419 pissn : , eissn : Original Article J Korean Orthop Assoc 2017; 52:

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1 419 pissn : , eissn : Original Article J Korean Orthop Assoc 2017; 52: 이중오프셋티타늄테이퍼스템을사용한무시멘트형인공고관절전치환술의최소 7 년추시결과 이경훈 * 이기행 노종호 고성준 가톨릭대학교의과대학부천성모병원정형외과학교실, * 나사렛국제병원정형외과 Cementless Total Hip Arthroplasty Using Dual Offset Titanium Tapered Stem: At Least 7-Year Follow-Up Kyung-Hoon Lee, M.D.*, Kee-Haeng Lee, M.D., Jongho Noh, M.D., and Seong-Jun Kho, M.D. Department of Orthopedic Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, *Department of Orthopedic Surgery, Nasaret International Hospital, Incheon, Korea Purpose: The purpose of current study is to evaluate the midterm results of cementless primary total hip arthroplasty (THA) using a dual offset titanium tapered stem. Materials and Methods: A retrospective analysis of 102 cases (84 patients), with a minimum of 7-year clinical follow-up, was performed. All of the cases consisted of patients who underwent primary cementless THA, using a dual offset titanium tapered stem in The Catholic University of Korea, Bucheon St. Mary s Hospital between July 2004 and May Clinical results were analyzed via the Harris hip score, level of thigh pain, squeaking around hip joint, and complication rate. Radiologic results were examined with stability and location of inserted prosthesis, hypertrophy of femoral cortex, and osteolysis. Results: Out of the 102 cases (84 patients; 47 males and 37 females), with the mean age of 55.9 years (range, years) and mean follow-up period of 99.2 months (range, months). The mean Harris hip score was 53.8 preoperatively (range, 26 75) and improved to 93.5 postoperatively (range, ) (p=0.000). All of the cases gained stable bony fixation on the final follow-up, including 2 cases of intra-operative proximal femur fracture. Calcar remodeling was observed in 94 cases, however, they were irrelevant with stem stability. Cortical hypertrophy of femur was seen in 12 cases and thigh pain in 4 cases; nonetheless, they were not relevant (p=0.067). There was 1 case of squeaking sound during joint movement. Hip dislocation occurred in 1 case early after the procedure, but the event was due to excessive anteversion of the acetabular cup, in which a revisional replacement procedure of the acetabular cup was conducted. No sign of ceramic breakage was observed. There were 2 cases of heterotrophic ossification. Conclusion: Results from a 7-year follow-up of cementless THA using dual offset titanium tapered stem were encouraging in both clinical and radiologic evaluations. Key words: total hip arthroplasty, cementless, dual offset, titanium tapered stem 서론 Received January 31, 2017 Revised April 20, 2017 Accepted April 24, 2017 Correspondence to: Kee-Haeng Lee, M.D. Department of Orthopedic Surgery, The Catholic University of Korea, Bucheon St. Mary s Hospital, 327 Sosa-ro, Wonmi-gu, Bucheon 14647, Korea TEL: FAX: keeleehip@gmail.com 무시멘트형인공고관절전치환술은 1970년대시멘트형인공고관절전치환술의실패율이높아지면서발달하기시작하여현재널리사용하고있는방법으로시멘트사용으로인한문제로부터자유로우며재치환술을시행할경우에도골조직에가해지는손상이적다는장점이있다. 1) 무시멘트형인공고관절전치환술은 The Journal of the Korean Orthopaedic Association Volume 52 Number Copyright 2017 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.

