대한족부족관절학회지 : 제 11 권제 1 호 2007 J Korean Foot Ankle Soc. Vol. 11. No. 1. pp.45-50, 2007 외상후성관절염에대한족관절인공관절전치환술 전남대학교의과대학정형외과학교실 Total Ankle Arthroplasty for the Post-traumatic Osteoarthritis Keun-Bae Lee, M.D., Sang-Gwon Cho, M.D., Byung-Soo Kim, M.D., Min-Sun Choi, M.D. Department of Orthopaedic Surgery, Chonnam National University Medical School, Gwangju, Korea =Abstract= Purpose: To evaluate the short-term clinical outcomes of total ankle arthroplasty for the post-traumatic osteoarthritis. Materials and Methods: Fourteen patients who had undergone total ankle arthroplasty from February 2005 to June 2006 were reviewed. Eleven patients were male and three patients were female. The mean age was 52.8 years (range, 33 to 69 years). The mean follow-up duration was 15.9 months (range, 12 to 24 months). Primary injuries were pilon fractures in eight cases, malleolar fractures in three, ankle syndesmotic injury in one, talus fracture and dislocation in one, and distal tibial physeal injury in one. Visual analogue scale (VAS), Range of motion (ROM), American Orthopaedic Foot and Ankle Society (AOFAS) score and complications were evaluated. Results: The mean VAS improved from 8.6 preoperatively to 2.6 at last follow-up. The mean ROM improved from 24.6 degrees preoperatively to 33.1 degrees postoperatively. The mean AOFAS score improved from 44.5 points preoperatively to 75.1 points postoperatively. Radiographically, all components were stable, but there were component malpositions in two cases, including one varus malposition of tibial component and one increased anterior translation of talar component. Complications were deep infection in one case, intraoperative malleolar fracture in three, marginal wound necrosis in two, and heterotopic ossification in one. One prosthesis was revised because of deep infection. Conclusion: Total ankle arthroplasty for the post-traumatic osteoarthritis is believed to be an useful method for preservation of the motion, relief of the pain and high satisfaction of patients in short-term results. Key Words: Post-traumatic ankle osteoarthritis, Total ankle arthroplasty 서 론 족관절의외상후성관절염은족관절주위의다양한골절 Address for correspondence Keun-Bae Lee, M.D. Department of Orthopedic Surgery, Chonnam National University Hospital, 8 Hak-dong, Dong-gu, Gwangju-si, 501-757, Korea Tel: +82-62-220-6334 Fax: +82-62-225-7794 E-mail: kbleeos@chonnam.ac.kr 과인대손상으로인해발생할수있으며, 이에대한치료로족관절유합술, 원위경골절골술, 인공관절전치환술등이시도되어왔으나, 족관절유합술이보편적인방법으로사용되어왔다 3,6,11). 그러나족관절유합술후의장기추시결과대부분의경우에서거골하관절이나중족부관절등인접관절의퇴행성관절염이발생하였다고보고되었으며 1,6), 이를극복하기위한방법으로서족관절의운동범위를유지할수있는인공관절전치환술이시도되었는데, 초기인공족관절의디자인에대한문제점과삼각인대및외측인대의중요성에대한인식부족으로그결과는만족스럽지못 - 45 -
