대한족부족관절학회지 : 제 10 권제 2 호 2006 J Korean Foot Ankle Soc. Vol. 10. No. 2. pp.207-212, 2006 골다공증과동반된족관절외과골절의지연나사를이용한치료 조선대학교의과대학정형외과학교실 이준영 이광철 Treatment of Ankle Lateral Malleolar Fractures Accompanying Osteoporosis using Lag Screw Jun-Young Lee, M.D., Kwang-Chul Lee, M.D. Department of Orthopedic Surgery, College of Medicine, Chosun University =Abstract= Purpose: To evaluate the results of ankle lateral malleolar fractures classified as Danis-Weber type B accompanying osteoporosis that were treated with lag screw. Materials and Methods: 15 cases of Danis-Weber type B ankle lateral malleolar fractures that had T score of less than -2.5 in BMD(bone mineral density) test were selected from June 2003 to December 2005. 10 cases were males and 5 cases were females with mean age of 59 years. The main injury mechanism was supination and external rotation. Mean follow-up period was 16 months. Clinical and radiologic evaluation was done according to Meyer and Kumler s criteria. Results: All cases showed satisfying result and mean radiologic bone union period was 3 months. Anatomic reduction and bone union was acquired in all cases without complications including wound infection, skin necrosis, delayed union and nonunion Conclusions: Lag screw fixation seem to be excellent treatment of Danis-Weber type B lateral malleolar fractures with osteoporosis as it can minimize soft tissue injury and enable anatomic reduction with firm fixation. Key Words: Lateral malleolus, Danis-Weber type B fracture, Osteoporosis, Lag screw 서 론 족관절골절의일차적치료목적은족관절을정상적기능으로되돌리는것이다. 전위된외과골절에서해부학적 Address for correspondence Jun-Young Lee, M.D. Department of Orthopaedic Surgery, Chosun University Hospital 588 Seosuk-Dong, Dong-Gu, Gwangju 501-717, Republic of Korea Tel: +82-62-220-3147 Fax: +82-62-226-3379 E-mail: leejy88@chosun.ac.kr * 이논문은 2006 년도조선대학교병원선택진료학술연구비에의하여연구되었음. 정복과견고한고정은이러한목적을만족시키기위해강조되어왔다 9,15,19,20). 내고정은정확한해부학적정복을유지하고술후합병증의발생없이충분한안정성을제공해야한다 13). 외과의골절의안정된고정에는금속판고정, 지연나사못고정, 환상강선고정등의여러가지치료방법들이쓰이고있다 15,18). 외측금속판고정술의가장큰단점은천공조작시천공기의끝이관절내로돌출되어발생하거나원위비골골편을잡기위한중립금속판을고정시키고자할때정확히측정하지못한긴나사를사용함으로써발생하는연골손상의위험성이크다는것이다. 이단점은 AO 원칙에따른외측
