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1 316 pissn : , eissn : Original Article J Korean Orthop Assoc 2018; 53: 회전근개파열관절증에대한역행성견관절전치환술시수술적접근법의차이 : 전상방도달법과삼각흉도달법에대한임상및방사선적결과비교 최창혁 곽병훈 오태범 대구가톨릭대학교병원정형외과 Difference in the Surgical Approach in Reverse Total Shoulder Arthroplasty for Cuff Tear Arthroplasty: Comparison of the Radiological and Clinical Result according to the Deltopectoral and Anterosuperior Approach Chang Hyuk Choi, M.D., Byung Hoon Kwack, M.D., and Tae Bum Oh, M.D. Department of Orthopaedic Surgery, Daegu Catholic University Medical Center, Daegu, Korea Purpose: This study compared the clinical and radiological results of reverse total shoulder arthroplasty (RSA) using an anterosuperior approach with those using a deltopectoral approach to determine the difference in cuff tear arthroplasty between both approaches. Materials and Methods: A retrospective review of 24 consecutive patients who underwent RSA due to cuff tear arthroplasty from February 2014 to November 2015 was performed. The anterosuperior and deltopectoral approaches were 12 cases each. The mean age was 72 years and the mean follow-up period was 13.2 months. The clinical results were assessed using the visual analogue pain scale, American Shoulder and Elbow Surgeon score, Korean shoulder scoring system, and the Constant score. The prosthesis-scapular neck angle (PSNA), peg-glenoid rim distance (PGRD), scapular neck-inferior glenosphere rim distance (inferior glenosphere overhang), acromion-greater tuberosity (AT) distance, glenoid-greater tuberosity (GT) distance were assessed, and severity of notching according to the Nerot-Sirveaux classification, were measured from the radiology evaluation. Results: Compared to the anterosuperior approach, the PSNA (9.6, p=0.018) and inferior glenosphere overhang (2.0 mm, p=0.024) were significantly greater in the deltopectoral approach and the PGRD (2.2 mm, p=0.043) was shorter. The AT and GT distance was similar in the two groups. Two and three cases of implant notching occurred on deltopectoral approach and anterosuperior approach, respectively. No metal loosening, acromion fracture, or nerve injury was noted. The clinical results improved significantly in both groups, but there was no statistically significant difference between the two groups. Conclusion: The anterosuperior approach could cause the superior position of the glenoid baseplate and a decrease in the inferior tilt compared to the deltopectoral approach, but the clinical results had improved in both groups and there was no difference between the two groups. Key words: shoulder, cuff tear athropathy, reverse total shoulder arthroplasty, anterosuperior approach, deltopectoral approach Received January 9, 2017 Revised June 16, 2017 Accepted November 10, 2017 Correspondence to: Byung Hoon Kwack, M.D. Department of Orthopaedic Surgery, Daegu Catholic University Medical Center, 33 Duryugongwon-ro 17-gil, Nam-gu, Daegu 42472, Korea TEL: FAX: kwackbyunghoon@nate.com ORCID: The Journal of the Korean Orthopaedic Association Volume 53 Number Copyright 2018 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.

