대한족부족관절학회지 : 제 13 권제 1 호 2009 J Korean Foot Ankle Soc. Vol. 13. No. 1. pp.85-90, 2009 종골의관절내골절후발생한불유합의수술적치료 부산의료원정형외과학교실 Operative Treatment of Nonunion after Intra-articular Calcaneal Fracture Il-Soo Eun, M.D., Chul-Young Jung, M.D., Jin-Wan Kim, M.D., Young-Chul Ko, M.D., Jung-Wook Huh, M.D. Department of Orthopedic Surgery, Busan Medical Center, Busan, Korea =Abstract= Purpose: Nonunion of intra-articular fractures of calcaneus is rarely reported complication. We present our experiences with 4 patients (5 cases) treated operatively for nonunion after intra-articular fracture of calcaneus. Materials and Methods: 4 patients (5 cases) with nonunion of intra-articular fracture of calcaneus after operative treatment were followed for 4 years (from 2002 to 2006). For assessment, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and Visual Analogue Scale (VAS) were assessed for clinical outcome and the union of fracture site, the talocalcaneal height and the angle of talar declination were determined for radiologic outcome. Results: The mean talocalcaneal height was 6.94 cm (range, 5.9 7.6 cm) preoperatively and 7.34 cm (range, 6.0 8.3 cm) at last follow-up. The mean angle of talar declination was 5.68 degrees (range, 4.6 8 degrees) preoperatively and 13.1 degrees (range, 5.7 21 degrees) at last follow-up. The mean preoperative AOFAS score and VAS were 20.4 (range, 14 36) and 4 (range, 3 6), respectively. At last follow-up, these scores improved to a mean of 59.6 (range, 54 68) and 3 (range, 2 4), respectively. Unions of previous nonunion site of intra-articular fracture of calcaneus were achieved in all 4 patients (5 cases). Conclusion: The reconstructive procedure for nonunion of intra-articular fracture of calcaneus showed good results in terms of bone union, radiologic results and functional improvement than preoperative state. Because the plantar pain for the inferior angular formation in nonunion site may happen, we will pay attention to reduction of fragment. Key Words: Calcaneus, Intra-articular fracture, Nonunion, Operative treatment 서 론 종골골절은전체골절의약 2% 를차지하며, 족부에발생하는골절중 65% 를차지하는빈번한골절로그중약 3/4 이 Address for correspondence Chul-Young Jung, M.D. Department of Orthopaedic Surgery, Busan Medical center, 1330 Geoje 2-dong, Yeonje-gu, Busan, 611-706, Korea Tel: +82-51-607-2862 Fax: +82-51-607-3001 E-mail: gizer00@hanmail.net 종골의관절내골절이다 6,16). 종골의관절내골절은거골하관절및종입방관절의외상성관절염, 종골의높이감소로발생하는경골거골경부간충돌, 경골또는비골신경의손상등의많은후기합병증이발생하는것으로알려져있으나불유합은매우드문것으로보고되고있으며, 그중에서종골의관절내골절후발생하는불유합은더욱드문것으로알려져있다 11). 이에저자들은종골의관절내골절후불유합이발생한 4명 (5예 ) 에대한수술적치료경험을문헌고찰과함께보고하는바이다. - 85 -
