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3 제 2 회관절경수술심포지엄 Current update of arthroscopic surgeries: Solution of practical problem, Video Illustration and Case discussion program 07:50~08:00 개회식회장 : 이범구 ( 가천의대 ) 08:00~09:10 Knee Arthroscopy (ACL & Meniscus) 좌장 : 안진환 ( 성균관의대 ) 1. Meniscus repair (10분 ) 이상학 ( 경희의대 ) 3 2. MAT: LM and MM (10분 ) 윤정로 ( 보훈병원 ) 5 3. ACL with modified trans-tibial technique (10분 ) 김진구 ( 인제의대 ) 9 4. ACL with trans-portal technique (10분 ) 인용 ( 가톨릭의대 ) ACL with Outside-In technique (10분 ) 왕준호 ( 성균관의대 ) 28 Discussion (20분 ) 09:10~09:40 Knee Arthroscopy (ACL & Meniscus) Case Panel Discussion (30 분 ) moderator 최남용 ( 가톨릭의대 ) 빈성일 ( 울산의대 ), 최종혁 ( 연세의대 ), 선종근 ( 전남의대 ) 09:40~11:15 Hip & Ankle Arthroscopy 좌장 : 이우천 ( 인제의대 ), 조윤제 ( 경희의대 ) 1. AS treatment of bony / soft tissue impingement syndrome (15분 ) 성기선 ( 성균관의대 ) AS treatment of osteochondral lesion of talus (15분 ) 정홍근 ( 건국의대 ) AS assisted ankle fusion (15분 ) 안재훈 ( 가톨릭의대 ) AS of intraarticular hip lesion - labral repair and bompectomy (15분 ) 김필성 ( 부민병원 ) AS of extraarticular hip lesion - snapping hip and unusual event (15분 ) 하용찬 ( 중앙의대 ) 58 Discussion (20분 ) 11:15~11:40 Coffee Break 11:40~13:15 Upper Extremity Arthroscopy 좌장 : 이광진 ( 한국병원 ), 이병일 ( 순천향의대 ) 1. TFCC capsular vs. foveal repair (15 분 ) 박민종 ( 성균관의대 ) 67

4 2. Elbow: AS debridement & capsular release (15분 ) 문준규 ( 고려의대 ) Elbow: AS ECRB release & plica resection (15분 ) 조형래 ( 좋은삼선병원 ) AS SLAP repair: Should we repair? (15분 ) 김영규 ( 가천의대 ) AS Remplissage: When can I do? (15분 ) 신상진 ( 이화의대 ) 92 Discussion (20분 ) 13:15~14:30 Lunch Lunch-on symposium 14:30~15:10 Shoulder Arthroscopy 좌장 : 김정만 ( 동작경희병원 ), 김성재 ( 연세의대 ) 1. AS Bankart repair (10분 ) 김철홍 ( 동아의대 ) AS reverse Bankart repair (10분 ) 박경진 ( 충북의대 ) AS bony Bankart repair (10분 ) 박진영 ( 건국의대 ) 109 Discussion (10분 ) 15:10~15:40 Shoulder Arthroscopy Case Panel Discussion (30 분 ) moderator 박태수 ( 한양의대 ) 노규철 ( 한림의대 ), 유재철 ( 성균관의대 ), 김양수 ( 가톨릭의대 ) 15:40~16:05 Coffee Break 16:05~17:10 Knee Arthroscopy & Osteotomy 좌장 : 배대경 ( 경희의대 ) 1. PCL reconstruction (10분 ) 정호중 ( 중앙의대 ) MPFL reconstruction (10분 ) 배지훈 ( 고려의대 ) Medial Open Wedge High tibial osteotomy (10분 ) 나경욱 ( 인제의대 ) Lateral closed wedge High tibial osteotomy (10분 ) 이상훈 ( 서울의대 ) Distal femoral osteotomy (10분 ) 민경대 ( 순천향의대 ) 144 Discussion (15분 ) 17:10~17:40 Knee Arthroscopy & Osteotomy Case Panel Discussion (30 분 ) moderator 정영복 ( 현대병원 ). 김형수 ( 관동의대 ) 이명철 ( 서울의대 ), 최충혁 ( 한양의대 ), 윤경호 ( 경희의대 ) 17:40~17:50 폐회사차기회장 : 이동철 ( 영남의대 )

5 제 2 회관절경수술심포지엄 Current update of arthroscopic surgeries: Solution of practical problem, Video Illustration and Case discussion Knee Arthroscopy (ACL & Meniscus) 좌장 : 안진환 ( 성균관의대 )

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7 Knee Arthroscopy (ACL & Meniscus) Meniscus Repair 경희대학교의과대학정형외과학교실 이상학 반월상연골은경골과대퇴골관절면사이에끼어있으면서관절면의접촉면을증가시켜관절연골에부하되는스트레스를분산시켜관절연골을보호하는기능, 체중을부하하는기능, 관절의안정성을증가시키는기능및윤활기능등슬관절의정상기능을유지하는데매우중요한역할을한다. 반월상연골전절제술후슬관절에퇴행성관절염이진행하는것이증명됨으로반월상연골기능의중요성이알려지면서반월상연골을보존하려는노력이이루어지고있다 1). 반월상연골은무혈성조직이나그변연부 3~5 mm( 내측반월상연골은폭의 10~30%, 외측반월상연골은폭의 10~25%) 는관절막과활액막에서모세혈관망 (parameniscal capillary plexus) 이분포되어혈액공급을받고있으며나이가들수록감소하게된다 (Fig. 1). 혈관분포에따른 red-red 구역, red-white 구역및 white-white 구역으로삼등분되며, red-red 구역은혈액공급을받고있으므로이부분의손상은봉합술의좋은적응이된다. Fig. 1. 반월상연골의혈액공급을보여주는사진으로내측및외측반월상연골의변연부 3~5 mm 부분은혈액공급을받고있으나내측구역은무혈성부위 (avascular area) 임을알수있다. 반월상연골봉합술의적응증은나이, 연골판파열의위치, 파열의크기, 파열의시기그리고파열면의상태등을고려하여결정하여야한다. 가장중요한요소는나이와연골판파열의부위가혈액공급을받는부위인지여부이며특히, 전방십자인대재건술과동반될경우에는반월상연골의봉합술후회복율이높으므로적극적인봉합술을고려하여야한다 2,3). 반월상연골봉합술의방법은 inside-out, outside-in, all-inside 방법이있으며반월상연골의손상부위및손상종류에따라다른적응증과장단점을가지고있다 3-6). 그중내측반월상연골의후내측부 (posteromedial corner) 의손상의경우 all-inside 봉합술의사용이어려워 inside-out 봉합술이나 3

8 제 2 회관절경수술심포지엄 bioabsorbable meniscus fixator를사용하여야한다. 기존의 Inside-out의봉합술은수직봉합이기술적으로어렵기때문에수평봉합으로시행해왔으나, 수평봉합은수직봉합에비하여고정력이낮으며파열부의정확한정복이어려운단점이있다. 또한, bioabsorbable meniscus fixator는충분한고정력을얻지못하며관절연골손상을초래하는상황이발생할수있다 7). 변형된 Inside-out 술식은기존의 inside-out 의수술수기를변형하여수직봉합이가능하고충분한고정력을얻을수있으며, 특히반월상연골후내측부및중간부 (middle third) 종파열의봉합에유용한방법이다 8). 만성전방십자인대손상의 2/3 이상에서내측반월상연골손상이동반되며후각의종파열이가장많고, 종파열이후각에서후내측부위나중간부 (middle third) 로연장되는경우양동이손잡이형파열이발생한다. 내측반월상연골의양동이손잡이형파열이있을경우후각은변형된 all-inside 술식으로봉합하며 2,9,10) 후내측및중간부부위는변형된 inside-out 술식으로봉합한다 8). 또한, 전각의종파열은변형된 outside-in의술식으로봉합할수있다 11). REFERENCES 01. Levy IM, Torzilli PA, Warren RF. The effect of medial meniscectomy on anterior-posterior motion of the knee. J Bone Joint Surg Am. 1982;64: Ahn JH, Bae TS, Kang KS, Kang SY, Lee SH. Longitudinal tear of the medial meniscus posterior horn in the anterior cruciate ligament-deficient knee significantly influences anterior stability. Am J Sports Med. 2011;39: Ahn JH, Lee YS, Yoo JC, Chang MJ, Park SJ, Pae YR. Results of arthroscopic all-inside repair for lateral meniscus root tear in patients undergoing concomitant anterior cruciate ligament reconstruction. Arthroscopy. 2010;26: Morgan CD. The all-inside meniscus repair. Arthroscopy. 1991;7: Noyes FR, Barber-Westin SD. Arthroscopic repair of meniscus tears extending into the avascular zone with or without anterior cruciate ligament reconstruction in patients 40 years of age and older. Arthroscopy. 2000;16: Rubman MH, Noyes FR, Barber-Westin SD. Arthroscopic repair of meniscal tears that extend into the avascular zone. A review of 198 single and complex tears. Am J Sports Med. 1998;26: Seil R, Rupp S, Dienst M, Mueller B, Bonkhoff H, Kohn DM. Chondral lesions after arthroscopic meniscus repair using meniscus arrows. Arthroscopy. 2000;16:E Ahn JH, Wang JH, Oh I. Modified inside-out technique for meniscal repair. Arthroscopy. 2004;20 Suppl 2: Ahn JH, Kim SH, Yoo JC, Wang JH. All-inside suture technique using two posteromedial portals in a medial meniscus posterior horn tear. Arthroscopy. 2004;20: Ahn JH, Yoo JC, Lee SH. Posterior horn tears: all-inside suture repair. Clin Sports Med. 2012;31: Ahn JH, Wang JH, Yoo JC, Kim SK, Park JH, Park JW. The modified outside-in suture: vertical repair of the anterior horn of the meniscus after decompression of a large meniscal cyst. Knee Surg Sports Traumatol Arthrosc. 2006;14:

