Archives of Hand and Microsurgery Arch Hand Microsurg 2019;24(1):56-62. https://doi.org/10.12790/ahm.2019.24.1.56 pissn 2586-3290 eissn 2586-3533 Case Report 척골단축술후발생한비후성지연유합및불유합 권영우 1 ㆍ박종웅 1 ㆍ박지헌 2 ㆍ최인철 1 ㆍ남재준 1 ㆍ서동훈 3 ㆍ강종우 3 1 고려대학교안암병원정형외과, 2 고려대학교구로병원정형외과, 3 고려대학교안산병원정형외과 Hypertrophic Delayed Union or Nonunion after Ulnar Shortening Osteotomy Young Woo Kwon 1, Jong Woong Park 1, Ji Hun Park 2, In Cheul Choi 1, Jae Jun Nam 1, Dong hun Suh 3, Jong Woo Kang 3 1 Department of Orthopedic Surgery, Korea University Anam Hospital, Seoul, Korea 2 Department of Orthopedic Surgery, Korea University Guro Hospital, Seoul, Korea 3 Department of Orthopedic Surgery, Korea University Ansan Hospital, Seoul, Korea Ulnar shortening osteotomy is the most popular surgical technique for ulnar impaction syndrome and has a successful clinical results. However, delayed union and nonunion of the osteotomy site remain the most critical complications and conventionally, plate change and autogenous bone grafting had been performed for the treatment of delayed union and nonunion. The authors present 2 patients who had delayed union and nonunion after ulnar shortening osteotomy using 2.7 mm low profile ulnar shortening osteotomy system and can be treated with only additional mini plating. Key Words: Ulna, Osteotomy, Nonunion, Delayed union 원위골간단부척골단축절골술은척골충돌증후군의수술적치료의표준술기로그임상결과도매우만족스럽다 1. 그러나절골부위를고정한금속판에의한자극증상 (plate irritation), 원위요척관절의불일치, 지연유합및불유합등의합병증도발생할수있어척골단축절골술을통한척골충돌증후군의수술적치료에서주의를요한다. 그중척골단축술후발생하는지연유합이나불유합의빈도는보고자에따라차이가있으나가장심각한합병증이며전통적으로금속판교환술 (plate change) 및자가골이식술 (autogenous bone grafting) 을통해치료를하였 다 2,3. 본저자들은 2.7 mm 척골단축절골시스템 (DePuy Synthes, West Chester, PA, USA) 을이용한척골단축절골술후발생한비후성지연유합및불유합 (hypertrophic delayed or nonunion) 환자에서부가적소형금속판 (mini plate) 고정술만을통해단기간에성공적인치료가가능하였던 2예를문헌고찰과함께보고하고자한다. Received December 17, 2018, Revised January 2, 2019, Accepted January 3, 2019 Corresponding author: Jong Woo Kang Department of Orthopedic Surgery, Korea University Ansan Hospital, 123 Jeokgeum-ro, Danwon-gu, Ansan 15355, Korea TEL: +82-31-412-5040, FAX: +82-31-412-5802, E-mail: oskang@korea.ac.kr Copyright c 2019 by Korean Society for Surgery of the Hand, Korean Society for Microsurgery, and Korean Society for Surgery of the Peripheral Nerve. All Rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 56
