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KMJ Original Article Treatment of Unstable Intertrochanteric Fracture with Bipolar Hemiarthroplasty of Hip in Elderly Population-Short-term Results- Gun Woo Lee, Jae-Man Kwak, So Hak Chung Department of Orthopedic Surgery, College of Medicine, Kosin University, Busan, Korea 고령에서발생한불안정성대퇴골전자부골절의인공관절반치환술을이용한치료 - 단기추시결과 - 이근우 곽재만 정소학 고신대학교의과대학정형외과학교실 Objectives: The aim of this study is to evaluate the short-term results and complications of treating the intertrochanteric fracture with bipolar hemiarthroplasty (BHA) in elderly population. Methods: We retrospectively reviewed 31 unstable intertrochanteric fracture patients who were treated with BHA between January 2007 and August 2009 in older populations more than 65 years old. The 6 males and 25 females had a mean age of 79.8 years (range: 66-88) and a mean follow-up of 36.3 months (range: 24-55). We analyzed the radiological outcomes, functional recovery grade, using Jensen s social function score and Harris hip score (HHS), and complications. Results: The average operation time and blood loss was 148.9 min (range, 110-215 min) and 455.2 ml (range, 200-1200 ml). Mean preoperative and postoperative hemoglobin (Hb) was 10.9 g/dl (range, 8.6-13.4 g/dl) and 10.5 g/dl (range, 5.1-14.1 g/dl) respectively. Average 1.3 pints of blood transfusion was performed. Ambulation with (or without) crutch was possible at mean 6.8 days postoperatively. The stability and alignment indices were adequate in all cases at final follow-up. On clinical results, the average HHS score, was changed from 79.7 points (range, 44-100) preoperatively to 73.0 points (range, 46-92) postoperatively, and the preoperative and postoperative Jensen s score was 1.8 (range, 1-3) and 2.1 (range, 1-4) respectively. Conclusions: The BHA is an acceptable alternative for unstable intertrochanteric fractures in older population. Key Words: Bipolar hemiarthroplasty, Femur, Unstable Intertrochanteric fracture 최근증가하고있는고관절주위골절중, 대퇴전자부골절은견고한내고정술을통해조기보행을유도함으로써욕창, 심폐기능부전, 정맥혈전증등장기간침상안정에의해발생하는합병증을줄이는것이치료적목표이다. 