Symposium J Korean Orthop Assoc 2014; 49: 95-106 http://dx.doi.org/10.4055/jkoa.2014.49.2.95 www.jkoa.org Osteotomy for Osteoarthritis of the Knee 95 노두현 이상훈 성상철 이명철 서울대학교의과대학정형외과학교실 pissn : 1226-2102, eissn : 2005-8918 Lateral Closing Wedge Osteotomy of Tibia for Degenerative Arthritis Du Hyun Ro, M.D., M.S., Sahnghoon Lee, M.D., Ph.D., Sang Cheol Seong, M.D., Ph.D., and Myung Chul Lee, M.D., Ph.D. Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Korea Proximal tibial osteotomy is an effective, well-established treatment for unicompartmental arthritic knee with varus or valgus deformity. Four basic types are commonly described: lateral closing wedge osteotomy, medial open wedge osteotomy, dome osteotomy, and medial opening hemicallotasis. The objective of this procedure is to realign the weight-bearing axis through the knee by redistributing the forces of weight to the less involved compartment of the knee. With thorough preoperative planning and careful selection of patients, optimal outcome can be expected with preservation of the patient s joint. In this article, we reviewed selection of patients, surgical planning, surgical technique, complications, pre- and post-operative change in mechanics, and long term surgical outcome of closing wedge osteotomy. Optimal outcome is expected in patients with young age (younger than 60), stable knee, medially confined osteoarthritis, and good range of motion. According to the literature, average 10-year survival rate is expected to be 60% to 90%. Closing wedge osteotomy allows for rapid bone healing, early weight bearing, rehabilitation, and low rates of correction loss. Surgeons should keep in mind that optimal indication, preoperative planning, and use of safe operative technique are essential to achievement of best results. Key words: osteotomy, high tibial osteotomy, lateral closing, osteoarthritis 서론 경골근위부절골술은내측구획슬관절골관절염의수술적치료 방법중하나로최근인공관절전치환술및부분치환술의발전으 로인해적응증이좁아졌으나내측구획관절염을호소하는젊고 활동적인환자에게그자체로도매우효과적인치료방법이며, 인 공슬관절치환술의시행시기를지연시킬수있는방법이다. 1-4) 1958 년 Jackson 이관절염의치료를위해경골근위부절골술을사 용할수있음을처음보고하였으며 1965 년 Coventry 5) 가관절염환 자에외측폐쇄형절골술을사용하여만족할만한결과를보고한 Received July 25, 2013 Revised August 13, 2013 Accepted August 28, 2013 Correspondence to: Myung Chul Lee, M.D., Ph.D. Department of Orthopaedic Surgery, Seoul National University Hospital, 101 Daehak-ro Jongno-gu, Seoul 110-744, Korea TEL: +82-2-2072-2368 FAX: +82-2-2764-2718 E-mail: leemc@snu.ac.kr 뒤관절염의치료방법으로널리알려지게되었다. 수술의목적은슬관절의내반변형을외반으로바꾸어내측구획에가해지는과도한압력을줄여주는데있으며불안정성이있는환자에서인대재건술과같이시행하는경우도있다. 수술방법은외측폐쇄절골술, 내측개방형절골술, 돔형절골술, medial opening hemicallotasis 등이있으며이중외측폐쇄형절골술과내측개방형절골술이가장널리쓰인다. 6,7) 이번논의에서는내반변형을동반하는골관절염으로외측폐쇄형절골술을시행하는경우의장, 단점과결과를알아보고환자선정, 수술전계획, 수술방법을고찰해보고자한다. 본론 1. 환자선정적절한환자선정은성공적인결과를얻을수있는가장중요한 The Journal of the Korean Orthopaedic Association Volume 49 Number 2 2014 Copyright 2014 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
