서울대학교병원정형외과학교실이동연, 김일영 Surgical Treatment of Diabetic Foot Disease Dong Yeon Lee, Il Young Kim Department of Orthopedic Surgery, Seoul National Univesity Hospital, Seoul, Korea Abstract 88 Diabetic foot diseases which require surgical treatment consists of diabetic foot ulcer, infection and neuropathic arthropathy. Surgical procedures for diabetic foot ulcers and infections such as drainage, debridement, partial foot amputation and major limb amputation are most common procedures and arthodesis with or without deformity correction can be performed for specific diabetic neuropathic arthropathies. Underlying pathomechanism of diabetic foot disease includes diabetic peripheral neuropathy and vasculopathy. Treating physicians should be aware that concomitant complications of long-standing diabetic status such as cardiovascular and renal dysfunction should be addressed to treat intractable diabetic foot diseases successfully. However, with advent of adjuvant treatment which increases vascular supply on ischemic limb disease, proper surgical treatment on diabetic foot disease can prevent or delay major limb amputations, sustaining functional capability of diabetic patients. (J Korean Diabetes 2011;12:88-94) Keywords: Diabetic foot disease, Ulcer, Infection, Neuropathic arthropathy, Debridment, Partial foot amputation, Major limb amputation 당뇨병성족부질환의병태생리에는당뇨병성신경병증과혈관병증이원인요소로작용하며약물치료및창상소독등의보존적치료에도불구하고호전되지않는경우가있다. 수술적치료를요하는당뇨병성족부질환의대부분은족부에생긴궤양과감염이고, 그밖에는신경병성관절병증 (neuropathic arthropathy) 으로인한관절파괴나변형이있다. 수술적치료를결정하기에앞서수술적치료의대상이되는당뇨병성족부질환환자들은대부분장기간당뇨병을앓아온환자들로혈당조절이잘되지않아심혈관계및망막, 신장등에도합병증을동반하는경우가많다는점을고려하여야한다. 따라서, 수술전후의위험도평가및위험관리에많은주의를기울여야하며수술적치료가성공을거두기위해서는적극적인혈당조절및신체기능을유기하기위한보존적치료가적절히이루어져야한다. 궤양및감염 당뇨병환자에서당뇨병성신경병증으로인한감각저하와함께당뇨병성혈관병증으로인한허혈상태가동반되면족부에생긴창상이잘치유되지못하고, 만성궤양화되며, 화농성염증이발생하게된다. 하지만, 당뇨병성혈관병증이없는경우에도혈당관리가잘되지않는경우에는정상적인창상치유기전이작용하지못하여감염의치유도지연되는것으로알려져있다. 말초신경병증이궤양을일으키는가장중요한원인이며궤양이있는환자중 80% 이상에서말초신경병증을가지고있다 [1]. 당뇨병성족부궤양의분류에는 Wagner 의분류가흔히사용되어왔으며 (Table 1) 이는창상의깊이를기준으로분류하는방법이다 [2]. 최근에는궤양의깊이와허혈의정도를나누어구분하는깊이 - 허혈 (Depth- 교신저자 : 이동연, 서울시종로구대학로 101 번지서울대학교병원 8 층정형외과의국, E-mail: leedy@snu.ac.kr
Ischemia) 분류법 (Table 2) 이도입되어많이사용되고있다 [3]. 1. 비수술적치료 비수술적인치료로는궤양이감염이없고, Wagner 분류상 1,2 등급의표재성이고, 하지혈류에큰문제가없을경우거즈, 필름, 하이드로콜로이드, 하이드로겔, 알지네이트, 폼등을이용하는고식적인창상치료와혈소판기원성장인자 (Platelet Derived Growth Factor, PDGF) 나섬유아세포성장인자 (Fibro-blast Derived Growth Factor, FDGF) 와같은다양한성장인자, 콜라겐등을사용한드레싱방법, Dermagraft 와같은국소적인약물요법과고압산소요법또는전접촉석고 (Total Contact Cast) 등을시도해볼수있다. 그외에여러가지약물치료가시도되고있으나아직까지그유용성이확실하지않고비용이매우높아경제적인부담이있다. 전접촉석고로치료할경우 5~8 주에 Table 1. Wagner-Meggitt classification Grade 0 Grade 1 Grade 2 Grade 3 80~90% 에서궤양의치유를얻을수있으나약 30% 내외에서다시재발한다고한다 [4]. 