Review Article pissn 1738-3757 eissn 2288-8551 J Korean Foot Ankle Soc 2021;25(1):32-37 https://doi.org/10.14193/jkfas.2021.25.1.32 만성발목불안정증수술후의지속적인발목통증 조병기, 안병현 충북대학교의과대학정형외과학교실 Residual Pain after Operative Treatment for Chronic Ankle Instability Byung-Ki Cho, Byung-Hyun Ahn Department of Orthopedic Surgery, College of Medicine, Chungbuk National University, Cheongju, Korea Patients with chronic lateral ankle instability often experience a range of associated injuries. The well-known comorbidities include intra-articular pathologies (osteochondral lesion, soft tissue or bony impingement, and loose body), peroneal tendon pathologies, neural injuries, and other extra-articular pathologies. Surgeons should have a high index of suspicion for these associated pathologies before operative intervention, correlate the clinical findings, and plan the treatment. Despite the restoration of ankle stability following ligament repair or reconstruction surgery, a high prevalence (13%~35%) of postoperative residual pain has been reported. This pain can negatively affect the clinical outcomes and patient satisfaction. This study examined the causes of persistent pain after surgical treatments for chronic ankle instability. Key Words: Ankle, Instability, Operative treatment, Pain 서 발목관절의외측염좌는가장흔한근골격계스포츠손상으로서 전체의약 15% 25% 가량을차지한다고보고되고있으며응급실 을방문하는환자의약 7% 10% 가량을차지한다고알려져있다. 1,2) 급성발목염좌에대한적절한초기치료와재발방지교육의중요성 이계속강조되고있음에도여전히상당한비율의환자들이재손상 을입고만성발목불안정증으로이행되고있다. 3-5) 또한발목염좌 시관절내혹은주변구조물들의손상이동반되는경우가흔하며, 만성통증이나기능저하의원인이될수있으나실제임상에서이 에대한손상초기의세심한접근은아직부족한실정이다. 만성발 목불안정증환자의주증상은대개발목관절의무력감 (giving way) Received December 19, 2020 Revised December 30, 2020 Accepted January 13, 2021 Corresponding Author: Byung-Ki Cho Department of Orthopedic Surgery, Chungbuk National University Hospital, 776, 1sunhwan-ro, Seowon-gu, Cheongju 28644, Korea Tel: 82-43-269-6077, Fax: 82-43-274-8719, E-mail: titanick25@naver.com ORCID: https://orcid.org/0000-0001-7746-598x Financial support: None. Conflict of interest: None. 