Original Article pissn 1738-3757 eissn 2288-8551 J Korean Foot Ankle Soc 2015;19(4):171-175 http://dx.doi.org/10.14193/jkfas.2015.19.4.171 역행성골수강내금속정을이용한경 - 거 - 종골유합술의술후결과 이명진, 이영구 *, 김동률, 유정우 * 동아대학교의과대학정형외과학교실, * 순천향대학교의과대학부천병원정형외과학교실 The Surgical Outcome of Tibiotalocalcaneal Arthrodesis Using a Retrograde Intramedullary Nail Myoung Jin Lee, Young Koo Lee*, Dong Ryul Kim, Jung Woo Yoo* Department of Orthopaedic Surgery, College of Medicine, Dong-A University, Busan, *Department of Orthopaedic Surgery, Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea Purpose: Tibiotalocalcaneal arthrodesis has been used as a treatment option for severe deformity including Charcot arthropathy, avascular necrosis of the talus, and severe osteoarthritis of the ankle and subtalar joint. The purpose of this study was to evaluate the result of the surgical outcome of tibiotalocalcaneal arthrodesis using a retrograde intramedullary nail. Materials and Methods: Tibiotalocalcaneal arthrodesis using a retrograde intramedullary nail was performed by one surgeon in 36 cases. Clinical and radiological finding was evaluated using assessment of fusion time, 5th metatarsal-tibial angle, possibility of postoperative complication, visual analogue scale for pain and American Orthopaedic Foot and Ankle Society (AOFAS) score. Results: Union was achieved in 33 cases at an average of 23 weeks (11 29 weeks). There were 3 cases of nonunion and 1 case of reoperation. Nail-tibial angle tended to be larger in nonunion cases. AOFAS score showed significantly poor outcome at malalignment ( 5 o ), negative value of 5th metatarsal-tibial angle. Conclusion: Tibiotalocalcaneal arthrodesis using a retrograde intramedullary nail is considered a useful treatment option for severe destruction and deformity involving ankle and subtalar joint. Key Words: Arthrodesis, Intramedullary nail, Tibiotalocalcaneal 서 경-거-종골관절유합은당뇨병성샤콧 (Charcot) 관절, 거골의골괴사, 류마티스관절염등의염증성관절염, 외상성및퇴행성관절염, 족관절과함께거골하관절의심한관절파괴및변형이있을경우사용가능한중요한수술방법이다. 1) 경-거-종골관절유합술에는외고정장치, 스텐만핀 (Steinmann pin), 금속판, 나사못, ㄷ자꺽쇠못 (staple), 골수강내금속정등을이용한많은수술방법 Received July 22, 2015 Revised October 26, 2015 Accepted November 6, 2015 Corresponding Author: Myoung Jin Lee Department of Orthopaedic Surgery, Dong-A University Hospital, 26 Daesingongwon-ro, Seo-gu, Busan 49201, Korea Tel: 82-51-240-5166, Fax: 82-51-254-6757, E-mail: tynitus@dau.ac.kr 론 이소개되었다. 2) 부하분담구조물로써역행성골수강내금속정을이용한유합술이상대적으로작은절개로인기를얻고있다. 3) 금속판을이용한방법과비교하여역행성골수강내금속정을이용한유합술은생역학적강도, 굴곡강도, 회전안정성및역동적압박력이우수하다고알려져있다. 4) 나사못을이용한유합술의경우유합위치의골결손이나사못고정의불안정성을초래할수있다. 족관절과거골하관절의유합에서나사못고정술보다골수강내금속정을이용한고정술이더높은안정성을획득하는데용이하다고알려져있으며 5) 나사못만을이용한경-거-종골관절유합술후높은합병증과불유합의빈도가보고되고있기에저자들은역행성골수강내금속정을이용한경-거-종골관절유합술의술후임상적, 방사선학적결과에대해연구하였다. Financial support: This paper is supported by Dong-A University research fund. Conflict of interest: None. Copyright c2015 Korean Foot and Ankle Society. All rights reserved. CC 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.
