대한정형외과학회지 : 제 40 권제 4 호 2005 J Korean Orthop Assoc 2005; 40: 슬관절전치환술에서자동항법장치와고식적인수술법에따른삽입물의방사선계측치에대한비교분석 배대경ㆍ윤경호ㆍ송상준 * ㆍ김선구ㆍ임양진ㆍ김만호 경희대학교의과대학정

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1 대한정형외과학회지 : 제 40 권제 4 호 2005 J Korean Orthop Assoc 2005; 40: 슬관절전치환술에서자동항법장치와고식적인수술법에따른삽입물의방사선계측치에대한비교분석 배대경ㆍ윤경호ㆍ송상준 * ㆍ김선구ㆍ임양진ㆍ김만호 경희대학교의과대학정형외과학교실, 포천중문의과대학교의과대학정형외과학교실 * 목적 : 자동항법장치를이용한슬관절전치환술과고식적슬관절전치환술에서삽입물의위치를방사선학적으로측정하여그결과를비교분석하고자하였다. 대상및방법 : 자동항법장치를사용하여슬관절전치환술을시행하였던 40예와고식적슬관절전치환술을시행하였던환자중연령, 성별, 진단명, 좌우, 사용한기구, 후방십자인대보존여부등을조화시킨 40예를대조군으로하여수술후방사선사진상대퇴골인공삽입물의내외반각 ( 각 ), 경골인공삽입물의내외반각 ( 각 ), 대퇴골인공삽입물의굴곡각 ( 각 ), 경골인공삽입물의경사각 ( 각 ) 을측정하고전방절흔 (anterior notch) 유무를관찰하였다. 결과 : 각, 각, 각, 대퇴골전방절흔은양군간에통계적으로유의한차이를보이지않았으나 (p>0.05), 각은자동항법장치를이용한슬관절전치환술군에서평균 0.28±1.96 이었고고식적인슬관절전치환술군에서평균 2.39±2.73 (p<0.0001) 로통계적으로유의한차이를보였다. 결론 : 자동항법장치를이용한슬관절전치환술과고식적슬관절전치환술에서의대퇴골삽입물내외반각, 경골삽입물의내외반각과후경사각, 대퇴골전방절흔의유무는통계적으로유의한차이가없었으나대퇴골삽입물굴곡각은통계적으로유의한차이가있었다. 자동항법장치를이용한슬관절전치환술시대퇴골인공삽입물을시상면상보다정확히위치시킬수있었다. 색인단어 : 슬관절, 전치환술, 자동항법장치, 방사선학적측정 Comparative Analysis of Radiologic Measurement According to TKR using Computer Assisted Surgery and Conventional TKR Dae Kyung Bae, M.D., Kyoung Ho Yoon, M.D., Sang Jun Song, M.D.*, Seon Goo Kim, M.D., Yang Jin Im, M.D., and Man Ho Kim, M.D. Department of Orthopaedic Surgery, School of Medicine, Kyung Hee University, Seoul; Department of Orthopaedic Surgery*, School of Medicine, Pochon CHA University, Seoul, Korea Purpose: To compare radiologic measurements of femoral and tibial component position in the total knee replacement (TKR) using computer-assisted surgery (CAS) with those of conventional TKR. Materials and Methods: Two groups of 40 TKRs each were operated on using a CT-free navigation system or the conventional technique. Patients in both groups were matched according to age, gender, diagnosis, prosthesis and PCL retaining or substitution. We measured femoral component frontal ( angle) and sagittal angle ( angle), tibial component frontal ( angle) and sagittal angle ( angle). We also studied whether femoral notch was present or not. Results: There were no significant differences in angle, angle, angle and femoral notch between CAS and conventional TKR (p>0.05). The mean angle in the group of TKRs using CAS was 0.28±1.96, and in the group of conventional TKRs was 2.39±2.73 (p<0.0001). This difference was statistically significance. 통신저자 : 배대경서울시동대문구회기동 1 경희대학교의과대학정형외과학교실 TEL: FAX: bdkyung@khmc.or.kr * 본논문의요지는 2004년도대한슬관절학회춘계학술대회에서발표되었음. Address reprint requests to Dae Kyung Bae, M.D. Department of Orthopedic Surgery, School of Medicine, Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul , Korea Tel: , Fax: bdkyung@khmc.or.kr 398

슬관절전치환술에서자동항법장치와고식적인수술법에따른삽입물의방사선계측치에대한비교분석 399 Conclusion: Our study has shown that there were no significant differences in alpha, beta, delta angle and incidence of femoral notching between CAS

2 슬관절전치환술에서자동항법장치와고식적인수술법에따른삽입물의방사선계측치에대한비교분석 399 Conclusion: Our study has shown that there were no significant differences in alpha, beta, delta angle and incidence of femoral notching between CAS TKR and conventional TKR. Gamma angle was different statistically between CAS TKR and conventional TKR. The CAS afforded to precisely place femoral component in sagittal plan than conventional method. Key Words: Knee, Arthroplasty, Computer-assisted surgery, Radiologic measurement 슬관절전치환술시적절한환자선별및삽입물선택, 올바른수술술기, 효율적인수술및전후관리등이성공의요인이된다. 삽입물의부적절한위치나부정정렬은삽입물의마모와해리를가속시켜불만족스러운기능적결과를가져온다고알려져있다 7,8,14). 인공삽입물의발전과함께정렬지시자도개량되어왔지만인공삽입물위치와하지정렬의오류는여전히보고되며, 숙련된술자에의해시행된슬관절전치환술의 10% 이상에서인공삽입물이 3 이상부정확한위치로삽입될수있다고추정된다 13). 정렬지시자의이러한한계때문에자동항법장치 (navigation system) 와로봇을이용한수술장치 (robot assisted system) 가개발되었다. 자동항법장치를이용한슬관절전치환술은골수강내정렬지시자를사용하지않으므로지방색전의가능성과실혈량을줄이며, 합병증없이좋은결과가보고되고있다 2-4,10,11). 이에저자들은자동항법장치를이용한슬관절전치환술과고식적슬관절전치환술에서삽입물의위치를방사선학적으로계측하여그결과를비교분석하고자한다. 예였다. 진단명은 A군, B군각각퇴행성골관절염 37 예, 류마토이드관절염이 3예였다. 인공삽입물은 A군, B군모두 16예에서 NexGen (Zimmer, Warsaw, Indiana), 24예에서 PFC sigma (Johnson & Johnson, Warsaw, Indiana) 를사용하였고, 후방십자인대보존형이 34예, 후방십자인대대치형이 6예였다. A군, B군모두한술자에의해시행되었고 A군은자동항법장치 (Vector Vision, BrainLAB, Heimstetten, Germany) 를이용하여대퇴골절골면의전후면상과시상면상정렬및회전, 경골절골면의전후면상과시상면상정렬및회전, 하지전장의전후면상과시상면상의정렬과내, 외측연부조직의균형등을평가할수있었다. 2. 연구방법슬관절전치환술후슬관절전후방방사선사진상대퇴골인공삽입물의내외반각 ( 각 ) 과경골인공삽입물의내외반각 ( 각 ) 을측정하였으며, 측면방사선사진상대 대상및방법 1. 연구대상 2003년 12월부터 2004년 2월까지자동항법장치를이용하여슬관절전치환술을시행하였던 40예와최근고식적슬관절전치환술을시행한환자중연령, 성별, 진단명, 좌우, 사용한기구, 후방십자인대보존여부등을조화 (matching) 시킨 40예를대조군으로하여비교분석하였다. 자동항법장치를이용한슬관절전치환술은재치환술환자나전신상태가불량하여수술시간이길어질경우수술후이환율이높을것으로사료되는경우를제외하고연속적으로시행하였다. 자동항법장치를이용하여슬관절전치환술을시행하였던경우는 A군, 대조군은 B군으로분류하였다. A군연령은평균 64.2세 (44-80세) 였고 B군연령은평균 64.1세 (36-78세) 였으며, 성비는 A군, B군각각남자 2예, 여자 38예였다. A군, B군각각우측슬관절이 21예, 좌측슬관절이 19 Fig. 1. Post-operative measurement of femoral component, angle and tibial component, angle in X-ray of coronal and sagittal view of knee. : The inclination angle of the femoral component is formed with the anatomical axis of the femur. : The inclination angle of the tibial component is formed with the mechanical axis of the tibia. : The angle of the femoral component is formed between the anatomical axis of the femur and perpendicular line to prosthesis. : The angle of the tibial component is formed with the mechanical axis of the tibia.

3 400 배대경ㆍ윤경호ㆍ송상준외 3 인 퇴골인공삽입물의굴곡각 ( 각 ) 과경골인공삽입물의경사도 ( 각 ) 를측정하였다 (Fig. 1). 대퇴골전방피질, 절골면과대퇴골인공삽입물의상대적위치를관찰하여 2 mm 이상의전방절흔유무를관찰하였다 (Fig. 2). 측정은양군에대한차이를모르는두명의정형외과의사가영상저장전송시스템 (PACS) 을이용하여각각 2 회씩측정한각의평균을구한후, 두측정치의평균을비교분석하였으며, 두관찰자간의상관관계를구하였다. A군과 B군에서대퇴골인공삽입물의내외반각, 굴곡각과경골인공삽입물의내외반각, 경사각의비교분석은 Student T-Test 를이용하였으며. A군과 B군에서대퇴골삽입물굴곡각이 -2 와2 사이인경우와대 Fig. 2. Anterior notch of femoral component. 퇴골전방절흔경우를 Pearson 의 chi-square test를이용하여비교분석하였다. 두관측자간의측정치는상관분석을하여관련성을평가하였다. SPSS version 11.0을이용하여통계처리하였으며유의성의판정은유의수준이 0.05 미만으로하였다. 결과두관측자의평균각은 A군에서 95.63±1.53, B군에서 95.18±1.65 이었고 (p=0.205), 각은 A군에서 90.11±1.36, B군에서 90.24±1.51 이었으며 (p=0.669), 각은 A군에서 0.28±1.96, B군에서 2.39±2.73 이었고 (p<0.0001), 각은 A군에서 85.62±1.71, B군에서 85.68±2.45 이었다 (p=0.898) (Table 1). 두관측자간의측정치는강한양적상관관계를보였고통계적으로유의하였다 (p<0.0001) (Table 2). 각, 각, 각은양군간에통계적으로의미있는차이를보이지않았으나각은 A군보다 B군에서굴곡되어삽입되었으며, -2 와2 사이인경우는 A군에서 60% (24/40예), B군에서 30% (12/40예) 이었다 (p=0.007) (Table 3). 2 mm 이상의대퇴골전방절흔은 A군에서 5% (2예 ) B 군에서 7.5% (3예) 이었다 (p=0.649). 고찰슬관절전치환술시정확한인공삽입물의위치와하지의정렬은삽입물의마모와이완등의측면에서매우중 Table 1. Results of radiographic assessment of total knee arthroplasty (degree) Group A* *, Total knee arthroplasty using CAS;, Conventional total knee arthroplasty. Group B Observer 1 Observer 2 Mean Observer 1 Observer 2 Mean angle 95.55± ± ± ± ± ±1.65 angle 90.30± ± ± ± ± ±1.51 angle 0.41± ± ± ± ± ±2.73 angle 85.35± ± ± ± ± ±2.45 Table 2. Differences between the observer 1 and observer 2 indicated by the Pearson correlation (correlation coefficient) Variable Group A* Group B angle angle angle angle p< *, Total knee arthroplasty using CAS;, Conventional total knee arthroplasty. Table 3. Number of cases of total knee arthroplasty according to angle angle Group A* Group B -2 < < , Total *, Total knee arthroplasty using CAS;, Conventional total knee arthroplasty.

4 슬관절전치환술에서자동항법장치와고식적인수술법에따른삽입물의방사선계측치에대한비교분석 401 요하므로, 인공삽입물을보다정확히위치시키기위하여최근에자동항법장치가개발되어사용되고있다 1,4,6). 자동항법장치를이용한슬관절전치환술시각단계는 1 미만의오차범위로유지할수있고, 전체정렬의오차범위를줄이고수술의정밀도를향상시킬수있다고알려져있다 5,11). 슬관절전치환술후하지정렬의범위는아직논쟁의여지가많으나, 3 이상의내반또는외반시삽입물이보다조기에실패될가능성이크고, 임상적결과가나쁘다고보고되고있다 8,14). Stulberg 12) 는고식적인골수강내정렬지시자를이용하여슬관절전치환술을시행한후인공삽입물과하지정렬의정확도를자동항법장치를이용하여평가하였는데, 대퇴골삽입물은내반, 굴곡, 내회전위치되는경향이있고, 경골인공삽입물은약간내반되어삽입되는경향이있다고보고하였다. 또한모든예에서 3 이상의하지의부정정렬을보인경우는없으나, 각인공삽입물의전후면과시상면, 회전면상모두에서 3 이내의정렬을보인경우는 20예중 4예뿐이었다고보고하였다. 그러나, 자동항법장치를이용한슬관절전치환술시, 각단계는 1 미만의오차범위로유지할수있고, 전체정렬의오차를줄여수술의정밀도를향상시킬수있다고보고하고있다 5,11). Hart 등 3) 은자동항법장치와고식적인방법을이용한슬관절전치환술의방사선학적결과를비교하여경골인공삽입물의경사각을제외한방사선학적측정치간의유의한차이는없었다고보고하였으나, 자동항법장치를이용한슬관절전치환술에서 2 이상의오차를보인경우는적었다고보고하였다. 국내에서선과송 9) 은자동항법장치와고식적인방법을이용한슬관절전치환술의방사선학적결과를비교하여대퇴골삽입물과해부학적축및기계적축이이루는각과경골삽입물경사각이자동항법장치를이용한군에서 3 이상오차를보이는경우가적었다고보고하였다. 저자들의경우자동항법장치를이용한군과고식적인슬관절전치환술군간의대퇴골인공삽입물의내외반각과경골인공삽입물의내외반각, 경사각에서는유의한차이를보이지않았으나, 대퇴골인공삽입물의굴곡각은자동항법장치를이용한군에서정확하게위치되었고, 2 이상의오차를보인경우도적었다. Sparmann 등 11) 은자동항법장치를이용한슬관절 전치환술의문제점으로자동항법장치는수학적연산에의해계산되기때문에자동항법지침자 (navigation tool) 를정확하게장착하는것이중요하나실제로불가능하여수술시작은오차가큰실수를야기할수있어술자가수술시에이를잘인지할수있어야한다고강조하였고, 또한자동항법지침자의장착을위하여보다큰절개가요구되어감염및상처치유지연등의가능성을제기하였다. 저자들의경우자동항법장치를이용하여슬관절전치환술을시행하는초기단계에지침막대 (pointer) 를이용한해부학적표지 (landmark) 를등록하는과정에서오류가발생한것을 2예에서인지하여술자의경험적판단에의해교정하였다. 또한수술후감염이나상처치유지연등의문제는발생하지않았다. 자동항법장치를이용한슬관절전치환술이모든경우에서인공삽입물과하지정렬을향상시키는지여부와자동항법장치를이용한정확도의향상이임상적결과를향상시키는지는아직알려져있지않으므로보다장기적인추시관찰과분석이필요하다. 결론자동항법장치이용한슬관절전치환술과고식적슬관절전치환술에서의대퇴골삽입물내외반각, 경골삽입물의내외반각과후경사각, 대퇴골전방절흔의유무는차이가없었으나대퇴골삽입물굴곡각은유의한차이가있었다. 자동항법장치를이용한슬관절전치환술시대퇴골인공삽입물을골수강을파괴하지않고시상면상보다정확히위치시킬수있었다. 참고문헌 1. Bach CM, Steingruber IE, Peer S, Nogler M, Wimmer C and Ogon M: Radiographic assessment in total knee arthroplasty. Clin Orthop, 385: , Glozman D, Shoham M and Fischer A: A surface-matching technique for robot-assisted registration. Comput Aided Surg, 6: , Hart R, Janecek M, Chaker A and Bucek P: Total knee arthroplasty implanted with and without kinematic navigation. Int Orthop, 27: , La Palombara PF, Fadda M, Martelli S and Marcacci M: Minimally invasive 3D data registration in computer and robot

5 402 배대경ㆍ윤경호ㆍ송상준외 3 인 assisted total knee arthroplasty. Med Biol Eng Comput, 35: , Mielke RK, Clemens U, Jens JH and Kershally S: Navigation in knee endoprosthesis implantation--preliminary experiences and prospective comparative study with conventional implantation technique. Z Orthop Ihre Grenzgeb, 139: , Nishihara S, Sugano N, Ikai M, et al: Accuracy evaluation of a shape-based registration method for a computer navigation system for total knee arthroplasty. J Knee Surg, 16: , Piazza SJ, Delp SL, Stulberg SD and Stern SH: Posterior tilting of the tibial component decreases femoral rollback in posterior-substituting knee replacement: a computer simulation study. J Orthop Res, 16: , Ritter MA, Faris PM, Keating EM and Meding JB: Postoperative alignment of total knee replacement. Its effect on survival. Clin Orthop, 299: , Seon JK and Song EK: The accuracy of lower extremity alignment in a total knee arthroplasty using computer-assisted navigation system. J Korean Orthop Assoc, 39: , Sparmann M and Wolke B: Value of navigation and robot-guided surgery in total knee arthroplasty. Orthopadics, 32: , Sparmann M, Wolke B, Czupalla H, Banzer D and Zink A: Positioning of total knee arthroplasty with and without navigation support. A prospective, randomised study. J Bone Joint Surg, 85-B: , Stulberg DS: How accurate is current TKR instrumentation? Clin Orthop, 416: , Stulberg SD, Loan P and Sarin V: Computer-assisted navigation in total knee replacement: results of an initial experience in thirty-five patients. J Bone Joint Surg, 84-A (Suppl 2): 90-98, Wasielewski RC, Galante JO, Leighty RM, Natarajan RN and Rosenberg AG: Wear patterns on retrieved polyethylene tibial inserts and their relationship to technical considerations during total knee arthroplasty. Clin Orthop, 299: 31-43, 1994.

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untitled 대한정형외과학회지 : 제 43 권제 6 호 2008 J Korean Orthop Assoc 2008; 43: 760-765 전자기장네비게이션과고식적방법을이용한슬관절전치환술의방사선학적결과와비교 원예연ㆍ최문권ㆍ이두형ㆍ박태호ㆍ허준혁ㆍ신동선 아주대학교의과대학정형외과학교실 Comparison of the Radiologic Results of Total Knee Arthroplasty