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1 Clinical Article The Korean Journal of Sports Medicine 2012;30(2): 아킬레스동종건을이용한전방십자인대재건술에서잔류조직보존술과비보존술의고유수용감각비교및보행운동형태분석 초당대학교간호학과교실 1, 중앙대학교체육과학대학 2, 원광대학교의과대학정형외과학교실 3, 원광의과학연구소 4 김광미 1 ㆍ한정규 2 ㆍ이영 3 ㆍ전철홍 3,4 Proprioceptive and Knee Joint Kinematics for Comparison of Remnant Preserved versus Non-remnant Anterior Cruciate Ligament Reconstruction Using Achilles Allograft Kwang Mee Kim, PhD 1, Joung Kyue Han, PhD 2, Young Yi, MD 3, Churl Hong Chun, MD 3,4 1 Department of Nursing, Chodang University, Muan, 2 Department of Sports Science, Chung-Ang University, Anseong, 3 Department of Orthopaedic Surgery, Wonkwang University School of Medicine, Iksan, 4 Institute of Wonkwang Medical Science, Iksan, Korea The purpose of remnant preserving technique in anterior cruciate ligament (ACL) reconstruction is to preserve mechanoreceptor and accelerate revascularization. In this study, we compared a group who underwent remnant preserving technique using Achilles tendon allograft with the other group of conventional ACL reconstruction in terms of proprioception, kinematic analysis, knee strength test and dynamic postural stability. Twenty-four patients were followed up for longer than 12 months after ACL reconstruction. They were separated into two groups; remnant preserving group (n=12) and non-remnant group (n=12). Proprioception test was conducted through joint position sense (JPS) and threshold to detection of passive motion. The remnant preserving group showed significantly less difference from the normal side than the non-remnant group. In kinematic analysis, there was statistically significant difference in peak flexion angle during the swing phase. However the 60 JPS, knee strength test, performance capacity test and dynamic postural stability did not showed the significant difference. Remnant preserving technique of ACL reconstruction was meaningful in preserving proprioception and the result showed akin to the unaffected gait. Key Words: Anterior cruciate ligament, Remnant preserving technique, Proprioception Received: April 23, 2012 Revised: August 7, 2012 Accepted: August 9, 2012 Correspondence: Churl Hong Chun Department of Orthopaedic Surgery, Wonkwang University School of Medicine, 859 Muwang-ro, Iksan , Korea Tel: , Fax: , cch@wonkwang.ac.kr CC This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 100 대한스포츠의학회지

2 김광미외. 전방십자인대재건술에서고유수용감각비교및보행운동형태분석 Table 1. Characteristics of study subjects 서론전방십자인대는슬관절의안정성유지및정상운동에관여하며고유수용감각기능에도기여하는것으로알려져있으며, 파열시슬관절의안정성과고유수용감각기능의회복이임상적결과에영향을미친다고하였다 1-3). 이에잔류조직을보존한전방십자인대재건술은기계적감각수용기의기능을보존하며재혈관화를촉진하는점에서시도되고있다 4,5). Lee 등 6) 은동종후경골건혹은자가슬괵건을이용한전방십자인대재건술에서고유조직을보호하여좋은임상적결과를발표하였고, Jeong 등 7) 은동종아킬레스건 (Achilles allograft) 을이용한전방십자인대재건술에서파열된인대의잔류조직을보존하는방법으로좋은임상결과를발표하였다. Adachi 등 8) 은자가슬괵건혹은동종건을이용하여전방십자인대보강술및재건술을시행한환자를비교한결과기계적감각수용기의기능을보존할수있는전방십자인대보강술을실시한군에서재건술을시행한군에비해안정성및관절위치감각등에서좋은결과를발표하였다. 본연구에서는아킬레스동종건을이용한잔류조직보존술을시행한군과비보존술을시행한군으로나누어고유수용감각기능과보행분석및근력, 기능수행능력및동적자세유지균형검사등을시행하였으며이에따른차이를비교하고자하였다. 연구방법 1. 대상과방법 2008년 1월부터 2010년 12월사이아킬레스동종건을사용하여전방십자인대재건술을받은남자환자를대상으로하였다. 이중수상후 3주이내의환자, 동반손상을가지고있지않은환자에서잔류조직보존술식을시행한 12명및비보존술을시행한군시행한 12명, 총 24명을기준없이선별하여임상적결과를평가하였다. 피험자들은모두저자들이지시한재활프로그램에순응한환자들이었으며, 두그룹으로잔류조직을보존하여재건술을시행한실험군 (remnant group, group I) 과잔류조직을완전히제거하고재건술을시행한대조군 (non-remnant group, group II) 으로나누었다 (Table 1). 관절경소견상절반이상의충분한전방십자인대의경골부잔류조직이있는경우잔류조직을보존하여재건술을시행하였으며 Group I Group II p-value Age (y) Sex Male only Male only Height (cm) Weight (kg) Group I: remnant preserving group, Group II: non-remnant group. 그렇지않은경우는잔류조직을완전히제거하고재건술을시행하였다. 많은급성전방십자인대파열에서절반정도에서전방십자인대근위부절반이내에서일어나게되어재건술시충분한길이를보이게되는데본연구에서도잔류조직보존술을시행한군에서는절반이상의충분한전방십자인대의경골부잔류조직이있었다. Group I (n=12) 는평균나이는 28.2세였으며, 이들은수상후수술까지 2일에서 3주 ( 평균 12.5일 ) 가소요되었다. Group II (n=12) 는평균나이는 30.3세였으며, 수상후수술까지 5일에서 3주 ( 평균, 14.2일 ) 가소요되었다. 수상기전은스포츠와관련된외상이 19예 ( 축구 12, 농구 5, 스키 2) 였고교통사고 4예, 낙상 1예였다. 전방십자인대재건술후완전한기능회복후검사를위해약 1년에서 1년 6개월되는시점에서두군의슬관절신전근력, 굴곡근력, 관절위치감각과동적자세유지균형능력, 기능수행능력및보행분석등의기능적차이를비교하였고, 관절위치감각능력과동적자세유지균형능력은구심성신경로의반응을얻기위하여정상측의결과치와환측의결과치의차이값을구하였다. 2. 수술기법 모든수술은동일시술자에의해이루어졌으며, 척추마취하에서수술전이학적검사를시행하고관절경으로관절내병변과전방십자인대의파열양상을확인하였다. 동종이식건은대퇴터널에삽입할골편은길이 25 mm, 직경 10 mm로준비하였다. 전방십자인대일부다발이보존된경우나파열단의길이가충분히남아있는경우는경골부에남은조직의전방부와후방십자인대와연결되어있는활액막에손상이없도록하였다 (Fig. 1A). 경골유도장치 (Arthrex, Naples, FL, USA) 유도침 (guide tip) 이등장점 (isometric point) 에위치할수있도록탐침을이용하여남아있는전방십자인대의경골부착부를유리시킨후전내측입구로수술용칼날을집어넣어유도핀삽입시경골고평면에서보일수있도록하기위해전방십자인대경골부착부에세로로절개선을가하였다. 제 30 권제 2 호

