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대한골절학회지제 23 권, 제 1 호, 2010 년 1 월 Journal of the Korean Fractrure Society Vol. 23,. 1, January, 2010 원위경골골절에서외측금속판을이용한최소침습적경피적금속판골유합술 손욱진ㆍ김대성 영남대학교의학대학정형외과학교실 목적 : 원위관절면에서 3 cm 내에위치하고내측연부조직의손상이동반된원위경골골절에서외측금속판 (Zimmer, Periarticular Lateral Distal Tibial Plates, USA) 을이용하여최소침습적경피적금속판골유합술후그유용성에대해평가해보고자한다. 대상및방법 : 원위경골골절로 2005 년 1 월부터 2007 년 12 월까지본원에서외측금속판을이용하여최소침습적경피적금속판골유합술후최소 1 년이상의추시가가능하였던 15 예를대상으로하였다. 방사선사진을통해골유합시기를, IOWA ankle rating system 을이용해임상적결과를평가하였으며, 합병증을알아보았다. 결과 : 전예에서방사선학적인골유합을얻었으며평균골유합기간은.7 (12 20) 주였다. 족관절기능적평가에서는평균 90.3 점으로만족할만한결과를얻었다. 최종추시시전예에서불유합, 5 도이상의각변형및감염은없었다. 결론 : 원위관절면에서 3 cm 내에위치하고내측연부조직의손상이동반된원위경골골절에서외측금속판을이용한최소침습적경피적금속판골유합술은만족할만한골유합률과낮은합병증으로기능적회복을얻을수있는유용한방법으로생각된다. 색인단어 : 원위경골골절, 최소침습적경피적금속판골유합술, 외측금속판 Minimally Invasive Percutaneous Plate Osteosynthesis Using a Lateral Plate in Distal Tibial Fracture Oog Jin Shon, M.D., Dae Sung Kim, M.D. Department of Orthopaedic Surgery, Yeungnam University College of Medicine, Daegu, Korea Purpose: To evaluate the efficacy of minimally invasive percutaneous plate osteosynthesis (MIPPO) using a lateral plate (Zimmer, Periarticular Lateral Distal Tibial Plates, USA) in distal tibial fracture within 3 cm to plafond, associated with medial soft tissue damage. Materials and Methods: From January 2005 to December 2007, 15 patients with distal tibial fracture treated by MIPPO technique using a lateral plate were analyzed. The duration of follow-up was more than 1 year. We evaluated union time by simple X-ray, clinical results by IOWA ankle rating system, and complication. Results: The bone union was achieved in all cases at average.7 weeks. Evaluation of the ankle function test showed an average of 90.3 points, resulting in satisfactory. At the last follow-up, there was no non-union, angular deformity more than 5 degrees or infection. Conclusion: We concluded that MIPPO technique using a lateral plate is a efficient method for high functional recovery with good bone healing and low complication in distal tibial fracture within 3 cm to plafond, associated with medial soft tissue damage. Key Words: Distal tibial fracture, Minimally invasive percutaneous plate osteosynthesis (MIPPO), Lateral plate 통신저자 : 손욱진대구시남구대명 1 동 317-1 영남대학교병원정형외과 Tel:053-620-3645 ㆍ Fax:053-628-4020 E-mail:min1913@hanmail.net 접수 : 2009. 