29 pissn : , eissn : Original Article J Korean Orthop Assoc 2018; 53:

29 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2018; 53: 29-37 https://doi.org/10.4055/jkoa.2018.53.1.29 www.jkoa.org Legg-Calve-Perthes 병에서나사를이용한대전자골단유합술의효과 김성수 김현준 정성윤 * 임철순 김동률 동아대학교의과대학정형외과학교실, * 대한민국육군제 22 보병사단 The Effect of Screw Apophysiodesis of Greater Trochanter in Legg-Calve-Perthes Disease Sung Soo Kim, M.D., Hyeon Jun Kim, M.D., Sung Yoon Jung, M.D.*, Chul Soon Im, M.D., and Dong Ryul Kim, M.D. Department of Orthopedic Surgery, Dong-A University College of Medicine, Busan, *The 22nd Infantry Division of Republic of Korea Army, Goseong, Korea Purpose: To evaluate the interstitial and appositional growth of greater trochanter post-screw apophysiodesis in Legg-Calve-Perthes (LCP) disease. Materials and Methods: A total of 17 patients, who were diagnosed with LCP and underwent greater trochanter screw apophysiodesis and metal removal between December 2003 and December 2012, and were followed-up for at least 4 years, were selected. Anterioposterior radiologic images were taken in each process of apophysiodesis, metal removal, and last follow-up. From such images, articulotrochanter tip distance (ATD), trochanter tip-screw distance (TSD), trochanter tip-trochanter lower margin distance (TLD), and screw-trochanter lower margin distance (SLD) were measured. Appositional growth and greater trochanter growth rates were compared using paired t-test, independent t-test, and correlation analysis. Results: The average ATD of the affected and unaffected sides was 14.2 and 16.8 mm, respectively at apophysiodesis and 9.2 and 14.8 mm at the last follow-up, with a significantly greater decrease observed on the affected side the unaffected side (p=0.030). TLD of the affected side during the follow-up increased 11.0 mm, from an average of 30.8 to 41.8 mm, while the un-affected side increased 14.3 mm, from an average of 26.7 to 41.0 mm. The growth of greater trochanter after the operation in the affected side was 76.7% of that in unaffected side. The ratio of TLD of the affected side to the unaffected side was significantly reduced, from 1.15 to 1.02 (p=0.014) at the final follow-up. TSD was significantly increased from 4.5 to 14.4 mm at metal removal (p<0.001) and increased to 17.0 mm at the last follow-up. Moreover, the ratio of TSD to SLD was significantly increased from 0.20 to 0.74 at metal removal (p<0.001) and increased to 0.84 at the final follow-up. Conclusion: The results of this study showed that screw apophysiodesis can suppress the overall growth, but not the appositional growth of the greater trochanter. Therefore, screw apophysiodesis may not be a good procedure to inhibit the growth of greater trochanter Key words: greater trochanter, Legg-Calve-Perthes disease, screw apophysiodesis, growth 서론 Received October 27, 2016 Revised February 24, 2017 Accepted June 19, 2017 Correspondence to: Hyeon Jun Kim, M.D. Department of Orthopedic Surgery, Dong-A University College of Medicine, 32 Daesingongwon-ro, Seo-gu, Busan 49201, Korea TEL: +82-51-240-2757 FAX: +82-51-254-6757 E-mail: hyeonjun@dau.ac.kr Legg-Calve-Perthes (LCP) 병에서는다음과같은세가지의합병증이흔히발생할수있다 : 1) 대퇴골두의아탈구와동반된거대골두 (coxa magna), 2) 근위대퇴골골단판의손상으로인한하지부동, 3) 단고 (coxa breva) 및대전자의상대적과성장. 1) The Journal of the Korean Orthopaedic Association Volume 53 Number 1 2018 Copyright 2018 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.

