Original Article J Korean Orthop Assoc 2013; 48: 요추의병변이슬관절전치환술의결과에미치는영향 The Effect of a Lu

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1 Original Article J Korean Orthop Assoc 2013; 48: 요추의병변이슬관절전치환술의결과에미치는영향 The Effect of a Lumbar Spinal Lesion on the Clinical Results of Total Knee Arthroplasty pissn : , eissn : 조우신 변성은 윤영선 * 선지호울산대학교의과대학서울아산병원정형외과학교실, * 분당척병원 목적 : 요추의병변이슬관절전치환술의결과에미치는영향을알아보고자하였다. 대상및방법 : 2009 년 8월부터 2010 년 5월까지퇴행성슬관절염으로단일집도의에의해슬관절전치환술을시행받은환자중 87명 149 예를대상으로수술후 1년및 2년에 Hospital for Special Surgery scale (HSS 점수 ) 과슬관절점수, Western Ontario & McMaster Osteoarthritis Index Score (WOMAC 점수 ) 및 Swiss Spinal Stenosis score (SSS 점수 ) 를측정하여전향적방법을통해조사하였다. 결과 : 수술전에비해슬관절점수와 HSS 점수및 WOMAC score 는수술후에월등히향상되었고, 수술후 1년보다 2년추시시더많이향상되었다. 수술후 SSS 점수와슬관절점수의상관관계는통계적으로유의하지않은결과를보인반면, HSS 점수와 WOMAC 점수및슬관절점수와 HSS 점수의차이값은 SSS 점수와뚜렷한상관관계를보였다. 결론 : 요추의병변이슬관절전치환술전, 후의평가에영향을주기때문에술후평가시요추의병변을반영하는평가법과병행하는것이바람직하며, 이중 SSS 점수가좋은평가법이라고생각된다. 색인단어 : 슬관절전치환술, HSS 점수, 슬관절점수, WOMAC 점수, SSS 점수 서론 슬관절전치환술은통증의경감및기능회복을목적으로시행된다. 이수술을받는환자는대부분고령이어서척추의퇴행성병변으로인한척추협착증의질환을앓고있는환자들이많다. 이로인하여수술은잘되어서무릎의상태는좋지만척추의병변에의한통증및기능의저하가있다면인공관절술의소기의목적을달성했다고볼수없다. 슬관절전치환술후환자의만족도는 75-89% 로보고되고있으며 1-8) 수술후의잔존통증과만족도는특히밀접한관련이있다. 그래서비록무릎외의원인으로발생하는외인성통증이있을경우수술의만족도는떨어지고수술의결과도왜곡될수있다. 고령의환자에서외인성통증의가장중요한원인은척추의퇴행성병변으로인한요추부협착증이기 때문에 3,7) 인공슬관절의결과평가에있어서동반질환, 특히척추질환에대한상태를아는것이매우중요하다할것이다. Swiss spinal stenosis score (SSS 점수 ) 는요추협착증환자에대한평가법으로요추의기능장애, 특히신경허혈적인특성및그에따른보행능력을평가하는데유용하며최근여러연구에서척추협착증에의한척추의상태를평가하는데사용되고있다. 9-12) 본연구는슬관절전치환술후 1년및 2년에슬관절점수와 Hospital for Special Surgery scale (HSS 점수 ), Western Ontario & McMaster Osteoarthritis Index score (WOMAC 점수 ) 의변화를알아보고, SSS 점수로평가한척추의상태가이들의변화에어떤영향을미치는가를알아보고자하였다. 대상및방법 접수일 2012 년 6 월 25 일수정일 2012 년 11 월 4 일게재확정일 2013 년 1 월 7 일교신저자조우신서울시송파구올림픽로 43 길 88, 서울아산병원정형외과 TEL , FAX wscho@amc.seoul.kr 1. 연구대상 2009 년 8월부터 2010 년 5월까지진행된퇴행성슬관절염 (Kellgren-Lawrence grade 3 이상 ) 으로단일집도의 (senior author) 에의해슬관절전치환술을시행받은환자 215 명 363 예중골절등의 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.

