REVIEW ARTICLE pissn eissn J Korean Soc Surg Hand 2017;22(1): JOURNAL OF THE KOREAN

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1 REVIEW ARTICLE pissn eissn J Korean Soc Surg Hand 2017;22(1): JOURNAL OF THE KOREAN SOCIETY FOR SURGERY OF THE HAND Recent Updates on the Treatment of Lateral Epicondylitis Kyoung-Hwan Koh, Hyun Il Lee Department of Orthopaedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea Received: January 12, 2017 Revised: [1] February 25, 2017 [2] March 3, 2017 Accepted: March 3, 2017 Correspondence to: Kyoung-Hwan Koh Department of Orthopaedic Surgery, Inje University Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang 10380, Korea TEL: FAX: osdoc.koh@gmail.com *We thank to Professor Min Jong Park from Samsung Medical Center and Professor Sang-Jin Shin from Ewha Womans University Mokdong Hospital for providing the surgery figures. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( 3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The natural course of lateral epicondylitis is widely regarded to be self-limiting within 1 year of symptom duration in 90% of all patients. The spectrum of treatments include simple wait and see, bracing, physical therapy, corticosteroid injection, and recently some biologic injection such as autologous blood and platelet rich plasma. However, recalcitrant lateral epicondylitis which are not responding to conservative treatments can be treated with surgical treatment although much remains unclear regarding the ideal treatment. Debates surrounding open procedures are the management for the defect after resection of pathologic tissue, necessity of decortication, selective denervation procedure, etc. Since the trend is changing to minimal invasive surgery and arthroscopic release of extensor carpi radialis brevis tendon are becoming more popular these days, surgical tips and pitfall to obtain good results and avoid complications have been reported recently. Bipolar radiofrequency (RF)-based microtenotomy or percutaneous tendon release is another surgical procedures reported to be effective in lateral epicondylitis. However, there are some patients who present with persistent pain after surgical treatment. Thus, selection of ideal candidates for surgery, thorough evaluation of all pathologies prior to surgery, and adequate surgical procedures would be essential in the surgical treatment of lateral epicondylitis. Keywords: Tennis elbow, Surgery, Review 서론 외상과염은 %- % 의성인에서발생하고, 명당 - 명의연간발생률이보고되는비교적흔한질환이다. 