대한민국 정형외과 전공의 평가시험 분석: 수부 및완관절 분야

김동희,김준엽,심승보,김주학 대한수부외과학회 2016 대한수부외과학회지 Vol.21 No.1

Purpose: To evaluate the questions of hand and wrist section of Korean orthopedic in-training examination (KOITE). Methods: We analyzed questions of hand and wrist section of KOITE between 2010 and 2014. The weight of hand and wrist section was calculated and topics were thoroughly analyzed. The construct of questions were evaluated and taxonomic classifications were also performed. The frequency of presentations of physical examinations and radiologic evaluations in diagnosis and treatment related questions were analyzed. The coverage of available references which were recommended by Korean Orthopedic Association (KOA) were analyzed. Results: Sixty one out of 500 questions (weight: 12.2%) were related with hand and wrist section. Disease (30/61, 48.2%) was more commonly asked than trauma, however most frequently asked topic with a broad classification was fractures and dislocations (19/61, 31.1%). The description only questions (46/61, 75.4%) were most commonly asked construct of question. According to taxonomic classification, taxonomy B (diagnosis; 27/61, 44.3%) was most frequently asked. The Campbell’s operative orthopedics (54/61, 88.5%) and textbook of KOA (53/61, 86.9%) were representative references covering questions most widely. Conclusion: This analysis of hand and wrist section of KOITE could be used as the check-up tools for resident training programs of each training hospitals. 목적: 본 연구에서는 정형외과 전공의 평가시험 중 수부 및 완관절 분야를 분석하여 평가시험의 출제 경향과 문제점을논의 하고자 한다. 방법: 2010년에서 2014년까지 5년간 치러진 정형외과 전공의 평가시험 문항 중 수부 및 완관절 관련 문항들을 분석하였다. 수부와 완관절 영역이 차지하는 비중과, 문제 주제, 출제 형태 및 유형에 따른 분류 등의 분석을 시행하였다. 또한정형외과 참고서적 및 문헌들의 가용 정도를 조사하였다. 결과: 수부 및 완관절 관련문항은 총 500문항 중, 61문항(12.2%)이었으며 대분류에서 질환 문제(30/61, 48.2%)가, 주제분류(광범위)로 골절 및 탈구 문항이(19/61, 31.1%) 출제 빈도가 높았다. 출제 형태는 단순 서술형 문제(46/61, 75.4%), 출제 유형에선 진단관련 문항(27/61, 44.3%)이 가장 빈번하였다. 참고서적으로 캠벨의 수술적 정형외과학(54/61, 88.5%)과 대한 정형외과학 교과서(53/61, 86.9%)가 광범위하게 이용되었다. 결론: 이번 수부 및 완관절 영역 전공의 평가시험 분석은 현재 수부 및 완관절 분야의 교육 프로그램의 적절성을 검토할만한 근거 자료가 될 수 있겠다.