9 Knee Arthroscopy (ACL & Meniscus) Meniscal Allograft Transplantation (MAT) 중앙보훈병원 윤정로 반월상연골이슬관절에서정상기능을유지하는데중요한역할을하는것은잘알려져있다. 봉합할수없는반월상연골손상으로인해연골절제술후발생하는결손부에대해반월상연골이식술은치료법의하나로서수술빈도가증가추세이다. 특히외측반월상연골결손시외측경골부가 convex한모양을하고있어체중부하가집중됨으로퇴행성관절염이내측보다조기에발생할수있어국내보험인정기준상반월상연골아전절제술또는전절제술시행후내측은 1년, 외측은 6개월을원칙으로시행할수있다. 최근들어반월상연골이식술후장기추시결과호의적보고들이 12,13) 있지만 chondro-protective effect에대한효과를단언을하기는어려운상태이고동통을포함한임상적증상의호전은기대할수있을것으로생각된다. 술후시간이경과함에따라반월상연골이식물이파열되고, shrinkage가생겨기능적으로약화되는소견을보인다. 특히이식물의 extrusion은임상적결과와는관련성이없다는보고 3,8,10) 가많지만이를방지하여보다해부학적위치에가깝게위치시키고자하는노력이시도되고있다. 반월상연골이식술은내측및외측이시행방법이다른데내측반월상연골은 bone plug technique (Fig. 1A) 을주로사용하는반면, 외측은 key-hole technique을주로사용한다 (Fig. 1B). 이들에대한수술방법을 1) Transplant sizing, 2) tunnel 방향 3) 이식물봉합법으로나누어 3가지관점에서고찰해보고자한다. A B Fig. 1. 5

10 제 2 회관절경수술심포지엄 Transplant sizing 반월상연골이식술시환자의크기에맞는이식물을삽입하는것이필수적이라할수있다. Dienst 2) 등에의하면외측반월상연골의경우 10% 큰이식물을삽입할경우관절연골로전달되는힘이커지게되고, 10% 작은이식물을삽입할경우관절연골로전달되는힘은늘어나지않지만반월상연골내에작용하는힘은커져서반월상연골자체의 failure가발생한다고하여 10% 이상의 mismatching은피할것을권유하였다. 또한반월상연골도사람마다 width (mediolateral length) 와 Length (anteroposterior) 의비율이달라 17) 두개의수치를모두일치시키는것이바람직하다. 현재환자의반월상연골크기를측정하는방법으로가장흔하게사용되는방법은 Pollard 방법 11) 이나 Length 측정시 10% 이상의차이를보일확률이 60% 임을감안할때 16) MRI 에서추가적으로 Length를참고하는것이오차를줄일수있다고사료된다. 또한실제적인문제가이식물표지에표시된수치가거의맞지않으며, 동결된상태이기때문에이식물에자를대고측정하는방법도오차가있어주의를요한다. Jang 등 4) 의보고에의하면 Pollard 방법을이용할경우 5% 작은이식물을사용할경우 extrusion을줄이는효과가있다고보고하였다. 이식물이준비되었는데환자의무릎에비해 Length가길경우골편의중심부를잘라길이를조절할수있는방법 6) 을이용하면효과적일경우가있다. 내측반월상연골의경우는전각부와후각부에해당되는터널의사이거리를조절하여이식물의길이를조정할수있다. 경골터널의방향 외측반월상연골이식술시주로 Keyhole 혹은 trough technique을사용하게되는데, 터널을형성할때외측에만들게되면 extrusion이많이일어난다고알려져있으며, 이를만들기위한방법으로 guide pin을삽입시 transpatellar approach를권장하기도한다 15). Choi 1) 등에의하면전체경골길이 (PL) 에대해외측경골부에서경골터널까지 (CB) -Fig. 2- 까지의길이가 42.05% 이상이면 extrusion이안일어난다고보고하였다. Lee 9) 등에의하면경골터널의위치를너무외측에서시작하지않게하므로각도를줄일수있고 (Fig. 3A) 이를통하여 extrusion을줄일수있다고보고하였다. 내측반월상연골이식술인경우 bone plug technique을주로사용하기때문에 (Fig. 2) 반월상연골전각부와후각부부분에일부뼈조직을만들어삽입하는방법으로이식부위의내측반월상연골전각부와후각부해당부위에터널을만들면된다 (Fig. 1A). 6

11 Knee Arthroscopy (ACL & Meniscus) Fig. 2. 이식물의봉합방법 이식물을봉합할때에도주의할점이있는데, 봉합후매듭을만들때너무장력을가하지않는것이추천되기도하며, 이에의한이식물파열이발생할수있으니조심해야한다 5). 관절막을경골외연에봉합해주면 extrusion을막는데효과적일수있다는술기도보고하였다 7). Popliteal hiatus 주위로봉합이적절하지않으면불안정하여파열이있을수있기때문에술후 probe를이용하여이부위안정성을확인하는것이도움이된다 14). 결론적으로반월상연골의이식술의술기는현재에도발전해가고있으며, 이를통하여보다정확한위치에이식물을위치시킬수있을것이며임상적결과도호전시킬수있을것으로생각된다. REFERENCES 01. Choi NH, Yoo SY and Victoroff BN: Position of the bony bridge of lateral meniscal transplants can affect meniscal extrusion. Am J Sports Med, 39:1955-9, Dienst M, Greis PE, Ellis BJ, Bachus KN and Burks RT: Effect of lateral meniscal allograft sizing on contact mechanics of the lateral tibial plateau: an experimental study in human cadaveric knee joints. Am J Sports Med, 35:34-42, Ha JK, Shim JC, Kim DW, Lee YS, Ra HJ and Kim JG: Relationship between meniscal extrusion and various clinical findings after meniscus allograft transplantation. Am J Sports Med, 38: , Jang SH, Kim JG, Ha JG and Shim JC: Reducing the size of the meniscal allograft decreases the percentage of extrusion after meniscal allograft transplantation. Arthroscopy, 27:914-22, Jung KA, Lee SC and Hwang SH: Suture-induced tear after human meniscal allograft transplantation. Knee, 17:88-91, Jung KA, Lee SC, Lee CK, Song MB, Kwon YJ and Kim SM: A modified keyhole technique for minimizing size mismatches during a smaller than optimal lateral meniscal allograft transplantation: surgical technique. J Knee Surg, 22:264-6, Jung YH, Choi NH and Victoroff BN: Arthroscopic stabilization of the lateral capsule of the knee in meniscal transplantation. Knee Surg Sports Traumatol Arthrosc, 19:189-91,

12 제 2 회관절경수술심포지엄 08. Koh YG, Moon HK, Kim YC, Park YS, Jo SB and Kwon SK: Comparison of medial and lateral meniscal transplantation with regard to extrusion of the allograft, and its correlation with clinical outcome. J Bone Joint Surg Br, 94:190-3, Lee DH, Kim JM, Lee BS, Kim KA and Bin SI: Greater Axial Trough Obliquity Increases the Risk of Graft Extrusion in Lateral Meniscus Allograft Transplantation. Am J Sports Med, in press. 10. Lee DH, Kim SB, Kim TH, Cha EJ and Bin SI: Midterm outcomes after meniscal allograft transplantation: comparison of cases with extrusion versus without extrusion. Am J Sports Med, 38: Pollard ME, Kang Q and Berg EE: Radiographic sizing for meniscal transplantation. Arthroscopy, 11:684-7, Van Thiel GS, Verma N, Yanke A, Basu S, Farr J and Cole B: Meniscal allograft size can be predicted by height, weight, and gender. Arthroscopy, 25:722-7, Verdonk PC, Demurie A, Almqvist KF, Veys EM, Verbruggen G and Verdonk R: Transplantation of viable meniscal allograft. Survivorship analysis and clinical outcome of one hundred cases. J Bone Joint Surg Am, 87:715-24, Yang JH, Jeong HI, Kim TS, Park SC and Yoon JR: The management of the popliteus hiatus during lateral meniscal transplantation. Knee, in press. 15. Yoon JR, Kim TS, Lee YM, Jang HW, Kim YC and Yang JH: Transpatellar approach in lateral meniscal allograft transplantation using the keyhole method: can we prevent graft extrusion? Knee Surg Sports Traumatol Arthrosc, 19:214-7, Yoon JR, Kim TS, Lim HC, Lim HT and Yang JH: Is Radiographic Measurement of Bony Landmarks Reliable for Lateral Meniscal Sizing? Am J Sports Med, Yoon JR, Kim TS, Wang JH, Yun HH, Lim H and Yang JH: Importance of independent measurement of width and length of lateral meniscus during preoperative sizing for meniscal allograft transplantation. Am J Sports Med, 39:1541-7,