KM Kim, et al. Proprioception and Knee Joint Kinematics of ACL Reconstruction Fig. 1. Remnant preserving technique.

(C) Postoperative radiographs. *Remnant of ACL; Achilles thedon allograft. 경골드릴유도기 (drill guide) 를 50 o 각도로고정한후유도침을정상전내측다발의경골부착부에위치시킨다음유도강선 (guide wire) 을삽입하였다.

경골터널을통하여대퇴유도장치 (femoral drill guide) 를과간절흔후방경계 (over the top) 의 11시 ( 우측 ) 혹은 1시 ( 좌측 ) 방향으로삽입시킨후 (Fig. 1A), 확공기를이용하여대퇴골에직경 10 mm의터널을뚫고동종이식아킬레스건을통과시켰다. 그후간섭나사 (interference screw) 를대퇴골에고정하고 (Fig.

수술후재활수술후재활은 Shelbourne과 Nitz 9) 가제시한전방십자인대재건술후가속재활프로그램에따라수술후 2일째부터대퇴사두근강화운동을지속적으로시키면서슬관절보조기및목발하부분체중부하를허용하였다. 관절운동은보조기착용하에 2주째까지 0 o 90 o 범위에서굴곡운동및신전운동을시행하였으며, 2주후에는 0 o 120 o 로 4 6주후에는완전굴곡을시행하였다.