5. 18 심사 ( 수정 ): 2009. 8. 12 게재확정 : 2009. 10. 25 Address reprint requests to:oog Jin Shon, M.D. Department of Orthopaedic Surgery, Yeungnam University Hospital, 317-1, Daemyeong-dong, Nam-gu, Daegu 705-717, Korea Tel:82-53-620-3645 ㆍ Fax:82-53-628-4020 E-mail:min1913@hanmail.net 42

원위경골골절에서외측금속판을이용한최소침습적경피적금속판골유합술 43 서 원위경골골절은골절의위치가관절면에가깝고분쇄가심하며주위연부조직의손상이많아치료가어려운손상으로알려져있으며, 과거전통적인관혈적정복술후금속판내고정술이나다양한방법의외고정술은연부조직괴사, 심부감염, 골수염등의여러가지합병증이보고되었다 1,,23). 또한골절선이관절면에서 3 cm 이하인경우골수강내금속정삽입술로는안정성을얻기어렵고조기관절운동을회복하기힘들다 7,22). 최근에이러한합병증을최소화하기위해내측금속판을이용한최소침습적술식으로연부조직의손상을최소화하고적절한고정을얻는등의좋은임상적결과들을보고하고있다 3,8,14,21). 또한이러한수술법에적합하도록얇고, 해부학적형상에잘맞는모양 (anatomically pre-shaped) 으로도안된금속판들이소개됨으로써수술이좀더용이하게되었다. 하지만경골의내측은피하연부조직이적어금속판이피부바로밑에위치하게되어피부자극증상등의불편감을줄수있고, 내측부에연부조직의손상이심한경우수술후피부괴사및금속판노출을초래할수있다 9,14,18,21). 따라서경골의외측으로최소침습적술식을이용하여외측금속판고정술을시행하게되었으며아직까지이와관련된논문은많지않다. 이에저자들은골절선이원위관절면에서 3 cm 내에위치하고내측연부조직의손상이동반된원위경골골절에서외측금속판 (Zimmer, Periarticular Lateral Distal Tibial Plates, USA) 을이용하여최소침습적경피적금속판 론 골유합술을시행한후치료결과를분석하고그유용성에대하여알아보고자하였다. 1. 연구대상및방법 대상및방법 골절선이원위관절면에서 3 cm 내에위치하고내측연부조직의손상이동반된원위경골골절로 2005 년 1 월부터 2007 년 12 월까지본원에서외측금속판을이용하여최소침습적술식을시행하고최소 1 년이상의추시가가능하였던 15 예를대상으로하였다. 환자의평균연령은 56.1 (38 74) 세였고, 남자가 8 명, 여자가 7 명이었다. 골절의원인으로는교통사고가 9 예, 실족사고가 6 예였다. AO/O 골절분류에서 A1 형골절이 1 예, 형골절이 8 예, 형골절이 5 예, C1 형골절이 1 예였고, 개방성골절은 7 예였고 Gustillo-Anderson 분류에서 I 형이 1 예, II 형이 4 예, IIIA 형이 2 예였다 (Table 1). 비골골절이동반된경우는 12 예였고, 내과골절이동반된경우는 1 예였다. 평균추시기간은 14.4 (12 20) 개월이었으며, 수상후금속판내고정술시행까지의기간은폐쇄성골절인경우평균 2.3 일이었고개방성골절인경우는심한부종및연부조직의손상으로인해일시적인외고정술이필요하여평균 17.7 일에수술을시행하였다. 동반된비골외과골절은 12 예모두고정술을시행하였고, 9 예는금속판및나사못을이용한내고정술을, 외측연부조직의손상이심한 3 Table 1. Patient data Case Age/Sex Injury mechanism AO/O classification G-A* classification Union time Ankle scoring Complication 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 74/M 51/F 38/M 50/M 59/F 66/M 58/F 53/F 64/M 63/F 41/M 65/F 65/F 54/M 41/M C1 A1 Type I Type II Type II Type III Type II Type III Type II 18 20 20 12 12 14 20 14 18 18 92 94 98 92 96 96 94 88 88 86 86 76 88 88 92 LOM LOM *G-A: Gustillo-Anderson classification, Ankle scoring: IOWA ankle rating system, : Traffic accident, : Slip down, LOM: Limitation of motion.