이준영 이광철 Ta b l e 1. Data of Patients Age/Sex BMD * (femur) No. of screw Associated injury F/U period 1 61/M -3.87 1 MM 18 2 55/F -4.58 2 12 3 60/F -3.98 1 MM 20 4 46/M -2.69 2 18 5 60/M -3.12 2 8 6 52/M -3.33 1 PM, Deltoid 13 7 68/F -4.45 2 12 8 57/M -2.62 2 6 9 55/M -3.11 2 MM 15 10 62/M -3.25 1 32 11 68/F -3.89 2 36 12 57/M -2.68 2 MM, PM, Syn, Deltoid 12 13 67/M -3.12 1 9 14 55/F -3.20 2 MM 14 15 66/M -3.41 2 15 * BMD, Bone marrow density; MM, Medial malleolar fracture; PM, Posterior malleoalr fracture; Deltoid, Deltoid ligament rupture; Syn, Syndesmotic injury. A B Figure 1. Oblique Danis-Weber type B fracture of lateral malleolus in a 55-year-old woman. (A) Preoperative anteroposterior and lateral views of X-ray show short fracture line less than 1.5 cm. (B) One 3.5 mm cortical lag screw fixation was done. 금속판을사용하여해부학적정복및견고한고정이이루어졌다하더라도임상적으로좋지않은결과를가져올수도있다 1,9,11,24). 족관절외과골절의 80-90% 는관상면상후방방향으로골절선을가진사상또는나선상골절양상을보이므로골절편간압박을주는술식이적절한치료방법이될수있다 6,14,15,18). 그리고비골은큰하중을견뎌야하는주요체중부하의뼈가아니므로외과골편은일반적으로적으므로중립 금속판이나지지금속판의사용외에도단지하나또는두개의피질지연나사만으로골절을해부학적정복하고안정적으로고정하는것은비교적안전하고효과적인방법이될수있다. 골다공증성골절의경우어떤내고정물을사용하더라도고정물의실패가일어날확률은일반골절의경우보다높다. 골다공증이동반된외과골절의경우금속판고정이나사만사용한고정보다는더안정적이지만금속판사용시 - 208 -
골다공증과동반된족관절외과골절의지연나사를이용한치료 발생하는합병증을고려하였을때다른수술방법또한대안이될수있다. 이에저자들은골다공증과동반된족관절외과골절중 Danis-Weber B형의골절에대해지연나사만을이용한치료의결과를보고하고자한다. 대상및방법 1. 대상 2003 년 6월부터 2005 년 12월까지 Danis-Weber B형의족관절외과골절이있었던환자중골밀도검사상 T-score 가 -2.5 이하의골다공증을가진 15예의환자를대상으로하였다. 남자가 10예, 여자가 5예였고평균나이는 59세 (46~68 세 ) 였으며주된손상기전은회내-외회전손상이었다. 골밀도검사상평균 T-score 는 -3.42(-4.8~-2.5) 였고동반손상으로내과골절이 5예, 후과골절이 2예, 삼각인대파열이 2예, 경비인대손상이 1예였다. 평균추시기간은 16개월 (6~36 개월 ) 이었다 (Table 1). 2. 수술방법모든골절에대해관혈적정복술을시행하고골편간지연나사고정술을시행하였다. 가능하면연부조직손상을최소화하기위해골절부을중심으로최소피부절개를시행하고골막을조심스럽게박리하였다. 골절을해부학적으로정복한후 AO-ASIF 지연나사고정방법을이용하여지연나사는골절면에수직으로삽입하였고비골의전방근위부에서후방원위부의방향으로나사를삽입하였다. 수술장에서 골절면의길이를재어 1.5 cm 미만의짧은사선형의골절에는하나의나사를사용하였고 (Fig. 1), 1.5 cm 이상의사선또는나선형의골절에는두개의나사를사용하였다 (Fig. 2). 사용한나사의수는 5예 (33%) 에서 1개, 10예 (67%) 에서 2개를사용하였다. 모든예에서 AO 3.5 mm 피질나사를사용하였으며고정후겸자를이용하여골절편을앞뒤로밀고당기는등의시도를하여안정성을평가하였다. 나사를삽입시입구를넓혀서피질골안에나사의머리부분이들어가도록한후절개하였던골막과연부조직을완전하게봉합하였다. 동반된내과골절에대해서는관혈적정복술을시행하고유관나사및 K-강선을이용한내고정을시행하였다. 후과골절에대해서는관절면의 25% 가넘는골절에대해나사못고정술을시행하였다. 경비결합인대의손상에대해서는외과고정술을시행후에도 2 mm 이상의불안정성이존재하면삼면피질나사못고정을시행하였다. 술후처치로 6주간단하지석고붕대로고정하였으며처음 4주간은비체중부하를실시하고이후 2주간은부분체중부하를허용하였다. 술후 6주째석고붕대제거후관절운동및견딜수있는범위내에서완전체중부하를허용하였다. 3. 결과판정모든환자들에대해인터뷰를실시하였고임상적, 방사선학적으로검사를실시하였다. 임상적으로동통및진통제사용유무, 강직정도, 부종정도, 보행보조기등의사용유무, 직업에미치는영향등을질문하였으며족관절의운 A B Figure 2. Oblique Danis-Weber type B fracture of lateral malleolus in a 4 6-y ea r-old m an. ( A) Preoperative an terop ost erior and lateral views of X-ray show long fracture line more than 1.5 cm. (B) Two 3.5 mm cortical lag screw fixation was done. - 209 -
