Symposium J Korean Orthop Assoc 2017; 52: Diagnosis and Joint Preserving Surgery in Di

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1 Symposium J Korean Orthop ssoc 2017; 52: Diagnosis and Joint Preserving Surgery in Disorders around Hip Joint 484 고관절관절경의최신지견 김필성 황득수 * 부민병원정형외과, * 충남대학교의학전문대학원정형외과학교실 pissn : , eissn : The Current Concepts of Hip rthroscopy Pil-Sung Kim, M.D. and Deuk-Soo Hwang, M.D.* Department of Orthopedic Surgery, Bumin Hospital, Seoul, *Department of Orthopedic Surgery, Chungnam National University School of Medicine, Daejeon, Korea Hip arthroscopy has been useful for resolving unexplained pains of the hip joint, despite its clinical applicability came after many other joints. Surgical indications have been increasing recently. Moreover, additional surgical techniques allow both the anatomy and function to return to its normal state. Recently, the concepts and treatments for extra-articular pathologies, such as deep gluteal syndrome, ischiofemoral impingement, subspinal impingement and iliopsoas impingement as well as classic indication, such as femoroacetabular impingement, acetabular labral tear, loose bodies, and synovial osteochondromatosis have been introduced. We present a diagnosis and treatment for diverse indications of hip arthroscopy, preoperative considerations, surgical technique and postoperative rehabilitation. Key words: hip, arthroscopy, indication, diagnosis, therapeutics 서론 정형외과분야에서관절경의적용은광범위하게이루어지고있 다. 깊게위치한고관절의위치, 관절주위의복잡한신경 혈관 구조, 관절경기구를운용하기에좁은관절간격등의해부학적 이유로인해고관절질환의관절경적접근은슬관절, 견관절등 에비해상대적으로늦게시작되었으나설명되지않았던고관절 의증상이대퇴비구충돌 (femoroacetabular impingement, FI), 비 구순파열등의개념과함께관절경적치료에의해해결되면서 효과적인술식으로인식되었다. 최근에는기존의관절내병변뿐 아니라관절외병변, 스포츠관련손상까지그임상범위가확대 되고있다. 관절경을시행하는술자는고관절의관절내구조와 관절낭, 근육, 인대등의관절주위의연부조직에대한해부학적 접근, 수술전준비, 수술기법, 수술중발생할수있는상황대처, Received May 2, 2017 Revised ugust 27, 2017 ccepted September 7, 2017 Correspondence to: Deuk-Soo Hwang, M.D. Department of Orthopedic Surgery, Chungnam National University School of Medicine, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea TEL: FX: dshwang@cnu.ac.kr 술후재활에대한이해가있어야성공적인결과를얻을수있다. 저자들은고관절관절경에대한임상적경험에대해기술하고, 최신지견에대한문헌고찰을하고자한다. 고관절관절경의수술기법 1. 고관절관절경수술전진단진단의오류와부적절한환자의선택은수술후지속적통증의원인이되므로정확한진단은수술의결과를결정하는가장중요한요인이며, 술자는관절경적수술선택에확실한기준이있어야한다. 임상적양상에서고관절관절내병변을가진환자는쪼그리고앉을때나관절의움직임에의해발생되는서혜부통증을호소하며, 증상이악화되면서빈도가증가되고안정시에도통증을느끼게된다. 환자들은움직일때 무언가찌르는느낌 (sticking), 관절이잠기는느낌 (locking), 잡혀있는느낌 (catching), 걸리는느낌 (clicking) 등으로표현하며, 통증의위치를물을때손의모양을 C 자모양으로고관절부위를붙잡는 C 증후 (C sign) 를보이는데 (Fig. 1), 이부위는진성고관절부위 (true hip region) The Journal of the Korean Orthopaedic ssociation Volume 52 Number Copyright 2017 by The Korean Orthopaedic ssociation This is an Open ccess article distributed under the terms of the Creative Commons ttribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 485 The Current Concepts of Hip rthroscopy B Figure 1. C sign of the hip. () Patient indicated painful site of the hip. (B) C shape of the hand. 로관절내병변의가능성을시사한다. 1) FI, 비구순파열등의병변은이학적검사에서고관절을굴곡, 내전, 내회전 (flexion, adduction, internal rotation [FDIR] test) 시키는전방고관절충돌검사 (anterior hip impingement test) 에서통증이유발된다. 2) 그러나통증의유병기간이짧은경우고관절활액막염및고관절주위근육의건병증의경우에도양성을보일수있어비스테로이드성진통소염제및물리치료등의보존적치료후재검사에서통증을보이는경우만을양성으로판정해야한다. 또한고관절을굴곡, 외전, 외회전하는 Patrick 검사에서양성을보이는경우나미만성통증이둔부나외측엉덩이부위에있는경우에는관절내문제의가능성이적으나통증의양상이날카로운급성통증을호소하며환자가서혜부에통증을영역화 (localization) 하는경우에는관절내병변이존재할가능성이높다. 환자의관절운동범위제한은고관절이과도하게깊은심부고 (coxa profundal), 돌출비구 (protrusio acetabuli) 및비구순의골화 (os acetabuli) 등의 pincer형충돌이고관절굴곡에영향을줄수있으며, cam형의충돌에서대퇴골두-경부의골성돌출 (bump) 이너무커서두경부가비구내로들어가지못하는경우에는고관절굴곡에따라대퇴부가외전되는현상이나타나는데이를 Drehmann 증후 라고하며고관절의내회전제한이나타난다. 3) 환자중골반의움직임이제한되며고관절의과도한덮힘증상과중증도의천장관절염을보이는경우강직성척추염과관계된고관절관절병증이나미만성특발성골격과골종 (diffuse idiopathic skeletal hyperostosis) 이 FI를유발할수있으며흉통 / 흉부강직의동반유무, 류마티스관절염에대한혈액학적검사, HL-B27 에대한유전자검사, 척추에대한방사선적평가및다른관절의관절병증에대해같이검사가진행되어야한다. 척추병변에의한방사통과감별하기위해서하지직거상검사 (straight leg raising [SLR] test) 는반드시실행되어야하며, 관절내 외병변을감별하기위해스테로이드와국소마취제를관절강내에주사후증 상의호전정도를관찰한다. 저자들은초음파나방사선투시기하에서 triamcinolone 40 mg/1 ml와 1% lidocaine 2 ml를혼합하여관절강내주사를시행하는데관절연골손상이나활액막염등에의한특발성염증질환은주사후급격한통증완화를보이는반면, FI나비구순파열등의관절내병변이존재하는경우에는증상의호전이없거나미미하며, 호전후증상이재발되는경우에는관절내기계적증상 (mechanical symptom) 으로해석한다. 4) 방사선적평가는단순방사선적사진, 3차원컴퓨터단층촬영 (3-dimensional computed tomography, 3D CT), 자기공명영상 (magnetic resonance imaging, MRI)/ 관절조영술, 초음파를통한 cam/pincer형 FI, 고관절의골성이상의유무, 관절내구조의이상유무, 관절외병변등의소견을확인한다 (Fig. 2). 특히수술전에 3D CT에서골성형술부위를측정하여수술중관절경소견, 방사선투시기의영상과부합시켜정확한위치의감압을시행하고술후재평가를통해골성형부위의범위와정도를평가해야한다. 5) 술전 MRI에서비구순파열의위치와정도, 원형인대파열유무, 비구순주위낭종존재를확인하고관계된관절외병변을확인한다. 2. 수술준비및삽입구제작 1) 관절경도구, 마취, 견인고관절의위치가골반심부에존재하기때문에수술기구의접근이어려워다른관절경에비해특별하게고안된수술기구와삽입구제작을위한여러기구가필요하다. 기본적으로하지견인기구, 방사선투시기 (fluoroscopy, C-arm intensifier), 고관절관절경기구가필요하다. 다른관절의관절경보다긴고관절관절경과삽입구제작에는 16게이지척추천자침 (16 gauge spinal needle) 및통과가능한가이드와이어가필요하며, 관절내조작을용이하게하기위해관절절개용나이프, 긴직선형 / 굴곡형