흔히테니스엘보라하여스포츠활동과관련이있음을시사하지만, 대다수의환자들은직업적인요소와관련이있으며육체노동자에서 %, 그리고일반인에서 %- % 의유병률을가진것으로알려져있다 -. 주발생연령은 - 대이며남녀간의유병률차이는크지않고육체노동과관련되어우세수에주로발생한다고알려져있으며완관절의신전과전완 부의회내전, 회외전되는동작과관련된반복적인작업을많이하면서서서히발생하게된다. 처음에는염증성질환으로여겨졌으나지금은과도한사용으로인한단요수근신전건 (extensor carpi radialis brevis, ECRB) 의미세손상 (microtrauma) 이병인으로여겨진다. 대부분의경우 - 개월정도로비교적오랫동안증상이지속되지만약 % 에서는 년정도안에증상이완전히좋아질수있다고알려져있지만 %- % 에서는결국수술적치료를받게되며, 가장효과적인치료에대해서는아직일관된결론은없다,. Copyright c The Korean Society for Surgery of the Hand 1

2 J Korean Soc Surg Hand Vol. 22, No. 1, March 2017 ANATOMY 관절경적단요수근신전건유리술시좋은수술결과를얻고합병증을피하기위해서는해부학적구조를이해하는것이중요하다. 단요수근신전건의기시부는외상과 (lateral epicondyle) 의앞쪽에있는장요수근신전건 (extensor carpi radialis longus, ECRL) 과총수지신전건 (extensor digitorum communis, EDC) 보다깊은곳에위치한다. 때로는근간격막 (intermuscular septum) 과아래에있는관절막 -인대구조 (capsuloligamentous structure) 를포함하는추가적인기시부를가지기도하며단요수근신전건은총수지신전건의힘줄과함께섞여그기시부 (origin) 를구분하기쉽지는않은경우가많다,. 단요수근신전건의기시부는인대와관절막부착부위의바로외측, 상부에놓여있다. 요골신경은외상과에서약 cm 근위부에서전방구획 (anterior compartment) 으로들어가고상완근 (brachialis) 과상완요근 (brachioradialis) 사이로부터나와외상과에서근위부로 cm, 원위부로 cm 사이에서표재 (superficial) 와심재 (deeper) 분지로나누어진다. 요골신경의심재분지는후방골간신경 (posterior interosseous nerve) 이며회외근 (supinator) 의후로세아케이드 (arcade of Frohse) 를통과하게되며근위부로는장요수근신전건과단요수근신전건으로부터전완부후방의근육들을차례로지배하게된다. 요골신경의표재분지는주로감각을담당하며상완요근아래에위치한다. 관절경입구위치와관련하여후방골간신경의위치가중요한데, 후방골간신경이후로세아케이드에들어갈때후방골간신경과요골 -상완소두관절 (radiocapitellar joint) 까지의거리는 ± mm이며외상과로부터 ± mm 로보고된바있다. 후방골간신경과요골- 상완소두관절까지의거리는특히회외전을하면 mm 정도까지가까워지고회내전을하면 mm로늘어난다고한다. 관절경기구와주관절주위의신경, 혈관등과의거리를늘리기위해서는관절을 굴곡시키고생리식염수로관절내를팽창시켜야한다. 근위전방외측의관절경입구 (proximal anterolateral portal) 에서관절경과요골신경의거리는. mm ( 범위, - mm) 이고관절경입구가원위부로갈수록요골신경까지의거리는가까워져중-전외측관절경입구 (mid-anterolateral portal) 에서는. mm, 윈위-전외측관절경입구 (distal anterolateral portal) 에서는. mm로줄어들게된다. 한편요골-상완소두관절레벨에서는최소한 mm의상완근이관절막과요골신경사이를나누고있는데반해요골경부레벨에서는관절막과신경사이에지방조직만있는경우가많다,. 근위 -전내측관절경입구 (proximal anteromedial portal) 와관 련해서정중신경 (median nerve) 이손상받을수있으며내측상과 (medial epicondyle) 에서 cm 전방, cm 근위부에서관절내를향해관절경입구를만드는경우캐뉼라에서. mm 정도에위치한다고한다. 또한척골신경 (ulnar nerve) 의경우에관절경입구가내측근간격막 (medial intermuscular septum) 에서전방에위치하는한위험하지않다. 알려진바와같이외측인대복합체 (lateral ligamentous complex) 중특히외측척골측부인대 (lateral ulnar collateral ligament, LUCL) 가중요한데, 외상과의바로원위부에서기시하며단요수근신전건에후방그리고보다깊이위치한구조물로써이것이손상되면후외방불안정성 (posterolateral rotatory instability, PLRI) 으로이어질수있다. PATHOPHYSIOLOGY 흔히자연히좋아지는질환 (self-limiting disease) 으로알려져있지만최근연구에따르면만족할만한예후를보이지않는다. Bot 등 은 % 의환자들이이환된지 년후에약간은호전되지만완전한회복은 / 에서만관찰된다고하였으며, Nilsson 은 % 는여전히통증이있고 % 는기능이감소했다고보고한바있다. 