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1 대한정형외과학회지 : 제 42 권제 2 호 2007 J Korean Orthop Assoc 2007; 42: 회전근개부분파열의임상양상및관절경소견 권오수 김양수 * 이규영 가톨릭대학교의과대학의정부성모병원정형외과, 강남성모병원 * 정형외과 Clinical Features and Arthroscopic Findings of Partial Thickness Rotator Cuff Tears Oh Soo Kwon, M.D., Yang Soo Kim, M.D.*, and Kyoo Young Lee, M.D. Department of Orthopaedic Surgery, Uijongbu St. Mary's Hospital, Kangnam St. Mary's Hospital*, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea Purpose: To compare the clinical features of partial thickness rotator cuff tears according to location of the tear and to classify the partial thickness rotator cuff tears based on arthroscopic findings. Materials and Methods: This study evaluated 138 patients who were arthroscpically proven to be partial thickness rotator cuff tears. Three groups were identified; 56 in the articular side tear, 58 in the bursal side tear, 24 in the both sides tear. The comparison included preoperative clinical features such as pain, range of motion and impingement sign. The partial thickness rotator cuff tears were classified according to the arthroscopic findings. Results: There was no significant difference in the clinical features between articular, bursal and both sides tears. Partial thickness rotator cuff tear can be divided into 5 groups. Type I (n=41): fraying or fibrillation on surface of the cuff. Type II (n=35): fiber disruptions with or without displacement. Type III (n=38): flap tear or fragmentation. Type IV (n=16): both articular and bursal side tears without communications. Type V (n=8): impending a full thickness tear. Conclusion: It is difficult to differentiate the clinical features based on the physical examinations according to the locations of tears. Newly designed classification may help in deternmining the appropriate arthroscopic treatment of a partial thickness rotator cuff tear. Key W ords: R otator cuff, Partial thickness tear, Arthroscopy 서론회전근개부분파열은흔히견관절동통및장애를유발하는질환이다. 지금까지대부분의기초또는임상연구는회전근개질환중견봉하충돌증후군또는회전근개전층파열이라는질병상태에대해서주로다루어져왔는데최근에기초연구를통한회전근개질환의발병기전이이해되고영상진단기법및관절경수술수기의발전에힘입어회전근개부분파열에대한인지와진단및치료과정에많은변화가오고있다 15). 그러나여전히 진단과치료를위한임상양상, 분류, 수술방법등에있어더욱명확한정의를필요로하고있다. 이논문에서는회전근개부분파열의파열위치에따른수술전임상양상을비교하고관절경소견에따라회전근개부분파열을분류하고자한다. 대상및방법 1. 연구대상 2002년 5월부터 2005년 10월까지관절경검사상회 통신저자 : 권오수경기도의정부시금오동 65-1 가톨릭대학교의정부성모병원정형외과 TEL: FAX: oskn@catholic.ac.kr Address reprint requests to 177