2 2 조우신 변성은 윤영선외 1 인 원인으로하지관절에수술받은병력이있는경우 (34 명 61예 ), 당뇨병성말초신경질환이있는경우 (4명 6예 ), 하지의혈액순환장애 (ankle-brachial index <0.8) 가있는경우 (2명 3예 ) 척추수술의병력이있는경우 (26 명 43예 ), 뇌졸중, 소아마비등하지기능에영향을주는신경학적질환을가진경우 (33 명 54예 ) 를제외한총 116 명 196 예를대상으로전향적방법을통해조사하였다. 대상환자들 (116 명 196 예 ) 의수술시평균연령은 68.0 세 (50-81 세 ) 였고남자 12명 (16 예 ), 여자 104 명 (180 예 ) 이었으며부위별로는우측 97예, 좌측 99 예였다. 2. 측정및분석방법슬관절전치환술전및술후 1년및 2년외래방문시 HSS 점수, 슬관절점수, WOMAC 점수, 관절운동범위를동일측정자에의해측정하였다. 수술전환자의병력및요추부단순방사선검사를통해환자의요추부병변유무를확인하였다. 척추의병변에대한평가를 SSS 점수의설문지를통해측정하였고 SSS 점수가슬관절결과평가에주는영향을분석하였다. 결과의통계적분석은 SPSS version 18.0 for Windows (PASW Statistics 18.0; IBM Co., Armonk, NY, USA) 를이용하여시행하였으며, 수술전과수술후 1년및 2년추시시각점수의변화는 Wilcoxon Signed Rank test 를통하여분석하였으며, 슬관절점수및 HSS 점수와 SSS 점수간의상관관계, WOMAC 점수와 SSS 점수간의상관관계는 Spearman's correlation analysis 를통하여분석하였다. 수술후 2년최종추시시의슬관절점수와 HSS 점수, WOMAC 점수에대한 SSS 점수의영향력에대해 linear regression model 을통하여분석하였다. 결과 연구에참여한 116 명 196 예의환자중추시기간중슬관절이외부위의하지골절이발생한경우 (2명 3예 ), 치환물주위골절, 감염등의합병증이발생하거나재치환술을시행한환자 (4 명 5예 ) 를제외한 112 명 190 예중 25명 41예를제외한 87명 149 예에서 2년추시가되었고, 대상환자들의 HSS 점수, 슬관절점수, WOMAC 점수, 관절운동범위를측정할수있었다. 환자들의평균연령은 67.8 세 (50-81 세 ) 였고남자 7명 (11 예 ), 여자 80명 (138 예 ) 이었으며부위별로는우측 71예, 좌측 78예였다. 수술전슬관절점수는 58.84, HSS 점수 이었으며, 수술후 1년추시시슬관절점수는 95.78, HSS 점수 였고, 수술후 2년슬관절점수 97.40, HSS 점수 이었다. 수술전에비해수술후의이들점수가월등히좋아졌으며, 수술후 2년추시시의슬관절점수및 HSS 점수모두수술후 1년에비해통계적으로유의한증가를보였다 (Table 1). WOMAC 점수또한수술전 38.27, 수술후 1년 8.83, 수술후 2년 7.70 으로수술전에비해수술후에향상되었으며수술후 1년에비해수술후 2년에서통계적으로유의한감소를보였다 (Table 1). 관절운동범위는수술전굴곡각도 도, 수술후 1년 도, 수술후 2년 도로측정되었다. 수술전촬영한요추부단순방사선검사를통해요추부병변유무를확인한결과, 87명중 81명 (93.1%) 에서요추부병변 ( 요추부척추증, 척추전방전위증, 추체간간격협소등 ) 이있는것으로확인되었으며, 6명에서만일상의방사선검사상요추부병변을발견할수없었다. SSS 점수는수술후 1년 이었으며수술후 2년 로통계적으로유의한증가를보였다 (Table 1). 슬관절점수의경우, 수술후 1년및 2년추시모두 SSS 점수와상관관계가통계적으로유의하지않은결과를보인반면, HSS 점수는 SSS 점수가높을수록낮은경향을보였다 (p<0.0001). 또한 SSS 점수가높을수록슬관절점수와 HSS 점수간의차이값이높은뚜렷한경향을보였다 (p<0.01). WOMAC 점수와 SSS 점수간의상관관계또한 SSS 점수가높을수록 WOMAC 점수가높은경향을보였다 (p<0.0001) (Table 2, Fig. 1). 수술후 2년최종추시시슬관절전치환술평가지수에대한 SSS 점수의영향력을 linear regression model 을통하여분석한결과, SSS 점수가슬관절점수에대한영향력이통계적으로유의하지않은결과를보인반면 (p=0.36), SSS 점수가높을수록 HSS 점수는감소하고 WOMAC 점수는증가하는경향이있었다 (p <0.001). 