골프로 발생한 유구골구 골절과 굴곡건 파열

김종민,팽정욱,유명재,우상현 대한수부외과학회 2016 대한수부외과학회지 Vol.21 No.1

Purpose: We report surgical results and the relationship between hamate hook fracture and flexor tendon rupture occurred during excessive golf practice or rounding. Methods: The 16 cases of patients with fracture of hamate hook or flexor tendon injury caused by golf swing were examined retrospectively. Hamate hook excision were underwent in fracture alone, flexor tendon reconstruction with tendon transfer of 3rd or 4th flexor digitorum sublimus (FDS) were done in the flexor tendon rupture. Postoperative results were evaluated by means of American Society for Surgery of the Hand (ASSH) to compare total range of motion and the grip strength. Results: The fracture gap was not far apart completely in computed tomography (CT) of hamate fracture alone cases. If the flexor tendon rupture with the fracture, the gap in CT was far apart completely. After flexor tendon transfer surgery, two cases were excellent, five cases were good, two cases were fair in ASSH assessment. One case was re-rupture. Grip strength as compared with the normal side was observed for the mean grip strength of 82% recovery. Conclusion: The instability of the hamate hook fracture affected to flexor tendon rupture rather than location of the fracture. Hamate hook excision and tendon transfer with FDS can be a good treatment option. 목적: 과도한 골프 연습이나 라운딩 도중에 발생한 유구골구 골절과 굴곡건 파열에 대한 관계 및 수술적 결과를 보고하고자 한다. 방법: 골프에 의해 발생한 유구골구 골절 또는 굴곡건 손상이 있는 환자 16예를 후향적으로 조사하였으며, 유구골구 골절은 골절제술, 굴곡건 파열 시 제3혹은, 제4천수지 굴곡건 이전술을 시행하였으며, 악력 및 . 미국수부외과학회(American Society for Surgery of the Hand, ASSH)의 방법으로 총 관절 운동범위를 평가하였다. 결과: 유구골구 단독 골절 시 computed tomography (CT)에서 골절틈이 완전히 벌어져 있지 않았지만 유구골구 골절 및굴곡건 파열시에는 CT상 골절틈이 완전히 벌어진 것이 관찰되었으며, 건파열이 있는 경우 굴곡건 이전술 후 ASSH 평가상 2예에서 매우 우수, 5예에서 우수, 2예에서 양호, 1예에서 재파열이 있었으며 건측과 비교하여 평균 82%의 악력회복을 관찰하였다. 결론: 골프로 인한 굴곡건 파열은 유구골구 골절의 위치보다는 골절부 전위에 의한 불안정성이 더 영향이 크며 건파열시 유구골 절제 및 천수지 굴곡건 전이술이 좋은 치료 방법이다.

요골 원위부 골절 환자에서 정형외과 의사가 시행한 초음파 유도 액와 상완 신경총 차단술

선두훈,이철형,김철우,정덕희,안충한 대한수부외과학회 2019 대한수부외과학회지 Vol.24 No.2

Purpose: The purpose of this study was to evaluate the usefulness of ultrasound-guided axillary brachial plexus block performed by orthopedic surgeon as an anesthetic method for distal radius fracture surgery.Methods: From October 2017 to October 2018, an ultrasound-guided axillary brachial plexus block was performed on 161 cases of distal radius fracture requiring surgery. The procedure was performed by orthopedic surgeons using solution (20 mL of lidocaine HCl in 2%, 20 mL of ropivacaine in 0.75%, and 10 mL of normal saline in 0.9%). The success rate of the anesthetic procedure, the duration of analgesic effect, and the complications were investigated. If the anesthesia induc-tion failed, additional local anesthetic methods were performed stepwise and reassessment about whether the operation could proceed was made.Results: Anesthesia was successful in 155 patients and the success rate was 96.3%. The duration of analgesic effect was 6 hours (3-10 hours). In 6 failed cases of anesthesia, local anesthesia was applied to the pain site in the operating room. In 5 cases, the operation was completed without discomfort. In 1 case complaining of pain around fracture site after the local anesthesia, ultrasound-guided radial nerve block was effective in controlling the pain.Conclusion: In open surgery of distal radius fractures, an ultrasound-guided axillary brachial plexus block performed by orthopedic surgeon allows anesthesia with high success rates. Even if the surgical anesthesia is incomplete, it is expected that the surgery cab be completed safely if the nerve is identified and the stepwise additional local anesthesia method is performed. 목적: 요골 원위부 골절 수술 시 정형외과 의사가 시행한 초음파 유도 액와 상완 신경총 차단술의 유용성에 대하여 알아보고자 한다.방법: 2017년 10월부터 2018년 10월까지 요골 원위부 골절 수술 전 마취 방법으로 초음파 유도 액와 상완 신경총 차단술을 시행한 161명을 대상으로 하였다. 2% lidocaine HCl 20 mL, 0.75% ropivacaine 20 mL, 0.9% nor-mal saline 10 mL의 혼합액을 이용하였으며 술기의 성공률, 무통 지속 시간 및 합병증을 조사하였다. 술기가 실패한 경우 단계적으로 추가 국소 마취를 시행한 뒤 재평가하였다. 결과: 161명 중 155명에서 마취가 성공하여 96.3%의 성공률을 보였다. 무통 지속 시간은 평균 6시간(3-10시간)이었다. 6명이 마취 실패로 수술실에서 통증 부위에 국소 마취제를 추가 투여하였으며 5명은 이후 환자의 불편감 없이 수술을 마칠 수 있었고, 1명은 초음파 유도 요골 신경 차단술을 통해 수술을 완료할 수 있었다.결론: 요골 원위부 골절 수술 시 정형외과 의사가 시행한 초음파 유도 액와 상완 신경총 차단술은 높은 마취 성공률을 보였고, 마취가 불완전 하더라도 해당 신경을 파악하여 단계적 추가 국소 마취 방법을 시행한다면 안전하게 수술을 완료할 수 있을 것으로 기대한다.