2 178 권오수 김양수 이규영 전근개부분파열로진단된 138예를대상을하였으며남자 68명, 여자 69명이었으며양측이이환된경우가 1 명이었다. 평균나이는 54.1세 (41-72) 였다. 환자의선정기준은관절경하에서확진된관절측또는점액낭측회전근개부분파열이었으며체상투구동작을하는운동선수, 회전근개전층파열, 견관절불안정성, 견봉쇄골관절의병변, 과거견관절수술력및류마토이드질환이있는경우는제외하였다. 2. 방법 1) 임상평가방법수술전이학적검사상동통, 관절운동범위, 충돌징후, 극상건검사, 외회전약화소견등을조사하여회전근개파열의위치에따라관절측, 점액낭측및양측파열로나누어비교하였다. 이학적검사중동통은 VAS (Visual analogue scale) 을이용하여측정하였고관절운동범위는전방굴곡과외회전을측정하였다. 2) 관절경검사방법전신마취후측와위에서견관절을전방굴곡 20도, 외전 도, 회전은중립위로고정하고약 10 lb 전후의피부견인을시행하였다. 통상적인후방삽입구를이용하여관절측을검사하여병변의유무를확인하면서점액낭측병변과의위치관계를용이하게파악할수있도록표시봉합사 (marker suture) 를삽입하였다. 점액낭측의관찰시에는상지를외회전또는내회전을시키면서견봉하공간에서최전방과최후방까지면밀하게관찰하였다. 관절측, 점액낭측또는양측의회전근개파열의위치, 크기, 형태등을조사하여이를바탕으로분류하였다. 3) 수술방법다음의수술방법은회전근개부분파열중관절측과점액낭측을모두침범하고양측모두층판형성및분획화된경우에대한술기이다. 지혈효과를얻기위해환자의수축기혈압을약 mmhg 로유지하였으며에피네프린을혼합한생리식염수 (1 cc/3,000 ml) 를사용하였다. 과도한관절부종을예방하여관절와상완관절과견봉하공간사이에삽입구교환이용이하도록관절경펌프의압력은 50 mmhg, 유입속도는 0.5 l/min 에서시작하였고깨끗한수술시야를얻기위해유출구를적절히 조절하였다. 관절측회전근개파열위치, 크기, 두께및동반병변의유무를확인한후파열의중심부를통과하도록 18G 척추바늘을경피적으로삽입하고단섬유 (monofilament) 봉합사 (nylon No.1-0) 를통과시켜전방삽입구로빼내어표시봉합사로이용하였다. 이어견봉하공간으로관절경을삽입하여표시봉합사에손상을주지않도록주의하면서견봉하감압술을시행하였다. 시야가확보되면점액낭측회전근개파열의여부를확인하는데이때상지를외회전또는내회전시키면서정확한파열의위치를확인하고크기를측정하였다. 이과정이끝나면관절경을관절측으로재삽입하여후방삽입구로관찰하면서봉합나사못삽입을위하여척추바늘을이용하여삽입위치를확인후두가닥의봉합사가연결되어있는봉합나사못 (Cork screw R, Arthrex, USA) 을회전근개를관통하여삽입하였다. 봉합나사못에부착되어있는봉합사 (ethibond No. 2) 를관절내로밀어넣어같은색깔의봉합사끼리두개의전방삽입구로각각빼내었다. 다시한번관절측파열의크기를확인하고가장전방의파열부위에서부터후방까지일정한간격으로파열가장자리에서약 5 mm 내측을통과하도록척추바늘을경피적 (percutaneous) 으로삽입하여단섬유봉합사 (nylon No. 1-0) 를통과시켜전방삽입구로빼낸다. 이때에표시봉합사와의위치관계를정확히파악하여차후의점액낭측파열의봉합을위해점액낭측파열의중심부를통과하지않도록하였다. 단섬유 (monofilament) 봉합사 (nylon No.1-0) 에미리나와있는봉합나사못에부착된봉합사를걸어셔틀 (shuttle) 을형성하여피부밖으로빼내었다. 이과정은봉합사끼리의꼬임을방지하기위하여전방에서부터차례로하나씩시행하였다. 피부밖으로나온봉합사를당겨관절내에서파열된가장자리부분의건이해부학적족적 (foot print) 에정복이되는것을확인하였다. 관절경을다시견봉하공간으로삽입하고봉합사의위치를확인한후봉합사가꼬이지않도록전방삽입구와외측삽입구를통해각각의봉합사를빼내어매듭형성을시행하였다. 이어관절경을후방삽입구를통해다시관절내로삽입하여파열되었던부분이해부학적족적에완전히봉합되어있는것을확인하였다. 점액낭측의봉합에대해서는이미봉합된조직에손상을주지않으면서통상적인방법으로봉합나사못을이용한단순봉합술을시행하였다.

결과부분파열의부위에따른분포는관절측 56예, 점액낭측 58예, 양측이 24예였으며각군간에나이, 성별, 외상력및이환기간등에따른통계학적인차이는없었다. 이학적검사에서관절운동범위, 충돌징후, 극상건검사, 외회전약화의양성빈도도각군간에통계학적차이가 관찰되지않았다 (Table 1).

3 회전근개부분파열의임상양상및관절경소견 179 Table 1. Fig. 1. Fig. 2. 4) 통계분석방법관절측, 점액낭측및양측부분파열에대한동통, 관절운동범위, 충돌징후, 극상건검사, 외회전약화소견등의임상양상과외상력, 이환기간에대해 one way ANOVA test와 Chi-square test를이용하여통계학적으로검증하였다. 결과부분파열의부위에따른분포는관절측 56예, 점액낭측 58예, 양측이 24예였으며각군간에나이, 성별, 외상력및이환기간등에따른통계학적인차이는없었다. 이학적검사에서관절운동범위, 충돌징후, 극상건검사, 외회전약화의양성빈도도각군간에통계학적차이가 관찰되지않았다 (Table 1). 회전근개부분파열은관절경소견상 5개의형태로분류될수있었다. 제 1형은닳아헤어진소견이있는경우이며 (Fig. 1), 제 2형은섬유의단열이있으며 (fiber disruption) 전위를동반할수도있다 (Fig. 2). 제 3형은층판을형성하거나분획화되어파열부위가불안정한경우이다 (Fig. 3, 4). 제 4형은관절측과점액낭측에모두파열이존재하지만양측간에교통은없는경우이며 (Fig. 5A, B), 제 5형은제 4형이더진행하여전층파열로의진행이임박한경우이다 (Fig. 6A, B). 제1형에서 3형까지는관절측또는점액낭측을명시할수있다. 제 1형은관절측이 20예, 점액낭측이 21예, 제 2형은관절측이 14예, 점액낭측이 21예, 제 3형은관절측이 22예, 점액낭측이 16예, 제 4형은 16예, 제 5형은

