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대한골절학회지제 22 권, 제 1 호, 2009 년 1 월 Journal of the Korean Fractrure Society Vol. 22, No. 1, January, 2009 경피적정복술을이용한경골후외측과골절의치료 이재성ㆍ이한준ㆍ유재현ㆍ김희천 * 중앙대학교의과대학용산병원정형외과학교실, 국립의료원정형외과 * 목적 : 족근관절삼과골절에서외과의해부학적정복후에도정복되지않았던후외측골편을 K- 강선을이용하여경피적방법으로정복했던경험을보고하고자한다. 대상및방법 : 2004 년 1 월부터 2006 년 12 월까지족근관절삼과골절에대하여수술적치료를받았던환자 72 예중, 외과골절의정복후에도원위경골후외측관절면에 2 mm 이상의층형성이남아있어경피적방법으로정복했던 5 예의결과를분석하였다. 정복방법은외측과의골절을예비정복후후외측골편이해부학적으로정복되지않았던경우 K- 강선을후외측골절편에삽입하여원위경골의관절면으로밀어내려정복한후지연나사를이용하여고정하였다. 결과 : 5 예의환자에서후외측골절편의관절면의침범정도는평균 30.2% 였고, 외과의해부학적정복후측면방사선촬영에서측정한층형성은평균 3.7 mm 였다. 최종추시에서관절면의층형성은 5 예모두에서 2 mm 이내로측정되었고 Baird and Jackson score 는 5 예중 3 예에서우수한결과를, 2 예에서양호한결과를보였다. 결론 : K- 강선을이용한경피적정복술은비교적간편한방법으로골절편이관절면의 25% 이상이고분쇄가심하지않은원위경골관절면의후외측골절정복에유용한방법으로생각한다. 색인단어 : 경피적정복술, 삼과골절, 후과골절 The Treatment of Posterolateral Malleolar Fractures using Percutaneous Reduction Technique Jae-Sung Lee, M.D., Han-Jun Lee, M.D., Jae-Hyun Yoo, M.D., Hee-Chun Kim, M.D., Ph.D.* Department of Orthopaedic Surgery, Yong-San Hospital, College of Medicine, Chung-Ang University, National Medical Center*, Seoul, Korea Purpose: To evaluate the usefullness of the percutaneous reduction technique with K-wire that could reduce the displaced posterolateral fracture fragment which persisted even after an anatomical reduction of the lateral malleolar fracture. Materials and Methods: From January 2004 to December 2006, we reviewed 72 patients who underwent surgical treatment for their trimalleolar fractures. We estimated the clinical and radiological results of 5 cases treated by percutaneous reduction technique with K-wire when more than the distal tibial articular step-off was left after reduction of the lateral malleolar fracture. The method of reduction starts with temporary fixation of lateral malleolar fracture followed by checking ankle radiographic image to confirm the accuracy of reduction. In case of incomplete reduction of the posterior fragment, a K-wire is inserted into the posterior fragment and pushed downward to the ankle joint level, and then lag screws were inserted. Results: The average articular involvement by the posterolateral fracture fragment was 30.2%. The average step-off after reduction of the lateral malleolar fracture was 3.7 mm. At the final follow up, step-off was less than 2 mm in all cases. In clinical results by Baird and Jackson score, 3 out of 5 cases were excellent, other 2 were good. Conclusion: Percutaneous reduction technique for posterolateral fragment using the K-wire