ORIGINAL ARTICLE 대한족부족관절학회지제 17 권제 4 호 2013 J Korean Foot Ankle Soc. Vol. 17. No. 4. pp.288-293, 2013 한림대학교의과대학강동성심병원정형외과학교실 이정길 김갑래 이진영 이의수 이재희 Experience of Arthroscopy of Ankle Joint with Manual Traction Jeong-Gil Lee, M.D., Gab-Lae Kim, M.D., Jin-Young Lee, M.D., Eui-Soo Lee, M.D., Jae-Hee Lee, M.D. Department of Orthopedic Surgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea =Abstract= Purpose: Number of arthroscopic surgery is gradually increasing with development of its equipment and technique. Arthroscopic ankle surgery performed with the traction device has various complications and need more time for preparation. We investigated whether the complication rate increased when surgery was performed without the traction device, and compared the complication rate of arthroscopic surgery with the traction device. Materials and Methods: From January 2009 to June 2012, arthroscopic ankle surgery was performed without the traction device in four hundred eleven cases. There were two hundred sixty-one males and one hundred fifty females. The average age at operation was 35 years (range, 17-56), and the average follow up period was 28 months (range, 12-41). Postoperative symptoms and complications were checked. Results: There were difficulties performing arthroscopic surgery without the traction device in five cases with severe traumatic osteoarthritis. However, after burring and shaving, we had enough space to work on. Superficial peroneal nerve symptom was found in two cases, grooving of talus was found in 11, and saphenous vein injury was found in five. Since preparing for the traction device was unnecessary, we were able to save time with the mean duration of surgery of 50 minutes (range, 30-120). Conclusion: With only manual traction, we could explore the entire ankle joint without damage on cartilage. Yet, skilled arthroscopic technique will be necessary for arthroscopic surgery without the traction device. Key Words: Ankle Arthroscopy, Traction, Non-traction 서 론 관절경기기및술기의발달로관절경을이용한시술 Received: October 20, 2013 Revised: November 2, 2013 Accepted: November 12, 2013 Corresponding Author: Gab-Lae Kim Department of Orthopedic Surgery, Kangdong Sacred Heart Hospital, 445 Gil-dong, Kangdong-gu, Seoul, 134-701, Korea Tel: +82-2-2224-2230 Fax: +82-2-489-4391 E-mail: kiga9@hallym.or.kr 이점점늘어나고있다. 족관절의관절경술은외상후또는만성적인관절질환을갖고있는환자의중요한치료도구로쓰이고있다. 1) 족관절의안전하고편리한관절경술을위해서는관절을충분히견인하여관절간격을확보해야시술시기구로인한관절손상을최소화할수있다고알려져왔다. 족관절관절경술을위한견인은많은합병증을동반한다. 2) 특히경골과종골에핀을고정하여이용하는침습적견인은여러가지합병증의위험이있어많이사용 - 288 -