2 420 Kyung-Hoon Lee, et al. 초기고정력을극대화하고골내성장을최대화하여견고한고정 을얻는것이중요하다. 2) 이를위하여다양한디자인의무시멘트 형대퇴스템이개발되었으나응력차단에의한골감소, 대퇴부 동통, 골용해와대퇴골의재형성등의문제점이드물지않게보 고되고있다. 1,3,4) 이러한문제를보완하기위해서많은노력이시 도되고있다. 근위고정형대퇴스템은골간단에스템을압박고 정하는방법으로이를사용하면기존의원위고정형스템의단점 인대퇴부동통, 응력차단등으로인한합병증을줄일수있다. 3,5,6) 최근에는 Summit system 대퇴스템 (Depuy, Warsaw, IN, USA) 과 같은이중오프셋및테이퍼형디자인과쐐기형개념을적용한 근위고정형스템이개발되어사용되고있으나이에대한추시 결과는대부분표준오프셋사용에국한되어있다. 7-10) 따라서본연구에서는무시멘트형이중오프셋티타늄테이퍼 형스템인 Summit system 대퇴스템을사용하여일차고관절전 치환술을시행한환자중 7 년이상추시가가능하였던환자를대 상으로임상적, 방사선적결과를후향적으로평가해보고자하였 다. 대상및방법 2004 년 7 월부터 2009 년 5 월까지가톨릭대학교부천성모병원에서 대퇴골두무혈성괴사, 퇴행성관절염, 류마티스관절염등으로이 Table 1. Demographic Characteristics of Enrolled Patients Characteristic Value No. of case (male:female) 102 (47:37) Age (yr) 55.9±11.9 (27 79) Body mass index (kg/m 2 ) 23.7±3.4 ( ) Follow-up period (mo) 99.2±13.0 (84 132) Preoperative diagnosis Avascular necrosis 60 Secondary osteoarthritis due to dysplastic acetabulum Reumatoid arthritis 4 Primary osteoarthritis 3 Infectious arthritis sequalae 2 Femoral neck fracture 2 Synovial chondromatosis 2 Proximal femur morphology* Type A 42 Type B 56 Type C 4 Values are presented as number only or mean±standard deviation (range). *Classification according to the Dorr et al. 14) 30 중오프셋티타늄테이퍼스템을사용한무시멘트형일차인공고관절전치환술을시행받은환자중적어도 7년이상추시관찰이가능하였던 102예 (84명) 를대상으로의무기록및단순방사선사진을통한후향적분석을시행하였다. 환자들의성별, 연령, 체질량지수, 추시기간, 수술전진단에대하여 Table 1에정리하였다. 모든수술은전신기도마취하에서단일집도의에의하여후외측도달법 (modified Gibson posterolateral approaches) 을이용하여시행하였다. 11) 모든예에서대퇴스템은 Summit system 대퇴스템을사용하였다. Summit system 대퇴스템은무시멘트형대퇴스템으로근위 1/3이 Porocoat porous coating (Depuy) 으로처리되어있고근위부에서원위부까지 3도의테이퍼를가지고있어근위대퇴골에응력전달을발생할수있게되어있다. 스템근위부의 ZTT TM step (Depuy) 은주변대퇴골로응력전달을증가시키고 hoop stress를감소시키면서스템의침강에저항할수있도록한다. 또한이중오프셋옵션이있어정상고관절의생역학구현을용이하게한다. 12) 이중오프셋옵션의선택은단순방사선사진으로시행한술전 templating에따라사용하였다. 비구컵은무시멘트형반구형태로다공표면처리가되어있는 DURALOC Option 컵 (Depuy) 또는 Pinnacle 컵 (Depuy) 을사용하였다. 관절면은 28 mm, 32 mm Biolox Forte Ceramic head (Depuy) 및 DURALOC Option Alumina Ceramic Insert (Depuy), 28 mm, 32 mm, 36 mm Biolox Delta Ceramic head (Depuy) 및 Biolox Delta Alumina Ceramic Insert (Depuy) 를사용하였다. 대전자부절골술은시행하지않았으며비구컵과대퇴스 Table 2. Number of Used Implants of Enrolled Patients Variable Number Standard offset 84 DUROLOC Option cup mm Biolox Forte Ceramic head mm Biolox Forte Ceramic head 10 Pinnacle cup mm Biolox Delta Ceramic head 0 32 mm Biolox Delta Ceramic head 4 36 mm Biolox Delta Ceramic head 18 High offset 18 DUROLOC Option cup mm Biolox Forte Ceramic head mm Biolox Forte Ceramic head 0 Pinnacle cup 6 28 mm Biolox Delta Ceramic head 0 32 mm Biolox Delta Ceramic head 2 36 mm Biolox Delta Ceramic head 4

421 Cementless THA Using the Summit Stem: 7-Year Results 템모두무시멘트방법으로압박고정하였다. 비구컵삽입시고정력을평가하여필요한경우한개내지두개의나사못고정을추가로시행하였다. 사용한삽입물들에대하여 Table 2에정리하였다.

수술결과에대하여수술전, 수술후 3개월, 6개월, 1년, 이후에는 1년마다추시하여임상적평가및방사선적평가를시행하였다. 임상적평가는수술전및가장최근에평가한 Harris 고관절점수에따른분류를이용하여비교하였다.

방사선적평가로는수술전, 수술직후및가장마지막에시행한고관절전후면및측면사진을이용하여평가하였다. 근위대퇴골의형태는 Dorr 등 14) 이제시한방법을사용하였다. 대퇴스템에대해서는위치와고정상태, 골내막골형성, 골용해, 해리, 응력차단, 대퇴거재형성, 수직함몰, 대퇴스템원위부 pedestal 반응, 피질골비후등을평가하였다.