론 또는불안감으로표현되는기능적불안정성 (functional instability) 이며의료진에의해확인된발목관절의기계적불안정성 (mechanical instability) 정도와재활치료경과등을종합적으로고려하여수술적치료를적용하게된다. 반복적인외측발목염좌와자주동반되는비골건손상, 발목관절의골연골또는활액막손상, 내측인대 (deltoid ligament) 손상, 경비인대결합 (distal tibiofibular syndesmosis) 손상, 발목주위신경의견인손상등에의해발목불안정증과더불어보행및운동시만성통증이동반되는환자들이많으므로 6-12) 이에대한자세한검사와감별진단도반드시염두에두어야한다. 동반된병변을놓치지않기위해세심한병력청취와적절한신체검사는매우중요하며이때다양한병인에의하여만성통증이발생할수있음을염두에두어야한다. 만성발목불안정증에대한현재까지의가장대표적인수술방법은발목외측인대의해부학적중첩봉합 (anatomical ligament repair) 을통해안정성을회복시키는변형 Broström 술식으로여러장점들과함께비교적합병증이적으며약 90% 95% 정도의만족스러운임상결과를보이는것으로알려져있다. 2,13) 그러나몇몇연구에따르면비교적높은빈도 (13% 35%) 의환자들이만성발목불안정증에대한수술후관절안정성의양호한회복에도불구하고지 Copyright c 2021 Korean Foot and Ankle Society. All rights reserved. CC 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.
Byung-Ki Cho, et al. Residual Pain after Surgery for Ankle Instability 33 속적인통증을호소하는것으로보고되었다. 12,14-17) 발목관절의안정성회복뿐만아니라일상생활및스포츠활동에서의통증해소는수술적치료의성패에큰영향을미치는요소로인대수술과더불어적절한동반술식이필요한경우가많다. 본고에서는만성발목불안정증에대한수술적치료후통증이남게되는원인을술전의진단부족 (insufficient diagnosis), 비효과적인술식 (ineffective procedure), 수술과관련된합병증 (iatrogenic complication) 의크게 3 가지문제로구분하여기술해보고자한다. 본론 1. 술전의진단부족 (unrecognized pathologies at the time of surgery) 만성발목불안정증에대한수술적치료시발목관절의연골또는골연골손상, 활액막염, 유리체와같은관절내병변유무에대해정확한진단이필요하며환자가호소하는통증의양상과밀접하게연관되는병변인지를판별해야한다. 또한내측인대나경비인대결합손상에의한불안정성유무, 발목주위의신경이나건손상과연관된증상유무에대한세밀한검사와감별진단이필요하다. 대개수술전자기공명영상 (magnetic resonance imaging, MRI) 검사를통해발목관절외측인대의파열정도와잔존인대의상태를점검하며관절연골및주변연부조직의상태를관찰하여간과한부분에대한명확한확인이필요하다. 1) 관절내동반병변만성발목불안정증과동반된관절내병변 (intra-articular pathologies) (Table 1) 은저자들마다약간의차이가있으나관절경검사상약 63% 95% 정도의높은발생빈도를보고하고있으며 9,11,12,15,18-20) 정확한진단이이루어지지못하는경우발목관절의만성적인불편감과퇴행성변화를초래할수있다. 11,12,17,21-23) 그러므로관절내동반병변에대한술전의세심한검사와적절한치료는발목불안정증수술후의만족스러운임상결과를얻기위해매우중요한고려사항이다. Ferkel과 Chams 15) 의연구에따르면변형 Broström 수술중의관절막절개를통해관절내동반병변중약 20% 정도만접근이가능하다고하였다. Hinterman 등 9) 은만성발 목불안정증환자들에서관절경검사를시행한결과 50% 이상에서거골골연골병변이확인되었으나술전의신체검사와방사선영상에서는단지 4% 에서만진단이이루어졌음을보고하였다. 또한술전에발견되지않았던연골병변이경골관절면 (8%), 내과 (11%), 외과 (2.5%) 등에서적지않은빈도로관찰되었다. 만성발목불안정증과동반된관절내병변의높은발생빈도와술전에미리인지되지못한병변이치료되지못하고그대로방치될가능성을고려했을때인대수술과동반된관절경검사및술식은매우필수적인보완책이라고생각된다. 9,10,15,24) 만성발목불안정증과동반된관절내병변중골연골병변의정확한평가를위해 MRI 검사는매우유용하나충돌증후군이나활액막염등의연부조직병변에대한 MRI의진단적가치에대해서는여전히이견이있다. 