3 KM Kim, et al. Proprioception and Knee Joint Kinematics of ACL Reconstruction Fig. 1. Remnant preserving technique. (A) Femoral tunnel was positioned at the proximal part of bifurcate ridge preserving the remnant of anterior cruciate ligament (ACL). (B) Allograft was passed through beside the remnant of ACL. (C) Postoperative radiographs. *Remnant of ACL; Achilles thedon allograft. 경골드릴유도기 (drill guide) 를 50 o 각도로고정한후유도침을정상전내측다발의경골부착부에위치시킨다음유도강선 (guide wire) 을삽입하였다. 유관확공기는이식건의직경보다 1 mm 작은직경부터시작하여이식건과같은직경의터널을만들었다. 경골관절면의피질골이감지되면조심스럽게진행하여활액막과잔류조직이손상되지않도록주의하였다. 대퇴터널역시전방십자인대잔류조직이손상되지않게주의하였다. 경골터널을통하여대퇴유도장치 (femoral drill guide) 를과간절흔후방경계 (over the top) 의 11시 ( 우측 ) 혹은 1시 ( 좌측 ) 방향으로삽입시킨후 (Fig. 1A), 확공기를이용하여대퇴골에직경 10 mm의터널을뚫고동종이식아킬레스건을통과시켰다. 그후간섭나사 (interference screw) 를대퇴골에고정하고 (Fig. 1B), 경골측은생체흡수성나사못 (bioabsorbable screw) 과금속나사못및스파이크와셔 (spiked washer) 를이용하여고정하였다 (Fig. 1C). 3. 수술후재활수술후재활은 Shelbourne과 Nitz 9) 가제시한전방십자인대재건술후가속재활프로그램에따라수술후 2일째부터대퇴사두근강화운동을지속적으로시키면서슬관절보조기및목발하부분체중부하를허용하였다. 관절운동은보조기착용하에 2주째까지 0 o 90 o 범위에서굴곡운동및신전운동을시행하였으며, 2주후에는 0 o 120 o 로 4 6주후에는완전굴곡을시행하였다. 4주후에는목발없이완전체중부하를허용하였고, 6개월후부터자전거타기, 조깅순으로운동을시행하였으며외상전의운동을부분적으로허용하였다 (Table 2). 환자에따라부종이나통증이심한경우에는이에따라적합한운동을할수있도록프로그램을다시구성하였다. Table 2. Anterior cruciate ligament reconstruction rehabilitati on protocol Postoperative period Rehabilitational goals 0 2 wk Full knee extension ROM 90 o knee flexion ROM Partial weight-bearing 50% to 75% with crutchs Quadriceps stengthening 2 4 wk Progress ROM to 120 o by 4 wk Full weight-bearing without crutches 4 6 wk Progress to full ROM by 6 wk Begin isokinetic hamstring work at 6 wk Progress closed chain exercises 8 10 wk Progress ioskinetic work Slow-form running wk Initiate jogging program Initiate light polymetric program wk Isokinetic strength test Agility training and sport-specific training 5 6 mo Return to sports determined by physician ROM: range of motion. 4. 평가 1) 슬관절근력평가 (Knee strength test) 근력측정은등속성운동기구인 Primus-RS, BTE을사용하여슬관절의신전근과굴곡근의최대우력을측정하여평가하였다. 등속성검사에서의각속도는 60 o /s에서 5회, 180 o /s에서 10회반복측정하여평균치의값을사용하였다. 모든검사에앞서각각 3회의연습을실시하여피험자들에게검사에대한적응성을향상시켰고, 일률적으로신전근근력을측정한후굴곡근근력을검사하였으며, 각속도측정간휴식시간은 1분으로하였다. 의자에앉아등을기댄상태로고정하였으며 102 대한스포츠의학회지

김광미외. 전방십자인대재건술에서고유수용감각비교및보행운동형태분석 Fig. 2. The method of measured joint position sense. (A) Put on Lokomat (Hocoma AG). (B) Flow diagram for the measured joint position sense.

검사중의최대우력측정을위해일정한톤으로구령을붙여주어자연스러운검사가되도록하였다. 2) 고유수용감각검사 (1) 관절위치감각검사 : 외골격 (exoskeletal) 장비인 Lokomat (Hocoma AG, Volketswil, Switzerland) 를통하여관절위치감각검사 (joint position sense, JPS) 를시행하였다.

이후다시피험자의다리를 90 o 굴곡되도록하여편안한상태로 10초간유지시킨이후피험자스스로인식시켰던각도의위치를찾아가도록하였다 (Fig. 2). 측정은제시된각도와실제로구현한각도와의오차를 15 o, 45 o, 60 o 에서각각 3회씩반복측정하였으며평균치의값을사용하였으며중간단계에서학습효과를줄이기위하여 5분간단순보행을시행하였다.