13 Knee Arthroscopy (ACL & Meniscus) ACL Reconstruction with modified trans-tibial technique 인제의대서울백병원정형외과 김진구 Operative Technique 1. EUA (Evaluation under Anesthesia) : Anterior drawer test, Lachmann test, Pivot shift test, Posterolateral drawer test 2. Arthroscopic examination : Meniscus (especially, LM posterior horn), Cartilage etc. 3. Hamstring harvest: solitary Semitendinosus tendon harvesting : folded into half to produce a quadruple semitendinous graft : shorter than 24 cm, a quadruple semitendinosus and gracilis graft 4. Preparation of femoral foot print : removing the soft tissue at the femoral insertion of ACL : preserving remnant ACL 5. Estabilish the anatomic landmark : just posterior to the bifurcate ridge and center of AP width of footprint 6. Anatomic centering with microfracture awl via trans AM portal : deepened and widened to allow room for the guide pin through the tibial tunnel 7. Establish the triangular slit to lead the guide pin to the anatomic center : triangular shaped funnel like bony trough (Fig. 1) Fig. 1. 9

14 제 2 회관절경수술심포지엄 8. Tibial tunneling (Fig. 2) : Starting point just superior to the pes anserinus and the anterior margin of MCL : ACL guide: extension of inner edge of LM, lateral side of medial tibial spine (Fixed angle: 47.5 ) Fig Inserting the guide wire through tibial tunnel (Fig. 3) : With a free hand technique, towarding the bony trough. A B C Fig. 3. D st 6 mm rigid reamer : Femoral reaming was done with an enough knee flexion which reduced the chances of blowing out the posterior wall and increasing the femoral tunnel length. 10

15 Knee Arthroscopy (ACL & Meniscus) 11. 4~5 mm reamer for preparation of suspensory fixation 12. Measuring the depth of femoral & tibial tunnel 13. Enlarging the tunnel with dilator The reamer throw the bending guide pin by changing the knee angle (gradually extension to flexion) or change the new femoral guide pin Gradually widen the tunnel with 1mm increment Use manual 2 dilators with 0.5 mm increment 14. Preparation of trans-fixation of femur : Endobutton and Bio-Cross Pin (RigidFix System, Mitek, Johnson & Johnson, USA). 15. Graft passage: Press fit technique prevent synovial fluid entering the bone tunnel, wind shield effect intensive contact: quick and complete graft incorporation 16. Cyclic loading 15 times cyclic ROM with N tension Even tension of the graft: key point of quadrupled hamstring graft 17. Tibial fixation Knee flexion: 30 degree HA screw If needed, additional fixation with staple or post-tie Characteristics of modified Trans-tibial technique 1. Enables anatomic femoral tunneling: anatomic centering via transam approach Tunnel preparation with transtibial technique 2. Relatively longer femoral tunnel depth 3. Strong fixation: press-fit fixation, double fixation 4. Smaller graft tunnel bending angle 5. Facilitate accelerate rehabilitation 6. Familiar and easy technique for most of Orthopedic surgeons Key Point of modified TT tech. (Fig. 4-9) 1. Anatomic centering of femoral tunnel via transam approach 2. Triangular trough 3. Bending of guide pin 4. Introducing the reamer for femoral tunnel with alternate extension & flexion 11

16 제 2 회관절경수술심포지엄 Fig. 4. Fig

17 Knee Arthroscopy (ACL & Meniscus) Fig. 6. Fig

18 제 2 회관절경수술심포지엄 Fig. 8. Fig

19 Knee Arthroscopy (ACL & Meniscus) Evaluation of the position of femoral tunnel using 3-Dimensional Computed Tomography and radiographs after single bundle Anterior Cruciate Ligament reconstruction with modified Transtibial Technique - Abstract - Background: The purpose of this study is to report a modified transtibial technique to approach the center of anatomical femoral footprint in anterior cruciate ligament (ACL) reconstruction and to investigate the accurate femoral tunnel position by 3 dimensional computed tomography (3D-CT) and radiograph after reconstruction. Methods: From Dec 2010 to Oct 2011, we evaluated 98 patients who underwent primary ACL reconstruction using a modified transtibial technique to approach the center of anatomical femoral footprint in single bundle ACL reconstruction with hamstring autograft and investigated the femoral tunnel position by 3-D CT and radiograph, postoperatively. Femoral tunnel angle was measured on postoperative radiograph in anteroposterior (A-P) view and the center of the femoral tunnel aperture on the lateral femoral condyle was assessed on 3D-CT according to the quadrant method by two orthopedic surgeons. Results: With the quadrant method by 3D-CT, femoral tunnel was measured at a mean of 32.94%±5.16% from the proximal condylar surface (parallel to the Blumensaat line; t) and 41.89%±5.58% from the notch roof (perpendicular to the Blumensaat line; h) with interobserver (intraclass correlation coefficients (ICC); 0.766, 0.793) and intraobserver reliability (ICC; 0.875, 0.893) respectively. According to the radiographic measurement method in A-P view, femoral tunnel angles averaged ±7.04 (ICC; 0.783, 0.911). Conclusion: Our modified transtibial technique is anticipated to provide more anatomical placement of the femoral tunnel during ACL reconstruction than the former traditional transtibial techniques. Level of Evidence: Level IV, case series Key Words: Femoral tunnel, ACL reconstruction, Trans-tibial technique, 3D-CT evaluation 15

20 제 2 회관절경수술심포지엄 Introduction Recently, various methods for anterior cruciate ligament (ACL) reconstruction have emerged, reflecting the development of novel biomechanical knowledge and surgical techniques 1-3). Studies on ACL reconstruction have mostly focused on how the characteristics of natural ACL can be restored. The femoral tunnel position in ACL reconstruction determines biomechanical property of the graft and affects knee function. Although the isometric point of the femoral side for single bundle ACL reconstruction had been used as the standard method, its potential to cause rotational instability has replaced the anatomical foot print method as the preferred tool. Techniques for creating anatomical femoral foot print in single bundle reconstruction have been reported, such as the trans-anteromedial(trans-am) portal technique and the outside-in technique. However, disadvantages such as insufficient femoral tunnel length, posterior wall breakage and a bent graft limit the use of trans-am portal technique 4). Similarly, acute femoral tunnel angle, inadequate femoral fixation, and additional lateral skin incision upon surgery are major hindrances for the use of outside-in technique 5). Conversely, in this paper we describe an unusual approach to use the traditional transtibial (TT) method to fix the anatomical femoral tunnel. The TT method, whilst overcoming disadvantages seen in the former two methods, has an advantage of relative easy and familiar technique for most surgeons and allowing early rehabilitation by initial strong fixation. However, a short and shallow tibial tunnel can be formed 6,7). The authors adapted this transtibial technique to make an anatomical femoral tunnel and evaluated the tunnel position with 3 dimensional computed tomography (3D-CT) and plain radiography. Our hypothesis was this modified transtibial technique that we have developed could create a functional anatomical femoral tunnel in ACL reconstruction. Methods Between December 2010 and October 2011, 98 patients who were diagnosed with isolated ACL rupture underwent primary ACL reconstruction using single bundle method with modified transtibial technique. Informed consent was obtained from all patients prior to receiving 3D- CT and radiograph for analyzing the femoral tunnel position after the operation. The patient pool consisted of 81 men and 17 women with a mean age of 27.3 years (15~60 years). The femoral tunnel angle was evaluated from the postoperative 3D-CT scan and radiograph by two orthopedic surgeons on two separate occasions at an interval of 2 weeks to assess the 16

21 Knee Arthroscopy (ACL & Meniscus) interobserver and intraobserver reliability. The quadrant method was used to measure the postoperative femoral funnel position by 3D- CT as followings: 1) A true lateral view cutting at the middle of the intercondylar notch of the proximal femur by 3D-CT was attained through the picture archiving and communication systems (PACS, Marotech) (Fig. 10A) 2) The image was enclosed with a rectangular measurement frame that was either in parallel or perpendicular to the Blumensaat line on Power Point (2007 versions, Microsoft Corporation, Redmond, Wash, USA) as shown in Fig. 10B. t calculated the deep to shallow distance in the center of the femoral tunnel parallel to the Blumensaat line, and h calculated the high to low distance perpendicular to the Blumensaat line. In addition, the anatomical femoral attachment site of ACL was shown on Table 1 using the quadrant method as before. Lastly, the femoral tunnel angle was measured on postoperative radiograph in the anteroposterior (A-P) view as seen in Fig. 10C by PACS. A B C Fig. 10. (A) The medial-lateral view of the lateral femoral condyle is obtained from the 3D-CT, and is rotated to the strictly lateral position. (B) A rectangular measurement frame is drawn over the medial-lateral view of the lateral femoral condyle described by Bernard et al. 8) (C) Measurement of lateral inclination of the femoral bone tunnel referenced to a line tangent to the femoral condyle 18). 1. Surgical Techniques After thorough arthroscopic evaluation of the ACL, a 3 cm-long longitudinal skin incision at 2 cm medial to the tibial tuberosity was made. A single semitendinosus tendon was harvested as usual. The graft was cut in half and folded into half to produce a quadruple semitendinous graft. If the harvested graft was shorter than 24 cm, a quadruple semitendinosus/gracilis graft was prepared by harvesting both the semitendinosus tendon and the gracilis tendon. 17