2 317 Comparison for Surgical Approach in RSA 서론 역행성견관절전치환술에서일반적으로사용하는삼각흉도달법 (deltopectoral approach) 1) 은삼각근을이완하여시야확보에용이하나견갑하근의박리가필요하다. 이러한문제점을보완하기위해서최근에는견갑하근을보존할수있는전상방도달법 (anterosuperior approach) 2) 이소개되고있다. 전상방도달법은견갑골관절와에대한시야확보는우수하나전방삼각근의근력약화가발생할수있으며, 삼각흉도달법은추가적인광범위도달법 (extensile approach) 과관절와하단부에대한접근성이우수하나견갑하근의기능부전으로인한불안정성이발생할수있다. 3-6) 고령환자의근위상완골분쇄골절에서상완골대결절에대한고정및수술시야확보가유리한전상방도달법이역행성견관절전치환술에유리하며이는회전근개파열관절증 (cuff tear arthropathy) 의경우에도효과적으로적용될수있다. 7,8) 하지만한국인들의체형은서양인에비하여키와몸무게및골격구조는작으나견봉의외측돌출이큰것으로알려져있다. 9) 따라서이러한체형상의특징이전상방도달법에서수술시차이를유발할수있으나한국인들을대상으로한수술적인접근법에따른차이점을직접비교한연구는부족한실정이다. 이에저자들은수술적접근법에따라시야및기구삽입에차이가발생할수있으며이로인하여결과에도변화가있을것으로가정하였다. 본연구의목적은전상방도달법과삼각흉도달법으로역행성견관절전치환술을받은환자들의수술후와추시방사선적인결과및임상결과를평가하여각각의수술적접근법에대한차이를평가해보고자하였다. 대상및방법 2014년 2월부터 2015년 11월까지대구가톨릭대학교병원에서회전근개파열관절증으로역행성견관절전치환술을시행한 26예를대상으로후향적연구를시행하였다. 본연구는본원생명의학연구윤리위원회 (institutional review board) 로부터연구승인을받고시행되었다 (CR L). 회전근개파열관절증으로역행성견관절전치환술을시행한환자중최소 12개월이상추시관찰이가능하였던환자를대상으로하였다. 골절및골절후유증, 류마티스관절염으로역행성견관절전치환술을받은환자와 12개월이상추시관찰이나방사선적검사가불가능하였던환자는배제하기로하였다. 2예가추시관찰중연락두절로배제되어 24예를대상으로하였다. 전상방도달법과삼각흉도달법으로역행성견관절전치환술을받은환자들은각각 12예였다. 2014년 2월부터 2015년 4월까지삼각흉도달법으로역행성견관절전치환술을시행하였으며 2015년 2월부터 2015년 11월까지전상방도달법으로역행성견관절전치환 술을시행하였다. 환자의평균나이는 72세 (56-86세) 였고남성이 6명, 여성이 18명이었다. 우측이 16예, 좌측이 8예였고평균신체질량지수는 24.7 kg/m 2 ( kg/m 2 ) 였다. 평균증상이환기간은 38.3개월 (12-120개월) 이었고평균추시기간은 13.2개월 (12-18개월 ) 이었다. 15예에서가성마비 (pseudoparalysis) 소견을보였으며이러한경우근전도검사로액와신경마비등의신경증상을배제하였고이에따른수술적접근법의차이를두지는않았다. 수술적접근법에따른환자의인구통계적자료에서유의한차이는보이지않았다 (Table 1). 모든수술은동일술자에의해이루어졌으며전신마취하에반좌위 (beach chair position) 에서시행되었다. 수술적인접근법은전상방도달법과삼각흉도달법으로나뉘어시행되었으나나머지수술과정은동일하게진행되었다. 상완골절제가이드를사용하여상완골두는 20 후방경사 (retroversion) 상태로절제하였으며, 관절와가이드핀을 15도정도하방으로기울게삽입하여관절와기저판에 15 하방경사 (inferior tilt) 를주었다. 모든환자에게 36 mm 편심성관절와반구 (eccentric glenosphere) 를적용한인공관절 (SMR Reverse Shoulder Prosthesis; Lima, Udine, Italy) 이사용되었다. 시험폴리에틸렌삽입물을결합하여역동적인상태에서투시검사로적절한안정성을평가한후폴리에틸렌삽입물의두께를결정하였다. 전상방도달법의경우에는골터널을이용한봉합법 (transosseous suture repair) 으로전방삼각근을재부착하였고, 삼각흉도달법의경우에는횡짝힘 (transverse force couple) 을유지하기위하여전체예에서골터널을이용한봉합법으로견갑하근을봉합하였다 (Fig. 1). 양군모두견갑하근은횡짝힘을유지하기위해재봉합및추가봉합을시행하였다. 모든환자는술후 4주간외전보조기를착용하였으며술후다음날부터능동적주관절운동및손쥐기운동 (hand grip exercise) 을시작하였다. 술 Table 1. Demographic Data Variable Anterosuperior approach group Deltopectoral approach group No. of patient p-value Mean age (yr) 73.2± ± Male:female 2:10 4: Involved side (right:left) 10:2 6: Dominant hand (right:left) 12:0 11: Previous operation (O:X) 4:8 5: Pseudoparalysis (O:X) 8:4 7: Body mass index (kg/m 2 ) 25.3± ± Symptom duration (mo) 47.0± ± Mean follow-up (mo) 13.0± ± Values are presented as number only or mean±standard deviation.

