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1 동종반월상연골이식후이차관절경소견및 MRI 를이용한임상적결과 대전선병원정형외과 전재균ㆍ송인수ㆍ김준범ㆍ정현윤ㆍ이창수 The Clinical Results Using the Second Look Arthroscopic Findings and MRI after Allogenic Meniscal Transplantation Je-Gyun Chon, M.D., In-Soo Song, M.D., Jun-Beom Kim, M.D., Hyun-Yoon Jeong, M.D., Chang-Soo Lee, M.D. Department of Orhopedic Surgery, Sun General Hospital Daejeon, Daejeon, Korea Purpose: The purpose of this study was to evaluate the clinical results and the changes of allogenic meniscal transplantation by using the second look arthroscopic findings and the MRI changes after surgery. Materials and Methods: From July 1997 to February 2007, among the patients that underwent allogenic meniscal transplantation, we chose 25 patients who underwent secondary arthroscopic evaluation. 16 of these 25 patients were men and 8 were women. Secondary arthroscopic evaluation was done without MRI in 3 cases. The mean age was 36.1 yr and the average follow up period was 28 months. Biopsy by the secondary arthroscopic evaluation was done in 2 cases. We evaluated the clinical results by the Lysholm knee scoring scale, the Knee Society Score (KSS) system and the Hospital for Special Surgery (HSS) knee score. Results: Second-look arthroscopy after allogenic meniscal transplantation revealed that 23 cases seemed normal at the probing procedure. 5 cases showed a decreased posterior horn size. The MRI findings and secondary arthroscopic findings matched in all cases. The clinical Lysholm score improved from preoperative 65.4 points to postoperative 80.6 points, the Knee Society Score (KSS) improved from preoperative 64.6 points to postoperative 82.6 points, the functional score improved from preoperative 70.2 points to postoperative 85.6 points and the Hospital for Special Surgery (HSS) knee score improved from preoperative 66.4 points to postoperative 82.5 points (p=0.000). The function after surgery improved on all the tests and this was proved by paired t-tests. Conclusion: Allogenic meniscal transplantation showed good results on the second look arthroscopy and the follow-up MRI and according to the clinical functional outcome. We think that confirmation through arthroscopy after follow-up MRI for the patients with clinical knee problems seems to be necessary. Key Words: Arthroscopy, MRI, Allogenic meniscal transplantation 서 론 통신저자 : 송인수 , 대전중구목동 10-7 번지대전선병원서관 2 층정형외과의국 TEL: , FAX: mrabdomen@nate.com 슬관절의반월상연골손상은최근생활습관의변화, 스포츠활동의보편화등으로증가추세에있다. 반월상연골은관절연골의영양공급, 하중의전달, 충격의흡수, 슬관절의윤활작용, 관절위치감각의담당, 슬관절의안정성등의기능을가진다 3,6,16). 반월상연골이외상, 수술등 35

36 의이유로손실되면체중부하의전이능력상실과 Hoop stress 의소실로슬관절의퇴행성변화를일으킨다는것은이미알려진사실이다 11,12,14).

은반월상연골의전절제술후회전불안정성이발생한다고보고하였으며, Rangger 등 23)

이에따라반월상연골손상에대한치료로서반월상연골봉합술, 동종반월상연골이식술, 자가슬개하지방또는슬개건을이용한이식술및 Scaffold

저자들은동종반월상연골이식술후자기공명영상결과와이차관절경소견및임상적결과를통해이식술에대한평가를하고자하였다.

여자는 8명 (9예 ) 이었다. 평균연령은 36.1 세 (17.0 45.0 세 ) 였다.

0 년 ) 이었다. 내측반월상연골은경골극과전방십자인대의손상을방지하기위하여전후방골편 (bone plugs) 을이용한고정을사용하였고 (Fig.