25,26) Staats 등 27) 은술전의 MRI와수술소견을비교한연구에서 MRI가골연골병변을제외한다른동반병변의진단에있어전체적으로낮은민감도 (sensitivity) 와높은특이도 (specificity) 를보였다고하였으며, 따라서 MRI 검사결과만으로관절경검사를대체할수는없다고보고하였다. O Neill 등 24) 도유사한디자인의연구에서진단방사선과전문가의술전 MRI 판독상연골병변의 39%, 비골건병변의 56%, 관절내유리체의 57% 정도만진단되었으며전체적인민감도는 45% 에불과하였음을보고하였다. 동일한연구에서정형외과전문의의경우연골병변의 47%, 비골건병변의 71%, 관절내유리체의 89% 정도가술전 MRI에서진단되었으며전체적인민감도는 63% 정도로역시불충분한결과를보였다. 만성발목불안정증과동반된골연골병변의발생빈도는약 17% 85% 정도로다양하게보고되어있으며 9-11,17,28) 거골과경골천장부 (plafond) 의외측면보다는내측관절면에서호발하는것으로알려져있다. 단순방사선영상에서발견되지않는경우도많으며특히경골천장부의골연골병변은간과되기쉬운것으로보고되고있다. 29) Okuda 등 11) 은발목불안정성의정도, 나이, 성별등은동반된골연골병변의유무와별다른상관관계가없음을보고하였다. 반면 Wang 등 28) 은여성보다는남성에서, 이환기간 (postinjury duration) 이 5년이상으로오래된환자일수록, 그리고연령이보다높은환자군에서골연골병변이나골극 (osteophyte) 이발생할위험성이더높다고보고하였다. 만성발목불안정증환자에서관절경검사상활액막염및관련된섬유성반흔조직의발견빈도는약 Table 1. Associated Intra-Articular Lesions in Patients with Chronic Ankle Instability 1 Osteochondral lesions of the talus (OLT): cartilage fibrillation, cartilage or osteochondral defect 2 Osteochondral lesions of the tibial plafond 3 Loose bodies 4 Anterolateral soft tissue impingement: hypertrophic synovial tissue interposition with ankle motion 5 Anterior tibial plafond or talar osteophyte (anterior bony impingement) 6 Chronic synovitis 7 Bassett s lesion: distinct thickened fascicle of the anterior inferior tibiofibular ligament (AITFL) 8 Syndesmosis instability
34 Vol. 25 No. 1, March 2021 32% 100% 정도로흔하며 8,14,18,30) 주로관절전방부와전외측부에서발생하는것으로보고되어있다. 경골천장부전방부와거골경부의골극에의한골성충돌증후군 (bony impingement) 은만성발목불안정증환자들의약 11% 19% 정도에서발견되며 10,15,18,23,28,30) 외측인대의손상에의한거골전방전위 (anterior translation) 의증가에대해관절의안정성을회복하기위한적응반응 (adaptive response) 인것으로고려되고있다. Moon 등 31) 은골극의크기가골연골병변의중중도 (severity) 와밀접한연관성이있으며골극이있는환자들의약 81% 에서골연골병변이동반되어있었음을보고하였다. 원위경비골간인대결합의손상을놓치는경우도비교적흔하며외측발목염좌로내원하는환자의약 10% 정도가경비인대결합손상이고전문적인운동선수일수록그빈도가증가하는것으로보고되어있다. 2,14) 인대결합의불안정증 (syndesmosis instability) 은반복적인발목외측염좌를유발시킬수있는것으로보고되어있으며만성통증의원인이될수있으므로염두에두어야한다. 