슬관절점수와 HSS 점수간의차이값역시 SSS 점수가높을수록증가하게되는경향을보였다 (p<0.001) (Table 3). Table 1. Preoperative and Postoperative 1- and 2-Year HSS Scale, Knee, WOMAC, and SSS Scores Clinical score Preoperative Postoperative 1 year Postoperative 2 year p-value* HSS scale (±7.49, 41-78) (±5.02, 74-97) (±4.47, 73-98) < Knee score (±6.49, 45-77) (±5.60, ) (±4.50, ) < WOMAC score (±8.19, 23-86) 8.83 (±7.43, 0-39) 7.70 (±6.78, 0-40) < SSS questionnaire (±6.21, 12-35) (±5.47, 12-36) (±6.72, 12-36) Range of motion (±18.31, ) (±9.75, ) (±11.10, ) Values are presented as mean (±standard deviation, range). *p-values of <0.05 were considered statistically significant. Wilcoxon s signed rank test. HSS scale, Hospital for Special Surgery scale; WOMAC score, Western Ontario & McMaster Osteoarthritis Index score; SSS score, Swiss Spinal Stenosis score.

3 3 요추병변과슬관절전치환술의결과 Table 2. Correlations between Clinical Scores and SSS Scores Clinical score Correlation coefficient (postoperative 1 year) Correlation coefficient (postoperative 2 year) HSS scale (p*< ) (p*< ) Knee score (p*=0.063 ) (p*=0.21 ) Knee score - HSS scale (p*= ) (p*< ) WOMAC score (p*< ) (p*< ) *p-values of <0.05 were considered statistically significant. Knee score minus HSS scale score. Spearman's correlation analysis. SSS score, Swiss Spinal Stenosis score; HSS scale, Hospital for Special Surgery scale; WOMAC score, Western Ontario & McMaster Osteoarthritis Index score. Figure 1. Plots of clinical scores versus SSS scores at 2 years after surgery. (A) Graph showing a significant correlation between HSS scale and SSS scores. (B) Graph showing no significant correlation between KS and SSS scores. (C) Graph showing a significant correlation between KS minus HSS scale scores and SSS scores. (D) Graph showing a significant correlation between WOMAC scores and SSS scores. SSS score, Swiss Spinal Stenosis score; HSS scale, Hospital for Special Surgery scale; KS, knee scores; WOMAC score, Western Ontario & McMaster Osteoarthritis Index score. 고찰 인공슬관절치환술을시행하는목표가통증의감소와기능의향상에있으나, 수술후통증은무릎자체의문제가아닌외인성원인에의한외인성통증이환자의만족도를떨어뜨리고수술의결 과를왜곡시킬수있다. 그러나슬관절전치환술후주로사용하는임상적평가방법은외인성통증에의한영향을배제하였다는문제점을내포하고있다. 13,14) 외인성통증을일으키는원인은여러가지가있으나 15,16) 고령의환자에서는척추의퇴행성병변으로인한척추협착증역시주요