318 Chang Hyuk Choi, et al. A B C D E F Figure 1. (A) An intraoperative photograph shows skin incision for the anterosuperior approach.

(C) An intraoperative photograph shows the sutures to reattach anterior deltoid.

(E) An intraoperative photograph shows the glenoid exposure and retractors placement for the deltopectoral approach.

후 2주부터수술부위의상태에따라서시계추운동및수동적견관절운동을시작하였고술후 4주부터관절운동 (active-assisted exercise) 과정상적인일상활동을허용하였다. 환자들은본원외래에서정기적인추시경과관찰이시행되었으며임상평가는동일술자에의해평가되었다.

임상결과는수술전과 12개월에서 18개월사이의최종추시결과에서시각통증등급 (visual analogue pain scale, VAS), American Shoulder and Elbow Surgeon (ASES) score, Korean shoulder

방사선적결과는술후견관절의진성전후면 (true anteroposterior view) 에대한단순방사선검사를이용하였으며, 관절와에서평행선을그려서대결절의가장외측을통과하는지점을대결절의기준점으로정의하고거리측정에이용하였다.

3 318 Chang Hyuk Choi, et al. A B C D E F Figure 1. (A) An intraoperative photograph shows skin incision for the anterosuperior approach. (B) An intraoperative photograph shows the glenoid exposure and retractors placement for the anterosuperior approach. (C) An intraoperative photograph shows the sutures to reattach anterior deltoid. (D) An intraoperative photograph shows skin incision for the deltopectoral approach. (E) An intraoperative photograph shows the glenoid exposure and retractors placement for the deltopectoral approach. (F) An intraoperative photograph shows the sutures to reattach subscapularis. 후 2주부터수술부위의상태에따라서시계추운동및수동적견관절운동을시작하였고술후 4주부터관절운동 (active-assisted exercise) 과정상적인일상활동을허용하였다. 환자들은본원외래에서정기적인추시경과관찰이시행되었으며임상평가는동일술자에의해평가되었다. 모든환자의의무기록 ( 입원및외래의무기록, 수술기록, 방사선사진 ) 은후향적으로분석되었으며, 방사선적지표는임상결과를숨긴채 2명의정형외과전문의에의해독립적으로측정되었고측정값의평균을통계분석에이용하였다. 임상결과는수술전과 12개월에서 18개월사이의최종추시결과에서시각통증등급 (visual analogue pain scale, VAS), American Shoulder and Elbow Surgeon (ASES) score, Korean shoulder scoring system (KSS), and Constant score, 능동적관절운동범위 ( 전방거상, 외회전, 내회전 ) 를이용하여평가하였으며신경손상과같은합병증의발생여부를확인하였다. 방사선적결과는술후견관절의진성전후면 (true anteroposterior view) 에대한단순방사선검사를이용하였으며, 관절와에서평행선을그려서대결절의가장외측을통과하는지점을대결절의기준점으로정의하고거리측정에이용하였다. 관절와기저판의경사를측정하기위하여기구-견갑골경부각도 (prosthesis-scapular neck angle, PSNA), 관절와기저판의위치를측정하기위하여말뚝-관절와거리 (peg-glenoid rim distance, PGRD), 관절와반구의하방돌출 (inferior overhang) 을측정하기위하여견갑골경부-관절와반구하단거리, 상완의길이변화에대한양을측정하기위하여견봉-대결절 (acromion-greater tuberosity, AT) 거리, 회전중심의내측및외측으로의이동을측정하기위하여관절와-대결절 (glenoid-greater tuberosity, GT) 거리를이용하여평가하였다 (Fig. 2) ) 최종추시단순방사선검사결과로 Nerot-Sirveaux의분류 13) 에따라견갑골절흔의정도를측정하였으며치환물의이완이나견봉골절과같은합병증의발생여부도확인하였다. 통계적인분석은 SPSS ver (SPSS Inc., Chicago, IL, USA)

319 Comparison for Surgical Approach in RSA 을이용하여연속형변수에대하여 Mann-Whitney U-test와 Wilcoxon signed rank test, 범주형변수에대하여 Fisher s exact test를사용하였다. 모든분석의통계적유의수준은 p값이 0.05 미만인경우로하였다.