2) 비골건병변만성발목불안정증과동반된비골건병변 (peroneal tendon problems) 은비골건활액막염 (peroneal tenosynovitis), 비골건파열 (peroneal tendon split tear), 비골건지대의손상 (attenuated peroneal retinaculum) 등이있으며, DiGiovanni 등 8) 은만성발목불안정증환자들의약 77% 정도에서비골건활액막염이발견된다고보고하였다. Strauss 등 32) 도만성발목불안정증과동반된관절외병변중비골건병변의발생빈도가가장높다고 (28%) 보고하였으며술후잔존통증의가장흔한원인도치료받지못한비골건병변이라고하였다. 이와같은높은발생빈도에근거하여몇몇저자들은외측인대수술시모든환자에서비골건에대한육안적인확인이필요함을주장하기도하였다. 또한 Odak 등 18) 의술전 MRI 분석연구에따르면만성발목불안정증환자들의약 5% 정도에서후경골건활액막염 (tibialis posterior tenosynovitis) 이발견되므로발목내측부통증에대한신체검사시이를고려해야한다. 하여자각증상의소실이있는지를알아보는신경차단검사 (lidocaine block test) 등이있으며무엇보다도세심한병력청취와신경손상가능성에대한의심이필요하다. 4) 기타관절외동반병변 (other extra-articular pathologies) 하지의내반부정정렬 (varus malalignment), 후족부의요내반변형 (cavovarus), 전신성인대이완증 (generalized ligamentous laxity) 이나관절의과운동성 (hypermobility), 족배굴건 (dorsiflexor) 또는비골건 (evertor) 의약화나마비, 아킬레스건의경직 (tightness), 족근골간결합 (tarsal coalition) 등발목염좌가쉽게발생할수있는선행요인을가지고있는지에대해서도염두에두어야하며이를인지하지못하는경우술후불안정성의재발과잔존통증이발생할가능성이높아진다. 외상및선천적요인등에의한경골의내반부정정렬은결과적으로발목관절에비대칭적인하중으로작용함으로써장기적으로만성발목불안정증과관절염을일으키는위험요소가될수있으며이를간과하고외측인대복합체에대한해부학적봉합술또는재건술을시행하였을경우좋지못한임상결과를얻을수있다. 그러므로술전평가시환측에대한평가뿐만이아니라전체하지의정렬상태를건측과비교하여확인해야한다. Strauss 등 32) 은만성발목불안정증과동반된관절외병변중불안정성의재발과관련된가장중요한요인은술전에미처진단되지못한후족부내반부정렬 (hindfoot varus malalignment) 이라고하였으며약 8% 정도의환자들에서발견되었음을보고하였다. 족근골간결합이동반되어있는환자는반복되는염좌수상과함께편평족변형및중족부통증을호소하는경우가많다. 35) 삼각골부골 (os trigonum) 은만성발목불안정증환자들의약 1% 13% 정도에서발견된다고보고되어있으며 32) 종골의내반변형을초래하거나환자가통증을피하기위해내반자세를취하게되어외측불안정성을야기하는것으로알려져있다. 거골하관절불안정성 (subtalar instability) 은외측발목불안정증과유사한증상을보이며발목외측거골동 (sinus tarsi) 부위의통증이반복적인발목염좌이후발생할수있다. 36) 3) 신경병변 (neuropathy around the ankle joint) 발목염좌손상시의과도한내번및족저굴곡에의해천부비골신경 (superficial peroneal nerve) 의신연손상이드물지않게발생하는것으로알려져있다. 33) 급성발목염좌후발목관절주위말초신경의손상을근전도검사 (electromyography, EMG) 로확인한 Nitz 등 34) 의연구에의하면 3도이상의심한발목염좌가발생하였던환자들의약 86% 에서비골신경손상이그리고 83% 에서경골신경 (tibial nerve) 손상소견이확인되었다. 급성염좌에의한신경손상이만성화되어증상이지속되는경우이를진단하는방법은손상된신경을자극하여방사통을유발시키는 Tinel 검사, 신경근전도검사 (EMG & nerve conduction velocity), 국소마취제를이용 2. 비효과적인술식 (unresolved pathologies with the surgical treatments) 만성발목불안정증에대한수술적치료와더불어관절내동반병변에대한관절경적 (arthroscopic) 처치를같이시행한후의임상결과는여러저자들에의해비교적만족스러운것으로보고되고있다. 11,14,15,20,23,32) 그러나인대봉합술또는재건술후약 5% 10% 정도의빈도로불안정증의재발이발생하는것으로알려져있으며 2,13) 관절경적처치 ( 활액막절제술, 연골성형술, 미세골절술 [microfracture], 다발성천공술, 골극절제술, 유리체제거술등 ) 후의임상결과도술자의숙련도및병변의중등도에따라다양할수있다. Choi 등 14) 의연구에의하면동반병변중원위경비골간인대
