대한정형외과학회지 : 제 43 권제 1 호 2008 J Korean Orthop Assoc 2008; 43: 17-23 외측폐쇄성쐐기절골술을이용한소아내반주변형의수술적치료 심종섭ㆍ설은진ㆍ하해찬ㆍ김창영 성균관대학교의과대학삼성서울병원정형외과학교실 Lateral Closing Wedge Supracondylar Osteotomy of the Humerus in Children with Cubitus Varus Deformity Jong Sup Shim, M.D., Eunjin Sul, M.D., Haechan Ha, M.D., and Chang Young Kim, M.D. Department of Orthopedic Surgery, SungKyunKwan University School of Medicine, Seoul, Korea Purpose: To evaluate the effectiveness, cosmetic and functional improvement of a supracondylar lateral closing wedge osteotomy of the humerus as a treatment for cubitus varus deformity in children. Materials and Methods: Forty-eight children with cubitus varus underwent a lateral closing wedge osteotomy, and were followed up for at least 1 year. Results: There were no complications such as a loss of correction, infection, or neurapraxia. The immediate postoperative lateral condylar prominence and secondary lazy S deformity was in proportion to the preoperative severity of the cubitus varus. However, it was lower at the last follow-up, and was related to the extent of preoperative cubitus varus, length of follow-up and age. Conclusion: A supracondylar lateral closing wedge osteotomy of humerus is an easy and effective surgical treatment for a posttraumatic cubitus varus of children. In addition, it shows good cosmetic results with good remodeling of the lateral condylar prominence of children. Key Words: Cubitus varus, Lateral condylar prominence, Osteotomy 서론과상부골절을위시하여원위상완골골절후장기합병증으로치료방법에상관없이내반주가가장흔한것으로알려져있다. 과상부골절에대한보존적치료이후내반주변형은 58% 까지보고된바있다 7). 변형은대부분부정유합의결과이며이변형은비록기능소실은크지않다고하더라도미용상교정하길원하는경우가많다 2,15). 상완골의길이성장은주로근위부에서발생하기때문에내반주변형이발생한경우재형성을통한원위골절부의교정은기대하기어렵다 4,22). 따라서내반주변형에대하여수술적가료를고려하는것이일반적이다. 원위상완골골절후내반주변형에대하여외측폐쇄성쐐기 절골술, 돔형교정절골술 12,17-19), 삼차원교정절골술 20), 외고정장치를이용한교정절골술 10,14) 등여러술식들이알려져있다. 이중외측폐쇄성쐐기절골술은술식이쉬운장점이있는반면에원위상완골외측에과돌출및이로인한이차적인느린 S 변형 (Lazy S deformity) 이발생할수있어서미용상으로바람직하지않을수있다고알려져있다 (Fig. 1) 6,12). 하지만소아는재형성능력이뛰어나기때문에외측폐쇄성쐐기절골술후외측과돌출및이로인한이차적인느린 S 변형이발생하더라도성장하면서변형이감소되며설사존재한다하더라도미용상으로도문제가없다는보고도있다 1,21). 통신저자 : 심종섭서울시강남구일원동 50 번지성균관대학교의과대학삼성서울병원정형외과 TEL: 02-3410-3509 ㆍ FAX:02-3410-0061 E-mail: jss3505@skku.edu * 본논문의요지는 2006 년도대한정형외과학회추계학술대회에서발표되었음. Address reprint requests to Jong Sup Shim, M.D. Department of Orthopedic Surgery, Samsung Medical Center, SungKyunKwan University School of Medicine, 50, Ilwon-dong, Gangnam-gu, Seoul 135-710, Korea Tel: +82.2-3410-3509, Fax: +82.2-3410-0061 E-mail: jss3505@skku.edu 17