22 제 2 회관절경수술심포지엄 The intercondylar ridge of the lateral femoral condyle, and the bifurcate ridge that divides the anteromedial bundle and the posteromedial bundle were confirmed by removing the soft tissue at the femoral insertion of ACL. The remaing ACL fibers were generally preserved. A bony mark at the anatomic center of ACL footprint (just posterior to the bifurcate ridge and center of AP width of footprint) was made by passing a microfracture awl through the anteromedial portal as in Fig. 11A. This center was deepened and widened to allow room for the guide pin through the tibial tunnel. Since the anatomical femoral tunnel is prepared by the trans AM portal, the transtibial guide pin tends to be located more to the anterior and proximal position of anatomic center than anticipated. The triangular shaped funnel like bony trough was employed to slip the eccentrically positioned guide into the anticipated anatomic center, which is part of our modified transtibial technique (Fig. 11A, B). The starting point of the tibial edge/periphery was just superior to the pes anserinus and the anterior margin of MCL (Fig. 11C). The intra-articular site is positioned immediately lateral to the medial tibial spine and (the extension of the inner margin of anterior horn of lateral meniscus). The angle of the ACL guide (Linvatec, Largo, Florida, USA) was set at The tibial tunnel was created using a reamer with diameter 1mm smaller than that of the prepared ACL graft. A B C Fig. 11. (A) The triangular shaped funnel trough is made in femoral ACL insertion. (B) A model picture of the triangular shaped funnel. (C) The starting point of the tibial tunnel (blue circle) is the point of interaction between lateral to anterior margin of the medial collateral ligament (MCL, white arrow) and upper margin of pes anserinus (black arrow). With a free hand technique, a guide pin was passed through the tibial tunnel towards the bony trough. Generally the guide pin was located distal and anterior to the anatomical center, and extension of the knee nudged the guide pin towards the proximal and posterior region of the anatomic center, but was bent at the intra-articular orifice of the tibial tunnel (Fig. 12). 18

23 Knee Arthroscopy (ACL & Meniscus) A B C Fig. 12. (A) After creating a tibial tunnel whose size is matched to the diameter of the graft, the guide wire is inserted into the tibial tunnel by free hand technique. (B) The guide wire is inserted toward the triangular shaped funnel trough of the femur. (C) While the knee is extended gradually, the guide wire is slided into the anatomical foot print in the bony trough. (D) To prevent posterior wall blowout, the knee is flexed gradually until 90 degrees. D Femoral reaming was done with an enough knee flexion which reduced the chances of blowing out the posterior wall and increasing the femoral tunnel length. When the reamer passes over the bending portion of the guide pin, the knee should be extended. After passing through the bending point, the knee could be flexed. After the graft passage, femoral fixation was done with Endobutton and Bio-Cross Pin (RigidFix System, Mitek, Johnson & Johnson, USA). If femoral tunnel was short, the graft was press fitted with only Endobutton. The graft was tensioned and fixed to the tibia by placing the HA screw (Bioscrew poly L-lactic acid, Linvatec Co, USA). 2. Postoperative Rehabilitation All patients underwent the same standardized rehabilitation protocol as a home-based exercise. We regularly performed follow-ups of the patients in the out-patient clinic and set up a protocol for rehabilitation. The patients were allowed full weight bearing with an unlocked brace 2 weeks after surgery. Partial weight bearing with crutches for 6 weeks was mandated for patients who underwent meniscal repair. The goal for the patients was to gain a 19

24 제 2 회관절경수술심포지엄 full range of motions at 2 to 6 weeks after surgery. A perturbation training program was started at 6 weeks after surgery. Running and side-cutting activities were allowed at 3 months, with a return to sports activities at 6 months after surgery. Results The position of the femoral tunnel was measured using the quadrant method 8) by 3D-CT, where t, representing the distance of the femoral tunnel center from the deepest subchondral contour, was 32.94%±5.16%, and h, representing the distance of the femoral tunnel center from the Blumensaat line, was 41.89%±5.58% (Fig. 13). These values were more distal and middle compared withprevious data (mean t; 29.85%, h; 33.2%) that measured by quadrant method using cadaveric knees for validating anatomical ACL foot prints (p<0.05) 9,10). The interobserver intraclass correlation coefficients (ICCs) were and 0.793, whereas the intraobserver ICCs were and The femoral tunnel angle on the anteroposterior (A- P) view was ±7.04, for which the interobserver ICCs were and 0.795, and the intraobserver ICCs were and On the process of optimizing this modified transtibial technique, mishaps such as breakage of the bended wire occurred on 3 occasions as the reamer was passed through the tibial tunnel, and a shallow tibial tunnel was formed on another occasion, which were all occurred during the initial series. However, as the authors became more practiced in executing this modified technique and when the safe zone of the bone stock was adjusted to the entry point of the tibia, such complications were avoided. Fig. 13. Distribution of mid-tunnel points of femoral tunnels with our modified transtibial technique. Blue circle is midtunnel point of femoral tunnel with traditional transtibial method 13). 20

25 Knee Arthroscopy (ACL & Meniscus) Discussion The purpose of this study was to describe a single bundle ACL reconstruction performed with modified transtibial technique for positioning the femoral tunnel to anatomical foot print. The femoral tunnel location was evaluated using 3D-CT scan reconstructions with the quadrant method as described by Bernard et al 8), and the results of these scans were compared with those derived from arthroscopic identification. The results of this study showed that the t value was 32.94%±5.16%, and the h value was 41.89%±5.58%. Abebe et al. 11) and Kaseta et al. 12) reported that the femoral tunnels were placed deeper or more proximal and higher or more anterior than the native ACL insertion of the femur when the transtibial technique was used, which could result in increased laxity of the graft. Contrary to these results, the femoral tunnel in this study was located shallower of more distal and lower or more posteior than the mean value of multiple measurements of the anatomical ACL foot prints of cadaveric knees (t: 29.85%, h: 33.2%) from previous studies that also used the quadrant method for calculation 9,10). The mean values of the femoral tunnel created by the authors were placed between the AM and PL bundle position, which were calculated as described by Kopf et al. 13) and Tsukada et al. 14). Rue et al 6) reported that a laterally oriented transtibial drilling femoral tunnel effectively overlapped approximately half of the AM bundle and half of the PL bundle. Miller et al. 15) proved that the intra-articular aperture of the femoral tunnel in all cases formed an ellipse, with the long and short axis averaging 13.9±1.6 mm and 9.4±0.8 mm in the trans AM method, and 12.1±0.8 mm and 10.6±0.6 mm respectively in the transtibial group. On the basis of these studies, if the center of the femoral tunnel is drilled relatively distal and posterior, the ellipse shaped tunnel would allow the incorporation of original portions of the AM and PL bundles leading to more anatomical reconstruction.hence, this modified transtibial technique has advantage over the traditional technique (t; 37.2%±5.5%, h; 11.3%±6.6%) 13) for placing more closely to its anatomical location. Ferretti et al. 10) reported the presence of a lateral intercondylar ridge in all patients who underwent ACL reconstruction and the bifurcate ridge in 82% of 60 knees. van Eck et al 16) described 88% and 48% of these landmarks, respectively for their patients at arthroscopy. However, arthroscopically identifying these landmarks on the medial wall of the lateral femoral condyle is difficult. Therefore, postoperative 3D-CT scans were used instead to validate whether this modified technique can reproducibly be used for the placement of the anatomic femoral tunnel. Our angle of the femoral tunnel in the coronal plane was on average ±7.04, when viewed by anteroposterior radiography, and it was lower than the results (61.7 ±5.5, 58.8 ± 21

26 제 2 회관절경수술심포지엄 8.3 ) of previous transtibial techniques, even when compared with the anteromedial portal technique (55.9 ±4.7, 50.9 ±8.3 ), which were measured by Chang et al. 17) and Dargel et al. 18). In addition, Bedi et al. 4) reported that the coronal angles of the oblique femoral tunnels with either the transtibial or the trans AM portal techniques were 54.1 ±7.17 and 45.9 ±6.9, respectively. Of note, the rate of the posterior wall blowout was 50% with the latter technique. Thus, not only is the modified transtibial technique more reproducible, but it is also safer when such complications of the AM portal technique is taken into consideration. There was no significant posterior wall blowout in our case series. The entrance of the tibial tunnel is essential for the placement of the anatomic femoral tunnel when using the transtibial technique for ACL reconstruction, especially if we want to prevent graft failure. 19) Recent studies have tried to accurately drill the tibial tunnel in relation to the native ACL footprint of the femur, but without success. 20,21) However, Heming et al. 22) reported the plausibility of the anatomical footprint using the transtibial technique, but commented that the starting point must be close to the joint line, and the tibial tunnel length must be shortened for an accurately positioned footprint. Arnold et al. 20) attempted to produce anatomical tunnels by transtibial drilling just proximal to the pes anserinus and ventral to the MCL, but in their case, the guide pin was projected too high in the notch and missed the femoral insertion in all cases. In this study, the authors followed Arnold s method to avoid creating shallow tibial tunnels, and furthermore used a newly modified method to prevent over-projecting the guide pin in the notch into a non-anatomical position. There are some advantages of this modified transtibial technique in which the femoral tunnel is drilled appropriately through the tibial tunnel. First, it is similar to the conventional method and easily replicated by surgeons who are familiar with the transtibial technique. Second, it is possible to create the femoral tunnel in an anatomic position through a relatively longer and deeper tibial tunnel with only a few additional and simple techniques; triangular shaped funnel like bony trough and by changing knee flexion angle during femoral tunneling. Third, it permits early rehabilitation through firm graft fixation resulting from tunnel lengthgraft length matching. The limitations of the study may be that the authors used the mean of values of the native ACL insertion derived from multiple previous studies for comparison. Although the methods used in this paper is the same as those used in the previous studies, variations in the experimental instruments used mean that the data does not reflect differences that arises from this, and is therefore simply a crude averaging of values. In addition, the intraobserver correlation coefficient was lower for the interobserver correlation coefficient in two observers, which may reflect the difficulty in selecting the true lateral view on the MRI sagittal image, 22