30 Sung Soo Kim, et al. 대전자의성장은성장판 (epiphyseal plate) 의길이성장 (interstitial growth) 과견열골단 (apophysis) 의부가성장 (appositional growth) 으로이루어지며기존의연구에따르면 1) 길이성장과부가성장은각각 50% 씩이루어진다. 대전자의과성장은대퇴경부골단판성장장애와동반되어고관절외전근의지렛대길이의감소를일으켜외전력감소를유발하며이로인해 Trendelenburg sign이나파행과같은골반기능부전현상 2,3) 및대전자와장골간의통증을동반한충돌현상을일으킬수있다. 4,5) 대전자부의과성장에대한수술적치료에는여러가지가있을수있으나나사를이용한골단유합술이가장비침습적이고손쉽게이루어질수있는장점이있다. 6) 본연구의목적은 LCP 병에서나사를이용한골단유합술시행이대전자부의성장판에의한길이성장및부가성장두가지모두에미치는영향에대해방사선적지표를통해평가하는것이다. 대상및방법 2003년 12월부터 2012년 12월까지동아대학교병원에서일측성 LCP 병으로진단받고나사를이용한대전자골단유합술을시행받은 17명의환자를대상으로후향적연구를시행하였다. 건측고관절이방사선적지표들의대조군으로이용되었다. 남자가 14명여자가 3명이었으며, 10세이후에수술한환자는남자 7명, 여자 1 명, 9세이전에수술한환자는남자 7명, 여자 2명이었다. 좌측이 11예, 우측이 6예였으며 10세이후에수술한환자는좌측 6명, 우측 2명, 9세이전에수술한환자는좌측 5명, 우측 4명이었다. 나사골단유합술시행당시의평균나이는 9.4세 (6-14세) 였으며 10세이후에수술한환자는 8명, 9세이전에수술한환자는 9명이었다. 추시관찰기간은평균 61.6개월 (48-121개월) 이었으며 10세이후에수술한환자는평균 63.4개월 (48-105개월), 9세이전에수술한환자는평균 60.3개월 (52-121개월) 이었다. 최종추시시의나이는평균 17.3세 (13-22세) 였으며 10세이후에수술한환자는평균 17.0 세 (13-20세), 9세이전에수술한환자는평균 16.8세 (15-22세) 였다. 수술당시 lateral pillar 분류상 B군이 5명, B/C군이 10명, C군이 2명이었으며 10세이후에수술한환자는 B군이 2명, B/C군이 5명, C군이 1명이었고 9세이전에수술한환자는 B군이 3명, B/C 군이 5명, C군이 1명이었다. Catterall 분류상 Stage 1이 5명, Stage 2 가 9명, Stage 3이 3명이었으며 10세이후에수술한환자는 Stage 1 이 2명, Stage 2가 5명, Stage 3가 1명이었고 9세이전에수술한환자는 Stage 1이 3명, Stage 2가 4명, Stage 3이 2명이었다 (Table 1). 1. 수술방법및동반치료나사골단유합술은환자를앙와위로눕힌뒤대전자성장판에유도강선 (guide pin) 을삽입한후확공 (reaming) 을시행하고두개의유관나사 (cannulated screw) 로고정하는방법을사용하였다. 모두유관부분나사산나사 (cannulatedpartial thread screw) 를사용하였으며이는대전자의성장판을억제함과동시에견인골단 (apophysis) 에서의부가성장또한억제하기위한목적이다 (Fig. 1). LCP 병에대한동반치료는 15예에서시행하였는데, 나사골단유합술이전에관절이개술 (arthrodiastasis) 2예, 무명골절골술 (Salter innominate osteotomy) 2예와내반감염절골술 (varusderotational osteotomy) 2예를시행하였고, 나사골단유합술과동시에선반비구성형술 (shelf acetabuloplasty) 을 9예에서시행하였다. 또한나사골단유합술을시행하고골단유합이이루어지면금속제거술을시행하였으며금속제거술은수술후평균 41.8개월 (10-74 개월 ) 에서시행하였다. 추시관찰에서대전자의과성장 (overriding) 이발생하여 articulo-trochanter tip distance (ATD) 가음의값을보이는 1예 (Case 8) 및 Trendelenburg sign 또는파행을보이던 4예 (Case 2, 7, 13, 14) 에서대전자이전술을시행하였으며, 대전자이전술을시행한환자에대해서는대전자이전술을시행하기직전까지를관찰기간으로하였다. 나사골단유합술후평균 47.6개월후시행하였으며, 이중 2예는 10세이후에나사골단유합술을시행하였고 3예는 9세이전에나사골단유합술을시행하였다. 2. 방사선적측정나사골단유합술시행시, 금속제거술직전, 최종추시관찰시의전후면단순방사선사진에대해환측과건측을비교하였으며전후면방사선사진촬영시중립굴곡및 15도내회전상태에서촬영하였다. ATD는대퇴골장축에대한수직인가상의선들중에서대퇴골두와가장근위부에서만나는선과대전자의근위첨 Table 1. Demographic Data of Legg-Calve-Perthes Patients Age of surgery Variable Total 10 years 9 years Sex (male/female) 14/3 7/1 7/2 Left/Right 11/6 6/2 5/4 F/U period (mo) 61.6 63.4 60.3 Age at last F/U (yr) 17.3 17.0 16.8 Lateral pillar classification B 5 2 3 B/C 10 5 5 C 2 1 1 Catterall classification Stage 1 5 2 3 Stage 2 9 5 4 Stage 3 3 1 2 Values are presented as number only or mean only. F/U, follow-up.