2 36 의이유로손실되면체중부하의전이능력상실과 Hoop stress 의소실로슬관절의퇴행성변화를일으킨다는것은이미알려진사실이다 11,12,14). Fairbank 5) 은반월상연골전절제술후 10년추시결과 80% 의환자에서퇴행성변화가관찰됨을보고하였고, Levy 등 15) 은반월상연골의전절제술후회전불안정성이발생한다고보고하였으며, Rangger 등 23) 은반월상연골의부분또는전절제술후에슬관절의이차적인퇴행성관절염이발생한다고보고하였다. 이에따라반월상연골손상에대한치료로서반월상연골봉합술, 동종반월상연골이식술, 자가슬개하지방또는슬개건을이용한이식술및 Scaffold 와세포배양을이용한반월상연골이식술등의이용이활발하게진행되고있다 18,19,24). 저자들은동종반월상연골이식술후자기공명영상결과와이차관절경소견및임상적결과를통해이식술에대한평가를하고자하였다. 대상및방법저자들은 1997 년 7월부터 2007 년 2월까지반월상연골동종이식술을시행한 25예의환자를대상으로하였고이중남자는 16명 (16 예 ), 여자는 8명 (9예 ) 이었다. 평균연령은 36.1 세 ( 세 ) 였다. 내측반월상연골이 15예, 외측반월상연골이 10예였고반월상연골절제술후동종반월상연골이식술시행까지의기간은평균 5.8 년 (5 개월 25.0 년 ) 이었다. 내측반월상연골은경골극과전방십자인대의손상을방지하기위하여전후방골편 (bone plugs) 을이용한고정을사용하였고 (Fig. 1), 외측반월상연골은열쇠구멍 (key hole) 수기를사용하였다 (Fig. 2). 연골의전각부는 outside-in 술식, 후각부는 all-inside 술식, 체부는 in- Fig. 1. The figure shows fixation methods of meniscal transplantation: Bone-plug method. Fig. 2. The figure shows fixation methods of meniscal transplantation: Key-hole method.

전재균외 : 동종반월상연골이식후이차관절경소견및 MRI 를이용한임상적결과 37 side-out 술식과 outside-in 술식의혼합방법을이용하였다. 일차적으로반월상연골절제술을시행한원인은스포츠손상이 11예, 원판형연골판이 7예, 작업중손상이 4 예, 추락손상 1예, 넘어지며수상한경우가 1예, 원인을알수없는경우가 1예였다.

동종반월상연골이식술의적응은 50세이하의비교적젊은연령의환자, 반월상연골아전절제술혹은전절제술시행받고증상이지속된환자, 내, 외측반월상연골중한측의손상, 방사선소견상 1 또는 2등급의관절연골퇴행성변화가있는환자중하지정렬이정상범위내에있는환자를대상으로하였고 9,25), 전례에서신선냉동보존 (fresh-frozen type) 동종연골을사용하였고,

PACS (picture archiving and communication system) 를이용하여방사선사진에서보이는두개의볼간격이 10 cm가되도록확대한후연골크기를측정하였다. 정전후면사진상을통해너비 (width) 로측정하고, 이는경골고평부 (tibial plateau) 의내측또는외측경계면에서각각의내측또는외측과간극까지의거리로하였다.