96 노두현 이상훈 성상철외 1 인 요소로관절염의위치와정도, 내반변형여부, 통증의정도에대한고려가필요하다. 수술의적응증은 1) 내측부관절염으로인해통증및장애가조절되지않아직장생활이나일상생활이어려운경우, 2) 슬관절의내반변형을동반하며내측부통증을호소하는경우, 3) 6주가량목발을짚고다닐수있을정도의충분한근 력및의지가있는경우해당된다. 하지만다음각사항에해당하는경우예후가나빠근위경골절골술을하지않는것이좋다. 4,8,9) 1) 외측관절간격의소실, 2) 경골의외측아탈구가 1 cm 이상, 3) 내측경골골소실 2-3 mm 이상, 4) 굴곡구축 15도이상, 5) 후속굴곡 90도미만, 6) 교정각이 20도이상필요한경우, 7) 염증성관절염인경우 ( 류마토이드성관절염, 통풍성관절염등 ), 8) 말초혈관질환이동반되는경우, 9) 나이가고령인경우이다. 일반적으로수술전다음조건을갖는환자들에게는좋은예후를기대할수있다. 4,6,8) 1) 60세이하의비교적젊은환자, 2) 내측부관절염만있는경우, 3) 슬관절불안정성이없는경우, 4) 수술전관절운동범위가 90도이상인경우, 5) 내반변형이 10도미만인경우, 6) 초기관절염인경우. 수술의목적은통증완화이며정상슬관절로회복되지않음을주지시켜야한다. 또한수술의한계점이존재하므로수술의결과에대해과도한기대를갖지않도록환자와상담이필요하다. Figure 1. Relationship between mechanical axis and anatomical axis in normal lower extremity. The mechanical axis is a line connecting the centers of the femur head and the tibiotalar joint, which passes through the center of the knee joint. It is in 3 degrees of valgus from the vertical axis of the body. Anatomical axis (femoral shaft axis) is in 6 degrees of valgus from the mechanical axis of the lower limb and 9 degrees of valgus from the true vertical axis of the body. 2. 수술전검사및계획성공적인결과를얻기위해철저한병력청취및수술전검사그리고정확한수술계획이필수적이다. 수술전관절운동범위측정, 동통의위치, 내반, 외반스트레스검사, 전후방스트레스검사를통해불안정성여부를평가해야한다. 환자의보행을평가하여야하며입각기에서 varus thrust gait 가없는지, 대퇴사두근회피보행 (quadriceps avoid gait), 전반슬 (recurvatum) 이없는지확인해야한다. 기본검사로체중부하상태에서촬영한양측슬관절전후면, 측면, Rosenberg view, teleradiograpy, skyline 상을얻고골관절염위치및정도를평가한다. 수술의적응증에해당하는지, 부적응 Figure 2. Progression of osteoarthritis in the varus knee (left to right). Varus deformity increases adduction moment of the knee during gait, which further increases medial tibiofemoral joint loading. Increased loading aggravates osteoarthritis and deformity. If lateral laxity accompanies, varus deformity can show rapid progress.
97 증에해당하지않는지확인한다. 내반스트레스사진촬영을통해외측인대의이완정도및내측연골의두께를추정할수있으며이를수술계획에반영하기도한다. 10,11) 자기공명영상을통해연골의두께및연골판의동반손상여부, 전후방십자인대의상태및연골하골의상태, 대퇴- 슬개관절염정도를평가해볼수있다. 컴퓨터단층촬영및 single-photon emission computed tomography/ computed tomography 검사의효용성여부는아직밝혀지지않았다. 12) Teleradiography 사진을통해관상면상변형정도를평가하고목표교정각을계산한다. 역학적축및해부학적축이교정전후의기준으로사용된다. 역학적축 (mechanical axis) 은대퇴골두중심에서거골의중심을잇는선을의미하며정상하지정렬을갖는환자의경우역학적축은슬관절의중심을지난다 (Fig. 1). 이경우내측구획을통해체중의 60%-70% 가, 외측을통해 30%- 40% 가전달되지만내반변형이있는환자의경우내측구획의체중부하가늘어난다. 13,14) 내반 6도의슬관절은체중의 95% 가내측을통과하게되어내측부압력을증가시켜통증을일으키고관절염을촉진시킨다. 14) 관절염으로인해내측관절간격은더욱좁아지게되며외측부이완을동반하는경우더욱심한변형을초래할수있다 (Fig. 2). 수술의목표는내반변형을외반으로교정하여내측부압력을감소시켜주는것이며 1) 해부학적축을기준으로 8-10 도외반으로과교정하는방법, 15) 2) 역학적축을기준으로 3-5 도외반으로교정하는방법, 15-17) 3) 역학축이경골부내측으로부터 62.5% 지점을지나도록하는방법이널리쓰인다 (Fig. 3). 18) Coventry 등 15) 은경골절골술후평균 10년장기추시연구에서교정각을외반 8도미만으로한경우 5년생존율이 38% 밖에되지않는반면 8도이상의과교정을한경우 90% 가되므로 8도이상의과교정이필요하다하였으며, Fujisawa 등 18) 은중앙에서외측으로 30%-40% 되는지점으로역학적축이지나갈때관절연골이가장잘회복됨을수술전, 후관절경으로확인하였다. 정도의차이는있으나슬관절을외반과교정하는것이수술의목표로서널리받아들여지고있으며여러장기추시결과들에의해뒷받침되고있다. 15-18) 반면몇몇저자들은환자개개인의연부조직및연골손상정도에맞춰교정목표를달리해야한다주장한다. Dugdale 등 10) 은수술전외측이완이심한경우수술후과교정되는경향이있어내반스트레스촬영을수술전시행하여외측간격이 1 mm 건측보다벌어질때마다목표치를 1도줄여야과교정을피할수있다주장하였다. 체중부하방사선은외측이완등으로부정확하기때문에비체중부하방사선촬영으로목표값을잡아야한다는주장도있다. 19) Marti 등 11) 은내측연골결손이심할수록역학적축을더욱외측으로지나가도록수술해야하며연골결손이 1/3 일경우중앙에서외측으로 10% 인지점에역학적축이지나가도록, 2/3 일경우 20%-25%, 전체결손일경우 30%-35% 외측인지점으로지나가도록수술해야한다주장하였다. Prodromos 등 20) 은보행분석을통한연구에서수술후같은교정각을얻더라도환자마다슬관절의내전모멘트가각기다르며모멘트가큰경우교정소실이증가함을보고하였다. 이에정적인사진을바탕으로계획을세우는기존방법에동적인보행분석이더해져 Figure 3. Preoperative simulation with a full-length standing radiograph. We simulate postoperative limb alignment according to the intersecting location of the mechanical axis. (A) This photograph shows preoperative alignment on the left extremity. (B) This photograph shows the mechanical axis that passes through the lateral tibial spine. (C) This photograph shows the Fujisawa point. We also measured anatomical axis and medial proximal tibial angle (MPTA) in each case. As the causes of varus deformity can differ, all of these variables should be considered together for development of an optimal results.
