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pissn : 1226-2102, eissn : 2005-8918 Instructional Course Lecture J Korean Orthop Assoc 2013; 48: 78-87 http://dx.doi.org/10.4055/jkoa.

1 pissn : , eissn : Instructional Course Lecture J Korean Orthop Assoc 2013; 48: 회전근개파열의치료 Current Concepts of Arthroplasty for the Treatment of Massive Rotator Cuff Tears 오주한 최준하서울대학교의과대학정형외과학교실, 분당서울대학교병원관절센터 광범위회전근개파열의여러치료방법중관절치환술에대한최신지견을알아보고자하며, 각종관절치환술술식의장단점과치료방침에대하여기술하고자한다. PubMed 논문검색창을통해 massive rotator cuff tears 와 arthroplasty 라는어구를사용하여최근나온문헌들을고찰하였으며, 광범위회전근개파열에대한수술방법중하나인관절치환술의역사와적응증, 임상결과및치료지침에대해알아보았다. 관절치환술은관절염이진행된광범위회전근개파열환자에서일차적치료법으로고려될수있다. 반관절치환술은가성마비가없는회전근개파열관절병증을가진환자에서오구견봉궁이건재할경우만족스러운결과를얻을수있다. 또한, 역행성견관절전치환술은가성마비를동반한고령의회전근개파열관절병증을가진환자에서통증완화와능동적거상을회복할수있는적합한수술방법이다. 환자의상태에따른적절한수술방법의선택은치료성공의중요한과정이며, 관절치환술역시적절한적응증과발전된술기등으로인하여좋은결과가기대된다. 색인단어 : 견관절, 광범위회전근개파열, 관절치환술 서론 광범위회전근개파열 (massive rotator cuff tears) 이란일반적으로파열부위의최대직경이 5 cm 이상인경우 1) 와 2개이상의건이전층파열된경우 2) 로정의되고있다. Neer 등 3) 은광범위회전근개파열로인해상완골두를관절와에일정하게중심화시켜동적인안정성을제공하는회전근개의기능이소실되어상완골두의상방전위가발생하고관절와및오구견봉궁 (coracoacromial arch) 의침식등을동반하는견관절염을회전근개파열관절병증 (rotator cuff tear arthropathy) (Fig. 1) 이라고명명하였으며, 발병기전은회전근개파열에따른기계적요인과함께관절연골의영양공급이훼손되어발생하는것으로알려져있다 (Fig. 2). 4) 대부분의회전근개광범위파열은보존적또는수술적치료가 접수일 2013 년 1 월 17 일수정일 2013 년 1 월 24 일게재확정일 2013 년 1 월 25 일교신저자최준하성남시분당구구미로 173 번길 82, 분당서울대학교병원관절센터 TEL , FAX junha78@gmail.com Figure 1. True anteroposterior radiograph of a shoulder with cuff tear arthropathy demonstrating glenohumeral arthritis, superior glenoid wear, proximal humeral migration, and acetabularization of the acromion. 대한정형외과학회지 : 제 48 권제 1 호 2013 Copyright 2013 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

79 Figure 2. (A) Mechanical and (B) nutritional factors have been hypothesized to contribute to joint destruction in rotator cuff tear arthropathy.

2 79 Figure 2. (A) Mechanical and (B) nutritional factors have been hypothesized to contribute to joint destruction in rotator cuff tear arthropathy. 4) 필요한데, 비록보존적치료의경과가좋은경우가있다고는하나장기간추시시실망스러운결과가보고되고있어, 5) 최근에는적극적인수술적치료도많이선호되고있다. 하지만, 회전근개의광범위파열은큰파열크기, 건의심한퇴축 (retraction) 및근육의위축 (atrophy), 지방변성등의퇴행성변화가동반되는경우가많아서봉합을시행하여도치유가될확률이상대적으로낮으며 6) 이러한퇴행성변화는대개비가역적이고따라서아예봉합이불가능한경우도있어수술적치료에상담한어려움이따른다. 7) 직접봉합할수없는광범위회전근개파열의수술적치료로는단순변연절제술 (debridement) 및견봉하감압술, 결절성형술 (tuberoplasty), 부분봉합술, 대흉근또는광배근을이용한근건이전술, 동종건및합성물을이용한재건술등다양한방법이소개되었으며해부학적인복원을하지못함에도불구하고비교적양호한결과들이발표되고있다. 8-13) 하지만회전근개파열관절병증이라고불리는독특한형태의견관절관절염은광범위회전근개파열에서비롯된상완골두의상방전위에의해서발생하는것으로, 전술한방법들로는불가역적인관절염을해결하지못하여최근여러형태의관절치환술이시행되게되었다. 14,15) 본저자들은광범위회전근개파열에대한여러치료방법중관절치환술과관련된최신문헌고찰을통하여그역사와적응증, 임상결과및치료지침을기술하고자한다. 본론 1. 관절치환술의역사 (history of arthroplasty) 가장초기의인공관절삽입물은구속형 (fully constrained) 전치환술디자인 (Fig. 3) 16) 으로상완골두부분이관절와부품안에서벗어나지않고그안에서만움직이는형태로, 관절의회전중심이고정되는효과로인해높은일치도 (conformity) 및구속력 Figure 3. Assembled constrained prosthesis: 1, metal glenoid cup; 2, tightened metal locking ring; 3, Series-I1 humeral head; 4, position of eccentric screw holes on the back plate; 5, central metal stem. 16) (constraint) 을갖는특징이있다. 그러나, 이디자인은관절와연의 지나친응력으로인한매우빠른관절와치환물의해리로, 87.5% 에이를정도로많은합병증이발생하여현재는더이상사용되 지않고있다. 16) 그다음세대로는상완골두의상방전위를막기 위하여보다크고덮개 (hood) 가있는관절와부품이특징인반구 속형 (semi-constrained) 인공관절 (Fig. 4) 17) 이개발되었는데, 이디 자인은상완골두를관절와부품내의중심에위치하게하는데는 효과적이지만관절운동범위가만족스럽지않고, 역시조기관절 와치환물해리의문제점을보였다. 18) 이후에고식적인견관절전 치환술이회전근개관절병증에서적용되어구속형과반구속형 디자인에비하여향상된임상결과를나타낸초기보고들이있었