했다 1,4,13). 최근삽입물의디자인발전과족관절인대의균형에대한이해가깊어지면서좋은결과가계속보고되고있으며 2,5,15), 족관절의외상후성관절염의치료방법으로인공관절치환술의사용이점차증가하고있다. 이에저자들은족관절주위골절이나인대손상후발생한말기외상후성관절염에대하여비시멘트성가동형인공관절인 Hintegra (Newdeal, Lyon, France) 를이용한족관절인공관절전치환술을시행한초기결과에대해보고하고자한다. 대상및방법 1. 연구대상 2005 년 2월부터 2006 년 6월까지족관절의외상후성관절염에대하여인공관절치환술을시행한 14명을대상으로하였으며평균추시기간은 15.9 개월 ( 범위, 12~24 개월 ) 이었다. 환자의연령은평균 52.8 세 ( 범위, 33~69 세 ) 였으며, 남자가 11명, 여자가 3명이었다. 골절의종류로는 Pilon 골절 8예, 과부 (malleolar) 골절 3예, 원위경비골관절손상 1예, 거골경부골절및탈구 1예및유년기의원위경골의성장판손상이 1예였다. 1예에서는원위경골교정절골술후선열을조정한뒤인공관절전치환술을시행하였다 (Table 1), (Fig 1). 전예에서비시멘트성가동형인공관절 시스템인 Hintegra 를이용하였다. 2. 수술방법수술은전신마취나척수마취하에앙와위에서환측둔부에실리콘주머니를위치시켜족관절을중립위로하여시행하였다. 피부절개는족관절의정중앙에약 11 cm의수직절개를시행하였으며, 전경골건과장족무지신전건사이로족관절에도달하였다. 관절막과활액막을제거한후경골과거골의골극을제거하고, 경골의역학적축을기준으로하여경골원위부관절면을절제하였다. 이때, 관절연골하골을최대한보존하는방향에서절제하도록노력하였다. 또한수술중자주발생하는내, 외과골절을방지하기위해골절제시얇은보호금속판을이용하였다. 거골절제후임시삽입물을삽입하여내, 외측인대균형을확인하고영상증폭기를이용하여삽입물의위치가적절한지평가하였다. 최종삽입물을삽입한후족관절운동범위및인대균형을확인하고창상봉합을시행하였다. 족관절의족배굴곡이부족하다고생각되는경우에선아킬레스건연장술을추가로시행하였다. 술전전방의골결손이심한경우절골된골중에서해면골을분리하여결손을보강하였고, 전후면상의선열이내반혹은외반변형이심한경우거골의골절제를조정하거나내측또는외측인대유리술을통하여균형을맞추었다. Table 1. Patien t Data An alys is Case Age (yr) Sex * Primary injury VAS ROM AOFAS hindfoot score Preop Postop Preop Postop Preop Postop Complications 1 39 M Malleolar fr 7 2 30 20 47 61 Ectoptic ossification 2 50 M Pilon fr 9 5 5 35 24 80 Lateral malleolar fr 3 62 F Syndesmotic 10 2 20 60 31 96 (-) injury 4 61 M Malleolar fr 8 2 55 35 37 87 Marginal wound necrosis 5 65 M Pilon fr 10 5 30 35 58 66 Marginal wound necrosis 6 54 M Physeal 10 2 10 35 24 85 (-) injury 7 54 M Pilon fr 7 5 20 45 68 68 Medial malleolar fr 8 39 M Malleolar fr 10 0 0 45 22 77 (-) 9 63 M Pilon fr 7 1 40 45 65 64 (-) 10 66 F Pilon fr 9 5 35 30 72 63 (-) 11 49 F Pilon fr 9 3 20 15 60 70 Medial malleolar fr 12 33 M Talus fr 9 1 10 20 26 88 (-) 13 51 M Pilon fr 9 3 45 20 45 74 (-) 14 69 M Pilon fr 6 0 5 15 64 72 (-) * M, Male; F, Female; VAS, Visual analogue scale; ROM, Range of motoion; AOAFS, American orthopaedic foot and ankle society; fr, fracture. - 46 -
