대한족부족관절학회지 : 제 14 권제 1 호 2010 J Korean Foot Ankle Soc. Vol. 14. No. 1. pp.25-30, 2010 S.E.R.I. 수술법을이용한소건막류의치료 연세대학교의과대학정형외과학교실 김선용 박광환 이진우 Treatment of Bunionette Deformity with S.E.R.I. (simple, effective, rapid, inexpensive) Operation Sun-Yong Kim, M.D., Kwang-Hwan Park, M.D., Jin Woo Lee, M.D. Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea =Abstract= Purpose: The purpose of this study was to evaluate the clinical and radiological outcomes of the S.E.R.I. (simple, effective, rapid, inexpensive) operation for the bunionette deformity. Materials and Methods: Between March 2005 and February 2009, 22 patients (26 feet) who had been treated for the bunionette deformity with minimally invasive osteotomy were reviewed retrospectively. Clinically, Visual Analogue Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, shoes selectivity, disappearance of callus and patient s satisfaction level by Coughlin scoring system were evaluated. Radiologically, the bunionette was classified as four types according to the Fallat classification. The 4-5 th intermetatarsal angle (4-5 th IMA), the 5 th metatarsophalangeal angle (5 th MPA) and the length of 5th metatarsal bone (5 th MTL) were analyzed at preoperatively and at final follow up visit. Results: VAS improved from 6.8±1.8 points to 2.2±1.8 points (p). AOFAS score improved from 54.0±14.2 points to 90.0±4.8 points (p). There was no change in shoes selectivity. 9 feet (34.6%) were satisfied with excellent results, 16 feet (61.5%) with good results and 1 foot (3.9%) with fair results. The average 4-5 th IMA was corrected from 10.1±2.3 to 4.4±1.7 (p). The average 5 th MPA was corrected from 11.5±8.6 to -0.1±4.1 (p). The average 5 th MTL was changed from 66.1±4.3 millimeters to 64.1±4.4 millimeters (p=0.069). There was no malunion, nonunion or delayed union and other perioperative complications. Conclusion: S.E.R.I. operation is less invasive and easy technique. This procedure is recommendable for the treatment of the bunionette deformity. Key Words: Bunionette deformity, Minimally invasive osteotomy, S.E.R.I. operation 서 론 Received April 19, 2010 Accepted May 13, 2010 Jin Woo Lee, M.D. Department of Orthopaedic Surgery, Yonsei University College of Medicine, #134 Shinchon-dong, Seodaemun-gu, Seoul 120-752, Korea Tel: +82-2-2228-2190 Fax: +82-2-363-1139 E-mail: ljwos@yuhs.ac 소건막류는제5 중족족지관절부위의돌출로인해보행시통증을유발하는질환이다. 제5 중족골두부위의골성혹은연부조직성돌출은신발과의사이에만성적인압력의증가를유발하여연부조직의비대, 점액낭의비후, 각질비후증등이나타나게되며심한경우피부및연부조직감염이나궤양등을유발하기도한다 1,2). Coughlin 3) 은소건 - 25 -
