대한골절학회지제 18 권, 제 1 호, 2005 년 1 월 Journal of the Korean Fracture Society Vol. 18, No. 1, January, 2005 고리강선을이용한변형긴장대고정술 이은우 이한준 김태호 중앙대학교의과대학부속용산병원정형외과학교실 목적 : 변형긴장대를이용한골절의고정은매우유용한치료방법이지만 K-강선의이완으로인한고정소실이문제점으로남아있다. 이러한내고정강선의이완을막고자내고정강선에고리를만들어변형긴장대고정술을시행하여그유용성여부를알아보았다. 대상및방법 : 1999년 9월부터 2002년 6월까지의기간에내원한 40명의환자중슬개골골절 16례, 주두골골절 8례, 쇄골골절 8례 ( 불유합 3례 ), 족근관절골절 5례, 견봉쇄골관절분리증 3례에대해고리강선을이용한변형긴장대고정술을시행하였다. 고리강선은환형외고정기구에사용되는강선을이용하여그장축에일치하도록고리를만들었다. 결과 : 수술후평균 20개월의추시관찰소견상전례에서고리강선의이완은없었으며, 기능적평가에서도만족할만한결과를얻었다. 불유합이나금속자극에의한합병증은없었다. 결론 : 고리강선을이용한변형긴장대고정술은내고정강선의전위를막을수있어그로인한합병증을줄일수있다고판단되며, 특히내고정강선의전위가잘일어나는주관절이나, 견관절부위의변형긴장대고정술시에유용한술식으로사료된다. 색인단어 : 변형긴장대고정술, 고리강선 Modified Tension Band Technique With Looped Pin Eun Woo Lee, M.D., Han Jun Lee, M.D., Tae Ho Kim, M.D. Department of Orthopaedic Surgery, Yong-San Hospital, Chung-Ang University, Seoul, Korea Purpose: Fixation of fracture using modified tension band is a very useful treatment method, but loss of fixation caused by loosening of K-wires still remain problem. So we have studied the usefulness of modified tension band with looped pin in order to prevent loss of internal fixation. Materials and Methods: From September 1999 to June 2002, we had treated 40 patients with this technique, including 16 patella, 8 olecranon, 8 distal clavicle fractures in which three were nonunion fractures, 5 ankle fractures and 3 acromioclavicular joint separations. We looped the pin which has been used for ring external fixator, in line with its long axis. Results: After mean postoperative follow-up of 20 months, there were no loosening of looped pin in all cases and we obtained satisfactory results of functional evaluation. There were no complications of nonunion or metallic irritation. Conclusion: We concluded that modified tension band with looped pin could prevent displacement of internal fixation, and reduce the subsequent complications. Especially in elbow and shoulder joint that the displacement of fixation pin occured frequently, It was considered as very useful operative technique. Key Words: Modified tension band technique, Looped pin 서 론 골절의내고정에있어서변형긴장대술식 (modified ten- sion band technique) 7,9,16,19,20) 은매우유용한치료방법이지만수술후조기재활중에내고정 K-강선의전위및이완으로인한고정의소실및합병증 8,13) 이발생할수있다. 이에저자들은보다안전한조기재활을할수있도록내고정강 통신저자 : 이은우서울특별시용산구한강로 3 가 62-207 중앙대학교부속용산병원정형외과 Tel : 02-748-9963 Fax : 02-793-6634 E-mail : osewlee@hanmail.net * 본논문의요지는 2001 년도대한골절학회추계학술대회에서발표되었음. ** 본논문은 2002 년도중앙대학교학술연구비지원으로작성되었음. Address reprint requests to : Eun Woo Lee, M.D. Department of Orthopaedic Surgery, Yong-San Hospital, Chung-Ang University. 62-207, 3-ga, Hangang-ro Yongsan-gu, Seoul 140-757, Korea Tel : +82.2-748-9963 Fax : +82.2-793-6634 E-mail : osewlee@hanmail.net 48