18 심종섭ㆍ설은진ㆍ하해찬외 1 인 Fig. 1. (A) Lateral closing wedge osteotomy was performed. (B) Lazy 'S' deformity was observed on the radiograph of two months after the operation. Fig. 2. (A) Humero-ulnar angle was measured on the anteroposterior radiograph of the elbow. (B) Shaft-condylar angle was measured on the lateral radiograph of the elbow. 이연구에서외상후내반주변형에대해외측폐쇄성쐐기절골술을이용한수술적치료를하고, 절골부위의재형성정도를관찰하고이에미치는요인들을파악하고자하였다. 대상및방법 1995년부터 2003년까지본원에서외측폐쇄성쐐기절골술후최소 1년이상추시된성장기환아총 48명을대상으로하였다. 남아 36명, 여자 12명이었으며, 수술시의평균연령은 8세 9개월 (5-16 세 ) 이었다. 우측주관절이 21명좌측주관절은 27명이었다. 32명은상완골과상부골절, 8명은상완골원위성장판분리, 1명은외측과골절, 1명은과간골절후발생된내반주변형이었으며, 6명은원인을알수없었다. 술전운동범위는신전평균 -9.8 도 (-25-5 도 ), 굴곡평균 127.1도 (100-140 도 ) 로평균 136.9 도 (120-150 도 ) 이었으며, 술전내반주변형은주관절완전신장상태에서전완부를회외전시킨뒤전후방단순방사선촬영상상완-척골각 (humero-ulnar angle) 을측정하였으며 (Fig. 2A), 평균 -17.4도(-43.4-3.2도) 로정상측 8.7도 (3.0-21.7 도 ) 에비하여평균 26.1 도 (13.7-53.4 도 ) 감소되었다. 동반된상완골의신전변형유무는주관절을 90도굴곡한상태에서상완골간- 과각 (shaftcondylar angle) 을측정하였으며평균 25.8 도 (12.6-36.5 도 ) 로정상 37.6 도 (29.4-45.0 도 ) 에비하여평균 Table 1. Results of Supracondylar Lateral Closing Wedge Osteotomy Last Index Parameter Preoperative p value* follow-up side Range of motion ( o ) 136.9 139.2 0.050 140.0 Humero-ulnar angle ( o ) 17.4 9.8 0.000 8.7 Shaft-condylar angle ( o ) 25.8 36.0 0.000 37.6 Lateral prominence index 2.27 1.17 0.000 1.00 Lateral prominence amount (%) 34.2 8.7 0.000 ( ) *p<0.05 was regarded as significant by paired t-test. 12.1도 (-28.0-1.0도) 감소되어있었다 (Table 1, Fig. 2B). 수술은모든환자에서주관절외측절개를통하여접근하였다. 수술장에서방사선영상투시하에두개의 K- 강선을술전미리측정한상완-척골각의교정할각도차로삽입하였다. 외측골막이손상되지않도록호만견인기 (Homan retractor) 로보호하면서두개의 K-강선사이에외측쐐기모양의절골술을시행하면서내측피질골을남겨둠으로써불완전절골을하였다. 내측피질골을지렛대로두개의 K-강선이평행이되도록외반력을작용함으로써측정된만큼의각도가교정되는폐쇄성절골술이되도록하였다. 변형의모양에따라필요하면굴곡또는신전절골술이되도록조절하였다. 절골하부외측돌출감소를위한절골하부내측전위는시행하지않
외측폐쇄성쐐기절골술을이용한소아내반주변형의수술적치료 19 Fig. 3. (A) The angle of cubitus varus deformity was measured intraoperatively with C-arm fluoroscopy. (B) The operation was performed through a lateral approach. (C) We used two preset Kirschner's wires. (D) Osteotomized site was fixed with Steinmann pins. (E) Cubitus varus was corrected after surgery. 았으며생리적신경차단 (neurapraxia) 을방지하기위한척골신경의전위 (transposition) 도시행하지않았다. 절골부위의고정은교차 Steinmann핀을이용하였으며평균 3.2개 (2-6 개 ) 를이용하였다. 수술장에서교정된상완- 척골각을방사선투시기로확인하고골막을봉합한뒤수술을마쳤다. 평균 5.5주 (4-6 주 ) 의석고고정을하였고 Steinmann 핀은평균 6.2주 (5-10 주 ) 에외래에서제거하였다. 평균추시기간은 2년 5개월 (12-74개월) 이었다 (Fig. 3). 외측과돌출을표현하기위해외측돌출지표와외측돌출량을측정하였다. 외측돌출지표 (lateral prominence index) 는상완골중심을이은장축으로부터상완골외측과까지의거리와장축으로부터상완골내측과까지의거리의비로서측정하였다 (Fig. 4A) 23). 외측돌출량 (lateral prominence amount) 은외측상완골간부의 Fig. 4. (A) Lateral prominence index (LPI) is BC/AB. (B) Lateral prominence amount (LPA) is BC/AC X 100 (%).