1 그러나대퇴전자부골절의특성상고령의환자에서골다공증이동반되어있을뿐만아니라불안정골절이 50-60% 를차지하여견고한내고정이매우어렵다. 2 전통 적으로사용되고있는활강압박고나사는분쇄상이심한불안정성골절이나, 외측대퇴피질골의골절이동반될경우골절의정복이불안정하여, 지연나사의대퇴골두천공등의합병증이나타나며, 최근에보고되고있는근위대퇴정또한분쇄가심한전자부골절에서는다양한합병증이보고되고있는실정이다. 3-7 인공관절반치환술은과거에는광범위한피부절개 Corresponding Author: So Hak Chung, Department of Orthopaedic Surgery, College of Medicine, Kosin University, 34 Amnamdong, Seo-gu 602-702 Busan, Korea TEL: 051) 990-6237 FAX: 051) 243-0181 E-mail: shchung@kosin.ac.kr Received: October 18, 2011 Revised: March 24, 2012 Accepted: April 30, 2012 37

및비교적많은출혈량, 대퇴주대골절및폴리에틸렌마모로인한해리등의여러합병증이보고되었다. 하지만, 최근수술기법의발전, 조직공학의발전으로인한기구의발달로인해합병증이감소하고, 생역학적으로좀더안정적이고조기체중부하가가능하게되어많이시행되어지고있으며국내외의여러연구에서만족스러운결과를보고하고있지만, 아직국내에서보고된논문은부족한실정이다. 8-14 심한골절편정복의불필요성, 이로인한수술시간의단축, 조기재활및운동의가능성등의인공관절반치환술을이용한전자부골절의치료에대한장점이널리알려지면서많이시행되어지고있다. 대퇴전자부골절은고령에서골다공증과동반되어발생하게되며대부분만성질환을동반하고있으므로, 인공관절반치환술을통한조기관절운동및보행은고령환자에많은도움이될것으로판단된다. 이에저자들은본원에서 65세이상의노령에서발생한불안정성대퇴전자부골절에서인공관절반치환술을시행한후임상적, 방사선학적초기결과를분석하고, 그유용성에대해보고하고자한다. 연구대상및방법 2007년 1월부터 2009년 8월까지본원정형외과에서 65 세이상의노인에서대퇴전자부골절로진단되어치료받은 83 예중, 2년이상추시가가능하고인공관절반치환술 (Accolade TM, TMZF, Stryker) 을시행하였던 31예를대상으로후향적연구를실시하였다. 다른부위에대한동반골절이있거나, 전이성종양에의한병적골절인환자는대상에서제외하였으며, 평균추시기간은 36.3 개월 ( 범위, 24-55 개월 ) 이었다. 31예의환자중 19명의환자는병원까지의거리가너무멀거나시간의제약등으로병원방문이가능하지못하여전화상으로기능적평가와만족도에대한평가만을시행하였으며, 12예의환자에대하여방사선학적평가를시행하였다. 수상당시의연령은평균 79.8세 ( 범위, 66-88 세 ) 였으 며, 남자가 5예, 여자가 26예로여자가많았다. 전자부골절손상의정도는 AO 골절분류방법을이용하였으며, A2 가 26예, A3가 5예였다. 골절원인으로는실족사고가 26예로가장많았고, 교통사고가 5예였다. 수상일로부터평균 11.4일 ( 범위, 1-16 일 ) 이후수술을시행하였으며, 당일응급수술을시행한경우가 7예였다. 수술은모두측와위에서외측도달법으로약 10 cm의피부절개후, 가능한한중둔근 (gluteus medius) 의손상을막기위하여중둔근보존수술방법 (gluteus medius sparing approach) 으로접근하였다. 대결절부혹은전자하부까지골절선이연장되어있는경우안정성여부를판단한이후, 불안정성인경우추가적인강선고정술 (wiring) 을시행하였으며, 안정한경우에는골절부의 manual reduction 이후대퇴스템고정시의시멘트로고정을유도하였다. 수술후 1일째부터앉는자세를허용하였으며, 수술후 2-7 일째환자의상태에따라, 보행기나목발보행을허용하였고, 능동적관절운동을시작하도록권장하였으며, 환자적응도에따라 5-14 일째자유보행을허용하였다. 진료차트를분석하여수술시간, 출혈량및수혈유무를평가하였고, 마취기록지상표기된출혈량을측정하였다. 출혈량및수혈유무의비교를위해내고정술및인공관절반치환술을이용하여치료된대퇴전자부골절중에서출혈량및수혈량이표시된국내외결과를이용하였다. 13,14,16,19-21,24,25 방사선적결과는정기적으로시행한방사선촬영을분석하여대퇴주대및골두컵의위치를측정하였고, 주대주위의해리및골분리정도를측정하였다. 대퇴주대의안정성을평가하는데있어서, Engh 등 9,10 이제시한방법에따른 2 mm 이상의침강 (subsidence), 발판반응 (pedestral reaction) 의유무, Gruen Zone 을기준으로한대퇴주대주위의방사선투과선을관찰하였다. 11 또한방사선학적으로대퇴삽입물의내외반각을대퇴장축을기준으로측정하여삽입물의삽입위치의적절성을평가 38