44 손욱진, 김대성 예는 Rush pin 을이용한골수강내고정술을시행하였다. 2. 수술방법및수술후처치 환자를전신마취또는척추마취하에방사선투시가가능한수술대위에앙와위로눕힌후비골외과골절이동반되어있는경우비골에대한고정을먼저시행하였다. Rush pin 으로고정할때와는달리금속판으로고정시에는전방피판의괴사발생의가능성을낮추기위해최소침습적술식을사용하였거나경골의외측절개선과의거리를최대한멀리하기위해가능한한비골의외측으로접근하여고정을시도하였다. 비골고정후 C 형방사선투시기보조하에도수견인으로원위경골골절부의간접적정복을시행하였다. 견인을통한도수정복으로원위경골골간단부의정렬을얻은후족관절전외측접근법으로원위부는족관절에서 1 cm 상방에서시작하여근위부로 2 3 cm 가량의종절개를가하고, 근위부는나사고정부위가필요한만큼의최소한의길이로 3 4 cm 가량의종절개를시행한후족무지신건과전경골근사이또는족무지신건과장지신건사이로경골을노출시켜신경혈관구조물을적절하게견인후에골막의박리없이금속판을삽입하였다 (Fig. 1A, B). 금속판삽입시영상증폭기감시하에금속판을골절의원위부에서근위부로경피적으로밀어넣고정복을확인한후먼저해면나사로원위부를고정하고, 근위부를피질나사로고정한후골절의정복상태및금속 판위치의적절성을재차확인하였다 (Fig. 1C, D). 전예에서외측금속판을사용하였고, 나사의수는골절원위부및근위부에최소 3 개이상의수로고정하였으며, 최대한안정성을갖도록하였다. 수상당시개방성골절이있는 7 예중부종과개방창이심하여즉각적인내금속판고정술이힘든 6 예의경우에초기도수정복및가교외고정장치를시행하였고내과골절이동반된 1 예에서는 K- 강선고정술시행하였다. 그리고개방창의충분한상처치료후연부조직이회복한다음에금속판고정술을시행하였는데, 외고정장치기간동안충분한항생제치료와상처치료로골수염과상처감염을제거한뒤 2 예에서피판술을시행하였다 (Fig. 2). 수술후골절선이관절면을포함하지않은경우는수술후 2 일째부터족관절및슬관절의관절운동을시행하였고, 골절선이관절면을포함한 1 예에서는수술후약 2 주간장하지석고부목을하였으며그후관절운동을시행하였다 (Fig. 3). 특히외고정장치를시행하여장기간의족관절운동을하지못한환자들은지속적이고충분한관절운동을시행하도록하였다. 모든환자에서수술후 4 6 주부터부분체중부하를허용하였고완전체중부하는골유합이확인되고, 골절부에통증이없으면시작하였다. 3. 치료결과의평가방법 수술후정기적인방사선사진을통해추시기간중골유 Fig. 1. (A) The initial film shows a comminuted fracture of the distal tibia with medial open wound. (B) Lateral plate was inserted anterolaterally through mini skin incision. (C) The location and size of plate was verified by C-arm. (D) Postoperative radiograph shows satisfactory position of plate and screws.

원위경골골절에서외측금속판을이용한최소침습적경피적금속판골유합술 45 Fig. 2. (A) A 64 year old man sustained a right distal tibial fracture (AO/O type 43, ) with medial open wound after traffic accident. (B) First, lateral malleolar fracture was fixed using MIPPO technique, and bridge external fixator was applied. (C) After 3 weeks, lateral plate fixation of distal tibia using MIPPO technique was performed, and postoperative radiograph at 1 year after the injury shows solid bony union and satisfactory alignment.

46 손욱진, 김대성 Fig. 3. (A) A 38 year old man sustained an intraarticular fracture of right distal tibia (AO/O type 43, C1) after traffic accident. (B) Medial open wound was showed. (C) First, lateral malleolar and tibial intraarticular fracture were fixed, and bridge external fixator was applied. (D) After 1 week, lateral plate fixation of distal tibia using MIPPO technique was performed, and postoperative radiograph shows satisfactory alignment. 