외상과염은대부분반복적인미세손상의결과로힘줄 ( 건 ) 의내부구조의손상과세포와세포기질의퇴행성변화를야기시키는질환으로보인다. 전통적으로건염 (tendinitis) 이라고불리고는있으나조직학적연구에서대식세포 (macrophage), 림프구 (lymphocyte) 나호중구 (neutrophil) 는많이관찰되지않으며, 섬유아세포의밀집현상, 혈관증식, 콜라겐의탈구조화 (dense population of fibroblast, vascular hyperplasia, disorganized collagen) 로특징되는일종의혈관섬유모세포성증식 (angiofibroblastic hyperplasia) 이관찰된다. 따라서외상과염보다반복적인미세손상으로인한건병증 (tendinosis) 이라고하는것이더적절할것이다. 병태생리학적으로제안된다른이론으로는단요수근신전건근위부주위의혈관분포가있다. Schneeberger 과 Masquelet 은 예의사체주관절을이용한연구에서단요수근신전건주변의동맥혈류공급을육안적으로조사하였으며, 특히단요수근신전건아래는혈류공급이희박하여이것이조기퇴행성변화와부분파열로이어질수있다고주장하였다. 또한 Bales 등 역시사체를이용하여현미경학적으로총수지신전건과외상과주위의혈류분포를조사하였는데외상과근위부와외상과 - cm 원위부의총수지신전건심부에혈류분포가희박한구역 (hypovascular zone) 이있음을보 2

3 Kyoung-Hwan Koh, et al. Treatment of Lateral Eicondylitis 여주었으며이러한저혈류구역이정상적인염증반응과미세손상에대한치유반응을저해하고결국외상과염의원인으로작용할지도모른다고주장한바있다. CLINICAL FEATURES 환자들은주관절외측의통증을호소하며손목관절의능동적신전혹은수동적굴곡시악화된다. 경우에따라전완부아래로방사되는양상을보이기도한다. 보통외상력은없고통증이서서히발생한다. 환자들은물건을들때, 문을열때, 열쇠를돌리거나악수를할때, 가방을들고다닐때와같이일상생활에서통증이있다고호소한다. 이학적검사에압통은외상과보다약간전하방에있으며운동범위는정상인경우가대부분이다. 저항을주면서손목을신전시킬때 (resisted wrist extension) 통증이심해지며, 팔꿈치를펴고회내전시킨상태로의자등을들게하면 (chair test) 증상이심해진다,. 감별진단으로는요골터널증후군 (radial tunnel syndrome), 요골-상완소두관절염, 박리성골연골염 (osteochondritis dissecans), 활액막증후군등이있다. 요골터널증후군의경우통증의양상이외상과로부터 - cm 정도원위부에서발생하는경우에의심할수있으며근전도검사가진단에도움이된다. 후방골간신경의경우운동신경에속하나신경이압박 (entrapment) 되는경우외상과염과유사한신경통성통증을호소할수있으며요골- 상완소두관절의관절염이나박리성골연골염이발생한경우유사한부위의통증을호소할수있다. 최근관심을받고있는활액막증후군 (plica syndrome) 역시외상과염과유사한통증을보일수있다. 정상적으로존재할수있는활액막주름 (synovial fold) 이두꺼워지고활액막염을일으키게되며, 특정자세에서발음 (snapping) 과통증을일으키는질환으로외상과염과통증의양상이유사하나활액막증후군에서통증은대개는후외측부에있으며외상과나신전건기시부에있지않다. 또한잠김 (locking) 이나캐칭 (catching) 을동반하는경우가많으며경우에따라서는이런증상없이통증만있을수도있다. 단순방사선검사를통해관절내유리체나관절염, 박리성골연골염과같은골성병변의유무를알수있다. 간혹공통신전건의부착부위를중심으로석회성물질의침착을관찰할수있는경우도있다. 초음파검사는진단에직접적인수단은아니나공통신전건기시부의비후나저에코 (hypoechoic) 소견, 건내파열 (intrasubstance tear) 등과같은병적인상태를아는데도움을줄수있다. 다만익히알려진바와같이민감도와특이도가높지않고검사자의 경험에의존적이다. 외상과염의진단은대부분임상적으 로이뤄지게되어자기공명영상 (magnetic resonance imaging, MRI) 등의영상검사를필요로하는경우는많지않다. 다만조 직의퇴행성변화를확인할수있고, 힘줄과주변관절막의부 분적인파열등을볼수있다. 신호강도의변화나신전건내 의부종이나비후를보이는경우가드물지않으나무증상환 자에서도흔히관찰될수있으며증상이없어진후에도상당 기간증가된신호강도소견이관찰될수있어, 치료의결정등 에큰도움이되지않는것으로보인다. 많은경우에 MRI 소 견은임상적인소견과연관하여해석해야할것으로보이며 많은수의 MRI 를분석한한연구에서이러한신호강도의변 화에대하여큰임상적의미를가지지않는다고하며환자의 연령만이환자의예후와관련된인자라고보고하였다. 경우 에따라서는동반되는외측척골측부인대의손상도함께진 단할수있는경우도있다 (Fig. ). 해부학적으로외상과염이 발생하는부위와인접해있는외측척골측부인대는보존적 인치료중에급성손상의형태로나타날수있으며, 특히스 테로이드주사등으로치료하는환자에서발생할가능성이 있으며이경우후외방회전불안정성의임상양상을보일수 있다,. TREATMENT 거의모든연구에서외상과염은자연적으로치유되는경 Fig. 1. Magnetic resonance imaging (MRI) of coronal T2 weighted image showed accompanying lateral ulnar collateral ligament complex insufficiency in a patient with lateral epicondylitis. 3