Treatment of Unstable Intertrochanteric Fracture with Bipolar Hemiarthroplasty of Hip in Elderly Population-Short-term Results- 하였고, 또한방사선검사를통하여대퇴근위부길이를측정하여양측하지길이차이를비교하였다. 12 방사선 Table 1. The assessment of social function of Jensen Score Social function groups Definition 1 Independent Manage everything Possible working 2 Slight dependent Manage household Meals-on-wheels 3 Moderately dependent Home-help < 4hrs/week Possibly district nurse 4 Totally dependent Living in nursing home or Long-term nursing at home 계측은방사선사진영상저장전송체계 (PACS, Picture Archiving and Communication System; Maroview Marotech, Seoul, Korea) 를이용하여분석하였다. 임상적결과는술후 24개월이상경과후외래방문과, 수술과상관없는정형외과전공의에의해전화인터뷰를통하여시행하였으며, Jensen 사회기능검사 (Table 1) 및해리스고관절기능검사 (Harris Hip Score, HHS) 를조사하여보행상태및고관절의기능을평가하였다. Table 2. Summarized data of patients about operative, functional outcomes and complications Case Age/ AO/ OTA LP time Hb Blood Jensen Score HHS* F/U OP No Sex type (min) Preop Postop loss (cc) pre post pre post (month) Complications & comment 1 86/F A2.3 El 160 11.4 8.7 300 1 1 100 92 30 (-) 2 66/M A3.2 EM 165 10.8 11.9 500 1 1 97 88 30 Dislocation at 6 months 3 80/M A3.1 El 170 8.7 11.3 400 2 2 87 81 38 (-) 4 79/F A2.3 El 115 13.4 14 1200 2 2 87 84 47 (-) 5 79/F A2.3 El 135 11.8 10.7 500 2 2 81 76 46 (-) 6 81/M A2.3 El 155 11 9.2 200 1 1 100 88 47 (-) 7 90/F A2.3 El 135 12.5 11.5 300 2 2 73 74 28 (-) 8 86/F A2.3 El 205 9.6 12.8 500 1 3 88 57 32 At postoperative, fat embolism onset. 9 87/F A2.3 EM 155 10.3 9.2 200 2 2 81 80 24 (-) 10 86/F A2.3 El 145 11.9 14.1 500 4 4 48 40 38 (-) 11 84/F A2.3 El 140 10.6 9.3 300 2 2 88 80 28 (-) 12 72/F A2.3 El 215 10.9 10.4 600 2 2 87 78 40 (-) 13 87/F A2.3 EM 120 12.3 10.9 300 1 1 93 88 48 (-) 14 81/F A3.3 El 145 11.4 12.9 500 2 2 88 80 32 (-) 15 75/M A2.3 El 110 11.1 6.9 300 1 1 90 86 26 (-) 16 87/F A3.1 El 210 11.4 13.9 700 3 4 44 42 28 Dislocation at 1 month 1 year later, died from aspiration pneumonia 17 83/F A2.3 El 130 10.8 10.9 600 2 2 80 80 38 (-) 18 