ORIGINAL ARTICLE 대한족부족관절학회지제 17 권제 3 호 2013 J Korean Foot Ankle Soc. Vol. 17. No. 3. pp.196-202, 2013 인제대학교상계백병원정형외과학교실, 대림성모병원정형외과 * 배서영 박재구 * 정의엽 Surgical Treatment of Achilles Tendon Rupture with Absorbable Suture Materials Only Su-Young Bae, M.D., Ph.D., Jae Gu Park, M.D.*, Eui Yub Jung, M.D. Department of Orthopedic Surgery, Sanggye Paik Hospital, Inje University, Seoul, Korea, Department of Orthopedic Surgery, Daelim St. Mary s Hospital, Seoul, Korea* =Abstract= Purpose: To report the clinical results from using absorbable suture materials instead of nonabsorbable materials which have been used more commonly to repair Achilles tendon. Materials and Methods: We retrospectively reviewed 21 cases of acute Achilles tendon rupture, treated surgically from 2004 to 2011. Mean follow-up period is 6 months. We repaired Achilles tendon using size 1 Vicryl (Polyglactin 910, Ethicon) for core suture and size 3-0 Vicryl for epitendinous suture. At three months after surgery, we evaluated clinical results with single heel raise height by centimeters, differences of calf circumference and passive range of motion of ankle joint, compared to contralateral side. Also we recorded clinical results with subjective satisfaction grades. Results: At three months after surgery, 20 of 21 patients were able to perform single heel raise over 5 cm in height. Calf circumference differences were less than 1 cm in 12 cases, between 1 cm to 3 cm in 5 cases, more than 3 cm in 4 cases. There was no difference in range of passive motion in 19 cases. All patients satisfied with daily activity except 2 cases with mild discomfort. There was no complication such as rerupture, elongation or infection. Conclusion: We experienced excellent clinical results from repairing Achilles tendon with using absorbable suture materials in terms of functional outcomes and patient s satisfaction without any complication. So we may consider using absorbable suture materials instead of nonabsorbable materials to repair Achilles tendon. Key Words: Achilles tendon, Acute rupture, Open repair, Absorbable suture material Received: July 14, 2013 Revised: August 11, 2013 Accepted: August 20, 2013 Corresponding Author: Su-Young Bae Department of Orthopedic Surgery, Sang-Gye Paik Hospital, Inje University, Dongil-ro 1342, Sanggye-dong, Nowon-gu, Seoul 139-707, Korea Tel: +82-2-950-1399 Fax: +82-2-950-1398 E-mail: youngos@paik.ac.kr 본논문의요지는 2012 년도대한족부족관절학회추계학술대회에서발표되었음. 