4 김광미외. 전방십자인대재건술에서고유수용감각비교및보행운동형태분석 Fig. 2. The method of measured joint position sense. (A) Put on Lokomat (Hocoma AG). (B) Flow diagram for the measured joint position sense. The subject is placed into the target angle by the Lokomat and is asked to memorize the angle. After being moved away from the target, the subject move the leg back to the target angle. 검사중의최대우력측정을위해일정한톤으로구령을붙여주어자연스러운검사가되도록하였다. 2) 고유수용감각검사 (1) 관절위치감각검사 : 외골격 (exoskeletal) 장비인 Lokomat (Hocoma AG, Volketswil, Switzerland) 를통하여관절위치감각검사 (joint position sense, JPS) 를시행하였다. 피험자를기립상태로자킷을이용하여공중에매달아중력을제거하였고, 위치에따른다리무게의변화를느끼지못하도록상체와골반및대퇴부와발목의내측과골직상방부위를각각외골격을이용하여고정한후근력보조를통하여최소의근력으로슬관절을능동운동하도록하였다. 눈을가린상태에서고관절이 90 o 굴곡되도록하고, 정해진각도에 10초간유지시켜슬관절의위치를인식하도록하였다. 이후다시피험자의다리를 90 o 굴곡되도록하여편안한상태로 10초간유지시킨이후피험자스스로인식시켰던각도의위치를찾아가도록하였다 (Fig. 2). 측정은제시된각도와실제로구현한각도와의오차를 15 o, 45 o, 60 o 에서각각 3회씩반복측정하였으며평균치의값을사용하였으며중간단계에서학습효과를줄이기위하여 5분간단순보행을시행하였다. (2) 수동운동역치검사 : 수동운동역치검사 (threshold to detection of passive motion, TDPM) 는 Primus-RS, BTE을이용하였다 (Fig. 3). Passive motion을이용하여 45 o 각도에서슬관절을고정시켜놓고, o /s의가장느린속도로서서히슬관절이펴지도록할때, 피험자가슬관절의움직임을인식하는순간피험자스스로정지버튼을누르게되며, 시작한각도인 45 o 에서벗어난각도를측정하게된다. 피험자가눈을가린상태로진행하였으며 2번의연습을거친후 3회반복측정하여평균치 Fig. 3. Primus-RS, BTE. Physical therapy equipment for multi-joint testing, orthopedic rehab, neuromuscular reeducation, and advanced musculoskeletal athletic training of the upper & lower extremities and the core. 의값을사용하였다. 3) 자세유지균형능력평가 자세유지균형능력 (dynamic postural stability) 은 Biodex Stability System (BSS, Biodex Medical Systems Inc., New York, USA) 을이용하였다 (Fig. 4). BSS의발판 (platform) 의움직임은 8단계로구분되며가장안정적인단계인 8단계에서시작하여가장불안정한단계인 1단계로서서히진행되도록하였다. 발판은모든방향으로최대 20 o 까지움직이도록되어있다. 먼저건측의한다리로선자세에서양손은양측허리에가볍게위치하게하였으며 30초간균형을유지하게하여측정하였다. 건측의검사를마친후 3분의휴식후환측을동일한방법으로측정하였다. 측정은 30초간발판으로전달된신체압력중심 (center of pressure) 의이동에따라전-후방, 내-외측의안정성 제 30 권제 2 호

KM Kim, et al. Proprioception and Knee Joint Kinematics of ACL Reconstruction 수치 (stability indexes) 를측정하여건측과환측의차이를백분율로분석하여사용하였다. 환측의불안정성이심할수록측정된백분율차가커지게된다.

5 KM Kim, et al. Proprioception and Knee Joint Kinematics of ACL Reconstruction 수치 (stability indexes) 를측정하여건측과환측의차이를백분율로분석하여사용하였다. 환측의불안정성이심할수록측정된백분율차가커지게된다. 4) 기능수행검사 (1) 카리오카검사 (Carioca test): 대상자에게발을엇갈리게 (cross-over step) 하여옆으로뛰게하였다. 처음에는왼쪽에서오른쪽으로 12 m (40 feet) 를뛰게하고그다음에오른쪽에서왼쪽으로다시되돌아오게하여최단시간을측정하였다. (2) 왕복달리기검사 (Shuttle run test): 대상자에게 6.1 m (20 feet) 거리를 2번왕복하여달리게한후소요되는최단시간을측정하였다. (3) 외발멀리뛰기검사 : 평평한바닥에서한쪽다리로힘껏앞으로뛰도록하여그거리를측정하였다. 한번뛰기 (single hop test) 를실시하였으며, 양쪽다리각각 3번씩실시하여가장멀리뛴거리를채택하였다. 5) 운동형상학분석 (Kinematics analysis) 보행분석은 Lokomat Hocoma의 supported treadmil mode에서시행하였다. 이기기는로보트하지외골격장치로 (robotic lower extremity exoskeleton) 외골격구조안에위치한전동기에의하여근력보조가가능하며, 외고정장치안에는관절유니트가존재하며이안에위치측정계 (potentiometer) 는관절각을 측정하게되어있다. 각각의좌우고관절의외과외측, 양측허벅지, 양측종아리를외고정장치에고정을하였으며, 각각의관절에외골격의관절유니트가위치하도록하였다. 또한상체에벨트를이용하여고정하고체중지지시스템을이용하에부하를줄인상태에서땅위에서있게된다. 보행시각각의위치측정계에서얻어지는결과가 motion analysis custom software를통하여 3차원영상으로분석되며, 운동형상학적변화를검사한다. 이를통하여슬관절내외반각을제외한굴곡신전각을얻을수있으나, 외골격으로인하여내외반은제한되도록되어있다. 피험자는이런장치를착용한상태에서 10 m의거리를대상자가스스로편안한속도로걷게하였으며매측정마다 3회이상반복보행후자연스러운보행양상을택하여기록하였고, 한사람당총 5회의보행검사를시행한후입각기, 말기입각기, 유각기의슬관절의각도를측정하였고평균치의값을사용하였다. 5. 통계본연구의측정자료들의통계는 SPSS ver (SPSS Inc., Chicago, IL, USA) 을이용하여시행하였다. Independent t-test를이용하여두집단을비교분석하였으며통계학적유의수준은 p<0.05로하였다. 결과 1. 등속성근력평가결과보존술을시행한군 (group I) 의신전근력 (extensor muscle strength) 의측정결과 60 o /s와 180 o /s의각속도 (angular velocity) 에서두그룹간의 60 o /s와 180 o /s에서의신전근력은유의한차이는없었다 ( 각각, p>0.05). 또한굴곡근력 (flexor muscle strength) 의측정결과 60 o /s와 180 o /s의각속도 (angular velocity) Table 3. Isokinetic strengthening Knee strength Group I (N/m) Group II (N/m) p-value Fig. 4. Biodex Stability System (BSS, Biodex Medical Systems Inc.) Consists of a movable balance platform that provides up to 20 o of surface tilt in a 360 o range of motion. The platform is interfaced with computer software that enables the device to serve as an objective assessment of balance. Extension 60 o /s 115.4± ± Extension 180 o /s 89.1± ± Flexion 60 o /s 82.1± ± Flexion 180 o /s 65.6± ± Group I: preservation of remnant group, Group II: no preservation group. 104 대한스포츠의학회지