4 4 조우신 변성은 윤영선외 1 인 Table 3. Linear Regression Model of Clinical and SSS Scores at 2 Years after Surgery Outcome score Beta Lower Upper p-value* R 2 SSS score HSS scale < Knee score Knee score - HSS scale < WOMAC score < *p-values of <0.05 were considered statistically significant. SSS score, Swiss Spinal Stenosis score; HSS scale, Hospital for Special Surgery scale; WOMAC score, Western Ontario & McMaster Osteoarthritis Index score. Table 4. Swiss Spinal Stenosis Score Swiss Spinal Stenosis Score In the past month, how would you describe 1. The pain you have on the average including pain in your back and buttocks as well as pain that goes down the legs? 2. How often have you had back, buttock or leg pain? Less than once a week At least once a week Every day, for at least a few minutes Every day, for most of the day Every minute of the day 3. The pain in your back or buttocks? 4. The pain in your legs or feet? 5. Numbness or tingling in your legs or feet? 6. Weakness in your legs or feet? 7. Problems with your balance? No, I ve had no problems with balance. Yes, sometimes I feel my balance is off, or that I am not surefooted. Yes, often I feel my balance is off, or that I am not surefooted. 8. How far have you been able to walk? More than 2 miles More than 2 streets, but less than 2 miles More than 50 feet but less than 2 streets Less than 50 feet 9. Have you taken walks outdoors or around the shops for pleasure? Yes, comfortably Yes, but sometimes with pain Yes, but always with pain No 10. Have you been shopping for groceries or other items? Yes, comfortably Yes, but sometimes with pain Yes, but always with pain No 11. Have you walked around the different rooms in your house or flat? Yes, comfortably Yes, but sometimes with pain Yes, but always with pain No 12. Have you walked from your bedroom to the bathroom? Yes, comfortably Yes, but sometimes with pain Yes, but always with pain No 한원인이라할수있다. 따라서척추의병변은무릎인공관절술 의적응을잡을때뿐만아니라수술의결과판정에서간과되어서 는안될점검사항이지만인공슬관절수술후평가에서척추의 병변과연계하여분석한보고는매우드물다. 요추협착증은퇴행성척추증의결과로발생하는경우가많으 며요추부의통증을동반하지않으면서엉덩이나하지의방사통