대퇴골골내막골형성, 골용 해, 해리, 응력차단등의위치는 Gruen 등 17) 의방법을이용하였고 스템주위골용해는추시방사선사진상수술직후없었던진행 성이며연속적인 2 mm 이상의대퇴스템과접한방사선투과음 영이있는경우로정의하였다.

비구컵의 골용해는 DeLee 와 Charnley 20) 의분류에의하여연속적인 2 mm 이상의방사선투과음영이있는경우로정의하였고비구컵의수 직및수평이동은수직이동은 teardrop 을기준으로, 수평이동은 Table 3.

$2 (74 100) Complication related to opeartion Intraopeative calca crack or fracture of proximal femur Early dislocation (<3 mo) 1 Periprosthetic infection (<1 mo) 0 Thigh pain (>6 mo) 4$

3 421 Cementless THA Using the Summit Stem: 7-Year Results 템모두무시멘트방법으로압박고정하였다. 비구컵삽입시고정력을평가하여필요한경우한개내지두개의나사못고정을추가로시행하였다. 사용한삽입물들에대하여 Table 2에정리하였다. 술후 2일부터대퇴사두근및중둔근강화운동, 고관절관절가동범위운동을시작하고기립침대 (tilting table) 및평행봉보행 (parallel bar gaiting) 등의재활치료를시행하였다. 술후 1주일이내보조기또는목발을이용한부분체중부하보행을시작하여술후 6주이후부터는특별한합병증이발생하지않는한전체체중부하보행을시행하였다. 수술결과에대하여수술전, 수술후 3개월, 6개월, 1년, 이후에는 1년마다추시하여임상적평가및방사선적평가를시행하였다. 임상적평가는수술전및가장최근에평가한 Harris 고관절점수에따른분류를이용하여비교하였다. 13) 이외에수술후고관절탈구및수술부위감염등의수술관련합병증여부를조사하였고최종추시시파행여부, 보행보조구필요여부, 대퇴부동통여부, 수술부위에발생하는소음여부등을평가하였다. 대퇴부동통은근위대퇴부에서슬관절상부의통증으로정의하였고소음은본인만이느끼는경우는제외한타인도들을수있는소음으로정의하였다. 방사선적평가로는수술전, 수술직후및가장마지막에시행한고관절전후면및측면사진을이용하여평가하였다. 근위대퇴골의형태는 Dorr 등 14) 이제시한방법을사용하였다. 대퇴스템에대해서는위치와고정상태, 골내막골형성, 골용해, 해리, 응력차단, 대퇴거재형성, 수직함몰, 대퇴스템원위부 pedestal 반응, 피질골비후등을평가하였다. 대퇴스템의위치는대퇴골장축과대퇴스템이이루는각이 3도보다큰경우를기준으로중립, 내반및외반으로평가하였다. 9,15) 대퇴스템의고정상태는 Engh 등 16) 의방법에따라골성고정, 안정된섬유성고 정, 불안정성고정으로분류하였다. 대퇴골골내막골형성, 골용 해, 해리, 응력차단등의위치는 Gruen 등 17) 의방법을이용하였고 스템주위골용해는추시방사선사진상수술직후없었던진행 성이며연속적인 2 mm 이상의대퇴스템과접한방사선투과음 영이있는경우로정의하였다. 18,19) 대퇴스템의수직함몰은 Callaghan 등 1) 의방법을이용하여, 소전자상단으로부터대퇴삽입물 의내측상단까지의거리로측정하고 3 mm 이상감소되었을때 의미있는것으로판단하였다. 대퇴골원위부피질골의비후유 무를판정하여대퇴부동통과의관련성을평가하였다. 비구컵의 골용해는 DeLee 와 Charnley 20) 의분류에의하여연속적인 2 mm 이상의방사선투과음영이있는경우로정의하였고비구컵의수 직및수평이동은수직이동은 teardrop 을기준으로, 수평이동은 Table 3. Clinical Results of Enrolled Patients Clinical result Value Preoperative Harris hip score 53.8±13.0 (26 75) Last follw-up Harris his score 93.5±4.2 (74 100) Complication related to opeartion Intraopeative calca crack or fracture of proximal femur Early dislocation (<3 mo) 1 Periprosthetic infection (<1 mo) 0 Thigh pain (>6 mo) 4 Squeaking 1 Ceramic head fracture 0 Values are presented as mean±standard deviation (range) or number only. 2 A B C Figure 1. Heterotrophic ossification occurred during the follow-up period after intraoperative periprosthetic fracture from a total hip replacement arthroplasty procedure with proximal femoral stem. (A) Neglected intraoperative periprosthetic fracture (Vancouver type A3) was observed (white arrowheads) on the radiograph taken 1 day after the surgical operation. (B) Circlage wiring fixation was performed 3 days after the surgery. (C) Femoral stem looks stable yet with heterotrophic ossification (black arrowhead) of Brook classification 21) grade 2, 12 years after the surgery.