6 김광미외. 전방십자인대재건술에서고유수용감각비교및보행운동형태분석 에서굴곡근력에서도두그룹간통계적으로유의한차이를보이지않았다 ( 각각, p>0.05) (Table 3). 2. 고유수용감각검사결과 JPS검사는 15 o, 45 o, 60 o 각도에서 group I, II 모두정상측에대하여유의하게증가되어있었다 (p<0.05). 두군간의비교는 JPS에서얻어진각을직접비교하지않고, 정상측과의차이를비교하였다. 그결과 15 o, 45 o 에서 group I이 group II에비하여유의하게정상측보다차이가적었다 (p<0.05) (Table 4). TDPM 검사측정결과 45 o 각도에서 group I이 group II에비하여유의하게정상측보다차이가적었다 (p<0.05) (Table 5). 역시두군간의비교는 TDPM에서얻어진각을직접비교하지않고, 정상측과의차이를비교하였다. 3. 동적자세유지균형능력검사동적자세유지균형검사에는두그룹간에는통계적유의한차이는 (p>0.05) 보이지않았다 (Table 6). 4. 기능수행능력검사결과카리오카검사는 group I이 group II보다유의하게짧은결과를보였으나 (p<0.05), 왕복달리기검사, 외발멀리뛰기검사에서는두군간의유의한차이는관찰되지않았다 (p> 0.05) (Table 7). 5. 운동형상학분석결과보행분석에서유각기최대굴곡각에서두군간의유의한수준의차이를보였으나 (p<0.05) 입각기굴곡각이나말기 Table 4. Joint position sence and threshold to detection of passive motion Test angle ( o ) Non OP group* Group I Group II The operated knee The opposite knee The operated knee The opposite knee p-value o ±1.22 o 2.74 o ±0.92 o 2.35 o ±1.17 o 3.08 o ±1.78 o 2.11 o ±1.27 o o ±0.66 o 0.97 o ±0.72 o o ±0.97 o 2.96 o ±1.54 o 2.57 o ±0.95 o 3.23 o ±1.36 o 2.41 o ±0.99 o o ±1.38 o 0.82 o ±1.47 o o ±1.16 o 2.68 o ±1.74 o 2.12 o ±1.13 o 2.72 o ±1.43 o 2.16 o ±1.19 o o ±0.72 o 0.56 o ±0.78 o Values are presented as mean±standard deviation. Non OP: non operation, Group: remnant preserving group, Group II: non-remnant group. *The opposite knee group that did not take surgery; The difference between the operated groups and the opposite group; p<0.05. Table 5. Threshold to detection of passive motion Test angle Non OP group* Group I Group II The operated knee The opposite knee The operated knee The opposite knee p-value 45 o 1.57 o ±0.5 o 2.38 o ±0.47 o 1.59 o ±0.57 o 3.31 o ±0.85 o 1.55 o ±0.43 o 0.79 o ±0.46 o 1.76 o ±0.72 o Values are presented as mean±standard deviation. Non OP: non operation, Group I: preservation of remnant group, Group II: no preservation group. *Total opposite knee group that differences in surgical method is not; The difference between the operated groups and the opposite knee group; p<0.05. Table 6. Dynamic postural stability Group I Group II p-value Dynamic postural stability (%) 25.32± ± Group I: remnant preserving group, Group II: non-remnant group. p<0.05. 제 30 권제 2 호