외상후성관절염에대한족관절인공관절전치환술 Fi gure 1. (A) Anteroposterior plain radiograph of 54 year-old male patient with posttraumatic osteoarthritis shows varus deformity of 34 degrees, space narrowing and sclerosis of ankle joint. (B) Anteroposteri or plain rad iograph at 1 month followi ng sup - ramalleolar os teotomy sh ow s grad ual c orrec ti on f or varus deformi ty of an kle. (C ) An teropos teri or plain radiograph at 10 months following supramalleolar osteotomy shows complete healing at osteotomy si te. (D) Anteroposteri or and lateral plai n radi ographs immedi at ely af t er t ot al ankle art hroplast y show good positoning of implant. (E) At postoperative 13 months, there is no loosening of component. 3. 술후처치 4. 연구방법 술후 2주간단하지석고부목고정을시행하면서수술부위상처를치료하였으며, 그후관절운동과함께부분체중부하목발보행을허용하였고, 4주째완전체중부하를허용하였다. Fi gure 2. Th e f ollow in g ref eren c e lin es, an gles, c irc le w ere us ed for evaluation of stability and loosening of the tibial and talar components postoperatively: (A) α = the angle on the AP view, between the longitudinal axis of the tibia and the articulating surface of the tibial component. (B) β = the angle on the lateral view, between the longitudinal axis of the tibia and the articulat ing surface of the tibial component; c = the center of the circle which was formed by the talar component. 술후 1개월, 3개월, 6개월, 12개월및 2년단위로외래추시하였으며, 임상적으로환자의주관적만족도와 VAS (Visual analogue scale), 족관절의운동범위와 AOFAS (American Orthopaedic Foot and Ankle Society) 점수 12) 를평가하였다. 수술에대한만족도는 매우만족한다 (very satisfactory), 대체로만족한다 (generally satisfactory), 술전에비하여좋지만만족스럽지못하다 (improved), 술전에비해좋지않다 (no change), 술전에비해더심하게나빠졌다 (aggravated) 의 5가지문항으로만들어선택하게하여평가하였다. 방사선학적으로족관절전후면및측면사진과후족부정열사진, 체중부하하지전장전후면사진으로결과를분석하였다 (Fig. 2). 경골부치환물은경골의기계적축과전후면사진상 90도를이루며 (α), 측면사진상 86도를이루는것을정상각도로평가하였으며 5도이상벗어난경우를부정정렬로판정하였다. 거골부치환물은거골부치환물의중심이경골부치환물의관절면의 40-45% 에위치할때를정상으로평가하였으며 5% 이상벗어난경우를부정정렬로판정하였다. 또한, 거골부치환물의관절면을연장하여이루는가상의원의중심이경골의기계적축에일치하거나바로전방에위치하는경우를이상적인삽입물의위치로평가하였다. 또한수술중및수술후합병증의유무를조사하였다. - 47 -
결과 1. 임상적결과환자의주관적만족도는 5예는매우만족스럽다고응답하였고, 6예는대체로만족스럽다고하여 79% 의환자에서만족감을표시하였다. 이외에도 3예에서술전에비해증상호전은있으나만족스럽지못하다고응답하였다. 평균 VAS 는술전 8.6( 범위, 6~10) 에서술후 2.6( 범위, 0~5) 으로호전되었다. 평균족관절의관절운동범위는술전 24.6 도 ( 범위, 0~55 도 ) 에서술후 33.1 도 ( 범위, 15~60 도 ) 로호전되었다. 족배굴곡은술전 4.2 도 ( 범위, -5~15 도 ) 에서술후 7.3 도 ( 범위, 0~20 도 ) 로호전되었으며, 족저굴곡은술전 20.4 도 ( 범위, 5~40 도 ) 에서술후 25.8 도 ( 범위, 10~40 도 ) 로호전되었다. 