고리강선을이용한변형긴장대고정술 49 선의이완을막고자내고정강선에고리 (loop) 를만들어변형긴장대술식을시행하고고리형강선의유용성및사용시문제점들에대해알아보고자하였다. 대상및방법 1999년 9월부터 2002년 6월까지 40명의환자를대상으로고리강선을이용한변형긴장대고정술을시행하였으며이중슬개골골절 16례, 주두골골절 8례, 쇄골골절 8례 ( 불유합 3례 ), 족근관절골절 5례. 견봉쇄골관절분리증이 3례였다. 이들의평균연령은 35세 ( 범위 22~58세 ) 였고, 남자는 28 례, 여자는 12례였다. 수술후추시기간은최단 12개월에서 30개월로평균 20개월이었다. 조기재활을위해수술후바 로수동적관절운동을시켰고동통이허락하는범위에서능동적관절운동을허용하였다. 치료에대한평가로는추시관찰시이학적검사및방사선학적검사를하여서관절운동범위, 골유합및내고정강선의전위여부를관찰하였다. 그리고내고정강선에대한인장강도실험 4,5,18) 을통해기존의 K-강선을이용한것과의고정력차이및고리부분의안정성을객관적으로평가하고자하였다. 1. 수술방법골절의고정은 AO group의변형긴장대술식을이용하였고 9,19,20) 내고정강선의고리를통해강선 (wire) 을통과시켜내고정강선을잡아줌으로써전위나이완을막도록하였으며 (Fig. 1), 기존의 K-강선으로고리를만들려고시도했으 A B C Fig. 1. Illustration of modified tension band technique (A) Modified tension band by K-wires. (B) Modified tension band by looped pins The loops block loosening of pins (arrows). (C) The looped pin inserted into the drill chuck prior to fixation. A B Fig. 2. (A) The photograph showed looped pins and wire passing through the loops. (B) Real photograph of looped pins. Loops are located at 5 cm or 10 cm distance from the end of pins.
50 이은우, 이한준, 김태호 A B Fig. 3. (A) Four points bending test was schematically illustrated. (L: loading point span-40 mm, S: support point span-300 mm) (B) The photograph showed processes of bending test. 나고리부분이약해져끊어지는경우가많아서신연에보다잘견디는직경이 1.5 mm인환형외고정기구에사용되는강선 (DKM, Korea) 을이용하여그장축에일치하도록환상의고리 (circular loop) 를술전에미리만들었다. 고리의위치는강선의한쪽끝에서 5 cm, 10 cm으로만들어골절에맞는것을이용하였다 (Fig. 2). 골절부위의고정은강선이삽입부반대편으로나오는것을볼수있는부위즉, 슬개골, 쇄골등은강선삽입후절단을했으며, 길이를측정해야하는부위는같은길이의강선을먼저삽입한후 depth gauge로길이를측정하여고리강선을알맞게절단하여삽입하였다. 2. 인장강도실험 Fig. 4. 31-year-old male patient with right acromioclavicular joint separation was injured by fall-down accident. Fixation of right acromioclavicular joint with looped pin was performed. Four months after operation, there was no loosening and migration of looped pin. 기존의 K-강선을이용한변형긴장대술식과고정력의차이및고리부분의안정성을객관적으로평가하기위하여아크릴로제작된원통을긴장대술식으로고정하여인장강도실험을하였다 (Fig. 3). 인장강도실험은고리강선과기존의 K-강선으로직경 30 mm, 길이 200 mm의아크릴원통 2 개를변형긴장대술식으로고정하여각각 30회씩시행하였다. Instron Model 8511 (Instron company, USA) 기종을이용하여고정된아크릴원통을지지점전장 (support point span) 300 mm, 하중점전장 (loading point span) 40 mm의사점-굴곡력 (four point bending force) 5) 이가해지도록장치한후대기압상온에서분당 10 mm의일정한속도로고정된긴장대부위가충분한변형이생길때까지힘을가하였다. 실험의시작에서종료까지컴퓨터를이용하여시편의변형과하중을저장하여하중변위선도 (load-displacement curve) 및최대굽힘하중 (maximaum bending load) 를구했고, 변형시고리부분의변화관찰을하였다. 그리고두집단간의최대굽힘하중의평균을