7 KM Kim, et al. Proprioception and Knee Joint Kinematics of ACL Reconstruction Table 7. Clinical result of performance capacities of each subject Group I Group II p-value Carioca (s) 9.18± ± * Shuttle run (s) 8.34± ± Single Hop test (cm) 150.1± ± Group I: remnant preserving group, Group II: non-remnant group. *p<0.05. Table 8. Result of kinematic gait analysis Group I Group II p-value Peak knee flexion in stance phase o ±2.74 o o ±3.76 o Peak knee extension in late stance phase 7.78 o ±1.82 o 7.33 o ±1.53 o Peak knee flexion in swing phase o ±3.98 o o ±3.06 o 0.028* Group I: remnant preserving group Group II: non-remnant group. *p<0.05. Fig. 5. Knee kinematics at average of each group. Group I was similar to the normal kinematics of the knee joint. 입각기신전각에서유의한차이는보이지않았다 (p>0.05) (Table 8, Fig. 5). 고 찰 전방십자인대파열시동종건의사용은일반적으로재수술또는복합인대손상의경우이용하였다 10,11). 그러나전방십자인대파열에서동종이식건의사용은점차늘어가는추세이며, 동종건을사용한전방십자인대재건술의경우면역반응을유발할수있고이식건조작으로인한물리적인약화등의단점이있으나 12,13), 조직확보가용이하고, 수술시간이단축되며, 피부절개를줄일수있고공여부위의손상이없으며, 재수술을시행하는경우이식조직확보에어려움이없고, 빠른재활이가능하다는장점이있다 10,11). 특히 Peterson 등 14) 이나 Linn 등 10) 은동결아킬레스건을이용한전방십자인대재건술이자가이식건을이용한재건술에비하여임상결과의차이가없다고발표하였다. 저자들의이전연구에서도동종이식건을사용한전방십자인대재건술은자가건에비하여나쁘지않은결과를보였다 15). 한편 Schultz 등 16) 이 1984년처음으로전방십자인대에서기계적수용체의존재를보고한이후감각기관으로중요성이커지고있다. 고유수용감각은특정한감각양식으로써관절의움직임과관절의위치감각에반응하고기능적인관절안정성에기여한다 5). 고유수용감각의감각수용기는기계적수용체라불리우며피부나근육, 건, 인대, 관절강내에존재하며, 관절내의기계적인부하를구심성신경자극으로변환시키는역할을한다 17). 더불어이를통한이차적안정성에도관여한다고알려져있다 18). Lee 등 6) 은전방십자인대잔류조직보존술식을이용하여전방십자인대재건술시행후고유수용감각을연구하여잔류조직의보존이술후이식건의치유와기능회복에도움이된다고보고하였다. Ochi 등 19) 은전방십자인대보강술로써전방십자인대잔류조직내의신경성분과기계적수용기를보존하며, 혈류공급과이식건으로의신경재지배에긍정적인영향등전방십자인대보강술식의장점을강조하였다. Fremerey 등 20) 은고유수용감각의회복정도와환자의만족도사이에깊은상관관계가있음을보고하였고, 성공적인전방십자인대재건술을위해서는기계적안정성의회복외에도슬관절고유수용감각의기능의회복이성공적인수술에필요하다고하였다 4,6). 최근이러한고유수용감각을측정하기위해가장자주쓰이 106 대한스포츠의학회지