되지않으며, 중족부와발뒤꿈치에끈을감아사용하는비침습적견인은비교적안전하나특별한견인장치나추를거는준비시간이길어지는단점이있다. 이번연구에서는기존논문에서보였던견인장치를사용한후발생한합병증률과저자들이견인장치없이도수견인으로관절경술을시행하였을때의합병증률과비교하여보았다. 1. 연구대상 대상및방법 2009년도 3월부터 2012년 6월까지견인장치없이족관절병변에대한관절경술을시행하고 6개월이상추시관찰이가능하였던 411례를대상으로하였다. 전체환자중남자는 261명, 여자는 150명이었고평균나이는 35세 (17~56세) 였다. 족관절부에만성적인불안정을호소하던급성외상환자또는 Grade III의급성외상환자가 303명, 족관절부질병에의한환자는 67명, 수술후지속적인통증을호소하여관절경을시 Table 1. Demographic of Study Sample Parameter Number of patients Gender Male 261 Female 150 Age 35 (Range:17~56) Mode Acute trauma on chronic instability, acute trauma (Gr III) 303 Disease 067 Post operation 037 Infection 004 행한환자는 37명, 감염에의한환자가 4명이었다 (Table 1). 수술전이학적검사, 방사선및자기공명영상촬영으로 71명의환자에서거골의골연골병변 (osteochondral defect), 19명의환자에서골관절염, 59명의환자에서활액막염 (synovitis), 235명의환자에서전경비인대 (ATFL, anterior tibiofibular ligament), 전하경비인대 (AITFL, anterior inferior tibiofibular ligament), 종비인대 (CFL, calcaneofibular ligament), 삼각인대 (deltoid ligament) 손상, 7명의환자에서통풍성관절염 (gouty arthritis), 20명의환자에서족관절부의유리체 ( loose body) 로진단되었다 (Table 2). 2. 수술방법전신또는경막외마취하에서앙와위로환자를눕히고충분히수술대의밑으로위치시켜환자의다리가수술대의끝부분까지오게한다. 족관절은중립위치에서 15~30 cc 수액을전내측삽입구에주사한다 (Fig. 1). 전내측삽입구를통하여 2.5 mm 관절경을삽입하여내측부터시작하여외측으로이동하면서관절상태를확인하고전외측을통해전동절제기또는겸자를삽입하여사용한다. 필요에따라서는후외측또는전방중앙에삽입구를만들어사용하기도하였다 (Fig. 2). 족관절전방에있는병변은쉽게관찰및내시경적시술을할수있으며관절의중앙부위, 전방및후방의거골의병변은보조자가발목을족저굴곡 Table 2. Diagnosis of Patients Diagnosis of patients Number of patients OCD 071 OA 019 Synovitis 059 Ligament rupture 235 Gouty arthritis 007 Loose body 020 OCD: osteochondral defect of talus, OA: osteoarthritis Figure 1. With supine position, place the patients foot on distal tip of the table and inject saline. - 289 -
이정길 김갑래 이진영 이의수 이재희 (plantarflexion) 시킴으로써관찰및시술을쉽게할수있다. 술자의배를이용하여발목을족배굴곡 (dorsiflexion) 시킴으로써주위신경과혈관이이완되어관절경및겸자의삽입시주위구조물손상을최소화할수있다 (Fig. 3). 후방부시술시에는술자의배에발을걸쳐서족배굴곡시킴으로써거골의후방부병변에대하여확인및내시경적절제술등의시술을할수있다 (Fig. 4). 견인장치를이용하지않으므로내시경을전진시킬때내시경의덮개 (sheath) 를굴리면서 (rolling) 회전함으로써내시경의전진을용이하게하 여연골면의손상을주지않도록주의하면서시행할수있다. 족관절부의구조를 21-point Ferkel s ankle arthroscopy criteria에따라관찰하였다. 3. 연구방법외래에서경과관찰은수술후 2개월까지는 2주마다, 그이후는한달간격으로추시하였고, 추시할때단순방사선사진을촬영하였고, 수술후 6개월까지추시관찰하여증상호전및합병증유무를관찰하였으며, 수술전과수술후 6개월의 VAS (Visual Analog Scale) score와 AOFAS (American Orthopaedic Foot and Ankle Society) score를비교하였다. 2008년 3월부터 2012년 3월까지후향적으로관절경을시행한 411명의족관절질환환자들의증상호전도및합병증발생여부를입원기록지, 외래기록지, 수술기록지를참고하여연구하였다. 결 과 Figure 2. Arthroscopic exam. From lateral gutter to anterior, central and medial gutter of ankle. 관절경적검사와함께시행된시술은미세골절술 (microfracturing) 및천공술 (drilling) 이 38례, 자가골연골이식술 (OATs, Osteochondral Autograft Transfer system) 이 33례, 변연절제술 (debridement) 가 217례, 활액막절제술 (synovectomy) 가 127례, 유리체제거술이 20례였다 (Table 3). 수술전환자들에게서측정한 VAS score는평균 6.1점이었으면 AOFAS Figure 3. Introduction of arthroscope in fully dorsiflexed position. Figure 4. The foot leans against the surgeon s belly. - 290 -