Young Woo Kwon, et al. Osteotomy Healing 증례 1. 증례 1 52세남자환자로우측척측손목통증을주소로내원하였다. 환자는비흡연자로여타기저질환은없었다. 척골충돌증후군으로진단되어 2.7 mm 척골단축절골시스템을이용한척골단축절골술을시행하였다. 절골부의안정을위하여술후 6주간장상지석고고정 (long arm cast immobilization) 을시행한후능동적관절운동을시행하였다. 술후주기적으로손목의 4면단순방사선사진촬영을통해절골부유합정도를관찰하였으며술후 1년까지도절골부의유합소견을볼수없었다. 절골부의불유합으로판단되었으나금속판의파손이나금속나사못 (screw) 의이완 (loosening) 소견이없어자가골이식술만을시행하기로계획하고수술적치료를시행하였다. 절골부의틈에는보통의불유합부위에서흔히관찰되는섬유성조직형성대신비후성불유합에서관찰되는미성숙골 (woven bone) 이가득형성되어절골부틈을메우고있었다 (Fig. 1). 저자들은최초수술시사용한 2.7 mm 저상형 (low profile) 금속판자체의미세움직임에의한절골부의비후성불유합으로판단하고절골부의안정성을증가시키기위하여 2.0 mm 소형금속판 (DePuy Synthes, West Chester, PA, USA) 을이용한내고정만을추가로시행후수술을종료하였다. 술후 1 개월에시행한단순방사선사진에서가교가골 (bridging callus) 형성이보였으며통증이사라져절골부 가유합되었음을알수있었다. 술후 2 개월에골화 (ossification) 가더진행된것을볼수있었으며최종추시시금 속판자극증상등의합병증없이임상결과는양호하였다 (Fig. 2). 2. 증례 2 57 세남자환자로우측요측및척측손목통증을주소 Fig. 1. Nonunion site was fully filled with whitish woven bone in revisional surgery of case 1. A B C D Fig. 2. Simple radiographs of case 1 (white arrows: osteotomy site). (A) Simple radiograph before ulnar shortening osteotomy. (B) Osteotomy was not united till 1 year after ulnar shortening osteotomy. (C) Bridging callus was seen at 1 month after additional mini-plating. (D) Progressive ossification was seen at 2 months after additional mini-plating. www.handmicro.org 57
Archives of Hand and Microsurgery Vol. 24, No. 1, March 2019 로내원하였다. 환자는비흡연자로여타기저질환은없었다. 내원시시행한단순방사선사진상척골양성변이 (ulnar positive variance), 월상골 (lunate) 척측의골미란 (bony erosion) 의소견, 주상골 (scaphoid) 골절불유합및요수근관절 (radiocarpal joint) 의외상후관절염 (posttraumatic arthritis) 소견이관찰되었다. 척골충돌증후군및주상골불유합진행성붕괴 (scaphoid nonunion advanced collapse) 로진단되었으며주상골불유합에대하여관혈적정복술, 자가장골이식술 (autogenous iliac bone grafting) 및요골경상돌기절제술 (radial styloidectomy) 을척골충돌증후군에대해서는척골단축절골술을시행하기로하였다. 척골단축절골술후절골부위는증례 1과동일한저상형금속판으로고정하였으며, 주상골골절불유합이동반되었던경우로술후 2주간장상지석고고정후 6주간단상지석고고정 (short arm cast immobilization) 을시행하였다. 술후 8주주상골의골유합이보여석고고정을제거하고능동적관절운동을시행하였다. 수술후 7개월까지주기적으로시행한단순방사선소견상절골부위의지연유합소견이확인되었다. 환자는직장으로의빠른복귀를원하였으며절골부금속판고정상태가양호하여절골부의자가골이식술을계획하고재수술을시행하였다. 수술소견에서증례 1과동일하게미성숙골이절골부틈에가득형성되어절골부의틈을메우고있는소견이보였으며증례 1과동일하게부가적소형금속 판고정술만을시행하였다. 술후 1개월째가교가골의형성이관찰되었으며통증이사라져절골부가유합되었음을알수있었다. 절골술후 2개월에골화가더진행된것을확인할수있었으며최종추시시금속판자극증상등의합병증없이임상결과는양호하였다 (Fig. 3). 고찰 척골충돌증후군은척골두와수근골의충돌에의해척수근관절 (ulocarpal joint) 의퇴행성변화와통증을유발되는질환이다. 원위골간부척골단축절골술은이러한충돌을피하고자원위골간부에서척골을절골하여단축시키는술식이며그임상결과도만족스럽다 4. 그러나척골단축술은금속판에의한연부조직자극증상, 신경손상, 감염, 원위요척관절의불일치, 지연유합이나불유합등의합병증이발생할수있으며그중지연유합과불유합이가장심각한합병증이다. 