고리강선을이용한변형긴장대고정술 51 내어그강도의비교를하기위하여 t-test 를시행하였다. 결 수술후평균 20개월의추시관찰소견상전례에서관절강직이나창상감염등의합병증없이거의전범위의능동적관절운동을보였고기능적으로도만족할만한결과를얻었다. 그리고방사선학적검사상에서내고정강선의이완및전위로인한합병증없이모두골유합과관절의안정성을이루었으며, 그기간은평균 9주 ( 슬개골 10주, 주두골 9주, 쇄골 8주, 족근관절 8주, 견봉쇄골관절 10주 ) 였다 (Fig. 4). 인장강도실험에서두긴장대의항복점과파열점은유의한차이를보이지않았다. 그리고파괴하중의수치비교에서두집단은 t-test 결과유의확률 (p-value) 값이 0.671로 95% 신뢰도를가지고고리강선과기존의 K-강선간에강도차이가없다는결론을얻을수있었다. 그리고파괴의양 Fig. 5. 31-year-old male patient suffered from car accident. The radiograph, one month after operation, showed bending of circlage wire and tension band wire. But wire loops were intact. 과 상은하중변위선도 (load-displacement curve) 상에서고리강선과 K-강선모두유사한경향을보였고 (Table 1), 고리강선의고리부분에서도별다른문제가발생되지않았다. 고찰골절부위에가해지는분산력과전단력을압박력으로전환시키는 AO group의변형긴장대술식은골절의고정에있어매우유용한치료방법으로정형외과영역에서다양한골절치료에쓰이고있다 2,6,8,9,11,12,14,17). 많은생역학적인연구에서이방법이수술후초기안정성을부여하여다양한골절에유용하게사용될수있음이증명되어왔다 1,3,15). 그러나수술시에충분한고정을얻었다할지라도관절운동시에내고정 K-강선의이완및전위로인한고정소실및금속자극에의한합병증 1~3,6,8,10,11,13,14) 이여러저자들에의해보고되었다. 이런합병증에대하여 Weber 등은그원인을내고정 K-강선의전위가아닌부적절한수술방법여부에서찾으려하였고 20), Larsen과 Jensen은내고정물의변형을꾀하기도하였다 10). 저자들은 AO group의긴장대고정술의기본원리를보존하면서내고정강선의전위를막아안전한조기재활을위해내고정강선에고리를만들어변형긴장대고정술을시행하였다. 처음에는긴장대고정술시에강선을먼저삽입한후에고리를만들려고하였으나, 기술적으로매우어려워서술전에미리고리를만든강선을이용하여변형긴장대고정술을시행하였다. Kinik 등 8) 의방법으로기존의 K- 강선을이용하려하였으나, 원형으로고리를만드는과정에서구부리는부위가부러져고리형강선을만드는데적합하지않다고판단되어올리브강선의제작에쓰이는재료에고리를만들었다. 기존의 K-강선과인장강도의차이및고리부분의안정성을평가하기위하여실행한실험에서파괴하중의유의한차이점을발견할수없었지만, 시편의파괴가 Table 1. There was no significant difference between looped pins and K-wire in load-displacement curve.(left: looped pin, Right: K-wire)
52 이은우, 이한준, 김태호 강선자체또는강선간의연결부에서는발생하지않으면서모사골절편의삽입부에서발생한것을고려해보았을때강선의삽입부의조건즉천공술의정확성, 천공직경그리고삽입강선의직경이파괴하중의크기에영향을준것으로판단된다. 따라서두강선의파괴하중에대한수치차이만으로임상적용시강선의성능을평가하기는다소무리가있다고사료되나기존의 K-강선에대한강도차이는크지않다고생각된다. 저자들의경험상우선수술시에내고정강선의고리안으로강선을통과시킴으로써고리자체가압박력을줄수있으므로골절부위의압박이보다더효율적으로이루어질수있다는점과정복된골절에보다정확하고견고한고정을할수있다는장점이있었다. 무엇보다도기존의변형긴장대고정술의주요실패원인중하나인삽입강선의이완을막을수있기때문에골절고정부위의초기안정성을확보할수있어조기재활에도움이되었다. 특히전위가잘생기는견, 주관절, 및견봉쇄골관절에유용하게사용할수있음을경험하였다. 또한내고정강선의전위로인한금속자극및피부돌출등도관찰되지않았다. 이강선에대하여제작시저자들이우려한문제점이었던실제골절의고정시에고리부위에서의강선파열에관하여서는인장강도실험결과그런문제점은발생하지않았고, 실제환자의경우에도발생하지않았다. 그러나수술시강선에고리가있기때문에 K-강선에비하여취급이불편하였고고리의축이강선의축과정확히일치하지않는경우에는정확한삽입이어려웠다. 그리고수술시고리부위가반드시골조직위에오도록해야하며그렇지않은경우연부조직이강선의고리와골조직사이에끼이게되어강선을감아고정할때에고리강선이휘게되어고정력이약화될수있었고실제로그런문제로인하여조기재활이늦어진 1례를경험하였다 (Fig. 5). 이런문제들을개선하여고리의위치를보다다양하게하여골절에따라편리하게사용할수있도록하는것과고리의축과강선의축이일치하도록제작하는것, 그리고수술시기술적측면을고려하여시술한다면변형긴장대고정술의적응이되는다양한골절치료에있어유용한방법으로생각되었다. 결론고리강선을이용한변형긴장대고정술은내고정강선의이완및전위에의한고정소실을막을수있어강선제작을위한기술적인향상이이루어진다면강선의이완이잘일어나는주두골이나, 슬개골, 그리고견관절부위의골절에사용하여견고한초기안정성을부여하여조기재활을가능케 하는유용한치료법으로사료된다. 참고문헌 1) Curtis MJ: Internal fixation for fractures of the patella. A comparison of two methods. J Bone Joint Surg, 72-B(2): 280-282, 1990. 2) Doursounian L, Prevot O and Touzard RC: Osteosynthesis by tension band wiring of displaced fractures of the olecranon. Ann Chir, 48(2): 169-177, 1994. 3) Fan GF, Wu CC and Shin CH: Olecranon fractures treated with tension band wiring techniques-comparisons among three different configurations. Changgeng Yi Xue Za Zhi, 16(4): 231-238, 1993. 4) Fyfe IS, Mossad MM and Holdsworth BJ: Method of fixation of olecranon fractures. An experimental mechanical study. J Bone Joint Surg, 67-B(3): 367-372, 1985. 5) Gould WL, Belsole RJ and Skelton WH Jr: Tension-band stabilization of transverse fractures: An experimental analysis. Plastic and reconstructive surgery, 73(1): 111-116, 1984. 6) Hung LK, Chan KM, Chow YN and Leung PC: Fractured patella: Operative treatment using tension band principle. Injury, 16(5): 343-347, 1985 7) Kim HS, Hong KD,Ha SS, Park YK and Chung NS: Modified tension band wiring and circumferential wiring in the operative treatment of Patella fracture. J Korean Fracture Soc, 7(2): 552-559, 1994. 8) Kinik H, Us AK and Mergen E: Self locking tension band technique in transverse patellar fractures. Int Orthop, 20(6): 357-358, 1996. 9) Kouwenhoven GC and Weber BG: Prestress osteosynthesis in olecranon fractures. Arch Orthop UnfallChir, 65(3): 244-250, 1969. 10) Larsen E and Jensen CM: Tension band wiring of olecranon fractures with non-sliding pins. Report of 20 cases. Acta Orthop Scand, 62(4): 360-362, 1991. 11) Levack B, Flannagan JP and Hobbs S: Results of surgical treatment of patellar fractures. J Bone Joint Surg, 67-B(3): 416-419, 1985. 12) Lotke PA and Ecker ML: Transverse fractures of the patella. Clin Orthop, 158: 180-184, 1981. 13) Macko D and Szabo RM: Complications of tension-band wiring of olecranon fractures. J Bone Joint Surg, 67-A(9): 1396-1401, 1995. 14) Murphy DF, Green WB and Dameron TB Jr: Displaced ole-
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