422 Kyung-Hoon Lee, et al. Kohler 선을기준으로하고 2 mm 이상의이동을의미있는것으로판단하였다. 그외이소성골형성은 Brooker 등 21) 의방법으로등급을평가하였다.

Kaplan-Meier 생존분석에서사건의발생은대퇴스템의방사선적이완으로재치환술또는수술중추가고정을시행한경우로정의하였다. 모든자료의통계적처리는 IBM SPSS ver. 20 statistical software (IBM Co., Armonk, NY, USA) 를이용하였으며, p값이 0.05 미만인경우를통계적으로유의하다고판단하였다.

수술중근위대퇴골골절이 2예에서있어환형강선으로추가고정을시행하였다 (Fig. 1). 3개월이내초기고관절탈구가 1예에서있었으나이는비구컵의과도한전염각에의한것으로판단하여비구컵재치환술을시행하였다 (Fig. 2). 대퇴부통증은 4예있었다. 수술부위에발생하는소음 (squeaking) 은 1예있었다. 추시기간동안세라믹삽입물의골절로인한문제는없었다.

Radiologic Results of Enrolled Patients Radiologic result Proximal femur morphology* Value Type A 42 Type B 56 Type C 4 Femoral component Stem position Neutral position 86 (84.

4 422 Kyung-Hoon Lee, et al. Kohler 선을기준으로하고 2 mm 이상의이동을의미있는것으로판단하였다. 그외이소성골형성은 Brooker 등 21) 의방법으로등급을평가하였다. 변수들에대한통계적검정은대응표본 T 검정 (paired t-test), Fisher의정확한검정 (Fisher s exact test), Kaplan-Meier 생존분석 (Kaplan-Meier survivorship analysis) 등을이용하여분석하였다. Kaplan-Meier 생존분석에서사건의발생은대퇴스템의방사선적이완으로재치환술또는수술중추가고정을시행한경우로정의하였다. 모든자료의통계적처리는 IBM SPSS ver. 20 statistical software (IBM Co., Armonk, NY, USA) 를이용하였으며, p값이 0.05 미만인경우를통계적으로유의하다고판단하였다. 이연구는가톨릭대학교부천성모병원연구윤리심의위원회 (institutional review board) 의승인을받고시행되었다 ( 승인번호 : HIRB-00206_2-001). 결과 임상적결과에대한요약을 Table 3에기재하였다. Harris 고관절점수는수술전평균 53.8점에서최종추시평균 93.5점으로수술전에비하여유의하게향상되었다 (p=0.000). 수술중근위대퇴골골절이 2예에서있어환형강선으로추가고정을시행하였다 (Fig. 1). 3개월이내초기고관절탈구가 1예에서있었으나이는비구컵의과도한전염각에의한것으로판단하여비구컵재치환술을시행하였다 (Fig. 2). 대퇴부통증은 4예있었다. 수술부위에발생하는소음 (squeaking) 은 1예있었다. 추시기간동안세라믹삽입물의골절로인한문제는없었다. 방사선적결과에대한요약을 Table 4에기재하였다. 최종추시 Table 4. Radiologic Results of Enrolled Patients Radiologic result Proximal femur morphology* Value Type A 42 Type B 56 Type C 4 Femoral component Stem position Neutral position 86 (84.3) Valgus position 12 (11.8) Varus position 4 (3.9) Stem stability Bone ingrowth 102 (100) Stable fibrous fixation 0 Unstable 0 Osteolysis 0 Calcar remodeling 94 (92.2) Subsidence 1 Pedestal reaction 0 Cortical hypertrophy 12 (11.8) Heterotrophic ossification 2 (2.0) Acetabular component Osteolysis 0 Horizontal migration 0 Vertical migration 0 Values are presented as number only or number (%). *Classification according to the Dorr et al. 14) A B C Figure 2. Anterior hip dislocation occurred 3 days after the surgery. (A) Radiograph taken immediately after the surgery was observed with 50 degrees of the inclinication angle and 42 degrees of the acetabular cup anteversion. (B) Anterior hip dislocation was seen 1 day after the surgery. (C) Revisional replacement of acetabular cup was done 3 days after the primary procedures, and the inclination angle was decreased to 40 degrees and the anteversion angle was decreased to 25 degrees.