수지 압궤 손상 후 조직 결손의 재건을 위한 유리 피판술

김백규,허찬영,은석찬,백롱민,형남경 대한수부외과학회 2011 대한수부외과학회지 Vol.16 No.3

Purpose: The crushing injury is one of the most severe type injuries in the finger. For the reconstruction of fingers with crushed and devitalized tissue, various surgical methods have been attempted to cover the soft tissue defects. We performed free flaps for finger reconstruction and investigated the results. Materials and Methods: Between March 2010 and July 2011, we retrospectively reviewed 14 patients who had soft tissue defects of fingers after severe crushing injuries. There were 8 pulp losses, 4 dorsal skin losses with bony exposure,1 nail complex loss, and 1 total loss of distal phalanx. In all cases, soft tissue defects in fingers were reconstructed with a free flap. Results: All flaps survived successfully. We could reserve the functional length without additional necrosis and amputation. Reconstructed fingers were returned to normal activity in a short time and the atrophy or deformity was not observed. Conclusion: Free flap transfer for the reconstruction of the finger defect after crushing injury is useful for the functional recovery and cosmesis. 목적: 수지의 심각한 압궤 손상은 수지에 발생한 손상 중 가장 심한 형태의 손상으로이로 인해 손실된 조직을 재건하기 위하여 여러 가지 수술적 방법들이 시도되고 있다. 본 연구에서는 유리 피판술을 시행하였으며 결과를 분석하였다. 대상 및 방법: 2010년 3월부터 2011년 4월에 걸쳐 심각한 압궤 손상 후 발생한 수지의 조직 결손에 대하여 치료받은 14명의 환자를 후향적으로 조사하였다. 결손 유형은수질부 결손이 8예, 골노출이 동반된 배부 피부 결손이 4예, 조갑 복합체 결손이 1예,원위지절 전체 결손이 1예이었다. 모든 환자에게 유리 피판술을 이용한 재건을 시행하였다. 결과: 모든 피판은 성공적으로 생존하였고 추가 괴사나 절단 없이 기능적 길이 보존이 가능하였다. 모든 환자가 단기간 내에 일상으로의 복귀가 가능하였으며 위축이나변형이 관찰되지 않았다. 결론: 압궤 손상으로 발생한 수지 조직 결손에 있어서 유리 피판술은 기능적으로나미용적으로 우수한 결과를 기대할 수 있는 유용한 방법이다.

The Usefulness of Radial Column Plate in Distal Radius Fracture: Indications and Results

안성진,이상현,김동희,장효석,홍성민,김학상 대한수부외과학회 2021 대한수부외과학회지 Vol.26 No.2

Purpose: The most common surgical treatment for distal radius fracture is internal fixation using volar locking plates, but it is sometimes difficult to maintain reduction with them. Therefore, this research reports the results of surgical treatment with additional radial column plates. Methods: We analyzed 12-month follow-up results in 100 cases. The patients had the B or C types of distal radius fractures, in accordance with AO classification, and underwent surgical treatment at our hospital from May 2013 to December 2019. There were 16 cases of B-type and 84 cases of C-type fractures. Out of these, 87 were treated with volar locking plates (V group) and 13 had additional radial column plates (VR group). The results of surgical treatment were examined clinically by measuring the disabilities of the arm, shoulder and hand (DASH) and Mayo wrist score, and radiologically by measuring the radial length, radial inclination, and volar tilt, before and after surgery. Results: After treatment, the radiographic average in the V group showed a radial length of 12.3 mm, radial inclination of 20.2°, and volar tilt of 5.8°, while the VR group showed 11.6 mm, 22.3°, and 9.0° respectively. A statistically significant difference was found in the DASH score, and the DASH score showed good results in the VR group. Conclusion: Additional radial column plate fixation is worth considering because it provides clinically and radiologically satisfactory results in treatment of B and C types distal radius fracture involving articular surface.