80 오주한 최준하 다. 1982 년 Neer 등 12) 은회전근개파열병증을가진 16명의환자에대해견관절전치환술을시행후평균 30개월추시결과, Neer 의제한적목표 (Neer's limited goals: 20 o external rotation and 90 o forward elevation) 를기준으로 91% 에서성공적인결과를보고한바있다.

회전근개광범위파열로인하여결국상하짝힘 (forced couple) 의균형을소실하게되고, 결국관절와표면에서의흔들목마 (rocking horse) 현상으로인해조기에관절와치환물의해리가발생되는문제가있다고하였다.

17) 회전근개파열병증을가진환자에있어서적합한치료가아니라고결론지을수있다. 2. 광범위회전근개파열의치료에서관절치환술의현재최근고식적인인공관절에대한대안으로역행성견관절치환술이광범위회전근개파열에서고식적치환술의문제점에대한해결책을제시하고있다.

3 80 오주한 최준하 다 년 Neer 등 12) 은회전근개파열병증을가진 16명의환자에대해견관절전치환술을시행후평균 30개월추시결과, Neer 의제한적목표 (Neer's limited goals: 20 o external rotation and 90 o forward elevation) 를기준으로 91% 에서성공적인결과를보고한바있다. 하지만 1988 년 Franklin 등 19) 은회전근개파열병증을가진 14명의환자에대해고식적견관절전치환술을시행후후향적으로분석한결과, 수술후평균 37개월째 50% 의관절와치환물의해리를보였고, 46% 에서지속적통증과 15% 에서불안정성이발생하였음을보고하였다. 회전근개광범위파열로인하여결국상하짝힘 (forced couple) 의균형을소실하게되고, 결국관절와표면에서의흔들목마 (rocking horse) 현상으로인해조기에관절와치환물의해리가발생되는문제가있다고하였다. 보다최근엔 Nwakama 등 20) 도회전근개파열병증을가진 7명의환자에대해견관절전치환술을시행한결과 Neer 의제한적목표를기준으로 1예에서만만족스러운결과를보고하였다. 결론적으로고식적견관절전치환술은치환물의높은실패와합병증으로인하여 Figure 4. Semiconstrained Dana shoulder prosthesis. 17) 회전근개파열병증을가진환자에있어서적합한치료가아니라고결론지을수있다. 2. 광범위회전근개파열의치료에서관절치환술의현재최근고식적인인공관절에대한대안으로역행성견관절치환술이광범위회전근개파열에서고식적치환술의문제점에대한해결책을제시하고있다. 그리하여현재는광범위회전근개파열에대한관절치환술은크게반관절치환술과역행성견관절전치환술로구분할수있으며치료방법의선택시에는환자의연령및활동성, 상완골두의상방전이정도, 그리고회전근개의상태등을고려하여야한다. 1) 반관절치환술 (hemiarthroplasty) 반관절치환술은특히역행성견관절전치환술을사용하기에는인공관절의수명이걱정되는젊은환자나 90 o 이상의능동적전방거상이가능한환자의치료로가능한수술방법이다. Goldberg 등 21) 은회전근개파열관절병증을가진 34명의환자에대해반관절치환술을시행하고평균 3.7 년추시결과, 76% 에서우수한임상적결과와관절운동범위의의미있는호전을보였으며, 특히수술전능동적전방거상이 90 o 이상가능했던환자에있어서보다우수한장기추시결과를보고하였다. Zuckerman 등 15) 도고령의진행된회전근개파열관절병증을가진 15명의환자에대해반관절치환술을시행후평균 28개월추시한결과 87% 에서통증의감소와만족할만한임상적결과를얻었으며전방거상및외회전의운동범위도증가하였음을보고하였다. 또한, 현재의반관절치환술부품의디자인은대결절부위로인공상완골두의크기를연장시켜크고특이한모양으로변화하였다. 기존에비해좀더커다란인공상완골두는관절와를포함하여견봉과오구견봉궁의하면과관절면을이루면서보다큰운동반경을가능하게한디자인으로서, 회전근개파열관절병증환자에게최근시행되고있다 (Fig. 5). 22) Visotsky 등 23) 은이러한디자인의인공상완골두를이용하여회전근개파열병증을가진 60명의환자를평균 2 Figure 5. Hemiarthroplasty with a laterally extended cuff tear arthropathy (CTA) head. (A) CTA prosthesis, (B) diagram of installed prosthesis. 22)