20 심종섭ㆍ설은진ㆍ하해찬외 1 인 재형성된새로운피질골선을원위부까지연장한선이상완골외측과와내측과사이를연결한선을수직으로배분한비를백분율로표시하였다. 최종추시시새로운피질골선이관찰되지않는경우과상부상 (supracondylar ridge) 에서새로운피질골선과이전의피질골선사이의각형성되는부위에서원위부까지선을연장하였으며, 그또한관찰되지않을경우외측돌출량을 0으로계측하였다 (Fig. 4B). 최종추시시의운동범위, 방사선측정값 ( 전후상완- 척골각, 측면상완골간 -과각, 절골부위의외측돌출지표, 외측돌출량 ) 등을 SPSS 12.0.1 을이용한 Wilcoxon, Spearman, Pearson, Mann-Whitmey 및 Kruskal- Wallis 검사등을 95% 의신뢰구간을기준으로통계적방법에의하여분석하였다. 결과수술직후상완-척골각의변화, 감염등의합병증은없었다. 술전주관절운동범위는 136.9도 (120-150도) 에서최종추시시 139.2도 (130-150도 ) 로경미하게증가하였다 (p=0.050). 방사선소견상상완-척골각은술전 -17.4 도 (-43.4-3.2도) 에서술후최종추시시 9.8 도 (3.3-16.7) 로증가하였다 (p=0.000). 측면상완골간- 과각은술전 25.8 도 (12.6-36.5 도 ) 에서최종추시시 36.0 도 (30.5-41.8) 로증가하였다 (p= 0.000). 술전내반주변형이심할수록외측돌출지표는술후증가되는경향을보였다 (p=0.000). 외측돌출지표는술후 2.27 (1.65-3.87) 에서최종추시시 1.17 (0.89-1.83) 로호전되어절골부위의현저한재형성소견을보였다 (p=0.000). 또한술전내반주변형이심한 예에서술후외측돌출량이증가되는경향을보였다 (p= 0.000). 외측돌출량은술후 34.2% (20.4-50.7) 에서최종추시시 8.7% (0.4-24.1) 로호전되었다 (p=0.000). 그러나정상측과비교하여완전한재형성을보이지는않았다 (p=0.000). 하지만수술직후의상완- 척골각의교정이손실된예는관찰되지않았다 (Table 1). 외측돌출지표의재형성은술전상완-척골각, 술전상완골간-과각과추시기간이증가될수록많이발생하였고 ( 각각 p=0.000, 0.000, 0.008), 외측돌출량의재형성은술전상완- 척골각, 술전상완골간 -과각과추시기간이증가되거나연령이감소될수록많이발생하였다 ( 각각 p=0.000, 0.000, 0.000, 0.000)(Table 2, Fig. 5). 무작위로추출한 12명의환아의외측돌출량의추시기간에따른변화를분석한결과외측돌출량은초기에가장빠른속도로감소되는것으로관찰되었다 (Fig. 6). 술후 1년에추시한 20명의환아에대하여외측돌출량의 1년간의변화와연령을 Mann-Whitney test 로분석한결과 12세이상에서이전연령보다유의하게변화가적었다 (p=0.001)(fig. 7). 고찰내반주변형에대하여원위상완골의외측폐쇄성쐐기절골술은가장간단한술식중하나로가장널리이용되고있지만그효과에대하여부정적인의견들이있다. Table 2. Factors Associated with the Remodeling of the Lateral Prominence Factor ΔLPI (p-value)* ΔLPA (p-value)* Preoperative humero-ulnar angle ( o ) 0.000 0.000 Preoperative shaft-condylar angle ( o ) 0.000 0.000 Age 0.678 0.000 Length of follow-up (months) 0.008 0.000 ΔLPI, change of lateral prominence index; ΔLPA, change of lateral prominence amount. *p<0.05 indicates that the factor contributed to remodeling of the lateral prominence according to univariate analysis. Fig. 5. (A) A six-year-old boy had the varus humeroulnar angle of 33 o on the preoperative radiograph. (B) On the immediate postoperative radiograph, LPI was 3.23 and LPA was 45.3 percent. (C) On the radiograph after a 4-year-follow-up, the LPI was 1.01, and the LPA was zero percent.