Arthroscopic image showing fragmentation on the bursal

on the articular side of the cuff and (B) a large flap

RC, rotator cuff; H, humeral head. Fig. 6.

4 180 권오수 김양수 이규영 Fig. 3. Arthroscopic image showing flap formation and fragmentation on articular side. RC, rotator cuff; H, humeral head. A A Fig. 4. Arthroscopic image showing fragmentation on the bursal side of the rotator cuff. A, acromion; RC, rotator cuff. B B Fig. 5. Arthroscopic views revealed (A) displaced fiber disruption on the articular side of the cuff and (B) a large flap formation on bursal side of the cuff. RC, rotator cuff; H, humeral head. Fig. 6. Arthroscopic finding demonstrated almost completely ruptured tendon fibers like full thickness tear with some fibers remaining in the middle layers of the cuff. (A) articular side and (B) bursal side. RC, rotator cuff; H, humeral head.

5 회전근개부분파열의임상양상및관절경소견 181 8예였다. 치료방법은제 1 형의경우대패기 (shaver) 또는고주파기구 (Radiofrequency device) 를이용하여변연절제술 (debridement) 을시행할수있으며제 2형은전위여부에따라전위가있는경우는봉합을, 전위가없는경우에는변연절제술을시행할수있다. 제 3형의관절측인경우불안정한파열변연부의일부를절제하고봉합나사못을이용한경건적 (transtendon technique) 수기를이용한봉합을할수있고점액낭측인경우통상적인봉합나사못을이용한단순봉합을시행할수있다. 제 4형의경우관절측과점액낭측에존재하는제 1형에서제 3형까지의파열의형태에대해각각변연절제술또는봉합술을시행할수있다. 제 5형의경우는전층파열로전환후봉합술을시행할수있다. 고찰조직학적구조및생역학적인측면에있어관절측과점액낭측이서로상이한양상을보이기때문에원인이나발생기전도차이를보일수있으며따라서회전근개부분파열의위치에따라임상양상에있어서도다른양상을보일수있을것으로예상되어다양한회전근개관련이학적검사중극상건약화검사, 외회전약화소견및충돌징후등의검사방법을이용하여관절측과점액낭측회전근개부분파열의임상양상을분석하였다 2,5,7,12,14-18,20,21). 본논문에서부분파열의위치에따른회전근개관련이학적검사상현저한차이를보이지는않았는데이는대상환자의증세이환기간이평균 5개월로서시간경과에따라동통과함께이차적인관절운동제한이수반되어전형적인이학적검사의발현이힘들었을것으로보인다. 본논문의대상환자군에서회전근개파열에어느정도의관절강직이동반되었으나이는전신마취후수동조작등의시술을하지않더라도관절운동범위확인과정에서대개의경우완전관절운동범위를회복할수있어진정한의미의관절강직보다는동통에의한이차적인결과로보는것이타당할것으로사료된다. 현재통상적으로사용되는회전근개부분파열의분류에는 Ellman의파열의위치, 두께및면적에따른분류, Snyder의파열의위치와정도에따른분류가있다 4,22). 회전근개파열은여러가지원인이복합되어발생하여매우다양한형태로나타나므로실제로어떠한분류라하더라도회전근개부분파열의모든양상을반영하기는 힘들며임상적으로는관절경수술시야상에서파열의위치와정도를파악하여치료방법의결정이나추시결과의분석이용이한분류가요구된다 15). 회전근개중극상건과극하건의조직학적배열은 5개의층으로구성되며서로다른구조적배열로되어있으며관절측은건, 인대, 관절낭의복합체로구성되어있어유연성이적어쉽게파열될수있는반면점액낭측은신장력 (tensile load) 에저항하는건다발로구성되어있어상대적으로관절측부분파열의빈도가더높다 5,21). 사체를이용한생역학적실험에서상지의외전시에극상건에걸리는압박력또는신연력은대부분관절측으로전달되어관절측회전근개의파열이먼저시작되며층간의서로다른변형률 (strain) 에의해염전력이작용하여건내파열 (intratendinous tear) 을유발하고결국에는전층파열을초래한다 7,9,19,20,25). 반면점액낭측파열은통상견봉하충돌증후군에의해주로발생하지만충돌증후군에의해관절측또는건내파열도발생할수도있다 13,19). 따라서생역학적인성질과함께연령에따른퇴행성변화등의내적요인과충돌증후군, 외상등의외적인요인이복합적으로작용하여발생하는회전근개파열은관절측및점액낭측에파열이공존할수있다 5). 최근의생역학적연구에서극상건의변형률은해부학적위치에따라차이가있으며양측의건표면의골부착부가구조적으로가장약할수있다는점을제시하여이와같은양측파열의존재를간접적으로시사하고있다 7). 본논문에서제시된분류에관절측과점액낭측각각에파열이존재하나양측사이에교통이없는파열의형태가이러한생역학적인연구결과를뒷받침하는임상적인근거가될수있을것으로사료된다. 본논문의분류에서건내파열에대해언급되지않았는데병리조직학적으로이러한병변을동반할수있으나임상적으로관절경시야상에서정확히진단하기는어려움이있으며부분파열의다양한형태에따른치료방법의결정이중요할것으로사료된다. 회전근개부분파열에대한치료는보존적요법이최초에시도될수있으나회전근개부분파열에서치유를위한생물학적인환경의변화는일어나지만적절한치유로진행되지않아시간경과에따라자연치유가일어나기힘들며파열의크기가점차커져결국전층파열로진행하므로수술적방법이제시된다 3,6,23,26). 회전근개부분파열의치료는변연절제술 (debridement) 또는견봉성