합시기와불유합또는부정유합등의합병증을조사하였다. 골유합의정의는방사선적으로경골의전후, 측면사진상가골의성숙이골절면의 3/4 이상폐쇄된경우로하였으며, 임상적으로골절부위의압통과움직임이없는상태로정의하였다. 또한, 각변형은 5 도이상의각변형이있을때변형이있다고정의하고, 건측경골에비해 10 mm 이상짧을때단축이있다고정의하였다. 족근관절의기능적평가는 IOWA ankle rating system 17) 을이용하여마지막추시방문시이학적검사와설문조사를통해측정하였다. 족관절의기능, 통증소실정도, 보행정도, 그리고족관절의운동범위정도의 4 가지로나누어조사하였으며총 100 점에서 90 100 점은우수 (excellent), 80 89 는양호 (good) 그리고 70 79 는보통 (fair) 으로분류하였다. 합병증으로는창상의파열이나피부괴사, 연부조직의감염, 금속판의자극증상유무등을조사하였다. 결 평균수술시간은 63.5 분이었고전예에서방사선학적인골유합을얻었으며평균골유합기간은.7 (12 20) 주였고폐쇄성골절인경우는평균 주, 개방성골절인경우는평균 17.4 주였다. 전예에서 5 o 이상의각변형이나 1 cm 이상의단축소견은보이지않았으며족관절의기능평가에서는마지막추시시평균 90.3 점으로 8 예에서우수, 6 예에서양호를보여 15 예중 14 예에서만족할만한결과 과 Table 2. IOWA ankle rating system Scores Mean 90 100 (Excellent) 80 89 (Good) 70 79 (Fair) 8 6 1 94.6 85.3 76 를얻었다 (Table 2). 합병증으로족관절의운동제한이 2 예가있었지만그이외에불유합이나지연유합, 피부괴사, 표재성또는심부감염, 나사못의파손등의다른합병증은나타나지않았고, 금속판자극증상도보이지않았다. 고 경골골절은고에너지손상에의해발생하는경우가많아골절의분쇄정도가심하고주위연부조직의손상을빈번히초래하며, 족관절과인접해있어서치료후운동장애를일으키기쉽다. 따라서관절면의해부학적정복과동시에연부조직의피복의안정성을동시에획득해야하므로치료에많은어려움이있다 1,,23). 과거외고정장치를이용한고정법은심한분쇄가있는골절의재건이힘들며지연유합, 부정유합, 핀삽입부감염, 외상성관절염등의문제점이많이발생하였고 10,25), 고식적인관혈적정복술및금속판내고정술은골절부의외상에의한연부조직손상에수술로인한피부절개및골 찰

원위경골골절에서외측금속판을이용한최소침습적경피적금속판골유합술 47 막의박리로미세순환손상이추가되어감염및지연유합이나불유합이높은것으로보고되고있다 6,7). 골수강내금속정고정술은골유합이빠르고합병증이적어경골간부골절에서가장널리사용하는치료방법으로알려져있지만 2,20), 골절선이관절면에서 3 cm 이하인경우넓은골수강으로인해골수강내금속정삽입술은교합나사의삽입과정에서금속정의이동이가능하고, 적절한고정력을얻기어려워서조기관절운동을회복하기힘들다 5,22). 최근에이러한합병증을최소화하기위해선호되고있는내측금속판을이용한최소침습적술식은경골의전내측부위에금속판을경피적으로넣어가교금속판형식으로고정하는술기로, 생물학적인고정을통해연부조직의손상을최소화하고, 골절주위의혈류및혈종을보존하여좋은임상적결과들을보고하고있다 3,8,13,18). 최근에 Borrelli 등 4) 은전경골및후경골동맥의분지들에의한골외혈류 (extraosseous blood supply) 가원위경골골간단부에많이존재함을알아내고, 관혈적정복술시에골의혈류량이심각하게손상됨을보고하였다. Pai 등 19) 및 Yoo 등 26) 은내측금속판을이용한최소침습적술식을시행하여모두골유합을얻었고임상적인만족도또한우수하였다고보고하여원위경골골절에서의좋은치료방법중의하나로생각된다. 또한이러한수술법에적합하도록얇고, 해부학적형상에잘맞는금속판들이소개됨으로써수술이좀더용이하게되었다. Kim 등 12) 은내측관절주위금속판으로최소침습적술식을시행하여피부자극증상없이전예에서골유합을얻었으며, 관절주위금속판이한국인에게적합한형태라고보고하였다. 하지만경골의내측은피하연부조직이적어특히, 내과골부위에서금속판으로인한피부자극증상등의불편감을줄수있고심한경우골유합을얻은후금속제거술이필요할수있으며내측부에연부조직의손상이심한경우수술후피부괴사및금속판노출등의합병증을초래할수있다 9,18,21). 이에저자들은원위경골골절에서골절선이관절면에서 3 cm 내에위치하고개방성골절등으로내측연부조직의손상이있는경우안정적인고정력을얻고조기관절운동을회복하며, 내측창상등으로인한금속판노출의위험성을피하기위하여경골의내측이아닌외측으로, 외측금속판을이용하여최소침습적경피적술식을시행하였다. 저자들의방법은내측금속판을이용한최소침습적술식과마찬가지로골절부를직접적으로피하여전외측부에최소절개를가하고간접적인정복을통하여경골의외측에가교금속판형식으로고정하는것이다. Hong 등 11) 은 20예의원위경골골간단부골절에서외측금속판인 periarticular lateral distal tibial plate (Zimmer, USA) 와 May anatomical plate (Link, Germany) 를이용한최소침습적 술식으로전예에서일차적으로평균.4 주에골유합을얻었으며전예에서양호이상의주관적인만족도를보였고, 내고정실패나창상의감염, 금속판의자극증상등은보이지않았다고하였다. 