3 Pil-Sung Kim and Deuk-Soo Hwang L FH C L FH B D Figure 2. Radiographic evaluation for hip arthroscopy. () Simple radiography. (B) Three-dimensional computed tomography of the hip. The angle in femoral head is alpha angle. Increased alpha angle is a evidence of cam impingement. (C) Magnetic resonance arthrography. (D) Ultrasonography., acetabulum; L, labrum; FH, femoral head. shaver, 기구삽입을위한개방형삽입관 (open cannula), 굴곡형고주파절제기 (flexible radiofrequency ablator), 골성형을위한절삭기 (arthroscopic burr) 등이필요하다 (Fig. 3). 마취는전신마취, 경막외마취및척추마취가시행될수있으나술자의경험및수술시간에따라선택적으로시행되어야한다. 전신마취는근이완제를통한하지근력이완을통해하지견인을용이하게하고, 경막외및척추마취는수술직후의통증을감소시킬수있는장점이있으나마취시간이한정되어수술이길어질경우전신마취로의전환가능성이있다. 관절경의수술자세는앙와위 (supine position) 와측와위 (lateral position) 를이용하는데앙와위의관절경적술식은수술자세가용이하고준비시간이짧으며술자가익숙하다는장점이있어대부분의술자는앙와위에서수술적접근을사용한다. 측와위는전방비구병변과후방유리체의관찰과심한비만에서접근이용이한이점이있으나특별하게고안된기구가필요하고견인을위해골반과대퇴골에나사를삽입해야하는침습적과정이있다. 앙와위에서하지견인은통상적으로견인테이블 (traction table) 이이용되며사타구니에위치한회음부기둥에의한역견인 (counter traction) 을이용하여하지를견인한다 (Fig. 4). 견인에서회음기둥에의한외측회음신경 (external pudenal nerve) 압박, 발목고정시전경골신경 (anterior tibial nerve) 압박, 그리고장시간의견인에의한좌골 Figure 3. Hip arthroscopic equipment. 신경병변 (sciatic nerve neuropathy) 이발생할수있다. 이러한신경손상을방지하기위해서는견인테이블의회음기둥과발목 / 발뒤꿈치에외과용면뭉치를이용하여충분하게충전한다. 수술자세준비과정에서환자의회음부가회음기둥과완전한접촉이되어야역견인을통한적절한견인을얻을수있으며, 남자의경우음경을배굴해서위치시켜야수술후압박에의한음경종창을피할수있다. 이후방사선투시기를이용하여관절견인

4 487 The Current Concepts of Hip rthroscopy 상태를확인한다. Eriksson 등 6) 은견인을위해서 N의견인력이필요하다고하였으나, 마취기술의향상으로 N의범위에서도성공적으로관절경을시행할수있다. 그러나대부분의견인테이블은견인력측정기가없어저자들은통상적으로관절경의두께의 2-3배정도 (8-10 mm) 의간격을기준으로한다. 너무적은견인은의인성비구순및대퇴골관절연골손상 (scuffing) 을유발하며 (Fig. 5), 과도한견인은신경병변을유발할수있다. 적절하게견인되었을때고관절내음압경사가증가되어방사선투시기에서견인력을선형적으로증가시키는진공현상 (vacuum seal) 을관찰할수있다. 남자는여자에비해더많은견인력이필요하며, 특히강직성척추염이나골성변형이많아견인이되지않는환자들은변연구획 (peripheral compartment) 부터삽입구를제작해야하는수술적접근이필요하기때문에반드시수술소독을시행하기전에견인상태를확인해야한다. 앙와위의자세는고관절을신전, 25 외전또는중립으로고정하고발목의회전정도에따라삽입구의위치가변하게되는데, 관절내병변이비구의외측에위치하면발을내회전상태에서, 병변이비구의전방 / 내측에위치하면발의위치를외회전상태에서삽입구를제작해야접근이용이하다. 술자와보조자, 수술간호사는수술시행하는측에서게되며관절경모니터는술자반대편에위치하고방 Figure 4. Position and traction. 사선투시기는환자의다리사이로접근된다. Brumback 등 7) 은짧은시간동안 500 N의견인은안전하지만 700 N 이상의견인이 1 시간이상지속될경우신경마비가발생할수있다고하였다. 대부분의수술은 500 N 이하의견인력에서시행되므로수술보조자는수술시간이 2시간이상지속될경우술자에게이를통보해야하여 10-20분정도견인을풀고다시수술을시작하거나변연구획부터수술시행후다시견인하여중심구획의수술을시행해야한다. 2) 삽입구 (portals) 고관절관절경삽입구는 18개이상으로보고되고있으나대부분의저자들은 9개정도의삽입구만으로도고관절관절경을안전하게시행할수있다고하였다. 8) Byrd 등 9) 은고관절관절경의해부학적연구에서삽입구의위치와관절외구조의관계를조사하면서전방, 전외측, 후외측 3개의기본삽입구 (standard 3 portals) 를제시하였다. 저자들은앙와위에서변형된전방삽입구 (modified anterior portal), 전외측삽입구 (anterolateral portal), 후외측삽입구 (posterolateral portal) 를기본삽입구로수술을시행하고있으며필요에따라부삽입구 (accessory portal), 내측으로관절경적접근이필요할때내측삽입구 (medial portal) 를추가적으로사용한다 (Fig. 6). (1) 변형된전방삽입구 : 대전자의전방과후방경계선의첨부의상부 1 cm의위치가각각전외측과후외측삽입구가되는데, 고식적전방삽입구 (classic anterior portal) 의위치는전외측삽입구에내측으로그은수평선과전상방장골극 (anterior superior iliac spine, SIS) 에서슬개골상극을향해원위부로그린선과만나는점으로 SIS에서평균 6.3 cm에위치한다. 변형된삽입구는고식적전방삽입구와전외측삽입구를한변으로하는정삼각형을원위부로그렸을때그려진역정삼각형의원위꼭지점의위치가되며비구순봉합시봉합나사의삽입각도를낮출수있어상대적으로안전한봉합을시행할수있다. 10) 전방관절낭을통과하기전에봉공근 (sartorius) 과대퇴직근 (rectus femoris) 을통과하며, 외측대퇴피부신경 (lateral femoral cutaneous nerve) 은전방삽입 FH FH L B Figure 5. Iatrogenic injury in establishing portals. () Labral injury: the obturator cannula perforated the labrum (L). (B) Scuffing: iatrogenic chondral injury (arrow) in the femoral head., acetabulum; FH, femoral head.

5 488 Pil-Sung Kim and Deuk-Soo Hwang Figure 6. Fluoroscopic image of the medial portal. 구부위에서 3개이상의가지로나뉘게되어전방삽입구는이가지사이로지나가야한다. 외측대퇴회선동맥 (lateral femoral circumflex artery) 은보통전방삽입구의하부로 3.7 cm에위치하고있으나과도한출혈이생긴보고는없다. 전방삽입구를통해관찰이용이한구조물로는대퇴골의전방부, 외측비구순, 상방지대주름, 횡비구인대전방부및원형인대등이있다. (2) 전외측삽입구 : 전외측삽입구는중둔근 (gluteus medius) 을뚫고관절낭의외측을관통하며, 전외측삽입구를제작할때는상둔부신경 (superior gluteal nerve) 의손상을주의해야한다. 전외측삽입구는비구중심부에서하부를걸쳐비구의외측모서리의관찰이용이하며, 유리체가잘이동하는부위를포함해서비구후방부관찰도용이하다. 앙와위에서기준삽입구로주로이용된다. (3) 후외측삽입구 : 후외측삽입구는대부분의관절내병변이전방에존재하므로후외측삽입구를작업삽입구로이용하는경우는드물고보통관절액의배수로이용된다. 중둔근과소둔근을뚫고관절낭의후방변연부에서외측관절낭을통과하여이상근건의상부와전방부를지난다. 외측관절낭부위에좌골신경 (sciatic nerve) 이위치하므로후외측삽입구제작시에는견인테이블의위치를높이고끝이무딘 obturator로부드럽게삽입해야좌골신경손상을피할수있다. 삽입구제작시표면해부학을통해대전자의전방과후방경계를펜을이용하여방사선투사기에서의대전자첨부전방과후방의근위 1 cm 지점이각각전외측삽입구와후외측삽입구의바늘삽입위치가된다. SIS에서슬개골의상극을향해선을그리는데이는대퇴혈관과신경과의경계선으로이용된다. 방사선투시기하에서변형된전방삽입구위치에 16게이지척추천자바늘을 의경사로관절강을향하여진입하면고관절관절낭과접촉을느낄수있으며, 이때저항이있으면비구나비구순과의접촉을의미하기때문에약간원위부로바늘을이동시켜부드러운진입을느끼면서관절낭과천자를시행한다. 이때척추천 자바늘의속침 (stylet) 을빼면일부공기가관절내로유입되면서방사선투시기에서공기관절사진 (air arthrogram) 을확인할수있다. 공기관절사진이보이지않는경우척추바늘의속침을빼고가이드와이어를척추천자바늘을통해진입시켰을때, 관절내로들어간경우는가이드와이어가반대측비구벽에접촉되어방사선투사기상에서휘어지는것을확인할수있다. 척추천자바늘을통해가이드와이어를삽입한후척추천자바늘을제거하고가이드와이어주변으로 1 cm 정도피부절개를한다음 obturator를통과시켜전외측삽입구를제작한후관절경을삽입하여관절내병변을확인한다 (Fig. 7). 방사선투시기와관절경하에서척추천자바늘을관절경의끝을맞춰진입시키게되는데통상적으로두부측, 후방으로 의각도로삽입할때관절내로들어가게된다. 관절경하에서척추천자바늘이관절강안으로안전하게삽입되면 obturator를이용하여변형된전방삽입구를제작한다. 전외측삽입구를맹검상태에서제작할경우, 의인성비구순또는대퇴골관절연골손상을유발할수있으므로맹검삽입구의삽입은후외측삽입구가유용하다. 관절견인시전방관절보다후방관절낭의면적이넓으며전방비구순보다후방비구순의길이가짧아상대적으로의인성손상이적다. 안전한삽입구제작을위해저자들의삽입구제작방법을소개하면, 방사선투시기하에서전외측삽입구에척추천자바늘을관절낭에접촉할때까지만진입시킨후관절낭만을살짝천자한상태로놓고, 맹검삽입구를후외측삽입구로척추천자바늘을두부측 5-10, 전방측 5-10 각도로진입시킨다. 그후첫번째관찰삽입구인후외측삽입구를제작한후관절경감시하에서전외측삽입구를제작한다음관절경을전외측삽입구로옮겨관절경감시하에서전방삽입구를제작한다. 이방법은관절경을후외측-전외측-전방삽입구순서대로이동시켜중심구획의구조물의손상을주지않고안전하게삽입구를제작할수있는장점이있다. 대부분의술자들은견인후중심구획의관절병변을회복한후변연구획을치료하는방법을이용하나일부술자는견인없이수술하는방법을보고하고있다. 관절내구조물은견인장치를이용해야하나대퇴골두의비체중부하관절연골, 대퇴경부의병변및내측및전측활액막주름 (medial and anterior synovial fold), 고관절윤대 (zona orbicularis) 관절의변연구획은견인장치없이도수술이가능하다. Dienst와 Kohn 11) 은일차적으로변연구획을통한수술적접근을시행하며변연구획의해부학적구조의정확한판단및대퇴골성형술의골절제가용이하다고하였다. 또한통상적으로비견인방법이전에견인방법을먼저숙지하는것이좋다고하였는데, 이는견인방법이환자의체위에더욱의존적이기때문이라고하였다. 견인을시도하였으나관절간격을얻을수없는환자는불가피하게변연구획수술후중심구획으로이어지는술식을선택해야한다. 변연구획의관절경적술

6 489 The Current Concepts of Hip rthroscopy B C D Figure 7. Serial fluoroscopic images of the classic portal insertion method in the central compartment. () Vacuum seal shadow due to negative intraarticular pressure is created by distraction of the joint. (B) Needle is inserted and the stylet is removed, then break the seal. (C) s obturator is inserted into the joint, the operator can identify successful insertion of the spinal needle by the shape of the spinal needle under fluoroscopy. (D) fter check of intraarticular pin insertion, arthroscopy is inserted. 식은앙와위에서전외측삽입구를통해시행하는데, 환자를골절테이블에위치시키고슬관절은약 45 정도굴곡시킨상태에서고관절을굴곡, 회전및외전을조절하면서삽입구를제작한다. 관절경검사에서고관절변연구획은전방대퇴경부, 내측대퇴경부, 내측대퇴골두, 전방대퇴골두, 외측대퇴골두, 외측대퇴경부및후방으로나눌수있다. 전외측삽입구를통해관절내로들어가면대퇴경부의전내측표면과고관절윤대의전내측부위가관찰된다. 30 관절경을이용하면내측활막주름이관찰되는데이는대퇴경부에부착하지는않고근위부대퇴골두의내측면에서원위부의소전자까지통과하며, 매우유용한표지자로, 특히구획내시야가활액막질환으로제한된경우더유용하다. 3. 고관절의관절경의수술술기 1) 중심구획 (central compartment) 중심구획에서의술기는 pincer형충돌의비구성형술 (acetabuloplasty), 비구순봉합술 (acetabular labral repair) 또는비구순절제술 (partial labrectomy), 관절연골성형술 (chondroplasty), 미세천 공술 (microfracture), 원형인대가열축소술 / 부분절제술 (thermal shrinkage/partial resection) 등이있다. 관절경삽입구를제작해고관절을관찰한후관절경용칼 (arthroscopic knife) 을이용하여관절낭을절개하고, 삽입구를연결시키는관절낭절개술 (capsulotomy) 를이용하여관절내조작을용이하게할수있다. 중심구획에서의비구측의접근을용이하게하기위해서는관절낭-비구순접합부위를고주파절제기 (radiofrequency ablator) 를이용하여관절낭을근위부로재끼고비구주위공간 (paralabral space) 을확보하기위해비구골을노출시키는과정이필요하다 (Fig. 8). 이때관절낭봉합술 (capsular repair) 이필요한환자는비구측관절낭을일부를남겨놓아야한다. 12) Pincer형충돌의비구성형술이성공적으로이루어지기위해서는술전계획에서 3D CT를통해절제가필요한부분을정확히인지하고있어야하며, 13) 수술중방사선투시기에서골반의정전 후방사진을촬영한후전방삽입구를통해관절경절삭기 (arthroscopic burr) 를절제할부위를접촉시킨후방사선투시기에서그위치를재확인한후비구성형술을시행한다. 비구의위치를비구횡인대 (transverse ligament) 의중심부를 6시, 비구상방

7 490 Pil-Sung Kim and Deuk-Soo Hwang 의위치를 12 시로정하고시계방향의시각에따라위치를정하 는 clockwise system 을이용하여 14) 수술전계획된부분과수술중 투시기에서의절제될부위의위치가일치하도록해야한다. 비구 의높이가낮아지면서비구순과비구관절연골이분리되는현상 을 labral take-down 이라고한다. 12) 비구성형술이후불안정해진 비구순은봉합나사를이용한봉합 (repair) 또는재부착 (refixation) 이필요한데, Redmond 등 15) 은비구순을비구경계에서떼어내지 않고봉합하는술식에대해보고하면서비구순을떼어낸다음재 부착해주는술식과비슷한임상적결과를보인다고하였다. 봉합 나사를비구에삽입할때비구순주위공간이협소하거나전방 삽입구의위치가부적절할경우봉합나사의삽입각도가커져서 비구관절연골손상, 봉합나사가관절내천공이거나삽입각도 가불안정하면봉합나사의 pull-out 강도가약해봉합나사가뽑 히는현상등의합병증이발생할수있다. 16) 이러한이유로안정 적인삽입각도를갖는변형된전방삽입구에서의비구순봉합이 Figure 8. Paralabral space (PS; white arrow)., acetabular bone; C, acetabuar cartilage; L, labrum. 고식적전방삽입구에서비구순봉합이시행될때보다관절내천공현상과봉합나사의뽑힘현상을줄일수있다고하였으며, 최근에는원위전외측삽입구 (distal anterolateral portal) 에서의봉합도시도되고있으나비슷한결과를보인다고했다. 17) 또한이러한봉합의역학에대한연구와함께비구순봉합술의방법에도발전이있었는데비구순을감싸는형태로봉합하는환형봉합술 (looped repair) 에비해비구순의해부학적구조를유지하면서비구순의기저부만을봉합하는기저부봉합술 (through repair) 의봉합방법이소개되었다 (Fig. 9). Philippon 등 18) 은비구순의기능중 fluid seal 효과를강조하면서사체연구를통해비구순부분 / 완전절제후관절내압력은각각평균 53%, 24% 인반면, 비구순봉합술이시행된고관절에서는환형봉합이시행된후평균관절내압력이 70% 이고, 기저부봉합술이시행된고관절의평균관절내압력은 134% 로기저부봉합이우월하다고했다. 그러나 Jackson 등 19) 은두봉합법의비교연구에서 2년추시에서임상적결과의유의한차이가없다고하였다. 또한고관절에서의비구순재건술 (labral reconstruction) 에대해보고되고있는데, Philippon 등 18) 의사체연구에서비구순재건술후관절내압력은 110% 로정도로우수한결과를보인다고하였고, 18) Chahla 등 20) 도비구순이결손된고관절에서비구순의재건은정상고관절과같은관절내압력상태로회복시킬수있다고하였다. 저자들도비구순이결손된고관절관절경재수술에서비구순재건으로좋은임상결과를얻었으나재건술의결과에대해서는장기적추시결과를요한다 (Fig. 10). 비구순봉합술이끝나면탐침자를이용하여봉합상태를확인한후관절경을관절내심부로진입시켜비구관절연골의상태를확인한다. Beck의분류에따르면비구관절연골손상은연골연화 (chondromalasia), 비구에서의연골분리 (debonding), 균열 (cleavage), 연골분리 (detached cartilage) 로분류할수있다. 21) 연골연화증이나연골분리는비구순을비구에서분리하지않고열퇴축술또는비구순봉합시연골봉합을동시에시행하는데, 15) 이때연골을비구에부착시키기위해 fibrin glue 등을삽입하기도 Figure 9. Methods of acetabular labral repair. () Looped repair or rolling repair: The fiber of suture anchor rolls up the torn labrum (L). In looped repair, eversion of L may be occurred after procedure. (B) Through or basement repair: The suture line is passed through the substance of the L and can fix the base area of the L. fter the repair, the anatomical shape of the L may be preserved., acetabulum; C, acetabular cartilage.

8 491 The Current Concepts of Hip rthroscopy Figure 10. cetabular labral reconstruction using autologous iliotibial band. () Labral defect by previous labral resection. (B) Harvest of iliotibial band from ipsilateral hip. (C) Harvested autogenous iliotibial band (triangle). (D) rthroscopic labral reconstruction was performed. The harvested iliotibial band (triangle) was transferred and repaired on acetabular margin for labral defect. (E) Identification of a successful reconstructed labrum at 2nd look arthroscopy. Triangle is harvested iliotibial band., acetabulum; C, acetabular cartilage; L, anterolateral portal; HS, Harvest site; FH, femoral head. 한다. 22) 연골의분리나균열은관절연골성형술후미세천공술이시행된다. 고관절은비구의오목한모양이천공송곳 (awl) 의삽입을방해하므로슬관절과달리천공각도를확보하기가힘들어추가적원위삽입구제작이필요한경우가있다. Marquez-Lara 등 23) 은고관절관절연골손상의체계적문헌고찰에서관절연골의변연절제 (debridement), 미세천공술, 자가연골세포이식 (autologous chondrocyte transplantation) 모두고도의관절연골손상에서단 중기추시시동등한임상호전을보였고, 손상부위와크기가술후결과에영향을주는요인이라고하였다. 관절경을비구와 (acetabular fossa) 에근접시키면원형인대를관찰할수있게되는데파열이있을경우수술적적응이될수있다. 원형인대는고정된발목을내회전, 외회전할때원형인대의움직임을확인할수있으며 (Fig. 11), 굴곡형고주파절제기를이용하여부분절제한다. 파열은보이지않으나전체적부종이있는경우는가열수축술 (thermal shrinkage) 를시행한다. de S 등 24) 은원형인대의부분파열이있을경우관절경적부분절제술이단기적임상증상을호전시키나고관절의불안정성이있는원형인대완전파열은자가, 동종, 합성인대를이용한재건술이필요하다고하였다. 2) 변연구획 (peripheral compartment) 중심구획의술식이끝나면견인을풀고비구순과대퇴골두-경부접합부와접촉을확인하는데통상적으로전외측삽입구가관찰삽입구로이용되고전방삽입구가작업삽입구로이용된다. 변연구획으로이동시에시야확보가어려운데, 견인을풀기전에전방삽입구에교환막대 (switching stick) 를넣고절개된관절낭의원위부로밀면서견인을풀어시야를확보한후 shaver와고주파절제기를이용하여관절낭을마름질하여관절경의해부학적구조를지속적으로인지해야한다. 수술보조자로하여금고관절을 정도굴곡시키면, 고관관절의대퇴골두-경부접합부가관절경시야로들어오게된다. 시야가적절하지않을경우관절낭절개를대퇴골경부부위로확장하는데, 고관절윤대를침범하지않도록해야한다. 고관절불안정성이있거나관절낭절개가큰경우모든술식후관절낭봉합술을시행한다. 전외측삽입구를통해대퇴골두-경부접합부의골성융기 (bump) 를확인하고, 수술보조자로하여금고관절의굴곡, 내회전, 외회전하여대퇴골과비구순의접합상태를확인하게하며, 전방삽입구를통해고주파절제기를이용하여대퇴골성형술의경계를표시한다. 관절경적절삭기를이용하여근위부에서원위부로골절

9 492 Pil-Sung Kim and Deuk-Soo Hwang Figure 11. Motions of ligamentum teres according to hip rotation. While ligamentus teres is relaxed on internal rotation (IR), it is tensed on external rotation (ER) of the hip. FH, femoral head; LT, ligamentum teres; F, acetabular fossa. FH L L FH B Figure 12. rthroscopic femoroplasty. () Subchondral bone of the femoral head (FH)-neck junction was exposed for decompression. (B) fter femoroplasty (arrow), the operator has to check the relationship between labrum (L) and FH. 제를시행하여대퇴골경부의오목한형태로대퇴골성형술을시행한다 (Fig. 12). 방사선투시기의 Dunn 촬영면에서대퇴골전방부의골융기정도와골절제부위정도를확인한다. 대퇴골경부의근위부로너무많은골절제를할경우대퇴경부의골결손으로 suction seal 효과의소실을유발할수있어유의해야하며, 대퇴골성형술을하는경우지속적흡인을하면서관절펌프의압력을높게유지해야이소성골화증을예방할수있다. 12) 또한대퇴골경부원위부의시야가확보되지않는경우원위부의절제가부족하여, 견인력을많이받는대퇴골전상방에 apple bite 라고불리는절흔을만들지않도록주의해야한다. 대퇴골성형술이끝난상태에서방사선투시기를정전 후방사진에서골절제상태를확인하고, 환자의다리를 frog leg 위치에서골절제상태를확인한다. 4. 수술후재활 (postoperative rehabilitation) 고관절관절경술기에따라수술후재활이달라지게되는데, 아직까지재활의방법에대해정립되지않았다. 하지만저자들의경우고관절내시경수술후관절내유착을방지하기위해지속적수동관절운동 (continuous passive motion exercise) 을아침, 점심, 저녁각 30분씩시행하게하고관절의진자운동 (pendulum exercise) 을교육하여관절내자극증상을감소시킨다. 비구순봉합술후체중부하에대한의견은다양하나예전에는 4주간의부분체중부하를시행한후 1개월부터체중부하를증가시키고술후 2개월후에는완전체중부하를허용하는점진적재활방법을사용하였다. 그러나최근에는비구순봉합에영향을주는고관절의과굴곡이나정상범위를벗어나는관절운동만을금하고관절연골손상이없는경우수술후바로체중부하를허용한다. 고관절내시경수술환자의대부분에서술후 1개월후에대전자부위의통증을호소하는대전자통증증후군 (greater trochanteric pain syndrome) 이동반될수있는데, 비스테로이드성소염진통제와물리치료로호전이되지않을경우통증의원인이되는중둔근의건부위에스테로이드와국소마취제의투여가증상을호전시키며체외충격파나건강화치료 (prolotheraphy) 도증상완화에도움이될수있다. 수영이나자전거타기등의비체중부하운동은환자의호전정도에따라허용되고, 경쟁적운동등의스포츠활동의완전한회복은수술후 6개월을기준으로한다.

10 493 The Current Concepts of Hip rthroscopy 고관절관절경고식적적응증과확대된적응증 저자에따라의견이분분하나일반적적응증과금기증은다음과 같다 (Table 1). 고관절관절경의수술적선택에있어유병기간이 가장중요하다. 저자들은유병기간이 6 개월이상경과된경우나 비스테로이드성소염진통제, 물리치료등의보존적치료를시행 한후에도 2 개월이상증상이지속되는경우, 보존적치료에도증 상의변화가전혀없거나조절되지않는통증이있을경우수술 적응으로판단한다. 고관절주위의여러질환들이소개되면서수 술적적응도확대되고있다. 이에저자들은고관절관절외병변 중보존적치료에실패할때수술적치료가시도되는질환에대 해기술하고자한다. 1. 심부둔부증후군 (deep gluteal syndrome) 고관절후방부의해부학과좌골신경에대한이해가발달되면서 이상근증후군 (piriformis syndrome) 외에둔부하공간 (subgluteal space) 여러부위에서의좌골신경압박에의한병변을심부둔부 증후군이라는용어로사용하게되었다. 25) 좌골신경은과굴곡, 외 전, 외회전동작에서대전자후방경계부부위로미끄러져들어가며, 반양막근 (semimembransus muscle) 의부착부와대전자의후방경계와만나게된다. 좌골신경의주행은슬관절의굴곡 신전에의하며무릎이굴곡되었을때는후외측으로, 무릎이신전되었을때는후방심부공간으로들어간다. 슬관절이신전된 SLR test에서좌골신경은고관절내측으로 28 mm 정도주행하게되는데심부둔부공간에서이러한주행에영향을주게되면신경병변이발생할수있다. 26) 가장흔한증상은엉덩이통증과대전자부후방부의압통과좌골신경통유사병변으로특징적인증상이없어관절내, 관절외증상, 척추방사통과감별해야한다. 능동적이상근검사 (active piriformis test) 는환자를측와위로위치시키고검사자가환자의뒤꿈치를민상태에서환자에게고관절을능동적외전, 외회전하도록하고검사자는저항을주면서이상근을촉지할때압통을느끼는경우를양성으로판정한다. 좌식이상근신장검사 (seated piriformis stretch test) 는환자가앉아있는상태에서무릎을펴고관절을수동적내전, 내회전시킬때후방둔부공간에서통증의유무를확인하는검사이다. 이두가지검사에서양성을보이는경우내시경적좌골신경포착의민감도와특이도를각각 91%, 80% 로보고하고있다. 27) 심부둔부증후군은 Table 1. Indication of Hip rthroscopy Indication Contraindication Intra-articular pathologies Femoroacetabular impingement nkylosis of impossible joint traction cetabular labral tear Soft tissue infection cetabular or femoral chondral injury Wound infection Tear of ligamentum teres Severe obesity Joint instability dvanced osteoarthritis Loose body Inflammatory synovial disease Rheumatoid arthritis Synovial osteochondromatosis Early osteoarthirtis Limited application for avascular necrosis Extra-articular pathologies Neuropathy by perineural cyst around hip Internal or external snapping hip Iliopsoas impingement Subspinal impingement Piriformis syndrome Deep gluteal syndrome Greater trochanteric pain syndrome Calcific tendinitis Ischiofemoral impingement Sports related injury: Hamstring avulsion fracture

11 494 Pil-Sung Kim and Deuk-Soo Hwang 생활습관변경, 물리치료, 비스테로이드성소염제를이용한보존적치료및국소마취제나스테로이드병변내주사를통해증상을경감시킬수있으나이러한치료에증상이호전되지않는경우개방또는내시경적수술적치료를고려할수있다. 여러연구에서개방후좌골신경감압후개선된임상결과를보고하였으며, 28,29) Dezawa 등 30) 이처음으로내시경적좌골신경감압을시도한이래 Martin 등 31) 은 35예의심부둔부증후군의내시경적치료에대해보고하였고, Hwang 등 32) 은좌골신경주위낭종에대한감압과이상근주위유착을제거하는관절경적감압술치료후호전된임상결과를보고하였다. 그러나성공적인내시경적치료를위해서는다수의임상적경험과좌골신경의해부학적구조를이해해야의인성좌골신경손상을피할수있다. 33) 2. 좌골대퇴충돌 (ischiofemoral impingement) 좌골대퇴충돌은 1977년에인공고관절전치환술후발생하는고관절의통증의원인으로처음보고되었다. 34) 좌골대퇴공간 (ischiofemoral space) 이라고불리는대퇴골소전자와좌골결절 (ischial tuberosity) 사이의공간에서대퇴사각근 (quadratus femoris) 의압박에의해통증이발생한다 (Fig. 13). 여성에서호발되며노화에따른근육손상, 35) 소전자에부착되는장요근, 좌골조면의슬건 (hamstring) 및윤활막염에의한압박, 36) 심부고, 34) 외반고 (coxa valga) 에서증가된대퇴골경간각, 37) Legg-Calve-Perthes 병, 38) 인공고관절전치환술후감소된대퇴 offset의주대를사용하거나비구컵의골반내측위치, 소전자를침범한전자주위골절, 34) 소전자주위의외골종 (exostoses) 35) 등이병인으로지목된다. 보존적치료또는 CT하대퇴사각근내국소마취제또는스테로이드주사가통증을완화시켜줄수있으며, 39) 다른질환에비해상대적으로낮은수술적응을보인다. Safran과 Ryu 40) 는좌골대퇴충돌로진단된환자의 5% 만이수술적적응이된다고하였고, 인공고관절전치환술후발생한좌골-대퇴충돌의개방성소전자절제는좌골-대퇴공간을넓힐수있으나술후고관절굴곡력감소와 35) 후방접근법을이용한고관절전치환술에서이술식이적용될때관절의불안정성을유발할수있어유의해야한다. 41) 보고된논문이상대적으로적지만몇몇저자들이많은수술적접근에대해발표하였고, 수술후합병증없이성공한예에대한보고도있다. 40,42) 3. 장골극하충돌 (subspinal impingement; anterior inferior iliac spine impingement) 장골극하충돌은비후된전하방장골극 (anterior inferior iliac spine, IIS) 과대퇴골경부원위부와의충돌로장골극과비구경계부사이에존재하는대퇴직근 (rectus femoris) 과비구순, 전방관절낭의손상이유발되고통증이발생하는현상을지칭한다. Hetsroni 등 43) 은 3D CT를이용하여극하충돌을 IIS의위치에따라비구경계근위부에존재하는경우를 I형, 비구경계선에위치하는경우를 II형, 비구경계원위부까지돌출되는경우를 III형으로분류하였다. II형과 III형은고관절굴곡과내회전의감소와관계되어있으며장골의 IIS의감압이필요하다. FI와비슷한증상을보이거나 FI 또는비구순파열이동반되어전방충돌검사에서양성을보이며, 고관절굴곡제한을보이기때문에 FI와 IIS 형태의방사선적평가가이루어져야한다. 44) 비수술적치료에대한효과는면밀히조사되지않은편이지만, 42) 기계적증상을보이는경우수술적치료가적용되어야한다. 관절경적장골의 IIS 감압술은공존하는관절내병변에대해관절경적치료후방사선투시기하에서 IIS의절제가시행되는데, 43) 여러연구에서술후스포츠활동으로의복귀와관절운동범위증가, Harris 고관절점수, 시각통증지수 (visual analogue scale) 통증점수의증가등의향상된 2년이상의단기추시결과를발표하였다. 43,45,46) F Figure 13. Ischiofemoral impingement occurred at the ischiofemoral space (IS) between the ischium and lesser trochanter of femur (F). The quadratus femoris muscle was injured and high signal intensity (white arrow) was shown in magnetic resonance imaging. IT, ischial tuberosity. IS IT 4. 장요근충돌 (iliopsoas impingement) 장골의내측면에서기시하는장근 (iliacus muscle) 과제12 흉추에서제5 요추측면에서기시하는요근 (psoas muscle) 이골반에서빠져나오면서장요근 (iliopsos muscle) 을형성하여대퇴골소전자에부착된다. 장요근과고관절사이의해부학적기능적인관계에서장요근의반복적인운동에의해비구-관절낭복합체의반복적손상과관절내반흔, 비구순파열등이형성으로통증이유발되는경우를장요근충돌이라고한다. 42,47) FI에서는대부분의비구순파열이전상방에서발생되는반면장요근충돌에서는충돌이비구순과장요근사이에서일어나기때문에비구순의병변

12 495 The Current Concepts of Hip rthroscopy FH L FH B Figure 14. cetabular labral tear by iliopsoas impingement is located more anteriorly than that by femoroacetabular impingement. () Spinal needle is located at 1 o clock from the anterior portal and labral tear (white arrow) at the far anterior position. (B) Labral tear (white arrow) is found at 3 o clock of acetabulum., acetabulum; FH, femoral head; L, labrum. 이 FI의비구순파열보다전방에발생하는특징이있다 (Fig. 14). lpert 등 48) 은신선사체연구에서장요근이비구-관절낭복합체앞으로주행하여전방비구순파열을유발하는것을증명하였다. 장요근충돌은젊고활동적인여성에서많이발생하며, 42,49) Domb 등 49) 은이환된환자의평균나이는 25.1 세 (15-37 세 ) 라고하였다. 고관절표면치환술과인공관절치환술을시행한후비구컵이큰경우나비구컵의전경 (anteversion) 이큰경우, 큰대퇴골두부품을사용할때장요근과의충돌로인해전방고관절통증이유발될수있다 ) 환자들은고관절을능동굴곡시서혜부통증을호소하며고관절굴곡, 외전, 외회전에서장요근에의한발음성고관절현상이나타나기도한다. 53,54) 또한장요근주행경로에비특이적국소통증과전방충돌검사에서양성소견을보이며, 저항성 (resisted) SLR test에서통증을호소한다. 49) 보존적치료가일차적으로고려되나증상의개선이없는경우관절경적장요근유리술을시행할수있는데, 장요근부분절제의부위는해부학적수준에따라 1) 중심구획의비구순수준에서, 2) 변연구획에서관절낭절개후장요근노출부위에서, 3) 소전자수준의장요근건접합부에서시행될수있으며, Ilizaliturri 등 55) 은세가지방법모두증상개선을보이나임상적으로유의한차이는없다고하였다. 저자들은전방비구순파열이있는경우중심구획에서비구순봉합술 / 절제술후비구순수준에서전방관절낭절개를통한장요근유리술을선호한다. 술후 1년추시에서증상개선, 관절운동회복, Harris 고관절점수의개선이보고되고있으며, 49,56) 고관절굴곡력은수술후 3개월에완전하게회복된다. 57) 고관절관절경의한계점 고관절관절경의발전과관절경기구의발달에도불구하고한계점을가지고있다. 관절경술기습득에긴학습곡선을보이고, 고관절해부학적기계적충돌에대한일차적병리기전에대한해석과인식이관혈적수술을시행하는정형외과의사와충돌할수있다는점이다. 58) 고관절의형태적이상이모두관절경적접근이 허용되지않는데, cam형변형이대퇴골두후방부까지형성되는경우나후방부관절연골의손상이있는경우관절경적접근만으로는해결하기힘들수있다. 후방대퇴골경부의 cam형변형은무증상일수있으나후방충돌 (posterior impingement) 이발생되는경우증상을유발할수있으며, 이때는개방성수술적방법이더욱효과적일수있다. 비구측변형에서경계성비구이형성이나고도의비구이형성은전방비구경계는후경 (retroversion) 되어있으나비구후방부의불안정성이있을수있어수술적치료에주의해야한다. 59) 비구연골손상과상대적으로큰비구와를가지는심부고나돌출비구, 전반적비구순골화에의한병변은관절경적접근이시도가되지만, 59) 적절한치료는아직정립되지않았으며비구경계의단독절제만으로증가된비구내손상을해결하는데한계가있다. 60) 관절외병변의치료에서도장골극하충돌증후군과장요근충돌은관절경적치료가상대적으로접근하기용이하여성공적인결과를얻을수있으나좌골대퇴충돌, 심부둔부증후군등의정확한진단과해부학적접근이어려운경우에관절경의경험이적은술자는개방성접근이더욱효과적일수있으며의인성손상을줄일수있다. 고관절의관절경후발생할수있는합병증은외측회음신경과좌골신경손상, 외측대퇴피부신경손상, 국소성화골성근염, 회음부의혈종등이있으며드물게관절세척액의복강내유출에의한급성복통및심정지의예도보고되고있어주의를요한다. 11,61) 결론 고관절관절경의발전으로관절내병변과관절외병변의관절경적치료의적응이점차확대되고있으며, 수술기법도발달하고있다. 고관절관절경후환자의만족스러운임상적결과를도출해내기위해서는정확한환자의선택, 철저한수술전계획, 수술기술, 수술후재활에대한정확한이해가필요하며그에따른풍부한경험이있어야한다. FI, 비구순파열, 관절내유리체, 활액

13 496 Pil-Sung Kim and Deuk-Soo Hwang 막성골연골종등의고식적적응증뿐아니라, 심부둔부증후군, 좌골대퇴충돌, 장골극하충돌증후군, 장요근충돌과같은관절외충돌의새로운개념에대해서도숙지해야하며, 술자는병변의치료있어관절경적접근의이점과한계에대한인식이필요하다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Konan S, Rayan F, Meermans G, Witt J, Haddad FS. Validation of the classification system for acetabular chondral lesions identified at arthroscopy in patients with femoroacetabular impingement. J Bone Joint Surg Br. 2011;93: Philippon MJ, Maxwell RB, Johnston TL, Schenker M, Briggs KK. Clinical presentation of femoroacetabular impingement. Knee Surg Sports Traumatol rthrosc. 2007;15: Kamegaya M, Saisu T, Nakamura J, Murakami R, Segawa Y, Wakou M. Drehmann sign and femoro-acetabular impingement in SCFE. J Pediatr Orthop. 2011;31: Kivlan BR, Martin RL, Sekiya JK. Response to diagnostic injection in patients with femoroacetabular impingement, labral tears, chondral lesions, and extra-articular pathology. rthroscopy. 2011;27: Ross JR, Bedi, Stone RM, et al. Intraoperative fluoroscopic imaging to treat cam deformities: correlation with 3-dimensional computed tomography. m J Sports Med. 2014;42: Eriksson E, rvidsson I, rvidsson H. Diagnostic and operative arthroscopy of the hip. Orthopedics. 1986;9: Brumback RJ, Ellison TS, Molligan H, Molligan DJ, Mahaffey S, Schmidhauser C. Pudendal nerve palsy complicating intramedullary nailing of the femur. J Bone Joint Surg m. 1992;74: prato, Giachino M, Masse. rthroscopic approach and anatomy of the hip. Muscles ligaments tendons J. 2016;6: Byrd JW, Pappas JN, Pedley MJ. Hip arthroscopy: an anatomic study of portal placement and relationship to the extraarticular structures. rthroscopy. 1995;11: Robertson WJ, Kelly BT. The safe zone for hip arthroscopy: a cadaveric assessment of central, peripheral, and lateral compartment portal placement. rthroscopy. 2008;24: Dienst M, Kohn D. Hip arthroscopy. Minimal invasive diagnosis and therapy of the diseased or injured hip joint. Unfallchirurg. 2001;104: Jackson TJ, Stake CE, Trenga P, Morgan J, Domb BG. rthroscopic technique for treatment of femoroacetabular impingement. rthrosc Tech. 2013;2:e Dandachli W, Najefi, Iranpour F, Lenihan J, Hart, Cobb J. Quantifying the contribution of pincer deformity to femoroacetabular impingement using 3D computerised tomography. Skeletal Radiol. 2012;41: Blankenbaker DG, De Smet, Keene JS, Fine JP. Classification and localization of acetabular labral tears. Skeletal Radiol. 2007;36: Redmond JM, El Bitar YF, Gupta, Stake CE, Vemula SP, Domb BG. rthroscopic acetabuloplasty and labral refixation without labral detachment. m J Sports Med. 2015;43: Lertwanich P, Ejnisman L, Torry MR, Giphart JE, Philippon MJ. Defining a safety margin for labral suture anchor insertion using the acetabular rim angle. m J Sports Med. 2011;39 Suppl:11S-6S. 17. Degen RM, Poultsides L, Mayer SW, et al. Safety of hip anchor insertion from the midanterior and distal anterolateral portals with a straight drill guide: a cadaveric study. m J Sports Med. 2017;45: Philippon MJ, Nepple JJ, Campbell KJ, et al. The hip fluid seal: part I: the effect of an acetabular labral tear, repair, resection, and reconstruction on hip fluid pressurization. Knee Surg Sports Traumatol rthrosc. 2014;22: Jackson TJ, Hammarstedt JE, Vemula SP, Domb BG. cetabular labral base repair versus circumferential suture repair: a matched-paired comparison of clinical outcomes. rthroscopy. 2015;31: Chahla J, Soares E, Bhatia S, Mitchell JJ, Philippon MJ. rthroscopic technique for acetabular labral reconstruction using iliotibial band autograft. rthrosc Tech. 2016;5:e Nepple JJ, Larson CM, Smith MV, et al. The reliability of arthroscopic classification of acetabular rim labrochondral disease. m J Sports Med. 2012;40: Stafford GH, Bunn JR, Villar RN. rthroscopic repair of delaminated acetabular articular cartilage using fibrin adhesive. Results at one to three years. Hip Int. 2011;21: Marquez-Lara, Mannava S, Howse E, Stone V, Stubbs

14 497 The Current Concepts of Hip rthroscopy J. rthroscopic management of hip chondral defects: a systematic review of the literature. rthroscopy. 2016;32: de S D, Phillips M, Philippon MJ, Letkemann S, Simunovic N, yeni OR. Ligamentum teres injuries of the hip: a systematic review examining surgical indications, treatment options, and outcomes. rthroscopy. 2014;30: Kulcu DG, Naderi S. Differential diagnosis of intraspinal and extraspinal non-discogenic sciatica. J Clin Neurosci. 2008;15: Coppieters MW, lshami M, Babri S, Souvlis T, Kippers V, Hodges PW. Strain and excursion of the sciatic, tibial, and plantar nerves during a modified straight leg raising test. J Orthop Res. 2006;24: Martin HD, Kelly BT, Leunig M, et al. The pattern and technique in the clinical evaluation of the adult hip: the common physical examination tests of hip specialists. rthroscopy. 2010;26: Meknas K, Kartus J, Letto JI, Christensen, Johansen O. Surgical release of the internal obturator tendon for the treatment of retro-trochanteric pain syndrome: a prospective randomized study, with long-term follow-up. Knee Surg Sports Traumatol rthrosc. 2009;17: Benson ER, Schutzer SF. Posttraumatic piriformis syndrome: diagnosis and results of operative treatment. J Bone Joint Surg m. 1999;81: Dezawa, Kusano S, Miki H. rthroscopic release of the piriformis muscle under local anesthesia for piriformis syndrome. rthroscopy. 2003;19: Martin HD, Shears S, Johnson JC, Smathers M, Palmer IJ. The endoscopic treatment of sciatic nerve entrapment/deep gluteal syndrome. rthroscopy. 2011;27: Hwang DS, Kang C, Lee JB, Cha SM, Yeon KW. rthroscopic treatment of piriformis syndrome by perineural cyst on the sciatic nerve: a case report. Knee Surg Sports Traumatol rthrosc. 2010;18: Martin HD, Reddy M, Gómez-Hoyos J. Deep gluteal syndrome. J Hip Preserv Surg. 2015;2: Johnson K. Impingement of the lesser trochanter on the ischial ramus after total hip arthroplasty. Report of three cases. J Bone Joint Surg m. 1977;59: Viala P, Vanel D, Larbi, Cyteval C, Laredo JD. Bilateral ischiofemoral impingement in a patient with hereditary multiple exostoses. Skeletal Radiol. 2012;41: Nakano N, Yip G, Khanduja V. Current concepts in the diagnosis and management of extra-articular hip impingement syndromes. Int Orthop. 2017;41: Siebenrock K, Steppacher SD, Haefeli PC, Schwab JM, Tannast M. Valgus hip with high antetorsion causes pain through posterior extraarticular FI. Clin Orthop Relat Res. 2013;471: Tannast M, Hanke M, Ecker TM, Murphy SB, lbers CE, Puls M. LCPD: reduced range of motion resulting from extra- and intraarticular impingement. Clin Orthop Relat Res. 2012;470: Patti JW, Ouellette H, Bredella M, Torriani M. Impingement of lesser trochanter on ischium as a potential cause for hip pain. Skeletal Radiol. 2008;37: Safran M, Ryu J. Ischiofemoral impingement of the hip: a novel approach to treatment. Knee Surg Sports Traumatol rthrosc. 2014;22: Jones CW, Biant LC, Field RE. Dislocation of a total hip arthroplasty following hip arthroscopy. Hip Int. 2009;19: de Sa D, lradwan H, Cargnelli S, et al. Extra-articular hip impingement: a systematic review examining operative treatment of psoas, subspine, ischiofemoral, and greater trochanteric/pelvic impingement. rthroscopy. 2014;30: Hetsroni I, Poultsides L, Bedi, Larson CM, Kelly BT. nterior inferior iliac spine morphology correlates with hip range of motion: a classification system and dynamic model. Clin Orthop Relat Res. 2013;471: Pan H, Kawanabe K, kiyama H, Goto K, Onishi E, Nakamura T. Operative treatment of hip impingement caused by hypertrophy of the anterior inferior iliac spine. J Bone Joint Surg Br. 2008;90: Larson CM, Kelly BT, Stone RM. Making a case for anterior inferior iliac spine/subspine hip impingement: three representative case reports and proposed concept. rthroscopy. 2011;27: Hapa O, Bedi, Gursan O, et al. natomic footprint of the direct head of the rectus femoris origin: cadaveric study and clinical series of hips after arthroscopic anterior inferior iliac spine/subspine decompression. rthroscopy. 2013;29: Sutter R, Pfirrmann CW. typical hip impingement. JR m J Roentgenol. 2013;201:W lpert JM, Kozanek M, Li G, Kelly BT, snis PD. Cross-sectional analysis of the iliopsoas tendon and its relationship to

15 498 Pil-Sung Kim and Deuk-Soo Hwang the acetabular labrum: an anatomic study. m J Sports Med. 2009;37: Domb BG, Shindle MK, Mcrthur B, Voos JE, Magennis EM, Kelly BT. Iliopsoas impingement: a newly identified cause of labral pathology in the hip. HSS J. 2011;7: Cobb JP, Davda K, hmad, Harris SJ, Masjedi M, Hart J. Why large-head metal-on-metal hip replacements are painful: the anatomical basis of psoas impingement on the femoral head-neck junction. J Bone Joint Surg Br. 2011;93: Browne J, Polga DJ, Sierra RJ, Trousdale RT, Cabanela ME. Failure of larger-diameter metal-on-metal total hip arthroplasty resulting from anterior iliopsoas impingement. J rthroplasty. 2011;26:978.e Piggott RP, Doody O, Quinlan JF. Iliopsoas tendon rupture: a new differential for atraumatic groin pain post-total hip arthroplasty. BMJ Case Rep. 2015;2015:bcr Winston P, wan R, Cassidy JD, Bleakney RK. Clinical examination and ultrasound of self-reported snapping hip syndrome in elite ballet dancer. m J Sports Med. 2007;35: Ilizaliturri VM Jr, Villalobos FE Jr, Chaidez P, Valero FS, guilera JM. Internal snapping hip syndrome: treatment by endoscopic release of the iliopsoas tendon. rthroscopy. 2005;21: Ilizaliturri VM Jr, Buganza-Tepole M, Olivos-Meza, cuna M, costa-rodriguez E. Central compartment release versus lesser trochanter release of the iliopsoas tendon for the treatment of internal snapping hip: a comparative study. rthroscopy. 2014;30: Nelson IR, Keene JS. Results of labral-level arthroscopic iliopsoas tenotomies for the treatment of labral impingement. rthroscopy. 2014;30: Tey M, lvarez S, Ríos JL. Hip labral cyst caused by psoas impingement. rthroscopy. 2012;28: Zaltz I, Kelly BT, Larson CM, Leunig M, Bedi. Surgical treatment of femoroacetabular impingement: what are the limits of hip arthroscopy? rthroscopy. 2014;30: Matsuda DK. Protrusio acetabuli: contraindication or indication for hip arthroscopy? nd the case for arthroscopic treatment of global pincer impingement. rthroscopy. 2012;28: Liechti EF, Ferguson SJ, Tannast M. Protrusio acetabuli: joint loading with severe pincer impingement and its theoretical implications for surgical therapy. J Orthop Res. 2015;33: Bartlett CS, DiFelice GS, Buly RL, Quinn TJ, Green DS, Helfet DL. Cardiac arrest as a result of intraabdominal extravasation of fluid during arthroscopic removal of a loose body from the hip joint of a patient with an acetabular fracture. J Orthop Trauma. 1998;12:294-9.

16 499 pissn : , eissn : Symposium J Korean Orthop ssoc 2017; 52: 고관절주변질환의진단과관절보존술 고관절관절경의최신지견 김필성 황득수 * 부민병원정형외과, * 충남대학교의학전문대학원정형외과학교실 고관절의해부학적구조및접근의어려움으로인해비교적늦게시작된골관절관절경은설명되지않았던고관절통증의원인을해결하면서수술적적응이확대되고있다. 또한여러가지수술기법이개발되면서정상구조로의수복과기능회복을얻을수있게되었다. 최근에는대퇴비구충돌, 비구순파열, 관절내유리체, 활액막성골연골종등의고식적적응증뿐아니라심부둔부증후군, 좌골대퇴충돌, 전하방장골극하충돌, 장요근충돌의새로운관절외병변이소개되고있으며, 치료방법도더욱다양해지고있다. 저자들은고관절의관절경의다양한적응증의진단과치료에있어수술전고려사항, 관절경수술기법및재활등에대해보고한다. 색인단어 : 고관절, 관절경, 적응증, 진단, 치료 접수일 2017 년 5 월 2 일수정일 2017 년 8 월 27 일게재확정일 2017 년 9 월 7 일책임저자황득수 35015, 대전시중구문화로 282, 충남대학교의학전문대학원정형외과학교실 TEL , FX , dshwang@cnu.ac.kr 대한정형외과학회지 : 제 52 권제 6 호 2017 Copyright 2017 by The Korean Orthopaedic ssociation This is an Open ccess article distributed under the terms of the Creative Commons ttribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.