4 J Korean Soc Surg Hand Vol. 22, No. 1, March 2017 과를가진질환으로 % 이상에서 개월안에증상호전을보고하고있다. 경과관찰 (wait and see), 부목고정, 보조기, 물리치료, 초음파와이온영동치료 (iontophoresis), 리도카인주사, 알코올주사, 스테로이드주사, 자가혈액 (autologous blood) 이나혈소판풍부혈장 (platelet rich plasma, PRP) 과같은각종생물학적주사요법 (biologic injection), 보툴리눔독소 (botulinum toxin), 충격파 (extracorporeal shock wave therapy, ESWT), 침 (Acupuncture), 레이저, 비스테로이드성소염제 (nonsteroidal anti-inflammatory drugs, NSAIDs) 와같은소염제등다양한치료방법이이러한증상을단축시키기위해시도되고있으나질환의자연경과에대하여어떤방법도우월하다고증명되지않았다. 또한저자에따라서는스트레스등의정신적인요소가증상의강도와기능적장애와직접적으로관련되어있다고하여치료과정중정신심리학적인요인에대해적절한상담을병행하는것이필요하다고주장한다. 1. Brace 외상과대항근보조기 (epicondylar counterforce brace) 는전완부에서수근신전건에의장력 (tension) 을감소시킬수있고, 신전건의기시부를원위부로옮겨주는효과를가져와단요수근신전건의골성기시부에작용하는장력을감소시킬수있다는이론에서시행되는치료법이다. 연구자에따라서는팔꿈치스트랩 (elbow strap) 이나완관절신전보조기 (wrist extension brace) 를사용하기도하지만, 메타분석 (metaanalysis) 에서는특정보조기가뛰어나다는결론을얻지못하고있다. 2. NSAIDs 등의소염제외상과염은비염증성질환이므로통증조절에있어서 NSAIDs 와같은소염제의사용은동반된활액막염이나주변조직의급성염증반응을감소시키는데작용하여이차적으로효과를가져오는것으로알려져있다,. 한연구에의하면위장관계부작용의가능성에비해 NSAIDs 를복용하는것이통증감소에는큰효과가없고파악력이나기능적인면에서도위약 (placebo) 을투여한군과차이가없다고보고된바있다. 3. Physical therapy 급성기의외상과염치료는휴식과, 소염제등의복용, 스테로이드의주사등이보다효과적이며, 물리치료 (physiotherapy) 는만성적이거나잘낫지않는경우에시행하 는것이적절하다. 외상과염에서운동치료는사실만성적인아킬레스건병증에서운동치료의긍정적인효과에근거한것으로스트레칭, 편심성근력운동 (eccentric strengthening) 과 mobilization 등에대한효과가연구되어왔다. 스트레칭과근력운동을병행해서시행한경우에위약이나대조군에비해서는효과가있다는연구가많으며스트레칭, 편심성, 동심성근력운동간의차이가있는지는명백하지않다. 크게보아서는운동치료단독으로시행하는것보다여러가지다양한보존적치료방법의하나로서이러한운동치료를포함하는것은부작용없이효과적으로사용할수있는좋은방법이다. 스트레칭운동은단요수근신전건을대상으로하여가장신전시킬수있는자세를취하게된다. 주관절신전상태에서전완부를회외전시키고, 완관절을굴곡, 척측사위로만드는자세이다. 다양한횟수와지속시간이제시되고있지만대체로 - 초정도지속하는것이효과적이라고한다 -. 근력운동의방법에대해서도많은연구가있는데크게보아서는특히편심성운동이여러보존적치료방법과함께보조적으로사용될때효과적인것으로보인다. 4. Steroid injection 앞서기술한바와같이스테로이드주사가일련의염증반응 (inflammatory cascade) 을억제하고통증에대한국소면역반응을감소시키는데반해, 외상과염에서염증세포들이거의없음에도불구하고통증감소의효과를보여주는것은아마도 Substance P와같은통증발생인자 (pain generator) 의감소로인한것으로생각한다,. 국소주사에관한체계적문헌고찰 (systematic review) 이나메타분석으로부터우리가얻을수있는몇가지유용한정보중의하나는, 증상의시작이 주이내인소위급성기에서가장좋은치료는휴식과안정을통한통증경감이며, 이에비해만성적이거나재발성의경우에는 NSAIDs 와스테로이드주사의사용또는 PRP 와같은소위복원을위한시술을고려해볼수있다는점이다. 이중스테로이드주사는단기적인효과는있으나 개월이상에서효과는크지않고오히려부정적인효과를가져올수있으며장기적인예후로는 PRP 등보다못한결과를가져올수도있다 -. 스테로이드주사의부정적인효과에대해가장널리알려진연구가바로 Smidt 등 에의한연구일것이다. 이들의연구에서물리치료가가장좋은효과를보였으며단순히기다려보는것 (wait and see) 도좋은효과를보였지만스테로이드주사는가장좋지않은결과를보여주었다. 더나아가서 Kachooei 등 의연구에따르면스테로이드주사를시행한경우수술을지연시키지만결국수술 4