3 전재균외 : 동종반월상연골이식후이차관절경소견및 MRI 를이용한임상적결과 37 side-out 술식과 outside-in 술식의혼합방법을이용하였다. 일차적으로반월상연골절제술을시행한원인은스포츠손상이 11예, 원판형연골판이 7예, 작업중손상이 4 예, 추락손상 1예, 넘어지며수상한경우가 1예, 원인을알수없는경우가 1예였다. 동반된손상으로는전방십자인대손상이 7예, 연골손상이 5예, 후방십자인대손상이 3예, 퇴행성관절염이 3예였다. 동종반월상연골이식술의적응은 50세이하의비교적젊은연령의환자, 반월상연골아전절제술혹은전절제술시행받고증상이지속된환자, 내, 외측반월상연골중한측의손상, 방사선소견상 1 또는 2등급의관절연골퇴행성변화가있는환자중하지정렬이정상범위내에있는환자를대상으로하였고 9,25), 전례에서신선냉동보존 (fresh-frozen type) 동종연골을사용하였고, 이식물은측정치보다약간큰이식물을선택하였다. 반월상연골의크기측정위해우선 10 cm 간격으로놓인두개의볼 (ball bearing) 로구성된길다란플라스틱의 확대표시기 (magnification marker)(fig. 3C) 를대상자의환측슬관절에부착한후슬관절의정전후면사진과측면사진을촬영하였다. PACS (picture archiving and communication system) 를이용하여방사선사진에서보이는두개의볼간격이 10 cm가되도록확대한후연골크기를측정하였다. 정전후면사진상을통해너비 (width) 로측정하고, 이는경골고평부 (tibial plateau) 의내측또는외측경계면에서각각의내측또는외측과간극까지의거리로하였다. 측면사진상에서는길이 (length) 를측정하였는데, 외측또는내측연골의가장앞쪽부착부위에서각각의가장뒤쪽부착부위까지의전후거리로하였다 26) (Fig. 3A, B). 환측연골크기를단순방사선사진을통해술전과술후모두측정하여변화를관찰하였다 (Table 1, 2). 또한술후추시자기공명영상과이차관절경검사상반월상연골이식물의변화를관찰하였다. 이식반월상연골의변연부아탈구 (subluxation) 는경골고평부의변연경계면에서연골의바깥쪽경계면 (outer Fig. 3. Preoperative sizing of meniscal allografts. (A) The true AP radiograph was used to measure meniscus width. Width is measured by obstaining the distance from the most medial or lateral aspect of the tibia at the level of the plateau to its respective intercondylar eminence peak. (B) The true lateral radiograph was used to measure meniscus length. Length is measured by obstaining the AP distance from the anterior-most insertion of the lateral or medial meniscus to the posterior most insertion. (C) This figure shows magnification marker that consists of two ball bearings embedded 10 cm apart in plastic.

38 edge of the meniscus) 까지의거리로정의하였고 7), 3 mm 이상아탈구된경우를변연탈구 (extrusion) 로정의하였다 4). 측정방법은 Verdonk 등 31) 이제시한방법을이용하였다 (Fig. 4). 첫이식술후재활치료는첫 4주는목발착용한상태에서 20% 의체중부하만허용하고, CPM ( 지속성수동적운 Table 1.

4 38 edge of the meniscus) 까지의거리로정의하였고 7), 3 mm 이상아탈구된경우를변연탈구 (extrusion) 로정의하였다 4). 측정방법은 Verdonk 등 31) 이제시한방법을이용하였다 (Fig. 4). 첫이식술후재활치료는첫 4주는목발착용한상태에서 20% 의체중부하만허용하고, CPM ( 지속성수동적운 Table 1. Preoperative Meniscal Size Transverse (mm) AP (mm) Ant. Mid. Post. 동 ) 을하였다. 4 6 주가지나면앉아서하는일을할수있게하고보조기를제거하였다. 8주이후에는자전거타기, 대퇴사두근강화운동을추가했으며, 3개월후부터는환자가목발이나보행기없이걸을수있도록단계적으로허용하였다. 임상적평가와기능적평가는 Lysholm score, Knee society knee score (KSS) system, The hospital for special surgery (HSS) knee score를이용하였고 1,10,30), 술후평균 28개월에 25예중 22예는이차관절경검사와자기공명영상촬영을모두시행하였고, 3예는이차관절경검사만시행하였다. Male Female Lat. Med. Lat. Med 결 1. 이학적및기능적평가 과 Table 2. Postoperative Meniscal Size (average 28.0 months) Male Female Lat. Med. Lat. Med. AP (mm) Transverse (mm) Ant. Mid. Post 술후 1예에서관절내삼출과관절면의압통소견이보였고, 전방십자인대손상, 후방십자인대손상이있는 10예에서십자인대재건술을시행하였고전례에서슬관절의불안정성이소실되었다. Lysholm score 평가지수는술전 65.4 점에서술후 80.6 점, KSS system 에서는슬관절점수가 64.6 점에서 82.6 점, 기능적점수가 70.2 점에서 85.6 점, HSS knee score 에서는 66.4 점에서 82.5 점으로향상되었다 (Table 3). 기능적평가의향상은 paired t-test 상에서통계학적유의성을보였다 (p=0.000). Fig. 4. Meniscus extrusion in the MRI study was assessed on coronal sections by drawing a line perpendicular to a horizontal line connecting both distal surfaces of the femoral condyles, and touching the outer edge of the articular cartilage of the femoral condyle, the tibial plateau and meniscal outer edge. Extrusion was defined as the distance from the femoral condyle or tibial plateau to the outer edge of the meniscus (described by Verdonk et al.). We was assessed the distance from the tibial plateau to meniscal outer edge (A: schematic, B: MRI).