81 년추시한결과, 능동적거상이수술전 56 o 에서수술후 116 o 로호전되었으며, 능동적외회전도수술전 8 o 에서수술후 30 o 로호전되었다고보고하였다. 그러나, 반관절치환술후골소실과상완골의불안정성이장기적문제로남아있으며특히, 오구견봉궁의보존여부가이런결과에매우중요한영향을미친다.

4 81 년추시한결과, 능동적거상이수술전 56 o 에서수술후 116 o 로호전되었으며, 능동적외회전도수술전 8 o 에서수술후 30 o 로호전되었다고보고하였다. 그러나, 반관절치환술후골소실과상완골의불안정성이장기적문제로남아있으며특히, 오구견봉궁의보존여부가이런결과에매우중요한영향을미친다. Sanchez- Sotelo 등 24) 은회전근개파열병증을가진 33명의환자에대해반관절치환술을시행하여평균 5년추시결과, 약 67% 의환자에서상당한통증감소를보였고관절운동범위의의미있는호전을보였으나, 과거력상견봉하감압술로오구견봉궁의손상이있던 7 예에서수술후전상방불안정성이발생하였다고보고하였다. 이렇듯, 회전근개파열병증에서반관절치환술을사용하는경우에는수술후의골소실과불안정성을개선하기위한추가적연구가필요할것으로판단된다. Figure 6. Grammont s original reverse total shoulder arthroplasty. 25) 2) 역행성견관절전치환술 (reverse total shoulder arthroplasty) 역행성견관절전치환술은고식적인인공견관절술식으로효과적으로치료되지않는여러견관절질환에대한해결방법으로 1985 년 Paul Grammont 가회전중심 (center of rotation) 의내측이동과상완골의하방이동에근거한생역학적개념을도입한이래지속적인발전을거두어왔다 (Fig. 6). 25) 즉, 회전중심의내측이동을통해삼각근의작용에대한회전팔 (monent arm) 을증가시키고하방이동을통해지렛대팔 (lever arm) 을증가시켜삼각근의작용력을높이는동시에, 상지의거상시상완컵 (humeral cup) 이압박력을받을수있도록하였다. 이를통해광범위회전근개파열등으로회전근개의기능이없는상태에서도고정된지렛대 (fixed fulcrum) 의작용이가능하게하여삼각근이상지의일차거상근으로작용할수있도록하였다 (Fig. 7). 26) 하지만, 내측회전중심을가진치환물에서관절와패임 (scapular notching) 등의합병증이 60% 까지높게보고되기도하며, 27,28) 회전중심을좀더외측으로이동한최근의역행성인공관절물디자인은관절와패임등의합병증을줄일수있다고한다. 즉, 초기연구에서보고된것보다훨씬적은기저판 (baseplate) 관련합병증이보고되고있는데, Cuff 등 29) 은회전근개결손을가진견관절관절염환자 96명을대상으로외측중심의역행성견관절전치환술을시행후최소 2년이상추시관찰한결과한명의기계적실패나관절와패임도발생하지않았다고보고하였다. 현재는내측회전중심과외측회전중심을가진두가지디자인의치환물모두가회전근개파열관절병증의치료에널리사용되고있으며관련연구들이계속진행중이다. 이러한역행적견관절전치환술은광범위회전근개의파열과회전근개파열관절병증에시행되어해부학적견관절치환술로는해결할수없었던관절불안정성문제를해결하면서상지의능동적거상및외전을가능하게하였고 29,30) 이후견관절가성마비, 실패한근위상완골골절 ( 불유합및부정유합 ) 의치료, 류마티스관절염및견관절재치환술등치료방법이마 Figure 7. (A) Earlier reverse total should er prosthesis design, with a small glenosphere component and a lateralized center of rotation. (B) The modern design with a large glenosphere, a non-anatomic val gus angle of the humeral implant, and medial and distal positioning of the center of rotation. 26)

82 오주한 최준하 땅치않은상황에서의선택적방법으로그적응증이넓어지고있다. 31,32) 하지만, 아직까지는실패한견관절치환술의재치환술, 류마티스관절염, 복합골절및악성종양절제술후사지구제술로사용된역행성견관절전치환술은, 회전근개파열관절병증과광범위회전근개의파열에비하여상대적으로수술적결과가좋지않은것으로알려져있다.