27 Knee Arthroscopy (ACL & Meniscus) and measuring the center of the femoral tunnel (formed an ellipse inter observers). Finally, there were a lack of full considerations for the length of the femoral tunnel and the characteristics of the tibial tunnel. Further studies to overcome these limitations are required and the necessity of the evaluation of clinical outcomes when this modified transtibial technique used cannot be overlooked to prove its superiority over the traditional techniques. Conclusion Our modified transtibial technique is anticipated to provide a true anatomical placement of the femoral tunnel during ACL reconstruction than the former traditional transtibial techniques. Table 1. Coordinates of ideal femoral position of anterior cruciate ligament insertion on grid of quadrant method in literature t h AMB PLB Mean AMB PLB Mean Study Colombet et al. 9) Tsukada et al. 10) Mean in literatures Note. Data represent percentage by t (deep to shallow) and h (high to low) measured on the grid. AMB, anteromedial bundle; PLB, posterolateral bundle. REFERENCES 01. Aglietti P, Giron F, Buzzi R, Biddau F, Sasso F. Anterior cruciate ligament reconstruction: bone-patellar tendon-bone compared with double semitendinosus and gracilis tendon grafts. A prospective, randomized clinical trial. J Bone Joint Surg Am. 2004;86-A(10): Woo SL, Wu C, Dede O, Vercillo F, Noorani S. Biomechanics and anterior cruciate ligament reconstruction. J Orthop Surg Res. 2006;1: Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL. Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o clock and 10 o clock femoral tunnel placement Richard O Connor Award paper. Arthroscopy. 2003;19(3): Bedi A, Raphael B, Maderazo A, Pavlov H, Williams RJ, 3rd. Transtibial versus anteromedial portal drilling for anterior cruciate ligament reconstruction: a cadaveric study of femoral tunnel length and obliquity. Arthroscopy. 2010;26(3): Garofalo R, Mouhsine E, Chambat P, Siegrist O. Anatomic anterior cruciate ligament reconstruction: the twoincision technique. Knee Surg Sports Traumatol Arthrosc. 2006;14(6): Rue JP, Ghodadra N, Bach BR, Jr. Femoral tunnel placement in single-bundle anterior cruciate ligament 23

28 제 2 회관절경수술심포지엄 reconstruction: a cadaveric study relating transtibial lateralized femoral tunnel position to the anteromedial and posterolateral bundle femoral origins of the anterior cruciate ligament. Am J Sports Med. 2008;36(1): Heming JF, Rand J, Steiner ME. Anatomical limitations of transtibial drilling in anterior cruciate ligament reconstruction. Am J Sports Med. 2007;35(10): Bernard M, Hertel P, Hornung H, Cierpinski T. Femoral insertion of the ACL. Radiographic quadrant method. Am J Knee Surg. 1997;10(1):14-21; discussion Colombet P, Robinson J, Christel P, et al. Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaveric dissection and radiographic study. Arthroscopy. 2006;22(9): Tsukada H, Ishibashi Y, Tsuda E, Fukuda A, Toh S. Anatomical analysis of the anterior cruciate ligament femoral and tibial footprints. J Orthop Sci. 2008;13(2): Abebe ES, Moorman CT, 3rd, Dziedzic TS, et al. Femoral tunnel placement during anterior cruciate ligament reconstruction: an in vivo imaging analysis comparing transtibial and 2-incision tibial tunnel-independent techniques. Am J Sports Med. 2009;37(10): Kaseta MK, DeFrate LE, Charnock BL, Sullivan RT, Garrett WE, Jr. Reconstruction technique affects femoral tunnel placement in ACL reconstruction. Clin Orthop Relat Res. 2008;466(6): Kopf S, Forsythe B, Wong AK, et al. Nonanatomic tunnel position in traditional transtibial single-bundle anterior cruciate ligament reconstruction evaluated by three-dimensional computed tomography. J Bone Joint Surg Am. 2010;92(6): Wang H, Zhou F, Zhang R, Zhong P, Tan D. Opening cranial cisterns by the anterior subtemporal keyhole approach to the superior petroclival region: anatomical study and comparative analysis. Surg Neurol. 2009;72(2): Miller CD, Gerdeman AC, Hart JM, et al. A comparison of 2 drilling techniques on the femoral tunnel for anterior cruciate ligament reconstruction. Arthroscopy. 2011;27(3): Dai Z, Liu Y, Liu R. [Anatomical changes and dynamic analysis after anterior submuscular transposition in treating cubital tunnel syndrome]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2004;18(4): Chang CB, Choi JY, Koh IJ, Lee KJ, Lee KH, Kim TK. Comparisons of femoral tunnel position and length in anterior cruciate ligament reconstruction: modified transtibial versus anteromedial portal techniques. Arthroscopy. 2011;27(10): Dargel J, Schmidt-Wiethoff R, Fischer S, Mader K, Koebke J, Schneider T. Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation. Knee Surg Sports Traumatol Arthrosc. 2009;17(3): Piasecki DP, Bach BR, Jr., Espinoza Orias AA, Verma NN. Anterior cruciate ligament reconstruction: can anatomic femoral placement be achieved with a transtibial technique? Am J Sports Med. 2011;39(6): Dvorak MF, Fisher C, Boyd M, Johnson M, Greenhow R, Oxland TR. Anterior occiput-to-axis screw fixation: part I: a case report, description of a new technique, and anatomical feasibility analysis. Spine (Phila Pa 1976). 2003;28(3):E Saringer WF, Reddy B, Nobauer-Huhmann I, et al. Endoscopic anterior cervical foraminotomy for unilateral radiculopathy: anatomical morphometric analysis and preliminary clinical experience. J Neurosurg. 2003;98(2 Suppl): Arnold MP, Kooloos J, van Kampen A. Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: a cadaver study. Knee Surg Sports Traumatol Arthrosc. 2001;9(4):

29 Knee Arthroscopy (ACL & Meniscus) 전내측구를이용한단일다발전방십자인대재건술 Anatomic Single-Bundle ACL Reconstruction from the Anteromedial Portal 가톨릭대학교서울성모병원정형외과 인 용 전방십자인대의주기능은경골의전방전위에대한일차적인억제작용이다. 최근에는전방십자인대의슬관절회전안정성에대한기능의중요함이강조되었는데이때전방십자인대는경골의내회전및외반부하에저항하게된다. 전방십자인대수술방법은새로운발견에따라진화해왔는데몇년동안은소위 over-the-top 위치에대퇴터널을위치시키는것이표준수술방법으로생각되어왔다 1). 이방법이다른대퇴터널위치방법에비하여우수하다는것이많은해부학적생역학적연구로발표되었다. 이때에는 isometry를얻는것이중요하며 11시위치가대퇴터널위치로언급되었다. 그러나정상전방십자인대는 isometry 개념에따르지않고 Loh 등 2) 은대퇴터널의위치를 11시위치에서 10시위치로내리는것이앞서언급한회전불안정성조절에더우수하다고하였다. 최근의추세는전방십자인대를해부학적 footprint에위치시키는방법이시도되고있다. 전방십자인대의해부학적위치가중요한데대퇴부착부위치의기술은슬관절신전보다는실제관절경수술위치인 90 도굴곡상태에서하게된다. Blumensaat 선아래에전내측다발은보다뒤쪽및위쪽에그리고후외측다발은보다앞쪽및아래쪽에위치하게된다. 해부학적연구에의하면전방십자인대의대퇴부착부는 14~23 mm라고한다. 정상전방십자인대의후방경계는대퇴후과에평행하게관절연골과의간격은 2~4 mm이며전방경계는다양한양상을보이나대개 resident ridge의후방으로알려져있다. 대퇴터널의위치결정에는여러해부학적지표들이사용되는데 2개의다발사이에있는 resident s ridge가유용하다. 대퇴터널을만드는방법은크게 2가지가있는데경골터널을통하여대퇴터널을만드는 ( 경경골대퇴터널 ) 방법과전내측구를통하는방법이다. Morgan 등 3) 이소개한경경골대퇴터널방법을통해이식건을대퇴골의해부학적위치에고정하는것은쉽지않다. 경골터널을더내측에서뚫어야한다. 그러나이경우경골고평부에손상을줄수있고내측측부인대에부분손상을줄수있다. 2009년미국정형외과학회설문조사결과 70% 의의사들이경경골대퇴터널방법을통하여대퇴터널을만든다고하였으며 80% 의의사는일년에 10개미만의전방십자인대재건술을시행한다고하였다 4). 이것은아마도경경골대퇴터널방법이쉽고일정한대퇴터널을뚫을수있다고생각하기때문인것으로사료된다. 부적절하게만들어진터널이전방십자인대수술실패중가장피할수있는원인으로알려지면서어떤수술방법을선택하던정확한터널의위치가중요함을인식하게되었다. 사체연구에서경골터널및대퇴터널의 footprint의중심에터널을만든경우생역학적으로정상전방십자인대와유사했다는결과가있다 2). 25