423 Cementless THA Using the Summit Stem: 7-Year Results A B Figure 3.

(A) Simple anteroposterior and lateral radiographs of the hip joint.

surgery; calcar remodeling (white arrowhead) was observed. A B Figure 4.

(A) Simple anteroposterior and lateral radiographs of the hip joint taken immediately

(B) Anteroposterior and lateral radiographs of the hip joint taken 9 years after the

17) showed cortical hypertrophy (white arrowheads). 상대퇴스템은중립위 86예, 외반위 12예, 내반위 4예였다.

8%) 에서있었다 (Fig. 4). 최종추시상비구컵은모든예에서골용해나수직, 수평이동소견없이안정된고정을얻었다. 이소성골형성은 2예가있었다 (Fig. 1).

고찰 시멘트형인공고관절치환술이시멘트와관련한골용해및이로인한삽입물의해리로인한실패율이높아지자무시멘트형인공고관절전치환술이그대안으로사용되고있다.

5 423 Cementless THA Using the Summit Stem: 7-Year Results A B Figure 3. Example of stable bony fixation. (A) Simple anteroposterior and lateral radiographs of the hip joint. (B) Anteroposterior and lateral radiographs of the hip joint taken 10 years after the surgery; calcar remodeling (white arrowhead) was observed. A B Figure 4. Cortical hypertrophy around the stem proximal area. (A) Simple anteroposterior and lateral radiographs of the hip joint taken immediately after the surgery. (B) Anteroposterior and lateral radiographs of the hip joint taken 9 years after the surgery; Zones 5 and 10 were classified by Gruen et al. 17) showed cortical hypertrophy (white arrowheads). 상대퇴스템은중립위 86예, 외반위 12예, 내반위 4예였다. 1예에서수직함몰이발생하였으나모든예에서추시기간동안안정된골성고정을얻었다 (Fig. 3). 대퇴거재형성은 94예 (92.2%) 에서있었다 (Fig. 3). 대퇴피질골비후는 12예 (11.8%) 에서있었다 (Fig. 4). 최종추시상비구컵은모든예에서골용해나수직, 수평이동소견없이안정된고정을얻었다. 이소성골형성은 2예가있었다 (Fig. 1). Kaplan-Meier 생존분석을시행하였을때 7년째대퇴스템의생존율은 98% (95% 신뢰구간, 96.6%-99.4%) 였다 (Fig. 5). 고찰 시멘트형인공고관절치환술이시멘트와관련한골용해및이로인한삽입물의해리로인한실패율이높아지자무시멘트형인공고관절전치환술이그대안으로사용되고있다. 1) 무시멘트형인공고관절전치환술은삽입물의표면을거칠게처리하여그표면 Survivorship from revision or additional fixation (index) Months post surgery Censored data Figure 5. Kaplan-Meier survivorship curve with accompanying 95% confidence intervals for the endpoint of survivorship for any revision or additional fixation during primary surgery.