172 Vol. 19 No. 4, December 2015 대상및방법 1. 연구대상 2008년도 1월부터 2013년도 12월까지동아대학교의료원과순천향대학교부천병원에서역행성골수강내금속정을이용하여족관절유합술을시행받은환자를대상으로후향적으로조사하였다. 한명의술자에의해총 36예의경-거-종골관절유합술이시행되었다. 당뇨병성샤콧관절, 거골의골괴사, 류마티스관절염등의염증성관절염, 외상성및퇴행성관절염, 족관절과함께거골하관절의심한관절파괴및변형이있을경우수술적치료의대상으로하였다. 그리고혈관이상, 피부의감염이있는환자들은제외하였다. 환자들의평균나이는 56세 (44 72세) 였으며남자는 21명, 여자는 15명이었다. 이들중 6명은이전나사못고정유합이실패한경우였으며 1명은족관절인공관절치환술이실패한경우였다. 평균추시기간은 16개월 (8 32개월) 이었다. 본연구는동아대학교의료원임상연구윤리위원회 (Institutional Review Board) 의승인을받았다. 2. 수술방법경-거-종골관절유합을위해역행성압박골수강내금속정 (Dyna Locking Ankle Nail TM ; U&I Corporation, Uijeongbu, Korea) 을사용하였다 (Fig. 1). 척추마취를시행한후, 환자를앙와위로눕힌상태에서측면절개 (transfibular approach) 를이용하여족관절과거골하관절을노출한후연골을제거하고, 해면골을노출시키는 A 방법으로유합될부위를전처치하였다. 족저부에서유도핀을삽입한후유도핀을따라골수강확공을하고금속정을삽입하였다. 발목관절이중립족배, 족저굴곡및외반 5도, 외회전 5도의중립위로유지된상태에서압박을위해경골압박나사와거골나사를차례대로삽입한뒤, 종골후면에서전방으로종골잠금나사를삽입하였다. 필요시골결손부위에동결동종골이식을시행하였으며, 심한골결손소견이있을경우비골지주동종골이식을시행하였다. 술후 2주간단하지석고붕대고정을하고체중부하를금하였으며이후 6주간은보조기및부츠 (cam-walker boot) 로교체하면서목발을이용한부분체중부하를허용하였다. 3. 방사선학적및임상적평가수술후골유합까지평균 4주간격으로추시관찰하였으며골유합을확인한뒤에는 6개월간격으로체중부하발목의전후및측면방사선사진을통하여경거골간의골소주연결을확인하였다. 6) 이학적검사를통해경거골의움직임, 탄발음, 수술부위통증및압통여부를확인하였으며, American Orthopaedic Foot and Ankle Society (AOFAS) score를통해술후 6개월째 75점이상인그룹과 75점미만인그룹을비교하였다. 술후성공적인유합유무판단은신체검진상체중부하시통증이없고가시적인관절운동이없으며방사선사진상유합부위의골소주연결이관찰될시성공적인유합으로판정하였다 (Fig. 2). 또한술후전후방사선사진을통해골수강내골수정의중심축과경골의중심축사이의각도를측정하여금속정-경골각도를구하였다 (Fig. 3). 이는경골골수강을 2등분하는선과골수강내금속정을 2등분하는선사이의각도를통해측정하였다. 그리고체중부하측면방사선사진를통해제 5중족골-경골각도를측정하였다 (Fig. 4). 이는경골골수강을 2등분하는선과제 5 중족골하연을연결하는선사이의각도를통해측정하였다. 술후 6개월째신체검진상경거골의움직임이관찰되거나방사선사진상유합부위의골소주연결이관찰되지않으면지연유합이라정의하였으며술후 12개월째상기소견이관찰될시불유합으로정의하였다. 또한관상면에서 5도이상의변형이잔존할경우부정유합으로정의하였다. 7) 모든자료는 IBM SPSS Statistics version 18.0 (IBM Co., Armonk, NY, USA) 을이용하여 Student t-test를시행하여통계처리하였으며, 유의성의판정은 p-value가 0.05 미만일경우로하였다. 결 과 Figure 1. Tibiotalocalcaneal arthrodesis is done with Dyna Locking Ankle Nail (U&I Corporation). (A) Anteropostieror view. (B) Oblique view. B 36명의환자중이전유합술에실패한경우가 6예, 족관절인공관절치환술에실패한경우가 1예였다. 당뇨병성샤콧관절은 12 예, 거골의골괴사는 5예, 족관절과함께거골하관절의퇴행성관절염이있는경우는 4예, 류마티스관절염은 6예, 외상성관절염은
