45 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2019; 54: 45-51 https://doi.org/10.4055/jkoa.2019.54.1.45 www.jkoa.org 족관절내과절골술및대형신연기를이용한제 3 형거골경부골절의치료결과 박성해 이준영 이정우 조선대학교의과대학정형외과학교실 Outcome of Type 3 Talar Neck Fractures by Means of Medial Malleolar Osteotomy and Large Distractor Sung Hae Park, M.D., Jun Young Lee, M.D., and Jung Woo Lee, M.D. Department of Orthopaedic Surgery, College of Medicine, Chosun University, Gwangju, Korea Purpose: The clinical and radiological results of patients with type 3 talar neck fractures treated with the anteromedial approach using medial malleolar osteotomy and large distractor were analyzed retrospectively. Materials and Methods: From March 2009 to August 2016, 12 patients with a type 3 talar neck fracture, who underwent the anteromedial approach using a medial malleolar osteotomy and large distractor and who could be followed-up for more than 12 months after the operation, were examined. The patients were examined for the presence of Hawkins signs by anteroposterior and lateral radiographs and osteonecrosis by magnetic resonance imaging (MRI) on the postoperative 3 months. Subsequently, every 3 months, radiographic union was assessed by a simple radiograph and clinical symptoms. Twelve months postoperatively, posttraumatic arthritis was assessed and the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was analyzed. Results: In 7 cases, osteonecrosis was found on MRI performed 3 months after surgery. On the other hand, at the 12 months follow-up, all of them obtained AOFAS scores of 83.86±4.53 without surgical treatment. Radiographic union was achieved in all cases. The mean union period was 5.3 months. In 10 cases, traumatic arthritis was found after the radiographical and clinical evaluation. In addition, all of them could carry on everyday life by conservative treatment. The AOFAS ankle-hindfoot score was measured to be 85.17 on average. Other complications included superficial wound infection in 2 cases. Conclusion: An anteromedial approach using a medial malleolar osteotomy and a large distractor in the surgical treatment of patients with type 3 talar neck fractures can achieve anatomical reduction of the displaced fragment without a lateral dissection. This is considered to be another good surgical option. Key words: talar neck fracture, medial malleolar osteotomy 서론 Received December 3, 2017 Revised February 5, 2018 Accepted March 2, 2018 Correspondence to: Jun Young Lee, M.D. Department of Orthopaedic Surgery, Chosun University Hospital, 365 Pilmun-daero, Dong-gu, Gwangju 61453, Korea TEL: +82-62-220-3147 FAX: +82-62-226-3379 E-mail: leejy88@chosun.ac.kr ORCID: https://orcid.org/0000-0002-9764-339x *This work was supported by a grant from the Clinical Medicine Research Institute of the Chosun University Hospital (2016). 제3형거골경부골절은매우드문골절로서주로고에너지외상에의한경우가많으며불유합, 무혈성괴사, 후외상성관절염, 창상감염등의다양한합병증이많이발생하여치료하기어려운골절중의하나이다. 1-3) 이러한합병증을최소화하기위해서는해부학적정복및견고한내고정이중요함은물론이고거골의독특한해부학적구조및취약한혈관공급체계에대한이해를바 The Journal of the Korean Orthopaedic Association Volume 54 Number 1 2019 Copyright 2019 by The Korean Orthopaedic Association 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.