감염이있는당뇨병성족부궤양의경우에는주로혐기성균과호기성균의혼합감염으로심부농양을형성하고근막을따라빠르게전파되고, 허혈과대식세포의기능저하등면역력이저하되며신장기능저하로전신적항생제투여에반응이뚜렷하지않고혼합치료 (cocktail therapy) 가곤란하여치료가어렵다. 2. 수술적치료 수술적치료로는궤양이골, 인대, 근막등심부까지진행되고심한골및연부조직감염이동반된경우에시행하며크게국소변연절제술, 재건술과절단술로나뉘며그외교감신경절제술, 동맥재건술등이있다. 1) 국소변연절제술국소변연절제술은혈관병증이심하지않은경우에는 Pre-ulcerative lesions; healed ulcers; presence of bony deformity Superficial ulcer without subcutaneous tissue involvement Penetration through the subcutaneous tissue: may expose bone, tendon, ligament, or joint capsule Osteitis, abscess, osteomyelitis 89 Grade 4 Partial foot gangrene Grade 5 Gangrene of the entire foot Adapted from Wagner. Orthopedics 1987;10:163-72 [2]. Table 2. The depth-ischemia classification of diabetic foot lesions Depth classification 0 The at-risk foot: previous ulcer or neuropathy with deformity that may cause new ulceration 1 Superficial ulceration, not infected 2 Deep ulceration exposing a tendon or joint (with or without superficial infection) 3 Extensive ulceration with exposed bone and/or deep infection Ischemia classification A Not ischemic B C Ischemic without gangrene Partial (forefoot) gangrene of the foot D Complete foot gangrene Adapted from Wagner. Orthopedics 1987;10:163-72 [2] and Brodsky. Instr Course Lect 1999;48:289-303 [3].
90 모든괴사조직, 굳은살, 농루 (s i n u s t r a c t), 누공 (fistula), 염증이있는골조직과연부조직및인대와같은무혈성조직등을모두제거하고배농술을실시하여야하며, 이때괴사조직의제거는반드시건강하고충분한출혈이있는조직이나올때까지시행하여야한다 (Fig. 1). 그러나제거이전에상처부위로의혈류상태를고려해야함은물론인데심한혈관병증이동반된궤양에서는괴사조직의제거술자체가더큰상처를만드는것이므로광범위한제거술은삼가고가급적괴사된조직만을제거하는것이좋다. 이후상처의상태에따른적절한상처드레싱을실시하여건강한육아조직이차오르게유도해야한다. 환자의입장에서상처치료에있어가장중요시되는점은반드시흡연을금지하고상처부위의체중부하를가급적금지시키는것이며이를위해적절히고안된신발이나운동화, 보행보조기, 목발등을사용하거나전접촉석고붕대등이권장되고있다. 2) 재건술재건술의목적은양발로보행이가능하게하고, 족부재건시골격계변형을교정하여궤양이재발하는것을방지하는데있다. 따라서궤양이 5 번중족골두부위에있으면중족골경부부터제거하는것이좋고, A B 2 번부터 4 번중족골두에궤양이있으면족배부를통해서절골술을하여족저부로돌출된중족골두를족배부로재위치시켜야한다. 1 번중족골두에생긴궤양은이곳에염증이있을때만제거하고가능하면보존해야한다. 족저부중간에생기는궤양도골성돌출과관계가있는경우가많으므로제한된골고정으로교정해주어야재발을방지해줄수있다. 재건술에는식피술, 국소피판술, 유리조직이전술등이있으며사용되는피판은감각의재생이가능하여체중부하시방어감각을유지할수있고, 감염을조절할정도의혈류공급이좋은조직이어야하며신발을착용하기에적합한모양을얻을수있어야하며보행중에발생하는전단력에저항할정도의내구성을갖추어야한다 [5,6]. (1) 식피술궤양결손부위가깊지않고, 건이나골등이노출되지않았을때우선적으로고려될수있다. 감염등이다조절되고난후피하에육아조직이충분히형성되면환자의다른공여부로부터부분층피부를채취하여이식을시행할수있다. 비교적간단한수술로서큰범위의피부결손을복구할수있어많이사용되는방법이다 (Fig. 1). C Fig. 1. Severe diabetic foot disease with infection was treated surgically by repeated debriment, negative pressure wound therapy (NPWT) and partial thickness split skin graft. (A) Debridment of severe diabetic foot disease with intractable infection. (B) Induction of healthy granulation tissue using NPWT. (C) Reconstruction of skin defect using split thickness skin graft after complete infection control.