8 김광미외. 전방십자인대재건술에서고유수용감각비교및보행운동형태분석 는기능적인검사는 TDPM과 JPS, 기립균형 (standing balance) 등이있다. TDPM은관절각이천천히변화할때움직임의변화에반응하는검사며, JPS는목표각을정해놓고스스로관절각을재현하거나움직이는동안목표각에반응하는검사다 21). 이에 JPS 검사는간편하고쉽고빠르게수행할수있다는장점이있어많이사용되고있으나그신뢰도에있어서는논란이되고있다. 반면 TDPM은 JPS 검사에비해신뢰성이있는것으로보고되지만검사방법이어렵고, 많은시간이소요된다는단점이있다. JPS 검사의신뢰도를떨어뜨리는요인으로는우선학습효과를꼽을수있으며일단환자가검사방법에익숙해지면다음검사때이방법에쉽게적응해서결과가향상되어나타난다 22). 다음으로, 보통앉거나옆으로누워서검사를하기때문에중력의작용으로하퇴의무게의변화를감지하거나실제기립시작용하는기계적수용체의작용이덜반영된다는점이있으며 23), 마지막으로장비의고정장치가피부표재감각에작용하여이신경회로의 feedback을차단하기어렵다는것이다 24). 이에 Domingo 등 25) 은외골격로봇 (Robotic Exoskeleton) 장비인 Lokomat을이용하여하지의 JPS를정량적으로측정하였다. 저자들도 JPS의신뢰도를높이기위하여이장비를이용하였다. 그러나장비의고정장치가피부표재감각에작용하는 feedback을차단하기는어려웠으며학습효과에대하여는여전히의문이있다. 저자들의연구에서 JPS와 TDPM는잔류조직보존술및비보존술각군에서정상측과의차이에대하여비교분석하였는데, 이는감각의유입에서반응까지의원심성및구심성신경회로에서쓰이는시간이각각다르기때문에정확한고유수용감각결과를비교하고자하였기때문이었다. 그결과 15 o, 45 o 의 JPS 및 TDPM에서보존술을시행한군 (group I) 이비보존술을시행한군 (group II) 에비하여유의하게정상측과의차이가적었다. 또한 JPS와 TDPM 간의유의한상관관계를확인하였다 (p<0.05). 반면, 근력에대한연구에서 Kim과 Park 26) 은슬관절의신전근력이나굴곡근력에서는큰차이를보이지않았는데수술후 1년정도의시간이흐르면근력회복하는수준이수술방법에의해서는차이가나지않기때문이라고하였다. 저자들의연구에서도슬관절의신전근력과굴곡근력은큰차이가관찰되지않았다. 동적자세유지및기능수행에관한능력은보통스포츠 활동시주로관절불안감에작용을하는데, 이중운동기능은하지와체간의근육들의조화가작용되는과정이며, 감각기능은고유수용감각을포함한체성감각과시각, 그리고청각기관으로부터수용된다양한감각들의조직화과정이다. 본연구에서는동적자세유지검사및카리오카검사를제외한기능수행검사 ( 외발멀리뛰기, 왕복달리기 ) 에서두군간의유의한차이는발견되지않았다. 한편전방십자인대결손슬관절의보행에대한연구는여러저자들에의해이루어졌는데, Berchuck 등 27) 은전방십자인대결손슬관절을가진환자중 75% 에서대퇴사두근회피보행 (quadriceps avoidance gait) 으로보행형태가변화한다고하였고, 입각기에대퇴사두근의활동부재로인하여 140% 정도의슬관절운동감소를보고하였다. 전방십자인대의재건술후에도보행시운동형상학 (kinematics) 의변화가있는데 Ernst 등 28) 은이를대퇴사두근의위축이나슬관절통증의결과라고하였다. 그러나 Timoney 등 29) 은정상군과전방십자인대재건술을시행한군을비교하여중간입각기에슬관절굴곡모멘트의감소를관찰하였으나이전에보고된전방십자인대결손슬관절보다차이가적었으며따라서전방십자인대재건술을시행한슬관절에서는진정한의미의대퇴사두근회피보행은일어나지않는다고하였다. 본연구에서도건측에비해환측이전반적으로굴곡각도의증가를보이고있었으나보존술을시행한군 (group I), 비보존술을시행한군 (group II) 두군간의입각기굴곡각이나말기입각기신전각에서유의한차이를보이지않았다. 또한입각기굴곡각과말기입각기신전각은슬관절신전근력이나굴곡근력과통계적으로유의한상관관계를보이고있었다. 단유각기최대굴곡각에서두군간통계적으로유의한차이가관찰되었으며, 이를통해고유수용감각보존에따른보행시운동형상학적차이가있으며, 잔류보존술식을사용한경우정상보행에가까운보행을보인다고추론하였다. 본논문의제한점으로는후향적연구라는점과표본수가작다는점, 고유수용감각검사방법의한계및검사방법의검증, 또한외골격장비로시행되어보행분석이굴곡과신전으로제한되어있는점등을지적할수있다. 그러나고유수용감각검사를더욱정량적으로측정하려고하였으며, 보행시의운동형상학및근력동적자세유지균형능력및기능수행능력간의상호관계를알아보고자하였다. 동종건으로잔류조직보존술식을시행한전방십자인대재건술이고유수용감각을보존하는데의미가있었으며슬관절의안정성및기능을회복하는데유용하였다. 동종건으로잔류 제 30 권제 2 호