80/M A2.3 El 125 11.8 9.6 300 2 2 83 81 37 (-) 19 84/F A2.3 EM 130 10.1 11.7 400 1 1 90 88 28 (-) 20 84/F A2.3 El 135 10.4 9.6 900 1 1 93 86 27 (-) 21 78/F A2.1 EM 205 10.6 13.4 200 2 2 77 78 44 (-) 22 78/F A2.3 El 150 10.7 5.1 1200 3 3 49 48 47 (-) 23 78/F A2.3 El 150 9.4 9.2 300 2 2 80 78 52 (-) 24 72/F A2.3 El 150 12.2 11.6 300 3 4 52 46 24 Periprosthetic infection Second-stage Revision perform 25 87/F A2.3 EM 160 10.7 8.2 200 3 2 73 76 27 (-) 26 77/F A2.3 El 130 8.6 11.4 300 1 3 87 52 49 general weakness 27 88/M A2.3 El 130 9.2 8.6 500 1 3 80 46 38 newly cerebral infarction occurred 28 78/F A3.2 El 170 11.7 8.2 300 3 3 49 51 37 (-) 29 80/F A2.3 El 120 11.7 10.8 300 2 2 77 76 55 (-) 30 86/F A2.3 EM 110 10.2 12.5 200 1 1 81 80 32 (-) 31 80/F A2.3 El 140 11.2 9.5 500 1 1 88 84 29 (-) HHS: Harris hip score, El: Elective, EM: Emergency. 39

결과 피부절개에서봉합까지걸린수술시간은평균 148.9 분 ( 범위, 110-215분 ) 이었고, 마취기록지에기록된출혈량은평균 445.16 ml ( 범위, 200-1200 ml) 였다. 골절의특성상전예에서응급실을통해내원하였으며, 수술전응급실에서시행한혈액학적검사상평균혈색소수치는 10.9 g/dl ( 범위, 8.6-13.4 g/dl) 였고, 수술직후에측정된평균혈색소수치는평균 10.5g/dL ( 범위, 5.1-14.1g/dL) 였다. 수술전후로평균 0.4 g/dl ( 범위, -5.6-2.2 g/dl) 의변화가있었다. 수술중마취과에서예방적인수혈을시행한경우가 17예있어, 이로인해술후혈색소가증가된경우가발생되었다. 술중혹은술후에 24 예에서평균 1.3 pint ( 범위, 1-3 pint) 의수혈을 시행하였다. 술전동반질환력에대한조사에서, 총 31예중 25예 (80.6%) 에서있었다. 가장흔한것은당뇨 (18예, 58.0%) 와고혈압 (11 예, 35.4%) 이었고, 특히뇌경색 (9예, 29.0%), 관상동맥질환등의심장질환력 (7예, 22.5%), 폐렴, 결핵등의폐질환력이 4예 (12.9%) 였다 (Table 2). 대퇴주대주위의방사선투과선은전후면방사선사진상 9예에서관찰할수있었다. Gruen zone 1에서 4예, zone 3에서 3예, zone 4에서 2예가관찰되었으나투과선은모두 2 mm 이내였으며, 추시기간동안의진행은관찰되지않았다 (Fig. 1). 즉, 추시방사선을촬영할수있었던 12 중, 전예에서스템의안정적인골성삽입을보였으며, 추시기간중대퇴스템의해리소견은관찰되지않았다. 대퇴스템삽입물의삽입위치는모든예에서대퇴의장축에대해 2도이하의내반을보였으며, 그이상의각변형을보인경우는없었다. 술후방사선계측및 SMD (supinemalleolar distance) 계측상양측하지길이차이는 3예 (25%) 에서나타났는데모두 1.5 cm 미만으로이와관련된증상은관찰되지않았다. Fig. 1. (A) Pelvic radiograph showed the unstable intertrochanteric fracture of right femur. (B) On postoperative radiograph, well-fixed and aligned stem and cup was seen. (C) At 28 months postoperatively, radiolucent line of zone 1 was noted between cement and cortex. However, stem stability was maintained. 