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1 대한견 주관절학회지제 12 권제 2 호 J. of Korean Shoulder and Elbow Society Volume 12, Number 2, December, 2009 골결손이동반된전방견관절불안정성에서개방적수술술기 경희대학교의과대학정형외과학교실 이봉근 이용걸 Open Techniques for Bone Defect in Anterior Shoulder Instability Bong-Gun Lee, M.D., Yong-Girl Rhee, M.D. Department of Orthopaedic Surgery, Kyung Hee University School of Medicine, Seoul, Korea Purpose: An osseous defect in the glenoid and humeral head is closely associated with recurrence of anterior shoulder instability. The purpose of this article is to describe the open surgical techniques and introduce our experiences with anterior instability with a significant osseous defect. Materials and Methods: We reviewed the articles that have focused on and/or mentioned the affect of osseous defects on anterior shoulder instability. The open surgical techniques and its related pearls are summarized in this review. Results: Accurate evaluation for the size and location of the osseous defect is critical for preventing recurrence after restoration of the anterior capsulolabral structure. The glenoid bone restoration techniques include the coracoids transfer (the Bristow procedure and the Latarjet procedure) and a structural iliac bone graft. Rotational humeral osteotomy and an osteoarticular allograft could be used for repairing a significant posterosuperior humeral defect (Hill-Sachs lesion). Shoulder arthroplasty may be tried for treating a humeral bone defect, but more study on this is needed. Conclusion: Open surgical restoration decreases the risk of recurrence anterior shoulder instability that is combined with a significant osseous defect. Arthroscopic surgery currently has limitations for treating an osseous defect, but it will become useful in proportion to the development of arthroscopic instruments and techniques in the future. Key Words: Shoulder, Glenoid, Hill-Sachs lesion, Anterior instability, Bone graft, Open technique 서 고식적으로절개하여 Bankart 술식을하는경우대 론 체적으로 2% 에서 8% 정도의재발률이보고된바있고관절경적시술은개방술에비해높은재발률을보고하고있었으나관절경기구및기술의발달에따라최근 통신저자 : 이용걸서울시동대문구회기동 1 번지경희대학교의과대학정형외과학교실 Tel: 02) , Fax: 02) , shoulderrhee@hanmail.net 접수일 : 2009 년 11 월 9 일, 1 차심사완료일 : 2009 년 11 월 23 일, 게재확정일 : 2009 년 12 월 22 일 255

대한견 주관절학회지제 12 권제 2 호 에는관혈적방법과비슷한결과를보고하는논문이발표되고있다 1,14). 본교실의경우에있어서도관혈적방법의경우 4%, 관절경술의경우에있어서는 7.6% 의재발률을보이고있다 10,31). 견관절탈구에대한수술의결과가좋아졌다고하지만일부환자에서여전히재탈구가발생하고있다. 재탈구를일으킬수있는원인은다양하다.