31 The Effect of Screw Apophysiodesis of Greater Trochanter in LCP Disease A B C D E Figure 1. Radiographs of a 7-year-old boy with unilateral Legg-Calve-Perthes disease. The patient received shelf operation and screw apophysiodesis. Preoperative radiograph (A), postoperative radiograph (B), postoperative 4 years radiograph (C), radiograph of metal removal (52 months after screw apophysiodesis) (D), and radiograph of the final follow-up (E). 부를지나는선간의거리를측정하였으며이는대전자의과성장정도및대퇴골두골단의성장저하정도를나타내는지표이다. Trochanter tip-trochanter lower margin distance (TLD) 는대전자성장판의가장원위부에서부터대전자첨부까지의거리를대퇴골장축과평행하게측정하였으며이는대전자의전체적인성장을나타내는지표이다. Trochanter tip-screw distance (TSD) 는근위나사의경부하부에서대전자첨부까지의거리이며금속제거술이후에는반대편피질골을뚫은위치에서부터나사의종축을따라나사의길이를잰뒤동일한높이의반대편피질골에서부터나사가고정되어있던음영을따라같은길이만큼위치를표시한뒤측정하는방법으로위치를추정하였고이는대전자의부가성장을나타내는정도이다. Screw-trochanter lower margin distance (SLD) 는근위나사의경부하부에서부터대전자성장판의가장원위부까지의거리를측정하였으며이는대전자성장판의길이성장정도를나타내는지표이다 (Fig. 2). 환측과건측의 TLD의비를이용하여대전자성장정도를비교하는지표로사용하였고 TSD의변화와 SLD에대한 TSD의비를이용하여대전자의부가성장정도를비교하였다. 3. 통계적분석세명의정형외과의사에의해측정된평균값을사용하였으며, PASW Statistics ver. 18.0 (IBM Co., Armonk, NY, USA) 으로대응 1 2 3 4 TLD ATD Figure 2. Schematic drawing of the hip affected by left Legg-Calve- Perthes disease. The measurement of various radiological indices. Line 1: femoral head articular line (perpendicular to Line *), Line 2: greater trochanter tip line (perpendicular to Line *), Line 3: proximal screw neck line (perpendicular Line *), Line 4: greater trochanter lower margin line (perpendicular to Line *), Line *: anatomical axis of femur. ATD, articulo-trochanter tip distance; TSD, trochanter tip-screw distance; TLD, trochanter tip-trochanter lower margin distance; SLD, screw-trochanter lower margin distance. * TSD SLD

32 Sung Soo Kim, et al. 집단 t-검정을이용하여수술을시행한쪽 ATD 감소가건측에비해유의한지, 수술을시행한쪽 TLD의증가정도가건측에비해나사골단유합술시행후에감소하는지, 이러한감소가금속제거술시행후에도유의하게유지되는지, TSD와 SLD에대한 TSD의비가나사골단유합술이후에유의하게변화하는지를분석하였다. 통계적유의수준은 p-value가 0.05 미만인경우로하였다. 또한독립집단 t-검정을이용하여 10세이후와 9세이전에나사골단유합술을시행한두군으로나누어 TSD와연간 TSD 성장량을비교하여부가성장의억제정도를비교분석하였다. 이를대전자이전술을추가로시행한 5예에서의대전자원위이전술전후의 TSD와연간 TSD 성장량과비교분석하였다. 