Myoung Jin Lee, et al. Tibiotalocalcaneal Arthrodesis Using a Retrograde IM Nail 173 A B Figure 2. Radiographs show successful fusion trabeculae crossing the fusion site on plain anteroposterior (A) and lateral (B) radiographs. Figure 3. Nail-tibial angle is measured between the line bisecting the intramedullary canal of the tibia (line a) and the line bisecting (connecting) the nail (line b). Figure 4. Fifth metatarsal-tibial angle is measured between the line bisecting the intramedullary canal of the tibia (line a) and the line bisecting (connecting) inferior margin of 5th metatarsus (line b). 9예였다. 평균유합기간은 23주 (11 29주) 였으며 36명의환자중 33명이유합을얻어 91.7% 의유합률을보였다. 3명의환자에서불유합소견이관찰되었으며이중 1명은당뇨병성샤콧관절환자로동측원위비골지주를이용한추가금속판고정술을시행하였다. 불유합환자중 2명은방사선학적으로경거골간의골소주연결이부족하였으나통증및증상이경미하여경과관찰하였다. 36명의평균금속정-경골각도는 2.6도였으며유합을얻은환자 33명의평균금속정-경골각도는 2.3도, 불유합환자 3명의평균금속정-경골각도는 4.2도였다. 족배굴곡시는양의값, 족저굴곡시는음의값으로하여평균제 5중족골-경골각도는 +1.6도였다. 술전및술후 6개월째평균 AOFAS score는 41점 (4 65점) 에서 81점 (61 86점) 으로향상되었으며 visual analogue scale (VAS) score는술전 8.2점 (4 10점) 에서술후 3.8점 (0 6점) 으로향상되었다 (Table 1). 나이, 성별, 질환, 관상면정렬, 금속정-경골각도의경우두군간에유의한차이가없었으나 5도이상의부정유합이있는경우와제 5중족골-경골각도의경우 p-value 값이 0.05 미만으로 AOFAS score에유의한결과를보였다 (Table 2). 술후합병증으로는 1예의외상성관절염환자에서심부감염의합병증이발생하였으며, 변연절제술및세척술과항생제를사용하여감염을치료하였다. 1예의당뇨병성샤콧관절환자에서술후 6개월째 17도의내반변형이확인되었으며종골나사의파손소
174 Vol. 19 No. 4, December 2015 Table 1. Change of the Mean AOFAS and VAS Score Preoperative 견이관찰되었다. 또한 1예의당뇨병성샤콧관절환자에서술후 2년째인접관절의통증을호소하였으며중족-족근관절의관절염소견이관찰되었다. 고 경-거-종골관절유합술은족근관절및거골하관절에발생하는다양한종류의관절염에의해통증과관절파괴가동반된변형을치료하는효과적인수단으로, 관절기능을유지하지만환자선택이제한된관절치환술에비해넓은적응증을가진다. 1) 관절유합술의원칙으로는유합이일어나는접촉면은넓고평평하며해면질골로이루어지도록하고, 연부조직에문제가있거나불량한골질을가진경우를제외하고가능한한견고한내고정을사용해야하며, 지면에체중부하가가능한편평한족부를얻기위해하지및전족부에대한후족부정렬을얻어야한다. 8) 견고한내고정및유합을얻은경우에는대다수의환자에서매우우수한통증의감소를기대할수있다. 또한술전의변형에대한교정을수술과동시에시행할수있으며, 적절한관절의위치에서유합이성공적일경우추가적인수술의필요성이적다. 