2 대한견 주관절학회지제 12 권제 2 호 에는관혈적방법과비슷한결과를보고하는논문이발표되고있다 1,14). 본교실의경우에있어서도관혈적방법의경우 4%, 관절경술의경우에있어서는 7.6% 의재발률을보이고있다 10,31). 견관절탈구에대한수술의결과가좋아졌다고하지만일부환자에서여전히재탈구가발생하고있다. 재탈구를일으킬수있는원인은다양하다. 저자들의연구 10) 와 Warren 등 25) 의연구에서도새로운외상이재발의가장큰원인으로있으나, 초기진단과수술시의오류도원인이될수있다. 초기진단의오류에는, 다방향불안정성을단방향전방불안정성으로오진하는경우또는수의성불안정성을수술한경우등이포함되고, 수술시의기술적오류에는파열된관절낭관절와순복합체의불완전한복원과과도한전하방관절낭을해결하지못한경우, 골결손이심한 Bankart 병변이나진입 (engaging) Hill-Sachs 병변을간과한경우등이있다. 관절와결손과 Hill-Sachs 병변은 Bankart 병변과더불어전방불안정성의 pathologic triad라불리고있다 4). 하지만그동안의견관절전방불안정성의관절경적수술은대개 Bankart 병변에초점이맞춰져있었다. 골결손이동반된전방불안정성의재발률은 60% 까지보고되기도하여, Hill-Sachs 병변과관절와의골결손이클경우이에대한치료가동반되어야재탈구의위험을낮출수있다 5,6). 저자들은외상성견관절전방불안정성의치료에서 Hill-Sachs 병변과관절와의골결손을치료하기위한개방적술식을알아보고자한다. 전방불안정성을가진환자를치료하기전에구징후 (sulcus sign), 불안감검사 (apprehension test), 과도이완 (hyperlaxity) 등을포함한이학적검사뿐만아니라골결손에대한평가가반드시필요하다. 골결손정도를파악해야만어떤수술을할것인지최종결정할수있다. 관절경적검사로골결손을진단하고필요시개방술로전환할수있겠으나, 비침습적인방사선검사도골결손을평가하는데대개유용하다. 골결손에대한방사선학적평가본교실에서는전방불안정성의기본방사선검사로견관절정전후방견관절촬영 (true shoulder AP view), 액와측면촬영 (axillary lateral view), 첨부사면촬영 (apico-oblique view) 그리고관절와윤곽촬영 (glenoid profile view) 를시행하고있다. 액와측면촬영에서관절와와상완골두의전후방위치관계를알수있고, 상완골두의압박골절, 전방혹은후방관절와골절, 오두돌기골절등을알수있다. 환자가통증으로팔을외전시킬수없을경우 Velpeau 액 A B Fig. 1. Glenoid profile view (A) Normal glenoid shows sharp triangular shape at anterior margin. (B) The glenoid with bone defect shows blurred triangular shape (black arrow) called blunted angle sign. (C) In 3-dimentional reconstruction CT of same case, significant glenoid defect is observed. C 256

이봉근 : 골결손이동반된전방견관절불안정성에서개방적수술술기 와촬영을하기도한다. 첨부사면촬영은흉곽면에 45 도하방으로 45 도기울인상태에서촬영하는것으로관절와의전하방의골결손이나골성 Bankart 병변뿐아니라, Hill-Sachs 병변도잘관찰되기때문에전방불안정성의골병변을진단하는데가장흔히사용되는촬영이다 30).

3 이봉근 : 골결손이동반된전방견관절불안정성에서개방적수술술기 와촬영을하기도한다. 첨부사면촬영은흉곽면에 45 도하방으로 45 도기울인상태에서촬영하는것으로관절와의전하방의골결손이나골성 Bankart 병변뿐아니라, Hill-Sachs 병변도잘관찰되기때문에전방불안정성의골병변을진단하는데가장흔히사용되는촬영이다 30). 관절와윤곽촬영 (glenoid profile view) 은손을머리위로반대측귀부분에대어팔이견갑면에서최대외전되도록한상태로지면에대해 30 도각도로견갑면에평행하게방사선을조사하여촬영하는것으로관절면의모양을파악하고및골결손을평가하기에유용하다 11) (Fig. 1A). 관절와전하방에골이식술을시행한후나사못의관절침범여부를확인하기에도유용한검사이다. 이검사에서관절와의전연이삼각형모양으로보이지않을경우 blunted angle sign이라고하여관절와의전방결손을의미한다 (Fig. 1B). 이외에사용되는방법으로 Stryker notch view와 West point view가있다. Stryker notch view는 Hill-Sachs 병변의크기와위치를평가하기에적절한반면, West Point view는관절와의전하방병변을검사하는방법이다. 컴퓨터단층촬영은단순방사선검사로진단하기어려운골병변을찾기에유용하고축상면및시상면촬영을통해 Hill-Sach 병변및관절와결손의크기와깊이를평가할수있다 (Fig. 1C). 3차원재건영상을할경우결손의크기와위치뿐만아니라방향 (orientation) 도가늠할수있다는장점이있다 34). 또한오구돌기이전술을시행하기전에오구돌기의길이및두께를미리가늠할수도있어본교실에서는수술전기본검사로시행하고있다. 자기공명검사는관절와순을포함한연부조직의상태를평가할수있다는장점이있으며, 기타회전근개나 SLAP 병변과같은동반병변도파악할수있다. 관절와결손 (Gelnoid defect) 관절와결손이 25% 이상일경우전방불안정성에영향을미치게된다 20,27). 그기전으로첫째, 탈구가일어나기위해필요한전단력 (translational force) 의감소이다. 관절와결손에의해관절와전후방직경의감소하게되면상완골두가아탈구되기위해이동해야하는관절와의거리가작기때문에적은외력에도쉽게탈구되는것이다. Itoi 등 20) 은관절와길이의 21% 이상또는폭 6.8 mm의이상의결손시아탈구에필요한전단력이유의하게감소한다고하였다. 둘째, 축성력 (axial force) 에저항하는 bony buttress 기능의상실이다. 골결손에의한 the arc of length (Fig. 2) 가감소되면서전하방골구조가받게되는축성력이관절낭관절와순복합체 (capsulolabral complex) 로전가되면서탈구의위험도증가하게된다 6). 셋째, 골결손이있는관절와에 Bankart 봉합술을시행하면전방관절낭의긴장이증가하여외회전감소가일어나게되며, 임상적결과도결손이없는경우보다좋지않을수있다 32). 재탈구의위험을증가시킬수있는관절와결손을해결하는개방적술식으로 Bristow 술식과 Latarjet 술식, 자가장골이식등이있다. 이는관절와의골결손을다른골조직을이용해해부학적으로재건하는방법으로관절와의 arc of length를증가시킬뿐만아니라 buttress effect를복원시키는역할을한다. Coracoid Transfer Bristow procedure 오구돌기의끝부분과 conjoined tendon을관절와의전하방으로이동시키는술식으로 1958년에 Helfet A B Fig. 2. Effect of glenoid defect (A) The glenoid without bone defect has a sufficient arc of length and bony buttress. (B) The glenoid with bone defect has a diminished arc of length and loss of buttress, which make the glenohumeral joint more unstable. 257