해리스고관절기능점수 (Harris Hip Score) 는술전평균 79.7점 ( 범위, 44-100 점 ) 에서술후평균 73.0점 ( 범위, 46-92점 ) 이었고, Jensen 사회기능점수는술전 1.8점 ( 범위, 1-3) 이었으나, 술후평균 2.1 점 ( 범위, 1-4) 이었다. 술전해리스고관절기능점수가 70점이상으로양호한경우였던 27예 (87%) 중 24예 (77.4%) 에서최종추시상해리스고관절기능점수가 70점이상으로일상생활이원활한상태이며, 3예에서술후고관절주위동통및전신쇠약으로일상생활에어려움을호소하였다. 이들 3예의경우, 뇌경색, 신장기능부전등의만성기저질환이있는경우였으며, 전신쇠약이심해최종추시시휠체어보행만이가능하였다. 3예를제외한경우에는수술후빠른관절운동및보행으로폐부종, 심장부전등의 40

Treatment of Unstable Intertrochanteric Fracture with Bipolar Hemiarthroplasty of Hip in Elderly Population-Short-term Results- 심각한합병증없이일상생활로복귀할수있었다. 술전뇌경색등의질환력으로보행이힘들어해리스고관절기능점수가 70점미만이었던 4예 (13%) 에서는술후해리스고관절기능점수는낮았으나, 술전과큰차이는없었다. 추시도중 2예에서관절탈구로인해정복하였으며, 술후감염으로실패한경우가 1예있었다. 관절탈구가발생되었던 2예중 1예는술후 28개월째기저질환으로사망하였으며, 1예는정복이후재탈구가관찰되지않아제한형으로의재치환술 (constrained type revision) 등의추가적인수술은시행하지않았다. 감염으로실패한 1예에대해서는재치환술을시행하였으며, 항생제가포함된시멘트모형으로감염조절이후재치환술을시행하였으며, 재치환술후 13개월째인최종추시까지특이소견은관찰되지않았다 (Table 2). 고찰 골다공증으로인한골소실및골절의분쇄성으로인하여견고한고정이어려운것으로알려져있는대퇴전자부골절은안정골절과불안정골절로나눌수가있으며, 이중안정골절은내고정물에상관없이잘유합되는것에비해불안정골절은이상적인치료방법이아직확립되지않았다. 8 견고한내고정이어려운대퇴전자부골절의고정을위하여여러가지형태의고정물이개발되었지만, 대표적인방법으로는골절부위의압박력을얻어골유합을촉진시킬수있도록고안된활강압박고나사와골수정으로크게이분할수있다. 6,13 하지만, 골절방향이운동방향에비해직각을넘게되는횡골절, 역사선골절및외측피질골의골절에의해유동성대전자가발생한경우에는원위골편에의한외측지지역할이많이감소되어정복소실, 전이및추가적인골절이발생하는골절붕괴가발생하게되어많은문제점이보고되었고, 3,7 이후생역학적으로좀더안정적으로도수정복후삽입이가능하도록고안된대퇴근위골수정또한대퇴골간부의골절및 수술수기의실패로인해발생되는여러문제점들이보고되고있는실정이다. 14,15 고령에서발생되는불안정성전자부골절은대부분골다공증이동반되어심한골절부의이완및함몰이예상되며, 또한많은환자에서내과적질환의동반과전신적합병증이발생되어유병률및사망률이높은것으로보고된다. 16-18 이러한측면에서고령의대퇴골전자부골절의일차목표는조기운동및보행을가능케하여장기간침상안정으로발생되는전신적합병증을줄이고, 술전의상태로빨리회복하는것이다. 하지만, 위에언급한것과같이내고정으로골절정복및유지는많은수술적문제점이야기되며, 조기보행이불가능하여전신적합병증이야기될가능성이많아이러한문제점을해결하기위해최근에는고관절인공관절반치환술이대두되고있다. 19-21 인공관절반치환술은절개범위가내고정술보다크고, 출혈량이많으며, 근육및건의손상가능성이있는등의수술자체의문제점과인공관절이갖는해리, 비구연골마모, 감염, 탈구등의술후합병증에대한우려가있는것이사실이다. 하지만, 수술술기의발달및중둔근의손상을최소화하는술식이보고가된이후, 출혈량및술후합병증이많이줄게되었다. 최근보고에서인공관절반치환술의출혈량은평균 300-500 cc 정도이며, 16,19-21,24,25 이는최근많이시행되어지는근위대퇴정 (proximal femoral nail, PFN) 에대한보고의평균인 266.57 ml ( 범위, 67.7 523 ml) 와비교하여큰차이가없으며, 4,6-8,13-15,18,23,24 본논문에서도 445.16 cc 정도로유사한결과를얻었다. 또한근위대퇴정의술후합병증발생에대한최근보고에서 Simmermacher 등 15 에의하면나사못의관절내돌출은 0.6%, 국소합병증은 13% 에서발생하였고, Al-yassari 등 22 은대퇴골두천공이약 8%, 골수정첨단부골절이 1.4% 발생하였다고하였으며, Herrera 등 23 은대퇴골두천공을 0.8% 에서, 지연나사의전위가 8% 에서나타난다고하였다. 또한이러한논문들에서성공률은모두 90% 이상으로보고하고있다. 인공관절반치환술의성공률은비록대퇴경부에서시행한논문 41