불유합은보고자에따라편차가있으나 6%-13% 빈도로발생한다 2,3. 불유합의발생시지속적인통증을유발하며절골부의유합없이직장, 스포츠및일상생활의복귀가불가능함으로불유합발생시수술적치료가반드시필요하다. 척골단축절골술후절골부의치유를지연시키거나방해하는위험인자로는흡연, 당뇨, 갑상선질환, 약물복용력 ( 항응고제, steroid 제재등 ), 감염, 알코올남용, 고령, 영양결핍등의환자자체의문제도있으나수술 A B C D Fig. 3. Simple radiographs of case 2 (white arrows: osteotomy site). (A) Simple radiograph before ulnar shortening osteotomy. (B) Osteotomy was not united till 7 months after ulnar shortening osteotomy. (C) Bridging callus was seen at 1 month after additional mini-plating. (D) Progressive ossification was seen at 2 months after additional mini-plating. 58 www.handmicro.org
Young Woo Kwon, et al. Osteotomy Healing 적요인도있으며척골단축술시절골부유합에영향을미치는수술적요인으로는내고정물 (plate) 의크기및경직도 (rigidity), 절골부의부위및절골방향 (orientation of osteotomy), 절골용톱날 (saw blade) 의크기및절골부의열손상 (heat injury) 의정도, 수술시연부조직박리 (dissection) 에의한미세혈액순환의단절등이대표적이다 5-10. 척골단축절골술후내고정물로는 3.5 mm DCP (direct compression plate), 3.5 mm LCP (limited contact plate), 2.7 mm LCP를주로사용한다 3. 문헌보고에의하면과거척골단축절골술후 2.7 mm 금속판보다 3.5 mm 두께의단단한금속판으로고정한경우절골부유합이더빨랐다고하여금속판의경직도가절골부의유합에영향을미친다고하였으나최근에는 2.7 mm 금속판과 3.5 mm 금속판을사용한경우절골부유합에는차이가없었거나오히려 2.7 mm 금속판에서절골부유합이더빨랐다는보고도있어금속판의경직도가절골부유합에미치는영향에대해서는아직논란이있다 2,9,10. 그러나과거 15년간약 400예의척골단축술을시행해본저자들의경험으로는 3.5 mm 금속판을사용한경우여타골유합방해요인없이절골부의정복 (reduction) 만양호하다면일차성유합 (primary bone healing) 이이루어지는경우가대부분이었으며불유합이나지연유합이발생하는경우대부분위축성으로발생하였다. 반대로 2.7 mm 금속판을사용한경우여타골유합방해요인없이절골부의정복이양호하다하더라도대부분가골형성을통한이차성골유합 (secondary bone healing) 이이루어지는경우가대부분이었으며불유합이발생한경우대부분비후성으로발생하였다. 또한 2.7 mm 금속판을사용한경우가 3.5 mm 금속판을사용한경우보다골유합시까지더많은시간이소요되기는하였으나최종적인골유합의성공률또는불유합의발생률에는차이가없었다. 이는저자들처럼골유합전조기에능동적관절운동을시행한경우 2.7 mm 금속판보다 3.5 mm 금속판을사용하는것이더빠른골유합에유리하다는것을뜻한다. 특히본증례들과같이골의크기가큰환자에서는 3.5 mm 금속판을사용하여절골부를고정하는것이골치유에더유리할것으로생각된다. 과거횡행 (transverse) 절골보다사형 (oblique) 절골이나계단식 (step-cut) 절골이절골부단면의면적이넓어절골부유합에더유리하다는보고가있었으나최근에는절골의방향이절골부의유합에영향을미치지않는다는보고도다수있어절골방향이절골부유합에미치는영 향에대해서도논란이있다 2,3,9,10. 또한선행논문에서사형이나계단식절골술을시행하는경우모두절골부에지체나사못 (lag screw) 을삽입하여절골부를압박 (compression) 하여절골부의간극 (osteotomy gap) 을최소화시키고부가적인고정으로고정력을증대시켰으며횡행절골술의경우지체나사못삽입없이금속판을통한압박만을시행하였음으로횡행절골술과사형또는계단식절골술을단순비교하여어느것이더골유합에우수하다고논할수는없을것이다 2,3,9,10. 저자들의생각으로는사형이나계단식절골술시절골부의압박을위해부가적으로삽입하는지체나사못이절골부의간극을줄이고절골부의고정력을증가시키게되므로절골부유합에더도움이될것으로생각되며저자들의경험에서도사형절골술을시행후지체나사를부가적으로삽입한경우비후성불유합또는지연유합이발생하지않았다. 절골도중필연적으로발생하는마찰열에의한절골부의열손상및수술시연부조직박리에의한미세혈액순환의단절도절골부유합에영향을미치는대표적인자이다 3,5. 