대한견 주관절학회지제 12 권제 2 호 가그의스승 Bristow의이름을붙이면서유래하게되었다 16). 이술식은소흉근 (pectoralis minor) 의부착부보다원위부에서오구돌기를절단하고 conjoined tendon ( 오구상완건과상완이두건 ) 과함께견갑하근을통하여관절와의전방에이전시키는것이다.

4 대한견 주관절학회지제 12 권제 2 호 가그의스승 Bristow의이름을붙이면서유래하게되었다 16). 이술식은소흉근 (pectoralis minor) 의부착부보다원위부에서오구돌기를절단하고 conjoined tendon ( 오구상완건과상완이두건 ) 과함께견갑하근을통하여관절와의전방에이전시키는것이다. 이때오구돌기의절단면이견갑골경부의전면 (anterior surface) 에맞닿도록한다. 이술식은관절와골결손외에도, Bankart 술식으로는관절낭관절와순복합체를복원할수없는관절낭결손에이용되기도한다 39). 대개단독으로시행되나 Bankart 술식과함께시행될수있다 42). 이전된오구돌기는골결손부를복원하여 arc of length 및 bony buttress를회복시켜줄뿐만아니라이전된 conjoined tendon은견관절이외전및외회전될때전하방관절낭의전방에위치하여 soft tissue buttress로작용한다는장점이있다. 임상적결과도우수한것으로보고되어 Schroder 등 35) 은 52 례의환자를평균 26 년추시한결과불안정성을느끼는경우는 8례 (15.4%) 이었고, 탈구는 5례 (9.6%) 에서발생하여 70% 에서좋은결과를보였다고하였다. Banas 등 2) 은 modified Bristow 술식을이용하여치료한 79 명을평균 8.6 년추시하여 4% 의재탈구율과평균 9도의외회전감소를보였고, 골유합은 82% 에서이루어졌다고하였다. 단점으로는 73% 의환자에서는어깨통증이있어나사못을제거하였다고하였다. 이외에도이술식의단점으로절골된오구돌기의골편이작아내고정을위한나사못을 1개밖에사용하지못하여 고정력이약하다는점과, 외회전제한이흔히동반되고, 이식물이견갑하근을통과하면서근육을단축시키는효과를나타내어내회전구축이나내회전력감소가나타나기도한다는점이다 17). 따라서운동선수에게사용하기는부담스러운술식이다 2). 술후합병증으로는통증을동반한불안정성의재발, 연골손상, 이식골의불유합, 나사못의이완과후방불안정성, 신경및혈관손상, 관절염등이보고되고있다 19,37,43). Hovlelius 등 18,19) 은성공적인수술을위한 5가지사항으로 1) 오구돌기는관절와전방연 (anterior rim) 보다 5 mm이하로내측에위치해야하며, 2) 관절와의전하방에위치해야하고, 3) 골유합이이루어져하며 4) 나사못이견갑골경부의후방피질골을통과해야하고 5) 나사못이관절면을침범하지않아야한다고하였다. 관절경적기술의발달로 Boileau 등 3) 은관절경적 Bristow 술식을보고하기도하였다. Latarjet procedure Latarjet 24) 에의해 1954년발표된이술식은 Bristow 술식과크게세가지점에서차이가있다. 첫째, Bristow보다더근위부에서오구돌기를절골한다. 그결과전이되는골편의크기가대개 2~3 cm 가되어고정시나사못2개를사용할수있어보다견고한고정을할수있다 (Fig. 3C). 둘째, 골편에오구견봉인대가부착되어있다는점이다. 고정시오구견봉인대는관절연에위치하여견관절관절낭과중첩하 A B C Fig. 3. Latarjet operation (A) Engaging Hill-Sachs lesion (B) The Latarjet procedure extends the glenoid arc to such a degree that the humerus cannot externally rotate enough to cause engagement of the Hill-Sachs lesion over the front of the graft(burkhart et al, Arthroscopy 2007;23(10): ). (C) A transferred coracoid process is well fixed on anterior aspect of glenoid and the arc of length has been restored. 258