또한나이에따른부가성장정도의변화에대해관련성을분석하기위해상관분석을시행하였으며연구자간측정의일치도를평가하기위해 kappa 계수를이용하여분석하였다. Kappa 계수의경우 0.41-0.60이면보통수준 (moderate agreement), 0.61-0.80이면높은수준 (substantial agreement), 그리고 0.81-1.0이면거의완벽하게일치 (almost perfect agreement) 하는것으로해석할수있으며, 본연구에서는연구자 1과연구자 2에서는 0.736, 연구자 1과연구자 3은 0.788, 연구자 2와연구자 3은 0.742로모두높은수준의일치도를보였다. 결과 ATD는환측과건측에서각각수술전평균 14.2 mm와 16.8 mm, 최종추시관찰시평균 9.2 mm와 14.8 mm로측정되며환측은건측에비해유의하게감소하였다 (p=0.030) (Table 2). 환측의 TLD는나사골단유합술시평균 30.8 mm에서최종추시시 41.8 mm로평균 11.0 mm 증가하였고, 건측은나사골단유합술시평균 26.7 mm에서 41.0 mm로 14.3 mm 증가하여수술을시행한환측의대전자성장은추시기간중건측의 76.7% 였다. 건측에대한환측의 TLD의비는처음 1.15에서금속제거시점에서 1.02까지유의하게감소하였다 (p=0.014) (Table 3). TSD는나사골단유합술시 4.5 mm 에서금속제거술시 14.4 mm (p<0.001), TSD의 SLD에대한비는나사골단유합술시 0.20에서금속제거술시 0.74로모두유의하게증가하였으며 (p<0.001) (Table 4), 금속제거술이후최종추시시의 TSD 및 TSD의 SLD에대한비역시나사골단유합술시와비교하여유의하게증가하였다 (p<0.001). 또한나사골단유합술을 10세이후와 9세이전에시행한두군으로나누어 TSD를비교하였으며 10세이후에수술을시행한군에서 TSD가낮았으나통계적유의성은관찰되지않았다 (Table 5). 대전자이전술을추가로시행한 5예에서대전자이전술시행부터최종추시시까지의 TSD 의연간성장량을비교하였으며 10세이후에나사골단유합술을시행한 2예에서는대전자이전술시행후 TSD가평균 1.3 mm/yr 의성장을보였으며 9세이전에나사골단유합술을시행한 3예에 서는대전자이전술시행후 TSD가평균 1.2 mm/yr의성장을보였다 (Table 6). 추가로대전자이전술을시행한 5예와대전자이전술을시행하지않은 12예의대전자이전술후의 TSD의연간성장량에대해서도비교하였으며이때대전자이전술을시행한군에서는대전자이전술로부터최종추시까지의기간을대상으로하였다. 대전자이전술을시행하지않은군에서는금속제거술로부터최종추시까지의기간을대상으로하였고대전자이전술을시행한군에서시행하지않은군에비해서대전자이전술후에도 TSD의성장정도가여전히높은것으로관찰되었으며둘사이에통계적유의성이관찰되었다 (p<0.001) (Table 7, 8). 고찰 LCP 병후유증으로발생한대퇴골대전자의과성장과그로인한대퇴경부의단축에대해서정상해부학적구조로복구하는방법으로는외측전위절골술, 7) 대전자원위이동술, 8,9) 대퇴경부연장절골술, 10) 대전자전진술 11) 등이있으며각수술법모두통증, 보 Table 2. Radiologic Measurement of ATD ATD (mm) at apophysiodesis Case no. Affected Unaffected side side ATD (mm) at last follow-up Affected side Unaffected side Case 1 8.2 16.5 12.6 14.6 Case 2 10.5 16.3 13.4 15.2 Case 3 27.1 20.1 12.5 24.3 Case 4 12.4 15.6 2.8 15.8 Case 5 9.0 16.0 10.7 19.8 Case 6 8.4 14.4 5.2 10.6 Case 7 13.0 17.4 21.4 13.3 Case 8 13.7 9.7-9.1 12.5 Case 9 18.6 23.5 7.2 20.0 Case 10 19.0 18.8 12.0 17.3 Case 11 22.3 24.1 6.4 19.7 Case 12 14.1 21.6 15.3 13.1 Case 13 13.8 8.7 8.3 4.4 Case 14 10.9 12.4 8.9 12.1 Case 15 10.8 16.2 12.3 11.9 Case 16 15.9 16.8 6.9 12.6 Case 17 14.2 16.6 9.2 15.0 Mean±SD 14.2±5.3 16.8±4.3 9.2±6.6 14.8±4.7 The p-value compared with ATDs at last follow-up=0.030. ATD, articulotrochanter tip distance; SD, standard deviation.