외측폐쇄성쐐기절골술을이용한소아내반주변형의수술적치료 21 Fig. 6. Lateral prominence amount decreased with the increasing follow-up duration. Fig. 7. The change in the amount of lateral prominence diminished with increasing age when the operation had been performed. Oppenheim 등은외측폐쇄성쐐기절골술을시행받은환자의 24% 에서생리적신경차단, 패혈증, 미용상용납될수없는흉터등을관찰하였다고하였다 16). Griffin은외측폐쇄성쐐기절골술은우선절골부위가변형부위인골간단부보다상부이기때문에견고한고정이힘들고, 교정후내측연부조직의긴장으로인하여교정소실의가능성이증가한다고하였다 6). Ippolito 등은외상후내반주변형에대하여과상부절골술을시행한 19명의환자를평균 23년간추시하였더니 2명을제외하고는술후획득한상완-척골각의교정을손실하였다고보고하였다 9). 이러한금속핀을이용한외측폐쇄성쐐기절골술은교정을견고하게유지할수없다는지적에대하여 2,5,9,16), 절골후금속판 4), ㄷ자금속핀 3), 외고정장치 10,14) 등을이용하여고정함으로써이를보완하려고시도하기도한다. 본연구에서외측폐쇄성쐐기절골술시행받은 48 명의환자중생리적신경차단, 패혈증의합병증을가진환자는없었으며, 평균 3.2개의교차 Steinmann 핀을이용하여고정하였으나유합시기까지교정된상완-척골각이소실된예는일례도없어서, 충분히견고한고정력을가진것으로판단하였다. 내반주변형의교정절골술시행의주목적이미용에있다면외측폐쇄성쐐기절골술후발생하는외측과돌출변형은수술목적에적합하지않는합병증이다. Griffin 은외측폐쇄성쐐기절골술이후외측과돌출및이로인한느린 S 변형으로인하여미용상문제가남을수 있다는점을지적하였다 6). 또한외측절개를통하여수술하기때문에후방절개나내측절개에비하여미용상문제가되며 8,11,19), LaBelle 등은외측절개를통한절골술후 60% 의환자에서흉터에대하여불만을가졌다고주장하였다 13). 상기단점을보완하기위하여돔형절골술을시행한그룹이있으며이들에의하면후방절개를통하여접근하여원위상완골의돔형절골을시행하고상완골의중심선을중심으로원위절골편을회전시켜서외측전이를방지함으로써내측연부조직긴장을줄여서교정성공률을증가시키고원위상완골의외측과돌출및이로인한이차적느린 S 변형을줄일수있다고보고하였다 12,17-19). 하지만 Wong 등은외측폐쇄성쐐기절골술을시행받은 22명의환자중 14명에서유의한외측과돌출변형을관찰하였으며이는내측피질골을유지한채절골술로인해넓이가달라진두외측피질골을유합시키는절골술의성격에서반영되는것이라고하였다. 그리고연령이낮을수록재형성에의해외측과돌출변형이감소되어보인다고하였다 23). Barrett 등은외측폐쇄성쐐기절골술이후 17명의환자중 1명만이외측과돌출변형및외측절개부위의흉터로불만을표했다고보고하였다 1). Voss 등은 36명의환자에서외측과돌출변형이존재하더라도미용상문제가되었던환자는없었다고주장하였다 21). 이와같이또다른여러저자들은성장기어린이들에서수술직후발생될수있는외측과돌출및이로인한느린 S 변형이성장과더불어재형성을통하여교정되기때문에, 간단한외측도달법에의한쐐기절골술및평활
22 심종섭ㆍ설은진ㆍ하해찬외 1 인 강선을이용한고정술의장점을부각하였다. 본연구에서외측폐쇄성쐐기절골술이후외측과돌출및이로인한느린 S자변형이추시시재형성에의해감소되는것을알수있으며, 그정도는나이가어릴수록, 수술직후의외측과돌출이심할수록재형성이크다는것을알수있다. 추시기간과외측과돌출의재형성이통계적으로유의하게연관이있다는점에서재형성이성장과더불어풍부하게일어남을간접적으로증명할수있으며, 내반주변형이관찰되어외측폐쇄성쐐기절골술을시행할경우, 가능한성장이많이남은 11세이하에서시행할수록그미용적인효과가클것으로판단되었다. 또한외측과돌출및이로인한이차느린 S 변형이크게생길것이라고술전에판단되더라도, 교정수술연령이낮으면변형에비례하여재형성이많이일어남을알수있었다. 한편, 본증례중에서는추시기간중에내반주변형이재발된예또한관찰할수없었으며외측절개에의한흉터로불만을표하는환자역시없었다. 본연구에서만족스러운결과에도불구하고몇가지의제한점을가지고있다. 첫째, 외측폐쇄성쐐기절골술의미용적인효과에대하여환자의주관적인만족도를계량적으로측정하지못한것이다. 둘째, 외측과돌출의재형성과나이와의관계에서 12세이상에서재형성이감소된다는통계적인결과를얻었으나골연령을고려하지못하였고 13세이상의수술환자군이적어서유의성이떨어진다는점이다. 