김선용 박광환 이진우 막류를방사선학적소견에따라 3가지로분류하여제5 중족골두의외측부비대가있는경우를 Type I, 제5 중족골두의외측부비대가없이원위간부의외측곡선변형이있는경우를 Type II, 제4-5 중족골간각이증가해있는경우를 Type III로정의하였고, Fallat 1) 은제5 중족골두의외측부비대, 원위간부의외측곡선변형, 제4-5 중족골간각의증가중두가지이상의변형이있는경우를 Type IV로정의하였다 (Fig. 1). 현재소건막류의수술적치료방법에있어서는원위갈매기형절골술 4), 원위수평중족절골술 5), 사면간부절골술 6), 근위반구형절골술 7) 등변형의종류와정도에따라다양한술기들이사용되고있으며, 내고정방법에있어서도금속나사와핀에서흡수성핀 8) 과단순내측밀착 9) 에이르기까지다양한방법들이이용되고있다. 이러한다양한수술적술기들은증상을호전시키고미용적목적을달성하면서소건막류의재발을방지할뿐아니라, 수술후제5 중족족지관절의기능을보존하는것에초점을두고발전되어왔다. 이러한다양한수술적술기들중 Giannini 등 10) 은최소침습형절골술인 S.E.R.I. (simple, effective, rapid, inexpensive) 수술법을이용하여우수한임상적결과를보고하였다. S.E.R.I. 수술법은피부및연부조직의절개가작 아회복이빠르면서원위간부사면절골술후근위중족골해면골내에 Kirschner's wire를단순삽입하는방법으로서수술술기가간단하고효율적인장점이있지만, 아직까지그치료효과및임상결과에대한보고는많지않다 10-12). 본연구는 S.E.R.I. 수술법을이용한소건막류치료의임상적, 방사선학적결과를알아보고자하였다. 대상및방법 1. 대상 2005년 3월부터 2009년 2월까지소건막류로최소침습형절골술을시행받은환자중 1년이상추시가가능하였던 22명의환자, 총 26예 ( 우족부 17예, 좌족부 9예 ) 를대상으로하였다. 연령은 49.0±11.8세 ( 범위, 22~67세 ) 였고, 모두여성이었으며, 추시기간은 33.5±14.0개월 ( 범위, 12.0 ~58.0개월 ) 이었다. 6개월이상의비스테로이드성소염제복용과신발교정등의보존적치료에반응하지않는통증을동반한소건막류에대해서수술적치료를시행하였다 (Table 1). 2. 수술방법및수술후관리 Figure 1. Classification of Bunionette Deformity. 환자를척수마취후수술대위에앙와위자세로눕힌상태에서대퇴부에지혈대를적용하고제5 중족골원위부의전외측에약 1.5 cm 크기의피부절개를가한후연부조직을박리하여중족골원위간부를노출시켰다. 족저근위부에서족배원위부방향으로절골술을시행하였고, 원위부를충분히내측으로전이시켰다. Kirschner s wire를절골부의원위연부조직에제5 족지의말단방향으로장축에평행하게삽입한후, 근위부방향으로삽입하여절골부의근위부해면골내로고정하고피부를봉합하였다 (Fig. 2). 수술후 3주동안단하지석고부목으로고정하고후족부를이용한체 Table 1. Patient Demographics and Preoperative Factors Characteristics n=26 Gender (female) 26 Age (years)* 49.0±11.8 (22.0-67.0) Follow up (months)* 35.5±14.0 (12.0-58.0) Site (right: left) 17:09 Simultaneous procedure (for hallux valgus) 19 Ludloff osteotomy 14 Distal chevron osteotomy 4 Distal closed wedge osteotomy 1 *Mean±Standard Deviation (range) - 26 -
S.E.R.I. 수술법을이용한소건막류의치료 중부하를허용하였다. 3주째에외래에서석고부목및 Kirschner s wire를제거하고수술후신발 (postoperative shoe) 을착용한채로체중부하를점진적으로허용하였으며, 수술후 6주에일반신발을신도록하였다. 3. 평가방법수술전, 후및최종추시시 Visual Analogue Scale (VAS) 와 American Orthopaedic Foot and Ankle Society (AOFAS) score를평가하였다. Lee 등 13) 의방법에따라신발의선택도를 신발을가리지않는다, 운동화류의볼이큰신발만을신는다, 특수깔창이나특수신발이필요하다 로분류하여평가하였다. 굳은살의위치는제5 중족골두의족배부, 족저부, 외측부로나누어각각의소실여부를관찰하였으며, Coughlin이제시한 scoring system 14) 을이용한환자만족도를우수, 양호, 보통, 불량의네단계로나누어서평가하였다 (Table 2). 방사선학적으로술전및술후, 최종추시시에족부기립전후면사진과측면사진을촬영하고 Fallat 1) 의분류에따라소건막류의형태를네가지로구분하여그발생빈도와수술후결과를분석하였다. 제 4-5 중족골간각 (4-5 th Intermetatarsal Angle) 은제4 중족골의간부를이등분하는선과제5중족골간부의근위내측부에평행한선이이루는각도, 제5 중족-족지간각 (5 th Metatarsophalangeal Angle) 은제5 중족골간부를이등분하는선과제5 근위족지골간부를이등분하는선이이루는각도로정의한후 13,15), 수술전후의변화를측정하였다. 그리고제5 중족골장축길이 (length of 5 th metatarsal bone) 의변화를측정하여수술전후단축의정도를평가하였다. 또한발생가능한실험자간오차 (interobserver bias) 를줄이기위하여 2명의실험자가독립적으로측정 (p) 하여그평균값을결과분석에이용하였다. 통계분석은 SPSS (version 12.0; SPSS, Chicago, IL) 를이용하였으며, Mann- Whitney 검정을적용하여수술전후의값을비교하였다. 