33 The Effect of Screw Apophysiodesis of Greater Trochanter in LCP Disease Table 3. Radiologic Measurements of TLD TLD (mm) at apophysiodesis TLD (mm) at metal removal TLD (mm) at last follow-up Case no. Affected Unaffected Affected Unaffected Affected Unaffected Ratio Ratio side side Side side side side Ratio Case 1 44.9 43.2 1.04 44.5 39.2 1.14 44.7 46.9 0.95 Case 2 24.3 19.9 1.22 33.2 43.5 0.76 35.4 38.2 0.93 Case 3 28.4 24.4 1.16 36.8 46.4 0.79 41.8 44.3 0.94 Case 4 35.1 38.9 0.90 49.0 43.8 1.12 47.4 41.0 1.16 Case 5 35.2 33.7 1.04 47.2 42.2 1.12 46.4 51.7 0.90 Case 6 39.3 25.9 1.52 40.0 48.4 0.83 35.0 31.9 1.10 Case 7 33.1 21.8 1.52 49.6 38.9 1.28 42.3 45.6 0.93 Case 8 29.2 40.2 0.73 33.0 27.9 1.18 41.8 41.6 1.01 Case 9 25.8 20.8 1.24 23.7 44.3 0.53 28.6 36.3 0.79 Case 10 23.2 30.0 0.77 42.3 23.7 1.79 43.5 43.3 1.00 Case 11 32.5 21.4 1.52 46.3 44.0 1.05 49.2 40.8 1.21 Case 12 38.1 26.1 1.46 39.0 33.0 1.18 43.3 39.0 1.11 Case 13 23.1 34.8 0.66 36.9 35.8 1.03 47.6 37.5 1.27 Case 14 23.5 11.2 2.10 34.0 40.7 0.83 41.8 40.3 1.04 Case 15 25.7 16.7 1.54 50.0 41.0 1.22 42.4 39.0 1.09 Case 16 32.1 17.7 1.82 33.2 33.9 0.98 37.8 38.2 0.99 Case 17 30.5 26.3 1.26 39.2 38.9 1.02 41.9 41.3 1.03 Mean±SD 30.8±6.6 26.7±9.3 1.15±0.4 39.9±7.6 39.2±6.8 1.02±0.28 41.8±5.4 41.0±4.7 1.03±0.12 p-value* - - - 0.028 0.033 0.014 0.013 0.021 0.033 *Compared with TLDs at apophysiodesis. TLD, trochanter tip-trochanter lower margin distance; SD, standard deviation. 행, 운동성, 외전근수축력개선에효과가있는것으로보고되어왔다. 12) 하지만대전자성장판의나사골단유합술은짧은수술시간, 적은실혈, 간단한술후관리와함께외전근의점진적인적응을가능하게한다는점에서대퇴골단골두의골괴사가있는환아에서일차적으로고려가능한수술로보고되고있으며, 7) 시행된연령이작았을때임상적효과가큰것으로조사되고있다. 6,13) Langenskiöld와 Salenius 14) 에의해 1967년에처음으로발표된대전자성장판골단유합술에대한연구에서는 tetracycline을이용하여대전자성장에대해분석하였으며골단유합술은대전자과성장에서 50% 에해당하는정도만억제할수있으며나머지 50% 는대전자두부의부가성장이있었다고보고하였다. 이후에도위에서언급하였던 ATD와대전자성장을평가하는여러가지방사선지표를이용한골단유합술의효과에대해분석하는연구가이루어졌다. 2) ATD는 Trendelenburg sign, 파행과같은임상적증상을판단하는데유리하지만, 대전자의골단판에서의성장외에도대퇴골단골두자체의성장에의해서도영향을받을수있는지표이기때문에대전자성장을평가하는데있어서부정확한지표로판단된다. 또한기존의 Schneidmueller 등 12) 과 McCarthy와 Weiner 15) 의 ATD, trochanter-to-trochanter distance, lesser trochanter-to-articular surface distance를지표로하여분석한연구에서는대퇴골장축과하지의종축이이루는각도의보정이이루어지지않았으며또한대전자의부가성장에대한분석이없었기때문에제한점이있다고생각된다. 본연구에서는기존에사용하던방사선적지표에비해대퇴골장축과하지의종축이이루는각도를보정하고자모든거리는대퇴골장축과평행한거리로만측정하였으며, 나사경부에서대전자의첨부까지의거리를대퇴골장축과평행한방향으로측정하여이를부가성장의정도를나타내는 TSD라는지표로설정하여분석함으로써근위대퇴골의전자간성장에있어서의골단판성장, 부가성장정도에대해서종합적으로분석하였다는점에서의미가있다고생각한다. 본연구에서 ATD는환측에서건측에비해유의하게감소하였다. 이는대전자나사골단유합술이대전자성장을적절하게억제하지못한결과로만판단하기는어려우며, LCP 병자체의병리기전으로인해대퇴골두골단의성장의감소에의한영향또한기인하였을것으로판단된다. 환측은건측에비해 TLD의변화량은 76.7% 정도로, 전자간성장의 23.3% 만큼을나사골단유합술을

34 Sung Soo Kim, et al. Table 4. Radiologic Measurements of TSD, SLD, and TSD/SLD Case no. Preoperative Metal removal Follow-up TSD (mm) SLD (mm) TSD/SLD TSD (mm) SLD (mm) TSD/SLD TSD (mm) SLD (mm) TSD/SLD Case 1 11.2 33.3 0.34 13.0 32.7 0.39 14.2 34.0 0.42 Case 2 1.2 24.6 0.05 14.2 41.2 0.34 18.5 16.7 1.10 Case 3 4.5 21.1 0.22 15.2 23.7 0.64 14.2 26.9 0.53 Case 4 2.5 28.6 0.09 16.0 27.1 0.59 17.6 27.7 0.64 Case 5 3.3 32.7 0.10 6.0 37.8 0.16 10.7 34.3 0.31 Case 6 2.7 22.2 0.12 11.2 23.2 0.48 8.8 23.9 0.37 Case 7 2.1 17.2 0.12 11.6 21.1 0.55 14.8 29.8 0.50 Case 8 6.0 18.1 0.33 11.5 14.9 0.77 24.3 14.3 1.70 Case 9 0.9 