이봉근 : 골결손이동반된전방견관절불안정성에서개방적수술술기 여봉합할수있어안정성에기여한다. 셋째, 고정시절골면이아닌오구돌기의하면 (inferior surface) 이견갑골경부의전면과맞닿도록한다. 오구돌기는대개하방으로오목하기때문에고정하기전에하면을편평하게하는과정이필요하다.

5 이봉근 : 골결손이동반된전방견관절불안정성에서개방적수술술기 여봉합할수있어안정성에기여한다. 셋째, 고정시절골면이아닌오구돌기의하면 (inferior surface) 이견갑골경부의전면과맞닿도록한다. 오구돌기는대개하방으로오목하기때문에고정하기전에하면을편평하게하는과정이필요하다. Latarjet 술식은 Bristow 술식과마찬가지로관절와의직경을넓게하고 buttress를복원하는 bony effect를가질뿐만아니라, 이외에도견갑하근의하방 1/3 이보존되고 (muscle effect), 오구견봉인대를이용하여관절낭을봉합할수있는장점 (capsular effect) 이있다. 이세가지효과를통틀어 Latarjet 술식의 triple blocking effect라한다 12). 저자들이경험한 28 례를분석해보면, 12례는골결손이있어일차수술로 Latarjet 술식으로치료했던경우이고 16 례는 Bankart 술식으로치료받은후재탈구되어재수술했던경우이다. 일차수술로 13 례는관절경으로, 3례는개방적방법으로 Bankart 술식을받았다. 수술시평균연령은 28.9 세였으며남자가 28 명여자가 4명이었다. 평균 11 개월추시상전방굴곡은술전 159.4도에서 160.2도로큰차이가없었으나, 외회전은술전 53.2 도에서 44.1도로 9.1도감소하였다. 1명의재탈구와 1명의아탈구가관찰되었다. 방사선검사에서골편의불유합이 2례에서관찰되었으나아탈구와는관련이없었다. Burkhart 등 7) 은골결손이있는 102 례를 Latarjet 술식으로치료한결과 4례에서재탈구, 1 례에서아탈구가일어나 4.9% 의재발을보여양호한결과를보고하였다. Latarjet 술식은관절와결손뿐만아니라 Hill-Sachs lesion이클경우에도이용될수있다. 관절와의반경 (arc of glenoid) 을더크게하면 Hill-Sachs 병변이관절와의전연 (anterior rim) 에진입 (engagement) 되기까지필요한상완골의외회전각도가커지게되어 Hill-Sachs 병변에의한탈구의위 험을감소시키게된다 7) (Fig. 3A,B). 최근에는 Laffosse 등 23) 이 44 례의관절경적 Latarjet 수술의경험을보고하였으나관절경술이개방술에비해어느정도효과가있는지는더경과를관찰할필요가있다. Structural iliac bone graft 자가장골이식 (autogenous iliac bone graft) 방법은이식골의크기를조절할수있으며, tricorical bone을얻을수있어이식편이견고하다는장점이있으며, 수술결과도양호한것으로보고되고있다 38). 하지만 Rahme 등 29) 은 77 례를평균 29 년장기추시한결과 74% 가만족하였으나 15 례 (20%) 에서불안정성을호소하였고, 8례에서재수술이필요하였으며, 47% 에서퇴행변화를보였다고하였다. 이술식은오구돌기이전술와비교해볼때, conjoined tendon에의한 soft tissue effect가없으며장골을떼어내어또다른수술흔이남고그부위에통증이크며, 수술시간이길어진다는단점이있다. 그러나오구돌기가작거나골절이있어오구돌기이전술을사용할수없을때유용한방법이다. 상완골두결손 (Hill-Sachs lesion) Hill-Sachs 병변은처음탈구된환자에게서도흔히관찰되지만, 탈구가반복될수록발생이증가하여탈구횟수와 Hill-Sachs 병변의빈도가비례하는것으로알려져있다 8,36). Hill-Sachs 병변은그크기뿐만아니라위치 (location) 와방향 (orientation) 도임상적인의의를가지고있다. Burkhart와 De Beer는 Hill- Sachs 병변에 engagement라는개념을부여하였는데, A B Fig. 4. Arthroscopic decision for Hill-Sachs lesion (A) Non-engaging Hill-Sachs lesion (B) Engaging lesion is parallel to the anterior glenoid rim in functional range of motion of shoulder. 259