문헌에의하면절골용톱날선택시가급적얇은것을선택하는것이좋으며절골도중에생리식염수세척 (saline irrigation) 으로절골부의열손상을최소화하여야한다고권고하고있다 3,5. 또한절골술을위한연부조직박리시에도절골과금속판고정에필요한만큼최소한으로골을노출시켜야한다. 저자들의경우에도열손상을최소화하기위해가급적얇은 0.5 mm 두께의톱날을사용하고절골도중에는 0 C의저온생리식염수세척 (cold saline irrigation) 을충분히시행하면서간헐적 (intermittent) 으로절골을시행하였다. 또한금속판고정과절골을위한최소한의박리를시행하였으며특히골막상박리 (supraperiosteal dissection) 를통해척골의골막 (periosteum) 을완전히보전한상태로절골부을노출시키고절골후에도금속판을골막위에위치시켜미세혈액순환의단절을최소화하였다. 골절후발생한불유합은불유합부위의골치유력에따라크게위축성및비후성불유합으로구분할수있으며이러한구분은그치료방침을정하는데매우중요하다. 일반적으로흡연과동반된내분비질환등의환자자체의위험인자들은위축형불유합을발생시킬수있으며, 절골부의기계적고정력이약할경우에는비후형불유합이발생할수있다 9,10. 위축성불유합의치료방침은골절부의치유력을촉진하는것이며자가골이식 (autogenous bone graft) 이대표적인치료법이다. 반면에비후형불유합의치 www.handmicro.org 59
Archives of Hand and Microsurgery Vol. 24, No. 1, March 2019 료는위축성불유합과는달리절골부치유력은충분하나절골부의기계적고정력이약해발생하는것이므로골이식없이절골부를추가로고정하거나더고정력이우수한내고정물로교환하는것이합당한치료법이다. 증례 1의경우술후 1년까지도골치유의소견이보이지않아절골부의불유합으로절골부의골유합을더이상기대할수없는상태였고, 추후금속판파손이나나사못의이완이발생할가능성이높다고판단되었으며, 환자가더이상의직장복귀를미룰수없는상태였으므로추가의수술적치료시행에논란이없을것이다. 그러나증례 2의경우술후 7개월까지추시결과절골부골유합이이루어지지않았던상태로불유합으로판단하기에는이른지연유합의상태였다. 지연유합시에는추가의수술적치료없이도절골부가유합될가능성이여전히존재하므로더추시관찰하는것이원칙이나본증례의경우재수술전의골치유의양상을시간순서로볼때상당기간골의치유가진행되지않았으므로자연골유합의가능성이희박한상태로판단되었으며무엇보다환자가빠른직장복귀를간절히원하고있어재수술을시행하였던경우였다. 본증례에서는 2예모두흡연력, 당뇨, 갑상선질환, 골다공증등골유합을방해할특이환자요인은없었다. 또한여타정상적으로골유합이진행되었던다수의환자와술식에서차이도없었다. 본증례들의경우재수술전단순방사선사진및재수술의육안소견에서모두비후성불유합및지연유합의소견을보였다는점, 비후성불유합의경우추가적인절골부고정만으로도충분히유합되므로추가의소형금속판고정술후 2예모두 1개월만에골유합이완료되었다는점, 두예모두에서횡행절골을시행하여금속판을통한고정과절골부압박만을시행하였고골유합전조기에능동적관절운동을시행하였다는점, 두예모두골의크기가큰남자환자라는점에서 2.7 mm 저상형금속판이본증례에서는절골부의절대적안정성 (absolute stability) 을제공하기에는상대적으로역부족이었으며이에따른절골부의미세움직임이본불유합및지연유합의원인이라고판단된다. 본증례의경우와는다르나만약척골단축절골술을시행하여야할환자가흡연, 골다공증, 당뇨, 갑상선질환등골치유력에결함이있는경우척골단축절골술대신 Wafer 술식또는관절경을이용한 Wafer 술식을고려하는것이절골부불유합및지연유합을예방하는데에는더욱유리할것이다 7. 그러나 Wafer 술식또는관절경을이용한 Wafer 술식은삼각섬유연골의천공이없는경우시 행할수없으며척골양성변위가긴경우충분한단축을할수없어항상가능한술식은아니므로환자선택에신중을기울여야한다 7. 이러한경우골간단부척골단축술 (metaphyseal ulnar shortening osteotomy) 이원위골간부척골단축술 (distal disphyseal ulnar shortening osteotomy) 의대안이될수있다 7. 척골의크기가큰환자에서 2.7 mm 저상형척골단축시스템을이용한횡행척골단축술을시행하고조기에관절운동을시행하게되면여타환자와달리절골부고정력이충분치않아절골부의미세움직임에따른비후성불유합또는지연유합이발생할수있다. 따라서이러한경우척골단축절골술을시행할때사형절골술후지체나사못의삽입을통해절골부압박력및고정력을강화시키면비후성불유합또는지연유합을예방에도움이될것으로생각된다. 또한저상형의척골단축시스템을이용한척골단축술후비후성불유합이발생하였을경우신속한절골부유합을통한빠른업무복귀와금속내고정물의파괴, 나사못이완등잠재된합병증을막기위해절골부위의추가적소형금속판고정술을적극적으로시행하는것이바람직할것으로생각된다. 본논문은두예의불유합및지연유합환자의치험례에대한증례보고로그불유합및지연유합의발생원인에대하여선행연구및저자들의임상경험을통해논리적으로추론하여기술하였으며추후많은연구대상을통한연구가필요할것으로생각된다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Friedman SL, Palmer AK. The ulnar impaction syndrome. Hand Clin. 1991;7:295-310. 