저자들의경우에도전예에서골유합을얻었으며평균골유합기간은.7 주였고, 주관적인만족도또한 15 예중 14 예에서양호한결과를보였다. 또한내측금속판으로인해생길수있는피부자극증상은보이지않았고, 내측연부조직의손상부위를피하여금속판을고정하여피부괴사나감염등의합병증도관찰되지않았다. 해부학적으로원위경골의전외측접근법으로최소침습적술식을이용하여고정하는경우신경혈관구조물의손상이발생할수있으므로조심스러운접근이필요한데, Wolinsky 등 27) 에의하면원위경골의외측절개시천비골신경은경피적으로위치해있어눈으로확인하기쉬우나, 심비골신경과전경골혈관은원위경골의전방으로금속판을가로질러지나가므로손상의위험성이높다. 이러한위험성을피하기위해저자는두가지방법으로접근을하였는데먼저절개선을족무지신전건과전경골근사이로넣을때는원위경골을노출시킨후신경혈관구조물이없는것을확인후에금속판을삽입및고정하였으며, 신경혈관구조물을눈으로직접확인하고자할때는족무지신건과장지신건사이로접근하여신경혈관구조물을절개 (dissection) 후조심스럽게당김후에금속판을삽입및고정하였다. 최근에는후자의방법을선호하는편이며, 저자들의경우신경혈관구조물의손상은없었다. 가교외고정장치 (bridging external fixation) 는원위경골골절에서연부조직의손상이심하거나심한분쇄골절이동반되었을경우초기접근방법으로적용되는좋은방법으로, 골절주위의연부조직이회복할수있게하고, 또한골의길이및정렬을유지할수있게한다 15,24). Helfet 등 8) 은관절을침범한원위경골골절에서먼저가교외고정장치를고정하여부종이소실된 5 7 일후금속판고정술을시행할것을추천하였다. 본연구에서는개방성원위경골골절에서심한부종이있거나다발성수포로인해일차적고정이힘든고에너지골절 6 예에서종골과경골에각각고정하는가교외고정장치를이용하여정렬을유지하고연부조직의회복을얻은후수상후평균 17.7 일에외측금속판고정술을시행하여전예에서골유합을얻었다. 골절치유후 2 예에서족관절의운동장애가발생하였는데, 1 예는경골및비골골절양상이심한분쇄상을나타내어과감한물리치료가어려웠던경우이고, 다른 1 예는골유합은 20 주에얻었으나동측의종골골절치료및광범위한개방성연부조직의손상으로인한외고정장치및피판

48 손욱진, 김대성 술 2 차례시행으로장기간관절운동제한이있은경우로현재물리치료하면서경과관찰중에있으며, 그외에는정상범위로회복되었다. 결과적으로외측금속판을이용한최소침습적경피적골유합술은최소절개를사용하고경골의골막을박리하지않아골절부의혈행공급을유지함으로써지연유합이나불유합없이최소침습적내측금속판고정술과비슷한골유합을얻고조기관절운동과체중부하를시행하여만족할만한임상적결과를얻을수있었으며수술후금속판에의한피부자극이없는장점이있었으나전체집단의크기가작아좀더많은증례가필요할것으로생각된다. 결 원위경골골절의치료에서내과골부에외상으로인한심한연부조직의손상이있고골절선이관절면에서 3 cm 이하로가까울때외측금속판을이용한최소침습적경피적골유합술을시행하여, 간접정복과생물학적고정으로연부조직의손상을줄이고, 골절부위로의혈류를보존하여적절한고정을얻음으로써전예에서만족할만한골유합을얻었으며, 주관적인만족도또한우수하였다. 최소침습적경피적외측금속판골유합술은원위경골골절의치료시좋은선택적대안중하나라고생각된다. 론 참고문헌 1) Anglen JO: Early outcome of hybrid external fixation for fracture of the distal tibia. J Orthop Trauma, 13: 92-97, 1999. 2) Asche G: Result of the treatment of femoral and tibial fractures following interlocking nailing and plate osteosynthesis. A comparative retrospective study. Zentralbl Chir, 114: 1146-1154, 1989. 3) Borg T, Larsson S, Lindsjo U: Minimally-invasive plating of distal tibia fractures: preliminary results in 21 patients. Injury, 35: 608-614, 2004. 4) Borrelli J Jr, Prickett W, Song E, Becker D, Ricci W: Extraosseous blood supply of the tibia and the effects of different plating techniques: a human cadaveric study. J Orthop Trauma, : 691-695, 2002. 5) Brumback RJ, McGarvey WC: Fractures of the tibial plafond. Orthop Clin rth Am, 26: 273-285, 1995. 