5 5 요추병변과슬관절전치환술의결과 을유발할수있고 17) 정도에따라보행능력에심각한영향을미칠수있다. Kalichman 등 18) 은전산화단층촬영 (computed tomography, CT) 을이용한분석에서 세의환자군에서 47.2% 의상대적협착증과 19.4% 의절대적협착증을보고하였으며, 나이가들수록유병률이증가하는경향을보인다고하였다. 또한 Issack 등 19) 은퇴행성요추협착증이고령의환자에서통증과기능저하의주요한원인이라고하였다. 따라서, 고령의환자에서인공슬관절수술후요추협착증으로인하여환자의만족도가떨어지는경우가발생하기때문에무릎인공관절술은수술의적응을잡을때부터신중을기해야한다. 요추협착증을임상에서확인하기위해단순방사선검사를시행할수있겠지만, 본연구결과에서확인한대로대부분의환자가요추부의퇴행성변화를보이기때문에실제그효율성은크지않다. 이런환자의모두에게척추의 CT나자기공명영상 (magnetic resonance imaging) 등의특수검사를시행하는것은방사선노출이나비용문제등현실적으로한계가있다. 본연구에서는 SSS 점수를이용하여요추협착증을평가하고, SSS 점수가슬관절전치환술의결과평가에사용하는임상적점수들에미치는영향을분석하였다. SSS 점수는 Stucki 등 20,21) 에의해개발된것으로요추협착증환자에서요추의기능장애, 특히신경허혈적인특성및그에따른보행능력을평가하는데유용한것으로알려져있다. 여러연구들을통해 SSS 점수의유효성및신뢰성이확인되었으며, 20-24) 최근요추협착증에대한여러연구에서주요결과평가방법 (primary outcome) 으로사용되고있다. 9-12) Pratt 등 22) 은요추부협착증환자에대한설문평가방법들인 Shuttle walking test, SSS, Oxford claudication score, Oswestry disability index 에대한신뢰도비교연구에서 SSS 점수가가장재현성이높다고보고하였다. 또한 North American Spine Society 17) 는척추협착증의결과를정량화하는데있어서 SSS 점수를 'gold standard' 로추천하였다. SSS 점수는총 12개의문항으로구성되어있으며, 증상점수 (symptom severity scale, 7개문항, 35점 ) 와기능점수 (physical function scale, 5개문항, 20점 ) 로나누어져총점 55점으로산정되고, 점수가높을수록증상및기능장애가심한것으로되어있다 (Table 4). 수술받은환자의경우수술후환자의만족도 (patient's satisfaction after treatment scale) 의 6개문항 24점을추가하여총 79점으로평가하게된다. SSS 점수를이용한요추부질환의평가는설문지를이용하기때문에산정하기가쉽고경제적이며, 정량적분석이어서환자간비교가쉽다는장점이있다. 본연구에서슬관절전치환술의결과평가를위해 HSS 점수, knee society score, WOMAC 점수를사용하였다. HSS 점수는다자간, 치환물간및시간의경과에따른비교를하기에좋아연구를하기에용이하다. 24) 그러나, 슬관절의상태와상관없는전신상태의변화나나이에따른점수의변화가발생할수있지만이의 원인을밝힐수없다는단점이있다. 13,14) HSS 점수의단점을보완하여개발한 knee society score 는슬관절점수 (knee score) 와기능점수 (function score) 를나누고, 신체적여건에대한분류 (patient classification system) 도추가하였다. 25) 따라서, 슬관절점수의경우나이나동반질환에따른기능의저하에영향을받지않고슬관절의상태만을반영한다는장점이있지만반대로환자가실제로느끼는통증및기능을반영하지못한다는단점이있다. WOMAC 점수는무릎평가에대한설문을환자자신이작성함으로써환자에의한주관적인평가법이라고할수있으며 26) 쉽고간단하여서무릎의인공관절술후의평가에널리쓰이고있지만이역시기능의저하및통증의외인적요인을알수없다는단점이있다. 본연구에서수술후 1년에비해수술후 2년에 HSS 및슬관절점수가증가하였는데, 이는대부분의슬관절전치환술후중 단기추시연구결과와일치하며, 27-29) 어느정도수술의목적을달성했다고할수있다. 본연구결과환자의통증및기능이무릎이외의원인에의하여영향을받는 HSS 점수와 WOMAC 점수는 SSS 점수에의해통계적으로유의하게영향을받았으며, 슬관절외적영향을배제하도록고안된슬관절점수는 SSS 점수에의한영향을받지않았다. 또한무릎외의원인에영향을받지않는슬관절점수와 HSS 점수의차이는 SSS 점수에의해통계적으로유의한영향을받는것으로보였다. 이는 SSS 점수를통하여확인한척추의병변으로인한기능의저하가 HSS 점수및 WOMAC 점수에상당한영향을미치며, 슬관절점수와 HSS 점수의차이와 SSS 점수와관련이깊다는것은 SSS 점수가슬관절전치환술환자의수술후기능과밀접한상관관계를가진다고해석할수도있을것이다. 따라서슬관절전치환술후의사와환자모두만족할만한결과를얻고수술후통증및낮은기능점수에대한원인을확인하기위해수술전및수술후 SSS 점수를이용하여척추병변의정도를확인하는것이도움이될것으로생각된다. 본연구의한계점은추시기간이 2년으로비교적짧다는것이나이연구가인공슬관절의장기추시결과를알고자하는것이아니고평가지수간의상관관계및영향을알고자하는것이기때문에본연구의의의는충분할것으로생각된다. 결론 슬관절전치환술전및후의평가에있어서일반적으로무릎의평가법으로사용되는평가방법외에본연구에사용된 SSS 점수와같은척추의병변을반영하는평가법과병행하는것이술전예후예측및술후기능평가에중요한것으로생각된다.