46 Sung Hae Park, et al. 탕으로한최소침습적인술기역시중요하다. 4-6) 거골경부골절에대한표준적인수술적접근법은전내측및전외측피부절개를통한이중접근법 7) 으로알려져있으나조선대학교병원에서는최소침습적인술기를위하여족관절내과절골술및대형신연기 (Large distractor; Synthes, Oberdorf, Swizerland) 를이용하여전내측절개만을통하여해부학적정복및견고한내고정을얻었고이에대한결과를보고하고자한다. 대상및방법 2009년 3월부터 2016년 8월까지조선대학교병원에서족관절내과절골술및대형신연기를이용하여전내측접근법으로단일술자에의해수술적처치를시행한제3형거골경부골절환자중 3 개월이상추시가가능했던 12명 (12예) 을대상으로후향적분석을시행하였다. 본연구는조선대학교병원 Institutional Review Board (IRB) 의승인을받고진행되었다 (IRB No. 2017-01-017). 남자가 10예, 여자가 2예였고, 전체평균연령은 40.8세 (16-65세) 였으며, 개방성골절이총 2예로, 1형 1예 (8.3%), 2형 1예 (8.3%) 였다. 원인은낙상이 6예 (50.0%) 로가장많았고, 교통사고가 4예 (33.3%), 압궤손상이 2예 (16.7%) 였다. 동반손상은족관절내과골절이 6예 (50.0%), 경골골절 3예 (25.0%) 다발성늑골골절 2예 (16.7%), 척추골절 1예 (8.3%) 순으로나타났다. 수상으로부터수술까지평균시간은 9.1 시간 (3-16시간) 으로, 전예에서 16시간이내수술을시행하였다. 평균추시기간은 16.9개월 (6-32개월) 이었다. 술전단순방사선사진및컴퓨터단층촬영을통해골절형태 를분석한뒤전신마취혹은척수마취하에앙와위에서수술적처치를시행하였다. 12예에서모두전경골건 (tibialis anterior tendon) 및후경골건 (tibilais posterior tendon) 사이로접근하는전내측접근법을이용하였고족관절내과에대하여골절된 6예에대하여는내과를그대로젖힌뒤골절부위를노출시켰으며내과골절이없는 6예에대하여는내과절골술을시행하여골절부위를노출시켰다 (Fig. 1). 영상증폭기 (image intensifier) 를이용하여족관절내과에대해유관나사고정위치에유도침을이용한 drilling 을우선시행한뒤절골술을시행하였다. 거골하관절면에서완전히탈구된골편의정복을위하여종골및경골근위부에대형신연기를장착한뒤최대한으로신연하여경골하관절공간을확보하였다. 전위된골편의연골부위가최대한손상되지않도록조심스럽게겸자를이용하여정복을시행한후삼각인대 (deltoid ligament) 부착부의상연에 2.0 mm/2.4 mm 소형잠김나사금속판 (2.0 mm/2.4 mm locking compression plate, compact hand/compact foot; Synthes) 을이용하여고정하였다 (Fig. 2). 상황에따라 Herbert screw (Zimmer Biomet, Warsaw, IN, USA), 4.0 mm 유관나사 (Solco, Pyeongtaek, Korea) 및 K-강선을이용한고정술을시행하였다. 절골술을시행한내과에대하여는절골술시행전 drilling한부위에그대로 4.0 mm 유관나사를삽입하여고정하였다. 배액관을사용하였으며상황에따라굴곡건지대및창상봉합후단하지석고부목으로보호하였다. 수술직후및 6주, 이후 3개월간격으로단순방사선사진을이용하여골유합여부를평가하였으며, 술후 12개월에단순방사선사진을통하여후외상성관절염발생여부 (Fig. 3) 및 Takakura Figure 1. Intraoperative photograph shows the anteromedial approach and medial malleolar osteotomy.
47 Outcome of Type 3 Talar Neck Fractures by Means of Medial Malleolar Osteotomy Figure 2. Intraoperative photograph shows a large distractor for ankle distraction and fixation using a mini-plate on the superior portion of the deltoid ligament attachment site. Figure 3. Last follow-up x-ray of the pa tient who showed the most severe radiologic posttraumatic ankle arthritic change. Preop., preoperative; Postop., postoperative; POD, postoperative day. stage를판정하였다. 전예에서술후 3개월에자기공명영상촬영을통한무혈성괴사여부를판정하였고 (Fig. 4), 8) 임상적결과의평가는술후 12개월에미국족부족관절정형외과학회 (American Orthopaedic Foot and Ankle Society, AOFAS) 의족관절-후족부수치 (ankle-hindfoot score) 를조사하여분석하였다. 나이, 성별, 발생원인, 수상으로부터수술까지걸린시간과유 합기간및 AOFAS 족관절-후족부수치사이의관련성에대하여단순상관분석을이용하여분석하였고, IBM SPSS ver. 22.0 프로그램 (IBM Co., Armonk, NY, USA) 을이용하였으며, p값이 0.05 미만인경우통계적으로유의한것으로판단하였다. 또한개방성골절유무에따른 AOFAS 족관절-후족부수치및유합기간에대하여비교분석하였다.