6) Fan CY, Chiang CC, Chuang TY, Chiu FY, Chen TH: Interlocking nails for displaced metaphyseal fractures of the distal tibia. Injury, 36: 669-674, 2005. 7) Hahn D, Bradbury N, Har tley R, Radford PJ: Intramedullary nail breakage in distal fractures of the tibia. Injury, 27: 323-327, 1996. 8) Helfet DL, Shonnard PY, Levine D, Borrelli J Jr: Operative Minimally Invasive plate osteosynthesis of distal fractures of the tibia. Injury, 28: 42-48, 1997. 9) Helfet DL, Suk M: Minimally invasive percutaneous plate osteosynthesis of fractures of the distal tibia. Instr Course Lect, 53: 471-475, 2004 10) Holbrook JL, Swiontkowski MF, Sanders R: Treatment of open fractures of the tibial shaft: ender nailing versus external fixation. A randomized, prospective comparison. J Bone Joint Surg Am, 71: 1231-1238, 1989. 11) Hong KD, Ha SS, Chung NS, Sim JC, Ahn SC: Lateral fixation of distal tibial metaphyseal fracture using minimally invasive plate osteosynthesis technique. J Korean Fracture Soc, 19: 22-28, 2006. 12) Kim YM, Yang JH, Kim DK: Minimally invasive percutaneous plate osteosynthesis using periarticular plate for distal tibial fractures. J Korean Fracture Soc, 20: 315-322, 2007. 13) Krackhardt T, Dilger J, Flesch I, Höntzsch D, Eingartner C, Weise K: Fractures of the distal tibia treated with closed reduction and minimally invasive plating. Arch Orthop Trauma Surg, 125: 87-94, 2005. 14) Maffulli N, Toms AD, McMurtie A, Oliva F: Minimallyinvasive plating of distal tibial fractures. Int Orthop, 28: 159-2, 2004. 15) Marsh JL, Bonar S, Nepola JV, Decoster, Hurwitz SR: Use of an articulated external fixator for fractures of the tibial plafond. J Bone Joint Surg Am, 77: 1498-1509, 1995. ) Marsh JL, Weigel DP, Dirschl DR: Tibial plafond fractures. How do these ankles function over time? J Bone Joint Surg Am, 85: 287-295, 2003. 17) Merchant TC, Dietz FR: Long-term follow-up after fractures of tibial and fibular shafts. J Bone Joint Surg Am, 71: 599-606, 1989. 18) Oh CW, Kyung HS, Park IH, Kim PT, Ihn JC: Distal tibia metaphyseal fractures treated by percutaneous plate osteosynthesis. Clin Orthop Relat Res, 408: 286-291, 2003. 19) Pai V, Coulter G, Pai V: Minimally invasive plate fixation of the tibia. Int Orthop, 31: 491-496, 2007. 20) Puno RM, Teynor JT, Nagano J, Gustilo RB: Critical analysis of result of 201 tibial shaft fracture. Clin Orthop

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