6 424 Kyung-Hoon Lee, et al. 사이로골조직이자라들어가삽입물과골을결합하게하는생물학적고정 (biologic fixation) 을이용한방법이다. 2) 무시멘트형대퇴스템은디자인에따라대퇴피질골과의접촉정도와접촉되는위치가달라초기고정력에차이가생기며, 이로인해주로골내성장이일어나골고정이일어나는위치또한달라진다. 대퇴스템의초기고정력을극대화하고골내성장을최대화하여견고한고정을얻기위하여현재까지다양한개념과디자인의무시멘트형대퇴스템이발달하였다. 4) 원위고정형대퇴스템은전장에걸쳐표면처리가되어있어강한고정력을얻을수있지만대퇴골근위부의응력차단에의한골감소와대퇴부통증이문제점으로제시되고있다. 5) 이를보완하기위하여스템근위부에만표면처리를한근위고정형스템은골간단에압박고정되어대퇴골근위부의응력차단에의한골감소가적고대퇴스템의원위부가골수강을채우지않기때문에대퇴부통증이적다. 4,7,9) Summit system 대퇴스템을사용한본연구및타발표의중기추시에대한결과들을 Table 5에요약하였다. 7-9) Summit system 대퇴스템을사용한본연구에서는최소 7년이상의추시상모든예에서내반위치로의추가적변형이나이완없이안정된골성고정을얻었다. 그러나수술중대퇴스템을삽입하는과정에서근위대퇴골골간단부선상골절이 2예에서있었으며환형강선을이용하여추가고정을시행하였다. 1예에서술후 3개월째대퇴스템수직함몰이 5 mm 발생하였으나최종추시상위치변형이나이완등의합병증없이안정된골성고정을얻었다. 이는대퇴부근위부에국한된다공성표면처리및대퇴부골간단에압박고정되는근위고정형대퇴스템의특성으로인한것으로생각되며대퇴스템주변골절부위의유합이이루어지기전에는함몰이발생하였으나유합후에는골내성장이이루어져더이상의함몰이나이완이발생하지않은것으로생각된다. 근위대퇴골대퇴스템의이완으로재치환술을시행한경우는없었다. 대퇴거재형성은대퇴근위부응력차단과관련이있을것으로 추정되어장기적으로대퇴스템의고정력을약화시킬수있다는우려가있었다. 22) 그러나 Karachalios 등 23) 은 10년추시결과대퇴거재형성은대퇴스템의고정력약화와는관련성이없다고하였다. Hwang 등 9) 은동일한대퇴스템을사용한 5년이상의추시연구에서 44.8% 의대퇴거재형성을보고하였다. 본연구에서는대퇴거재형성은 94예 (92.2%) 에서관찰되었으나전예에서대퇴스템은안정된고정을보여대퇴거흡수와대퇴스템의안정성은무관하였다. 인공고관절전치환술후발생하는대퇴부통증의원인으로는골강도보다높은강도의대퇴스템이원위부에서고정이이루어지는경우, 대퇴스템의미세운동등다양한가설이제시되고있다. 24) Herzwurm 등 25) 은 2.5년추시에서대퇴스템원위부주변에발생하는피질골비후가대퇴부통증과의관련성이있다고보고하였으나 Katsimihas 등 26) 은유의한관련성이없다고보고하기도하였다. 동일한대퇴스템을사용한 5년이상의추시연구에서 Hwang 등 9) 은 3% 의대퇴부통증과 13% 의대퇴피질골비후가있었으나두소견사이의통계적관련성은없었다고하였다. 본연구에서는대퇴피질골비후는 12예 (11.8%) 에서있었고대퇴부통증은 4예에서있었다. 대퇴피질골비후 12예중 2예가대퇴부통증을호소하였다. Fisher의정확한검정상두요소사이의통계적연관성은없었다 (p=0.067). 환자들이호소하는통증은간헐적으로장시간보행시발생하였는데일상생활에제한이있는수준은아니었으며최종추시에서는대퇴부통증은소실되었다고하였다. 관절운동시소음 (squeaking) 이 1예에서발생하였다. Lee 등 27) 은알루미나관절면을사용한무시멘트형일차인공고관절전치환술에서비구컵의경사각의증가를소음발생의유의한인자로기술한바있다. 본환자에서는비구컵의경사각은 50도로안정범위내에속해있었다. 환자는통증이없고단순방사선사진상삽입물의상태가양호하여단순관찰하였다. 수술후전방탈구가 1예에서발생하였다. 후외측도달법은탈 Table 5. The Mid-term Follow-up Results of the Summit Stem Variable Study Dalury et al. 7) Hwang et al. 9) Goetz et al. 8) Current study No. of hip (no. of patient) 100 (98) 115 (104) 100 (88) 102 (84) Follow-up (yr) Minimum 5 Minimum Minimum 7 Bearing surface material Not reported Ceramic Polyethylene (73%), metal (27%) Ceramic Rivision rate (%) Bone ingrowth (%) Femoral osteolysis Not reported 0 1 proximal 0 Average HHS (range) 96 (57 100) 60 (21 87) 89.5 (46 100) 93.5 (74 100) HHS, Harris hip score.