48 Sung Hae Park, et al. AVN Hawkins sign AVN Progressing bony union Figure 4. Images showing an example of a Hawkins sign and osteonecrosis on the talar dome. AVN, avascular necrosis. Table 1. Patients Demographic Data and Clinical and Radiologic Results Sex/age (yr) Injury mechanism Union Union time (mo) AVN occurrence on MRI Posttraumatic OA & Takakura stage AOFAS anklehindfoot score Wound necrosis M/31 Traffic accident 8 O (20%) O (II) 80 X 16 M/51 Fall down 7 X O (II) 82 X 3 M/38 Traffic accident 5.5 O (60%) O (I) 83 X 13 M/36 Fall down 4 X X 88 O 8 M/28 Fall down 5 X X 94 X 6 M/44 Fall down 5 X O (IIIA) 78 X 5 F/65 Traffic accident 6 O (40%) O (II) 80 X 11 M/42 Crushing 4 O (10%) O (I) 92 X 15 M/31 Crushing 6 O (10%) O (I) 87 O 8 Surgery interval (h) M/65 Fall down 3 O (20%) O (I) 80 X 5.5 F/42 Traffic accident 4 O (50%) O (II) 85 X 14 M/16 Fall down 6 X O (I) 88 X 5 AVN, avascular necrosis; MRI, magnetic resonance imaging; OA, osteoarthritis; AOFAS, American Orthopaedic Foot and Ankle Society; M, male; F, female. Table 2. Simple Correlation Analysis between Age, Sex, Etiology, Interval to Surgery, and Union Period Variable Pearson correlation p-value Age & union period -0.295 0.351 Sex & union period 0.413 0.182 Etiology & union period 0.096 0.767 Interval to surgery & union period 0.185 0.633 p-value by simple correlation analysis. Table 3. Simple Correlation Analysis between Age, Sex, Etiology, Interval to Surgery, and AOFAS Ankle-Hindfoot Score Variable Pearson correlation p-value Age & AOFAS score 0.022 0.946 Sex & AOFAS score -0.175 0.587 Etiology & AOFAS score -0.206 0.520 Interval to surgery & AOFAS score 0.038 0.922 p-value by simple correlation analysis. AOFAS, American Orthopaedic Foot and Ankle Society.
49 Outcome of Type 3 Talar Neck Fractures by Means of Medial Malleolar Osteotomy 결과 전체 12예에서완전한골유합을보였고유합기간은평균 5.3개월 (3-8개월) 이었으며불유합및부정유합은없었다 (Table 1). 술후 12개월추시에서 AOFAS 족관절-후족부수치는평균 85.17점이었고통계적분석결과나이, 성별, 발생원인과수상으로부터수술까지걸린시간과유합기간및 AOFAS 족관절-후족부수치사이의유의한차이는보이지않았다 (Table 2, 3). 또한개방성골절이동반된 2예에서 AOFAS 족관절-후족부수치는각각 88점과 87점, 유합기간은 4개월과 6개월로비개방성골절군과비교하여열등한결과를보이지않았다 (Table 1). 합병증으로술후 3개월의자기공명영상검사상거골체부의무혈성괴사가총 7예 (58.3%) 에서발생하였고단순방사선검사상후외상성관절염이 10예 (83.3%) 에서발생하였으며 Takakura stage I이 5예, stage II가 4예, stage IIIA가 1예였다. 보행시의간헐적인통증과부분적인운동제한이 6예발생하였으나추가적인수술적처치를요하는경우는없었다. 얕은창상감염이 2예 (16.7%) 에서발생하였으나정맥내항생제투여및음압치료를시행하여호전되었다. 고찰 거골경부골절에서가장흔히사용되는분류법은 Canale와 Kelly 9) 에의한 Hawkins classification으로 4가지유형으로골절을분류하는것이다. 제1형골절은비전위골절, 제2형골절은원위거골경부골편이거골하관절에서탈구, 제3형골절은거골하관절및경거골관절의탈구, 제4형골절은거골하관절, 경거골관절및거주상관절의탈구를나타낸다. 이중제3형거골경부골절은매우드문골절로서, 주로고에너지외상에발생하게되고본연구에서도교통사고, 추락, 압궤손상의고에너지손상에의해발생하였다. 