평균 VAS, ASES score, KSS, Constant score, 전방거상, 외회전, 내회전의변화량은두군모두수술전에비해최종추시임상결과에서의미있는기능향상을보였으나 (Table 3) 양군간에통계적으로유의한차이는확인할수없었다 (Table 4).

4 319 Comparison for Surgical Approach in RSA 을이용하여연속형변수에대하여 Mann-Whitney U-test와 Wilcoxon signed rank test, 범주형변수에대하여 Fisher s exact test를사용하였다. 모든분석의통계적유의수준은 p값이 0.05 미만인경우로하였다. 결과 A B C D E 평균수술시간및폴리에틸렌삽입물의두께는양군간에통계적으로유의한차이를확인할수없었다. 전상방도달법에비해삼각흉도달법이평균 1.5 mm 두꺼운폴리에틸렌삽입물을사용하였으나통계적으로유의한차이는없었다 (Table 2). 평균 VAS, ASES score, KSS, Constant score, 전방거상, 외회전, 내회전의변화량은두군모두수술전에비해최종추시임상결과에서의미있는기능향상을보였으나 (Table 3) 양군간에통계적으로유의한차이는확인할수없었다 (Table 4). 전상방도달법에서삼각근의재파열은없었으며외회전범위는수술전에비해유의한호전을보였으나양군간에통계적으로유의한차이는확인할수없었다. 전상방도달법에비해삼각흉도달법이평균 AT와 GT 거리가각각 2.0 mm, 1.5 mm 컸으나양군간에통계적으로유의한차이는없었다 (Table 5). 전상방도달법에비해삼각흉도달법이평균 PSNA와하방돌출이각각 9.6 (p=0.018), 2.0 mm (p=0.024) 컸으며평균 PGRD가 2.2 mm (p=0.043) 적음을확인할수있었다 Figure 2. (A) The prosthesis-scapular neck angle. (B) The peg glenoid rim distance. (C) The scapular neck-inferior glenosphere rim distance. (D) The acromion-greater tuberosity distance. (E) The glenoid-greater tuberosity distance. Table 2. Operative Data Variable Anterosuperior Deltopectoral p-value Operation time (min) 176.6± ± Polyethylene thickness (mm) 2.0± ± Values are presented as mean±standard deviation. Table 3. Clinical Result Assessment between Preoperative Values and Final Follow-Up Clinical result Anterosuperior Deltopectoral Preoperative Final follow-up p-value Preoperative Final follow-up p-value VAS 3.4± ± ± ± ASES score 43.5± ± ± ± KSS 36.1± ± ± ± Constant score 26.1± ± ± ± FF ( ) 59.6±35.6 (0 90) 128.3±21.2 (90 150) ±33.8 (0 90) 135.8±27.8 (90 170) ER ( ) 20.0±16.5 (0 50) 32.5±14.8 (0 50) ±19.3 (0 50) 25.8±10.8 (10 40) IR L5 (buttock L3) L4 (buttock L2) L5 (buttock L1) L3 (buttock T10) Values are presented as mean±standard deviation, mean±standard deviation (range), or mean (range). VAS, visual analogue pain scale; ASES, American Shoulder and Elbow Surgeon; KSS, Korean shoulder scoring system; FF, forward flexion; ER, external rotation; IR, internal rotation.