98 노두현 이상훈 성상철외 1 인 최상의결과를얻을수있을것이라주장하였다. 상기서술한각각의수술목표는후향적분석에의한경험론적인결과로각각의한계점이존재한다. 그러므로단순히하나의목표값을정하여수술을하는것보다는여러가지측면을고려하여수술목표를결정해야하겠다. 한편관절염이아닌후외측불안정성과동반한 varus thrust gait 에대한교정을위해근위경골절골술을시행할경우역학적축이경골의가운데에오도록교정을해야한다. 21) 교정각도계산은 3가지방법이널리쓰인다. 첫째, 교정각 1도에 1 mm씩계산하는방법으로이는절골이가해지는부분 ( 관절면하 2.0-2.5 cm 아래 ) 의내외측경골폭이 56 mm에해당할때정확하며그보다클경우적게, 그보다작을경우많이교정된다. 실제대부분환자들의경골폭은 56 mm보다커서이는일괄적으로적용하기에부정확한방법이다. 둘째, 공식을사용하여하는방법이있다. 경골절골을가하는부분 ( 관절면하 2.0-2.5 cm 아래 ) 에서관절면과평행한경골의내외측길이를 x라고하고, 교정각을 θ 라할때제거해야할골절편의길이 y=x tan (θ) 로계산하는방법이다 (Fig. 4). 하지만외측경골면은비스듬하므로오차가발생하며방사선사진은보통확대되므로확대율을나누어주거나실제길이를나타내는장치를같이촬영하여해당배율만큼나누어계산해야하는점에유의해야한다. 셋째로방사선사진에서직접측정하는방법으로 picture archiving and communication system (PACS) 이되는컴퓨터를사용할경우가장간편하다. 역학축이지나갈지점을정한다음목표교정각을계산한다. 그다음경골관절면 2 cm 아래에서목표교정각에해당하는각을표시한뒤경골근위부외측에서제거할양을직접측정하면된다. 마찬가지로방사선사진이확대될수있으므로보정을해야한다 (Fig. 5). 발생하지않는다. 또한 7) 골이식이나골대체물이필요없으며, 8) 교정각의소실빈도가적다는장점이있다. 이에반해단점으로는 1) 교정하는쪽의하지길이가감소하고, 2) 정확한교정을얻기가힘들며, 3) 비골절골술혹은경비골분리술이추가로필요하며, 4) 술기가비교적어렵고, 5) 신경합병증및불유합의가능성이있으며, 6) 인공슬관절전환시골결손이크다는단점이지적되기도한다. 22) 문헌에서보고하는단편적인장, 단점보다는술자의숙련도및환자의특성에맞게적절한술식을적용하는판단력이더중요하며, 외측폐쇄형절골술시고려할사항및합병증은다음과같다. 1) 경골경사변화외측폐쇄형절골술이후경골경사는감소하고내측개방형절골술이후경골경사는증가한다. 이는절골시시상면상회전중심 (center of rotation angulation) 이경골의뒷부분으로가기쉬워일어난다. 회전중심이시상면상뒤에위치할경우신연시 (distraction) 경골경사각이증가하고압박시 (compression) 경골경사각이감소한다. 그러므로내측개방형절골술후굴곡구축이 3. 외측폐쇄형절골술의장점및단점외측폐쇄형절골술의장점으로 1) 골유합이빨라조기보행이가능하며, 2) 대퇴사두근의수축이압박력으로작용하여초기안정성이우수하고, 3) 변형이발생한부위에서가깝게교정을하며, 4) 경골경사의증가가미미하고, 5) 수술시같은절개선을이용하여관절면을관찰할수있으며, 6) 슬개골하위 (patella baja) 가잘 Figure 4. Calculation of wedge height usinga trigonometric method. Actual wedge height (y) is calculated with the desired angle of correction (θ) and actual tibial width (x). Actual tibial width should be measured at 2.0 2.5 cm distal to the joint line and should be normalized according to the amount of magnification. Figure 5. Calculation of wedge height using a picture archiving and communication system (PACS). Desired angle of correction is measured using teleradiography. In this figure, desired angle of correction is 10 degrees when the mechanical axis passes through the Fujisawa point. This angle is marked at 2 cm distal to the joint line and the wedge height can then be measured directly.