Byung-Ki Cho, et al. Residual Pain after Surgery for Ankle Instability 35 결합의불안정증 (syndesmosis widening), 거골골연골병변, 비골하골편 (subfibular ossicle) 이술후의임상결과에영향을주는예후인자였으며특히인대결합의해부학적정복이중요하다고하였다. 반면, 동반병변중가장높은발생빈도 (81.5%) 를보인연부조직충돌 (soft tissue impingement) 이나골극에대한절제술유무는임상결과에별다른영향을주지않는것으로보고하였다. Ferkel 과 Chams 15) 는관절내동반병변의수가증가할수록예후에부정적인결과를초래한다고하였으며, 거골골연골병변에대한치료가가장중요한인자라고보고하였다. Hua 등 20) 도만성발목불안정증과더불어골연골병변이동반되어있는환자군이유의하게더낮은임상평가점수 (American Orthopaedic Foot and Ankle Society score, AOFAS score) 를보였으며골연골병변의동반유무가가장중요한임상적예후인자라고보고하였다. 반면 Okuda 등 11) 은국소적인골연골병변유무가만성발목불안정증에대한수술적치료 ( 인대재건술 ) 후의중기추시임상적, 방사선학적결과에별다른영향을주지않았음을보고하였다. 발목불안정증의유병기간과관절내병변, 특히거골골연골병변의중등도와의상관관계에대해서는아직뚜렷한결론이정해지지않은부분이나이환기간이오래될수록반복적인염좌손상을입을가능성이높아지고그와관련된관절내동반병변의수가증가한다는사실에는대부분의저자들이동의하고있다. 28) Lee 등 30) 은여성보다는남성에서, 체질량지수 (body mass index, BMI) 가 30 kg/m 2 이상인환자에서, 연령이높은환자군에서두개이상의관절내동반병변이발견될가능성이더높다고보고하였다. 원위경골전방부또는거골배측의골극 (anterior bony impingement) 에대해서 Scranton 등 37) 은제거술유무가임상결과에별다른영향을주지않았음을보고하였으나 Cannon과 Hackney 38) 는골극제거술후더나은임상결과를보고하였다. 오랜기간의발목불안정증병력을가지고있는중년의환자에서수술적치료가시행되는경우에는술후발목관절의안정성이잘회복되더라도이미진행되어있는퇴행성변화에의해보행및운동시의통증이지속될수있음을고려해야한다. 33,39,40) Takao 등 41) 은만성불안정증이동반된발목퇴행성관절염환자들에서해부학적인대재건술 (anatomic lateral ligament reconstruction with autologous gracilis tendon graft) 과관절경적다발성천공술 (drilling) 을시행한결과, Takakura 분류상 stage 2에서는우수한임상결과 (87.4 points in AOFAS scale) 를보였으나 stage 3에서는최종추시상평균 61.2점의불만족스러운결과를보여중등도이상의관절염에서는추천하기어렵다고하였다. Cho 등 39) 도 Takakura stage 2의환자군에서해부학적인대봉합술 (modified Broström procedure) 과관절경적변연절제술을시행한결과, 유의한임상결과의호전을보였으나평균 56.2개월의중기추시상약 27.3% 의환자들에서관절염등급의진행이발생하였고, 36.4% 의환자들에서보행시의잔존통증이남았음을보고하였다. 이연구에서술후발 목불안정증의재발률은 4.5% 로비교적낮게나타나관절염등급의악화는불안정증의재발보다는이미진행되어있는퇴행성변화가주된요인인것으로분석되었다. 그러므로만성발목불안정증에대한수술적치료시동반된골연골병변과퇴행성변화를명확히구분하여치료방법을선택하고, 중등도이상의퇴행성관절염이동반된환자들에서는보다현실적인접근이필요하다. 40) 또한연골하골이노출된골연골병변 (full thickness chondral defect), 연골하낭종 (subchondral cyst) 이동반된골연골병변, 크기가큰골연골병변등에서단순한연골성형술 (abrasion chondroplasty) 이나미세골절술만시행되는경우에는성공적인연골재생에실패하여퇴행성관절염으로진행할가능성이있다. 