5 전재균외 : 동종반월상연골이식후이차관절경소견및 MRI 를이용한임상적결과 방사선적소견전례에서슬관절직립전후방사진과 45도슬관절굴곡후전방사진및단순측방사진을촬영하였고, 술후평균 5.3 개월후에자기공명영상을촬영하였다. 반월상연골의크기는술전과술후를비교하였을때남자에서내측반월상연골의전후방길이는수술전평균 41.5 mm에서수술후평균 40.1 mm로 1.4 mm, 전각부는수술전평균 6.6 mm에서수술후평균 6.2 mm로 0.4 mm, 후각부는수술전평균 13.7 mm에서수술후평균 13.1 mm로 0.6 mm 감소된결과를보였고, 외측반월상연골의전후방길이는수술전평균 33.2 mm 에서수술후평균 31.2 mm로 2.0 mm, 전각부는수술전평균 6.2 mm 에서수술 후평균 5.8 mm로 0.4 mm, 후각부는수술전평균 12.8 mm에서수술후평균 11.8 mm로 1.0 mm 감소된결과를보였고, 여자에서는내측반월상연골의전후방길이는수술전평균 37.2 mm 에서수술후평균 36.7 mm 로 0.5 mm, 전각부는수술전평균 5.5 mm에서수술후평균 5.1 mm로 0.4 mm, 후각부는수술전평균 12.6 mm에서수술후평균 11.5 mm로 1.1 mm로감소하였고, 외측반월상연골의전후방길이는수술전평균 30.5 mm 에서수술후평균 29.6 mm 로 0.9 mm, 전각부는수술전평균 5.2 mm에서수술후평균 4.9 mm로 0.3 mm, 후각부는수술전평균 12.1 mm 에서수술후평균 10.5 mm 로 1.6 mm 감소된결과를보였다 (Table 2). 7예에서관절간격의협소화가있었다. Table 3. Preoperative Meniscal Size No. Age/Sex Injury knee Cause Combined injury Interval Lysholm score to surgery (Preop./Postop) (yrs) KSS score (Preop./Postop) Total Functional HSS score (Preop./ Postop) 1 37/M Lt. MM* Work OA /87 62/84 55/70 68/ /M Rt. MM Unknown PCL rupture /81 65/85 75/85 72/ /F Lt. LM Sports injury ACL rupture /78 60/85 80/90 62/ /M Rt. MM Sports injury ACL, OA 25 57/81 52/75 45/80 55/ /M Rt. LM Work OCD (LFC**) /56 45/60 40/75 47/ /F Lt. MM Sports injury ACL rupture /88 77/90 80/90 75/ /M Rt. LM Sports injury None 14 73/89 75/92 75/85 70/ /M Lt. MM Sports injury ACL rupture 12 69/80 72/80 80/90 68/ /M Rt. LM Sports injury ACL, OCD (LFC) 1 55/81 53/75 45/80 58/ /M Rt. LM DM None /84 75/87 85/90 75/ /M Lt. MM Sports injury ACL rupture 11 68/81 65/80 80/85 65/ /F Lt. MM DM None /89 81/90 85/95 82/ /F Rt. MM Fall down PCL, OCD (LFC) /82 55/79 60/80 59/ /M Rt. MM Sports injury None 12 81/90 85/95 90/90 85/ /M Rt. MM Sports injury PCL rupture /83 62/85 70/90 68/ /F Lt. LM Work OCD (LFC) /78 62/80 80/90 66/ /M Rt. MM DM None 5 77/88 70/85 80/90 75/ /M Lt. MM DM None /84 72/85 90/95 72/ /M Lt. MM Sports injury None /82 66/83 72/86 68/ /M Lt LM Sports injury None 1 55/81 58/85 62/85 68/ /M Lt LM Work OA /81 72/90 74/90 70/ /M Rt MM Sports injury ACL rupture 3 46/80 43/80 45/85 50/ /F Lt LM DM OCD (LFC) /65 57/75 65/80 52/ /F Rt LM DM None /70 57/75 70/80 55/ /F Rt LM DM None /78 69/85 72/85 75/84 Avr / / / /82.5 *MM: medial meniscus, OA: osteo arthritis, PCL: posterior cruciate ligament, LM: lateral meniscus, ACL: anterior cruciate ligament, OCD: osteochondral defect, **LFC: lateral femoral condyle, DM: discoid meniscus

intensity in peripheral regions on posterior horn (arrow).