이제한점은환자군이더크거나추시기간이길어지면향후그유의성이높아질것으로사료된다. 결론소아내반주변형에대한다양한수술방법중, 외측폐쇄성쐐기절골술은쉽고효과적인방법이다. 또한, 장기추시시절골외측원위부의돌출감소가현저히발생되어미용적으로도매우우수한결과를보이는수술이다. 따라서, 환아의나이가어린경우이러한변형을예방하기위한광범위한수술적방법은필요하지않을것으로사료된다. 참고문헌 1. Barrett IR, Bellemore MC, Kwon YM: Cosmetic results of supracondylar osteotomy for correction of cubitus varus. J Pediatr Orthop, 18: 445-447, 1998. 2. Bellemore MC, Barrett IR, Middleton RW, Scougall JS, Whiteway DW: Supracondylar osteotomy of the humerus for correction of cubitus varus. J Bone Joint Surg Br, 66: 566-572, 1984. 3. Danielsson LG, Hussein S, el-haddad I, Gupta RP: Staple fixation of osteotomy for cubitus varus. A simple technique used in II children. Acta Orthop Scand, 62: 55-57, 1991. 4. Devnani AS: Lateral closing wedge supracondylar osteotomy of humerus for post-traumatic cubitus varus in children. Injury, 28: 643-647, 1997. 5. Graham B, Tredwell SJ, Beauchamp RD, Bell HM: Supracondylar osteotomy of the humerus for correction of cubitus varus. J Pediatr Orthop, 10: 228-231, 1990. 6. Griffin PP: Supracondylar fractures of the humerus. Pediatr Clin North Am 22: 477-486, 1975. 7. Høyer A: Treatment of supracondylar fracture of the humerus by skeletal traction in an abduction splint. J Bone Joint Surg Am, 24: 623-637, 1952. 8. Hui JP, Torode IP, Chatterjee A: Medial approach for corrective osteotomy of cubitus varus: a cosmetic incision. J Pediatr Orthop, 24: 477-481, 2004. 9. Ippolito E, Moneta MR, D'Arrigo C: Post-traumatic cubitus varus. Long-term follow-up of corrective supracondylar humeral osteotomy in children. J Bone Joint Surg Am, 72: 757-765, 1990. 10. Karatosun V, Alekberov C, Alici E, Ardic CO, Aksu G: Treatment of cubitus varus using the Ilizarov technique of distraction osteogenesis. J Bone Joint Surg Br, 82: 1030-1033, 2000. 11. King D, Secor C: Bow elbow(cubitus varus). J Bone Joint Surg Am, 33: 572-576, 1951. 12. Kumar K, Sharma VK, Sharma R, Maffulli N: Correction of cubitus varus by French or dome osteotomy: A comparative study. J Trauma, 49: 717-721, 2000. 13. LaBelle H, Bunnell WP, Duhaime M, Poitras B: Cubitus varus deformity following supracondylar osteotomy of the humerus in children. J Pediatr Orthop, 2: 539-540, 1982. 14. Levin MJ, Horn BD, Pizzultillo PD: Treatment of posttraumatic cubitus varus in the pediatric population with