서론 아킬레스건은인체에서가장크며, 강력한건으로최근여가및스포츠활동의증가로파열의발생빈도가증가하고있다. 아킬레스건파열의수술적치료와보존적치료사이에는아직까지논란이있으나, 수술적치료가일반적으로받아들여지고있다. 1-4) 봉합술에는보편적으로 - 196 -
비흡수성봉합사가사용되고있는데, 그이유는조작이쉽고, 인체에무해하며, 인장강도의감소가적은장점이있기때문이다. 하지만비흡수성봉합사는건치유과정에서매듭에의한육아종, 섬유화, 걸림 (Triggering) 이발생할수있고, 봉합사가건실질내에영구적으로남아이물반응을유발할수있다. 5) 저자들은체내에서소실되기때문에이물반응을유발하지않고, 초기인장강도가충분한흡수성봉합사인 Polyglactine absorbable suture (Vicryl) 을이용하여아킬레스건봉합후비교적우수한결과들을경험하였기에이를후향적으로분석하여안정성을평가해보고자하였다. 대상및방법 1. 연구대상 2009 년 4 월부터 2012 년 12 월까지급성아킬레스건 파열로본원에내원하여일차봉합술을시행받았던 21 예를대상으로하였다. 평균추시기간은 6개월이었으며우측이 5예, 좌측이 16예였으며남자가 14예, 여자가 7예였고평균나이는 44세 (23~59세) 였다. 족저건 (Plantaris tendon) 이남아있어이를이용하여보강술을시행할수있었던경우는 8예였다. 2. 수술방법환자를전신마취또는척추마취후복와위로위치시킨뒤, 수술전건측아킬레스건의긴장정도를슬관절 90도굴곡하여저항이없는상태에서의족저굴곡각을측정하거나사진으로남겼다. 파열부위를중심으로아킬레스건내측을따라약 15 cm 정도종절개를가한후아킬레스건을싸고있는건주위조직 (paratenon) 과건중간막 (mesotenon) 을절개하여파열된아킬레스건을노출시킨후파열단의변연절제술을시행하였다. 건파열의형태를파악하여단순파열인경우에는 Modified Kessler 술식을, 파쇄파열 (Shredded) 인경우 Krackow 술식을이용하여 1번 Vicryl로중심봉합하였다. 봉합건의긴장도는전술한바와같이측정된건측의 Figure 1. We adjusted core suture tension by 10 degrees of plantar flexion compared to contralateral side with 90 degrees of knee flexion. Figure 2. We repaired Achilles tendon using size 1 Vicryl for core suture with Krackow technique and size 3-0 Vicryl for epitendinous suture. - 197 -
배서영 박재구 정의엽 각도에비해약 10도정도족저굴곡된상태로유지되도록조절하였다 (Fig. 1). 근위및원위파열단이완전히접촉된상태에서봉합사매듭이파열단내에위치하도록하고 3-0 Vicryl 을이용해파열된건주위를한바퀴돌아가면서연속봉합하였다 (Fig. 2). 족저건이파열되지않고남아있으면이를근위근건연결부에서채취하여파열부를통과한후남은길이의족저근을펼쳐서파열부위에보강하였다. 절개했던건주위조직을 4-0 Vicryl을이용하여전, 후면을연속봉합하고, 근막봉합후배액관을삽입하였으며, 피하층과피부를차례로봉합하였다. 3. 재활방법수술후 2주째피부봉합사를제거하고, 4주까지족저굴곡상태에서단하지석고고정후비체중부하보행을유지하였다. 4주부터각 1 cm 높이의 5개의쐐기를중첩시켜후족부를거상된상태로단하지경첩보조기를착용시켰으며 (Fig. 3) 환측하지를전방에위치시킨상태로체중부하보행을허용하였다. 중첩된쐐기는 3~5일마다하나씩점차제거하였다. 수술후 6주째발뒤꿈치가중립위상태에도달한후체중을이용하여수동적스트레칭을시작함과동시에양쪽발뒷꿈치의능동적거상운동을시행하였으며, 근력호전후점 차한쪽발뒤꿈치의능동적거상운동을시켜보조기는 3개월까지점진적으로제거하였다. 3개월째부터는보조기없이일상생활로복귀를허용하였으나, 스포츠활동은 6개월까지제한하였다. 4. 