score는평균 73점으로측정되었다. 수술후 6개월환자들에게서측정한 VAS score는평균 3.3점이었고 AOFAS score는평균 91점으로측정되었다 (Table 4). 411례중 5례에서내시경적관찰이힘들었고모두외상성골관절염이심해서관절간격의확보가용이하지않았으나관절경절삭기 (arthroscopic burr) 을이용한절삭술 (burring과 shaving) 을시행한후관절간격을확보할수있었다. 견인장치없이관절경술을시행한 411례중 18례 (0.044%) 에서합병증이나타났다. 11례 (0.027%) 에서거골에홈이생겼고, 5례 (0.012%) 에서복재정맥손상, 2례 (0.005%) 에서천비골신경손상에의한증상이나타났다 (Table 5). 견인장치를하지않기때문에수술준비시간이짧았고수술준비시간을포함한수술이평균 50분 (30분 ~2시간 ) 이내에완료될수있었다. 고 찰 골격견인과비침습적견인에서신경학적합병증이발생할수있다는것은여러논문을통해알려진사실이다. 3-7) 침습적견인은천비골신경압박과같은신경학적인합병증, 비골및경골의골절, 혈관및인대의손상, 핀사이트감염의우려로거의사용되지않고있고비침습적인견인은일정한견인을유지하기힘들고 Table 3. Arthroscopic Procedure Arthroscopic procedure Number of patients Microfracturing 038 OATs 018 Debridement 217 Synovectomy 127 Loose body removal 020 OATs: Osteochondral autologous autograft, taking a bone and cartilage plug for another site such as knee and transplanting it into talar lesion. 견인의한계가있으며견인을하게되면관절의앞쪽공간이거의없어지게되어전방시술에어려움을초래할수있다. 또한피부에직접적인마찰및압력이가해져피부손상및주위신경압박으로인한합병증의발생이불가피하다. 최근연구에따르면지속적인견인으로인해족관절수술후합병증의발생률은 8~17% 이며평균 10.7% 에달한다. 2,3,5-17) 또한신경학적인합병증의발생율이 5.4% 에달한다고한다. 11) 견인장치없이관절경술을시행하였을경우족관절은작은관절이라관절부의간격이좁다. 따라서시야확보가어렵고연골의손상의가능성이높다고알려지고있다. 18) 기구의발달로저자들은 2.5 mm의작은관절경을이용하였고견인장치없이관절경술을시행하였을때수술시야확보에문제가없었고연골손상도거의없었다. Ferkel s criteria에따라관절의전방및외측으로관절경술을시행은문제가없었으나외상성관절염이심한환자의경우에는 burring을시행해야관절의중심부및후방까지도관절경술이가능하였다. 견인장치의사용은견인장치의사용은기구를사용함에따라수술자가너무바쁠수있고, 무균조작에어려움을줄수있다. 견인장치없이족관절을족배굴곡시킨상태에서관절경술을시행하는방법은오히려앞쪽및옆쪽수술시야확보에도움이되었고견인장치를한상태에서한수술과비교해보았을때수술결과에큰차이를보이지않아추천할만한방법이다. 18) Lozano-Calderón SA 등에 18) 의하면비침습적인견인은견인장치없이시행한관절경술보다전방및외측족관절부관찰에어려움이있었다고보고하고있다. 중앙및후방관절에대한관절경술시견인장치를하지않았을때더어려웠다는보고가 18) 있지만저자들이소개한내시경을전진시킬때내시경의덮개 (sheath) 를이용하여회전함으로써내시경을전진시키는방법으로해결할수있었다. Peter A. J. 등은 10) 족배굴곡시견인장치를시행하 Table 4. VAS Score and AOFAS Score before Operation and 6 Months after Operation Time VAS score AOFAS score Before operation 6.3 73 6 Months after operation 3.3 91 Table 5. Complications after Ankle Arthroscopy Complications Number of patients (%) Grooving of talus 11 (0.027%) Saphenous vein injury 05 (0.012%) Superficial peroneal nerve injury 02 (0.005%) - 291 -
이정길 김갑래 이진영 이의수 이재희 였을때보다상대적으로앞쪽관절수술공간의확보가용이함을사체연구를통해밝혔다. 최근의연구들은관절경술의질이떨어지고연골손상이발생할수있는가능성이있더라도견인장치를했을때발생할수있는합병증을피할수있는견인장치없는관절경술을고려하고있다. 18) 견인장치를하지않고족관절을족배굴곡시키는방법은날카로운관절경이삽입되었을때신경이나혈관이피할수있는공간을마련하여수술과정에서생길수있는신경이나혈관손상이더적었다. 1,10) 연구에따르면족관절을족배굴곡시킨상태에서관절경술을시행하였을때합병증발생율이 3.4% 밖에되지않는다고한다. 19) 또한겸자의삽입시관절안쪽까지깊게삽입하는데더용이하였다. 반면견인된족관절에서는족관절앞쪽으로의접근시신경이나혈관손상을줄뿐아니라수술공간을좁히는결과를가져왔다. 10) 견인장치를하는데소요되는시간의단축은수술시간의단축으로이어졌고마취를오래했을때의합병증이나수술시간이증가함으로써발생할수있는감염에대한합병증발생의감소를보였다. 