is relatively easy. This technique may be useful when the posterolateral fragment is large (more the 25% of articular surface) and not severely comminuted. Key Words: Percutaneous reduction, Trimalleolar fracture, Posterior malleolar fracture 통신저자 : 이한준서울시용산구한강로 3 가 65-207 중앙대학교용산병원정형외과 Tel:02-748-9774 ㆍ Fax:02-793-6634 E-mail:gustinolhj@hanafos.com * 본논문은 2007 년도중앙대학교교내임상연구비의지원을받아이루어졌음. 접수 : 2008. 9. 25 심사 ( 수정 ): 2008. 11. 6 게재확정 : 2009. 1. 3 Address reprint requests to:han-jun Lee, M.D. Department of Orthopaedic Surgery, Yong-San Hospital, College of Medicine, Chung-Ang University, 65-207, Hangang-ro 3ga, Yongsan-gu, Seoul 140-757, Korea Tel:82-2-748-9774 ㆍ Fax:82-2-793-6634 E-mail:gustinolhj@hanafos.com 19

20 이재성, 이한준, 유재현, 김희천 서 론 대상및방법 족근관절골절에있어서경골후과골절은원위경골관절면을침범하기때문에내고정에대한적응증은골절편의크기와골절의전위정도에따라결정된다 4,6,11,12,15). 족근관절삼과골절시외과골절에대하여해부학적정복을시행하면대부분의경우후외측의골절편은후하방경비인대의인대정복술 (ligamentotaxis) 에의해저절로정복되지만, 때로는외과골절이해부학적으로정복되더라도후외측골절편이정복이되지않는경우를접할수있다. 후외측골절편의정복이이루어지지않은경우대부분의저자들은골절편이경골관절면의 25% 이상을차지하거나층형성 (step-off) 이 2 mm 이상인경우해부학적정복을권유했다 4,6,8,9,11,12,15). 저자들의경험에의하면후과골절의내고정시전통적인후외측접근법은몇가지문제점을갖고있다. 첫째, 충분한수술시야확보의어려움이있으며둘째, 의인성비복신경손상의가능성이있고셋째, 과도한연부조직의박리로인한수술후연부조직의합병증이생길가능성이있다. Weber 16) 는후과골절편을후외측, 후내측골절편으로분류하였는데, 저자들은의인성신경혈관손상의위험성이있기때문에후내측골절편인경우에는이방법을사용하지않았다. 저자들은전위된족근관절후외측과골절의정복을얻을수있는 Kirschner-wire (K- 강선 ) 를이용한경피적정복술을소개하고그유용성을알아보고자하였다. 2004 년 1 월부터 2006 년 12 월까지족근관절삼과골절에대하여수술적치료를받았던환자 72 예를대상으로하였다. 이중 40 예는외과의고정후후방골절이함께정복되었고 16 예는골편이작아서고정의필요가없었으며 11 예의경우는외과골절의분쇄가심해해부학적정복을얻을수없었던증례를제외하고외과골절의해부학적정복후에도원위경골후외측관절면에 2 mm 이상의층형성이남아있어경피적방법으로정복했던 5 예를대상으로 Fig. 1. CT image shows large non-comminuted posterior malleolar fragment. Fig. 2. Percutaneous K-wire location is confirmed by C-arm image. Post-reduction image (A) is taken by C-arm image intensifier and the schematic image is shown (B).

경피적정복술을이용한경골후외측과골절의치료 21 하였으며평균추시기간은 14 개월이었다. 연령분포는평균 30.2 세 (19 65) 였고, 골절의원인은실족이 3 명 (60%) 으로가장많았고, 다음이교통사고 1 명 (20%), 스포츠손상 1 명 (20%) 의순이었다. 골절의분류는 Lauge-Hansen 분류법을적용하였으며, 모든환자군을대상으로수상직후및도수정복후의단순방사선촬영및컴퓨터단층촬영을시행하여주골절선을기준으로골절편의분쇄가심하지않은하나의후외측골절편을가지고있었던경우만을연구대상에포함시켰다 (Fig. 1). 수술방법은환자를수술대위에앙와위로눕히고, 대퇴부에지혈대를감은후, 환자의골질에따라서나사못을이용하거나 0.062 in K- 강선를이용하여외측과의골절을예비정복후영상증폭기로측면사진을확인했다. 이때예비정복을하는이유는외과골절에대해금속판고정술을시행하면후외측골편의정복정도를알수없기때문이다. 후외측골편이해부학적으로정복되지않았던경우에는 0.062 in K- 강선을후외측골절편에삽입하여원위경골의관절면까지밀어내린다 (Fig. 2). 밀어내리는힘을유지하면서첫번째 0.062 in K- 강선주위에추가적인 0.062 in K- 강선을삽입해서후외측골편의정복을유지한다 (Fig. 3). 지연나사를삽입하기위한유도침을전경골근건의내측에서후외측을향하여삽입한다. 이때효과적인지연효과 (lag effect) 를위해서유도침은골절선에수직을이루는각도로삽입해야하며 (Fig. 4) 삽입방향은수술전에찍은컴퓨터단층영상을보고미리예측할수있다. 