99 발생할수있으며외측폐쇄형절골술이후에는전반슬이발생할수있다. 23,24) 외측폐쇄형절골술시에후면의골을의도적으로더절제하여이를방지할수있으며내측개방형절골술시뒷부분을더신연시켜이를방지할수있다. 상기이유로굴곡구축이있는환자는내측개방형절골술보다는외측폐쇄형절골술이더선호되며전반슬이있는환자는내측개방형절골술이유리하다. 일반적으로내측개방형및외측폐쇄형절골술이후경골경사각의변화는 5도미만으로대부분의경우임상적으로큰문제는없으며절골술시전방부를의도적으로적게제거하여이를최소화할수있다. 23,24) 다만전후방불안정성이동반된환자에서경골경사의변화는십자인대에과도한긴장을줄수있으므로이에대한고려가필요하다. 경골경사각이늘어나는경우경골의전방전위가증가하는경향이있어전방십자인대에긴장이, 경골경사각이감소하는경우과신전을일으켜후방십자인대에긴장이가해질수있다. 전방십자인대의기능부전이있는경우경골경사각의감소가안정성에도움이되기도하므로외측폐쇄형절골술이유리하다. 23,24) 2) 슬개골위치변화외측폐쇄형절골술은슬개건부착부보다근위부에절골을가하고뼈를제거한다. 그러므로수술후슬개골의위치는상대적으로높아지며내측개방형절골술의경우반대로슬개골의위치가낮아진다. 25,26) 외측폐쇄형절골술후슬개골하위를보이는경우도많이보고되는데이는주로과거오랜기간고정뒤발생한슬개인대주변의섬유화, 반흔화가원인인것으로보이며단단한내고정및조기관절운동시행으로슬개골하위의빈도는감소하였다. 26-28) 슬개골하위가발생하는경우인공관절술로전환시수술술기의어려움을보고하는경우가있으므로외측폐쇄형절골술시에슬개인대주변의연부조직을다룰때에세심함이요구되며외측절골술식시단단한내고정및수술후조기관절운동이중요하다. 22,26-29) 경골하이중절골술 (biplanar osteotomy) 을통해슬개골위치변화를최소화할수있으나골절의위험성이있다. 3) 외측폐쇄형절골술이후합병증 (1) 구획증후군 : 드문합병증이나항상염두에두고있어야한다. Gibson 등 30) 은외측폐쇄형절골술을시행하고배액관을거치하지않은 10명의환자중 7명에서전방구획의압력이 45 mmhg 이상상승하였고그중 5명이일시적인증상을경험한다보고했다. 반면배액관을거치한환자들의경우구획압력이 30 mmhg 이하이며구획증후군증상도없어적절한배액관의설치를통해구획증후군의위험을최소화할수있다하였다. 십자인대재건등의관절경수술이동반되는경우 extravasation 으로인한구획압력증가의가능성이높기때문에각별히주의를기울여야한다. 31) (2) 골절선의관절내파급 : 절골술후골절선의관절내파급 의빈도는 0%-20% 로보고된다. 4,32-35) 절골술을관절면에너무가깝게시행하거나내측골이많이남아외반력에대한저항이큰경우발생하며교정각이큰경우의도하지않은추가골절이발생할확률이높아진다. 이를방지하기위해절골술은관절면 2.0-2.5 cm 아래에서시행하여단단한연골하골이충분히포함되도록하며내측피질골은최소한으로남기도록한다. 36) 예상교정각이큰경우드릴로경골내측피질골에구멍을뚫어이를방지할수있다. 37) 관절내골절이발생한경우수술장내에서이를인지하는것이중요하며방사선투시장치등을사용하여전위여부를확인하도록한다. 전위가심한경우에는정복후압박나사등의고정이필요하다. 그러나대부분의관절내골절은전위가없으며임상증상을유발하지않는다. 38) (3) 불유합 : 외측폐쇄형절골술은해면골의접촉면적이넓고대퇴사두근이압박력으로작용하기때문에불유합및지연유합이드물며 1%-5% 정도의빈도로보고되고있다. 3,4,35,39) 지연유합의경우체중부하를천천히시키고필요에따라부목을오래거치함으로써대부분치유되나잠김나사금속판, 외고정장치골이식등을사용한추가수술이필요할수있다. (4) 신경손상 : 비골신경마비의빈도는 0%-20% 로보고된다. 3,4,32,35,40,41) 부적절한신경의보호로인한직접손상, 수술후구획압력증가로인한신경마비가주요원인이며지혈대의사용, 교정시에발생할수있는신경의신연도관련이있다. 42) 장무지신전근 (extensor halluces longus) 의기능부전이가장흔하다. 40) 비골신경은대퇴이두근과비복근사이를지나비골경부를감싸고장비골근안에서천부와심부신경으로분지하는데심부신경은비골두아래 7-15 cm 지점에서장무지신전근으로신경을 2-3 개분지하며이부분에서비골절골술을시행하는경우특히높은빈도로마비가발생한다. 