9 KM Kim, et al. Proprioception and Knee Joint Kinematics of ACL Reconstruction 조직보존술식을시행하는방법은재건술후상대적으로우수한결과를기대할수있는술식으로생각되며더많은증례로장기간의추시관찰이필요할것으로생각된다. 참고문헌 1. Bray RC, Dandy DJ. Meniscal lesions and chronic anterior cruciate ligament deficiency. Meniscal tears occurring before and after reconstruction. J Bone Joint Surg Br 1989;71: Georgoulis AD, Pappa L, Moebius U, et al. The presence of proprioceptive mechanoreceptors in the remnants of the ruptured ACL as a possible source of re-innervation of the ACL autograft. Knee Surg Sports Traumatol Arthrosc 2001; 9: Shino K, Inoue M, Horibe S, Nakata K, Maeda A, Ono K. Surface blood flow and histology of human anterior cruciate ligament allografts. Arthroscopy 1991;7: Barrett DS. Proprioception and function after anterior cruciate reconstruction. J Bone Joint Surg Br 1991;73: Reider B, Arcand MA, Diehl LH, et al. Proprioception of the knee before and after anterior cruciate ligament reconstruction. Arthroscopy 2003;19: Lee BI, Min KD, Yoon ES, Kim JB, Choi HS, Lee DH. Mechanoreceptors in the remnants of ruptured anterior cruciate ligaments in human knees. J Korean Orthop Assoc 2006;41: Jeong HJ, Shin HK, Lee J, Choi K, Jeon B. Preserving remnant tissue in arthroscopic ACL reconstruction using achilles tendon allograft. J Korean Knee Soc 2010;22: Adachi N, Ochi M, Uchio Y, Iwasa J, Ryoke K, Kuriwaka M. Mechanoreceptors in the anterior cruciate ligament contribute to the joint position sense. Acta Orthop Scand 2002;73: Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med 1993;21: Linn RM, Fischer DA, Smith JP, Burstein DB, Quick DC. Achilles tendon allograft reconstruction of the anterior cruciate ligament-deficient knee. Am J Sports Med 1993;21: Noyes FR, Barber-Westin SD. Reconstruction of the anterior cruciate ligament with human allograft. Comparison of early and later results. J Bone Joint Surg Am 1996;78: Jackson DW, Windler GE, Simon TM. Intraarticular reaction associated with the use of freeze-dried, ethylene oxide-sterilized bone-patella tendon-bone allografts in the reconstruction of the anterior cruciate ligament. Am J Sports Med 1990;18: Roberts TS, Drez D Jr, McCarthy W, Paine R. Anterior cruciate ligament reconstruction using freeze-dried, ethylene oxide-sterilized, bone-patellar tendon-bone allografts. Two year results in thirty-six patients. Am J Sports Med 1991; 19: Peterson RK, Shelton WR, Bomboy AL. Allograft versus autograft patellar tendon anterior cruciate ligament reconstruction: A 5-year follow-up. Arthroscopy 2001;17: Chun CH, Han HJ, Lee BC, Kim DC, Yang JH. Histologic findings of anterior cruciate ligament reconstruction with Achilles allograft. Clin Orthop Relat Res 2004;(421): Schultz RA, Miller DC, Kerr CS, Micheli L. Mechanoreceptors in human cruciate ligaments. A histological study. J Bone Joint Surg Am 1984;66: Miura K, Ishibashi Y, Tsuda E, Okamura Y, Otsuka H, Toh S. The effect of local and general fatigue on knee proprioception. Arthroscopy 2004;20: Tsuda E, Okamura Y, Otsuka H, Komatsu T, Tokuya S. Direct evidence of the anterior cruciate ligament-hamstring reflex arc in humans. Am J Sports Med 2001;29: Ochi M, Iwasa J, Uchio Y, Adachi N, Sumen Y. The regeneration of sensory neurones in the reconstruction of the anterior cruciate ligament. J Bone Joint Surg Br 1999;81: Fremerey RW, Lobenhoffer P, Zeichen J, Skutek M, Bosch U, Tscherne H. Proprioception after rehabilitation and reconstruction in knees with deficiency of the anterior cruciate ligament: a prospective, longitudinal study. J Bone Joint Surg Br 2000;82: Corrigan JP, Cashman WF, Brady MP. Proprioception in the cruciate deficient knee. J Bone Joint Surg Br 1992;74: Oh SJ, Yang SJ, Ha JK, Seo JG, Choi JY, Kim JG. The effectiveness of joint position sense test in evaluating the proprioceptive function after anterior cruciate ligament reconstruction. Korean J Sports Med 2011;29: Refshauge KM, Chan R, Taylor JL, McCloskey DI. Detection of movements imposed on human hip, knee, ankle and toe joints. J Physiol 1995;488 (Pt 1): Collins DF, Refshauge KM, Todd G, Gandevia SC. Cutaneous receptors contribute to kinesthesia at the index finger, elbow, and knee. J Neurophysiol 2005;94: Domingo A, Marriott E, de Grave RB, Lam T. Quantifying lower limb joint position sense using a robotic exoskeleton: a pilot study. IEEE Int Conf Rehabil Robot 2011;2011: 대한스포츠의학회지

10 김광미외. 전방십자인대재건술에서고유수용감각비교및보행운동형태분석 26. Kim DK, Park WH. Proprioceptive and strength comparison of remnant preserved versus conventional anterior cruciate ligament reconstruction. Korean J Sports Med 2011: Berchuck M, Andriacchi TP, Bach BR, Reider B. Gait adaptations by patients who have a deficient anterior cruciate ligament. J Bone Joint Surg Am 1990;72: Ernst GP, Saliba E, Diduch DR, Hurwitz SR, Ball DW. Lower extremity compensations following anterior cruciate ligament reconstruction. Phys Ther 2000;80: Timoney JM, Inman WS, Quesada PM, et al. Return of normal gait patterns after anterior cruciate ligament reconstruction. Am J Sports Med 1993;21: 제 30 권제 2 호

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untitled Clinical Article The Korean Journal of Sports Medicine 2011;29(2):99-104 http://dx.doi.org/10.5763/kjsm.2011.29.2.99 잔류조직보존술을이용한전방십자인대재건술과잔류조직을제거한재건술에따른근력과고유수용감각의비교 성균관대학교의과대학삼성서울병원재활의학과스포츠의학실 김도경ㆍ박원하