통계학적유의수준은 p값이 0.05 미만인경우로하였다. 결 과 단순방사선사진에서 Fallat에의한분류는제2형이 2예 (7.7%), 제3형이 19예 (73.1%), 제4형이 5예 (19.2%) 였다. 양측족부에증상을동반한소건막류가있는환자는총 4명이 A B C D Figure 2. The right foot of a 43-year-old woman with a bunionette. (A) Preoperative standing anteroposterior radiograph shows a type III bunionette deformity. (B) In the postoperative radiograph, the bunionette deformity was corrected by S.E.R.I. operation. (C) At the postoperative 3 months, standing anteroposterior radiograph shows a bony union of the osteotomy site. (D) She had a minimal sized scar (about 1.5 cm) at the dorsolateral surface of the foot. Table 2. Scoring System by Coughlin Rating Excellent Good Fair Poor Specification Without problems, very satisfied, mild or no pain, walks without difficulty A few problems, satisfied, mild pain, walks without difficulty or with mild difficulty, would still have had surgery Moderate pain, limited walking, reservation about success of surgery Continued pain, little improvement in walking ability, regrets surgery - 27 -
김선용 박광환 이진우 었으며이들은모두양측무지외반증이있었다. 전체 26예중 19예에서무지외반증이동반되어교정술을동시에시행하였다 (Table 1). VAS는수술전 6.8±1.8점 ( 범위, 4~10점 ) 에서수술후최종추시시 2.2±1.8점 ( 범위, 0~5점 ) 으로감소하였으며, AOFAS score는수술전 54.0±14.2점 ( 범위, 23~69점 ) 에서수술후 90.0±4.8점 ( 범위, 84~100 점 ) 으로호전되었다 (p, Table 3). 무지외반증과소건막류교정술을동시에시행한 19예의경우에 VAS는수술전 6.6±1.9 점 ( 범위, 4~10점 ) 에서수술후최종추시시 2.2±1.8점 ( 범위, 0~5점 ) 으로감소하였으며, AOFAS score 는수술전 54.8±15.1점 ( 범위, 23~69점 ) 에서수술후최종추시시 90.2±4.6점 ( 범위, 84~100 점 ) 으로호전되었다 (p). 또한, 소건막류교정술만을시행한 7예의경우에 VAS는수술전 7.3±1.6점 ( 범위, 5~10점 ) 에서수술후최종추시시 2.1±1.9점 ( 범위, 0~5점 ) 으로평가되었으며, AOFAS score 는수술전 51.7±11.9점 ( 범위, 34~64점 ) 에서수술후최종추시시 89.4±5.4점 ( 범위, 85~100 점 ) 으로평가되었다 (p< 0.05). 신발의선택도는수술전과수술후큰차이를보이지않았지만, 대부분의환자에서수술전과같은신발착용시통증의감소를경험하였다. 굳은살은수술전제5 중족골두배부 1예, 저부 2예, 외측부 9예로총 12예관찰되었으며, 수술후최종추시시제5 중족골두저부 3예, 외측부 1예로총 4예관찰되었다. Coughlin이제시한 scoring system 14) 에따른수술후만족도는 9예 (34.6%) 에서우수, 16예 (61.5%) 에서양호, 1예 (3.9%) 에서보통으로평가되었다 (Table 4). 유형별로는제2형은전예에서우수, 제3형은우수 5예, 양호 13예, 보통 1예였으며, 제4형은우수 2예, 양호 3예로평가되었다. Table 3. Clinical Outcomes VAS score AOFAS score Pre-operative Post-operative p-value 6.8±1.8 54.0±14.2 2.2±1.8 90.0±4.8 VAS, Visual Analogue Scale; AOFAS, American Orthopaedic Foot and Ankle Society. The value are given as the mean± standard deviation. Table 4. Subjective Satisfaction (by Coughlin scoring system) Rating Excellent Good Fair Poor Total (n=26) 9 (34.6%) 16 (61.5%) 1 (3.9%) 0 (0%) 방사선학적으로제4-5 중족골간각은수술전 10.1±2.3 도 ( 범위, 5.3~14.3도 ) 에서수술후최종추시시에 4.4± 1.7 도 ( 범위, 1.8-6.9도 ) 로감소하였고 (p), 제5 중족-족지간각은수술전 11.5±8.6도 ( 범위, -11.9~19.8도) 에서수술후 -0.1±4.1도( 범위, -11.5~4.5도) 로감소하였다 (p). 