평균 AOFAS 점수는술전 44.5 점 ( 범위, 22~72 점 ) 에서술후 75.1 점 ( 범위, 61~96 점 ) 으로호전되었다. 2. 방사선적결과전후면및측면방사선사진상허용범위를벗어나는삽입물의위치는 2예에서발견되었으며, 경골부치환물의내반삽입이 1예, 거골부치환물의전방전이가 1예관찰되었다. 최종추시상삽입물의해리및골용해등은관찰되지않았다. 3. 합병증합병증은수술중외과와내과의비전위골절이 3예발생하여나사못고정을시행하였고, 수술창상의변연부괴사가 2예에서발생하였으나지속적인상처드레싱에의하여육아조직으로치유되었다. 1예에서관절후내측의이소성골형성이발생하였으며, 이로인한족관절후내측통증은술후 14개월에이소성골의절제술후호전되었다. 술후심부감염이 1예발생하여삽입물의재치환술을시행하였다. 신경, 혈관손상등은발생하지않았다. 고찰족관절주위의다양한골절은해부학적인정복이이루어지지않거나수상당시심한관절연골의손상이있는경우족관절의외상후성관절염을발생시키며, 통증이심하여일상생활에많은장해를초래하는경우엔대부분족관절유합 술로치료하여왔다 3,6,11). 족관절은고관절과슬관절에비하여상대적으로외상후성관절염의빈도가높은데 7), 그이유로는관절연골의두께가얇고접촉면적이적어손상을받으면잔여관절연골에가해지는응력이급격히증가한다는설과관절연골이더강성 (stiffness) 이므로관절면이약간만불규칙해져도이를보상하지못한다는설이주장되고있다 5). 1879 년 Alert 가처음으로족관절유합술을보고한이래로 30여가지의족관절유합술이보고되었고, 족관절은유합시키더라도다른관절과달리기능상의큰장애가없고 80-100% 성공률을보여외상후성족관절관절염의통증감소를위한가장일반적인치료법으로알려져있다. 그러나족관절유합술후시간이경과할수록인접관절에퇴행성관절염이발생하며 1,6) Coester 등 6) 은 22년추시상모든환자에서동측의거골하관절및족관절주위관절에서증상이있는관절염이관찰되었다고보고하였다. 그리고, 족관절유합술후약 3-6 개월의유합을위한장기간의고정기간이필요하며, 불유합의가능성, 보행장애등이보고되었고, 이로인해지속적으로인공족관절전치환술이시도되고발전되어왔다 14). 하지만, 초기인공관절은삽입물의디자인에대한문제점과삼각인대및외측인대의중요성에대한인식부족, 그리고시멘트의사용으로인해결과가좋지않았다 1,4,13). 또한연부조직상태가다른관절에비해좋지않고, 기구의형태나크기가다양하지않으며, 선열을맞추기가쉽지않은문제점이있었다. 하지만, 최근삽입물의발전과인대균형에대한지식의축적으로점차좋은결과가보고되고있으며, Hintermann 등 9) 은 122 예의족관절관절염에대해 Hintegra 치환물을이용한인공관절전치환술을시행한결과평균 18.9 개월추시상 84% 의환자에서만족하였고, 평균관절운동범위는 39도로향상되었고, AOFAS 점수는 40점에서 85점으로향상되었음을보고하였다. 또한 Buechel-Pappas 를이용한 San Giovanni 등 15) 은 28예에서평균 8.3 년추시상 89%, Ali 등 2) 은 34예에서평균 5년추시상 97% 의환자에서만족하였음을보고하였다. 저자들의경우추시기간이짧지만관절운동범위는술전 24.6 도에서술후 33.1도로, AOFAS 점수는 44.5점에서 75.1점으로향상되었다. 또한, Soohoo 등 16) 은인공족관절전치환술과족관절유합술간에비용효과분석에서이론적으로인공족관절전치환술이비용효과면에서족관절유합술을대체할수있다고보고하였다. 외상후성관절염으로시행한족관절전치환술의결과는원발성관절염에비해더나쁘다고알려져있다. 외상후성 - 48 -
외상후성관절염에대한족관절인공관절전치환술 관절염환자군은이미여러차례수술을받았거나수술당시의원인으로인해유발된연부조직손상이창상합병증과인대균형에영향을일으킬수있고, 골결손이나부정정렬및관절운동제한등이동반되어인공관절시술결과에나쁜영향을끼칠것으로생각된다. Valderrabano 등 17-19) 은사체실험을통해정상족관절군과족관절유합술을시행한군, 그리고 Agility, Hintegra, STAR 의 3가지종류의인공관절삽입을시행한군을서로비교하여족관절의인공관절치환술이관절운동범위의측면에서관절유합술에비해전후면, 시상면, 수평면에서유의하게정상족관절에유사한움직임을보이고족부와경골사이의운동전이 (movement transfer) 가적으며, 거골의운동범위가크다고보고하였다. 또한 3 콤포넌트삽입물인 Hintegra, STAR 가 2 콤포넌트삽입물인 Agility 에비해보다해부학적인설계로정상족관절에유사한운동범위와운동전이, 거골의운동범위를보인다고보고하였다. 합병증에대한보고들을살펴보면, 수술자의경험이많을수록인공족관절전치환술도중및수술후합병증이감소한다고하였으며 8,10), Haskel과 Roger 8) 은내과및외과골절이 8-22%, 경미한창상치유의지연및주변괴사등이 2-30%, 심각한심부감염이 0-7% 에서발생하였다고보고하였다. 