 Entry point 자체보다중요한것은대퇴골간부축과 entry portal이이루는각이사용하고자하는전자골수정의근위부 bending angle과같거나조금적게 entry portal을만드는것이중요하다 (Fig. 21D, 21E). Conventional nail 중에도 cephalomedullary nail로고정할수있는것들이있으므로 ( 예 : reconstruction type nail, Russel-Talyor) 이를사용할때는 entry를이상와에서시작하여대퇴축에평행하게 entry portal을만들어야한다. 요약 대퇴골전자하부골절의수술적치료는골수내정고정술이주로사용되는데굴곡, 외전, 외회전변형된근위골편을정복하지못하고골수정을삽입하여부정유합이빈번하게발생하며이러한기술적어려움을극복하고자관혈적정복을시도하는경우에는불유합및감염의빈도가높아경피적으로근위골편을정복한후골수정으로고정하는것이중요하다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Kim JW, Oh CW, yun YS, et al. biomechanical analysis of locking plate fixation with minimally invasive plate osteosynthesis in a subtrochanteric fracture model. J Trauma. 2011;70:E19-23. 2. Tencer F, Johnson KD, Johnston DW, Gill K. biomechanical comparison of various methods of stabilization of subtrochanteric fractures of the femur. J Orthop Res. 1984;2:297-305. 3. Wiss D, rien WW. Subtrochanteric fractures of the femur. Results of treatment by interlocking nailing. Clin Orthop Relat Res. 1992;283:231-6. 4. Yoon YC, Jha, Oh CW, et al. The pointed clamp reduction technique for spiral subtrochanteric fractures: a technical note. Injury. 2014;45:1000-5. 5. brahamsen, Eiken P, Eastell R. Subtrochanteric and diaphyseal femur fractures in patients treated with alendronate: a register-based national cohort study. J one Miner Res. 2009;24:1095-102. 6. lack DM, Kelly MP, Genant HK, et al; Fracture Intervention Trial Steering Committee; HORIZON Pivotal Fracture Trial Steering Committee. isphosphonates and fractures of the subtrochanteric or diaphyseal femur. N Engl J Med.
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214 pissn : 1226-2102, eissn : 2005-8918 Symposium J Korean Orthop ssoc Hyung 2015; 50: Jin 202-214 Kim, et al. http://dx.doi.org/10.4055/jkoa.2015.50.3.202 www.jkoa.org 대퇴골근위부골절 대퇴전자하부골절 : 골수내정고정술의술기를중심으로 김형진 이태진 오종건 고려대학교의과대학고려대학교구로병원정형외과학교실 대퇴골전자하부골절의수술적치료는골수내정고정술이주로사용되는데굴곡, 외전, 외회전변형된근위골편을정복하지못하 고골수정을삽입하여부정유합이빈번하게발생하며이러한기술적어려움을극복하고자관혈적정복을시도하는경우에는불유합 및감염의빈도가높아경피적으로근위골편을정복한후골수정으로고정하는것이중요하다. 색인단어 : 전자하부골절, 골수내정, 경피적정복, 골수정삽입위치, 환상강선고정술 접수일 2015 년 6 월 16 일게재확정일 2015 년 6 월 16 일책임저자오종건서울시구로구구로동로 148, 고려대학교구로병원정형외과 TEL 02-2626-3088, FX 02-2626-1164, E-mail jkoh@korea.ac.kr 대한정형외과학회지 : 제 50 권제 3 호 2015 Copyright 2015 by The Korean Orthopaedic ssociation This is an Open ccess article distributed under the terms of the Creative Commons ttribution 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.