5), 최종자기공명영상에서 5예에서이식된반월상연골의봉합사로관절막에부착된중간부위에서는이식한반월상연골측면부의아탈구소견이보였으나, 이식골에부착된전각부,

관상면상이식된연골이변연부에서잘고정되어있었고, 비해부학적위치에서의골교고정 (bone bridge fixation) 소견은관찰되지않았다 (Fig.

1예를제외한 24예 (96%) 에서관절막에봉합된연골부의완전치유소견과양호한혈관분포소견을보였고 (Fig. 7), 18예 (72%) 에서위축소견없었다.

6 40 3. 자기공명영상촬영및관절경소견 Fig. 5. Follow up MRI after meniscal transplantation: It demonstrate increased signal intensity in peripheral regions on posterior horn (arrow). 자기공명영상촬영상 9예에서이식반월상연골변연부, 전, 후각모두에서신호강도의증가소견이보였고 (Fig. 5), 최종자기공명영상에서 5예에서이식된반월상연골의봉합사로관절막에부착된중간부위에서는이식한반월상연골측면부의아탈구소견이보였으나, 이식골에부착된전각부, 후각부에서는관찰되지않았다. 관상면상이식된연골이변연부에서잘고정되어있었고, 비해부학적위치에서의골교고정 (bone bridge fixation) 소견은관찰되지않았다 (Fig. 6). 술후 2차관절경검사는평균 28개월에 25예에서시행하였다. 1예를제외한 24예 (96%) 에서관절막에봉합된연골부의완전치유소견과양호한혈관분포소견을보였고 (Fig. 7), 18예 (72%) 에서위축소견없었다. 7예 (28%) 에서외측반월상연골이식부의후각부에서이식된반월상연골의위축소견이관찰되었고, 모두자기공 Fig. 6. Preoperative and Postoperative MRI: coronal MRI image shows normal meniscal position. (A) Before meniscal transplantation MRI: MM total meniscectomy & ACL reconstruction state. (B) After meniscal transplantation MRI: using Bone-plug method.