이준영 이광철 Table 2. Criteria used in Assessment of the Result (Meyer and Kumler, 1980) Result Excellent Clinical No pain with full range of motion Radiologic Normal X-ray Calcification of interosseous ligament or deltoid ligament Good Pain after strenous activity with 15 loss of motion Fair Pain with normal activity, 15 ~ 30 loss of motion Maunion or nonunion Poor Constant pain, over 30 loss of motion Joint narrowing, marginal osteophyte A B C D Figure 3. Spiral Danis-Weber type B fracture of lateral malleolus in a 56-year-old woman. (A) Preoperative anteroposterior and lateral views. (B) Immediate postoperative radiographs show anatomic reduction with no visible fracture gap on the lateral malleolus fixed with two 3.5 mm cortical lag screw in the anteroposterior and lateral radiographs. (C) Radiographs taken 3 months after the operation show bony union and no osteoarthritic change. (D) Lag screw was removed by local anesthesia in 13 months after operation. 동범위를 측정하였다. 방사선학적으로 족관절 전후방, 외측 및 격자상 방사선 사진을 촬영하고 골 유합 유무, 관절 간격 의 협소, 변연부 골극의 형성, 골간막이나 삼각인대의 석회화 등에 대해서 조사하였다. 최종 결과 판정은 Meyer 와 Kumler13)의 평가 기준에 따라 매우 만족, 만족, 보통, 불만족의 네 그룹으로 나누어 평가하였다고 합병증의 유무 를 조사하였다(Table 2). - 210 - 결 과
골다공증과동반된족관절외과골절의지연나사를이용한치료 전예에서해부학적정복및골유합을얻을수있었으며방사선학적평균골유합기간은 3개월 (2.5~4.4 개월 ) 이었다. 임상적으로일상생활에불편함을호소하는환자는없었고 1예에서족관절의운동범위감소와오래걸었을때동통을호소하였다. 최종추시상임상적으로 14예에서매우만족, 1예에서만족의결과를보였다. 방사선학적으로는관절간격의협소나골극의형성소견은관찰되지않았다 (Fig. 3). 창상감염이나피부괴사와같은국소합병증은없었으며지연유합및불유합, 부정유합등의합병증도관찰되지않았다. 천공시술중발생하는비골건의손상과관련된합병증도없었다. 고찰족관절골절에있어외과의전위는거골의전위를초래하기때문에외과의정확한해부학적정복이선행되면, 거골과내과의해부학적정복도함께수반되어불안정성및합병증을줄일수있다. 족관절외과골절의치료에있어현재까지는일반적으로 AO-ASIF 원칙에의거하여외측금속판및지연나사의고정이정설로받아들여지고있다. 몇몇저자들은이러한방법으로치료한수백명의환자들을대상으로한연구에서 90% 이상만족할만한결과를얻었다고하였고 3,5,11) Mak 등 15) 도금속판을이용한치료에서 80% 이상의좋은결과를보고하였다. 하지만금속판을사용하였을때발생하는합병증들은여전히존재하고, Lindsjo 11) 는금속판을사용하여고정한외과골절환자중 12% 에서외상후관절염이발생하였다고하였다. Bauer 등 1) 도 AO-ASIF 원칙에따라정확하게정복하고금속판으로고정한환자들에서수상후 5년이상잔존하는금속판으로인한불편함이있으며관절염의발생율이높다고하였고이원인으로수술이손상받은관절연골에부가적인손상을주었을것이라고하였다. 본연구에서는전예에서관절간격협소의소견이관찰되지않았고이결과는이전에발표된외측금속판고정시발생하는높은관절염의유병률에비해매우낮다는것을보여준다. Wilson 과 Skilbred 24) 는비수술적으로정확하게정복한경우보다금속판이나금속핀을사용하여수술적으로정확하게정복한경우관절염이더빈발하였다고하였고본연구에서관절염의발생하지않은이유는나사가골절양상에따라전방에서후방의방향으로삽입되기때문에나사를고정할때발생하는우발적인관절연골의손상의위험성이없었기때문이라고생각된다. 골절후골유합에관계하는요소들중연부조직의손상정도는생물학적관점에서매우중요하다. 일반적으로금속판을이용한치료의경우골절부를노출하고금속판을고정하기위해비교적광범위한연부조직박리를필요로하며이러한것들이골유합에음성적인요인이된다. 