골절의기전은 Penny와 Davis 10) 의연구에서잘기술되어있는데, 과도한족배굴곡력으로거골경부가경골천정의전방모서리에충돌하게되며족배굴곡력이계속되어종골과거골골두가점차전방으로아탈구가되고체부의후내측탈구가발생하게된다. 이러한제3형거골경부골절은골절의해부학적특성상해부학적정복이어려운경우가많다. 11) 거골경부골절에대한일반적인수술적접근법은전내측및전외측피부절개를통한이중접근법으로, 7) 전내측도달법만을사용하는경우에는후내측으로탈구된거골체부의정복자체가어려운경우가많고거골경부의내측이분쇄되어정복의정확성을판단하기어려운경우가있으며금속나사내고정시충분한압박력을주기어렵거나금속나사를삽입할공간이부족한경우도있어이중접근법이표준술식으로받아들여지고있는추세이다. 12,13) 전내측도달법은전경골건과후경골건사이로접근하고 전외측도달법은장족지신근건과제3비골건의외측으로접근하는방법이다. 14) 하지만두가지도달법을동시에사용하는경우거골경부배측의연부조직을많이박리하게되므로거골두의순환장애로인한무혈성괴사혹은창상회복에문제가발생할위험성이있다. 15) 이에저자들은전내측도달법만을사용한후내과에대한절골술을시행하여시야를확보한뒤대형신연기를이용하여경골과종골사이의공간을확보한다음후내측으로탈구된거골체부를정복하는방법을사용하였고단 2예에서얕은창상합병증이발생하는만족할만한결과를얻을수있었다. 최근에는수술시기에대한논란이있으나, 16) 본연구에서는전예에서 24시간이내해부학적정복및견고한내고정을시행함으로써수술시기에따른변수를줄이고자하였고통계적분석결과 24시간이내에서는수상으로부터수술까지걸린시간과술후결과의차이는없었다. 수술적정복후고정방법으로는금속나사를이용한내고정이전위된거골경부골절에널리이용되고있으나금속판내고정또한고려할수있는고정방법중하나로서, 특히거골경부내측에심한분쇄가있는경우금속나사고정에비해과도한압박력을피하므로거골의단축을막아부정유합을줄일수있다는장점을가지고있다. 17,18) 내반부정유합은부정유합의가장흔한형태로서이는내측거골경부골절의부적절한정복및부정확한수술기법에의해발생하게되는데금속판은내측과외측의지주의버팀역할을제공함으로써해부학적정복을유지하는데도움이되며내반부정유합을예방하는데도움이된다. 19) 본연구에서는족관절내과의절골술을시행하여골절부위를노출시키며정복을시행하였기때문에전예에서내측에지주버팀금속판내고정을시행하였고필요시추가적인안정성을위하여금속나사및 K-강선을이용하여고정하였다. 거골경부골절의수술후삽입물의제거는드물게시행되는데, Attiah 등 13) 은수술한 31명의환자중 8명 (25.8%) 에서삽입물제거가필요하였다고기술하였다. 하지만본연구에서는내측의금속판에의한자극증상을호소하는환자는없어금속물제거는시행하지않았다. Halvorson 등 20) 은거골경부골절의치료후부정유합은 17% 가량에서발생하고불유합이 5% 가량에서발생한다고하였으나본연구에서시행한수술적도달법및내고정법으로수술후부정유합및불유합은발생하지않았다. 또한후외상성관절염의경우에도제3형만을따로분석하지는않았으나제1형부터 4형까지를포함하는전체거골경부골절에있어서 67.8% 의발병빈도를보고하였고본연구에서는제3형만을평가하였을때 83.3% 의빈도를보였으며 Takakura stage IIIA를보인 1예를제외한나머지 11예에있어서 Takakura stage I이나 II의비교적경한관절염소견만을보여이에크게뒤떨어지지않는다고평가할수있겠다. Metzger 등 21) 은제3형거골경부골절에서의무혈성괴사의발생
50 Sung Hae Park, et al. 률을 78% 로보고하였고, 본연구에서는 58.3% 로좋은결과를보였음을알수있었다. 창상합병증의경우본연구에서는얕은창상감염 2예만이발생하였고, 그중에서도 1예는제2형개방성골절로내원당시창상의상태가심히좋지않은상태인경우였으며, 심부감염은전예에서발생하지않았다. 증례수가적어일반화하기는어렵겠지만본연구에서사용한전내측단일접근법이이중접근법에비하여창상에공급되는혈류를보존할수있다는분명한장점이있어이로인한결과로판단된다. 본연구에서는전예에서비교적만족스러운치료결과를얻었다고하나그증례수가적고추시기간이짧으며후향적분석, 임상적결과의지표로 AOFAS 족관절-후족부수치한가지에국한된점등의한계점을가지고향후상기치료한환자들에대한지속적인추시관찰및증례수의확보가필요할것으로보인다. 결론 제3형거골경부골절의수술적치료에서족관절내과절골술과대형신연기를이용한전내측접근법은충분히좋은해부학적정복을얻을수있게하였고, 술후무혈성괴사의빈도 (58.3%) 도다른여러연구들에서보인무혈성괴사의빈도와비교하였을때손색이없어외측절개없이시행할수있는수술적옵션중하나로고려해볼수있겠다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg Am. 1970;52:991-1002. 2. Pajenda G, Vécsei V, Reddy B, Heinz T. Treatment of talar neck fractures: clinical results of 50 patients. J Foot Ankle Surg. 2000;39:365-75. 3. Canale ST. Fractures of the neck of the talus. Orthopedics. 1990;13:1105-15. 4. Haliburton RA, Sullivan CR, Kelly PJ, Peterson LF. The extra-osseous and intra-osseous blood supply of the talus. J Bone Joint Surg Am. 1958;40:1115-20. 5. Mulfinger GL, Trueta J. The blood supply of the talus. J Bone Joint Surg Br. 1970;52:160-7. 