대한견 주관절학회지제 12 권제 2 호 관절와의전연의방향 (orientation) 과 Hill-Sachs 병변의방향이기능적인관절운동범위에서일치할경우쉽게탈구되게되는데이렇게방향이관절와의전연과일치하는 Hill-Sachs 병변을진입형 (engaging type) 이라고하였다 6) (Fig. 4).

6 대한견 주관절학회지제 12 권제 2 호 관절와의전연의방향 (orientation) 과 Hill-Sachs 병변의방향이기능적인관절운동범위에서일치할경우쉽게탈구되게되는데이렇게방향이관절와의전연과일치하는 Hill-Sachs 병변을진입형 (engaging type) 이라고하였다 6) (Fig. 4). Yamamoto 등 41) 은 glenoid와접촉하는 humeral head의부분을 glenoid tract 이라는하였는데, glenoid tract의내측연은 foot print로부터평균 18.4 mm 정도에위치하며, Hill- Sachs 병변이 glenoid tract의내측연보다더내측에위치할수록탈구의위험이높다고하였다. Hill-Sachs 병변을치료하는방법으로골이식을통해골결손을복원하는해부학적방법이있고, 비해부학적방법으로골결손을극하건및후방관절낭으로덮어주는 Remplissage 수술법과, Hill-Sachs 병변이기능적관절운동범위에서관절와전연에이르지않도록절골후골두를내회전시키는회전절골술이있다. Weber 절골술 (Rotational humeral osteotomy) Weber등은 1964년부터전방불안정성과연관된상완골두의후외방골결손을회전절골술을통해치료하였다. 이수술의원리는상완골두의후염각 (retroversion) 을증가시켜외회전시골결손부가관절와의전연에이르지않도록하는것이다 40). Weber는 180 례를추시하여 5.7% 의재탈구를보였으며, 90% 에서양호한결과가관찰되었고평균외회전각의감소는 5도미만이었다고하였다. 이술식의결과는양호한것으로보고되고있으나, 다른술식에비해침습적이며, 불유합이나지연유합의가능성이있고, 내고정물을제거해 야할경우추가적인수술이필요하며, 정상적인해부학적구조를변화시켜생역학적인변화를초래한다는단점이있다. Kronberg와 Brostrom 21) 은5년간 20례를경험하면서관절염의합병증은없었다고하였으나, Flury 등 13) 은 14 년이상의장기추시한 34 례중 90% 에서퇴행성변화를보였으며, 이는절골후골두를내회전시킨각도와비례한다고하여골두를 20 도이상의내회전시키지않도록권유하였다. 이술식에대해분석한보고가많지않은점을볼때일반화되기어려운술식으로보인다. 골관절동종이식 (Osteoarticular allograft) Hill-Sachs 병변의해부학적복원은골결손에대한근본적인치료법이겠지만, 침습적이고적절한이식물을얻기어려운단점이있다. Miniaci 등 25) 은관절연골을포함한동종골 (allogenous bone graft) 을 Hill-Sach 병변에이식하는방법으로치료한재발된전방불안정성 18 례의결과를보고하였다. 평균 50 개월을추시한결과평균 constant score는 78.5점이었고, 16례가직업활동에복귀하여양호한결과를나타내었다. 하지만연장된삼각흉간접근법 (extended delto-pectoral approach) 을사용하고, 관절낭과견갑하근을절개하여침습적이라는단점이있을뿐만아니라, 이식한골의붕괴, 관절염, 아탈구등의합병증을보였으며 2례에서유관나사못을제거하는술식이필요하여아직일반적으로적용하기에는무리가있는수술방법이다. Kropf 와 Sekiya 22) 는전방불안정성에서제한적후방도달법 (limited posterior approach) 을이용한골이식방법 A B C Fig. 5. Arthroplasty in locked dislocation (A) A 72 years old woman presented locked anterior shoulder dislocation in left shoulder. (B) Intraoperative photograph shows large bone defect on humeral head and rotator cuff deficiency. (C) Reverse total shoulder arthroplasty was performed. 260