제5 중족골길이는수술전 66.1±4.3 mm( 범위, 55.0~72.0 mm) 에서수술후 64.1±4.4 mm( 범위, 53.0 ~69.0 mm) 로평균 2.0 mm정도감소하였으나 (Table 5) 통계학적으로유의하지는않았다 (p=0.069). 수술후절골부위의불유합, 감염및전이성중족골통등의합병증은관찰되지않았다. Table 5. Radiological Outcomes 4-5 th IMA 5 th MPA 5 th MTL Pre-operative ( ) Post-operative ( ) p-value 10.1±2.3 11.5±8.6 66.1±4.3 고 찰 소건막류의원인은꽉끼는신발, 제5 중족골두의외측골성돌출, 제5 중족골간부의외측만곡등이고, 증상은보행시통증, 압통, 부종, 홍반, 굳은살, 궤양등이있다. 증상이있는소건막류는치료의대상이되는데, 보존적치료로는볼이넓은신발, 교정용깔창등을이용하여제5 중족골두와신발과의마찰과압력을낮추는방법이주로사용된다. 보존적치료에실패한경우, 수술적치료를시도할수있으며 3,16), 변형의형태와정도에따라다양한수술방법이소개되고있다. Fallat 1) 은방사선학적분류에따라제1형은단순골절제술, 제2형, 제3형은원위부절골술, 제4형은근위부절골술을시행할것을제안하였다. Mann과 Mann 17) 은제1형소건막류환자에원위갈매기형절골술을시행하여만족할만한결과를얻었다고하였고 Ajis 등 18) 은제2형소건막류환자에게원위부또는간부절골술을, 제3형은간부또는근위부절골술을, 제4형은근위부절골술을시행하여만족할만한결과를얻었다고하였다. 일반적으로원위부절골술은간부또는근위부절골술에비해교정력이떨어지는것으로알려져있으며 16), Okuda 등 7) 은총 10예의근위부절골술후제4-5 중족골간각이평균 7.4도교정되고제5 중족- 족지각이평균 16.3도교정되었으며모두우수한임상적결과를보였다고하였다. 본연구에서는제4-5 중족 4.4±1.7-0.1±4.1 64.1±14.4 0.069 IMA, intermetatarsal angle; MPA, metatarsophalangeal angle; MTL, length of metatarsal bone. The value are given as the mean± standard deviation. - 28 -
S.E.R.I. 수술법을이용한소건막류의치료 골간각이평균 5.7도교정되고제5 중족- 족지간각이평균 11.4도교정되어근위부절골술에비해교정각의크기가작았다. 그러나수술후최종추시시제4-5 중족골간각은 4.4도 ( 범위, 1.8~6.9도 ) 로 Fallat과 Buckholz 19) 가제시한평균인 6.47도이내였고전예에서 Schoenhaus 등 20) 이제시한정상범위인 8도이하에속하였다. 임상적으로는총 26예중 25예 (96.1%) 에서양호이상의결과를얻을수있었다. 최근내고정에따른합병증을방지하고수술적술기를간단하게하기위해흡수성나사사용 8) 또는단순밀착 9) 만을시행하는방법등이이용되고있고, 최소침습적고정으로좋은결과를얻는다는보고가있다 8-10). 최소침습적고정을이용하는 S.E.R.I. 수술법은원위간부사면절골술로서간부절골술, 근위부절골술, 다른원위부절골술보다수술적술기가간단할뿐아니라회복기간이빠르며수술합병증도적다는장점이있다 16,17,21,22). 그리고고정방법이 Kirschner s wire의단순삽입이므로수술상처도작다. 본연구에서의사면절골술은 Coughlin 14) 의방법과반대로족저근위부에서족배원위부방향으로시행하였는데 Lint와 Wijffels 6) 은골막과근막이중족골간부에서근위부로갈수록강하기때문에수술후체중부하를하게되면절골부위에압박력을주어골유합에도움을준다고하였다. 이는본연구에서견고한내고정없이도전예에서골유합을얻을수있었던이유라고사료된다. Mann과 Mann 17) 은제4,5 중족골이다른중족골에비해유연하고제5 중족골은특히유연하여, 단축이발생할경우제4 중족골로전이성중족골통이나타날수있어단축을최소화하는것이좋다고하였다. 수술전과수술후평균 2.0 mm의제5 중족골단축을보였으나통계학적인의미는없었으며 (p=0.069) 전이성중족골통이나타난예도없었다. 그외에굴곡구축, 피부및연부조직감염등의합병증이보고되고있지만 8,21,22) 본연구에서는발생하지않았다. S.E.R.I. 수술법은술기가간단하고 Kirschner s wire를외래에서쉽게제거할수있어간편하고경제적이며, 내고정물에인한합병증이적고근위절골편에고정된 Kirschner s wire가절골편의외측전위에대한안정성을부여해줄수있는수술법이라고생각된다. 결론 S.E.R.I 수술법은덜침습적이고술기가간단하며임상적, 방사선학적결과가우수하여증상이있는소건막류의치료에있어추천할만한술식으로사료된다. REFERENCES 1. Fallat LM. Pathology of the fifth ray, including the tailor s bunion deformity. Clin Podiatr Med Surg. 1990;7:689-715. 2. Vienne P, Oesselmann M, Espinosa N, Aschwanden R, Zingg P. Modified Coughlin procedure for surgical treatment of symptomatic tailor's bunion: a prospective followup study of 33 consecutive operations. Foot Ankle Int. 2006;27:573-80. 