6 점으로, 능동적거상이수술전 73 o 에서수술후 138 o 로향상되었으며, 96% 의환자에서통증이의미있게감소되었음을보고하였다. Young 등 33) 도 8명의회전근개파열관절병증환자를대상으로역행성견관절치환술을시행후평균 38개월추시결과, 96% 에서임상적으로우수한결과를보였고, 능동적거상도수술후평균 122 o 로향상되었음을보고하였다.

5 82 오주한 최준하 땅치않은상황에서의선택적방법으로그적응증이넓어지고있다. 31,32) 하지만, 아직까지는실패한견관절치환술의재치환술, 류마티스관절염, 복합골절및악성종양절제술후사지구제술로사용된역행성견관절전치환술은, 회전근개파열관절병증과광범위회전근개의파열에비하여상대적으로수술적결과가좋지않은것으로알려져있다. 역행성견관절치환술의가장흔하고중요한적응증은회전근개파열관절병증이다. 특히통증이있는가성마비를동반한환자들이주요적응증이라고할수있다. Sirveaux 등 27) 은회전근개파열관절병증을가진 80명을대상으로역행성견관절전치환술을시행후평균 44개월추시결과, Constant 점수에서수술전 22.6 점에서수술후 65.6 점으로, 능동적거상이수술전 73 o 에서수술후 138 o 로향상되었으며, 96% 의환자에서통증이의미있게감소되었음을보고하였다. Young 등 33) 도 8명의회전근개파열관절병증환자를대상으로역행성견관절치환술을시행후평균 38개월추시결과, 96% 에서임상적으로우수한결과를보였고, 능동적거상도수술후평균 122 o 로향상되었음을보고하였다. Frankle 등 34) 은회전근개파열관절병증환자 60명을대상으로역행성견관절치환술을시행후약 2년의단기추시결과, 능동적거상은수술전 55 o 에서수술후 o 로, 통증에대한주관적시각척도 (visual analogue scale, VAS) 는수술전 6.3 에서수술후 2.2 로호전되어통증의완화및기능향상에상당한효과가있는것으로보고하였다. Favard 등 35) 은다기관연구를통해회전근개파열관절병증으로역행성견관절전치환술을시행한 484 명의환자를장기추시결과, 치환물의 10년생존율은 89% 였지만, 시간이지남에따라 Constant 점수가점차적으로감소하였고, Constant 점수가 30점이하 ( 매우불량한결과 ) 로떨어질때를종료점으로잡았을때, 10년째생존율은 72% 까지떨어졌음을보고하였다. 그러므로, 역행성전치환술을시행할때환자의나이가고려되어야하며, 대부분의저자들은낮은요구도를가진 65세이상의고령의환자에게제한하여시행되고있다. 견관절의관절염이없지만직접봉합할수없는광범위회전근개파열도역행성견관절전치환술의적응증이될수있다. 이에대해최근세가지연구들이보고되고있는데, 견관절관절염이 없고, 광범위회전근개파열이거나광범위회전근개파열로수술에실패한환자들을대상으로역행성견관절전치환술을시행후수술적결과를보고하였다. 32,36,37) 세연구의평균나이는 세였고, 최소 2년이상의추시결과회전근개파열관절병증을대상으로시행한환자들과유사하게기능적점수와능동적전방거상에서향상된결과를보였다. 그중두연구 36,37) 에서수술전능동적거상이 90 o 이하였던환자들에서수술전 90 o 이상이었던환자들에비해서의미있게우수한관절운동범위와임상적결과를보였고, 만족도또한높았다. 이에두연구에서는수술전능동적전방거상이 90 o 이상가능한환자들에대해서는단순변연절제술, 부분또는완전회전근개봉합술등을고려해야한다고결론지었다. 그러므로견관절관절염이없이, 봉합할수없는광범위회전근개파열환자에서는가성마비가동반되었을때에국한하여역행성견관절전치환술이고려되어야할것이다. 38) 그러나, 역행성견관절전치환술은통증완화와능동적거상및외전은회복시켜줄수있지만능동적외회전은회복되기어려운한계가있다. 28,30) 광범위한회전근개파열과함께능동적외회전기능의소실이있었던경우는대부분극하근과소원형근에상당한퇴축 (retraction) 및지방침윤 (fatty infiltration) 이있어, 역행성견관절전치환술후봉합이쉽지않고봉합을시행하더라도심한지방침윤및근육변성으로외회전기능이잘회복되지않는다 (Fig. 8). 삼각근이잘보존되어있는경우라도삼각근만으로는외회전작용을독립적으로할수없어극하근과소원형근의외회전기능을대체할수없으며, 역행성견관절전치환술에서회전중심 (center of rotation) 의내측이동이후방삼각근섬유의동원을증가시키기는하지만동시에삼각근의외회전기능을감소시키는방향으로작용하므로능동적외회전기능의회복이더욱어려워지는문제가있다. 따라서, 이러한경우능동적외회전의회복을위해역행성견관절전치환술과함께광배근 (latissimus dorsi) 및대원형근 (teres major) 이전술을고려할수있다. 10,39) 역행성견관절치환술후여러합병증도보고되고있는데감염, 견갑골패임 (scapular notching), 불안정성, 탈구, 치환물해리, 견봉의피로골절등이보고되고있다. 최근 Zumstein 등 40) 은여러학자들에의해보고되어있는합병증이나재수술의정의가다소 Figure 8. (A) Severe fatty infiltration of the infraspinatus and teres minor (B) loss of active external rotation of the right shoulder.