6 6 조우신 변성은 윤영선외 1 인 참고문헌 1. Anderson JG, Wixson RL, Tsai D, Stulberg SD, Chang RW. Functional outcome and patient satisfaction in total knee patients over the age of 75. J Arthroplasty. 1996;11: Bonnin M, Laurent JR, Parratte S, Zadegan F, Badet R, Bissery A. Can patients really do sport after TKA? Knee Surg Sports Traumatol Arthrosc. 2010;18: Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res. 2010;468: Hawker G, Wright J, Coyte P, et al. Health-related quality of life after knee replacement. J Bone Joint Surg Am. 1998;80: Heck DA, Robinson RL, Partridge CM, Lubitz RM, Freund DA. Patient outcomes after knee replacement. Clin Orthop Relat Res. 1998;356: Noble PC, Gordon MJ, Weiss JM, Reddix RN, Conditt MA, Mathis KB. Does total knee replacement restore normal knee function? Clin Orthop Relat Res. 2005;431: Robertsson O, Dunbar M, Pehrsson T, Knutson K, Lidgren L. Patient satisfaction after knee arthroplasty: a report on 27,372 knees operated on between 1981 and 1995 in Sweden. Acta Orthop Scand. 2000;71: Wylde V, Learmonth I, Potter A, Bettinson K, Lingard E. Patient-reported outcomes after fixed- versus mobile-bearing total knee replacement: a multi-centre randomised controlled trial using the Kinemax total knee replacement. J Bone Joint Surg Br. 2008;90: Fokter SK, Yerby SA. Patient-based outcomes for the operative treatment of degenerative lumbar spinal stenosis. Eur Spine J. 2006;15: Hansraj KK, Cammisa FP Jr, O'Leary PF, et al. Decompressive surgery for typical lumbar spinal stenosis. Clin Orthop Relat Res. 2001;384: Iversen MD, Katz JN. Examination findings and self-reported walking capacity in patients with lumbar spinal stenosis. Phys Ther. 2001;81: Zucherman JF, Hsu KY, Hartjen CA, et al. A multicenter, prospective, randomized trial evaluating the X STOP interspinous process decompression system for the treatment of neurogenic intermittent claudication: two-year follow-up results. Spine (Phila Pa 1976). 2005;30: Cho WS, Park SS, Kim DH, Jeong YG, Baek SK, Park CJ. The reliability of HSS knee rating system. J Korean Knee Soc. 2000;12: Cho WS, Kim MY, Youm YS. Cho s knee joint arthroplasty. 2nd ed. Seoul: Young-chang publisher; Bonnin MP, Basiglini L, Archbold HA. What are the factors of residual pain after uncomplicated TKA? Knee Surg Sports Traumatol Arthrosc. 2011;19: Al-Hadithy N, Rozati H, Sewell MD, Dodds AL, Brooks P, Chatoo M. Causes of a painful total knee arthroplasty. Are patients still receiving total knee arthroplasty for extrinsic pathologies? Int Orthop. 2012;36: North American Spine Society. Evidence-based clinical guidelines for multidisciplinary spine care: diagnosis and treatment of degenerative lumbar spinal stenosis. Burr Ridge: North American Spine Society; Kalichman L, Cole R, Kim DH, et al. Spinal stenosis prevalence and association with symptoms: the Framingham Study. Spine J. 2009;9: Issack PS, Cunningham ME, Pumberger M, Hughes AP, Cammisa FP Jr. Degenerative lumbar spinal stenosis: evaluation and management. J Am Acad Orthop Surg. 2012;20: Stucki G, Liang MH, Fossel AH, Katz JN. Relative responsiveness of condition-specific and generic health status measures in degenerative lumbar spinal stenosis. J Clin Epidemiol. 1995;48: Stucki G, Daltroy L, Liang MH, Lipson SJ, Fossel AH, Katz JN. Measurement properties of a self-administered outcome measure in lumbar spinal stenosis. Spine (Phila Pa 1976). 1996;21: Pratt RK, Fairbank JC, Virr A. The reliability of the Shuttle Walking Test, the Swiss Spinal Stenosis Questionnaire, the Oxford Spinal Stenosis Score, and the Oswestry Disability Index in the assessment of patients with lumbar spinal stenosis. Spine (Phila Pa 1976). 2002;27: Tuli SK, Yerby SA, Katz JN. Methodological approaches to developing criteria for improvement in lumbar spinal stenosis surgery. Spine (Phila Pa 1976). 2006;31: Tomkins CC, Battié MC, Hu R. Construct validity of the physical function scale of the Swiss Spinal Stenosis Questionnaire for the measurement of walking capacity. Spine (Phila Pa 1976). 2007;32: Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res.