15.9 0.06 7.5 23.7 0.32 10.4 25.9 0.40 Case 10 5.2 16.1 0.32 16.5 24.8 0.67 20.2 19.4 1.04 Case 11 2.0 22.6 0.09 25.1 13.5 1.86 25.8 14.8 1.74 Case 12 3.6 22.5 0.16 7.4 29.4 0.25 13.1 27.0 0.49 Case 13 6.6 16.2 0.41 13.3 21.7 0.61 14.3 26.7 0.53 Case 14 3.6 11.0 0.33 16.8 15.0 1.12 17.1 15.2 0.84 Case 15 3.6 15.1 0.24 28.4 15.9 1.79 27.9 19.5 1.43 Case 16 5.7 22.5 0.25 16.8 13.3 1.26 19.8 14.2 1.40 Case 17 5.4 15.7 0.35 4.0 24.1 0.16 13.7 32.2 0.43 Mean±SD 4.5 21.2 0.20 14.4±5.3 23.7±3.2 0.74±0.55 17.0±5.62 23.7±4.5 0.84±0.42 p-value* - - - <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 *Compared with preoperative TSD and TSD/SLD. TSD, trochanter tip-screw distance; SLD, screw-trochanter lower margin distance; SD, standard deviation. Table 5. TSD between the Two Groups (One Performing Apophysiodesis above Age of 10 Years and the Other Performing Apophysiodesis below Age of 9 Years) Variable Age of apophysiodesis (yr) TSD (mm) (mean±sd) p-value Preoperative 10 4.6±1.5 0.658 9 4.2±1.3 Metal removal 10 14.5±4.9 0.233 9 15.1±5.2 Last F/U 10 16.5±5.9 0.287 9 17.9±5.7 TSD, trochanter tip-screw distance; SD, standard deviation; F/U, followup. 통해억제한것으로보이며, 건측에대한환측의 TLD의비는 1.15 에서 1.02까지유의하게감소하였으며 (p=0.014), 금속제거시점에도 1.02로동일하므로금속제거술시행후에도 TLD의억제가유의하게일어나고있음을알수있었다 (Table 3). TSD/SLD의비또한 0.20에서 0.74로유의하게증가하였는데이는나사골단유합 술이대전자첨부의부가성장을조절하지못하는것으로판단된다. 금속제거술이후에 3예 (Case 3, 6, 15) 에서는최종추시관찰시 TSD가오히려감소하는결과를보였다. 이는상대적으로 SLD의성장이큰것으로보아금속제거술이후에길이성장이크게일어났으며나사를제거한위치에골유합이진행되면서기존삽입위치의정확한구분이어려워지면서측정상의오차로인한것으로판단된다. McCarthy와 Weiner 15) 는 6세이전의집단과비교할때 8세이후에대전자골단유합술을시행할경우더욱효과적인대전자성장억제를이룰수있다고보고하였고, Matan 등 2) 은 LCP 병에서임상적, 방사선적호전을모두성취할수있는적절한대전자골단유합술의시행시기는평균 8세라고보고하였다. 그러나본연구에서는보고된적절한대전자골단유합술시행시기인 8세보다늦은평균 10세경에골단유합술을시행하는경우에도대전자골단유합술과함께선반비구성형술, 관절이개술, 무명골절골술, 내반감염절골술을동시에시행하여대전자성장을충분히억제할수있는지평가하고자하였으며 10세를기준으로하여 10세이상과 9세이하집단으로나누어전자부성장정도를각각비교하였

35 The Effect of Screw Apophysiodesis of Greater Trochanter in LCP Disease Table 6. Growth Rate of TSD after Distal Transfer of Greater Trochanter Age of apophysiodesis (yr) Case no. Postoperative TSD (mm) TSD (mm) at last F/U Distal transfer last F/U (yr) Changes of TSD (mm)/yr Average growth (mm/yr) 10 Case 2 0.5 6.9 6 1.1 1.3 Case 14 1.1 12.8 8 1.5 9 Case 7 0.3 10.0 7 1.4 1.2 Case 8 2.4 3.5 1 1.1 Case 13 1.2 13.4 10 1.2 TSD, trochanter tip-screw distance; F/U, follow-up. Table 7. Comparison of the Annual Growth of TSD between the Two Groups (Cases Performing Distal Transfer of Greater Trochanter) Postoperative TSD (mm) TSD (mm) at last F/U Distal transfer-last F/U (yr) Change of TSD (mm)/yr Average growth (mm/yr)* 0.50 6.88 6 1.1-0.31 9.95 7 1.4-2.41 3.51 1 1.1 1.3±0.2 1.22 13.41 10 1.2-1.08 12.79 8 1.5 - Average of changes of TSD (mm)/years of two groups=0.7±0.16. *p<0.001. TSD, trochanter tip-screw distance; F/U, follow-up. Table 8. Comparison of the Annual Growth of TSD between the Two Groups (Cases Not Performing Distal Transfer of Greater Trochanter) TSD (mm) at metal removal TSD (mm) at last F/U Metal removal-last F/U (yr) Change of TSD (mm)/yr Average growth (mm/yr)* 12.9 14.2 3 0.4-15.2 14.2 5-0.2-16.0 17.6 2 0.8-6.0 10.7 5 0.9-11.2 8.8 2-1.2-7.5 10.4 5 0.6 0.4±0.2 16.5 20.2 5 0.7-25.1 25.8 1 0.7-28.4 28.0 1-0.4-16.8 19.8 2 1.5-4.0 13.7 8 1.2-6.7 8.3 5 0.3 - Average of changes of TSD (mm)/years of two groups=0.7±0.16. *p<0.001. TSD, trochanter tip-screw distance; F/U, follow-up. 