40,43) Wootton 등 40) 은비골두에서부터의거리에따라절골술이가해지는위치를 Zone 1에서 4로나누고 Zone 1인근위경비골관절을분리하는경우, Zone 4인비골두하방 15 cm에서절골술을하는경우비골신경마비가발생하지않아해당부위에서분리술혹은절골술을하는것이안전하다고하였다. (5) 반대쪽피질골의골절 : 외측폐쇄형절골술시외반력을가하는과정에서내측피질골골절이발생할수있으며이의빈도는 50%-80% 가량, 내측개방형절골술시외측피질골골절의빈도는 35% 가량으로외측이조금높은것으로보고된다. 44,45) 전통적으로반대편피질골의골절은교정각의소실, 나쁜예후와연관이있다고알려져있으나이견이존재한다. 3,44,45) van Raaij 등 44) 은외측폐쇄형절골술에서반대쪽피질골골절이발생하는경우원하는교정각을더잘얻을수있었으며외반교정상태의소실없이잘유지됨을보고한반면, 내측개방형절골술에서반대쪽피질골의골절이발생한경우교정각의소실이관찰되었다고보고하였다. 외측폐쇄형절골술시발생하는내측피질골의골절
100 노두현 이상훈 성상철외 1 인 은큰임상적의미가없는것으로생각한다. 4. 수술방법관절면 2.0-2.5 cm 아래에경골결절에서부터비골두까지관절면과평행하게 5-8 cm 가량피부절개를시행하여근막을노출시킨다. Langer s line 을따라절개하게되므로후에반흔이적게남는장점이있다 (Fig. 6A). 넓은시야를위해긴사선형절개나 L shape 절개를할수도있으나평행절개로도대개시야는충분하다. 피부절개후전경골근을노출하고경골의외측면을따라서근육부착부에서골막하박리한다 (Fig. 6B). 크기가작은스테이플혹은 Rigid stepped plate (RSP) 를사용할경우내고정물삽입을위해필요한공간은위아래 5 cm 및폭 3 cm 가량으로박리해야할면적은그리크지않다. 제르디결절에부착하는장골경골근막띠 (iliotibial band) 의일부를절제한다 (Fig. 6C). 경골절골을진행하기전에비골절골을시행한다. 비골두를일부절제할수도있으나 비골신경손상가능성때문에비골골간부절골술혹은경비골분리를하는편이선호된다. 비골두아래 15 cm에서피부절개를가하고주변조직을 Hohmann retractor 로잘보호한뒤 oscillating saw 로절골한다. 비골절골이후경골절골을진행한다. 관절면을주사기바늘로확인한뒤방사선투시기하에서관절면 2.0-2.5 cm 아래에서 S-pin 을관절면과평행하게삽입한다. 미리계획한골절제량을표시하여두번째 S-pin 을경골내측을향해비스듬히삽입하고예상골절제량을다시한번확인한다 (Fig. 6D). 외측폐쇄형절골술은정확한양의골절제가수술의성패에매우중요하므로이는아무리강조해도지나치지않다. 신경혈관손상은드물지만치명적인합병증이므로절골술을하기전이에대해철저한주의를기울여야한다. 절골술이가해질부위, 특히경골후면을 Cobbs elevator 로골막하박리를하도록하며 Cobbs elevator 혹은 malleable retrector 를골바로뒤에위치시켜후면의근육및신경혈관구조를보호하여야한다. 또한슬개건뒷부 Figure 6. Intraoperative picture (see text for detailed description). (A) Transverse skin incision from tibial tuberosity to the fibular head. (B) Exposed fascia. (C) Subperiosteal stripping using an elevator. (D) Insertion of the guide pin under the c-arm. (E) Proximal wedge removal. (F) Distal wedge removal. (G) Application of gentle valgus force to make plastic deformation of the contralateral cortex. (H) Internal fixation.