임상적결과기록 1) 근력의평가결과수술후임상결과의평가로종아리근력정도는한쪽다리로선상태에서발꿈치를능동거상시켜지면에서발뒤꿈치까지의높이로측정하였고, 5 cm 이하, 5~10 cm, 10 cm 이상으로분류하였다. 종아리의최장둘레를측정하여양측종아리둘레차이를 1 cm 이하, 1~3 cm, 3 cm 이상으로분류하였다. 2) 관절운동범위측정양측족근관절의수동적족배굴곡운동범위는건측과비교하여그차이가 5도이하, 5~10도, 10도이상의세단계로구분하여평가하였다. 3) 환자의주관적만족도환자의주관적만족도는불편감없음, 가벼운불편감, 보행시불편감, 보행이불가능한경우로나누어기록하였다. 4) 합병증합병증으로재파열, 감염, 창상괴사, 건의결절성구축, 늘어남여부를확인하여기록하였다. 결 과 1. 근력의평가결과 수술후 3개월추시에서 1예를제외하고 20예에서는한쪽발뒤꿈치들림이가능하였다. 종아리근력정도의지표로삼은발뒤꿈치와지면사이의거리는 5~10 cm 이 19예, 10 cm 이상이 1예였다. 양측종아리둘레차이가 1 cm 이하인경우 12예, 1~3 cm 사이인경우 5 예, 3 cm 이상인경우는 4예가있었다 (Table 1). Figure 3. We used hinged short leg brace at 4 weeks after surgery with five heel wedges. Each wedges has 1 cm height - 198 -
2. 관절운동범위 양측족근관절의수동적족배굴곡운동범위의차이가 5도이하가 19예, 5~10도차이는없었으며, 2예에서 10도이상의차이를보였다 (Table 1). 3. 환자의주관적만족도 환자의주관적만족도는불편감없음이 19예였고간헐적으로가벼운불편감을호소한경우가 1예, 보행시당기는느낌을호소하는경우가 1예있었다. 4. 합병증 재파열이나창상관련합병증, 건의결절성구축, 늘어남은없었고, 술후 6개월째모든환자에서정상보행과일상생활이가능하였다. 고 찰 아킬레스건파열의치료는크게보존적치료와수술적치료로나눌수있으며, 보존적치료를주장하는학자들은수술적치료가감염, 창상반흔, 동통, 종괴, 피부괴사및유착등의많은합병증을가지고있으며, 이러한합병증으로인해술전의활동력이얻을수없다고주장한다. 10-13) 반면에수술적치료를주장하는학자들은비수술적치료가족저굴곡력약화, 건이신연된 Table 1. Clinical Parameters at 3 Months after Repair of Achilles Tendon. Parameters Number of cases Height at single heel raise 5~10 cm 19 10 cm 01 Difference of calf circumference 1 cm 12 1~3 cm 05 3 cm 04 Difference of passive ROM 5 19 5~10 00 10 02 상태에서치유되는점, 재파열빈도가높다는것을이유로수술적치료의합병증에도불구하고빠른시일내에환자를일상생활로복귀시키기위해서수술적요법이시행되어야한다고주장한다. 1,14-20) 두치료에대해서는아직논란이있으나, 우리나라에서는재파열의위험성이적고, 파열부를정확히봉합할수있으며, 빠른재활이가능한수술적치료를보편적으로선호한다. 파열된아킬레스건봉합수술에는일반적으로비흡수성봉합사를흔히사용한다. 비흡수성봉합사로는 Ticron, Ethibond, Mersilene, Prolene, Nylon이있으며, 이중 Ethibond를가장많이사용한다. 21-24) 비흡수성봉합사는조작이쉽고, 생체에무해하며, 인장강도의감소가적은장점이있지만건치유과정에서매듭에의한육아종, 섬유화등이발생할수있고봉합사가체내에존재해조직반응을유발하는단점이있다. 5,6) 아킬레스건개방성봉합수술후비흡수성봉합사에의한합병증에대한보고는없으나경피적으로비흡수성봉합사를이용해아킬레스건봉합시결찰부위의자극증상이나 23) 매듭에의한자극으로걸림 (triggering) 25) 등이발생한다는보고들로미루어보았을때비흡수성봉합사의잔존이자극을줄수있다고판단된다. 이러한것을우려하여본저자들은이물반응이지속되지않고, 매듭의안정성이높으며, 7-9) 인장강도가충분한흡수성봉합사를사용해왔고이로인한별다른합병증없이경과가양호하여흡수성봉합사가아킬레스건과같은큰건의봉합에도안전하다고판단하여사용하였다. 흡수성봉합사는일반적으로인장강도의소실과, 체내에서염증반응이적고, 매듭의안전도가높고, 적절한인장강도를가져최근건봉합시흡수성봉합사의이용이늘어나고있고대표적으로 PDS와 Vicryl이많이사용되고있다. 7-9) 현재아킬레스건파열의치료시일반적으로사용되는비흡수성봉합사인 Ethibond, Ticron과 Vicryl을비교했을때 2번 Ethibond와 1번 Vicryl은단면적이비슷하며, 기계적강도인최대파손하중, 변형율, 강성에서유사하여 9) 비슷한인장강도를가진다고볼수있다. 또한Vicryl의인장강도는시간이경과할수록약해져체내에서 4주경과후초기강도의 25% 로감소하고 8~10주경과후체내에흡수된다고한다. 9) 그러나봉합된건의인장강도는봉합후 3일까지감소하고이후점진적으로증가하고 4주후봉합된건의강도는봉합직후의강도에비해 8배증가하고 - 199 -