5 320 Chang Hyuk Choi, et al. Table 4. Clinical Result Assessment between the Group Difference of clinical result* Anterosuperior Deltopectoral p-value VAS -3.1± ± ASES score 38.6± ± KSS 44.7± ± Constant score 34.5± ± FF ( ) 68.8± ± ER ( ) 12.5± ± IR 0.6± ± Values are presented as mean±standard deviation unless otherwise indicated. *The difference is a value obtained by subtracting the final follow-up from the preoperative values. Mean±standard deviation (the difference of spine level). VAS, visual analogue pain scale; ASES, American Shoulder and Elbow Surgeon; KSS, Korean shoulder scoring system; FF, forward flexion; ER, external rotation; IR, internal rotation. Table 5. Radiologic Result Assessment between the Group Radiologic result Anterosuperior Deltopectoral p-value PSNA ( ) 99.9± ± PGRD (mm) 23.9± ± AT distance (mm) 32.8± ± GT distance (mm) 38.6± ± Inferior overhang (mm) 4.1± ± Inferior notching at final follow-up Nerot-Sirveaux grade of notching (0/1/2/3/4) 9/3/0/0/0 10/2/0/0/0 NA Values are presented as mean±standard deviation or number only. PSNA, prosthesis-scapular neck angle; PGRD, peg-glenoid rim distance; AT, acromion-greater tuberosity; GT, glenoid-greater tuberosity; NA, not applicable. (Table 5). 견갑골절흔은전상방도달법에서 3예, 삼각흉도달법에서 2예발생하였으며양군간의견갑골절흔발생률에서는통계적으로유의한차이는없었고 (p=1.000, Table 5) 수술후탈구및불안정성, 신경손상, 치환물의이완, 견봉골절과같은합병증도발생하지않았다. 고찰 수술적인접근법에따라삼각흉도달법은불안정성과견봉골절의위험성이높은것으로, 전상방도달법은견갑골절흔과관절와이완의위험성이높은것으로알려져있으나양군간의임상결과에차이는없는것으로알려져있다. 6,14) 하지만서양인에비해견봉의외측돌출이심한한국인들을대상으로한수술적인접근법에따른차이점에대한연구및두방법을직접비교한연구는부족한실정이다. 본연구는동일술자에의해역행성견관절전치환술이시행되었으므로삼각흉도달법에비해전상방도달법이관절와기저판의중심이 2.2 mm 상부에위치 (p=0.043) 하였으며하방경사가 9.6 적은것 (p=0.018) 으로보아수술적인접근법이기구삽입에영향을주었음을확인할수있었다. Molé 등 5) 은전상방도달법에서관절와이완의위험성이높음을보고하면서관절와의상방경사와관련되었을것으로추정하였다. Gillespie 등 4) 은전상방도달법이삼각흉도달법에비해관절와경사가 7 상방됨을보고하면서전상방도달법에서유도핀삽입시남아있는상완골에의한접근각의문제임을보고하였다. 따라서이들은관절염에의한상완골하부골극및관절구축이있을경우하부관절낭에대한접근이용이한삼각흉도달법을시행하며, 전상방도달법은전신마취하에서상완골의상방이동이정복가능하며수동외회전이최소 25 이상가능하고상 완골하부골극이작은경우에시행할것을권하였다. 회전근개파열관절증을대상으로한본연구에서도전상방도달법에서관절와기저판의위치가상대적으로높았고하방경사가적었으며관절와반구의하방돌출이 2 mm 적음 (p=0.024) 을확인할수있었다. 이는남아있는상완골및개방위치에따른수술시야의차이로인한결과로생각된다. Lynch 등 15) 은견관절전치환술 (anatomic total shoulder arthroplasty) 에서삼각흉도달법이술후신경손상의위험성이높음을보고하였으며 Boileau 등 16) 은역행성견관절전치환술후 2% 에서신경손상이발생함을보고하였다. Lädermann 등 17) 은역행성견관절전치환술후팔길이가평균 27 mm 증가하고역행성견관절치환술이견관절치환술에비해신경손상빈도가높음을보고하면서팔길이의증가가신경손상과관련이있을것으로추정하였다. 수술적인접근법을비교한다른연구에서는팔길이가삼각흉도달법에서 5 mm 증가함을확인하였으나통계적의미는찾을수없었음을보고하였다. 18) 본연구에서도삼각흉도달법의평균 AT와 GT 거리가 2.0 mm, 1.5 mm 컸음을확인할수있었다. 폴리에틸렌삽입물의두께가평균 1.5 mm 컸음을감안할때, AT 거리가 0.5 mm 더길었던것을확인할수있었으나통계적의미를확인할수없었다. 양군에서신경증상을보인예는없었다. Gutiérrez 등 19) 은생역학적연구에서 15 하방경사에서뼈-기구사이의스트레스와미동 (micromotion) 을최소화하고압박력을최대화할수있음을보고하면서하방경사가관절와치환물의이완을줄일수있는효과적인방법임을강조하였다. de Wilde 등 20) 은컴퓨터시뮬레이션연구를통하여관절와하방경사가 1 증가할때마다하방충돌에자유로운움직임이 1 씩증가함을보고하였다. 본연구에서는삼각흉도달법의하방경사가 9.6 커져있었으나관절가동범위에서양군간의통계적차이를확인할수없었