30 제 2 회관절경수술심포지엄 Knee Arthroscopy (ACL & Meniscus) Isometry를얻지못하더라도해부학적위치에재건하는것이더좋은결과를얻을수있다는것이다. 이중다발방법이발전하면서대퇴터널에대한연구가축적되고그리하여다른방법인낮은전내측구를이용하는방법이소개되었다. 이방법이새로운방법은아니지만경골터널에독립적으로대퇴터널을만들수있다는것이장점이다. 전방십자인대재건술에서대퇴골의천장에이식건이충돌되면안되는데전내측구를통해경골터널과따로대퇴터널을만들면보다수평터널이가능하여이러한충돌을피할수있다. 경골터널은기존의터널보다앞쪽, 내측으로위치시킬수가있는데후방십자인대전면에서 15 mm 전방에위치시킬수있다. 보다해부학적위치에대퇴터널을아래로위치시켜회전안정성을얻을수있다는것도큰장점이다 5,6). 이방법은또한다양한이식건과고정방법을사용할수있다. 간섭나사를사용하는경우대퇴터널과벌어짐 (divergence) 없이평행하게고정할수있다. 또한단일다발, 이중다발, 보강술, 재수술등에다양하게시행할수있다. 물론주의할점도있는데내측대퇴과, 반월상연골비골신경등주변조직의손상을특히주의하여야한다. 그리하여수술시슬관절굴곡각도가 120도이상이되어야안전하다. Alentorn-Geli 등 7) 의메타분석에의하면전내측구를이용한경우가경경골대퇴터널방법보다슬관절의안정성, 관절운동범위, 조기달리기복귀등이가능하여전내측구가효과적인방법이나이러한장점이중장기결과에서는보이지않아어느방법이더낫다고할수는없다고하였다. 전내측구를만들때는관절경으로전외측구에서관찰하면서바늘을이용하여내측반월상연골의바로위에전내측구의위치를확인후절개한다. 이때확공기가들어갈때대퇴내과에손상이가지않는지확인한다. 기존의경경골대퇴터널방법에쓰던 offset 가이드는전내측구를통한전방십자인대재건술에는안맞을수있다. 최근에는 flange가펴져있어핀삽입을위하여슬관절을최대굴곡하여도적절한위치를정할수있는가이드가상용화되었다. 전내측구를사용하는경우경경골대퇴터널방법보다대퇴터널의길이가짧아지게되는데슬관절굴곡정도에따라고도굴곡시대퇴터널이길어질수있으니가능한한고도굴곡하는것이중요하다. 이번발표에서는저자의전내측구를이용한전방십자인대재건술수술방법을동영상위주로소개하고자한다. REFERENCES 01. Bylski-Austrow DI, Grood ES, Hefzy MS, Holden JP, Butler DL. Anterior cruciate ligament replacements: a mechanical study of femoral attachment location, flexion angle at tensioning, and initial tension. J Orthop Res l1990;8: Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL. Knee stability and graft function following anterior cruciate ligament reconstruction: Comparison between 11 o clock and 10 o clock femoral tunnel placement Richard O Connor Award paper. Arthroscopy l2003;19: Morgan CD, Kalman VR, Grawl DM. Definitive landmarks for reproducible tibial tunnel placement in anterior cruciate ligament reconstruction. Arthroscopy l1995;11: Lopez-Vidriero E, Hugh Johnson D. Evolving concepts in tunnel placement. Sports Med Arthrosc l2009;17:

31 Knee Arthroscopy (ACL & Meniscus) 05. Chhabra A, Kline AJ, Nilles KM, Harner CD. Tunnel expansion after anterior cruciate ligament reconstruction with autogenous hamstrings: a comparison of the medial portal and transtibial techniques. Arthroscopy l2006;22: Harner CD, Baek GH, Vogrin TM, Carlin GJ, Kashiwaguchi S, Woo SL. Quantitative analysis of human cruciate ligament insertions. Arthroscopy l1999;15: Alentorn-Geli E, Lajara F, Samitier G, Cugat R. The transtibial versus the anteromedial portal technique in the arthroscopic bone-patellar tendon-bone anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 18:

32 제 2 회관절경수술심포지엄 Knee Arthroscopy (ACL & Meniscus) ACLR with outside-in technique 삼성서울병원정형외과 왕준호 수술전평가 환자의슬관절불안정성에관한정확한평가를위해서마취하에서이학적검사를다시시행하는것이필요하다. 라크만검사, 피봇쉬프트검사, 또는후방전위검사등의전후방불안정성을평가와측부인대손상을평가하기위한신전혹은 30도굴곡상태에서의내외반불안정성검사등의이학적검사를시행이필요하고, 동반되었지만정확히진단되지않아놓치지쉬운회전불안정성을평가하기위한 30도및 90도굴곡상태에서의 dial test를시행하는것이필요하다. 정확한해부학적부착부를확인하기위해소독전에 90도굴곡상태를확인하기위한표시를미리해두는것이수술중부착부위의정확한위치및방향을정하는데도움이된다. 1. 삽입구의생성 (portal formation) 전방십자인대재건술을시행하는데있어서는전방십자인대부착부의위치및기준점들을정확하게확인하기위해적절한삽입구의설정이중요하다. 일반적으로 30도굴곡상태에서전외측삽입구를먼저만들게되며슬개건의외측부위에슬개골의원위의끝보다바고근위부에일상적인삽입구보다조금높은곳에만드는것을추천한다. 높은위치에삽입구의장점으로는슬개골뒤쪽의지방층의영향이적다는점과정확한경골부착부의확인이가능하다는점등이있다. 전내측삽입구는슬개건바로내측에전외측삽입구와대칭적인위치및높이에일반적으로만들게되며, 만들기전 18 gauge의 spinal needle을이용하여미리방향과위치를관절경하에서확인하면서반월상연골을침범하는지확인한후삽입한 spinal needle이과관절흔사이공간으로무리없이들어감을확인한후에만들어야한다. 전방십자인대의대퇴부착부를정확히확인하면서박리등이작업을하기위해서는부전내측삽입구 ( Accessory anteromedial portal) 을추가적으로만드는것이필요하다. 분저내측삽입구를만들경우 1) 두개의전내측삽입구로기구를삽입할때의기구간에간섭을최소화하기위해최대한멀리떨어지게만든다는점과 2) 전방십자인대의부착부에대퇴내과의연골에손상없이접근이가능한지에대한확인후만들도록한다. 먼저전내측삽입구를통하여관절경을삽입하고부전내측삽입구를통하여기구 (Instrument) 를삽입하여대퇴골의전방십자인대부착부위인과간절흔의외측벽을확인하고남아있는십자인대조직들은최소한으로조금씩제거하면서해부학적부착부를확인하는작업이필요하며, 기능을할수있는다발이남아있 28

33 Knee Arthroscopy (ACL & Meniscus) 는경우에는그다발에손상을주지않고재건술을하는것은높은혈류량을유지하고, 기계적수용체의보존으로기능적으로도우월한결과를가져온다고보고되고있다. 하지만기능을하지못하는잔류조직에대해서는정확한해부학적인위치를찾기위해제거하고수술을시행하는것과조금이라도잔류조직을보호한상태에서재건술을시행하고남은조직을재건된인대에붙여주는잔류조직보전술식 2,29) 간에어떠한것이더좋은지에관한이견이아직있을수있다. 전방십자인대손상이생긴후오랜시간이지난경우잔류조직이거의없어부착부위가구분이안되는경우도있다. 이러한경우에는골성지표를사용해서전방십자인대부착부를추정하는방법을사용해야한다. 지금까지알려진대로전방십자인대부착부의앞쪽경계는외과간절흔능선 (lateral intercondylar ridge) 으로, 외갈라진능선 (lateral bifurcated ridge) 은두개의다발사이에존재한다는해부학적연구결과를바탕으로이런지표를이용하여해부학적전방십자인대재건술을시행할수있다. 경골의부착부파악은대퇴골에비해서잔유조직이남아있는경우가대부분이기때문에부착부위를찾는것이비교적쉽다. 그러나그외에참고할수있는골성지표인경골관절면의내외측경골극 (tibial spine) 과외측반월상연골판전방부부착부위, 후방십자인대부착부등을이용하여해부학적부착부를찾는다. 이러한방법으로정해진전내측및후외측부착부위의중심에미세골절술용 awl를이용하여 3~4 mm깊이로표시를해놓는것이향후가이드핀을삽입하기위해유리하다. 대퇴터널의 outside-in의방법은 outside-in수술법을이용하여제작된가이드를사용하는것이좋다. 인대와터널사이의각을원만하게하려면가능하면가이드의큰각을사용하도록하는것이좋다. Arthrex사의 outside-in 가이드의경우는최대 115도의각까지가능하다. 경골의터널을만들기위해서는피부절개가필요하며, 약 4 cm 크기의수직피부절개를시행할수있으며피부주름을따라서절개를시행한다. 피하지방층을정리한후전후방으로연부조직을박리하여경골터널을만들충분한위치를확보한후전외측삽입구에관절경을삽입하고관절경하에서전내측삽입구에전방십자인대경골가이드 (ACL tibial guide) 를넣어가이드의표시부분을경골부착부의중심에가져다놓고가이드핀을고정하여해부학적부착부에터널을형성하게된다. 이중다발십자인대재건술을시행할때는마찬가지방법을각각후외측다발부착부의중심및전내측다발부착부의중심에가져다놓고터널을만든다. 2. 이식건의통과및고정 만들어진대퇴골및경골의터널에주어진고정방식에맞추어이식건을통과시키고각방식에맞추어대퇴골에고정을한후, 이식건을당긴상태에서약 20 회의관절각도운동을시행하여대퇴골의고정을안정화시킨다음, 이식건에적절한긴장을준상태에서, 경골을최대한후방전위를시킨상태에서경골부에고정을시행하게된다. 고정시의슬관절의각도는아직이견이있으며, 술자에따라굴곡 30도또는 60 도에서고정하는방법과완전신전상태에서고정하는방법이이용되고있다. 경골의고정은일반적으로간섭나사로고정하는방법이갖아일반적인방법이고나사를박은후인대를잡고있는추가적나사고정을이용한이중고정방법이쓰이고있으며, 고정후에는관절경하에서슬관절을굴곡및신전시키며이식된전방십자 29

34 제 2 회관절경수술심포지엄 Knee Arthroscopy (ACL & Meniscus) 인대가과간절흔에충돌되지않는지확인하여야하며, 2차적인퇴행성변화가생겨서과간절흔에골극이형성되어좁아진경우에는과간절흔성형술이필요로할수있다. 결 론 전방십자인대재건술시의등장점의개념은최근에는사용되고있지않으며해부학적인재건술의개념이사용되고있다. 해부학적인재건술을위해대퇴터널을만드는방법중에변형된경경골방법, 전내측삽입구를사용하는방법, outside-in 방법등이있다. 그중 outside-in의방법은몇가지의단점이있는데도비교적쉽게사용될수있으면서도안전한방법이다. 30

35 제 2 회관절경수술심포지엄 Current update of arthroscopic surgeries: Solution of practical problem, Video Illustration and Case discussion Knee Arthroscopy (ACL & Meniscus) Case Panel Discussion moderator 최남용 ( 가톨릭의대 ) 빈성일 ( 울산의대 ), 최종혁 ( 연세의대 ), 선종근 ( 전남의대 )

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37 Knee Arthroscopy (ACL & Meniscus) Case Panel Discussion Knee Arthroscopy (ACL & Meniscus) Case Panel Discussion 빈성일 ( 울산의대 ), 최종혁 ( 연세의대 ), 선종근 ( 전남의대 ) 33

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39 제 2 회관절경수술심포지엄 Current update of arthroscopic surgeries: Solution of practical problem, Video Illustration and Case discussion Hip & Ankle Arthroscopy 좌장 : 이우천 ( 인제의대 ), 조윤제 ( 경희의대 )

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41 Hip & Ankle Arthroscopy 발목관절의충돌증후군 Impingement syndrome of ankle 성균관의대삼성서울병원 성기선 Definition and Classification 발목관절의내반손상은일반인과운동선수모두에서가장흔한손상중에하나이며, 이들손상중대부분은보존적치료로좋은경과를보이면서호전되지만, 15~20% 에서만성후유증을남기는것으로알려져있다 1). 만성후유증으로는골연골병변, mechanical instability, peroneal tendon problem 과충돌증후군등이감별진단에포함된다. 이들상태는단독으로진단될수있으나, 복합되어발현되는경우도많은것으로보인다. 이중충돌증후군은뼈와연부조직의이상에의해초래되는관절의운동시통증을동반한기계적제한 (painful mechanical limitation of full ankle movement secondary to osseous or/and soft tissue abnormality) 으로정의될수있다. 이질환은활동적인사람들에주로발생되는데, 이는아마도재발성의 subclinical 손상이주요발병인자이기때문인것으로보인다. 증상의시작은다양한데, insidious 할수있고발목의여러부위의손상에의해촉발되기도한다. 분류는주로충돌이발생하는해부학적위치에따라전외측, 전방및후방으로나뉠수있고, 후내측과전내측충돌증후군에대한보고도있다. 충돌의병리적원인에따라연부조직과골성으로나눌수도있다 2). 1. Anterolateral Impingement 발목관절의전외측부위는경골과비골이뒤에위치하며관절막과이를보강하는전거비인대 (anterior talofibular ligament) 및종비인대 (calcaneofibular ligament), 그리고전하방경비인대 (anteroinferior tibiofibular ligament) 로구성되어있다 (Fig. 1). 37

42 제 2 회관절경수술심포지엄 A Fig. 1. ATFL (black arrow head), Capsule (white arrow) 전외측충돌증후군은주로경미한발목관절의족저굴곡, 내반손상이반복될때발생하는것으로생각되는데, 뚜렷한기계적불안정성을초래할정도의심한인장력은아니지만기능적불안정성이나반복적인미세손상이관절막의출혈, 비후및반흔조직등이일련의병리조직형성을유발할수있다. 또한비후된원위전방경비인대 (hypertrophy of inferior fiber of anterior tibiofibular ligament, Basset ligament or lesion) 과골극도원인병리일수있으나주된병변은아닌것으로알려져있다 3-5). 주된증상은운동시통증으로, 족저굴곡및내반시통증의악화가관찰될수있고, 관절의종창, 전외측압통및수동적족배굴곡및외반이통증을악화시키는것이특징적인소견으로알려져있다. 위에서기술한대로충돌증후군은골연골병변또는건손상등다른병리와동반되어존재할수있어진단시주의가요구된다. 2. Anterior Impingement 전방충돌증후군은전통적으로 footballer s ankle 으로알려진만성질환으로여러가지기전에의해발생한다고알려져있다. 반복적인내반손상으로발목의관절연골전내측경계부의손상을유발할수있고 6,7), 강제적인족배굴곡과신연력 ( 축구의 striking 또는슈팅동작 ) 은전방관절연골과관절막에직접적인미세손상을야기시킨다 8,9). 관절연골경계부위의만성손상은섬유조직의재생을유도하고, 순차적으로이소성골화의반응으로연결되어골극이형성되게된다 (Fig. 2). 이는전외측충돌증후군과다르게골성조직이전방충돌증후군의주요병리적특징으로볼수있다 6,9-12). 전방골극이반드시증상을일으키지는않는데, 증상이없는전문운동선수를대상으로한방사선연구에서약 45 에서 59% 에서전방경골, 거골골극이관찰되었다는보고 13) 가있어, 골극형성에추가적으로연부조직의병리가추가되어야증상을유발한다고추측할수있다. 38

43 Hip & Ankle Arthroscopy A B C Fig. 2. 전방골극형성과관절막비후소견 임상증상은운동시전방통증, 신전제한등의불편을호소하고, 진찰시전방압통, 부종및강제적족배골곡시통증및신전제한등을확인할수있다. 3. Posterior Impingement 후방충돌증후군은발목의반복된또는강제적인족저굴곡에의해원위경골후방과종골후상방사이조직의압박에의해발생하는데, lateral talar process (Stieda process) or os trigonum가연부조직의압박을강화하는작용을할수있는데, 이경우이부위에골부종등스트레스반응이동반될수있는데, 이것도통증의원인으로생각된다 (Fig. 3). 장족지굴곡건 (FHL) 은거골의외측과내측돌기사이를주행하므로, 이역시이차적으로병변에포함될수있는데, 원발성 stenosing tenosynovitis의경우와감별이필요하다 14). A B C Fig. 3. 후방충돌증후군의연부조직양상 39