유도침삽입후, 영상증폭기를통하여전후면및측면촬영을시행하여유도침의위치및방향의적절성과후외측 골절편의정복상태를판단하고, 삽입나사의길이를측정하고, 부분해면골나사 (partially threaded cancellous screw) 를전방에서후방으로삽입한다. 이때, 골절편의크기에따라서한개의나사를추가적으로삽입할수있다. 후외측골편의고정후, 외과골절에대하여금속판고정술을시행하였다 (Fig. 5). 수술후처치는골절부위의손상정도와고정방법등에따라, 먼저술후 4 주간단하지석고고정을시행한다음, 추가로탈부착이가능한단하지부목을 4 주간시행하였다. 그리고체중부하는수술 3 주후부터발끝접촉보행을하다가, 6 주후부터는부분체중부하를허용하였으며, 전체중부하는내고정정도나방사선촬영을통한골유합정도에따라 8 주에서 12 주사이에시작하였다. 치료결과에대한판정은 Baird 와 Jackson 1) 의임상학적판정과마지막추시관찰시의족관절측면방사선영상을통한원위경골관절면의층형성을측정하여판정하였다. 결 Lauge-Hansen 골절분류상전례에서회외 - 외회전에의한골절이었다. 골절편의크기, 즉관절면의침범정도는평균 30.2% (27 35%) 였고, 일차적도수정복술후후과골절편의전위정도는관절면의층형성을측정하였으며평균 3.7 mm (2.8 4.2 mm) 였다. 총 5 예의후외측과골절에서최단 12 개월에서최장 25 개월간추시관찰한결과를 Baird and Jackson 1) 의판정방법을이용하여우수, 양호, 보통, 불량으로구분하여평가하였다. 5 예중 3 예 (60%) 에 과 Fig. 3. Additional K-wire is inserted to maintain the reduction status. Fig. 4. A guide wire is inserted from anteromedial to posterior direction under the C-arm monitoring.

22 이재성, 이한준, 유재현, 김희천 Fig. 5. This photo shows completion of definite fixation. The medial malleolar fracture was reduced by non absorbable suture. Table 1. Result clinical assessment (by Baird and Jackson) Score Excellent Good Fair Poor Number of patients 서우수한결과를, 2 예 (40%) 에서양호한결과를보였으며 (Table 1), 관절면의층형성에대한방사선소견에의한판정결과는 5 예모두에서 2 mm 이내로측정되었다 (Table 2). 고 족근관절의후과골절은주로회전력또는수직부하에의한손상에의한후과골절은전체족근관절골절의 7 44% 를차지한다 2,3,7,13,14). 경골후과골절의치료에있어가장중요한것은골편의크기이며골편의관절면침범정도가족관절의불안정성을유발할수있는 25% 이상일경우수술적치료가필요하다고알려져있다 3,10,11). Haraguchi 등 5) 은족관절경골후과골절을병리해부학적으로 1) 후외측 - 사선형 (posterolateral-oblique type, type I), 2) 내측 - 신전형 (medial-extension type, type II), 3) 소후연골절 (small shell type, type III) 로분류한바있는데, 저자들은 type II 와 type III 는각각의인성신경혈관손상의위험성및골절편이넓고얇아서생길수있는추가적분쇄위험때문에대상에서제외하고, type I 에해당하는후과의후외 찰 3 2 0 0 Table 2. The results of radiological assessment (intra-articular step-off of the distal tibia) Case 1 Case 2 Case 3 Case 4 Case 5 Average (mm) Pre-operative displacement 4.1 4.2 3.6 2.8 4.0 3.74 Post-operative displacement 1.4 1.6 측골절만을적응증으로선택하였다. 족관절경골후외측골절시외측과골절을해부학적으로정복하더라도후외측골절편은해부학적정복이안되는경우가있는데, 이것은후하경비인대 (posterior inferior tibiofibular ligament) 및하횡인대 (inferior transverse ligament) 의파열이있거나작은골편들의감입에의해인대정복술이방해받기때문일것으로추측된다. 저자들의경우에는외과의길이를정확하게유지하기위해외과골절을예비고정후영상증폭기를통해정면및측면영상을확인하는데본연구에서의첫번째증례에서외과고정후에도후외측골편이저절로정복되지않았기때문에그후로계속측면영상을확인한결과연구대상이될수있는삼과골절 45 예중 5 예의증례를얻을수있었다. 저자들의문헌고찰에서는이비율을알수없었으나보다많은증례를연구한다면그비율을예측할수있을것이다. Strenge 와 Indusuyi 15) 는후외측골절편의내