83 Figure 9. Plain radiograph (A) showing scapular notching at the lateral pillar of the inferior glenoid neck and a polyethylene insert (B) attrited by the scapular notching phenomenon.

치환물의전체또는부분교체나제거를시행하는수술적치료를재치환술 (revision) 로정의하였다. 이를통해 1995 년부터 2008 년까지여러학자들에의해보고된 21 편의논문을분석한결과, 총 782 예중에서합병증은 188 예 (24%) 였고, 불안정성 (4.7%), 감염 (3.8%), 관절와해리 (3.5%) 순이었다.

6 83 Figure 9. Plain radiograph (A) showing scapular notching at the lateral pillar of the inferior glenoid neck and a polyethylene insert (B) attrited by the scapular notching phenomenon. 모호하여학자들간의보고에차이가있는점을고려하여역행성견관절치환술후발생하는합병증을환자의최종결과에영향을미치지않는경우를문제점 (problem), 환자의최종결과에영향을주는경우를합병증 (complication) 으로구분하였고, 이차적수술도치환물의재치환없이견관절의다른이유로수술을진행하는경우를재수술 (reoperation), 치환물의전체또는부분교체나제거를시행하는수술적치료를재치환술 (revision) 로정의하였다. 이를통해 1995 년부터 2008 년까지여러학자들에의해보고된 21 편의논문을분석한결과, 총 782 예중에서합병증은 188 예 (24%) 였고, 불안정성 (4.7%), 감염 (3.8%), 관절와해리 (3.5%) 순이었다. 가장흔하게관찰되었던견갑골패임현상 (35%) 은합병증이라기보다는수술후문제점으로분류하였다. 이로인해시행한이차적수술은 105 예 (13%) 로이중재수술은 26예 (3.3%), 재치환술은 79 예 (10.1%) 이었다. 역행성견관절전치환술후가장흔히발생하는문제인견갑골패임현상은수술후 2년이내에발생하는것으로알려져있으며, 50-96% 까지발생하는것으로보고되고있으나이것이임상적결과에어떤영향을미칠지는논란이있다. 28,41,42) 이러한견갑골패임은상완골컵의내측면과 glenosphere 바로아래부위인견갑골외측의 pillar 부위사이에서기계적충돌에의해발생하고견갑골을내회전할때충돌이심화된다 (Fig. 9). 초기단계에서는기능적결과에영향이없으며, 시간이경과하면서하방나사못을넘어진행되면나사못의이완이우려될수있으나, 아직견갑골패임현상과관련된치환물해리는보고되지않고있다. 30) 이러한견갑골패임현상을줄이기위한방법으로 glenosphere 를큰사이즈로교체하거나, 관절와부품을최대한아래쪽으로위치시키고약간하방경사를주어삽입하는것이도움이된다. 43,44) 외측회전중심을가진역행성견관절치환물은이러한견갑골패임현상을줄일수있다고보고되고있으나, 관절와삽입물의이완이나견관절외전력의약화등의단점이보고되기도한다. 흔한합병증중의하나인불안정성은 2-9% 의발생률로보고되고있으며, 이는연부조직의결손정도, 수술시접근법, 치환물의 후방경사도, 삼각근의긴장도, 견갑하근의봉합여부등이복합적으로관여된다. 30,45) 수술후심부감염은 3.8% 에서 5.1% 까지보고되고있고이것은견봉하관절의커다란 'dead space' 가생김에따른혈종의형성, 환자의약화된전신상태, 큰수술적박리등과관련이있고, 특히재치환술에서더높게보고되고있다. 견봉이나견갑극 (spine) 의수술후골절은 % 정도로발생하고삼각근의과도긴장, 골의피로, 수술전존재하는견봉의병변등이원인이될수있으며, 골절발생시보존적치료에비교적잘반응하는것으로알려져있다. 3. 광범위회전근개파열의치료방침 (proposed treatment algorithm) 광범위회전근개파열환자의평가에있어서환자의병력중몇가지요소들은수술자들이치료계획을수립하는데중요한지침이될수있다. 물론각각의환자들마다고유한치료결정이필요하지만, 단순화된치료방침은 Fig ) 과같다. 이치료방침은봉합이불가능한광범위회전근개파열관절병증을가진환자에있어서나이와가성마비, 견관절관절염의유무에따른치료방침이다. 환자를평가할때고려해야할두가지중요한요소는환자의나이와기대하는활동의수준 (desired activity level) 이다. 어떤환자들은그들의실제나이 (chronologic age) 와맞지않는생리적나이 (physiologic age) 를가지고있을수있고, 이런환자들중일부는수술후, 비슷한나이의환자들에비해보다높은수준의활동과관절운동범위의향상을기대하게된다. 그러한환자들에있어서는반관절치환술보다는역행성견관절전치환술이보다만족한결과를보일것이다. 반대로통증의완화만이목적인비교적활동수준이낮은환자들은반관절치환술이더적합한치료일수있다. 즉환자가주로불편한것이통증인지관절운동범위의감소인지를구별하는것이중요하다. 또다른고려해야할중요한요소는가성마비 (pseudoparalysis) 유무를확인하는것이다. 견관절관절염과함께가성마비가동반된환자들은팔을거의못올