대상및방법 2002 년부터 2006 년까지종골의관절내골절로관혈적정복술및금속내고정술을시행한환자중불유합이발생한 4명 (5예 ) 를대상으로하였으며이중 1명은양측이었다. 환자 4명중남자는 3명, 여자는 1명이었고, 평균연령은 48.25 세 ( 범위, 30 65 세 ) 였으며평균추적관찰기간은 3.2년 ( 범위, 1 5년 ) 이었다. 종골골절수상기전은추락 3예, 교통사고 1예이었고, 흡연자는 3명이었다. 종골의관절내골절에서 2예는 Gustilo grade I의개방성골절 8) 이며 3예는폐쇄성골절이었고, Sanders 분류상 17) 1예는 Sanders Ⅳ형, 나머지 4예는 Sanders Ⅲ형이었다. 종골의관절내골절에대한치료는모두관혈적정복술및금속고정술을시행하였고, 술후비체중부하상태로보낸기간은평균 10주 ( 범위, 6 12 주 ) 였다. 술후불유합의진단까지걸린기간은평균 7.2 개월 ( 범위, 6 12 개월 ) 이었고, 모든예에서거골하관절염이확인되었다 (Table 1). 수술방법은환자를측와위로한상태에서압박성지혈대를한후피부를절개하였는데, 본연구에서는 5예모두 에서이전금속내고정물의제거와관절유합술을함께하기위해이전수술절개반흔을따라종골외측에서 L자형태로절개하였고, 필요시절개를근위부로연장하였다. 비복신경과비골건을확인하고보호하면서종골과거골하관절의외측에접근하여기존금속고정물을제거하고, 불유합후상방전위된후방골편의원활한교정을위해아킬레스건신연술을시행하였다. 불유합부위를벌려서종골골절부위의불유합여부를확인한후, 섬유조직과무혈성골조직을점상출혈이나타날때까지철저히제거하되, 불유합경계면의경화가심할경우드릴로다발성천공을시행하였다. 그리고상방전위된후방골편을최대한아래로내려교정한후파쇄동종해면골이식술을시행하고종골불유합부위를금속판또는유관나사를이용하여고정하였다. 거골하관절염에대해서 3예는거골하신연골편관절유합술을시행하였고, 2예의경우후방골편의정복이어렵고거골하관절을신연할경우불유합부위의골편간격이더증가하는소견이관찰되어 in situ 거골하관절유합술을시행하였다. 거골하신연골편관절유합술시추궁확장기를거골하관절에넣고벌려서거골경사각이교정되도록하였다. 거골 Table 1. Demographics of the Patients Patient Sex Age Sanders grade Closed/Open Smoking Initial ORIF* Non-weight bearing Time to nonunion method (weeks) diagnosis (months) 1 M 30 3 Closed Yes H-plate 8 6 2 M 65 3 Closed Yes Y-plate 6 6 3 M 48 3 Right-Open Yes H-plate 12 6 4 Left-Open H-plate 12 6 4 F 50 3 Closed No H-plate 12 12 *Open reduction and internal fixation. A B Fi g ur e 1. (A) Lat eral radi ograph of a 65-year-old man wi t h calcaneal int ra-articular fracture shows nonunion of the calcaneus, decrease in the talar declination angle and talocalcaneal height. (B) Postoperat ive lat eral radiograph af t er subt alar dist ract ion bone block arthrodesis with cannulated screw shows of a improvement of heel height, talar declination angle. - 86 -
종골의관절내골절후발생한불유합의수술적치료 A B Fi g ur e 2. (A) Lateral radiograph of a 48-year-old man with nonunion of intra-articular fracture of calcaneus shows nonunion of the calcaneus. (B) Postoperative lateral radiograph after subtalar distraction bone block arthrodesis with cannulated screw shows a improvement of heel hei ght, talar decli nation angle. Table 2. Data of Patients Patient Treatment 1 TAL*, ORIF with plate, In situ 2 TAL, ORIF with CS, SDBBA 3 Right TAL, ORIF with plate, In situ Left TAL, ORIF with CS, SDBBA 4 TAL, ORIF with plate, SDBBA Talocalcaneal Talar declination height(cm) angle(degree) AOFAS score VAS score Complication Preop Postop FU** Last Preop Postop Last FU Preop Last FU Preop Last FU 1 5.9 6.1 6 4.6 6.8 5.7 20 60 5 4 Plantar pain Follow-up (years) 1 7.9 8.5 8.2 4.8 16.3 6.8 22 58 4 3-5 6.5 6.8 6.5 5 14 12 14 54 6 4 Infection, WD, Plantar pain 5 6.9 7.9 7.7 8 24 20 22 58 3 2 Infection, WD 4 7.6 8.5 8.3 6 24 21 26 68 3 2 - *TAL, Tendo-Achilles lengthening; n situ, In situ subtalar arthrodesis; SDBBA, Subtalar distraction bone block arthrodesis; WD, Wound dehiscence; AOFAS score, American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score; VAS score, Visual Analogue Scale Score; **FU, follow-up. 하연골을제거하여골이드러나게한후사이공간을계측하였다. 장골에서쐐기모양의삼방피질골편을채취하여거골하관절공간에골편을삽입한후종골후방에서거골까지유관나사를이용하여고정하였고 5) (Fig. 1, 2), in situ 거골하관절유합술의경우거골하관절연골을제거하고거골하관절과불유합부위에파쇄동종해면골을이식하였다 (Table 2). 술후초기 6주간단하지석고붕대로고정하여체중부하는금하였고다음 6주간단하지석고붕대고정하 부분체중부하를시행하였다. 술후 12주부터석고붕대를제거하고전체중부하와족관절운동을시행하였다. 결과분석은방사선학적으로골유합유무및거-종골높이, 거골경사각등을통해평가하였고, 미국정형외과족부족관절학회평가표및시각상사척도동통점수 (visual analog scale, VAS) 를이용하여임상적인평가를시행하였다 9). - 87 -
결 과 고 찰 1. 방사선학적결과 5예모두에서종골의관절내골절후발생한불유합에대해술후골유합과거골하관절유합을얻을수있었다. 거- 종골높이는술전평균 6.94 cm( 범위, 5.9 7.6 cm) 에서술후평균 7.56 cm( 범위, 6.1 8.5 cm), 최종추시시평균 7.34 cm( 범위, 6.0 8.3 cm) 으로측정되었다 (Table 2). 거골경사각은술전평균 5.64 도 ( 범위, 3.6 8 도 ) 에서술후평균 16.96 도 ( 범위, 6.8 24 도 ) 로개선되었으며, 최종추시시 13.82 도 ( 범위, 5.7 22 도 ) 로측정되었다 (Table 2). 2. 임상적결과술전미국정형외과족부족관절학회평가점수는평균 20.4 점 ( 범위, 14~26 점 ) 에서최종추시상 59.6 점 ( 범위, 54~68 점 ) 으로향상된결과를보였으며, VAS 는술전평균 4( 범위, 2~6) 에서마지막추시상 3( 범위, 2 4) 으로향상되었다 (Table 2). 술후 8주까지지속적인창상관찰을시행한결과로 2예에서감염및창상벌어짐이발생하였으나반복적인세척술과항생제투여로치료하였다. 후방골편의정복이어려워 in situ 거골하관절유합술을시행한 2예의경우거- 종골높이소실로인한전방경- 거골의충돌로인한발목통증이남아있는상태였다. 그리고아킬레스건신연술을시행하였음에도불구하고상방전위된후방골편이교정되지않아불유합부위의하방각형성으로인한족저부통증이 2예에서발생하였고지속적인통증으로골극제거술을시행하였다 (Fig. 3). 종골골절은전체골절의약 2% 를차지하며그중약 3/4 이종골의관절내골절이다 2). 종골골절후발생할수있는후기합병증으로는거골하관절및종입방관절의외상성관절염, 종골의높이감소로발생하는경골-거골경부간충돌, 경골또는비골신경의손상, 뒤꿈치패드동통, 반사성교감신성이영양증, 외반변형, 만성종골골수염등이있으나 7) 불유합은매우드문합병증으로보고되고있으며, 그중에서종골의관절내골절후발생하는불유합은더욱드문것으로알려져있다. Zwipp 등 19) 은관혈적정복술및금속고정술을시행한종골의관절내골절 157 예에서약 1.3% 로낮은빈도의불유합을보고하였다. Reddy 등 14) 은 2007 년까지종골골절후발생한불유합을다룬문헌은극히드물다고보고하였으며, 최근 Molloy 등 11) 이종골관절내골절의불유합 14예에대해보고하였다. 종골의관절내골절에서불유합이드문이유는관혈적정복술시시행하는외측도달법의경우단지비골동맥의가지의손상이발생할수있어술후혈액공급의차단가능성이낮으며종골의체부는주로해면골로이루어져있기때문이다. 11,14) 그럼에도불구하고종골골절의불유합이발생하게되는가장중요한위험인자는관혈적정복의부정확성과불충분한내고정이라고알려져있으며 14), 본증례의 5예모두에서종골의관절내골절시관혈적정복술및내고정이불충분하여전반적인골정렬이점진적으로악화되는소견을관찰할수있었다. 또한당뇨, 개방성골절, 흡연등도종골골절의관혈적정복술및내고정술후불유합의위험인자로알려져있다 4,11). 본증례에서는당뇨환자는없었으나 2예에서 Gustilo I형의개방성골절이었으며 4명중 3명이흡연자였다. Molloy 등 11) 은종골의관절내골절후발생한불유합 14 A B C Fi g ur e 3. (A) Lateral radiograph of a 48-year-old man with nonunion of intra-articular fracture of calcaneus showed a decrease in the talar declination angle, talocalcaneal height and displacement of posterior fragment. (B) After open reduction and internal fixation with in situ subtalar art hrodesi s was perf ormed, lat eral radiograph showed a evidence of union of calcaneus and subtalar joint. But the severe plantar pain occurred for inferior angular formation in fracture site. (C) Lateral radiograph after bony spur excision showed smoothing inferior angle in fracture site. - 88 -