9) 1951년에 Charnley 10) 는족관절유합방법에대하여골이식을시행하지않고외고정장치를이용한압박기법에의한유합술을보고하면서, 압박기법은관절간간격을최소화하고전단력을제거할수있는장점이있다고하였다. 이는불유합으로인한유합술의실패를감소시키는결과를가져왔으며효과적인유합술의방법으로평가되고있다. 압박기법을이용한유합술은현재까지관절유합술의기본적인원칙중하나로이어져오고있으며현재는노출된연골하골간의압박및직접적접촉은대부분내고정술로가능하게되었다. 앞서내고정술방법으로금속판, 나사못, ㄷ자꺽쇠못, 골수강내금속정등을이용한많은수술방법이소개되었다. 2) 그러나여러수술방법중흔히사용되는나사못고정술로는유합부위의골소실이있거나골질이좋지않은경우에충분한안정성을얻을수없다. 5) 역행성골수강내금속정을이용한금속정삽입술은평균 88% 의높은유합률을가지며 11) 일반적으로관절유합술에서골수강내고정술은지연나사고정술에비해휨과비틀림에생역학적으로더견고하다. 5) 또한유합률에서도역행성골수강 찰 Postoperative 6 mo AOFAS score Pain 12 32 Function 24 41 Alignment 5 8 VAS score 8.2 3.8 AOFAS: American Orthopaedic Foot and Ankle Society, VAS: visual analogue scale. Table 2. Logistic Regression Analysis between Groups of Postoperative 6 Months AOFAS Score over 75 and below 75 Factor p-value Odds ratio 95% CI Age 0.435 0.756 0.379 1.480 Sex 0.076 1.022 0.997 1.051 Disease 0.682 3.290 1.783 6.152 Alignment (<5 o ) 0.059 2.543 1.133 5.885 Malalignment ( 5 o ) 0.021 2.678 1.461 4.958 Nail-tibial angle 0.573 0.762 0.378 1.506 5th metatarsal-tibial angle 0.011 0.976 0.961 0.989 Values are presented as number or range. AOFAS: American Orthopaedic Foot and Ankle Society, CI: confidence interval. 내금속정은금속판고정술과비교하여높은성공률을보인다. 12) 저자들은변형을교정하기위해후족부를더외반하여금속정을 삽입한결과사선방향으로금속정이고정되었으며금속정-경골각도수치가보다높게측정되었다. 또한본연구에서는금속정-경골각도가증가할수록불유합의확률도증가하는경향이나타났다. 변형교정을위해과도하게후족부를외반하는것은술후불유합의확률을높일가능성이있으므로술중변형교정시주의가필요하다. 술후 5도미만의정상각도범위내의변형에서는각도의정도와상관없이 AOFAS 및 VAS score가모두향상되었다. 일반적으로약 5도의외반상태에서의족관절의고정이바람직하며, 내반상태로고정되었을시횡족근관절의잠금현상을유발시켜보행중에정상적인체중부하가되지않으므로주의해야한다. 또한제 5중족골-경골각도가음의값을가질경우좋지않은결과를보인반면양의값을가진경우는 AOFAS score가높은결과가나타났다. 이는족저굴곡을통한보행이통증과기능에더좋지않은영향을미치는것과관련이있으리라생각된다. 과도한족배굴곡은발꿈치동통및궤양을유발할수있고, 과도한족저굴곡은중족골통증및대퇴사두근이약한경우전반슬 (back knee) 보행을일으킬수있다. 본연구의제한점으로는역행성골수강내금속정삽입술을통한관절유합술을시행받은환자들에서선택한후향적연구라는점과다양한질환군의관절염환자를대상으로유합술을시행하였으므로질환군에따른유합률의차이는고려하지못했다는점이다. 결 족관절과함께거골하관절의관절파괴및변형이있을시역행성골수강내금속정을이용한경-거-종골관절유합술은환자의만족도가높은좋은수술방법중하나로생각된다. 론
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