Table 3. Published literature regarding treatment methods Author Type of Surgery Number of patients Mean follow-up (months) (range) Complication (number) (%) Main Comments (cases) Current study BHA 31 36.3 (24-55) 3 (9.6%) D/L (2), Infection (1) Simmermacher [15] PFN 190 12 (4-21) 36 (18%) Hematoma (14), Infection (3) Delayed wound healing (4) Poor reduction (2), cut-out (1) Al-yassari G [22] PFN 76 5.49 (3-12) 7 (9.2%) Screw cut-out (4), hematoma (1) Infection (1) Herrera A [23] PFN 125 12 79 (63.2%) Hematoma (17), infection (4) Mal-reduction (10), migration (10) Gamma-nail 125 12 88 (70.4%) Hematoma (13), Infection (4) Cut-out (5), Fracture (4) Overgaard S [24] BHA 168 72 (36-108) 23 (13.7%) Infection (7), Fracture (6) D/L (4), Nerve palsy (1) Moon K [25] BHA 31 31.2 (24-52) 1 (3.22%) Ectopic osteogenesis (1) BHA: Bipolar hemiarthroplasty, PFN: Proximal femoral nail, D/L: Dislocation 들이기는하나, Overgaard 등 24 은 6년추시상 95% 의성공률을보고하였고, 문등 25 도 70세이상환자의보고에서 2년추시상 100% 의성공률을보고하였다 (Table 3). 이를볼때, 비록반치환술에서내고정술에비해광범위한절제, 근육및건의손상을야기하지만최근수술술기및기기의발전으로양군의결과는큰차이가없을것으로판단한다. 또한, 술후관절운동및보행의측면에서내고정술군에서는조기운동은가능하나, 체중부하보행은적어도 2-3 주이상지연되지만, 반치환술군에서는환자의상태에따라술후 2-7 일에체중부하를시작하여좀더조기에보행이가능하다. 이는고령에서발생되는전신적합병증의가능성을줄여수술과연관된유병률및사망률을줄일수있다고사료된다. 고령의전자부골절환자가내원하면전신상태및동반질환의유무, 골절의성격, 골절전환자의활동도, 환자의남은수명을고려하여수술방법을결정해야한다. 하지만, 저자들의경험상, 대부분의고령환자들은내과적질환이동반되어있으며, 내고정을통한골유합을얻기위한기간동안의활동제한이오히려노인들에게심장및폐질환의악화등의합병증및사망을유발시키는요인이될수있고, 또한이를경험하였기에, 고관절부분치환술의선택이내고정술에비해좀더유용한치료방법 이라고판단한다. 본연구의단점은노인환자들에대한평가이므로병원및지역적인특성, 환자개개인에따라변수가많을수있다. 또한, 고령을대상으로진행된연구이기에더많은임상결과들을비교하지못한단점이있으며, 전반적으로고령에서오는전신상태의불균형으로장기추시관찰이될수없었기에, 비교적단기추시의한계가있으며, 이에대한추가적인연구가필요할것으로판단된다. 또한, 전예를대상으로방사선학적검사를시행하지못하여결과를일반화시키는데제한이있을것으로보이며, 이에대해서도추가적인연구결과가필요할것으로판단된다. 결론적으로, 고령환자에서대퇴골의불안정성전자부골절에서인공관절반치환술은조기운동및보행이가능하여술후합병증이적으며, 최근의수술술기및기구의발달로인해수술로인한조직손상및출혈량을줄일수있어, 고령환자에서시행할수있는효과적인치료방법이라고판단된다. 참고문헌 1. Templeman D, Baumgaertner MR, Leighton RK, Lindsey RW, Moed BR. Reducing complications in the surgical treatment 42

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