6 321 Comparison for Surgical Approach in RSA 으며관절와이완도양군모두에서확인되지않았다. 관절와반구의하방돌출이견갑골절흔을예방할수있는가장우수한방법으로알려져있으며 20) Poon 등 21) 은 3.5 mm 이상하방돌출이확보되면견갑골절흔을막을수있다고주장하고있다. 2 mm의하방돌출로도견갑골절흔예방효과가있다고주장하는저자들도있으나 20) Mizuno 등 22) 은 40.4% 의견갑골절흔발생률을보고하면서예방효과는없으나견갑골절흔의중증도를줄일수있음을보고하였다. 본연구에서는삼각흉도달법에비해전상방도달법의하방돌출이 2 mm 작게확보되었으나평균 4.1 mm로충분한하방돌출이확보되어수술적접근법에따른차이점을확인할수없었다. 본연구의한계점은전향적연구보다비뚤림가능성이큰후향적연구라는점, 동일술자에의해평가된의무기록으로임상평가를후향적으로분석했다는점, 추시기간이짧아서수술적접근법에따라차이가확인된방사선지표의장기적인영향을확인할수없다는점, 외전력의차이보다는외전운동범위의회복으로기능회복정도를평가하여수술적접근법에따라차이가발생할수있는근력에대한측정이없다는점, 모집단의수가적어서비모수통계를사용했다는점이다. 견갑골절흔은술후평균 4.5 개월이후부터발생하므로 10) 발생률비교에는문제가되지않으나방사선지표의영향에대한추가추시가필요할것으로생각된다. 본연구의강점으로는동일기관에서동일술자에의해수술적접근법을제외한동일한방법으로수술이진행되어결과도출과정에서발생할수있는비뚤림을최소화할수있었으며, 회전근개파열관절증으로역행성견관절전치환술을받은환자만을대상으로하여질환에대한비뚤림을줄일수있었다고생각한다. 요약하자면수술적접근법에따른임상결과, 관절가동범위, 견갑골절흔발생률에차이는없으나삼각흉도달법에비해서전상방도달법이부적절한기구삽입 ( 관절와중심의상방위치및관절와반구의하방돌출이적어짐 ) 과하방경사가적게발생할수있다. 따라서본연구의결과로보아상대적으로관절염이심하거나구축이심할경우삼각흉도달법이방사선적지표상유리할것으로판단된다. 결론 회전근개파열관절증으로역행성견관절전치환술을시행할때삼각흉도달법에비해전상방도달법이관절와중심의상방위치및하방경사가적어짐을확인할수있었으나양군간의임상결과에서차이점을확인할수는없었다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Neer CS 2nd. Replacement arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am. 1974;56: Mackenzie DB. The antero-superior exposure for total shoulder replacement. Orthop Traumatol. 1993;2: 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: Gillespie RJ, Garrigues GE, Chang ES, Namdari S, Williams GR Jr. Surgical exposure for reverse total shoulder arthroplasty: differences in approaches and outcomes. Orthop Clin North Am. 2015;46: Molé D, Wein F, Dézaly C, Valenti P, Sirveaux F. Surgical technique: the anterosuperior approach for reverse shoulder arthroplasty. Clin Orthop Relat Res. 2011;469: Valenti P, Sauziéres P, Cogswell L, O'Toole G, Katz D. The reverse shoulder prosthesis: surgical technique. Tech Hand Up Extrem Surg. 2008;12: Cazeneuve JF, Cristofari DJ. Delta III reverse shoulder arthroplasty: radiological outcome for acute complex fractures of the proximal humerus in elderly patients. Orthop Traumatol Surg Res. 2009;95: Gallinet D, Clappaz P, Garbuio P, Tropet Y, Obert L. Three or four parts complex proximal humerus fractures: hemiarthroplasty versus reverse prosthesis: a comparative study of 40 cases. Orthop Traumatol Surg Res. 2009;95: Cabezas AF, Krebes K, Hussey MM, et al. Morphologic variability of the shoulder between the populations of North American and East Asian. Clin Orthop Surg. 2016;8: 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: De Biase CF, Delcogliano M, Borroni M, Castagna A. Reverse total shoulder arthroplasty: radiological and clinical result using an eccentric glenosphere. Musculoskelet Surg. 2012;96 Suppl 1:S27-34.