배서영 박재구 정의엽 Vicryl은 4주째초기인장강도의 75% 가감소한다고한다. 26) 따라서저자들의재활방법에따른다면석고고정을제거하고재활을시작하는시기에봉합후점진적으로증가된건의강도자체가감소한 Vicryl의인장강도를충분히보상해줄수있다고생각된다. 아킬레스건파열후합병증으로건괴사에의한건병증이보고된바있다. 27-29) 이는아킬레스건이종아리부위에서 90도꼬여종골조면에붙게되고, 혈액공급은근위부에서는비복근내의동맥분지로부터원위부에서는종골의건부착부에서골간혈관으로부터건주의조직을통해서이루어져종골의건부착부에서근위부로 2~6 cm 부위가상대적으로혈관공급이취약하고, 30-32) 파열후발생하는섬유화및퇴행성변화들로인한증가된혈액공급으로인한것이라고생각된다. 아직까지아킬레스건괴사에의한건병증과비흡수성봉합사와의직접적인연관성을밝힌논문은없지만본저자는비흡수성봉합사가매듭이지어진채로영구히체내에존재하여지속적으로건을혈액공급을방해할수있고, 또한매듭에의한섬유화등이상대적인혈액공급을저해하여건괴사를일으킬수있다고생각한다. 따라서이러한점으로보아초기에적절한인장강도를가지면서도시간이지나면서체내로흡수될수있는흡수성봉합사의사용이아킬레스건봉합에적절하다고생각한다. 본연구에서는술후 3개월째추시에서 21예중 20예에서한쪽발뒤꿈치들림이가능하였다. 여러연구에서는대부분 6개월이전에는이를측정하지않았고최소 6개월이후최종추시에서는대부분한쪽발뒤꿈치들림이가능하다고보고하고있다. 24,33-35) 따라서기존의연구결과들과정확한비교를할수없으나비교적조기에한쪽발뒤꿈치들림이가능했던것은양하지능동거상운동을보조기착용하에약 6~8주사이에스트레칭과함께시작하며이운동이어려움이없으면곧바로환측하지의능동거상운동을시켰기때문이라고판단된다. 환측하지로서서발꿈치를드는능력은단순히아킬레스건뿐아니라환측하지로서서균형을잡는내번근, 외번근과대퇴사두근, 고관절의외전근까지기능이회복되어야가능한데이는환측하지로서서균형을잡는운동을조기에시키면좀더용이해지기때문이다. 또한술후약6주부터환측하지를보조기착용하에전방에두고걷는것을허용하는데이것이고유감각을 보존하는데중요한역할을한다고생각한다. 그러나한쪽발꿈치들기가가능한시기에관한한, 향후많은사례에대하여검토와분석이필요할것이다. 본연구에서는 2 예에서건측에비해족관절의족배굴곡의범위가차이가난경우가있었다. 1예에서는술후 2개월째자의로보조기를제거한상태로일상생활을하여건측보다족배굴곡범위가늘어난경우였고, 한달간보조기를고정한채, 스트레칭을제한한후 4 개월추시에서건측과관절운동범위의차이는없었다. 다른 1예에서는수술후 8주째부터비골건주행을따라통증및동통이발생하여보행시불편감과한쪽발뒤꿈치들림이불가능하였으며, 정상적인재활스케줄을따르지못하여관절운동범위의제한이있어보행시당김을호소하였다. 이경우비골건염동반이의심되어 2주간휴식및소염진통제복용후통증은회복되었고, 최종추시에서는불편감없이일상생활로복귀하였다. 따라서술후 3개월째일부불편을호소하거나운동범위의차이를보였던경우로 6개월추시에서는별다른증상을남기지않아전예에서최종결과는우수하였다. 결론 본연구는아킬레스건파열의수술적봉합에있어서흡수성봉합사만을이용하였으며그임상적결과는기존의비흡수성봉합사를이용한봉합술의보고들과유사한정도로우수하였다. 또한전예에서매듭에의한자극이나이물반응이없으며재파열이나감염또한발견되지않아, 비흡수성봉합사잔존에의한합병증을피하기위해서는흡수성봉합사사용을권장할수있을것으로사료된다. REFERENCES 01. Cetti R, Christensen SE, Ejsted R, Jensen NM, Jorgensen U. Operative versus nonoperative treatment of achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med.1993;21:791-9. 02. Inglis AE, Sculco TP. Surgical repair of ruptures of the tendo Achillis. Clin Orthop Relat Res. 1981;160-9. 03. Nistor L. Surgical and non-surgical treatment of Achilles - 200 -
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