7 이봉근 : 골결손이동반된전방견관절불안정성에서개방적수술술기 을소개하였다. 이는전방의 Bankart 병변은관절경적으로복원하고 Hill-Sachs 병변이클경우추가적으로시행한것으로광범위삼각흉도달법 (extensive deltopectoral approach) 보다는비교적비침습적이라는장점이있으나증례보고외의임상결과가보고되지않아쉽게시도해볼만한수술은아닌것으로생각된다. 관절경을이용한골이식도시도되어 Chapovsky 와 Kelly 9) 는관절경을이용한동종골이식방법을증례보고하였지만관절경적시술은아직더많은연구와경험이필요하다. Shoulder arthroplasty 전방불안정성에서상완골두의골결손이심할경우인공관절치환술이시도될수있다. Hill-Sachs 병변에대한부분관절면치환술 (partial articular resurfacing) 이시도되고있으나 15,26), 현재까지는증례보고에국한되어있고, 전치환술에대한보고는아직없어그사용이제한적이다. 정복되지않는전방불안정성에대한치료로인공관절치환술이사용될수있다 28,33). 고령에서는정복되지않는견관절에서골결손이나광범위회전근개파열및관절염이동반되었을때적응증이될수있지만젊은연령에서인공관절치환술은인공관절의수명을고려할때적용하기어려운술식이다 (Fig. 5). 결 견관절의전방불안정성에서관절와및상완골두의골결손, 즉관절와라는그릇과상완골두라는공, 양쪽의상태를염두에두고수술을하여야재발을최소화시킬수있다. 25% 이상의관절와결손이있을경우오구돌기이전술은유용한술식이며, 경우에따라서는자가장골이식이사용될수있다. 크기가크고진입 Hill-Sachs 병변이있을경우상완골두에동종골이식술을절개하거나관절경술로시도할수있으나아직도장기간의노력이필요한부분이며, 인공관절치환술은고령의환자에서진행된관절염이있거나정복되지않는탈구인경우에한해선택적으로시행되는것이타당할것으로보인다. 론 REFERENCE 01) Abrams JS, Savoie FH 3rd, Tauro JC, Bradley JP: Recent advances in the evaluation and treatment of shoulder instability: Anterior, posterior, and multidirectional. Arthroscopy, 18: 1-13, ) Banas MP, Dalldorf PG, Sebastianelli WJ, DeHaven KE: Long-term followup of the modified Bristow procedure. Am J Sports Med, 21: , ) Boileau P, Bicknell RT, El Fegoun AB, Chuinard C: Arthroscopic Bristow procedure for anterior instability in shoulders with a stretched or deficient capsule: The Belt-and-suspenders Operative technique and preliminary results. Arthroscopy, 23: , ) Bost FC, Inman VT: The pathological changes in recurrent dislocation of the shoulder: A report of Bankart's operative procedure. J Bone Joint Surg Am, 24: , ) Burkhart SS, Danaceau SM: Articular arc length mismatch as a cause of failed Bankart repair. Arthroscopy, 16: , ) Burkhart SS, De Beer JF: Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the invertedpear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy, 16: , ) Burkhart SS, De Beer JF, Barth JR, Cresswell T, Roberts C, Richards DP: Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss. Arthroscopy, 23: , ) Calandra JJ, Baker CL, Uribe J: The incidence of Hill-Sachs lesions in initial anterior shoulder dislocations. Arthroscopy, 5: , ) Chapovsky F, Kelly JDt: Osteochondral allograft transplantation for treatment of glenohumeral instability. Arthroscopy, 21: 1007, ) Cho NS, Hwang JC, Rhee YG: Arthroscopic stabilization in anterior shoulder instability: Collision athletes versus noncollision athletes. Arthroscopy, 22: , ) Edwards TB, Boulahia A, Walch G: Radiographic analysis of bone defects in chronic anterior shoulder instability. Arthroscopy, 19: , ) Elattrache NS: Surgical techniques in sports medicine, Philadelphia, Lippincott Williams & Wilkins: , ) Flury MP, Goldhahn J, Holzmann P, Simmen BR: Does Weber s rotation osteotomy induce degenerative joint disease at the shoulder in the long term? J Shoulder Elbow Surg, 16: , ) Gartsman GM, Roddey TS, Hammerman SM: Arthroscopic treatment of anterior-inferior glenohumeral instability. Two to five-year follow-up. J Bone Joint Surg Am, 82: , ) Grondin P, Leith J: Case series: Combined large Hill-Sachs and bony Bankart lesions treated by Latarjet and partial humeral head resurfacing: A report of 2 cases. Can J Surg, 52: , ) Helfet AJ: Coracoid transplantation for recurring dislocation of the shoulder. J Bone Joint Surg Br, 40:

8 대한견 주관절학회지제 12 권제 2 호 202, ) Hovelius L, Akermark C, Albrektsson B, et al.: Bristow-latarjet procedure for recurrent anterior dislocation of the shoulder. A 2-5 year follow-up study on the results of 112 cases. Acta Orthop Scand, 54: , ) Hovelius L, Korner L, Lundberg B, et al.: The coracoid transfer for recurrent dislocation of the shoulder. Technical aspects of the Bristow-Latarjet procedure. J Bone Joint Surg Am, 65: , ) Hovelius L, Sandstrom B, Saebo M: One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: Study II-the evolution of dislocation arthropathy. J Shoulder Elbow Surg, 15: , ) Itoi E, Lee SB, Berglund LJ, Berge LL, An KN: The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: A cadaveric study. J Bone Joint Surg Am, 82: 35-46, ) Kronberg M, Brostrom LA: Rotation osteotomy of the proximal humerus to stabilise the shoulder. Five years experience. J Bone Joint Surg Br, 77: , ) Kropf EJ, Sekiya JK: Osteoarticular allograft transplantation for large humeral head defects in glenohumeral instability. Arthroscopy, 23: , ) Lafosse L, Lejeune E, Bouchard A, Kakuda C, Gobezie R, Kochhar T: The arthroscopic Latarjet procedure for the treatment of anterior shoulder instability. Arthroscopy, 23: , ) Latarjet M: [treatment of recurrent dislocation of the shoulder.]. Lyon Chir, 49: , ) Miniaci A, Gish MW: Management of anterior glenohumeral instability associated with large Hill-Sachs defects. Tech Shoulder Elbow Sur, 5: , ) Moros C, Ahmad CS: Partial humeral head resurfacing and Latarjet coracoid transfer for treatment of recurrent anterior glenohumeral instability. Orthopedics, 32: 8, ) Porcellini G, Campi F, Paladini P: Arthroscopic approach to acute bony Bankart lesion. Arthroscopy, 18: , ) Pritchett JW, Clark JM: Prosthetic replacement for chronic unreduced dislocations of the shoulder. Clin Orthop Relat Res, 216: 89-93, ) Rahme H, Wikblad L, Nowak J, Larsson S: Longterm clinical and radiologic results after Eden-Hybbinette operation for anterior instability of the shoulder. J Shoulder Elbow Surg, 12: 15-19, ) Rhee YG: The shoulder: Diagnosis and treatement. 1st ed. Seoul, Young Chang: 31-38, ) Rhee YG, Ha JH, Cho NS: Anterior shoulder stabilization in collision athletes: Arthroscopic versus open Bankart repair. Am J Sports Med, 34: , ) Rhee YG, Lim CT: Glenoid defect associated with anterior shoulder instability: Results of open Bankart repair. Int Orthop, 31: , ) Rowe CR, Zarins B: Chronic unreduced dislocations of the shoulder. J Bone Joint Surg Am, 64: , ) Saito H, Itoi E, Minagawa H, Yamamoto N, Tuoheti Y, Seki N: Location of the Hill-Sachs lesion in shoulders with recurrent anterior dislocation. Arch Orthop Trauma Surg, 129: , ) Schroder DT, Provencher MT, Mologne TS, Muldoon MP, Cox JS: The modified Bristow procedure for anterior shoulder instability: 26-year outcomes in naval academy midshipmen. Am J Sports Med, 34: , ) Spatschil A, Landsiedl F, Anderl W, et al.: Posttraumatic anterior-inferior instability of the shoulder: Arthroscopic findings and clinical correlations. Arch Orthop Trauma Surg, 126: , ) Stromqvist B, Wingstrand H, Egund N: Recurrent shoulder dislocation and screw failure after the bristow-latarjet procedure. A case report. Arch Orthop Trauma Surg, 106: , ) Warner JJ, Gill TJ, O Hollerhan JD, Pathare N, Millett PJ: Anatomical glenoid reconstruction for recurrent anterior glenohumeral instability with glenoid deficiency using an autogenous tricortical iliac crest bone graft. Am J Sports Med, 34: , ) Weaver JK, Derkash RS: Don t forget the Bristow- Latarjet procedure. Clin Orthop Relat Res, 308: , ) Weber BG, Simpson LA, Hardegger F: Rotational humeral osteotomy for recurrent anterior dislocation of the shoulder associated with a large Hill-Sachs lesion. J Bone Joint Surg Am, 66: , ) Yamamoto N, Itoi E, Abe H, et al.: Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension: A new concept of glenoid track. J Shoulder Elbow Surg, 16: , ) Yamashita T, Okamura K, Hotta T, Wada T, Aoki M, Ishii S: Good clinical outcome of combined Bankart-Bristow procedure for recurrent shoulder instability: 126 patients followed for 2-6 years. Acta Orthop Scand, 73: , ) Young DC, Rockwood CAJ: Complications of a failed bristow procedure and their management. J Bone Joint Surg Am, 73: ,