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8 323 pissn : , eissn : Original Article J Korean Orthop Assoc 2018; 53: 회전근개파열관절증에대한역행성견관절전치환술시수술적접근법의차이 : 전상방도달법과삼각흉도달법에대한임상및방사선적결과비교 최창혁 곽병훈 오태범 대구가톨릭대학교병원정형외과 목적 : 회전근개파열관절증으로인해전상방도달법과삼각흉도달법으로역행성견관절전치환술을받은환자들의임상및방사 선적인결과를평가하여각각의수술적접근법에대한차이를평가해보고자하였다. 대상및방법 : 2014 년 2 월부터 2015 년 11 월까지대구가톨릭대학교병원에서회전근개파열관절증으로역행성견관절전치환술 을시행한 24예를대상으로후향적연구를시행하였으며전상방도달법과삼각흉도달법은각각 12예였다. 환자의평균나이는 72 세였고평균추시기간은 13.2개월이었다. 임상결과로시각통증등급 (visual analogue pain scale), Americans Shoulder and Elbow Surgeon score, Korean shoulder scoring system, Constant score, 능동적관절운동범위 ( 전방거상, 외회전, 내회전 ) 를이용하여측정하였으며방사선적결과로기구-견갑골경부각도, 말뚝-관절와거리, 견갑골경부-관절와반구하단거리, 견봉-대결절거리, 관절와-대결절거리를측정하였고 Nerot-Sirveaux의분류에따라견갑골절흔의정도를측정하였다. 결과 : 삼각흉도달법에서기구-견갑골경부각도 (9.6, p=0.018) 와견갑골경부-관절와반구하단거리 (2.0 mm, p=0.024) 가더컸으며, 말뚝-관절와거리 (2.2 mm, p=0.043) 가더적은결과를보였다. 견봉-대결절거리와관절와-대결절대결절거리는양군간에통계적으로유의한차이는없었다. 견갑골절흔발생은삼각흉도달법에서 2예, 전상방도달법에서 3예가확인되었으며양군모두신경손상, 치환물의이완, 견봉골절과같은합병증은없었다. 임상결과에서두군모두의미있는기능향상을보였으나양군간에통계적으로유의한차이는확인할수없었다. 결론 : 전상방도달법이삼각흉도달법에비해기저판의위치가상대적으로높았으며하방경사가적음을확인할수있었으나양군간의임상결과에서차이점을확인할수는없었다. 색인단어 : 견관절, 회전근개파열관절증, 역행성견관절전치환술, 전상방도달법, 삼각흉도달법 접수일 2017 년 1 월 9 일수정일 2017 년 6 월 16 일게재확정일 2017 년 11 월 10 일책임저자곽병훈 42472, 대구시남구두류공원로 17 길 33, 대구가톨릭대학교병원정형외과 TEL , FAX , kwackbyunghoon@nate.com, ORCID 대한정형외과학회지 : 제 53권제 4호 2018 Copyright 2018 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.

153 심한동통과함께능동적인관절운동은불가능한상태였으며신경학적검사상특이소견은없었다. 단순방사선촬영상상완근위부해부학적경부골절과골절편의전위및상완골두골절편의전방탈구와함께견갑와에관절염소견을동반하고있었고컴퓨터단층촬영에서오구돌기에비전위성골절선이관찰되었다. 타병원에서촬영된자기공명영상

153 심한동통과함께능동적인관절운동은불가능한상태였으며신경학적검사상특이소견은없었다. 단순방사선촬영상상완근위부해부학적경부골절과골절편의전위및상완골두골절편의전방탈구와함께견갑와에관절염소견을동반하고있었고컴퓨터단층촬영에서오구돌기에비전위성골절선이관찰되었다. 타병원에서촬영된자기공명영상 Case Report J Korean Orthop Assoc 2011; 46: 152-157 doi:10.4055/jkoa.2011.46.2.152 www.jkoa.org Reverse Shoulder Arthroplasty for Humeral Head Fracture with Massive Rotator Cuff Tear in Elderly Patient