7 7 요추병변과슬관절전치환술의결과 1989;248: Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988;15: Wohlrab D, Hube R, Zeh A, Hein W. Clinical and radiological results of high flex total knee arthroplasty: a 5 year follow-up. Arch Orthop Trauma Surg. 2009;129: Lee DH, Choi J, Nha KW, Kim HJ, Han SB. No difference in early functional outcomes for mini-midvastus and limited medial parapatellar approaches in navigation-assisted total knee arthroplasty: a prospective randomized clinical trial. Knee Surg Sports Traumatol Arthrosc. 2011;19: Song EK, Seon JK, Yoon TR, Park SJ, Bae BH, Cho SG. Functional results of navigated minimally invasive and conventional total knee arthroplasty: a comparison in bilateral cases. Orthopedics. 2006;29:S145-7.

8 8 pissn : , eissn : Original Article J Korean Orthop Assoc 2013; 48: 조우신 변성은 윤영선외 1 인 The Effect of a Lumbar Spinal Lesion on the Clinical Results of Total Knee Arthroplasty Woo-Shin Cho, M.D., Seong-Eun Byun, M.D., Young-Sun Yoon, M.D.*, and Ji-Ho Sun, M.D. Department of Orthopedic Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, *Bundang Chuk Hospital, Seongnam, Korea Purpose: Patients with osteoarthritis of knee joint often concomitantly suffer from degenerative disease of the spine. Furthermore, resulting spinal problems could influence function and pain after total knee arthroplasty (TKA), and hence, cause the results of TKA to be misinterpreted. The purpose of this prospective study was to evaluate the effect of spinal disorders, as assessed by Swiss Spinal Stenosis score (SSS scores), on knee function as assessed by knee scores, the Hospital for Special Surgery scale (HSS scale) and Western Ontario & McMaster Osteoarthritis Index scores (WOMAC scores) in patients that after TKA. Materials and Methods: One hundred and forty nine osteoarthritic knees of 87 patients were enrolled in this study. All patients received TKA by single surgeon (W-S Cho) from August 2009 to May Preoperative and postoperative 1- and 2-years HSS scale, Knee, WOMAC, and SSS scores were recorded and analyzed. Results: Postoperative HSS scale, Knee, and WOMAC scores showed marked improvements versus preoperative scores, and scores at 2 years postoperatively were better than at 1 year postoperatively. No significant correlation was found between postoperative Knee scores and SSS scores. On the other hand, statistically significant correlations were found between HSS and SSS scores and between WOMAC and SSS scores. Interestingly, differences between Knee scores and HSS scores were found to be significantly correlated with SSS scores. Conclusion: When evaluating outcome after TKA, spinal problems should be investigated concomitantly. SSS scores appear to provide a suitable means of assessing spinal problems. Key words: total knee arthroplasty, Hospital for Special Surgery scale, knee score, Western Ontario & McMaster Osteoarthritis Index score, Swiss Spinal Stenosis score Received June 25, 2012 Revised November 4, 2012 Accepted January 7, 2013 Correspondence to: Woo-Shin Cho, M.D. Department of Orthopedic Surgery, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul , Korea TEL: FAX: wscho@amc.seoul.kr 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.

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical