04-07-이기행

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1 Review Articles Soft Tissue Disease around the Hip Kee-Haeng Lee, MD Department of Orthopedic Surgery, Holy Family Hospital, The Catholic University of Korea, Bucheon, Korea Hip pain is a common but nonspecific symptom that has many etiologies. Due to the complex anatomy of the hip and pelvis, locating the exact origin of pain may be difficult. Soft tissue diseases around the hip are relatively rare and their clinical symptoms are often nonspecific. For such patients, it is necessary to understand various hip diseases, and do proper history taking and examination to correctly diagnose and treat soft tissue diseases of the hip. Advances in imaging studies such as MRI and ultrasonography can provide accurate information on soft tissues. This article reviews the soft tissue diseases of the hip that are experienced by clinics. It may be helpful in the differential diagnosis of hip pain arising from soft tissue structures and in the treatment of such diseases. Key Words: Hip, Soft tissue disease 서 고관절부위의이상으로비교적흔하게증상이발생되며, 고관절동통의형태역시다양하다. 이때고관절및골반의복잡한해부학적구조로인해정확한동통의원인을찾는것이어려울수있으며감별해야할질환도매우다양하다. 고관절동통은고관절자체의질환또는근골격계를침범하는전신질환의일부로인하여나타날수있으며그외고관절주위로의방사통으로인하여, 또는고관절주위의연부조직이상으로인하여나타나는등매우다양한원인이있다. 이중고관절주위의연부조직이상으로인해발생되는동통의경우, 그빈도가상대적으로드물고임상증상이특이하지않은경우가많다. 정확한진단과치료를위해서는다양한고관절의특성을이해하고이에알맞은진찰이나검사등이필요하다. 감별진단을위한영상의학적방법으로는단순방사선, 초음파 (ultrasonography), 전산화단층촬영 (CT), 자기공명영상 (MRI) 등이있다. 론 Submitted: April 22, st revision: May 21, nd revision: May 29, 2009 Final acceptance: May 29, 2009 Address reprint request to Kee-Haeng Lee, MD Department of Orthopaedic Surgery, Holy Family Hospital, The Catholic University of Korea, 2, Sosa-dong, Wonmi-gu, Bucheon, Kyounggi-do , Korea TEL: FAX: holyoslkh@yahoo.co.kr 여기서는고관절동통을유발할수있는대표적인연부조직질환의진찰방법및동통의특징, 진단그리고치료에대하여여러문헌들을고찰하고기술하고자한다. 발음성고관절 (Snapping hip) 발음성고관절은 snapping hip 또는 coxa saltans 라고하며주로고관절을굴곡, 내전, 내회전할때구축된장경대가대퇴전자부의상부경계위를미끄러지면서청진, 시진, 촉진할수있는탄발 (snapping) 을유발한다. 발음성고관절을일으키는원인은크게관절외부의원인 (extra-articular type) 과관절내부의원인 (intraarticular type) 의두가지로나눌수있으며, 관절외부의원인은다시 external type ( 또는 lateral type) 과 internal type ( 또는 medial type) 으로나눌수있다 15,56). 특징적으로수의적으로동통없이간헐적으로생길수도있고, 불수의적으로동통을동반하고만성적으로발생하기도한다. Zoltan 64) 등은동통이전자부점액낭염의진행과관계있다고믿었으며특정동작에서대퇴전자부에걸친무디고, 쑤시는동통이예리하고 (sharp) 강한 (intense) 동통으로진행한다고기술하였다. Larsen 34) 등은장경대이완술을시행하는과정에서전자부점액낭을따라장경대의섬유화와퇴행성변화가일부에서발견되었다고보고하였으나항상그런것은아니며, Binnie 6) 등은고관절의탄발음과전자부점액낭에생긴염증은서로관계가없다고보고하였다. 일부저자들은장경대, 대전자후방, 대둔근의 116

2 Kee-Haeng Lee: Soft Tissue Disease around the Hip 전방경계에압통이있다고보고하였다 6,64). 역동적초음파 (dynamic sonography) 를이용하여대부분의환자에서관절외부의원인 (extra-articular type) 을감별할수있다 11,46). Pessler 46) 등은 24 명 26 예의발음 성고관절증에대하여역동적초음파를시행한결과 23 명 24 예에서특징적으로구조적전위가발생하는구조를발견하였다고보고하였으며, 탄발을유발시키면서초음파검사를시행하게되면건의회전운동또는직선운동을관 A B Fig year-old female with greater than 10-year history of hip pain with catching and a snap, especially with rotation, with a dynamically confirmed snapping hip. (A) Frame captures from a sonographic cine clip just prior to snapping shows the iliopsoas tendon (arrow) in a vertical orientation but beginning to rotate. (B) In the frame immediately after the snap, the iliopsoas tendon (arrow) is now rotated into a horizontal position and opposed to the acetabular rim 18). A B Fig. 2. (A) Forty-three year old man without snapping hip. T2-weighted axial MR image reveals normal iliotibial band (short arrow) and gluteus maximus muscle. (B) Forty-four year old man with snapping hip. Thickened iliotibial band and anterior border of the gluteus maximus insertion (white black arrow) is noted in the space between the greater trochanter iliotibial band 36). 117

3 찰할수있다 (Fig. 1). 자기공명영상에서는 T2 강조영상에서일반적으로비대한장경대와대둔근건은염증과체액저류로인해고신호강도로나타나며 (Fig. 2), 초음파역시인대의비대와점액낭의크기를재는데유용하며자세변화에따른장경대의위치파악도가능하다. 관절의탄발이나발음 (popping) 을듣거나느끼는경우는흔하나수술이필요할정도의동통이나장애가있는경우는드물다. 대부분의환자에게병의원인을인지시키고탄발을유발하는동작을피하는것으로증상이개선된다. 그러나일부소수의환자에서지속적인동통, 기능제한, 장거리보행시증상의악화와보존적치료에실패를보이는경우수술적치료의적응증이될수있다. external type 의경우장경대의두꺼워진후방경계나대둔근의전방경계가대퇴전자부위를미끄러지면서발생하게되는데 2,14) 일반적으로통증이없기때문에수술이필요한경우는드물고, 통증이있는경우에도물리치료, 국소주사요법, 활동수정 (activity modification) 등으로조절하며경과도양호하다. 보존적치료방법으로는활동제한, 온열, 비스테로이드성약물과물리치료가있다. 스테로이드의주입이보존적치료의한요소가될수있으며보통 1 회이상의주입이필요하다. Gordon 24) 등은 51 명의환자를추적한결과 49 명에서스테로이드와마취제를같이주입한경우에는평균 1.5 회, 마취제만주입한경우에는 1.8 회의주입으로양호이상의결과를얻었다. 대부분의외부형고관절탄발음 은 6 개월에서 12 개월의보존적인치료로호전된다. 장경대를수술한첫보고는장경대가대전자에부착된곳을이완해준것이다. 수술적치료가필요한경우국소마취하에긴장된장경대를찾아길이를연장시키거나두꺼워진장경대후방부를전방으로이동시키는방법등이이용된다. Orlandi 44) 등은 20 명의환자군에서대전자에장경대의재접합을시도하여 16 명에서완전한통증해소를얻었으나 2 명에서는고관절내회전시통증이있었으며 2 명에서는재발하였다고보고하였다. 여러저자들은또단순절개와재접합외에도연장술및복원술을시도하였다. Sarkis 50) 등은 4 명의환자모두에서대전자위를주행하는장경대를앞쪽으로옮겨주어탄발음및동통의소실과함께효과적인길이연장효과를얻었다고하였으며, Larsen 34) 등은평균 2 년동안관절강주위탄발음을가진 31 명의환자를대상으로 27 명에서는대둔근의부착부위에서장경인대의후방 1/2 의절제술을시행하였으며, 4 명에서는장경대의후방피판을근막의전외측면에봉합해주었으며, 이들 31 명중 8 명에서는전자부점액낭의절제술을병행하였다. 수술소견에서 31 명중 30 명에서는장경대의비정상적인비후가발견되었으며, 4 년추시상에서 22 명 (71%) 에서완전한증상소실, 6 명 (19%) 에서통증없는탄발음, 3 명 (10%) 에서통증을동반한탄발음의결과를얻었다. 통증이남아있는 3 명중 2 명은재수술하여좋은결과를얻었다. Brignall 9) 등은외부형탄발음성고관절이있는 8 명에 A B Fig. 3. (A) With flexion of the hip. the iliopsoas tendon shifts laterally in relation to the center of the femoral head. (B) With extension of the hip. the iliopsoas tendon shifts medially in relation to the center of the femoral head 2). 118

4 Kee-Haeng Lee: Soft Tissue Disease around the Hip 서장경대의 Z-성형술을시행하여보고하였는데, 모든환자들은탄발음의감소를보였고수술후평균 3년안에동통이없어졌다고하였다. 이중 2명의환자 3례에서운동시때때로대전자위의통증이있었다하였으며수술후 4 개월뒤한명의환자가재수술을받았고그후 6년동안동통을느끼지않았다고하였다. 국내보고로 Kyung 33) 등은 5명 7예에서 Z-성형술을시행하여수술하여 1예에서운동시약간의동통을호소하였으나, 모든환자에서탄발음이소실되어만족할만한결과를얻었다고보고하였고 Lee 37) 등은 4명 6예에서 Z-성형술을시행하여모든환자에서탄발음이소실되어만족할만한결과를얻었다고보고하였다. internal type의경우장요근건이나장요근밑에있는점액낭에의해발생되며, 고관절굴곡시장요근건이대퇴골두의외측으로이동했다가고관절신전하면건이내측으로미끄러지면서탄발이유발된다 12) (Fig. 3). 진단에는단순방사선과초음파를이용하거나 46), 관절내부의이상을감별하기위해자기공명영상이유용하며 39), 비후된장요근점액낭의확인에는 iliopsoas bursography도도움이된다. Bernard 5) 등은증상이있는 internal type의 54명의환자에서단순방사선과초음파를이용한경우 83% 에서진단할수있었으며추가로 MRI를시행한경우 100% 에서진단할수있다고보고하였다. 따라서초기진단방법으로는단순방사선과초음파를이용하고추가로자기공명영상을시행할것을추천하였다. 치료는장요근건의계단식연장술 (step cut lengthening) 이나수술적이완술을시행할수있다. Jacobson과 Allen 27) 은증상이있는 18명 20예에서장요근건의연장술을시행하여 14예에서재발없이치료되었다고보고하였으며, Taylor와 Clarke 60) 는통증이있는 16예에서수술적이완술을시행하여 10예에서통증및탄발음소실을얻었으며, 5예에서는통증이소실되었다고보고하였으며, 합병증으로는대퇴부로가는신경에손상을주어대퇴전외측부의감각소실을유발할수있다고하였다. 관절내부의원인 (Intra-articular type) 의경우골연골종증, 관절내유리체, 비구순파열, 고관절아탈구, 골절골편등이유발원인이다. 진단은주로자기공명관절조영술 (MR arthrography) 을이용한다. Toomayan 61) 등은비구순파열진단에서통상적인자기공명영상을시행하였을경우민감도가 25% 인것에비해자기공명관절조영술 (MR arthrography) 을시행하였을경우에는민감도가 92% 라고보고하였으며, Schmid 52) 등은고관절연골결손에서자기공명관절조영술을시행하여진단하였을경우민감도는 79%, 특이도는 77% 라고보고하였다. 치료는관혈적또는관절경을이용하여유발인자를제거하거나복원해주는방법이있다 62). 고관절주위건염및점액낭염 (Tendinitis & Bursitis) 1. 대전자동통증후근 (Greater trochanteric pain syndrome) 대전자동통증후근 (GTPS) 은가장흔한 regional pain syndrome 중하나로측와위에서대퇴전자부위로촉진시압통을호소하는질환을의미한다 40). 외전근건의이상이소위 GTPS 의흔한원인이며중년또는노년의여성에서호발한다 32). GTPS 의유병률에대한자료는적으나, 만성하부요통을호소하는환자의 20~35% 가신체검사를통해 GTPS 를진단받는다. Kingzett-Taylor 32) 등은하부요통이있는 250 명의환자를대상으로시행한자기공명영상소견중 35 명에서중둔근건과소둔근건의건염및건파열을발견하였고이중 8 명은완전파열, 14 명은부분파열을보였다고보고하였다. GTPS 는주로중둔근건과소둔근건을침범하며이들근육들이주요기능중하나인고관절의내회전을담당하기때문에 고관절회전근개 (hip rotator cuff) 라고하며, 건염, 부분또는완전파열, 견열등을나타낸다 32). 견관절의회전근개와비교하여고관절의회전근개의구성은내회전을하는견갑하근은장요근으로소전자에부착하며, 두개의외전근인극상근과극하근은대전자부에부착하는중둔근과소둔근, 상완이두건장두는대퇴골두를가로지르는대퇴직근으로고관절의회전근개가구성된다. 고관절회전근개파열의가장많은유형은중둔근앞쪽건의부분파열이있는경우와중둔근의파열과소둔근의부분파열이동반된경우이다 38). Bunker 10) 등은대퇴경부골절이있는 50 명의환자중 11 명에게중둔근과소둔근의만성파열이있는것에대하여보고하였다. GTPS 는 전자점액낭염 (trochanteric bursitis) 으로불려지기도하는데일반점액낭염과의차이점은염증에의한통증이아니며원인역시근막동통과연관되어발생하게된다 38). 고관절의생역학적불균형으로인하여중둔근및소둔근의반복적인미세외상이건, 근육, 연부조직의퇴행성변화를가져오는것으로생각되고있다. 따라서고관절의퇴행성관절염, 척추병변, 하지길이부동등이병을유발할수있다. Segal 53) 등은여성, 장경대압통, 슬관절퇴행성관절염, 하부요통이있는경우 GTPS 의발병과연관이있다고보고하였다. 임상증상으로는고관절의측부로만성적, 간헐적인통증을보이며, 경우에따라서는급성으로예리하고강한통증을호소하기도한다. 신체검사가진단에매우중요하며, 수동적고관절운동은모두정상이나능동적으로고관절을 90 도굴곡하고외회전시대퇴전자부측면에통증을호소하며저항을준상태에외전시 50~70% 환자에서통증을나 119

5 타낸다. 또한신체검사에서중둔근보행 (Trendelenburg gait) 양성소견을보이기도한다. Bird 7) 등은 24명의환자를대상으로 11명에대하여자기공명영상을시행한결과 3/4에서중둔근보행양성소견을보였다고하였다. 초음파를이용하여 GTPS를진단할수있는데중둔근건과소둔근건의대퇴전자부부착부위가표재성 (superficial position) 으로위치하기때문에초음파가유용하며부분또는완전파열이있는경우 90% 의민감도와 95% 의특이도를보인다 16). 자기공명영상에서는파열된건주위로고신호강도 (high signal intensity) 및액체신호 (fluid signal), 얇아지거나두꺼워진건을확인할수있다 (Fig. 4) 6). Bunker 10) 등은전형적인원형또는타원형의중둔근및소둔근건파열이주로대전자부상부 1 cm 이내에서발견된다고보고하였으며, Cvitanic 17) 등은자기공명영상이 GTPS를진단하는데 91% 높은정확성을가진다고보고하였다. 핵의학검사상대퇴전자부의흡착 (uptake) 이증가된소견을볼수있다. 치료는대개보존적치료에잘반응하나증상이지속되거나재발한경우수술적복원술또는재접합술이필요한경우가있다 10). Gordon 24) 등은 51명의환자에서국소마취제주사 (local anesthetic injection) 와글루코코티코이드주사 (glucocorticoid injection) 를시행한결과 49명의환자에서양호 (good) 또는우수 (excellent) 한결과를보였으며, Swezey 58) 등은트리암시놀론 (triamcinolone) 40 mg을투 여한결과 60% 의환자에서증상의호전을보였다고보고하였다. 최근연구에서는 70~100% 의환자에서부신피질호르몬 (corticosteroid) 를주사한결과증상의호전을보이며이중 25% 는 10개월이내에증상의재발을보인다고하였다 51). Mohammad 40) 등은 12~40 mg 베타메타손 (betamethasone) 또는 40~80 mg 메칠프레드니솔론 (methylprednisolone) 을 4~6 ml 1% 리도카인 (lidocaine) 과혼합주사하여 60% 의환자에서증상의호전을보였으며, 스테로이드의용량이많을수록증상호전의정도가더높았다고보고하였다. 수술적치료가필요한경우로는, 첫째만성또는반복적인증상재발하거나, 둘째방사선학적검사에서건파열이확인된경우, 셋째주입검사에서양성인경우, 넷째중둔근의퇴축이나지방변성이없는경우시행하게된다. 주입검사는초음파유도하에 procain을주사하여시행하게되며통증이소실되거나증상이현저히개선되는경우양성으로판단하게된다. 통증이재발할경우수술적치료의적응이된며, 보통재접합술이선호된다. 괴사또는변성된부분을제거한후남아있는 tendon stump를비흡수성봉합사를이용하여뼈에재접합하게된다. 접근을위해절개를가한장경대는봉합하지않고열어놓는다. 대부분작은병변이라도건과인접해있는점액낭의경우파열되어있기때문에관절경을이용하거나관혈적으로점액낭제거술을동시에시행한다. Lequesne 38) 등은 7명의환자에대해서재접합술을시행한결과 6예에서증상의완전소실을보였고나머지 1예에서는증상의호전을보였다고보고하였다. 그외에도여러저자들이보고한결과예후는양호하였다. 2. 점액낭염 (Bursitis) Fig. 4. On the fat-suppressed T2-weighted turbo spin echo image the gluteus medius tendon demonstrates extensive thickening with increased signal (white arrowheads). In addition, bursitis of the medial subgluteal bursa is visible (black arrowhead) 5). 고관절주위점액낭염의경우해부학적구조및위치에따라둔부하점액낭염 (subgluteal bursitis), 전자점액낭염 (trochanteric bursitis), 좌둔점액낭염 (ischiogluteal bursitis), 장치점액낭염 (iliopectineal bursitis) 으로나눌수있다 47) (Fig. 5). 둔부하점액낭은해부학적으로대둔근과대퇴전자부및단외회전근 (short external rotator muscle) 사이에위치한다. 발생원인에따라크게감염성및비감염성점액낭염으로나눠지며, 감염성타입의경우화농성고관절염과감별을요하며주로고관절의후방과심부조직에동통이있고전신적인감염징후 (infection sign) 가있으면의심해볼수있다. 관절천자를시행하거나초음파를이용하여위치를확인하고직후외측절개 (straight posterolateral incision) 를이용하여배액을시행하여치료한다. O Conner 43) 등은일반적인점액낭의치료에있어서 PRICEMM (protection, rest, ice, compression, elevation, medication, modalities) 란 120

6 Kee-Haeng Lee: Soft Tissue Disease around the Hip 치료지침을보고하여좋은결과를보고하였는데, 이와같이비감염성타입의경우항염증약물, 물리치료, 국소주사등을이용하여치료한다. 전자점액낭은대둔건부착부위와외측광근사이에위 Fig. 5. Schematic diagram of bursae around greater trochanter 40). 치한다. 원인으로는주로급성화농성감염에의한경우가흔하며드물게결핵 28), 류마티스관절염 59) 에의한경우도있다. 점액낭을압박하는외전및외회전자세에서통증이악화되며자기공명영상에서액체가찬점액낭 (fluid filled bursa), 중격및벽조영증강 (septations and wall enhancement) 소견을관찰할수있다. 감염성타입일경우항생제치료와함께점액낭절제및외과적배액을시행한다. Gerber 23) 등에의하면점액낭과관절낭사이의밸브기전에의하여관절액교환을역동적으로조절한다고하였으며, 잦은재발을보이는경우이러한일방향밸브 (check valve) 기전의제거를위한낭종절제술과관절낭봉합술을고려해야한다고하였다. 좌둔점액낭은좌골조면과대둔근사이에위치한다. 소위 Weaver s bottom 이라고하여지속적인자극 (irritation) 에의해유발되며오랫동안앉아서일하는직업 ( 미싱공, 재단사 ) 에서주로발생한다. 방사선학적검사에서는단순방사선촬영은대부분음성이며전산화단층촬영 (CT), 자기공명영상 (MRI) 을이용할수있으나 Zeiss 63) 등은자세한이학적검사로추간판탈출증이나직장의질환을감별하여이러한고가의검사는필요가없다고도하였다. 초음파검사도점액낭염검사로유용하게사용되기도하지만골및주위의연부조직과의관계는명확히알수없는단점이있으며전산화단층촬영은골조직과의관계는명확히알수있으나종물의성격을알수없는단점이있다. 자기공명영상소견상 T1 강조영상에서는저신호강도와 T2 강조영상에서는고신호강도를보이는내부의균일한포함물이관찰되며신체검사상좌골조면의바로아래종물이만져지면서통증및압통을호소할경우대둔근좌골점액낭염을의심해야한다. 고관절 A B Fig year-old female with lung tranplant with hip pain. (A) Coronal T2 fat-suppressed images show a large left iliopsoas bursal collection (arrow) (B) Static sonographic images prior to injection of the bursa show the hypoechoic bursal collection with area of debris medial to the iliopsoas tendon and lateral to the femoral vessels (arrow) 18). 121

7 굴곡시동통이증가되고보행시동통감소를위해보폭이짧아진다. 감별진단해야할질환으로는수핵탈출증이나혈관정맥염등이있다. 대부분보존적치료로증상이호전되며급성화농성감염시에는외과적배액술을시행한다. 피부절개시 Boutin 8) 등은횡절개로접근하여야좌골신경, 후대퇴피신경 (posterior femoral cutaneous nerve), 회음신경 (perineal nerve) 등을안전하게보호할수있다고하였다. 장치점액낭은고관절주변에서가장큰점액낭으로고관절낭전방에위치하고, 장요근의후방을따라골반까지퍼져있으며, 9~15% 는고관절과통해있다 56). 증상으로는고관절전방부통증및장골서혜부종양, 고관절굴곡자세및신전제한, 스카르파삼각 (scarpa triangle) 주위에압통이있다. 주로고관절염증으로인하여이차적으로발생한다. 전산화단층촬영, 자기공명영상, 초음파를이용해진단하게되며관절천자를시행하여확진하게된다 (Fig. 6). 치료는경피적도관배액술이나외과적배액술을시행하게된다. 3. 고관절주위석회화건염 (Calcific tendinitis around hip joint) 고관절주위석회화건염의경우서혜부통증이나하지방사통같은비전형적인증상이나드문발생빈도로인해정확한진단이어려울수있다 29). 조직학적으로관절주위조직및건의석회인산염 (calcific phosphate) 이특징적이며, 임상증상은갑작스럽게발생하여서서히소실되는 통증을보인다. 급성기에는국소염증반응및미열을나타내며만성통증과압통또는증상이없는경우도있다. 외전건에발생할경우요추간판탈출증과유사한대퇴우회측통증을유발한다. 40~70 세사이에주로발생하며대퇴골의대둔결절의대둔건부착부위에가장호발한다. 그외에도및대퇴직근 (rectus femoris), 외측광근 (vastus lateralis), 이상근 (piriformis), 장요근 (iliopsoas), 대내전근 (adductor magnus), 대퇴이두근 (biceps femoris), 중둔근 (gluteus medius), 소둔근건 (gluteus minimus tendon) 에도발생될수있다. 원인은정확하지는않으나유전적요인및당뇨, 갑상선질환, 결핵등과연관이있다. 발생기전은근부착부위의반복적운동, 만성적과부하, 국소허혈에의한연골변성, 석회침착등이제시되었으며석회침착물의분해가심한통증을유발한다고알려져있다 22). 감별해야할질환으로는비구부골, 견열골절, 대퇴직근의종자골, 화골성근염, 악성종양 ( 피질골에인접한골막연골종, 연골육종, 활막육종 ) 등이있다. 단순방사선검사상전후면또는 frog-leg lateral view 를시행하여비정형성형태의석회결절을확인할수있으며건주위피질골의미란또는천공성병소도나타날수있다. 전산화단층촬영을시행하여악성종양과감별할수있으며 25), 자기공명영상을시행하여염증의정도를확인하며이것은통증의정도와비례하게된다 30). 단순방사선검사상석회화건염은비정형성형태의석회화병변으로나타난다. 전산화단층촬영이석회화병변의발생위치를찾는데민감도가높으며, 자기공명영상검사를 A B Fig year-old man with calcific tendinitis of the left rectus femoralis. (A) Radiography of the pelvis shows small calcifications adjacent to the acetabulum, suggesting calcifications in the orgin rectus femoris tendon. (B) Sonographic image of the left rectus femoris tendon shows thickening of the tendon and tiny calcific spots without shadowing 35). 122

8 Kee-Haeng Lee: Soft Tissue Disease around the Hip 통해서관절및연부조직의변화를확인할수있다. 최근에는초음파를이용한석회화건염진단및치료에대하여보고되고있는데, 특히초음파는건의정확한상태에대해검사할수있는장점이있으며, 초음파소견상건의비후, 후방음향음영을동반하거나또는동반하지않은난원형의고에코음영, 색도플러검사상혈류증가를보인다 (Fig. 7). Chiou 15) 등은 color 또는 doppler 초음파를견관절의석회화건염환자에서시행한결과임상증상이심할수록혈류가더증가하는소견을보여서로연관성이있다고보고하였다. 치료는비스테로이드소염제, 진통제를투약하거나전산화단층촬영유도 57) 또는초음파유도 55) 하에부신피질호르몬과국소마취제의혼합주사를시행하여통증의빠른소실을얻을수있다. Sarkar 30) 등은전산화단층촬영유도하에메칠프레드니솔론 (methylprednisolone) 80 mg 과 0.5% bupivacaine 2 ml 를조합하여국소주사하여대퇴직근의 reflected head 에서발생했던석회화건염 6 예중 5 예에서추가적인시술없이즉각적인증상의소실을얻었고, 모든예에서방사선추시상 4 개월내에석회화병변이완전히소실되었다는보고하였으며, 국내에서는 Ahn 1) 등은고관절주위대퇴직근석회화건염환자들에서는골절침대에환자를앙와위로눕히고방사선투시기유도하에석회화병변의실질부에도달하여흡입후 methylprednisolone 80 mg 과 0.5% bupivacaine 2 ml 혼합물을주입하여빠른증상의소실을보고하였다. 반면 Faure19) 등은미세결정에의한염증치료를목적으로부 신피질호르몬을투여할수있는데감염의위험성에주의해야한다고하였으며, 건내의주사는국소괴사를유발할수있다고하였다. 그외에도급성석회화건염에서다발성탐침술 (multiple needling) 의효과가보고되고있다. 치료로관혈적또는관절경을이용하여수술적제거술을시행하기도한다. Kandermir 31) 등은내시경을이용하여고관절주위만성석회화건염을효과적으로치료하였다고보고하였다. 주로보존적치료에오랫동안반응이없거나주사요법이실패한경우, needle phobia 가있는경우, 악성종양과감별이필요한경우수술적제거술을시행하게된다. 이상근증후근 (Piriformis syndrome) 이상근증후군은드문질환이며둔부의압통, 동통, 하지의감각이상및방사통으로인해요추의추간판탈출증으로종종오인되어잘못된치료를할수가있으며그치료방법도추간판탈출증과다르기때문에좌골신경통을유발하는타질환과의감별이필수적이다. 이상근증후군은대좌골절흔 (greater sciatic notch) 부위의좌골신경근위부에서의포착증후군으로설명할수있다 년 Robinson 48) 은처음으로이상근증후군이라고명명하였으며, 특징적인임상양상을보고하였다. 첫째, 둔부나천장관절부위외상력, 둘째, 보행시악화되는천장관절, 대좌골절흔, 이상근주위의동통및하지로의방사통, 셋째, 물건을들거나허리를굽힐때악화되는증상, 넷 A B Fig. 8. Magnetic resonance image demonstrates the slightly hypertrophied right piriformis muscle (arrow) of the right hip. (A) axial image, (B) coronal image 37). 123

9 째, 증세가악화될때촉지되는심한압통이발생하는이상근주위의종물, 다섯째, 하지직거상검사상양성소견, 여섯째이환기간에따른둔부의위축소견이다. 이상근은천추의골반면, 대좌골절흔의상연, 천결절인대 (sacrotuberous ligament) 의골반면에서기시하여대좌골절흔을통과하여원형의근건형태로대전자의상연에부착하고제 5 요추신경, 제 1 천추신경, 제 2 천추신경의지배를받는다. 일반적으로좌골신경은이상근전방으로상하로주행하지만 10~21% 에서해부학적기형이있는것으로보고되고있다 26). 이상근은골반내에서기시하여대좌골절흔을통과하기때문에근육과좌골신경이근접하고접촉이되면좌골신경통 (sciatic pain) 이발생할수있으며, 이를이상근증후군이라부른다. 이상근증후군의원인으로는둔부외상에의해속발된이상근과근막의염증및부종으로인한좌골신경의압박, 이상근의유발점증후군, 이상근의기형으로인한좌골신경의압박등으로생각할수있다. 이상근증후군을진단하는데에는많은어려움이있으며, 좌골신경통의발생으로인해추간판탈출증으로종종오인되기때문에추간판탈출증에대한치료를받거나다른치료를받으며여러병원을방문하는경우가대부분이다. 이상근증후군을확진하기위해서는임상적소견및자기공명영상검사, 근전도등여러가지검사를종합적으로고려하여판단하여야한다. 이상근증후군의진찰소견으로는둔부의대좌골절흔부분의압통, 고관절외전및내회전시에증가하는동통, 하지직거상검사상제한된소견등이관찰된다. Freiberg 씨징후및고관절을굴곡한상태에서외전하려고하는것을방해할때근력약화와동통, 기능의감소가나타나는 Pace 씨징후등의소견을보이며환자를앙와위로눕혔을때이환된부위의외회전으로인해비대칭적인모습을보이는이상근 (Piriformis) 징후 21) 를관찰할수있다. 컴퓨터단층촬영및자기공명영상검사상이상근의비대 45,49) 를보이거나 (Fig. 8) 비골신경을자극하여그에따르는마미활동전위 (Cauda equina action potential) 의변화를관찰 41) 하여이상근증후근을의심할수있으나확실하게진단할수있는방법은없으며, 상기에서술한질환들과감별하면서임상적및방사선학적소견을종합하여진단을하는것이필수적이다 42). 이상근증후군은대부분의경우에있어서물리치료, 비스테로이드성항염증제의투여, 경직장마사지 (transrectal massage) 등의보존적치료로치료가되나 3), 보존적치료에효과가없는경우마취약제나스테로이드제제의국소주사를시행할수도있다. 최근에는초음파유도하에국소주사를시행하거나, Botulinum toxin 의이상근내근육주사가동통감소의효과가있다고보고하는저자들도있다 12,20). 수술적요법으로는이상근의유리술또는절제술, 섬유대및혈관의제거, 신경해리술 (neurolysis) 등이있 으며예후는양호한것으로보고되고있다. 근절제술의경우 60~80%, 유착박리술의경우 70~100% 까지성공율이보고되고있다 4). 결 고관절동통은그형태와원인들이매우다양하며, 그중연부조직질환으로인한고관절동통은그빈도가드물고임상증상이특이하지않아정확한진단과치료를위해서는고관절주위연부조직들의특성을이해하고이에알맞은진찰이나검사등이필요하다. 앞에서고찰해본연부조직질환들에대한적절한진찰및검사를바탕으로정확한진단방법을이해하고, 이를바탕으로올바른치료를시행함으로써연부조직질환으로인한고관절동통에대하여바르게대처해야할것이다. 론 REFERENCES 01. Ahn GY, Jang JH, Yun HH. Calcific Tendinitis of the Rectus Femoris Around the Hip Joint. J Korean Hip Soc 18: 73-78, Allen WC, Cope R. Coxa saltans. The snapping hip revisited. J Am Acad Orthop Surg, 3: , Barton PM. Piriformis syndrome: A rational approach to management. Pain, 47: , Benson ER, Schutzer SF. Posttraumatic piriformis syndrome: Diagnosis and results of operative treatment. J Bone Joint Surg, 81-A: , Bernard M, Christian WAP, Juerg H. Hip pain in adults: MR imaging appearance of common causes. Eur Radiol 17: , Binnie JF. Snapping hip (Hanche a resort; Schnellend Hefte). Ann Surg, 75-A: , Bird PA, Oakley SP, Shnier R, Kirkham BW. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis Rheum, 44: , Boutin FJ Sr, Boutin RD, Boutin FJ Jr. Operative orthopaedics, Philadelphia, J.B.Lippincott Co: , Brignall CG, Stainsby GD. The snapping hip. J Bone Joint Surg, 73-B: , Bunker TD, Esler CN, Leach WJ. Rotator-cuff tear of the hip. J Bone Joint Surg, 79-B: , Cardinal E, Kenneth B, Capello W, Duval N. US of the snapping iliopsoas tendon. Radiology, 198: , Childers MK, Wilson DJ, Gnatz SM, Conway RR, Sherman AK. Botulinum toxin type A use in piriformis muscle syndrome : a pilot study. Am J Phys Med Rehabil, 81: , Choi JC, Kim YH, Na HY, et al. Treatment of Calcific 124

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11 Kee-Haeng Lee: Soft Tissue Disease around the Hip Tendinitis around Hip Joint. J Korean Hip Soc, 17: 83-87, Choi YS, Lee SM, Song BY, et al. Dynamic sonography of external snapping hip syndrome. J Ultrasound Med, 21: , Chiou HJ, Chou YH, Wu JJ, Hsu CC, Huang DY, Chang CY. Evaluation of calcific tendonitis of the rotator cuff: role of color Doppler ultrasonography. J Ultrasound Med, 21: , Connell DA, Bass C, Sykes CA, Young D, Edwards E. Sonographic evaluation of gluteus medius and minius tendinopathy. Eur Radiol, 13: , Cvitanic O, Henzie G, Skezas N, Lyons J, Minter J. MRI diagnosis of tear of the hip abductor tendons.(gluteus medius and gluteus minimus) AJR Am J Roentgenol, 182: , Donna G. Blankenbaker, Michael J. Tuite. The painful hip.: new concepts Skeletal Radiol, 35: , Faure G, Daculsi G. Calcified tendinitis: a review. Ann Rheum Dis, 42(suppl): 49-53, Fishman LM, Anderson C, Rosner B. BOTOX and Physical therapy in the treatment of piriformis syndrome. Am J Phys Med Rehabil, 81: , Foster MR. Piriformis syndrome. Orthopedics, 25: , Gartner J, Simons B. Analysis of calcific deposits in calcifying tendonitis. Clin Orthop Relat Res, 254: , Gerber NJ, Dixon AS. Synovial cyst and juxtaarticular bone cysts. Semin Arthritis Rheum, 3: , Gordon EJ. Trochanteric bursitis and tendinitis. Clin Orthop Relat Res, 20: , Harris JH Jr, Coupe KJ, Lee JS, Trotscher T. Acetabular fractures revisited: Part 2, a new CT-based classification. AJR Am J Roentgenol, 182: , Indrekvam K, Sudmann E. Piriformis muscle syndrome in 19 patients treated by tenotomy-α1 to 16-years follow-up study. Int Orthop, 26: , Jacobson T, Allen WC. Surgical correction of the snapping iliopsoas tendon. Am J Sports Med 18: 470-4, Jaovisidha S, Chen C, Ryu KN, Siriwongpairat P, Pekanan P, Sartoris DJ, et al. Tuberculous tenosynovitis and bursitis?: imaging findings in 21 cases. Radiology, 201: , Johnson GS, Guly HR. Acute calcific periarthritis outside the shoulder: A frequently misdiagnosed condistion. J Accid Emerg Med, 11: , Sarkar JS, Haddad FS, Crean SV, Brooks P. Acute calcific tendinitis of the Rectus Femoris. J Bone Joint Surg, 78-B: , Kandemir U, Bharam S, Philippon MJ, Fu FH. Endoscopic treatment of calcific tendinitis of gluteus medius and minimus arthroscopy, 19: E4, Kingzett-Taylor A, Tirman PF, Feller J, McGann W, Prieto V, Wischer T, et al. Tendinosis and tear of gluteus medius and minimus muscles as a cause of hip pain.: MR imaging finding. AJR Am J Roentgenol, 173: , Kyung HS, Kim SY, Jung HS, Kim YG. Treatment of snapping hip caused by a tight iliotibial tract. J Korean Orthop Soc Sports Med, 2: , Larsen E, Gebuhr P. Snapping hip after total hip replacement. J Bone Joint Surg, 70-A: , Lee HS, Lee YH, Sung NK, et al. Sonographic findings of calcific tendinitis around the hip. J Korean Soc Ultrasound Med, 24: , Lee KH, Kim YS, Sung MS, et al. External snapping hip treated by z-plasty of the iliotibial band. J Korean Hip Soc, 17: 52-57, Lee SU, Kim KT, Cho YJ, Ryu KN, Chun YS. Sciatic pain caused by piriformis syndrome. J Korean Orthop Assoc, 40: , Lesquesne M. From periarthritis to hip rotator cuff tears. Trochanteric tendinobursitis. Joint Bone Spine, 73: , Miller TT. Abnormalities in and around the hip: MR imaging versus sonography. Magn Reson Imaging Clin N Am, 13: , Mohammad IS, Eric LM. Trochanteric Bursitis.(Greater trochanter pain syndrome) Mayo clic Proc, 71: , Nakamura H, Seki M, Konishi S, Yamano Y, Takaoka K. Piriformis syndrome diagnosed by cauda equine action potentials: report of two cases. Spine, 28: E37-40, Nicola AD, Brian DB. Assessment and differential diagnosis of the painful hip. Clinical Orthopedics and Related Research, 406: 11-18, O Connor FG, Sobel JR, Nirschl RP. Five-step treatment for overuse injuries. Physician Sports Med, 20: , , , Orlandi S, Ossola A, Pellegrini F. L anca a scatto extraarticolare. Arch Sci Med, 138: , Pamela MB. Piriformis syndrome: A rational approach to management. American Academy of Physical Medicine and Rehabilitation in Seattle, WA, on 2 November, Pelsser V, Cardinal E, Hobden R, Aubin B, Lafortune M. Extra articular snapping hip: sonographic findings. AJR Am J Roentgenol, 176: 67-73, Pfirrmann CWA, Chung CB, Theumann NH, Trudell DJ, Resnick D. Greater trochanter of the hip: Attachment of the abductor mechanism and a complex of three bursae- MR imaging and MT bursography in cadavers and MR imaging in asymptomatic volunteers. Radiology, 221: , Robinson DR. Piriformis syndrome in relation to sciatic pain. Am J Surg, 73: , Rossi P, Cardinali P, Serrao M, Parisi L, Bianco F, DeBac S. Magnetic resonance imaging findings in piriformis syndrome: a case report. Arch Phys Med Rehabil, 82: 125

12 , Sarkis F, Chicote-campos F. Die schnappende hufte. Orthop Praxis, 14: , Schapira D, Nahir M, Scharf Y. Trochanteric bursitis: A common clinical problem. Arch Phys Med Rehabil, 67: , Schmid MR, Notzli HP, Zanetti M, Wyss TF, Hodler J. Cartilage lesions in the hip: diagnostic effectiveness of MR arthrography. Radiology, 226: , Segal NA, Felson DT, Torner JC, et al., Multicenter Osteoarthritis Study Group: Greater trochanteric pain syndrome epidemiology and associated factors. Arch Phys Med Rehabil, 88: , Seo YJ, Chang JD, Chang SK, Lee GK. Calcific tendinitis of the Rectus femoris: Case Report. J Korean Orthop Assoc, 39: , Shabshin N, Rosenverg ZS, Cavalcanti CF. MR imaging of iliopsoas musculotendinous injuries. Magn Reson Imaging Clin N Am, 13: , Steiner E, Steinbach LS, Schnarkowski P, et al. Ganglia and cysts around joints. Radiol Clin North Am, 34: , Sung YB, Hwang SH, Ahn JK, et al. Calcific tendinitis of the rectus femoris: a case report. J Korean Hip Soc, 13: 70-72, Swezey RL. Pseudo-radiculopathy in subacute trochanteric bursitis of the subgluteus maximus bursa. Arch Phys Med Rehabil, 57: , Tanaka H, Kido K, Wakisaka A, Mine T, Kawai S. Trochanteric bursitis in rheumatoid arthritis. J Rheumatol, 29: , Taylor G.R, Clarke NM. Surgical release of the snapping iliopsoas tendon. J Bone Joint Surg, 77-B: , Toomayan GA, Holman, WR, Major NM, Kozlowicz SM, Vail TP. Sensitivity of MR arthrography in the evaluation of acetabular labral tears. AJR Am J Roentgenol, 186: , Feb, Yamamoto Y, Hamada Y, Ide T, Usui I. Arthroscopic surgery to treat intra-articular type snapping hip. Arthroscopy, 21: , Zeiss J, Coombs Rj, Booth RL, Saddemi SR. Chronic bursitis presenting as a mass in the pes anserinus bursa: MR diagnosis. J Comput Assist Tomogra, 17: , Zoltan DJ, Clancy WG, Keene JS. A new operative approach to snapping hip and refractory trochanteric bursitis in athletes. Am J sports Med, 14: ,

13 , Sarkis F, Chicote-campos F. Die schnappende hufte. Orthop Praxis, 14: , Schapira D, Nahir M, Scharf Y. Trochanteric bursitis: A common clinical problem. Arch Phys Med Rehabil, 67: , Schmid MR, Notzli HP, Zanetti M, Wyss TF, Hodler J. Cartilage lesions in the hip: diagnostic effectiveness of MR arthrography. Radiology, 226(2): , Segal NA, Felson DT, Torner JC, et al., Multicenter Osteoarthritis Study Group: Greater trochanteric pain syndrome epidemiology and associated factors. Arch Phys Med Rehabil, 88: , Seo YJ, Chang JD, Chang SK, Lee GK. Calcific tendinitis of the Rectus femoris: Case Report. J Korean Orthop Assoc, 39: , Shabshin N, Rosenverg ZS, Cavalcanti CF. MR imaging of iliopsoas musculotendinous injuries. Magn Reson Imaging Clin N Am, 13: , Steiner E, Steinbach LS, Schnarkowski P, et al. Ganglia and cysts around joints. Radiol Clin North Am, 34: , Sung YB, Hwang SH, Ahn JK, et al. Calcific tendinitis of the rectus femoris: a case report. J Korean Hip Soc, 13: 70-72, Swezey RL. Pseudo-radiculopathy in subacute trochanteric bursitis of the subgluteus maximus bursa. Arch Phys Med Rehabil, 57: , Tanaka H, Kido K, Wakisaka A, Mine T, Kawai S. Trochanteric bursitis in rheumatoid arthritis. J Rheumatol, 29: , Taylor G.R, Clarke NM. Surgical release of the snapping iliopsoas tendon. J Bone Joint Surg, 77-B: , Toomayan GA, Holman, WR, Major NM, Kozlowicz SM, Vail TP. Sensitivity of MR arthrography in the evaluation of acetabular labral tears. AJR Am J Roentgenol, 186: , Feb, Yamamoto Y, Hamada Y, Ide T, Usui I. Arthroscopic surgery to treat intra-articular type snapping hip. Arthroscopy, 21: , Zeiss J, Coombs Rj, Booth RL, Saddemi SR. Chronic bursitis presenting as a mass in the pes anserinus bursa: MR diagnosis. J Comput Assist Tomogra, 17: , Zoltan DJ, Clancy WG, Keene JS. A new operative approach to snapping hip and refractory trochanteric bursitis in athletes. Am J sports Med, 14: ,