5 Kyoung-Hwan Koh, et al. Treatment of Lateral Eicondylitis 로이어질가능성이더높고대부분의경우 년이내에수술을시행하게되는경향이있음을보고하였다. 스테로이드의사용과관련한합병증도보고된바있는데, 가장흔한것은피부의탈색 (skin depigmentation) 과주사부위의지방조직위축 (fat atrophy), 그리고당뇨환자에서일시적인혈당상승등이있을수있다. 그외에도치유과정을위한정상적인면역반응 (natural healing inflammatory response) 의손상으로인한신전건의파열, 손상의가능성이나외측척골측부인대의손상등도보고된바있다,. 5. Biologic injection 스테로이드주사외에외상과염에서사용되고있는주사에는여러종류가있다. 대표적으로자가전혈주사 (autologous whole blood injection), 혈소판풍부혈장주사, 줄기세포치료 (stem cell therapy) 등을들수있다. 이론적으로건병증 (tendinopathy) 에서발생하는세포자멸과정 (apoptotic process) 을극복하기위해손상부위에기능하는세포 (functional cell) 을공급함으로써힘줄 ( 건 ) 의구조를회복할수있을것으로기대되는방법이다. 특히 PRP 와관련하여혈소판유래성장인자 (platelet-derived growth factor), 형질전환성장인자 (transforming growth factor), 혈관표피성장인자 (vascular endothelial growth factor) 등세포증식 (cell proliferation), 주화성 (chemotaxis), 세포분화 (cell differentiation), 그리고혈관신생 (angiogenesis) 와관련된많은성장인자 (growth factor) 를분비할수있다고많은연구결과들이보고되고있으나여전히그효과에대해서는논란의여지가있으며,,, 대부분의연구에서진정한의미에서의대조군선정이어렵기때문에자연경과에대한이러한생물학적주사의차이점을분명하게밝히지못하고있다. 체계적고찰에서역시중기, 그리고장기추시결과에서자가전혈주사가효과적이라는것을입증하지못하고있다. 6. ESWT 외상과염의치료로써 ESWT 효과에대한근거는아직충분하지않다. 저자에따라서는효과적이라고보고한연구자도있으나 다른연구에서는만성외상과염에대한 ESWT 의효과에대한이중맹검연구에서위약효과이상의결과는보이지못했다,. 일부저자가그치료효과를믿고있으나아직까지대체적으로는근거가부족하다고생각한다. 전형적인외상과염의임상소견을보이고방사선검사에서석회성음영이관찰되는경우를볼수있다. 현재까지의문헌상에서이러한석회성음영의침착을보이는외상과염에대 해서는재활의학과를중심으로충격파치료의좋은대상으로보는경향이있으며, 견관절석회성건염에서충격파의효과에대해서는어느정도의공감대가있으나만성외상과염에서석회성침착이동반된경우에대해서도이와같은효과가있는지에대해서는아직밝혀진바가많지않다. 최근한연구에서석회성침착의여부가 ESWT 의치료효과에차이를보이지못하였으나신전건의손상이동반된경우에는석회성침착이동반되면치료효과가떨어진다고보고한바있다. SURGICAL TREATMENT 정형외과의사의관점에서외상과염과관련해서는수술의적응증을어떻게설정하는지가관심의대상일것이다. 대부분의경우에있어서자연치유되는질환이며보존적치료가대상이기는하지만그럼에도불구하고여전히수술이필요한경우가있고, 그렇다면어떤환자들에게수술이필요하고, 어떤환자들에게이러한수술적치료가효과적인지, 어떤요인이중요한지가관심이다. 한연구에따르면술전신전건의상태와성별이수술의예후에영향을미친다고보고하고있다. 또다른연구에서는재해보상과관련이있는경우, 이전의주사병력, 요골터널증후군, 이전의정형외과적수술, 개월이상의증상이있었던경우에있어서비수술적치료의실패와수술적치료를시행하게되는요인으로분석된바있다. 수술의방식은크게전통적인개방적술식, 관절경술식, 그리고경피적술식등으로나눌수있으며대부분좋은결과를보고하고있으며그외에도주근이전술 (anconeus transfer) 이나탈신경술식 (denervation procedure), 후방골간신경감압술 (posterior interosseous nerve decompression), 그리고외측척골측부인대재건술을함께시행하는것을주장하는연구자들이있다. 1. Open surgery 다소간다른방식의많은개방적술식이소개되었고그중 Nirschl 과 Pettrone 에의한술식이가장전통적인방식일것이다. 역사적으로는단요수근신전건의원위부의 Z 연장술 (distal Z-lengthening), Garden 술식과같은건연장술도시행되어왔으며, 공통신전건기시부전체의유리술을시행하는저자들도있다. 대부분의경우단요수근신전건은장요수근신전건기시부의뒤편에위치하면서총수지신전건기시부와구별하기는어렵다. 따라서섬유성, 육아조직의제거는단요수근신전건뿐아니라총수지신전건의기시부와장요수근신전건의일부를포함할가능성이높다 (Fig. ). 개방적술식 5

6 J Korean Soc Surg Hand Vol. 22, No. 1, March 2017 증후군이동반된경우에외상과염에대한보존적치료가실패할가능성이보고된바있고, 수술후에도지속적인통증을호소하는경우에해결되지않은요골터널증후군으로인한것임을보고한저자도있다. 이에따라외상과염에대한수술적치료시선택된환자에대해서는이러한후방골간신경의유리술이나요골터널유리술이함께시행되어더욱좋은결과를얻을수도있을것이다. Fig. 2. Nirschl lesion observed during the open procedure. The lesion is involving extensor carpi radialis brevis and some portion of common extensor tendon and distinguished from the relatively healthy-looking distal tendinous portion. 에서논란의여지가있는또다른부분은외상과의일정부분 에대한피질골제거술을시행 (decortication) 하는지의여부일 것이다. 저자에따라서는 decortication 을포함하기도하고필 요없는과정이라고주장하기도한다,. 한편외상과의병변부에대한충분한변연절제술을시행 하게되면조직의결손이형성될수있는데이러한결손부위 를봉합하는것이필요하다는주장이있다. 이러한조직의결 손에대해주근 (anconeus muscle) 의이전술을시행한경우 변연절제술만시행한경우에비해통증이나운동범위, 파악 력등에는차이가없지만, 기능적인면에서우월하다고보고 된바있다,. 주근의이전술을하지않더라도봉합구 (suture anchor) 를이용한총수지신전건이나단요수근신전건의봉 합을옹호하는저자들도있다. 해부학적연구들에서외상과주변으로후방피부신경의후 방분지 (posterior branches of the posterior cutaneous nerve) 가일정하게분포한다고알려져있다는점에주목하여선택 적인탈신경수술 (denervation surgery) 의결과가보고된바 있다. Rose 등 은 개월이상의보존적치료에호전이없으면 서후방분지에대한진단적신경차단술후에통증의감소와 파악력호전을보이는환자에대하여이러한후방분지를절 단하여통증과파악력이 % 의환자에서호전되었다고보고 하였다. 드물지만외상과염과동반되거나혹은외상과염으로오인 될수있는상태로요골터널증후군의가능성이있다,. 후방 골간신경이요골신경의운동분지임에도불구하고요골터널 2. Arthroscopic surgery 관절경적단요수근신전건유리술은관절의내부를관찰하여동반된병변에대한평가가용이하며, 재활이짧고원래직업으로의회복이빠르다는장점이있으며관절경적수술이개방적술식보다다소나은결과를보고하는연구도있다. 관절경적단요수근신전건절단술 (arthroscopic tenotomy) 과개방적술식 (open Nirschl procedure) 을비교한다른논문에서는개방적술식을시행한그룹의. % 의환자에서매우좋음 (excellent),. % 에서좋음 (good) 결과를보인데반해관절경수술을시행한그룹의. % 환자에서매우좋음,. % 에서좋음,. % 에서나쁨 (poor) 의결과를보여통계적으로차이가없는것으로보이나, 힘든일을할때개방적수술을한그룹에서., 관절경수술을한그룹에서. 의통증점수 (pain visual analogue scale, VAS pain) 를보여통계적으로는개방적술식이낫다고보고하였다. 대부분의술식은단요수근신전건의병적이조직에대하여변연절제술을하거나유리술을시행하는것이다. 하지만일부저자들은변연절제술만으로충분하다고주장한다. 이러한변연절제술만으로도건강한조직을남기고병적인조직만제거하게된다고한다 (Scratch test). 변연절제술과유리술을비교한연구가많지않으나최소 년후의결과에서두군간의임상적결과는차이를보이지않았다. 그러나수술후원래의직업으로복귀하는데있어서는변연절제술이보다나은결과가보고된바있다. 또다른장점으로는동반된관절내병변의치료가용이하다는점인데, 앞서기술한것처럼활액막증후군으로의심되는병변이관찰되는경우에이를쉽게제거할수있다 (Fig. ). 관절경하에서단요수근신전건유리술을시행함에있어서해부학적으로단요수근신전건을육안적으로장요수근신전건이나총수지신전건과완벽하게구별하기어려운점을고려할때, 실질적으로도장요수근신전건과총수지신전건의일부도제거될수있다. 이러한경우특히변연절제술이너무표면쪽으로진행하는경우외측피부조직의손상가능성이있어유의해야한다. 또한요골두의앞쪽반에서근위부로 6

7 Kyoung-Hwan Koh, et al. Treatment of Lateral Eicondylitis A B C Fig. 3. Arthroscopic finding of posterior synovial plica during the surgery for lateral epicondylitis. (A) Synovial plica covering radial head prior to removal, (B) partially debrided synovial plica tissue, and (C) completion after removal of impinged synovial plica tissue between the radial head and capitellum. Fig. 5. Radiofrequency based microtenotomy in a patient with chronic lateral epicondylitis. Fig. 4. Arthroscopic view showing pathologic extensor carpi radialis brevis (ECRB) tendon and articular capsule from proximal anteromedial portal. ECRL, extensor carpi radialis longus. 