2. Köppel M, Hargreaves IC, Herbert TJ. Ulnar shortening osteotomy for ulnar carpal instability and ulnar carpal impaction. J Hand Surg Eur Vol. 1997;22:451-6. 3. Jungwirth-Weinberger A, Borbas P, Schweizer A, Nagy L. Influence of plate size and design upon healing of ulnashortening osteotomies. J Wrist Surg. 2016;5:284-9. 4. Martin DE, Zlotolow DA, Russo SA, Kozin SH. Comparison of compression screw and perpendicular clamp in ul- 60 www.handmicro.org
Young Woo Kwon, et al. Osteotomy Healing nar shortening osteotomy. J Hand Surg Am. 2014;39:1558-64. 5. Firoozbakhsh K, Moneim MS, Mikola E, Haltom S. Heat generation during ulnar osteotomy with microsagittal saw blades. Iowa Orthop J. 2003;23:46-50. 6. Chen F, Osterman AL, Mahony K. Smoking and bony union after ulna-shortening osteotomy. Am J Orthop (Belle Mead NJ). 2001;30:486-9. 7. Barbaric K, Rujevcan G, Labas M, Delimar D, Bicanic G. Ulnar shortening osteotomy after distal radius fracture malunion: review of literature. Open Orthop J. 2015;9:98-106. 8. Iwasaki N, Ishikawa J, Kato H, Minami M, Minami A. Factors affecting results of ulnar shortening for ulnar impaction syndrome. Clin Orthop Relat Res. 2007;465:215-9. 9. Darrow JC Jr, Linscheid RL, Dobyns JH, Mann JM 3rd, Wood MB, Beckenbaugh RD. Distal ulnar recession for disorders of the distal radioulnar joint. J Hand Surg Am. 1985;10:482-91. 10. Oskam J, Kingma J, Klasen HJ. Ulnar-shortening osteotomy after fracture of the distal radius. Arch Orthop Trauma Surg. 1993;112:198-200. www.handmicro.org 61
Archives of Hand and Microsurgery Vol. 24, No. 1, March 2019 척골단축술후발생한비후성지연유합및불유합 권영우 1 ㆍ박종웅 1 ㆍ박지헌 2 ㆍ최인철 1 ㆍ남재준 1 ㆍ서동훈 3 ㆍ강종우 3 1 고려대학교안암병원정형외과, 2 고려대학교구로병원정형외과, 3 고려대학교안산병원정형외과 원위골간부척골단축절골술 (distal diaphyseal ulnar shortening osteotomy) 은척골충돌증후군 (ulnar impaction syndrome) 의수술적치료에서가장널리사용되는술식으로그임상결과도만족스럽다. 그러나절골부의지연유합 (delayed union) 및불유합 (nonunion) 은가장심각한척골단축절골술의합병증이며전통적으로금속판교환술및자가골이식술을통해치료하였다. 최근저자들은저상형 (low-profile) 의 2.7 mm 척골단축시스템 (ulnar shortening system) 을이용한척골단축술후발생한지연유합및불유합환자에서부가적소형금속판 (mini-plate) 고정술만으로치료한치험례를보고하는바이다. 색인단어 : 척골, 절골술, 불유합, 지연유합 접수일 2018 년 12 월 17 일수정일 2019 년 1 월 2 일게재확정일 2019 년 1 월 3 일교신저자강종우 15355, 경기도안산시단원구적금로 123, 고려대학교안산병원정형외과 TEL 031-412-5040 FAX 031-412-5802 E-mail oskang@korea.ac.kr 62 www.handmicro.org