3. Coughlin MJ. Etiology and treatment of the bunionette deformity. Instr Course Lect. 1990;39:37-48. 4. Diebold PF. Basal osteotomy of the fifth metatarsal for the bunionette. Foot Ankle. 1991;12:74-9. 5. Radl R, Leithner A, Koehler W, Scheipl S, Windhager R. The modified distal horizontal metatarsal osteotomy for correction of bunionette deformity. Foot Ankle Int. 2005;26:454-7. 6. De Lint JA, Wijffels NAT. The oblique diaphyseal osteotomy for bunionette. Foot and Ankle Surgery. 1998;4:99-104. 7. Okuda R, Kinoshita M, Morikawa J, Jotoku T, Abe M. Proximal dome-shaped osteotomy for symptomatic bunionette. Clin Orthop Relat Res. 2002;396:173-8. 8. Boyer ML, Deorio JK. Bunionette deformity correction with distal chevron osteotomy and single absorbable pin fixation. Foot Ankle Int. 2003;24:834-7. 9. Kitaoka HB, Leventen EO. Medial displacement metatarsal osteotomy for treatment of painful bunionette. Clin Orthop Relat Res. 1989;243:172-9. 10. Giannini S, Faldini C, Vannini F, Digennaro V, Bevoni R, Luciani D. The minimally invasive osteotomy S.E.R.I. (simple, effective, rapid, inexpensive) for correction of bunionette deformity. Foot Ankle Int. 2008;29:282-6. 11. Legenstein R, Bonomo J, Huber W, Boesch P. Correction of tailor s bunion with the Boesch technique: a retrospective study. Foot Ankle Int. 2007;28:799-803. 12. Roukis TS. The tailor s bunionette deformity: a field guide to surgical correction. Clin Podiatr Med Surg. 2005; 22:223-45, vi. 13. Lee KT, Young KW, Kim JY, Cha SD, Kim ES, Ahn YJ. Treatment of Bunionette Deformity with Distal Chevron Osteotomy. J Korean Orthop Assoc. 2006;41:14-8. 14. Coughlin MJ. Treatment of bunionette deformity with longitudinal diaphyseal osteotomy with distal soft tissue repair. Foot Ankle. 1991;11:195-203. 15. Kitaoka HB, Holiday AD Jr. Lateral condylar resection for bunionette. Clin Orthop Relat Res. 1992;278:183-92. 16. Koti M, Maffulli N. Bunionette. J Bone Joint Surg Am. 2001; 83:1076-82. 17. Mann RA, Mann JA. The bunionette deformity. Instr Course Lect. 2004;53:303-9. 18. Ajis A, Koti M, Maffulli N. Tailor s bunion: a review. J Foot Ankle Surg. 2005;44:236-45. 19. Fallat LM, Buckholz J. An analysis of the tailor s bunion by radiographic and anatomical display. J Am Podiatry Assoc. 1980;70:597-603. - 29 -
김선용 박광환 이진우 20. Schoenhaus H, Rotman S, Meshon AL. A review of normal inter-metatarsal angles. J Am Podiatry Assoc. 1973;63:88-95. 21. Kitaoka HB, Holiday AD Jr. Campbell DC, 2nd. Distal Chevron metatarsal osteotomy for bunionette. Foot Ankle. 1991;12:80-5. 22. Moran MM, Claridge RJ. Chevron osteotomy for bunionette. Foot Ankle Int. 1994;15:684-8. - 30 -