경피적정복술을이용한경골후외측과골절의치료 23 고정을위해서내과와외과를고정한후발목관절을최대한족배굴곡하면후과골절을정복할수있다고하였으나, 외과의고정에사용된고정물에의해후과골편의정복여부를정확히알기어려울것으로판단되며환자의골질 (quality) 이적절한경우에는유용할수있으나골다공증이있는고령의환자에서는과도한족배굴곡은골절편의정복소실을일으킬수있을것으로판단된다. 저자들이소개한방법에서는지연나사를전방에서후방으로삽입하였으나골편의크기가충분치않은경우에는같은술식으로후방에서전방으로의삽입도가능하리라생각한다. 또한전통적인후외측외과적접근법을통한수술시생길수있는의인성비복신경의손상, 시야확보를위한과도한연부조직박리에서생길수있는합병증을피할수있는장점이있다. 결 저자들이경험한 K- 강선을이용한비관혈적정복및내고정술을분쇄가심하지않고골절편이관절면의 25% 이상을차지하는후외측골편의정복시에유용한방법으로생각한다. 론 참고문헌 1) Baird RA, Jackson ST: Fractures of the distal part of the fibula associated disruption of the deltoid ligament. Treatment without repair of the deltoid ligament. J Bone Joint Surg Am, 69: 1346-1352, 1987. 2) Boggs LR: Isolated posterior malleolar fractures. Am J Emerg Med, 4: 334-336, 1986. 3) Court-Brown CM, McBirnie J, Wilson G: Adult ankle fractures--an increasing problem? Acta Orthop Scand, 69: 43-47, 1998. 4) De Vries JS, Wijgman AJ, Sierevelt IN, Schaap GR: Long-term results of ankle fractures with a posterior malleolar fragment. J Foot Ankle Surg, 44: 211-217, 2005. 5) Haraguchi N, Haruyama H, Toga H, Kato F: Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am, 88: 1085-1092, 2006. 6) Harper MC, Hardin G: Posterior malleolar fracture of the ankle associated with external rotation-abduction injuries. Results with and without internal fixation. J Bone Joint Surg Am, 70: 1348-1356, 1988. 7) Jaskulka RA, Ittner G, Schedl R: Fractures of the posterior tibial margin: their role in the prognosis of malleolar fractures. J Trauma, 29: 1565-1570, 1989. 8) Jeong HJ, Kin CK, Chung SW: Treatment of the posterior malleolar fracture. J Korean Fracture Soc, 11: 924-931, 1998. 9) Kim SJ, Choi IY, Ahn TK: A clinical study of the trimalleolar fractures of the ankle. J Korean Fracture Soc, 2: 145-154, 1989. 10) Lee CS, Suh JS, Yi JW: Comparative study for th results of ankle fracture depending on the extension of the posterior malleolus Fracture. J Korean Orthop Assoc, 42: 470-474, 2007. 11) Mc Danial WJ, Wilson FC: Trimalleolar fractures of the ankle. An end result study. Clin Orthop Relat Res, 122: 37-45, 1977. 12) Michelson JD: Fractures about the ankle. J Bone Joint Surg Am, 77: 142-152, 1995. 13) Neumaier Probst E, Maas R, Meenen NM: Isolated fracture of the posterolateral tibial lip (Volkmann's triangle). Acta Radiol, 38: 359-362, 1997. 14) Nugent JF, Gale BD: Isolated posterior malleolar ankle fractures. J Foot Surg, 29: 80-83, 1990. 15) Strenge KB, Indusuyi OB: Technique tip: percutaneus screw fixation of posterior malleolar fractures. Foot ankle Int, 27: 650-652, 2006. 16) Weber M: Trimalleolar fractures with impaction of the posteromedial tibial plafond: implications for talar stability. Foot Ankle Int, 25: 716-727, 2004.