6 182 권오수 김양수 이규영 형술 (acromionplasty) 을포함한견봉하감압술 (subacromial decompression) 에서부터봉합술까지다양한방법이보고되었는데이중부분파열의봉합술은전층파열로의전환후봉합하는방법과경건적수기 (transtendon technique) 를이용한봉합술이대표적인방법이다 10,11,12,22,24). 부분파열을전층파열로전환후봉합하는방법은잔존하는정상회전근개섬유에손상을줄수있으며원래의해부학적족적 (footprint) 으로의재건이어렵다는단점이있다 10,12). 또한극상건내의변형률 (strain) 에대한생역학적실험에의하면부분파열의두께에비해잔존하는정상건의변형률 (strain) 은상대적으로크게증가하지않으므로전층파열로전환후봉합은바람직하지않다는근거를제시하고있다 1). 관절측부분파열의봉합은문헌상에서다양한수술방법을찾을수있는데 Snyder 가기술한회전근개부분파열의봉합수기는관절측회전근개의족적 (foot print) 에서견열된극상건 (PASTA: partial articular supraspinatus tendon avulsion) 에회전근개를관통하여삽입된봉합나사못의봉합사를통과시켜점액낭측에서매듭을형성하는방법으로점액낭측의정상회전근개섬유는손상을주지않으면서봉합이가능하다 22). 이를바탕으로한다양한수기가제시되었다 10-12,24). 본논문에서제시된분류상제 3형의파열이관절측에존재하는경우이와같은경건적수기 (transtendon technique) 를이용한봉합술의적응이될수있다. 이같은수기를이용하여봉합할때에는가능한한낮은유입액압력을유지하여조직으로의부종을예방하여원활한관절측과점액낭측간에삽입구교환이이루어지고피부표면의해부학적이정표 (anatomic landmark) 파악이용이하게하며관절측에서봉합의시행전에견봉하감압술과함께견봉하공간에대한철저한관절경검사를시행하여정확한해부학적족적 (foot print) 재건을위한관절측파열과위치관계의파악, 차후의매듭형성 (knot tying) 시의시야확보및수술전에인지되지않은점액낭측회전근개병변의탐색이가능하도록하는것이바람직할것으로사료된다. 결론회전근개부분파열의진단에서수술전이학적검사를통한임상양상에따라파열위치를예측하기는어려울것으로사료되며관절경하소견을통한새로운분류가 회전근개부분파열의치료방침을결정하는데에도움을줄수있을것으로생각된다. 참고문헌 1. Bey MJ, Ramsey ML, Soslowsky LJ: Intratendinous strain fields of the supraspinatus tendon: effect of a surgically created articular-surface rotator cuff tear. J Shoulder Elbow Surg, 11: , Burkhart SS, Esch JC, Jolson RS: The rotator crescent and rotator cable: an anatomic description of the shoulder's suspension bridge. Arthroscopy, 9: , Carpenter JE, Thomopoulos S, Flanagan CL, DeBano CM, Soslowsky LJ: Rotator cuff defect healing: a biomechanical and histologic analysis in an animal model. J Shoulder Elbow Surg, 7: , Ellman H: Diagnosis and treatment of incomplete rotator cuff tears. Clin Orthop Relat Res, 254: 64-74, Fukuda H: The management of partial-thickness tears of the rotator cuff. J Bone Joint Surg Br, 85: 3-11, Fukuda H, Hamada K, Yamanaka K: Pathology and pathogenesis of bursal-side rotator cuff tears viewed from en bloc histologic sections. Clin Orthop Relat Res, 254: 75-80, Huang CY, Wang VM, Pawluk RJ, et al: Inhomogeneous mechanical behavior of the human supraspinatus tendon under uniaxial loading. J Orthop Res, 23: , Jobe CM: Rotator cuff disorder: anatomy, function, pathogenesis and natural history. In: Orthopaedic knowledge update. Shoulder & Elbow, AAOS: , Lee SB, Nakajima T, Luo ZP, Zobitz ME, Chang YW, An KN: The bursal and articular sides of the supraspinatus tendon have a different compressive stiffness. Clin Biomech (Bristol, Avon), 15: , Lehman RC, Perry CR: Arthroscopic surgery for partial rotator cuff tears. Arthroscopy, 19: E81-E84, Lichtenberg S, Siebold R, Habermeyer P: Arthroscopic supraspinatus tendon repair using suture anchors and a modified Mason-Allen technique: an intra-articular approach. Arthroscopy, 20: , Lo IK, Burkhart SS: Transtendon arthroscopic repair of