7 425 Cementless THA Using the Summit Stem: 7-Year Results 구가발생할경우주로후방탈구가많은것으로알려져있어수술방법에의한것과는관련성이적은것으로생각되었다. 28,29) 방사선적평가에서비구컵전염각이 30도로비구컵의과도한전염각에의한것으로생각되었다. 30) 이에대하여비구컵재치환술을시행하였으며재치환술후탈구는발생하지않았다. 이소성골형성은최종추시상 2예에서관찰되었다. Brooker 등 21) 의분류상 1단계가 1예, 2단계가 1예로이로인한통증이나관절운동제한은없어단순관찰하였다. 본연구의한계점으로는첫째, 대퇴부동통및소음에대한진단기준이명확하지않은점및후향적인연구로그분석및결과신뢰도에한계가있다. 둘째, 대퇴스템은동일하나두종류의비구컵과 3세대와 4세대세라믹관절면을혼합하여사용하였으며그차이에대한분석이이루어지지않았다. 마지막으로추시기간이 7년으로짧아추후대퇴골이완, 세라믹삽입물관련합병증등장기추시에대한분석이필요할것으로생각된다. 결론 무시멘트형이중오프셋티타늄테이퍼형스템인 Summit system 대퇴스템을사용하여일차고관절전치환술을시행한환자중 7 년이상추시가가능하였던 102예를대상으로한본연구에서는모든예에서방사선적으로안정된골성고정을얻었고임상적측면에서도양호한결과를보였다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Callaghan JJ, Dysart SH, Savory CG. The uncemented porous-coated anatomic total hip prosthesis. Two-year results of a prospective consecutive series. J Bone Joint Surg Am. 1988;70: Brinker MR, Rosenberg AG, Kull L, Galante JO. Primary total hip arthroplasty using noncemented porous-coated femoral components in patients with osteonecrosis of the femoral head. J Arthroplasty. 1994;9: Engh CA, Bobyn JD. The influence of stem size and extent of porous coating on femoral bone resorption after primary cementless hip arthroplasty. Clin Orthop Relat Res. 1988;231: Khanuja HS, Vakil JJ, Goddard MS, Mont MA. Cementless femoral fixation in total hip arthroplasty. J Bone Joint Surg Am. 2011;93: Kim YH, Kim VE. Cementless porous-coated anatomic medullary locking total hip prostheses. J Arthroplasty. 1994;9: Cinotti G, Della Rocca A, Sessa P, Ripani FR, Giannicola G. Thigh pain, subsidence and survival using a short cementless femoral stem with pure metaphyseal fixation at minimum 9-year follow-up. Orthop Traumatol Surg Res. 2013;99: Dalury DF, Gonzales RA, Adams MJ. Minimum 5-year results in 96 consecutive hips treated with a tapered titanium stem system. J Arthroplasty. 2010;25: Goetz DD, Reddy A, Callaghan JJ, Hennessy DW, Bedard NA, Liu SS. Four- to six-year follow-up of primary THA using contemporary titanium tapered stems. Orthopedics. 2013;36:e Hwang BH, Lee WS, Park KK, Yang IH, Han CD. Straight tapered titanium stem with alumina bearing in cementless primary total hip arthroplasty: a minimum 5-year follow-up. J Arthroplasty. 2011;26: Yang IH, Park SH, Han CD. Cementless total hip arthroplasty using ceramic-on-ceramic summit(r) system: 3 years follow up. J Korean Hip Soc. 2007;19: Moed BR. The modified Gibson approach to the acetabulum. Oper Orthop Traumatol. 2014;26: Dolhain P, Tsigaras H, Bourne RB, Rorabeck CH, Mac Donald S, Mc Calden R. The effectiveness of dual offset stems in restoring offset during total hip replacement. Acta Orthop Belg. 2002;68: Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51: Dorr LD, Faugere MC, Mackel AM, Gruen TA, Bognar B, Malluche HH. Structural and cellular assessment of bone quality of proximal femur. Bone. 1993;14: Martell JM, Pierson RH 3rd, Jacobs JJ, Rosenberg AG, Maley M, Galante JO. Primary total hip reconstruction with a titanium fiber-coated prosthesis inserted without cement. J Bone Joint Surg Am. 1993;75: Engh CA, Massin P, Suthers KE. Roentgenographic assessment of the biologic fixation of porous-surfaced femoral components. Clin Orthop Relat Res. 1990;257: Gruen TA, McNeice GM, Amstutz HC. "Modes of failure" of cemented stem-type femoral components: a radiographic