7 전재균외 : 동종반월상연골이식후이차관절경소견및 MRI 를이용한임상적결과 41 Fig. 7. Second look arthroscopic finding at 7 months after meniscal transplantation: it shows complete healing with firm attachment around the entire circumference of the meniscal rim and no shirinking meniscal size. 명영상촬영상증가된신호강도소견을보였던예이다. 봉합사파열로고정되지않은 1예에서재봉합을시행하였다. 동종이식반월상연골의파열이나퇴행성변화는관찰되지않았다. 고 슬관절내반월상연골은간엽조직 (mesenchyme) 에서분화하여섬유성콜라겐그물망과 proteoglycan gel로구성된섬유연골세포로형성된다 3,17,22,33). 그러나아전절제술및전절제술후반월상연골의재생은활액막세포에서분화되는섬유조직으로이루어져기능수행에장애를일으킨다 28). 따라서, 현재반월상연골의손상에대한치료는봉합술, 부분절제술등의연골을보전할수있는술기가보편화되어있다. 하지만반월상연골을보전하기힘든경우반월상연골의동종이식술은대안이될수있다. 반월상연골동종이식술의성공을위해서는적당한크기의이식물을정확한해부학적위치에고정하는것이중요하다. Chen 등 2) 은 pressure-sensitive film을이용하여하중분산 (load distribution) 실험에서안정적인반월상연골이식의골부착또는전, 후각을단단히고정한경우는정상관절과같은접촉면적과최대접촉압력을가지며, 반월상연골의전, 후각중한곳만고정한경우는정상반월 찰 상연골과반월상연골전절제술의중간결과를보이고, 고정하지않은경우는반월상연골전절제술과같은결과를보인다고보고하였다. 따라서연부조직고정방법이나, 골조각고정방법은반월상연골고유의 hoop tension 을유지할수없어하중분산의정상기능을하지못하는것으로보고하였다. 반월상연골의이식술은변연부를봉합하는연부조직고정방법 (soft tissue fixation), 전후각에원통모양의골조각을붙여경골구멍에고정하는골편고정법 (bone plug fixation), 그리고전후각을골교 (bone bridge) 로연결하여경골의도랑에고정하는골교고정법 (bone bridge fixation), 반월상연골과경골의부착부위를포함하여좁은경골편을경골홈에끼워고정하는열쇠구멍수기 (key hole method) 등의방법이있다 8,20,27,29). 저자들은내측반월상연골이식전례에서골편고정법 (bone plug fixation) 을사용하여경골극과전방십자인대기시부의손상을방지하였으며, 또한전방십자인대재건술을시행한 7예에서는관절내에서부터경골하부방향으로경골터널을위한유도기를이용하여관절선에서 10 mm 홈을만들어전방십자인대재건을위한홈과의간섭을방지하고, 불필요한긴홈으로인한골소실을최소화하였다. 외측반월상연골이식전례에서열쇠구멍수기 (key hole method) 를이용하여술기를단순화시켰다. 반월상연골의보존방법역시다양하여신선 (fresh), 신선 -냉동 (fresh-frozen), 심냉동 (deep-frozen), 냉동건조 (freezedried) 및초냉동 (cryo-preserved) 등이있다 8). 저자들은전례에서신선 -냉동연골을사용하였는데이는기술적으로간단하며, 저비용의장점이있으나, 냉동으로이식연골의크기가변화할수있으며보존시탈수와해빙과정에서조직파괴가될수있다는단점이있다 27). 저자들이관절경으로추시관찰한 25예중 7예에서이식된반월상연골의위축소견이관찰되었다. 이식된반월상연골의위축은내측보다는외측반월상연골에서, 전각부보다는후각부의위축이두드러졌으며, 그이유는내측및외측반월상연골의해부학적형태의차이와반월상연골의후각부파열시 All- inside 봉합기술이나봉합기구를사용하여봉합을시행하고, 전방및측방부위봉합을한후후각부를봉합할때연골이전방및측방부위로전위가되고이를보상하기위해서불가피하게더긴장된봉합이이루어져외측후각부에서위축이심한것으로생각된다. 따라서, 후각부를먼저봉합함으로써후각부의긴장된봉