7 84 오주한 최준하 Figure 10. A proposed treatment algorithm for the management of massive, irreparable rotator cuff tears. RTC, rotator cuff; GH, glenohumeral; RTSA, reverse total shoulder arthroplasty; CTA, cuff tear arthropathy. 46) 리고기능이현저히떨어져있기때문에, 기능적관절운동범위를복원하기위하여역행성견관절전치환술이요구된다. 비록역행성견관절전치환술후높은합병증의발생이보고되고있지만, 가성마비가동반된견관절관절염을가진환자에있어서이것은효과적인치료방법일수있다. 또한추가적인광배근이전술을시행하여보다향상된외회전운동을얻을수있을것이다. 반대로가성마비가없이견관절관절염이있는환자에있어서는반관절치환술이적응이될수있고, 이것은안정적인견관절운동을가지고상완골두의전상방이동을막는오구견봉궁이건재한환자들에있어서보다만족스러운결과를얻을수있을것이다. 그러므로, 환자의생리적나이와기능적목표를고려하고임상적, 방사선학적검사를통한적절한평가가수술자에게광범위회전근개파열을가진환자에있어서최선의수술적치료지침을제공해줄것이다. 요약 관절치환술은관절염이진행된광범위회전근개파열환자에서일차적치료법으로고려될수있다. 반관절치환술은가성마비가없는회전근개파열관절병증을가진환자에서오구견봉궁이건재할경우만족스러운결과를얻을수있다. 또한, 역행성견관절전치환술은가성마비를동반한고령의회전근개파열관절병증을가진환자에서통증완화와능동적거상을회복할수있는가장적합한수술방법이다. 결론적으로치료가어려운광범위회전근개파열환자에서적절한관절치환술의선택은견관절의통증완화와기능적관절운동범위회복을가능하게할수있는주요한치료방법중하나라고생각된다. 그러나, 높은합 병증의발생을고려할때제대로된적응증을가지고환자의선택을하고충분한경험을가지고수술에임해야할것으로생각한다. 참고문헌 1. Post M, Silver R, Singh M. Rotator cuff tear. Diagnosis and treatment. Clin Orthop Relat Res. 1983;173: Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am. 2000;82: Neer CS 2nd, Craig EV, Fukuda H. Cuff-tear arthropathy. J Bone Joint Surg Am. 1983;65: Feeley BT, Gallo RA, Craig EV. Cuff tear arthropathy: current trends in diagnosis and surgical management. J Shoulder Elbow Surg. 2009;18: Zingg PO, Jost B, Sukthankar A, Buhler M, Pfirrmann CW, Gerber C. Clinical and structural outcomes of nonoperative management of massive rotator cuff tears. J Bone Joint Surg Am. 2007;89: Hersche O, Gerber C. Passive tension in the supraspinatus musculotendinous unit after long-standing rupture of its tendon: a preliminary report. J Shoulder Elbow Surg. 1998;7: Gladstone JN, Bishop JY, Lo IK, Flatow EL. Fatty infiltration and atrophy of the rotator cuff do not improve after rotator cuff repair and correlate with poor functional outcome. Am J