또한견인장치가없기때문에족관절의자유로운위치이동이나체위변화로수술을더쉽게할수있었고병변에대한접근도용이하였다. 이번연구의제한점으로는견인장치를시행한대조군에대한비교논문이아니었던점이라고할수있다. 결론 견인장치를사용하지않고손을이용한견인과내시경의조작만으로충분하게족관절의모든부분을관찰할수있으며연골부분에손상을주지않으면서시술을할수있었다. 준비시간의단축으로수술시간뿐만아니라마취시간의단축은분명히수술의합병증을낮추는요소가될수있을것으로본다. 다만시술중견인장치가없어서시술자가관절경을다루는기술에대한연마가필요할것으로사료된다. 도수견인을통한족관절관절경은제한점이있지만견인장치를사용할수없는특수한상황에서사용이가능한술식으로사료된다. REFERENCES 01. Zengerink M, van Dijk CN. Complications in ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc 2012;20:1420-31. 02. Barber FA, Click J, Britt BT. Complications of ankle arthroscopy. Foot Ankle 1990;10:263-6. 03. Amendola A, Petrik J, Webster-Bogaert S. Ankle arthroscopy: outcome in 79 consecutive patients. Arthroscopy 1996;12:565-73. 04. Kim HN, Ryu SR, Park JM, Park YW. Subtalar arthroscopy with calcaneal skeletal traction in a hanging position. J Foot Ankle Surg. 2012;51(6):816-9. 05. Ferkel RD, Heath DD, Guhl JF. Neurological complications of ankle arthroscopy. Arthroscopy 1996;12:200-8. 06. Guhl JF. New techniques for arthroscopic surgery of the ankle: preliminary report. Orthopedics 1986;9:261-9. 07. Unger F, Lajtai G, Ramadani F, Aitzetmuller G, Orthner E. Arthroscopy of the upper ankle joint. A retrospective analysis of complications. Unfallchirurg 2000;103:858-63. 08. Bonnin M, Bouysset M. Arthroscopy of the ankle: Analysis of results and indications on a series of 75 cases. Foot Ankle Int. 1999;20:744-51. 09. Cutsuries AM, Saltrick KR, Wagner J, Catanzariti AR. Arthroscopic arthroplasty of the ankle joint.clin Podiatr Med Surg. 1994;11:449-67. 10. Peter AJ. de Leeuw, Pau Golanó, Joan A. Clavero, and van Dijk CN. Anterior ankle arthroscopy, distraction or dorsiflexion? Knee Surg Sports Traumatol Arthrosc. 2010;18(5):594-600. 11. Scranton PE, Jr, McDermott JE. Anterior tibiotalar spurs : A comparison of open versus arthroscopic debridement. Foot Ankle. 1992;13:125-9. 12. Martin DF, Baker CL, Curl WW, Andrews JR, Robie DB, Haas AF. Operative ankle arthroscopy. Long-term followup. Am J Sports Med. 1989;17:16-23. 13. Lerman BI, Gornish LA, Bellin HJ. Injury of the superficial peroneal nerve. J Foot Surg. 1984;23:334-9. 14. Jerosch J, Schneider T, Strauss JM, Schurmann N. Arthroscopy of the upper ankle joint. List of indications from the literature?realistic expectations?complications. Unfallchirurg. 1993;96:82-7. 15. Hedley D, Geary NP, Meda P. Ankle arthroscopy: A new technique for non-invasive ankle distraction. Foot Ankle Surg. 2001;7:137-9. 16. Frey C, Feder KS, DiGiovanni C. Arthroscopic evaluation of the subtalar joint: Does sinus tarsi syndrome exist? Foot - 292 -
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