거골골연골병변에대한관절경적골수자극술 (bone marrow stimulation) 후의장기추시상약 33% 정도에서퇴행성관절염으로의진행이발견되는것으로보고되고있다. 42,43) 따라서골연골병변의중등도및환자의나이등을충분히고려하여자가골연골이식술 (osteochondral Autograft Transfer System [OATS] or mosaicplasty), 자가연골세포이식술 (autologous chondrocyte implantation, ACI), 연골재생술 (chondrogenesis) 등의적절한치료법을적용해야만술후의잔존통증을줄일수있다. 3. 수술과관련된합병증 (Iatrogenic pathologies by the surgical procedures) 만성발목불안정증에대한인대봉합술이나재건술, 관절경적처치등의수술적치료후술전에없던통증이새롭게발생할수있으며이는임상결과와환자의만족도에큰영향을미치게된다. 관절경술식과관련하여 Vega 등 44) 은수술중발생하는의인성 (iatrogenic) 연골손상의빈도가 31% 정도였으며이중연골두께의 50% 이상을침범하는심부손상도 6.7% 까지발생하였음을보고하였다. 이연구에서가장흔한손상부위는거골관절면의중앙과전외측면이었으며전체의인성연골손상의 65% 는관절내병변에대한치료과정에서, 나머지 35% 는관절경삽입과정 (portal creation) 에서발생하였다. 인대수술을위한피부절개나연부조직박리과정에서의손상, 관절경삽입구주변에서의손상, 수술중의견인등에의한발목주위말초신경의손상이비교적흔하게보고되고있으며발생빈도는 7% 19% 까지다양하다. 45) 가장흔한신경손상은천부비골신경의외측분지에서보고되고있으며비복신경 (sural nerve) 이나복재신경 (saphenous nerve) 의손상도보고되어있다. 33) 비교적드문빈도를보이나국소복합통증증후군 (complex regional pain syndrome, CRPS) 이발생한경우도보고되어있으므로비특이적인신경증상과심한통증이지속되는경우염두에두어야한다. 최근 Guelfi 등 13) 에의한체계적문헌고찰에따르면변형 Broström 수술과연관된합병증발생빈도는 7.9% 였으며주로국소적인창상문제, 발목외측부의감각이상, 지속적인통증등이보고되었다. 또한
36 Vol. 25 No. 1, March 2021 관절경적 Broström 수술과연관된합병증빈도는 15.3% 였으며천 부비골신경손상, 창상회복의지연, 불안정성의잔존, 비흡수성봉 합사 (non-absorbable suture material) 에의한피부자극등이주 로보고되고있다. 13) 결 만성발목불안정증에대한수술적치료후발목관절의안정성회 복뿐만아니라일상생활및스포츠활동에서의통증해소는임상결 과에큰영향을미치는요소로인대수술과더불어관절경같은적절 한동반술식의적용이필요하다. 만성발목불안정증과흔히동반되 는다양한관절내병변과주변건, 신경손상의유무에대해수술전 세심한병력청취와신체검사, MRI 검사등을통해확인하는것이 중요하다. 또한수술후잔존통증이지속되는경우다양한병변의 가능성에대한의심과감별진단이필요하며, 환자가호소하는통증 의양상과밀접하게연관되는병변인지명확하게판별해야한다. 론 ORCID Byung-Hyun Ahn, https://orcid.org/0000-0001-9906-022x REFERENCES.1 Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ Jr. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010;92:2279-84. doi: 10.2106/JBJS.I.01537..2 DiGiovanni CW, Brodsky A. Current concepts: lateral ankle instability. Foot Ankle Int. 2006;27:854-66. doi: 10.1177/107110070602701019..3 Hubbard TJ. Ligament laxity following inversion injury with and without chronic ankle instability. 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