7 회전근개부분파열의임상양상및관절경소견 183 partial-thickness, articular surface tears of the rotator cuff. Arthroscopy, 20: , Luo ZP, Hsu HC, Grabowski JJ, Morrey BF, An KN: Mechanical environment associated with rotator cuff tears. J Shoulder Elbow Surg, 7: , MacDonald PB, Clark P, Sutherland K: An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. J Shoulder Elbow Surg, 9: , Matava MJ, Purcell DB, Rudzki JR: Partial-thickness rotator cuff tears. Am J Sports Med, 33: , Murrell GA, Walton JR: Diagnosis of rotator cuff tears. Lancet, 357: , Nakajima T, Rokuuma N, Hamada K, Toomatsu T, Fukuda H: Histologic and biomechanical characteristics of the supraspinatus tendon: reference to rotator cuff tearing. J Shoulder Elbow Surg, 3: 79-87, Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG: Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg Am, 87: , Reilly P, Amis AA, Wallace AL, Emery RJ: Mechanical factors in the initiation and propagation of tears of the rotator cuff. Quantification of strains of the supraspinatus tendon in vitro. J Bone Joint Surg Br, 85: , Reilly P, Amis AA, Wallace AL, Emery RJ: Supraspinatus tears: propagation and strain alteration. J Shoulder Elbow Surg, 12: , Rhee YG: Strength weakness, anatomy and biomechanics. In: The shoulder: diagnosis and treatment. Yeong Chang Medical Books: , Snyder SJ: Arthroscopic repair of articular supraspinatus tendon avulsions: PASTA lesion of the rotator cuff. In: Shoulder arthroscopy. 2nd ed. Lippincott Williams & Wilkins: , Uhthoff HK, Sano H: Pathology of failure of the rotator cuff tendon. Orthop Clin North Am, 28: 31-41, Waibl B, Buess E: Partial-thickness articular surface supraspinatus tears: a new transtendon suture technique. Arthroscopy, 21: , Wakabayashi I, Itoi E, Sano H, et al: Mechanical environment of the supraspinatus tendon: a two-dimensional finite element model analysis. J Shoulder Elbow Surg, 12: , Yamaguchi K, Tetro AM, Blam O, Evanoff BA, Teefey SA, Middleton WD: Natural history of asymptomatic rotator cuff tears: a longitudinal analysis of asymptomatic tears detected sonographically. J Shoulder Elbow Surg, 10: , = 국문초록 = 목적 : 대상및방법 : 결과 : 결론 : 색인단어 :

02-01 최의성

02-01 최의성 대한견 주관절학회지 제16권 제2호 Clinics in Shoulder and Elbow Volume 16, Number 2, December, 2013 Original Article doi:http://dx.doi.org/10.5397/cise.2013.16.2.84 회전근 개 층간 분리 파열에서 관절경을 이용한 층상 교량형 봉합술의 임상 결과 충북대학교