(2) 국소피판술감염이동반되어건이나근막등이노출된경우에비교적크기가작고혈행이잘유지될경우에시행해볼수있으며전신상태가좋지않은당뇨병환자에게적절한수술방법으로사료된다. 장점으로는족부결손부위를족부조직으로덮어줄수있으나회전축에따른적용범위의제한성, 혈액순환의저하로인한실패가능성과결손부위가큰경우에는부적합할경우가많다. 족저부재건에이용할수있는국소피판은대개후경골동맥에의해혈액공급을받으므로이부위의혈관에병변이있는지확인해야한다. 따라서혈관우회수술을전경골동맥이나비골동맥에시행하면국소동맥피판을사용하지못하므로유리피판을사용하여재건하여야한다. 혈관의병변확인은혈관조영술과같은침습적인검사보다는초음파나도플러를이용한혈류측정을하는것이좋을것으로사료된다. 그러나궤양의크기가크거나비침습적인검사에서혈류장애가의심되는경우는혈관조영술을시행하여유리조직이식술의가능여부, 절단술의필요여부, 절단술의범위등을결정할수있을것으로사료된다. 국소피판의단점으로는감각피판을얻기힘들다는점인데이로인한궤양의재발가능성이높고새로운궤양의발생도고려해야할것이다 [6]. (3) 유리피판술궤양의적절한변연절제술후감염이조절되었을때식피술이나국소피판술로피복되지않는연부조직결손에사용될수있는데특히건이나골조직이노출되었을때유용한적응증이될수있다. 유리피판의장점으로는술자에의해크기를조절할수있고좀더근치적으로괴사및감염된조직이나반흔조직을제거할수있는장점이있지만비용이많이들고보행이가능할때까지의치료기간이길다는단점이있다 [7]. 인조혈관이식술은당뇨병이나신부전이있는환자에서는수술의부적응증일뿐아니라수술실패의주요원인으로여겨지고있다. 하지만인조혈관이식술과유리피판술을동시에시행하여성공한예가보고되고있고, 이런수술방법이절단의높이를제한하고치유속도를촉진시키고조기보행이가능하게하며주변조직의저항을낮추어혈행을개선시키며또한이는감염을예방하며혈관을새로자라게할수있어궁극적으로사지를보존할수도있어고려해볼수도있다 [8-10]. 3) 절단술장골 ( 長骨, long bone) 부위에서자르는것을절단, 관절부위에서자르는것을관절이단 ( 關節離斷, disarticulation) 이라고한다. 수술시절단단 (stump end) 을봉합하는것은폐쇄성 ( 閉鎖性, closed) 절단이며, 절단부위에잔존하는감염등을치료하기위하여절단단을한시적으로열어놓은것을개방성 ( 開放性, open) 절단이라한다. 최근까지도절단술은당뇨병성족부궤양의주된수술적치료였다. 현재도적절한보존적치료에도반응을보이지않는저항성감염이나허혈성손상으로인한괴사소견이있을때에는 1 차적으로고려되는수술방법이다. 하지만, 당뇨병환자에서하퇴절단이나대퇴절단후활동능력이현저히떨어지고 5 년내사망할확률이높아진다는점을감안하여최근에는최대한발뒤꿈치를살리는제한적인절단술을시행하면서절단단의생존을돕기위한추가적인시술을시행하는방법들이많이시도되고있다. 제한적절단술을시행할때는절단부끝에통증이없으면서외상에견딜수있게재건해야한다 [11,12]. (1) 족지절단 (Toe Amputation) (Fig. 2) 발가락이괴사된경우나창상이골수염등으로진행하여낫지않는경우발가락뼈 ( 족지골 ) 부위에서절단수술을시행하게된다. 괴사가있는부위바로근위부의지골을절단하고연부조직을봉합하면모양으로도큰차이가없고보행에도큰지장이없을수있다. 다만무지의경우중족골 - 족지관절에서이단술을시행할경우보행시감아올림효과 (windlass effect) 가없어지므로보행에지장이오게된다. 무지를절단할경우다른족지들에족저부에궤양이생길가능성이높으면, 중간발가락 (2,3,4 지 ) 의절단시주변발가락의변형이필연적이기때문에두개이상의족지를절단해야할경우족지전체를절단하는것이오히려결과가좋다. (2) 중족골절단 (Transmetatarsal Amputation) (Fig. 2) 여러발가락이괴사되어있거나괴사부위가근위부로퍼지는경우, 감염이동반되어있는경우중족골을통해발앞쪽부위를전체적혹은부분적으로절단하게되는데, 하나나두개의발가락에괴사가진행되어중족골부위에서절단할경우족지열절단 (lay amputation) 이라하고발가락전체가괴사혹은감염되어전체를절단할경우전체중족골절단 (total transmetatarsal amputation) 이라고한다. (3) 리스프랑절단 (Lisfranc Amputation,Metatarso- Tarsal Joint Disarticulation) (Fig. 2) 리스프랑관절이란발중간부위의중족골 (metatarsal) 과족근골 (tarsal bone) 이이루는관절로이부위에서 91