8 42 합을최소화하고, 측정된이식연골보다는약간큰이식물을선택함으로써봉합으로인한긴장을최소화하려고노력하였다. 일부연구에서는반월상연골이식술후약 30 40% 의반월상연골아탈구를보고하고있으며본연구에서는 5 예 (20%) 에서추시자기공명영상에서이식된반월상연골측면부의아탈구소견이관찰되었다. 이는저자들이강한봉합 (tension suture) 을피하고술전단순방사선사진상의주형 (template) 크기보다약간큰이식물을삽입함으로써나타난결과라고생각된다. 이식된동종반월상연골의술후의자기공명영상의신호강도는술후초기에는정상측과구별할수없는저신호강도였다가시간이지남에따라반월상연골의변연부에서신호강도가증가하여술후 6주에고강도의신호강도를보이며시간이경과함에따라다시신호강도가감소한다 13,21). 저자들은술후평균 28개월에자기공명영상을추시한결과 9예에서증가된신호강도가관찰되었다. 신호강도의증가는신생혈관의증식 (neovascularization), 연골점액성변성 (chondromucoid degeneration) 등에의한것으로판단된다 32). 총 25예중 1예에서관찰된후각부봉합사의파열은술후환자의조기과활동으로사료되며재봉합후증상은소실되었지만, 조기과운동및회전운동을삼가고최소 6 주이상보호를함으로써좋은결과를얻을수있을것으로생각된다. 술전시행한슬관절직립전후방사진과 45도슬관절굴곡후전방사진에서대퇴경골간관절간격이 16예에서는정상 7예에서는관절간격의협소화가있었다. 추시상이식된반월상연골의크기및관절간격의변화를측정하였으며최종추시상술전관절간격이정상인군에서보다술전관절간격의협소화를보인 7예에서더욱심한연골위축소견을보였다. 그러나대상환자수가적고추시기간이짧아더욱적극적인연구가필요할것으로생각된다. 결론반월상연골이식술은연골손상후나타나는퇴행성변화를최소화하고젊고활동적인환자에게유용한시술이나이식연골의위축, 변연부아탈구, 관절간격의협소 화, 봉합사의파열등을관찰할수있었다. 이식후임상적문제를가진환자의경우단순방사선상의관절간격협소화및추적 MRI 상의신호강도변화등을주의깊게관찰하고, 이후이차관절경술을통해정확한평가가이루어져야한다고생각된다. REFERENCES 1. Binazzi R, Soundry M, Mestriner LA, Insall JN: Knee arthroplasty rating. J Arthroplasty, 7: , Chen MI, Branch TP, Hutton WC: Is it important to secure the horns during lateral meniscal transplantation? A cadeveric study. Arthroscopy, 12: , Clark CR, Ogden JA: Development of the menisci of the human knee joint. Mophological changes and their potential role in childhood meniscal injury. J Bone Joint Surg Am, 65: , Costa Cr, Morrison WB, Carrino JA: Medial meniscus extrusion on knee MRI: is extent associated with severity of degeneration or type of tear? AJR Am J Roentgenol, 183: 17-23, Fairbank TJ: Knee joint changes after meniscectomy. J Bone Joint Surg Am, 30: , Fukubayashi T, Kurosawa H: The contact area and pressure distribution pattern of the knee. A study of normal and osteoarthritis knee joints. Acta Orthop Scand, 51: , Gale DR, Chaisson CE, Totterman SM, Schwartz RK, Gale ME, Felson D: Meniscal subluxation: association with osteoarthritis and joint space narrowing. Osteoarthritis Cartilage, 7: , Goble EM, Kane SM: Meniscal allograft transplantation. In: James CY chow ed. Advanced arthroscopy. 1st ed. New York, Springer Inc: , Henning CE, Lynch MA: Current concepts of meniscal function and pathology. Clin Sports Med, 4: , Insall JN, Dorr LD, Scott RD, Scott WN: Rationale of the knee society clinical rating system. Clin Orthop Relat Res, 248: 13-14, Johnson RJ, Kettlekamp DB, Clark W, Leaverton P: Factors affecting late results after meniscectomy. J Bone Joint Surg Am, 56: , 1974.