6. Peterson L, Goldie IF. The arterial supply of the talus: a study on the relationship to experimental talar fractures. Acta Orthop Scand. 1975;46:1026-34. 7. Gonzalez A, Stern R, Assal M. Reduction of irreducible Hawkins III talar neck fracture by means of a medial malleolar osteotomy: a report of three cases with a 4-year mean follow-up. J Orthop Trauma. 2011;25:e47-50. 8. Chen H, Liu W, Deng L, Song W. The prognostic value of the Hawkins sign and diagnostic value of MRI after talar neck fractures. Foot Ankle Int. 2014;35:1255-61. 9. Canale ST, Kelly FB Jr. Fractures of the neck of the talus. Long-term evaluation of seventy-one cases. J Bone Joint Surg Am. 1978;60:143-56. 10. Penny JN, Davis LA. Fractures and fracture-dislocations of the neck of the talus. J Trauma. 1980;20:1029-37. 11. Lal H, Kumar A, Mittal D, Sabharwal VK. A method of open reduction of an irreducible Hawkins type III fracture of the talar neck. J Foot Ankle Surg. 2015;54:677-82. 12. Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ. Talar neck fractures: results and outcomes. J Bone Joint Surg Am. 2004;86:1616-24. 13. Attiah M, Sanders DW, Valdivia G, et al. Comminuted talar neck fractures: a mechanical comparison of fixation techniques. J Orthop Trauma. 2007;21:47-51. 14. Vallier HA, Nork SE, Benirschke SK, Sangeorzan BJ. Surgical treatment of talar body fractures. J Bone Joint Surg Am. 2003; 85:1716-24. 15. Park JK, Kim YM, Choi ES, Shon HC, Cho BK, Cha JK. Clinical outcomes of anterior open reduction and posterior percutaneous screw fixation for displaced talar neck fractures. J Korean Foot Ankle Soc. 2013;17:106-14. 16. Patel R, Van Bergeyk A, Pinney S. Are displaced talar neck fractures surgical emergencies? A survey of orthopaedic trauma experts. Foot Ankle Int. 2005;26:378-81. 17. Na WC, Lee SH, Lee JY, Lee SJ, Kim B. The result of open reduction and mini-plate fixation for displaced talar neck fracture. J Korean Fract Soc. 2015;28:215-22. 18. Fleuriau Chateau PB, Brokaw DS, Jelen BA, Scheid DK, Weber TG. Plate fixation of talar neck fractures: preliminary review of a new technique in twenty-three patients. J Orthop Trauma. 2002;16:213-9. 19. Daniels TR, Smith JW, Ross TI. Varus malalignment of the talar neck. Its effect on the position of the foot and on subtalar motion. J Bone Joint Surg Am. 1996;78:1559-67. 20. Halvorson JJ, Winter SB, Teasdall RD, Scott AT. Talar neck fractures: a systematic review of the literature. J Foot Ankle Surg. 2013;52:56-61. 21. Metzger MJ, Levin JS, Clancy JT. Talar neck fractures and rates of avascular necrosis. J Foot Ankle Surg. 1999;38:154-62.