하지만지연나사를사용할경우비교적적은피부절개와금속판보다작은종면적을가지고있는 3.5 mm 피질나사의사용으로연부조직손상을최소화할수있고나사삽입구를넓히는조작으로절개한골막을완전하게봉합할수있어서골절유합에더좋은환경을제공할수있다. 금속판을사용하여외과고정후발생하는국소창상합병증으로는창상의와해나창상주변부의괴사, 감염등이있다 3-5,11). 특히손상정도가심하여골절부의부종이심하였던경우국소창상합병증의가능성이높으며금속판자체의이물감및자극으로인해금속판의노출이나골수염의빈도가증가할수있다. 하지만지연나사를이용하여고정할경우기구의작은종면적과적은연부조직의박리로이러한국소합병증의빈도를줄일수있다. 본연구에서도이러한국소창상합병증은발생하지않았다. 금속물제거술을시행하여야할때는두가지인자를생각해야한다. 금속물과관련된불평과생역학적인측면이다. Jacobson 등 10) 은금속강선이나스테플을이용한고정으로치료한환자보다외측금속판고정으로치료한환자에서금속물과관련된불평이더많았다고하였고 Schaffer 등 6) 은외측금속판고정시금속판으로인한자극으로금속판제거술이필요하다고하였다. 지연나사를이용하여고정을시행할경우나사가골간단부에위치하기때문에생역학적인회복을위한외과의나사제거술등의이차적인술기가필요없으며수술부위의불편함도적다. 금속물제거와관련된비용이나한번의수술로골절을치료할수있다는환자의심리적인이점을고려할때 2) 지연나사의사용은비교적좋은결과를보였다. 나사고정만하는것은염전력에대해안정성이떨어질수있기때문에때때로부가적인고정을필요로한다 6,15,17,20). 특히하나의지연나사는단단한고정이라고말할수는없으므로부가적으로석고고정등의외고정이필요하다. Sondenaa 등 22) 은무작위연구에서족관절의 6주간의부목고정이조기운동과비교하여큰임상적결과차이를보이지않았다고하였고저자들의경우에도초기손상이심했던 1예를제외하고는 6주간석고고정후만족할만한임상적결과를보였다. 본연구에서하나또는두개의나사고정과 6주간의석고붕대고정이 Danis-Weber B형의외과골절에서골절의해부학적유합을유도하는데충분한안정 - 211 -
이준영 이광철 성을보인다고하겠다. 골다공증을동반한환자에서골절은내고정물의고정력이결과에중요한요소이다. Hammacher 등 7) 은골다공증이심한 50대이상의환자를대상으로한연구에서두개의지연나사를사용하여 18예중 17예의우수한결과를보고하였고좋지않은골질을가진경우에도비교적골편간압박을주는데는큰문제가없다고보고하였다. 본연구에서도수술소견상골편간압박에큰문제는없었으며비교적골다공증이심한경우에도지연나사를고정하는데있어문제점은발견되지않았다. 결 론 Danis-Weber B형의외과골절의치료에있어지연나사고정술은연부조직의손상이적고해부학적인정복이가능하며비교적단단한고정을할수있고합병증이적으므로골다공증이있는외과골절환자에서지연나사를이용한고정은비교적유용한치료방법이라고사료된다. REFERENCES 1. Bauer M, Bergstrom B, Hemborg A and Sandegard J: Malleolar fractures: nonoperative versus operative treatment. A controlled study. Clin Orthop, 199: 17-27, 1985. 2. Bostman O, Hirvensalo E, Vainionpaa S, et al: Ankle fracture treated using biodegradable internal fixation. Clin Orthop, 238: 195-203, 1989. 3. Broos PLO and Bisschop APG: Operative treatment of ankle fractures in adults: correlation between types of fracture and final results. Injury, 22: 403-406, 1991. 4. Carragee EJ, Csongradi JJ and Bleck EE: Early complications in the operative treatment of ankle fractures. Influence of delay before operation. J Bone Joint Surg, 73-B: 79-82, 1991. 5. DeSouza LJ, Gustilo RB and Meyer TJ: Results of operative treatment of displaced external rotation-abduction fractures of the ankle. J Bone Joint Surg, 67-A: 1066-1074, 1985. 6. Gonza ER and Harrington IJ: Biomechanics of Musculoskeletal Injury. Baltimore: Williams and Wilkins: 1-25, 87-129, 1982. 7. Hammacher ER, Schutte PR and Bast TJ: Minimal osteosynthesis of lateral malleolar fractures. Neth J Surg, 38: 87-89, 1986. 