단요수근신전건의기시부를변연절제술을시행할때전반 부의후방으로의변연절제술은외측측부인대의기시부를 손상시킬가능성이있다 (Fig. ). 관절경수술의단점으로지적되는것들은관절외부의병변 에대해관절내부를통하여수술한다는점, 수술준비시간이 길고, 비용이더비싸다는점, 혈관신경구조물의손상과같 은합병증의가능성이있다는점이다. 또한관절외건병증의 전반적인상태가관절경을통해효과적으로구별해내기어 려울수있다는점등이지적되고있다. 최근소개된새로운치료법중하나는양극성고주파기반 술식 (bipolar radiofrequency [RF]-based approach) 이다 (Fig. ). 이는최초허혈성충혈성심부전 (ischemic congestive heart failure) 에서 RF- 혹은 laser- 를기반으로한경심장재혈관화 시술 (RF- or laser based transmyocardial revascularization) 이혈관신생효과 (angiogenic response) 를가져온다는연구에서시작되었으며, Tasto 등 이최초고주파미세건절단술 (RF microtenotomy) 의성공적인치료결과를보고하였다. 고주파미세건절단술에대하여많지는않으나만족할만한임상적결과가보고되고있다 -. 고주파미세건절단술과신전건유리술후봉합술을비교한연구에서는고주파미세건절단술에서조기통증회복과파악력의회복을보인바있다. 고주파미세건절단술의작용기전에대한가설은 α v integrin, 혈관표피성장인자등을자극하여건조직에혈관신생효과를가져와치유를유도할것이라고설명하고있다. 동물실험에서는조직학적으로이러한고주파미세건절단술이 regular crimping, dense collagen fiber, hypercellularity 와같은콜라겐재형성 (collagen remodeling) 을보여주며정상비퇴행성건조직 (nondegenerated tendon) 과유사한모양을보여준다고한다,. 건병증에서병적인신경분지의성장이나신경의자극이통증을유발시키는이유중의하나로설명되기도하는데 7

8 J Korean Soc Surg Hand Vol. 22, No. 1, March 2017 이러한고주파미세건절단술의다른작용기전으로이러한신경섬유의제거를통해작용한다고설명하기도한다. 이러한퇴행성변화를보이는신경섬유가치료후 개월정도지나면재생되는것이보고되고있으며이시술후의조기통증감소가지속되는근거로제시되고있다. 이보다간단한술식으로경피적건유리술역시일부저자들에의해좋은결과가보고되고있다. 국소마취혹은전신마취하에서압통이가장심한부위에 게이지바늘을이용하여공통신전건기시부에대하여경피적으로유리술을시행할수있고, 개방적술식과비교했을때통증감소와직업으로의복귀가더빠르며간단한술식으로보고하고있다,. 다만이러한연구들에서통계적으로더낫다고보고한점수들이임상적으로의미있는차이가아니거나무작위배정연구로재현되지못하고있다는점에비추어각술식의이점과위험성을잘고려하여적절한환자군의선택과술식의선택이필요할것으로보인다. COMPLICATIONS 한체계적고찰에의하면개방적수술에서. %, 관절경수술에서. % 정도의합병증비율이보고된바있다. 이중신경손상이가장많은합병증 (. %) 이었으며상처와관련된합병증이두번째 (. %), 그리고감염 (. %) 과운동범위감소 (. %) 순으로조사되었다. 이중특히신경손상의비율은각각 %,. % 로크게다르지않고감염률은오히려. %,. % 로관절경수술에서더많은것으로조사된바있다. 실제우리가경험할수있는가장흔한합병증중에하나는수술후에도지속적인통증이있는경우일것이다. 수술후에도지속되는통증에대한연구는많지않다,. Morrey 는처음수술에서단요수근신전건의유리가불충분하였거나처음진단이잘못되었던그룹이있으며다른하나의그룹은후외방회전불안정성과같은외측측부인대손상 (ligamentous insufficiency) 이동반된경우였다고보고하였다. 수술후지속되는통증에관한또다른연구에서도처음수술시유리술이나변연절제술이부적절하였던것을재수술의가장흔한원인으로분석하였다. 다시말해외상과염수술중에는불충분한단요수근신전건의유리술이될가능성을염두에두고충분한변연절제술과유리술이되도록할필요가있으며, 또한외측측부인대복합체의부전이동반되었는지의여부를수술전철저하게점검해보아야한다. 다만외상과염의자연경과를고려해보았을때수술후에도통증호전이 - 년에걸 쳐일어날수있으므로, 다시충분한기간의보존적치료를시행해보고지속적으로호전이없는경우에원인을탐색해보는것이바람직한것으로보인다. 결론 외상과염은흔한주관절통증의원인으로대부분임상적병력과신체검진을통해진단이이뤄진다. 힘줄의퇴행성변화에의해발생한다고보는경향이있으며대부분의경우자연치유되며일년정도의시간이지나면증상이완전히좋아지는경우가많은질환이라는점을염두에두고진료를할수있다. 외상과염의치료에대해모든치료자들이동의할수있는하나의방법이있지는않다. 스테로이드주사는단기간에는효과적으로통증을감소시킬수있으나증상의재발할가능성이높다는우려가있을수있다. 대부분자연치유되는경향이있다는점을고려하여증상을호전시키기위해다양한보존적치료방법들을함께사용하는것으로충분한경우가많으며, 잘낫지않는재발성의만성외상과염의경우수술적치료도고려해볼수있을것이다. 