Simultaneous Volar Pulp and Nail Bed Reconstruction with the Second Toe Onychocutaneous Free Flap

이경진,박일우,노시영,고성훈,김진수,홍민기 대한수부외과학회 2021 대한수부외과학회지 Vol.26 No.2

Fingertip injury is one of the most common hand injuries. Although several types of advancement and cross-finger flaps exist, they would not be essential for nail bed defects. The authors present a simultaneous volar pulp and nail bed reconstructive technique that uses a second toe onychocutaneous free flap. Four patients without amputees underwent fingertip amputation reconstruction between 2011 and 2019. After thorough debridement, the defect size was estimated, and the digital arteries, nerves, and veins of the recipient were evaluated. The flap, composed of pulp tissue and nail bed, was harvested with continuity from the second toe. Additional split-thickness skin grafts were performed in two cases. All flaps survived without considerable complications. We evaluated the scar and contour, and nail growth was reported over Zook’s criteria grade B. The second toe onychocutaneous free flap provides a reliable option for fingertip defects that involve pulp tissue and nail bed without further amputation.

난치성 수근관 증후군

이재후,박민종 대한수부외과학회 2021 대한수부외과학회지 Vol.26 No.2

수근관 유리술의 실패와 합병증은 3%에서 25%까지 보고되며, 이에 따른 재수술은 일차 수술에 비해 결과가 좋지 않고 예후를 예측하기 어렵다. 수근관 증후군 환자에서 수술 후에도 증상의 호전이 없거나 재발되는 경우의 원인은 다양하나, 수술 이후 증상의 발생 양상에 따라 수술 후에도 지속되는 증상, 호전 후 재발되는 증상, 호전 후 새로운 증상의 발생의 세 가지로 크게 분류할 수 있다. 이에 대한 적절한 치료도 원인에 따라 결정되어야 한다. 저자들은 난치성 수근관 증후군의 임상 증상, 원인, 진단, 그리고 치료에 대하여 기술하고자 한다. Complications and failures after carpal tunnel release have been reported from 3% to 25%. And the revision surgeries usually show poorer outcomes than the primary surgeries. There are diverse etiologies causing neuropathic symptoms after the carpal tunnel release, which became a clinical challenge. Potential causes of the symptoms are categorized into three by those natures; persistent symptom, recurrent symptom, and new symptom. The decision of proper management should be based on the etiologies of reproduced symptoms. This article described an overview of the clinical presentation, etiologies, diagnosis, and treatments of the recalcitrant carpal tunnel syndrome.

주관절 건병증의 생물학적 제재 치료

정형석,이재성 대한수부외과학회 2021 대한수부외과학회지 Vol.26 No.4

Although elbow tendinopathy is the one of common diseases causing elbow pain, ideal nonoperative treatment to provide long-term satisfaction has not been introduced. Recently, there is significant interest in biological treatment to facilitate the healing environment and tissue proliferation in elbow tendinopathy. Biological agents such as platelet-rich plasma (PRP) or stem cells are likely to be established as one of the nonoperative treatment methods that can have long-term therapeutic effects in the future, given their theoretical basis. Despite many previous studies using biological agents such as PRP and stem cells in the elbow, its beneficial effect on elbow tendinopathy is controversial. Thus, the purpose of this review is to provide an evidence-based summary of the biologic agent for treating elbow tendinopathy and to identify areas where further research is warranted. 주관절 건병증은 팔꿈치의 통증을 유발하는 가장 대표적인 질환 중 하나로 그동안 여러 가지 치료 방법들이 소개되었지만 일시적인 효과를 보일 뿐 장기적으로 만족을 줄 수 있는 이상적인 비수술적 치료 방법은 아직 밝혀지지 않았다. 최근 주관절 건병증에서 치유 환경을 향상시키고 조직의 증식을 촉진하는 생물학적 제재를 이용한 치료 방법이 각광을 받고 있다. 혈소판 풍부 혈장이나 줄기세포 같은 생물학적 제재는 그 이론적 근거를 볼 때 향후 장기적인 치료 효과를 볼 수 있는 비수술적 치료 방법으로 자리를 잡을 가능성이 높다. 하지만 혈소판 풍부 혈장이나 줄기세포 같은 생물학적 제재를 이용한 여러 연구에도 불구하고 아직 그 효과에 대해서는 논란이 있다. 따라서 여러 문헌 고찰을 통해 주관절 건병증에서 생물학적 제재 치료의 근거를 알아보고 향후 연구 방향에 대해 알아보고자 한다.