51 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2019; 54: 45-51 https://doi.org/10.4055/jkoa.2019.54.1.45 www.jkoa.org 족관절내과절골술및대형신연기를이용한제 3 형거골경부골절의치료결과 박성해 이준영 이정우 조선대학교의과대학정형외과학교실 목적 : 족관절내과절골술및대형신연기를이용하여전내측접근법으로수술적처치를시행한제3형거골경부골절환자들의임상적, 방사선적결과를후향적으로분석하여보고하고자하였다. 대상및방법 : 2009년 3월부터 2016년 8월까지조선대학교병원에서족관절내과절골술및대형신연기를이용하여전내측접근법으로수술적처치를시행한제3형거골경부골절환자중 12개월이상추시가가능했던 12명 (12예) 을대상으로하였다. 술후 6주에외래추시시시행한전후면및측면단순방사선사진으로 Hawkins sign의유무를확인하였고술후 3개월에자기공명영상촬영을시행하여무혈성괴사여부를판정하였다. 이후 3개월간격으로단순방사선사진및임상증세기반으로골유합여부및시기를판정하였고술후 12개월에시행한단순방사선사진으로후외상성관절염발생여부및 Takakura stage를판정하였으며미국족부족관절정형외과학회 (American Orthopaedic Foot and Ankle Society, AOFAS) 의족관절-후족부수치 (ankle-hindfoot score) 를조사하여분석하였다. 결과 : 7예에서술후 3개월에시행한자기공명영상상무혈성괴사가발생하였으나모두술후 12개월추시에서수술적처치없이 AOFAS 점수 83.86±4.53점이라는결과를얻었다. 전예에서평균 5.3개월에방사선적골유합을얻었고총 10예에서방사선적후외상성관절염이발생하였으나모두 Takakura stage IIIA 이하로보존적처치를통하여일상생활이가능하였다. AOFAS 족관절-후족부수치는평균 85.17점으로측정되었다. 그외합병증으로 2예에서얕은창상감염이발생하였다. 결론 : 제3형거골경부골절환자의수술적치료에있어족관절내과절골술및대형신연기를이용한전내측접근법은외측절개없이해부학적전위골편의정복을얻을수있어거골의혈류를비교적보존할수있는수술적접근법중하나가될수있을것으로판단된다. 색인단어 : 거골경부골절, 내과절골술 접수일 2017 년 12 월 3 일수정일 2018 년 2 월 5 일게재확정일 2018 년 3 월 2 일책임저자이준영 61453, 광주시동구필문대로 365, 조선대학교병원정형외과 TEL 062-220-3147, FAX 062-226-3379, E-mail leejy88@chosun.ac.kr, ORCID https://orcid.org/0000-0002-9764-339x * 본논문은 2016 년도조선대학교병원임상의학연구소연구비에의하여연구되었음. 대한정형외과학회지 : 제 54 권제 1 호 2019 Copyright 2019 by The Korean Orthopaedic Association 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.