101 Figure 6. Continued. 분을조심스럽게박리하고손상받지않도록보호한다. 슬개건의과도한박리시에슬개골하위가올가능성이높아진다. 전통적으로절골술시슬관절을 90도굴곡하는것이슬와동맥을절골부에서멀리한다고여겨지지만이는잘못된생각이며오히려완전신전시보다더가까워진다는보고도있다. 46,47) 즉동맥손상의방지를위한슬관절의굴곡보다는적절한 retrector 의위치, 경골후면의골막하박리를하는것이더욱중요하며술자가편안한자세를유지할수있는위치에서절골술을하는것이가장좋다. 절골은한번에끝까지하지않고박리한부분에서가까운부분의골을먼저 oscillating saw 로제거한뒤시야가확보되면먼쪽의골을추가로제거한다 (Fig. 6E, 6F). 처음부터완전절골을하지않고원위피질골을불완전절골상태로 5-10 mm 가량일부남겨둔채서서히외반력을가하며포복 (creep) 현상을이용하여내측피질골의소성변형 (plastic deformation) 을유도하는것이좋다 (Fig. 6G). 이때내측피질골에드릴로구멍을여러개만드는것도하나의방법이다. 37) 변형을가할때무리한외반력은골절선의전파로관절내골절이나예기치않은골절양상을만들수있어주의 를요한다. 정렬상태를방사선투시기혹은컴퓨터항법장치로확인한다. 골이 1-2 mm 가량목표보다덜절제되었거나정렬상태가목표치에미치지못할때 saw 로추가절제한다면목표보다오히려많은부분이절제될수있다. 이때근위절골면의해면골을 curette 로일부제거하면원위피질골이 1-2 mm 가량근위부로감입되어이를효과적으로해결할수있다. 절골술후내고정기구는 Stepped staple (Coventry staple) (Fig. 7A), Blade plate (Fig. 7B), L-plate (Fig. 7C), 나사고정 (Fig. 7D) 등이있으며외고정장치등도가능하다. 이들은크게 staple, 금속판, 외고정장치로나누어볼수있으며이중 staple 이가장널리쓰인다. 금속판은고정력이우수하지만연부조직박리를많이해야하는단점이있고외고정장치는감염의위험으로잘쓰이지않는다. 하지만 staple 은고정력이충분치못해통상오랜고정이필요하므로저자들은이들을보완한 RSP (Solco Biomedical, Seoul, Korea) 를사용한다 (Fig. 6H, 7E). RSP 는통상적인금속판보다경도 (stiffness) 가우수하고내반- 외반긴장검사에서생역학적우수함이입증되었다. 48) 수술뒤실패의원인으로부적절한고정으로인한교정각의소
102 노두현 이상훈 성상철외 1 인 Figure 7. Fixation device for closing wedge osteotomy. (A) Stepped staple (Coventry staple). (B) Blade plate. (C) L-plate (condylar buttress plate). (D) Screw fixation. (E) Rigid stepped plate. 실, 불유합이있으나고정기구의발달로부적절한고정으로인한실패는줄어들었다. 49-52) 5. 수술후재활방법일부문헌에수술후즉시 contineous passive movement (CPM) 을시행하도록되어있으나우리나라는심부정맥혈전증의빈도가낮기때문에첫날은장하지석고부목후안정을취하고다음날부터 CPM 을시행하는것이나을것으로생각한다. 대퇴사두근수축운동및발목운동 (ankle pumping exercise) 을지속적으로시키며하지를거상하여부종을감소시키도록한다. 배액관은 2 일내지 3일사이에제거하도록하며수술 2일후탈부착식부목을착용하고발끝만닫는정도의보행을허용토록한다. 보행시에목발을사용하여야하며체중부하는점진적으로수술후 6주째까지 50% 의체중부하를허용하며 6주이후에는완전체중부하를허용한다. 수술후초기에무리한관절운동은과도한부종을일으킬수있어수술후 2주간은 120 도까지제한하며이후점진적으로하도록한다. 가벼운운동은 3개월부터, 격렬한운동 (contact sports) 은완전한골유합을확인후허용하는데보통 6개월이후가능하다. 운전은보통수술후 6-10 주사이근력및통증이호전되어반사기능이정상인경우에허용하도록한다. 6. 수술후결과근위경골절골술은 Jackson 이관절염의치료를위해사용할수있음을처음보고한이후여러장기추시결과보고가있었다 (Table 1). 3,4,15,28,33,35,53-59) 현재까지보고된 5년추시생존율은 80%- 95% 10년장기추시생존율은 60%-90% 정도이며절골술후골유합이이뤄진경우통증의완전한소실은 95% 에서, forgotten knee Table 1. Survival Rates in High Tibial Osteotomy Series Study (yr) n 10-year survival rate (%) Billings et al. (2000) 28) 64 53 Ritter and Fechtman (1988) 56) 78 58 Majima et al. (2000) 55) 48 61 Insall et al. (1984) 3) 95 63 Coventry et al. (1993) 15) 87 66 Cass and Bryan (1988) 53) 86 69 Sprenger and Doerzbacher (2003) 35) 66 74 Aglietti et al. (2003) 33) 102 78 Naudie et al. (1999) 4) 85 80 Rudan and Simurda (1991) 57) 128 80 Hernigou and Ma (2001) 54) 245 85 Schallberger et al. (2011) 58) 54 92 Akizuki et al. (2008) 59) 118 98 는 80% 에서얻을수있으며관절운동범위는수술전과거의동일 하게얻을수있다. 