8 85 Sports Med. 2007;35: Burkhart SS. Arthroscopic treatment of massive rotator cuff tears. Clinical results and biomechanical rationale. Clin Orthop Relat Res. 1991;267: Gartsman GM. Massive, irreparable tears of the rotator cuff. Results of operative debridement and subacromial decompression. J Bone Joint Surg Am. 1997;79: Gerber C, Maquieira G, Espinosa N. Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears. J Bone Joint Surg Am. 2006;88: Kempf JF, Gleyze P, Bonnomet F, et al. A multicenter study of 210 rotator cuff tears treated by arthroscopic acromioplasty. Arthroscopy. 1999;15: Neer CS 2nd, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am. 1982;64: Rockwood CA Jr, Williams GR Jr, Burkhead WZ Jr. Debridement of degenerative, irreparable lesions of the rotator cuff. J Bone Joint Surg Am. 1995;77: Sarris IK, Papadimitriou NG, Sotereanos DG. Bipolar hemiarthroplasty for chronic rotator cuff tear arthropathy. J Arthroplasty. 2003;18: Zuckerman JD, Scott AJ, Gallagher MA. Hemiarthroplasty for cuff tear arthropathy. J Shoulder Elbow Surg. 2000;9: Post M, Jablon M. Constrained total shoulder arthroplasty. Long-term follow-up observations. Clin Orthop Relat Res. 1983;173: Amstutz HC, Thomas BJ, Kabo JM, Jinnah RH, Dorey FJ. The Dana total shoulder arthroplasty. J Bone Joint Surg Am. 1988;70: Orr TE, Carter DR, Schurman DJ. Stress analyses of glenoid component designs. Clin Orthop Relat Res. 1988;232: Franklin JL, Barrett WP, Jackins SE, Matsen FA 3rd. Glenoid loosening in total shoulder arthroplasty. Association with rotator cuff deficiency. J Arthroplasty. 1988;3: Nwakama AC, Cofield RH, Kavanagh BF, Loehr JF. Semiconstrained total shoulder arthroplasty for glenohumeral arthritis and massive rotator cuff tearing. J Shoulder Elbow Surg. 2000;9: Goldberg SS, Bell JE, Kim HJ, Bak SF, Levine WN, Bigliani LU. Hemiarthroplasty for the rotator cuff-deficient shoulder. J Bone Joint Surg Am. 2008;90: Frankle MA. Rotator cuff deficiency of the shoulder. New York: Thieme Medical Publishers, Inc.; Visotsky JL, Basamania C, Seebauer L, Rockwood CA, Jensen KL. Cuff tear arthropathy: pathogenesis, classification, and algorithm for treatment. J Bone Joint Surg Am. 2004;86 Suppl 2: Sanchez-Sotelo J, Cofield RH, Rowland CM. Shoulder hemiarthroplasty for glenohumeral arthritis associated with severe rotator cuff deficiency. J Bone Joint Surg Am. 2001;83: Baulot E, Sirveaux F, Boileau P. Grammont's idea: the story of Paul Grammont's functional surgery concept and the development of the reverse principle. Clin Orthop Relat Res. 2011;469: Gartsman GM, Edwards TB. Shoulder arthroplasty. 1st ed. Philadelphia: Elsevier Saunders; Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Molé D. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. Results of a multicentre study of 80 shoulders. J Bone Joint Surg Br. 2004;86: Werner CM, Steinmann PA, Gilbart M, Gerber C. Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am. 2005;87: Cuff D, Pupello D, Virani N, Levy J, Frankle M. Reverse shoulder arthroplasty for the treatment of rotator cuff deficiency. J Bone Joint Surg Am. 2008;90: Boileau P, Watkinson D, Hatzidakis AM, Hovorka I. Neer Award 2005: the Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. J Shoulder Elbow Surg. 2006;15: Bufquin T, Hersan A, Hubert L, Massin P. Reverse shoulder arthroplasty for the treatment of three- and four-part fractures of the proximal humerus in the elderly: a prospective review of 43 cases with a short-term follow-up. J Bone Joint Surg Br. 2007;89: Wall B, Nové-Josserand L, O'Connor DP, Edwards TB, Walch G. Reverse total shoulder arthroplasty: a review of results according to etiology. J Bone Joint Surg Am. 2007;89: Young SW, Everts NM, Ball CM, Astley TM, Poon PC. The SMR reverse shoulder prosthesis in the treatment of cuff-deficient shoulder conditions. J Shoulder Elbow Surg. 2009;18: Frankle M, Levy JC, Pupello D, et al. The reverse shoulder prosthesis for glenohumeral arthritis associated with severe