종골의관절내골절후발생한불유합의수술적치료 예에대한수술적치료결과를발표하였는데, 이중 10예는거골하관절유합술을시행하였고 4예는삼중관절유합술을시행하여임상적결과와방사선학적결과를보고하였다. 방사선학적인평가로 Molloy 등 11) 은술전평균거골경사각은 8.3도 ( 범위, -2.0 2.5 도 ) 였고, 최종추시시평균 21 도 ( 범위, 10 27 도 ) 로보고하였고, 임상적결과로술후미국정형외과족부족관절학회평가점수를평균 69 점 ( 범위, 40 88 점 ) 였으며시각상사척도동통점수는평균 3( 범위, 1 8) 으로보고하였다. 본연구의경우거골경사각은술전평균 5.64 도 ( 범위, 3.6 8 도 ) 에서술후평균 16.96 도 ( 범위, 6.8 24도 ) 로개선되었으며, 최종추시시 13.82 도 ( 범위, 5.7 22 도 ) 로측정되었고, 술전미국정형외과족부족관절학회평가점수는평균 20.4 점 ( 범위, 14~26 점 ) 에서최종추시상 59.6 점 ( 범위, 54~68 점 ) 으로향상된결과를보였으며, 시각상사척도동통점수는술전평균 4( 범위, 2~6) 에서최종추시시 3( 범위, 2 4) 으로향상되었으나 Molloy 등 11) 이보고한결과와차이를보였다. 본연구의경우종골의관절내골절에대한일차관혈적정복술및금속내고정술후부정정렬이교정되지않은증례가다수포함된것이원인일것으로생각되며, 임상적결과의경우또한부정정렬에교정되지않았고불유합에대한수술시후방골편의정복이불충분하여발생한불유합부위의하방각형성으로인하여 2예에서족저통증이발생한것이원인으로작용한것으로사료된다. 종골의관절내골절에발생한불유합에대해골이식을이용한관혈적정복술및금속내고정술, 그리고거골하관절유합술시행후대부분골유합을얻었다고보고하고있다. Molloy 등 11) 은 15명의환자중 14명의환자에서골유합을얻을수있었다고하였으며 1명에서골수염에의한불유합이있었다고보고하였다. 본연구에서는 5예에서모두골유합을얻을수있었다. 종골의관절내골절후불유합이동반된거골하관절염이발생한경우거골하관절유합술을시행한본연구에서술전에비하여향상된방사선학적, 임상적결과를얻을수있었으나종골골절후불유합없이발생한거골하관절염으로거골하신연골편관절유합술을시행한경우와비교하여나은결과를얻지못하였다. Trnka 등 18) 은종골골절후발생한거골하관절염으로거골하신연골편관절유합술을시행한 41예의술후결과를보고하였는데방사선학적평가로거-종골높이는평균 6.87 cm에서술후평균 7.45 cm로증가하였으며최종높이는평균 7.35 cm로보고하였고, 거골경사각은술전평균 6.5 도에서술후평균 24.8 도로증가한소견을보고하였다. 임상적평가로미국정형외 과족부족관절학회평가점수를이용하였는데술전 21.1 점에서술후 68.9 점으로향상된결과를보고하였다. 본연구의경우종골의관절내골절후발생한불유합에대해아킬레스건신연술을시행하였음에도불구하고후방골편의정확한정복이어렵고, in situ 거골하관절유합술을시행한 2예에서거-종골높이소실을교정하지못하였기때문에전방경-거골의충돌로인한발목통증이발생함에따라 Trnka 등 18) 에비해임상적평가가낮게나온것으로사료된다. 또한후방골편의정복이불충분하여발생한불유합부위의하방각형성으로인하여족저통증이발생한것도임상적결과에영향을미쳤을것으로생각된다. 본연구의경우술전에비하여환자의증상완화와보행능력등의생활력향상에있어서만족할만한결과를보였지만연부조직의문제및술기상의어려움등으로인하여문제점이발생할수있다. 5예중 2예 (40%) 에서창상벌어짐및연부조직감염이발생하여세척술및항생제투여로치료하였으며, 아킬레스건신연술을시행하였음에도불구하고상방전위된후방골편이교정되지않아불유합부위의하방각형성으로인한족저부통증이 2예에서발생하여골극제거술을통하여치료하였고술후족저부통증이경감하였다. 종골의관절내골절후발생한불유합의수술시아킬레스건신연술을시행하여후방골편을가능한해부학적으로정복하여불유합부위의하방각형성을교정하는데주의를기울여야할것으로사료된다. Molley 등 11) 은술후환자의 60% 에서재수술을경험하였는데특히환자의 20% 에서창상벌어짐이발생하였다고보고하였고, 이는술기의복잡함및광범위한골결손, 그리고불량한골질에의해발생한다고하였다. 결론종골의관절내골절후드물게발생할수있는합병증인불유합은골이식을이용한관혈적정복술및금속내고정술, 그리고거골하관절유합술을시행하여치료를하는경우술후높은골유합률을얻을수있고술전에비해나은방사선학적, 임상적결과를얻을수있으나후방골편의완전한교정이어려운경우불유합부위의하방각형성에따른족저통증등이발생할수있어주의를기울여야하겠다. 그러나증례수가많지않고추시기간이비교적짧아좀더장기적인관찰및연구가필요할것으로사료된다. - 89 -
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