외측폐쇄성쐐기절골술을이용한소아내반주변형의수술적치료 23 humeral osteotomy and external fixation. J Pediatr Orthop, 16: 597-601, 1996. 15. McCoy GF, Piggot J: Supracondylar osteotomy for cubitus varus. J Bone Joint Surg Br, 70-B: 283-286, 1988. 16. Oppenheim WL, Clader TJ, Smith C, Bayer M: Supracondylar humeral osteotomy for traumatic childhood cubitus varus deformity. Clin Orthop Relat Res, 188: 34-39, 1984. 17. Pankaj A, Dua A, Malhotra R, Bhan S: Dome osteotomy for posttraumatic cubitus varus: A surgical technique to avoid lateral condylar prominence. J Pediatr Orthop, 26: 61-66, 2006. 18. Tachdjian MR: Osteotomy for distal humerus for correction of cubitus varus. In: Smith AB ed. Pediatric orthopedics. Philadelphia, Saunders WB: 1588-1591, 1972. 19. Tien YC, Chih HW, Lin GT, Lin SY: Dome corrective osteotomy for cubitus varus deformity. Clin Orthop Relat Res, 380: 158-166, 2000. 20. Usui M, Ishii S, Miyano S, Narita H, Kura H: Threedimensional corrective osteotomy for treatment of cubitus varus after supracondylar fracture of the humerus in children. J Shoulder Elbow Surg, 4: 17-22, 1995. 21. Voss FR, Kasser JR, Trepman E, Simmons E, Hall JE: Uniplanar supracondylar humeral osteotomy with preset Kirschner wires for posttraumatic cubitus varus. J Pediatr Orthop, 14: 471-478, 1994. 22. Williams PL, Warwick R: Gray's anatomy. 36th ed. Philadelphia, WB Saunders Co: 365, 1980. 23. Wong HK, Lee EH, Balasubramaniam P: The lateral condylar prominence: a complication of supracondylar osteotomy for cubitus varus. J Bone Joint Surg Br, 72: 859-861, 1990. = 국문초록 = 목적 : 소아외상후내반주변형에대해외측폐쇄성쐐기절골술을이용한수술적치료를하고, 이에대한결과를평가하고자하였다. 대상및방법 : 외측폐쇄성쐐기절골술을시행한후최소 1 년이상추시된성장기환아총 48 명을대상으로하였다. 결과 : 술후교정의소실, 감염등의합병증은없었고, 술전내반주변형이심할수록외측과돌출 (lateral condylar prominence) 및이차적인느린 S 변형 (lazy S deformity) 은심하게나타났지만, 최종추시시유의하게감소되어절골부위의현저한재형성소견을보였으며이는술전내반주변형정도, 추시기간및연령과통계적으로유의한관계를보였다. 결론 : 소아내반주변형에대한외측폐쇄성쐐기절골술은쉽고빠르게할수있는방법으로, 장기추시시절골외측원위부의돌출감소가현저히발생되어미용적으로도매우우수한결과를보이는수술로사료된다. 색인단어 : 내반주변형, 외측과돌출, 절골술