절단하는것을리스프링절단이라고한다. 뒤꿈치로디딜수있는장점이있으나첨족변형 ( 발목이아래쪽으로꺽이는변형 ) 이발생할가능성이높아많이사용되지는않는다. (4) 쇼파절단 (Chopart Amputation, Mid-tarsal Joint Disarticulation) (Fig. 2) 쇼파관절이란발중간부위의족근골사이에이루어지는관절로이부위에서절단하는것을쇼파절단이라고한다. 쇼파절단역시뒤꿈치로디딜수있는장점이있으나첨족변형 ( 발목이아래쪽으로꺽이는변형 ) 이발생할가능성이높다. (5) 사임절단 (Syme Amputation) (Fig. 2) 발목관절보다 1 cm 정도상방부위에서경골및비골을절단하고, 거골과종골 ( 발뒤꿈치뼈 ) 을제거한후발뒤꿈치의두꺼운피부판을이용하여절단단을형성함으로써체중부하가쉽도록절단하는방법이다. 절단시에는내과와외과부위의튀어나온부위를절제해주어야의지착용시나보행시피부에가해지는압력을줄일수있다. 리스프랑절단이나쇼파절단에비해서도더효과적인의지착용이가능할수있다. (6) 하퇴절단 (Transtibial Amputation, Below Knee Amputation) (Fig. 3) 많이시행되는표준절단술로경골과비골의중간부를통해서절단이이루어지며절단단의길이가 12.5~17.5 92 Fig. 2. Amputations around foot and ankle. Fig. 3. Major amputations of lower limb.
cm 이이상적이다. 이보다짧으면짧은하퇴절단이라고하는데, 하퇴의지를착용하기위해서는최소한 3~5 cm 의절단단이필요하다. (7) 대퇴절단 (Transfemoral Amputation, Above Knee Amputation) (Fig. 3) 하퇴절단과함께표준적인절단술로대퇴골의중간부위에서절단이이루어지는데, 슬관절의지착용을위해서는슬관절에서약 10 cm 상부에서절단하는것이좋다. 정상측의 35% 이내를남기는절단을짧은대퇴절단이라고아는데, 이경우에도최소한소전자부에서 5 cm 이상의길이가보존되어야한다. 신경병성관절병증 (Neuropathic Arthropathy) 신경병성관절병증이란중증의감각신경마비가있는환자에게서저절로발생하는뼈와관절의손상으로정의되며, 당뇨병, 매독, 척수공동증, 말초신경손상, 나병등으로인한감각신경마비가원인으로알려져있으며최근에는당뇨병으로인한신경병성관절병증의발생이가장큰원인을차지한다. 우리나라는선진국에 A 비해당뇨병성신경병성관절병증의빈도가적은편이기는하지만점차빈도가증가하는것으로알려져있으며특히오랜기간이환된당뇨병환자가증가함에따라급격히증가할가능성도있다. 당뇨병성신경병성관절병증시에는뼈의흡수와파괴가나타나는것이일반적이며급성염증기에는골수염과같은다른당뇨합병증과감별하는것이중요하다. 기본적으로는수술전후의결과가좋지않고불유합이나감염등의합병증의빈도가높기때문에보존적인치료를하는것이원칙이지만, 보존적인치료의단점으로오랫동안체중부하를하지못한다는점, 환자가의사의지시를잘따르지않아악화될가능성, 석고나보조기에의한피부손상등이있어수술적치료가필요한경우가있다 [13, 14]. 수술적치료를시행할경우에는변형을교정하고견고한내고정을시행하며, 자가골이식등의방법을통해골형성을촉진하여야합병증의빈도를낮출수있다 (Fig. 4). 참고문헌 01. S Levin ME. Preventing amputation in the patient with 93 B Fig. 4. Case of diabetic arthropathic patient. (A) Severe bone destruction and resorption due to diabetic neuropathic arthropathy. Usually patients complain lesser degree of pain than nonneuropathic arthritic patients because of neuropathy. (B) We achieved successful ankle fusion by stable fixation of ankle joint and addition of autogenous bone graft.
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