9 전재균외 : 동종반월상연골이식후이차관절경소견및 MRI 를이용한임상적결과 Jørgensen U, Sonne-Holm S, Lauridsen F, Rosenklint A: Long term follow-up of menisectomy in athletes. A prospective longitudinal study. J Bone Joint Surg Br, 69: 80-83, Kuhn JE, Wojtys EM: Allograft meniscus transplantation. Clin Sports Med, 15: , Kurosawa H, Fukubayashi T, Nakajima H: Load-bearing mode of the knee joint: physical behavior of the knee joint with or without the menisci. Clin Orthop Relat Res, 149: , Levy IM, Torzilli PA, Warren RF: The effect of medial meniscectomy on anteior-posterior motion of the knee. J Bone Joint Surg Am, 64: , Lysholm J, Hamberg P, Gilquist J: The correlation between osteoarthrosis as seen on radiographs and on arthroscopy. Arthroscopy, 3: , McDevitt CA, Wabber RJ: The ultrastructure and biochemistry of meniscal cartilage. Clin Orthop Relat Res, 252: 8-18, Mikic ZD, Brankov MZ, Tubic MV, Lazetic AB: Allograft meniscus transplantation in the dog. Acta Orthop Scand, 64: , Milachowski KA, Weismerir K, Wirth CJ: Homologous meniscus transplantation. Experimental and clinical results. Int Orthop, 13: 1-11, Min BH, Kim HS, Jang DW, Kang SY: Technical note of meniscal allograft transplantation using minimal incision. J Korean Arthroscopy Soc, 3: 54-61, Patten RM, Rolfe BA: MRI of meniscal allografts. J Comput Assisttomogr, 19: , Peters TJ, Smillie IS: Studies on the chemical composition of the menisci of the knee joint with special reference to the horizontal cleavage lesion. Clin Orthop Relat Res, 86: , Rangger C, Klestil T, Gloetzer W, Kennleer G, Benedetto KP: Osteoarthritis after arthroscopic partial meniscectomy. Am J Sports Med, 23: , Rath E, Richmond JC, Yassir W, Albright JD, Gundogan F: Meniscal allograft transplantation. Two-to eight-year results. Am J Sports Med, 29: , Rodeo SA: Meniscal allografts-where do we stand? Am J Sports Med, 29: , Shaffer B, Kennedy S, Klimkiewicz J, Yao L: Preoperative sizing of meniscal allografts in meniscus transplantation. Am J Sports Med, 28: , Shelton WR, Dukes AD: Meniscus replacement with bone anchors: a surgical technique. Arthroscopy, 10: , Smillie IS: Observation on the regeneration of the semilunar cartilage in man. Br J Surg, 31: , Stone KR, Rosenberg T: Surgical technique of meniscal replacement. Arthroscopy, 9: , Tegner Y, Lysholm J: Rating system in the evaluation of knee ligament injuries. Clin Orthop Relat Res, 198: 43-49, Verdonk P, Depaepe Y, Desmyter S, et al: Normal and transplanted lateral knee menisci: evaluation of extrusion using magnetic resonance imaging and ultrasound. Knee Surg Sports Traumatol Arthrosc, 12: , Verstraete KL, Verdonk R, Verstraete P, De Rooy J, Kunnen M: Current status and imaging of allogarft meniscal transplantation. Eur J Radiol, 26: 16-22, Yasui K: Three dimensional architecture of normal human menisci. JJph OrthopAssoc, 52: , 1978.

10 44 = 국문초록 = 목적 : 동종반월상연골이식술후이차관절경소견및자기공명영상을통해이식물의변화를관찰하고그임상적결과를보고하고자하였다. 대상및방법 : 1997 년 7 월부터 2007 년 2 월까지동종반월상연골이식술을시행받은환자에서이차관절경검사와자기공명영상추시가가능하였던 25 예를대상으로하였다. 이중남자는 16 명, 여자는 8 명이었다. 3 예는자기공명영상추시없이이차관절경검사만시행하였다. 평균연령은 36.1 세, 평균추시기간은 28.0 개월 (6.0 개월 7.0 년 ) 이었다. 이차관절경검사시 2 예에서는조직검사를시행하였다. 환자의기능적평가는 Lysholm score, Knee society score (KSS) system, The hospital for special surgery (HSS) knee score 를이용하였다. 결과 : 이차관절경검사상 25 예중 23 예에서이식물이변연부와완전한치유소견을보였다. 25 예중 5 예에서후각부의크기가감소되어있었다. 자기공명영상에서는전예에서이차관절경검사와일치된소견을보였다. Lysholm score 는술전평균 65.4 점에서술후평균 80.6 점, Knee society score (KSS) system 에서는슬관절점수가평균 64.6 점에서평균 82.6 점, 기능적점수가평균 70.2 점에서평균 85.6 점, The hospital for special surgery (HSS) knee score 에서는평균 66.4 점에서평균 82.5 점으로향상되었다. 모든기능테스트에서수술후에기능이향상되었고, 이는 paired t-test 로평가되었다 (p=0.000). 결론 : 동종반월상연골이식술은이식된연골이주변조직과함께완전히치유되었고임상적으로도호전되어반월상연골결손환자의치료에유용한방법이라고생각되고, 임상적으로문제가있는환자의평가에있어서는 MRI 검사후관절경술을통한확인이필요하다고생각된다. 색인단어 : 관절경검사, 자기공명영상, 동종반월상연골이식

( ) Jkra076.hwp

( ) Jkra076.hwp Vol. 11, No. 4, December, 2004 Objective: Ultrasonography (USG) of joints has a unique position for the diagnosis of joint diseases. Bone surface, cartilage, periarticular soft tissue and their pathologic