수술뒤스포츠활동도가능하여활동적인환 자에서우선적으로고려할수있다. Aglietti 등 33) 은 102 예의외측 폐쇄형절골술뒤 5년추시상 96% 에서, 10년추시상 78%, 15년추 시상 57% 의생존율을보고했다. 이중 10년뒤 1/3 가량에서인공 관절이필요했으며 10년뒤에도좋은결과를보인환자는 49% 로 보고했다. 교정각이외반 8도에서 15도인경우, 근력이좋으며남 자인경우좋은결과를보였다. 이에저자들은적절한환자선택 을통해슬관절의통증을 10년가량은조절할수있으나영구적 인통증의소실을가져다줄수없다결론지었다. Billings 등 28) 은
103 64명의환자에대한평균 8.5 년추시에서 2/3 의환자에서좋은결과를얻었으며인공슬관절치환술의전환도어렵지않다보고하였다. 저자들은활동적인생활유지를원하는환자에서단단한내고정및조기관절운동으로최적의결과를얻을수있다보고하였다. Cass 와 Bryan 53) 은 86예의연구에서 10년생존율 69% 를보고하였으며성별및나이와수술결과의상관관계는없으며 10도이상의외반교정이좋은결과를가져온다주장했다. Akizuki 등 59) 은 132 명의환자를대상으로한전향적연구에서 97.6% 의높은 10 년생존율을보여주었으며아울러좋은임상결과를보고하였다. 이처럼대부분의연구에서 10년생존율 60%-90% 정도생존율을보여주며결과에악영향을미치는인자들은다음과같다. 4,8,9) 1) 외측관절간격의소실, 2) 경골의외측아탈구가 1 cm 이상, 3) 내측경골골소실 2-3 mm 이상, 4) 굴곡구축 15도이상, 5) 후속굴곡 90도미만, 6) 교정각이 20도이상필요한경우, 7) 염증성관절염인경우 ( 류마토이드성관절염, 통풍성관절염등 ), 8) 말초혈관질환이동반되는경우, 9) 나이가고령인경우, 10) 과거관절경수술을시행한경우. 체질량지수 (body mass index, BMI) 와술후결과의관계에대해서는이견이있다. 4,15,34,59,60) Naudie 등 4) 은저체중환자 (BMI<25 kg/m 2 ) 에서조기실패의비율이많았으며이는저체중환자의활동이더활발하기때문이라주장하였다. Matthews 등 34) 도과체중환자에서단기추시결과가좋다하였다. Coventry 등 15) 은과체중인환자 (ideal body weight 보다 30% 이상일경우 ) 에서, Akizuki 등 59) 은과체중환자 (BMI>27.5 kg/m 2 ) 에서조기실패가많다하였다. 좋은결과를기대할수있는경우는 1) 60세이하의비교적젊은환자, 2) 내측부관절염만있는경우, 3) 슬관절불안정성이없는경우, 4) 수술전관절운동범위가 90도이상인경우, 5) 내반변형이 10도미만인경우, 6) 초기관절염인경우이다. 내측개방형절골술과외측폐쇄형절골술의단기추시결과는비슷한것으로보이며고정물에의한환자의불편감이적었다. 61) 이상의문헌들을종합해보면불유합의위험인자를가지는경우 ( 흡연, 스테로이드의사용, 당뇨등 ), 슬개골하위가있는경우, 골이식을원치않는환자, 십자인대수술과절골술이동시에필요한환자는외측폐쇄형절골술이내측개방형절골술보다더이상적이라하겠다. 두가지술식의직접비교는추후좀더정교한연구에의한장기추시가필요하다. 결론 외측폐쇄형근위경골절골술은내측관절염으로통증을호소하는환자에서효과적인치료방법중하나로자기관절을살리며통증의경감을얻을수있는좋은치료방법이다. 내측부관절염으로통증을호소하며불안정성및관절운동범위가정상인 60세미만의환자에서시행할경우최적의효과를기대할수있으며평균 10년생존율은 60%-90% 를기대할수있다. 외측폐쇄형절 골술은 50년이상널리사용된수술방법으로높은골유합및골이식이필요하지않은장점이있고경골경사각의증가가없으며단단한내고정및조기운동을할경우슬개골하위가발생하지않는다. 수술시발생할수있는합병증을숙지하고발생하지않도록주의를기울여야하며수술의장점과한계점을파악하여적절한환자에게시행한다면관절염환자의통증경감에많은도움이될것이다. REFERENCES 1. Yasuda K, Majima T, Tsuchida T, Kaneda K. A ten- to 15- year follow-up observation of high tibial osteotomy in medial compartment osteoarthrosis. Clin Orthop Relat Res. 1992;282:186-95. 