본연구에서는술후 6개월째심부감염이 1예발생하여치환물제거후항생제혼합된시멘트로감염을치료한뒤재치환술을시행하였는데, 인공관절수술후증상호전되다가증상발현되었으며원인은정확히알수는없으나예방적항생제투여없이발치한후발생된점을볼때인공관절수술후환자관리및교육이중요할것으로생각되며, 특히연부조직이적고혈액공급이원활치못한발목관절의인공관절수술은감염에취약하므로감염예방에더욱신경을써야할것이다. 외과및내과골절이초기 3예 (21%) 에서발생하였으며, 이러한골절을예방하기위해저자들은얇은보호금속판을개발하여사용중이며, 창상변연부괴사가 2예에서발생하였는데, 외상후성관절염에서는원발골절당시의연부조직손상이있을수있고또한한국인의인종적특성상신전건지대의두께가얇으므로연부조직봉합에일차성관절염보다더어려움이있어창상과관련된합병증이발생할가능성이있기때문에이를최소화하도록노력해야한다. 저자들은전경골근건에의한상처긴장도를감소시켜창상괴사등의합병증을줄이기위해술후약 2주정도단하지석고부목으로족관절족저운동을제한시켰다. 결 론 족관절의외상후성관절염에대한인공관절전치환술은비록초기결과이기는하나, 족관절유합술에비하여관절운동범위를보존하면서통증을감소시키고, 환자의높은만족도를보이는유용한치료방법이라생각된다. 하지만, 외상후성관절염의경우원발성관절염에비해골결손, 부정정렬및연부조직손상이더심하므로합병증의감소를위해서는술전철저한계획과세심한수술술기를요할것으로생각된다. REFERENCES 1. Ahlberg A and Henricson AS: Late results of ankle fusion. Acta Orthop Scand, 52: 103-105, 1981. 2. Ali MS, Higgins GA and Mohamed M: Intermediate results of Buechel Pappas unconstrained uncemented total ankle replacement for osteoarthritis. J Foot Ankle Surg 46: 16-20, 2007. 3. Buchner M and Sabo D: Ankle fusion attributable to posttraumatic arthrosis: a long-term follow-up of 48 patients. Clin Orthop Relat Res, 406: 155-164, 2003. 4. Buck P, Morrey BF and Chao EY: The optimum position of arthrodesis of the ankle. A gait study of the knee and ankle. J Bone Joint Surg, 69-A: 1052-1062, 1987. 5. Buckwalter JA and Saltzman CL: Ankle osteoarthritis: Distinctive characteristics. AAOS, Instr Course Lect, 48: 233-241, 1999. 6. Coester LM, Saltzman CL, Leupold J and Pontarelli W: Long-term results following ankle arthrodesis for posttraumatic arthritis. J Bone Joint Surg, 83-A: 219-228, 2001. 7. Demetriades L, Strauss E and Gallina J: Osteoarthritis of the ankle. Clin Orthop Relat Res, 349: 28-42, 1998. 8. Haskell A and Mann RA: Perioperative complication rate of total ankle replacement is reduced by surgeon experience. Foot Ankle Int, 25: 283-289, 2004. 9. Hintermann B, Valderrabano V, Dereymaeker G and Dick W: The HINTEGRA ankle: rationale and short-term results of 122 consecutive ankles. Clin Orthop Relat Res, 424: 57-68, 2004. 10. Hopgood P, Kumar R and Wood PL: Ankle arthrodesis for failed total ankle replacement. J Bone Joint Surg, 88-B: 1032-1038, 2006. 11. Katcherian DA: Treatment of ankle arthrosis. Clin Orthop Relat Res, 348: 48-57, 1998. 12. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS and Sanders M: Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int, 15: 349-353, 1994. - 49 -
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