Biomechanical Analysis of Resorbable Barbed Suture Tenorrhaphy

이상환,김석환,오화영,박은수,신호성,정성균 대한수부외과학회 2016 대한수부외과학회지 Vol.21 No.4

Purpose: To evaluate the tensile strength and repair-site profile of a technique of resorbable barbed suture tenorrhaphy. Methods: Forty-eight flexor digitorum profundus tendons were collected from the 8 adult cadavers. In the test group, the tendons were sutured using absorbent 2-0 barb knotless sutures in a 2-strand or 4-strand zig-zag pattern. In the control group, 2-0 Prolene and 3-0 polydioxanone (PDS) were used to suture the tendons using the 2-stand Modified Kessler method and the 4-strand cruciate suture method. Using a tensile force measurement machine, the breaking load (N) and the stiffness (N/mm) were measured. The types of rupture were categorized into suture breaking, knot rupture, and pullout. Results: In the comparative analysis between the absorbent 2-0 Quill (Angiotech Pharmaceuticals, Canada) suture that used the 2-strand core suture and the 3-0 PDS and 2-0 Prolene sutures, the average breaking load for the 2-0 Quill suture was 26.83±7.47 N, and 21.96±6.78 N and 17.20±4.93 N for the 2-0 Prolene and 3-0 PDS sutures. In the comparison using the 4-strand core suture, the average breaking load for the 2-0 Quill suture was 62.50±13.34 N, and 22.35±5.72 N and 18.67±4.27 N for the 2-0 prolene and 3-0 PDS sutures. The most common type of rupture were knot rupture. Conclusion: For flexor tendon sutures using the absorbent barb sutures, compared to the conventional 2-0 Prolene or 3-0 PDS sutures, absorbent barbed sutures have a higher tensile strength.

Usefulness of Color Doppler Ultrasonography for the Preoperative Evaluation of Thin Anterolateral Thigh Flap Perforators

Kyung Jin Lee,박일우,Si Young Roh,Sung Hoon Koh,Jin Soo Kim,Dong Chul Lee,구진회 대한수부외과학회 2021 대한수부외과학회지 Vol.26 No.4

Purpose: The anterolateral thigh flap is commonly applied to various body sites for reconstruction. However, surgeons often struggle against unexpected locations and the nature of perforator vessels during surgery. Thus, this study aimed to assess the accuracy and usefulness of color Doppler ultrasonography as a preoperative tool for the perforator position and course of anterolateral thigh flaps. Methods: A prospective study involving 77 anterolateral thigh flaps was conducted between March 2016 and February 2021. Among them, 37 perforators (group A) were detected using the preoperative color Doppler ultrasound, and the other 40 perforators (group B) were tested using a hand-held Doppler only. All patients in group A underwent color Doppler ultrasonography performed by a radiologist at our institution. The nature and course of the perforator vessels were recorded, and their precise locations were plotted in an orthonormal coordinate system. Results: A total of 37 anterolateral thigh perforator flaps (group A) were successfully dissected. The median distance between the preoperative color Doppler ultrasonography and the real location during surgery of the perforators was 7.50 mm, which was statistically smaller than 10 mm (p<0.001). This preoperative ultrasound test also had a success rate of 94.6% to determine the nature of the perforators (musculocutaneous type vs. septocutaneous type). Conclusion: Preoperative color Doppler ultrasonography provides a harmless, reliable, and accurate technique for visualizing the vascular anatomy of anterolateral thigh flaps. It has a high correlation with surgical findings, allowing surgeons to cope with variable vascular anatomy.