9 이봉근 : 골결손이동반된전방견관절불안정성에서개방적수술술기 초록 목적 : 견관절전방불안정성에서관절와및상완골두의골결손은재탈구와밀접히연관되어있다. 의미있는골결손이동반된전방불안정성에서적용될수있는개방적술식을고찰하고저자들의경험을소개하고자한다. 대상및방법 : 전방불안정성에서골결손에대해연구하고발표된논문을조사하여시술되고있는개방적술식들요약하고정리하였다결과 : 전방관절낭관절와순을복원한후재탈구를예방하기위해수술전에방사선학적으로골결손을정확히평가하는것은중요하다. 관절와결손을복원하기위해오구돌기이전술 (Bristow 술식또는 Latarjet 술식 ) 이나자가장골이식을사용할수있고, 상완골두의후상방골결손 (Hill-Sachs병변 ) 에대해서는회전절골술이나동종골이식등이사용될수있다. 골결손에대한인공관절치환술은시도되고있으나아직제한적이며더많은연구가필요하다. 결론 : 개방적술식을통해골결손을복원해야재탈구의위험을낮출수있다. 관절경술을통한골병변의치료가시도되고있으나아직도장기간의노력과연구가필요하다. 색인단어 : 견관절, 관절와, Hill-Sachs 병변, 전방불안정성, 골이식, 개방적술식 263

08-고상훈/47-52

08-고상훈/47-52 대한견 주관절학회지제 13 권제 1 호 J. of Korean Shoulder and Elbow Society Volume 13, Number 1, June, 2010 광범위한 Hill-Sachs 병변에서 Remplissage 술기를이용한관절경적재건술 - 최소 6 개월이상추시결과 - 울산대학교의과대학울산대학교병원정형외과학교실 고상훈 정광환 전형민 박한창 Arthroscopic