2. Bauer GC, Insall J, Koshino T. Tibial osteotomy in gonarthrosis (osteo-arthritis of the knee). J Bone Joint Surg Am. 1969;51:1545-63. 3. Insall JN, Joseph DM, Msika C. High tibial osteotomy for varus gonarthrosis. A long-term follow-up study. J Bone Joint Surg Am. 1984;66:1040-8. 4. Naudie D, Bourne RB, Rorabeck CH, Bourne TJ. The Install Award. Survivorship of the high tibial valgus osteotomy. A 10- to -22-year followup study. Clin Orthop Relat Res. 1999;367:18-27. 5. Coventry MB. Osteotomy of the upper portion of the tibia for degenerative arthritis of the knee. A preliminary report. J Bone Joint Surg Am. 1965;47:984-90. 6. Rossi R, Bonasia DE, Amendola A. The role of high tibial osteotomy in the varus knee. J Am Acad Orthop Surg. 2011;19:590-9. 7. Lee DC, Byun SJ. High tibial osteotomy. Knee Surg Relat Res. 2012;24:61-9. 8. Aglietti P, Rinonapoli E, Stringa G, Taviani A. Tibial osteotomy for the varus osteoarthritic knee. Clin Orthop Relat Res. 1983;176:239-51. 9. Rudan JF, Simurda MA. High tibial osteotomy. A prospective clinical and roentgenographic review. Clin Orthop Relat Res. 1990;255:251-6. 10. Dugdale TW, Noyes FR, Styer D. Preoperative planning for high tibial osteotomy. The effect of lateral tibiofemoral separation and tibiofemoral length. Clin Orthop Relat Res. 1992;274:248-64. 11. Marti CB, Gautier E, Wachtl SW, Jakob RP. Accuracy of frontal and sagittal plane correction in open-wedge high tibial
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106 pissn : 1226-2102, eissn : 2005-8918 Symposium J Korean Orthop Assoc 노두현 2014; 이상훈 49: 95-106 성상철 외 http://dx.doi.org/10.4055/jkoa.2014.49.2.95 1인 www.jkoa.org 슬관절퇴행성관절염에서의절골술 노두현 이상훈 성상철 이명철 서울대학교의과대학정형외과학교실 경골근위부절골술은내반혹은외반변형을동반한슬관절골관절염에서널리사용되는수술적치료방법중하나로외측폐쇄형절골술, 내측개방형절골술, 돔형절골술, medial opening hemicallotasis 가있으며이중외측폐쇄형절골술과내측개방형절골술이가장널리쓰인다. 수술의목적은슬관절의내반변형을외반으로바꾸어내측구획에가해지는과도한압력을줄여주는데있다. 환자본인의관절을살리며통증의경감을얻을수있는효과적인치료방법으로신중한환자선택과철저한수술전계획이필수적이다. 본종설에서는환자선택에서부터수술전검사및계획, 외측폐쇄형절골술의방법및주의할점, 수술의합병증, 절골술이후발생하는경골경사각의변화, 슬개인대의변화, 보행의변화를살펴보고그간보고된장기추시결과를고찰해본다. 수술의장점과한계점을파악하여적절한환자에게시행한다면관절염환자의통증경감에많은도움이될것이다. 색인단어 : 절골술, 근위경골절골술, 외측폐쇄형절골술, 관절염 접수일 2013 년 7 월 25 일수정일 2013 년 8 월 13 일게재확정일 2013 년 8 월 28 일책임저자이명철서울시종로구대학로 101, 서울대학교병원정형외과 TEL 02-2072-2368, FAX 02-2764-2718, E-mail leemc@snu.ac.kr 대한정형외과학회지 : 제 49 권제 2 호 2014 Copyright 2014 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.