하지만수술을시행하는경우에도남는증상이적지않다는점을염두에두고, 후외방회전불안정성의병변과같은동반질환에대한적절한검토가필요하다. REFERENCES 1. Walker-Bone K, Palmer KT, Reading I, Coggon D, Cooper C. Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis Rheum. 2004;51: Solheim E, Hegna J, Oyen J. Extensor tendon release in tennis elbow: results and prognostic factors in 80 elbows. Knee Surg Sports Traumatol Arthrosc. 2011;19: Ahmad Z, Siddiqui N, Malik SS, Abdus-Samee M, Tytherleigh-Strong G, Rushton N. Lateral epicondylitis: a review of pathology and management. Bone Joint J. 2013;95: Karkhanis S, Frost A, Maffulli N. Operative management of tennis elbow: a quantitative review. Br Med Bull. 2008;88: Goldie I. Epicondylitis lateralis humeri (epicondylalgia or tennis elbow): a pathogenetical study. Acta Chir Scand Suppl. 1964;57(Suppl 339): Riek S, Chapman AE, Milner T. A simulation of muscle force and internal kinematics of extensor carpi radialis 8

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12 J Korean Soc Surg Hand Vol. 22, No. 1, March 2017 Res Soc. 2003;28: Panthi S, Khatri K, Kharel K, et al. Outcome of percutaneous release of tennis elbow: a non-randomized controlled trial study. Cureus. 2017;9:e Dunkow PD, Jatti M, Muddu BN. A comparison of open and percutaneous techniques in the surgical treatment of tennis elbow. J Bone Joint Surg Br. 2004;86: MacDermid JC, King GJ. Functional outcome was better after percutaneous surgery than after open formal release for tennis elbow. J Bone Joint Surg Am. 2005;87: Organ SW, Nirschl RP, Kraushaar BS, Guidi EJ. Salvage surgery for lateral tennis elbow. Am J Sports Med. 1997;25: Graham DJ, Smith GC. Persistent pain after surgery for enthesopathy of the extensor carpi radialis brevis origin. J Hand Surg Am. 2015;40: 외상과염치료의최신지견 고경환 이현일인제대학교일산백병원정형외과 외상과염은자연적으로치유되는경과를가진질환으로 % 이상에서 개월안에증상호전을보인다고보고하고있다. 일반적인보조기, 운동치료, 스테로이드주사외에최근에는자가전혈주사나혈소판풍부혈장과같은각종생물학적주사요법, 보툴리눔독소등도시도되고있다. 보존적치료에실패한경우시행하는전통적인개방적 Nirschl 술식과관련하여, 변연절제술후에만들어지는조직결손에대한처리, 병변부위피질골제거술의유용성, 선택적탈신경수술을함께시행할지에대한논란이있다. 최근관절경수술이보편화됨에따라관절경하단요수근신전건유리술의결과가보고되고있다. 다만보다좋은결과를위해충분한유리술과함께측부인대의손상은피해야할것이다. 최근에는고주파미세건절단술, 경피적건유리술과같은새로운치료의결과도보고되고있으나이러한치료이후에도지속적인증상을보이거나재수술을시행하는경우가여전히존재하고있으며, 따라서보다정확한진단과동반된병변에대한평가가수술전에충분이이뤄져야하며수술시이러한병변에대한치료가적절히이뤄지도록해야할것이다. 색인단어 : 테니스엘보, 외상과염, 수술적치료, 리뷰 접수일 2017 년 1 월 12 일수정일 1 차 : 2017 년 2 월 25 일, 2 차 : 2017 년 3 월 3 일게재확정일 2017 년 3 월 3 일교신저자고경환경기도고양시일산서구주화로 170 인제대학교일산백병원정형외과 TEL FAX osdoc.koh@gmail.com 12