8 426 Kyung-Hoon Lee, et al. analysis of loosening. Clin Orthop Relat Res. 1979;141: Maloney WJ, Jasty M, Harris WH, Galante JO, Callaghan JJ. Endosteal erosion in association with stable uncemented femoral components. J Bone Joint Surg Am. 1990;72: Joshi RP, Eftekhar NS, McMahon DJ, Nercessian OA. Osteolysis after Charnley primary low-friction arthroplasty. A comparison of two matched paired groups. J Bone Joint Surg Br. 1998;80: DeLee JG, Charnley J. Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop Relat Res. 1976;121: Brooker AF, Bowerman JW, Robinson RA, Riley LH Jr. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg Am. 1973;55: Kröger H, Venesmaa P, Jurvelin J, Miettinen H, Suomalainen O, Alhava E. Bone density at the proximal femur after total hip arthroplasty. Clin Orthop Relat Res. 1998;352: Karachalios T, Tsatsaronis C, Efraimis G, Papadelis P, Lyritis G, Diakoumopoulos G. The long-term clinical relevance of calcar atrophy caused by stress shielding in total hip arthroplasty: a 10-year, prospective, randomized study. J Arthroplasty. 2004;19: Lavernia C, D'Apuzzo M, Hernandez V, Lee D. Thigh pain in primary total hip arthroplasty: the effects of elastic moduli. J Arthroplasty. 2004;19:S Herzwurm PJ, Simpson SL, Duffin S, Oswald SG, Ebert FR. Thigh pain and total hip arthroplasty: scintigraphy with 2.5- year followup. Clin Orthop Relat Res. 1997;336: Katsimihas M, Katsimihas G, Lee MB, Learmonth ID. Distal femoral cortical hypertrophy: predisposing factors and their effect on clinical outcome. Hip Int. 2006;16: Lee TH, Moon YW, Lim SJ, Park YS. Meta-analysis of the incidence and risk factors for squeaking after primary ceramicon-ceramic total hip arthroplasty in Asian patients. Hip Pelvis. 2014;26: Petis S, Howard JL, Lanting BL, Vasarhelyi EM. Surgical approach in primary total hip arthroplasty: anatomy, technique and clinical outcomes. Can J Surg. 2015;58: Berstock JR, Blom AW, Beswick AD. A systematic review and meta-analysis of complications following the posterior and lateral surgical approaches to total hip arthroplasty. Ann R Coll Surg Engl. 2015;97: Seagrave KG, Troelsen A, Malchau H, Husted H, Gromov K. Acetabular cup position and risk of dislocation in primary total hip arthroplasty. Acta Orthop. 2017;88:10-7.

9 427 pissn : , eissn : Original Article J Korean Orthop Assoc 2017; 52: 이중오프셋티타늄테이퍼스템을사용한무시멘트형인공고관절전치환술의최소 7 년추시결과 이경훈 * 이기행 노종호 고성준 가톨릭대학교의과대학부천성모병원정형외과학교실, * 나사렛국제병원정형외과 목적 : 이중오프셋티타늄테이퍼스템을사용한무시멘트형일차인공고관절전치환술의최소 7년추시결과를분석하였다. 대상및방법 : 2004년 7월부터 2009년 5월까지가톨릭대학교부천성모병원에서이중오프셋티타늄테이퍼스템을사용한무시멘트형일차인공고관절전치환술을시행받고최소 7년이상추시가가능하였던 102예 (84명) 를대상으로후향적분석을시행하였다. 임상적결과는 Harris 고관절점수, 대퇴부동통, 수술부위소음, 합병증등을평가하였고, 방사선적결과는삽입물의안정성과위치, 대퇴피질골비후, 골용해등을평가하였다. 결과 : 총 102예 (84명) 중남자 47명, 여자 37명, 평균나이는 55.9세 ( 범위, 27-79세 ) 였으며평균추시기간은 99.2개월 ( 범위, 개월 ) 이었다. 평균 Harris 고관절점수는술전 53.8점 ( 범위, 26-75점 ) 에서술후 93.5점 ( 범위, 점 ) 으로향상되었다 (p=0.000). 최종추시상수술중근위대퇴부골절 2예를포함한모든예에서안정된골성고정을얻었다. 대퇴거재형성은 94예가있었으나대퇴스템의안정성과무관하였다. 대퇴피질골비후는 12예, 대퇴부동통은 4예있었으며관련성은없었다 (p=0.067). 관절운동시소음은 1예있었다. 초기술후고관절탈구가 1예에서발생하였으나이는비구측삽입물의과도한전염각에의한것으로비구측삽입물재치환술을시행하였다. 세라믹삽입물의골절은없었다. 이소성골형성은 2예있었다. 결론 : 이중오프셋티타늄테이퍼스템을사용한무시멘트형일차인공고관절전치환술의최소 7년추시결과는임상적및방사선적측면에서만족스러운결과를보였다. 색인단어 : 인공고관절전치환술, 무시멘트, 이중오프셋, 티타늄테이퍼스템 접수일 2017 년 1 월 31 일수정일 2017 년 4 월 20 일게재확정일 2017 년 4 월 24 일책임저자이기행 14647, 부천시원미구소사로 327, 가톨릭대학교부천성모병원정형외과 TEL , FAX , keeleehip@gmail.com 대한정형외과학회지 : 제 52 권제 5 호 2017 Copyright 2017 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.

06-09 신헌규

06-09 신헌규 J Korean Hip Soc 21(4): 314-319, 2009 Original Article The Clinical and Radiologic Results of Total Hip Arthroplasty with an AML Hip Prosthesis - Minimum 7 Years Follow-up Study - Hun-Kyu Shin, MD, Jae-Yeol