고통계적으로유의한차이는보이지않았으며, 또한대전자나사골단유합술시행후대전자원위이전술을시행하는비율도 10세이상과 9세이하에서나사골단유합술을시행하는경우에도차이를보이지않았다. 대전자원위이전술을시행한 5예를나사골단유합술을 10세이상에시행했던군과 9세이하에서시행한군으로나누었을때대전자원위이전술후의부가성장정도도두군에서각각 1.3 mm/yr, 1.2 mm/yr으로큰차이를보이지않았으며대전자원위이전술을시행한군에서의 TSD의연간성장량 은 1.3 mm/yr로전체평균인 0.7 mm/yr보다높은것으로보아 (p <0.001) 부가성장은나사골단유합술이나대전자원위이전술에도불구하고지속성장하는것으로생각된다. 본연구의제한점으로는대전자나사골단유합술을시행하기전또는시행과동시에부가적인수술 ( 관절이개술, 무명골절골술, 내반감염절골술, 선반비구성형술 ) 을시행하여나사골단유합술만의효과를분석하는데제한이있었다는점이다. 또한대상집단개체수가적고짧은추시기간으로인한오차가발생할

36 Sung Soo Kim, et al. 수있을것이라생각되며보다많은연구대상에서개개인의성장이끝난시점에서의결과를토대로비교연구가이루어져야타당한결론을도출할수있을것으로생각된다. 결론 LCP 병에서나사를이용한골단유합술은대전자의전체성장은억제할수있었으나부가성장을억제하지못하여대전자과성장을억제하지못하고대전자원위이전술을추가로필요로하므로나사를이용한골단유합술은대전자성장억제에좋은방법이아닌것으로판단된다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Van Tongel A, Fabry G. Epiphysiodesis of the greater trochanter in Legg-Calvé-Perthes disease: the importance of timing. Acta Orthop Belg. 2006;72:309-13. 2. Matan AJ, Stevens PM, Smith JT, Santora SD. Combination trochanteric arrest and intertrochanteric osteotomy for Perthes' disease. J Pediatr Orthop. 1996;16:10-4. 3. Maquet P. Importance of the position of the greater trochanter. Acta Orthop Belg. 1990;56:307-22. 4. Iwersen LJ, Kalen V, Eberle C. Relative trochanteric overgrowth after ischemic necrosis in congenital dislocation of the hip. J Pediatr Orthop. 1989;9:381-5. 5. Leitch JM, Paterson DC, Foster BK. Growth disturbance in Legg-Calvé-Perthes disease and the consequences of surgical treatment. Clin Orthop Relat Res. 1991;262:178-84. 6. Gage JR, Cary JM. The effects of trochanteric epiphyseodesis on growth of the proximal end of the femur following necrosis of the capital femoral epiphysis. J Bone Joint Surg Am. 1980;62:785-94. 7. Litt R, Albassir A, Willems S, Debry R. Coxa vara. Isolated growth of the greater trochanter. Prevention-treatment. Acta Orthop Belg. 1990;56:301-6. 8. Garrido IM, Moltó FJ, Lluch DB. Distal transfer of the greater trochanter in acquired coxa vara. Clinical and radiographic results. J Pediatr Orthop B. 2003;12:38-43. 9. Takata K, Maniwa S, Ochi M. Surgical treatment of high-standing greater trochanter. Arch Orthop Trauma Surg. 1999;119:461-3. 10. Hasler CC, Morscher EW. Femoral neck lengthening osteotomy after growth disturbance of the proximal femur. J Pediatr Orthop B. 1999;8:271-5. 11. Fernbach SK, Poznanski AK, Kelikian AS, Tachjdian MO, Marzano MJ. Greater trochanteric overgrowth: development and surgical correction. Radiology. 1985;154:661-4. 12. Schneidmueller D, Carstens C, Thomsen M. Surgical treatment of overgrowth of the greater trochanter in children and adolescents. J Pediatr Orthop. 2006;26:486-90. 13. Edgren W. Coxa plana. A clinical and radiological investigation with particular reference to the importance of the metaphyseal changes for the final shape of the proximal part of the femur. Acta Orthop Scand Suppl. 1965:Suppl 84:1-129. 14. Langenskiöld A, Salenius P. Epiphyseodesis of the greater trochanter. Acta Orthop Scand. 1967;38:199-219. 15. McCarthy JJ, Weiner DS. Greater trochanteric epiphysiodesis. Int Orthop. 2008;32:531-4.