9 86 오주한 최준하 rotator cuff deficiency. A minimum two-year follow-up study of sixty patients surgical technique. J Bone Joint Surg Am. 2006;88 Suppl 1 Pt 2: Favard L, Levigne C, Nerot C, Gerber C, De Wilde L, Mole D. Reverse prostheses in arthropathies with cuff tear: are survivorship and function maintained over time? Clin Orthop Relat Res. 2011;469: Boileau P, Gonzalez JF, Chuinard C, Bicknell R, Walch G. Reverse total shoulder arthroplasty after failed rotator cuff surgery. J Shoulder Elbow Surg. 2009;18: Mulieri P, Dunning P, Klein S, Pupello D, Frankle M. Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis. J Bone Joint Surg Am. 2010;92: Oh JH, Kim SH, Shin SH, et al. Outcome of rotator cuff repair in large-to-massive tear with pseudoparalysis: a comparative study with propensity score matching. Am J Sports Med. 2011;39: Boileau P, Chuinard C, Roussanne Y, Bicknell RT, Rochet N, Trojani C. Reverse shoulder arthroplasty combined with a modified latissimus dorsi and teres major tendon transfer for shoulder pseudoparalysis associated with dropping arm. Clin Orthop Relat Res. 2008;466: Zumstein MA, Pinedo M, Old J, Boileau P. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg. 2011;20: Lévigne C, Boileau P, Favard L, et al. Scapular notching in reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2008;17: Simovitch RW, Zumstein MA, Lohri E, Helmy N, Gerber C. Predictors of scapular notching in patients managed with the Delta III reverse total shoulder replacement. J Bone Joint Surg Am. 2007;89: Gutiérrez S, Greiwe RM, Frankle MA, Siegal S, Lee WE 3rd. Biomechanical comparison of component position and hardware failure in the reverse shoulder prosthesis. J Shoulder Elbow Surg. 2007;16:S9-S Nyffeler RW, Werner CM, Gerber C. Biomechanical relevance of glenoid component positioning in the reverse Delta III total shoulder prosthesis. J Shoulder Elbow Surg. 2005;14: Edwards TB, Williams MD, Labriola JE, Elkousy HA, Gartsman GM, O'Connor DP. Subscapularis insufficiency and the risk of shoulder dislocation after reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2009;18: Nam D, Maak TG, Raphael BS, Kepler CK, Cross MB, Warren RF. Rotator cuff tear arthropathy: evaluation, diagnosis, and treatment: AAOS exhibit selection. J Bone Joint Surg Am. 2012;94:e34.

10 87 pissn : , eissn : Instructional Course Lecture J Korean Orthop Assoc 2013; 48: Management of Massive Rotator Cuff Tear Current Concepts of Arthroplasty for the Treatment of Massive Rotator Cuff Tears Joo Han Oh, M.D., Ph.D., and Jun Ha Choi, M.D. Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Joint Disease Reconstruction Center, Seoul National University Bundang Hospital, Seongnam, Korea The purpose of this article was to explore current concepts of arthroplasty as a treatment for massive rotator cuff tears. Pubmed was searched using the words massive rotator cuff tears and arthroplasty for suitable articles, which were then reviewed and investigated with respect to history, indications, clinical outcomes, and treatment algorithms of arthroplasty in patients of massive rotator cuff tear. Arthroplasty can be considered a primary surgical treatment for patients with irreparable massive rotator cuff tears and hemiarthroplasty may be the treatment of choice in younger patients with an intact coracoacromial arch and no pseudoparalysis. Reverse total shoulder arthroplasty is the best surgical treatment for pain relief and the restoration of active forward flexion in elderly patients with cuff tear arthropathy and pseudoparalysis. Proper selection of arthroplasty can provide pain relief and functional improvement in patients with massive rotator cuff tears. However, complication rates remain high, and emphasize the importance of appropriate patient selection and careful operative technique. Key words: shoulder, massive rotator cuff tears, arthroplasty Received January 17, 2013 Revised January 24, 2013 Accepted January 25, 2013 Correspondence to: Jun Ha Choi, M.D. Joint Disease Reconstruction Center, Seoul National University Bundang Hospital, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam , Korea TEL: FAX: junha78@gmail.com The Journal of the Korean Orthopaedic Association Volume 48 Number Copyright 2013 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

22-김명선/

22-김명선/ 대한견 주관절학회지제 13 권제 1 호 J. of Korean Shoulder and Elbow Society Volume 13, Number 1, June, 2010 광범위회전근개파열에서관절성형술 전남대학교의과대학정형외과학교실 김명선 문은선 Massive Rotator Cuff Tears: Arthroplasty Myung-Sun Kim, M.D., Eun-Sun