8. Heim U and Pfeiffer KM: Internal Fixation of Small Fractures: Technique Recommended by the AO-ASIF Group. 3rd ed. Berlin: Springer-Verlag: 304-306, 1988. 9. Hughes JL, Weber H, Willenegger H and Kuner EH: Evaluation of ankle fracture: non-operative and operative treatment. Clin Orthop, 138: 111-119, 1979. 10. Jacobsen S, Lichtenberg MH, Jensen CM and Torholm C: Removal of internal fixation: the effect on patients' complaints. A study of 66 cases of removal of internal fixation after malleolar fractures. Foot Ankle Int, 15: 170-171, 1994. 11. Lindsjo U: Operative treatment of ankle fracturedislocations. Clin Orthop, 199: 28-38, 1985. 12. Mak KH, Chan KM and Leung PC: Ankle fracture treated with the AO principle: an experience with 116 cases. Injury, 16: 265-272, 1985. 13. Meyer TL and Kumler KW: A.S.I.F. Technique and ankle fractures. Clin Orthop, 150: 211-221, 1980. 14. Michelson JD: Current concept review. Fractures about the ankle. J Bone Joint Surg, 77-A: 142-152, 1995. 15. Muller ME, Allgower M and Schneider R: Manual of Internal Fixation. 3rd ed. New York, Springer-Verlag: 32-44, 148-149, 595-612, 1991. 16. Ostrum RF: Posterior plating of displaced Weber B fibula fractures. J Orthop Trauma, 10: 199-203, 1996. 17. Savage TJ, McGarry JJ and Stone PA: The internal fixation of ankle fracture repair. Clin Podiatr Med Surg, 12: 603-631, 1995. 18. Schaffer JJ and Manoli A: The antiglide plate for distal fibular fixation. A biomechanical comparison with fixation with a lateral plate. J Bone Joint Surg,. 69-A: 596-604, 1987. 19. Segal D, Pick RY, Klein HA and Heskiaoff D: The role of the lateral malleolus as a stabilizing factor of the ankle joint. J Foot Ankle Surg, 2: 25-29, 1981. 20. Sequin F and Texhammar R: AO/ASIF Instrumentation. Berlin, Springer-Verlag: 16-24: 244, 1981. 21. Solonen KA and Lauttamus L: Operative treatment of ankle fractures. Acta Orthop Scand, 39: 223-237, 1968. 22. Sondenaa K, Hoigaard U, Smith D and Alho A: Immobilization of operated ankle fractures. Acta Orthop Scand, 57: 59-61, 1986. 23. Treadwell JR and Fallat LM: The antiglide plate for the Danis-Weber type B fibular fracture: a review of 71 cases. J Foot Ankle Surg, 32: 573-579, 1993. 24. Wilson FC Jr and Skilbred LA: Long-term results in treatment of displaced bimalleolar fractures. J Bone Joint Surg, 48-A: 1065-1078, 1966. - 212 -