37 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2018; 53: 29-37 https://doi.org/10.4055/jkoa.2018.53.1.29 www.jkoa.org Legg-Calve-Perthes 병에서나사를이용한대전자골단유합술의효과 김성수 김현준 정성윤 * 임철순 김동률 동아대학교의과대학정형외과학교실, * 대한민국육군제 22 보병사단 목적 : Legg-Calve-Perthes (LCP) 병에서시행한대전자나사골단유합술후대전자부의성장판에의한길이성장및부가성장두 가지에미치는영향을조사하였다. 대상및방법 : 2003 년 12 월부터 2012 년 12 월까지동아대학교병원에서 LCP 병으로진단받고대전자의나사골단유합술및추후금 속제거술까지시행한환자중 4년이상의추시관찰을시행한환자 17명을대상으로하였다. 골단유합술시행시, 금속제거술시, 추시관찰시전후면방사선사진을이용하여대퇴골장축에대하여수직을이루는선중에서대퇴골두와가장근위부가만나는선과대전자의가장근위첨부를지나는선간의거리인 articulo-trochanter tip distance (ATD), 나사경부에서대전자의첨부까지의거리를대퇴골장축과평행한방향으로측정한거리인 trochanter tip-screw distance (TSD), 대전자성장판의원위부부터대전자첨부까지의거리를대퇴골장축과평행하게측정한거리인 trochanter tip-trochanter lower margin distance (TLD), 나사경부에서대전자성장판의원위부까지거리인 screw-trochanter lower margin distance (SLD) 를측정하였다. 결과 : ATD는환, 건측에서수술전평균 14.2 mm, 16.8 mm, 최종추시관찰시평균 9.2 mm, 14.8 mm로환측이건측에비해감소하였다 (p=0.030). 환측의 TLD는나사골단유합술시평균 30.8 mm에서최종추시시 41.8 mm로 11.0 mm 증가하였고, 건측은평균 26.7 mm에서 41.0 mm로 14.3 mm 증가하여수술한환측의대전자성장은건측에비해 76.7% 였다. 건측에대한환측의 TLD 비는처음 1.15에서금속제거술시 1.02로감소하였다 (p=0.014). TSD는나사골단유합술시 4.5 mm에서금속제거술시 14.4 mm로증가하였으며 (p<0.001) 최종추시시에는 17.0 mm로측정되었다. TSD의 SLD에대한비도나사골단유합술시 0.20에서금속제거술시 0.74로증가하였으며 (p<0.001) 최종 0.84로증가하였다. 결론 : LCP 병에서나사를이용한골단유합술은대전자의전체성장은억제할수있었고부가성장은억제못하였고대전자과성장을억제못하여대전자원위이전술이필요하였다. 나사를이용한골단유합술은대전자성장억제에좋은방법이아닌것으로판단된다. 색인단어 : 대전자, Legg-Calve-Perthes 병, 나사골단유합술, 성장 접수일 2016 년 10 월 27 일수정일 2017 년 2 월 24 일게재확정일 2017 년 6 월 19 일책임저자김현준 49201, 부산시서구대신공원로 32, 동아대학교의과대학정형외과학교실 TEL 051-240-2757, FAX 051-254-6757, E-mail hyeonjun@dau.ac.kr 대한정형외과학회지 : 제 53권제 1호 2018 Copyright 2018 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.