44 제 2 회관절경수술심포지엄 전형적인임상양상은반복적인족저굴곡동작이필요한발레무용수, 축구또는멀리뛰기선수에서서서히발현되는발목의후방통증이다. 다른부위의충돌증후군과유사하게증상이발현하기위해서는충분한연부조직의형성이필요하다고하며, 급성외상이후에정상이서서히나타나는경우도드물지않다. 증상은발목의족배및족저굴곡시후방통증이며, 이는각각후방연부조직이신연및압박되면서발생하고, 진찰시에도같은소견을확인할수있고, 후외측또는후내측압통이관찰되는데, 아킬레스건의병변이아닌점이확인되어야한다. Diagnosis and Management 위에서기술한대로, 발목관절의급성염좌는보존적치료에대부분좋은결과를보이는데, 3개월이상의적절한치료에도불구하고통증이지속될경우에는불안정성, 골연골병변, 유리체, 숨은골절의불유합또는지연유합, 연부조직충돌증후군등에대한검사가필요할수있다. 이중관절내충돌증후군에대한진단은앞서기술한환자의증상을잘듣고, 적절한이학적검사를시행한후진단의실마리를잡는것이중요하다. 영상검사는대개이러한의심되는진단을확인하는데이용될수있겠다. 대개의경우단순방사선검사에서는정상소견을보일수있겠으나, 일부운동선수나증상이오래된환자에서골극의형성이발목관절의전방, 전내방또는후방에서관찰될수있고, 외과또는내과말단부에소골이확인될수있다. 필요에따라골주사검사또는초음파검사가시행될수있으나, 골연골병변의확인등동반손상에대한전체적인확인을위하여 MRI 검사를하는경우가많다. 그러나, 충돌증후군특히연부조직충돌증후군의경우에는 MRI의임상적효용에대한의문이있어, 이등은 fat suppressed contrast enhanced 3D-FSPGR의방법을이용한 MRI가연부조직충돌증후군진단에도움이될수있다고주장하였다 15). 최소 6개월이상적절한보존적치료에도불구하고증상의호전이없을경우수술적치료를고려할수있다. 대다수저자들이관절경적변연절제술과활액막절제술이증상의호전과기능회복에매우효과적이라고보고하고있다. 골극의경우에도통증을유발하지않으면치료가필요없을수있으나, 통증과운동제한등의증상이지속될경우에는골극제거가고려될수있다. REFERENCES 01. Ogilvie-Harris, D.J., M.K. Gilbart, and K. Chorney, Chronic pain following ankle sprains in athletes: the role of arthroscopic surgery. Arthroscopy, (5): p Robinson, P., Impingement syndromes of the ankle. Eur Radiol, (12): p Ferkel, R.D., et al., Arthroscopic treatment of anterolateral impingement of the ankle. Am J Sports Med, (5): p Liu, S.H., et al., Arthroscopic treatment of anterolateral ankle impingement. Arthroscopy, (2): p Robinson, P., et al., Anterolateral ankle impingement: mr arthrographic assessment of the anterolateral recess. Radiology, (1): p

45 Hip & Ankle Arthroscopy 06. van Dijk, C.N., P.M. Bossuyt, and R.K. Marti, Medial ankle pain after lateral ligament rupture. J Bone Joint Surg Br, (4): p van Dijk, C.N., J.L. Tol, and C.C. Verheyen, A prospective study of prognostic factors concerning the outcome of arthroscopic surgery for anterior ankle impingement. Am J Sports Med, (6): p Tol, J.L., et al., The relationship of the kicking action in soccer and anterior ankle impingement syndrome. A biomechanical analysis. Am J Sports Med, (1): p Tol, J.L. and C.N. van Dijk, Etiology of the anterior ankle impingement syndrome: a descriptive anatomical study. Foot Ankle Int, (6): p Tol, J.L., C.P. Verheyen, and C.N. van Dijk, Arthroscopic treatment of anterior impingement in the ankle. J Bone Joint Surg Br, (1): p Tol, J.L., et al., The anterior ankle impingement syndrome: diagnostic value of oblique radiographs. Foot Ankle Int, (2): p Tol, J.L. and C.N. van Dijk, Anterior ankle impingement. Foot Ankle Clin, (2): p , vi. 13. Cheng, J.C. and R.D. Ferkel, The role of arthroscopy in ankle and subtalar degenerative joint disease. Clin Orthop Relat Res, 1998(349): p Hamilton, W.G., M.J. Geppert, and F.M. Thompson, Pain in the posterior aspect of the ankle in dancers. Differential diagnosis and operative treatment. J Bone Joint Surg Am, (10): p Huh, Y.M., et al., Synovitis and soft tissue impingement of the ankle: assessment with enhanced threedimensional FSPGR MR imaging. J Magn Reson Imaging, (1): p

46 제 2 회관절경수술심포지엄 Osteochondral Lesion of Talus (OLT) 의관절경적치료 건국대학교병원정형외과학교실 정홍근 치 료 1. 비수술적치료 일반적으로제시되고있는비수술적치료는 1) 휴식 / 스포츠활동등의제한, 비스테로이드성진통소염제 2) 최소 3주이상의 cast immobilization으로나뉜다 18). 비수술적치료에대한성공률은저자마다매우다르게보고하는데그범위가 0~100% 이다 18). 급성병변에대한비수술적치료에서 Flick과 Gould 19) 는 4~6 주간비체중부하석고고정및 2~8주간연속적인체중부하증가치료방식을통해 6명의환자에서 good, excellent 결과가없었음을보고하였으며, 만성병변에대해서는스포츠활동등의제한방식을통한연구들에서평균성공률에 56% 정도보고되었다 18). Canale과 Belding 20) 은 stage I, II의병변은반드시비수술적요법으로치료되어야하며, stage III의내측병변도수술시도이전에석고고정으로치료되어야한다고하였으며, stage III의외측병변과모든 stage IV는수술적으로치료되어야한다고하였다. 비수술적치료를시행시에는반드시반복적으로방사선사진을찍어서병변의변화를확인하여야하며, 상대적으로높은실패율이문헌상으로보고되고있음을알아야한다. 2. 수술적치료 일반적으로관절경을이용한치료가관절개방적치료법보다재활기간이짧고, 관절의강직이덜발생하며, 내과절골술등의추가술식에의한합병증을줄일수있는장점이있다. 수술적치료의목적은골결손부위를재혈류화시키는것이다. 관절초자연골 (articular hyaline cartilage) 은무혈관조직이고따라서재생능력이매우약하다. 따라서연골하판 (subchondral plate) 를통과하지못하는손상은염증반응이나치유반응을유도할수가없다. 그러나손상의깊이가연골하골까지들어가게되면골수세포들이자극을받게되어서새로운조직을형성하여, 결손부위를채우게된다. 그런데이러한과정은섬유연골 (fibrous cartilage) 의형성을유도하게되고, 섬유연골은초자연골보다생역학적성질이다소부족한문제가발생하게된다. 작은결손부위에는섬유연골이어느정도초자연골을대체할수있으므로, debridement, drilling, microfracture 등의시술이가능하게된다. 하지만결손부위가클경우에는섬유연골만으로는 42

47 Hip & Ankle Arthroscopy 기능을다할수없으므로, 초자연골을형성해주는시술-자가연골이식, 동종연골이식, 연골세포이식등의방법이제시되고있다. 1) 연골판안정술 ( 내고정술 ) 크고불안정한골연골병변이생존가능한 (viable) 연골하골부분을가지고있을때즉제3 또는 4형의급성골연골골절일때시도될수있으며, 최근에는소형나사이외에생체흡수성핀등을이용하기도한다. 2) Debridement, microfracture/multiple drilling: 가장많이시행되고있으며일차적수술법으로널리사용되고있다. 섬유연골의증식을유도하는방법으로, 약 10 mm이하의작은크기의 shear형태의병변이주로연골손상만유발하고연골하골의손상이최소일때적용할수있다. 3) 역행적 drilling 연골하골병변이덮고있는연골의손상없이존재할때시도할수있는방법이나정확한위치를파악해서상층의연골손상없이역행적 drilling을시행해야하는기술적어려움이있다. 그러나단순히병변을감압만을시행하면, 관절면의붕괴가이어질수있으므로, 감압후에골이식을주로시행하나, 골이식대체물 (calcium sulfate, etc) 을넣어주는방법을같이사용하기도한다. 4) 연골조직이식술이러한이식술을시행할때는손상부위에대하여수직으로접근하는방식이필요한데, 따라서절골술등의추가술식이요구된다. 대부분의거골원개는절골술이없이도수직으로접근할수있지만, 내측거골원개의 17%, 외측거골원개의 20% 는절골술없이접근할수없다 21). 내과절골술은내측, 외측거골원개대부분에수직접근을가능하게해주지만중앙부 15% 는내과절골술후에도수직으로접근할수없다. 절골술후에는절골술부위의불유합이나, 부정유합을주의해야하며세개의나사고정이 2개의나사고정보다우수하다고생각된다. (1) 자가골연골이식 (Osteochondral autologous transfer system-oats) or Mosaicplasty: 슬관절대퇴골의체중비부하관절연골면에서골연골편을채취해서이식하는방식이다. 수술술기가복잡하고, 연골공여부가제한적이며, 슬관절의연골두께와족관절의연골두께가 mismatchong되는단점이있다. (2) 자가연골세포의배양후이식 (autologous chondrocyte transplantation): 슬관절연골의일부를떼어내어시험관내에서연골세포를분리하여배양한후거골의골연골결손부에주입하는방법으로, 2번의수술, 비싼비용, 술기의복잡성, 연골세포의과다성장으로인한층형성등의단점이있다. (3) 동종골골연골이식 (ostochondral allograft transplantation): (4) 동종골로부터큰골연골편을이식하는방법으로냉동방법사용시연골세포의 viability가떨어질수 43

48 제 2 회관절경수술심포지엄 있다는점과, 면역학적인문제가발생할수있는단점이있다. 매우큰 OLT 병변일때고려할수있다. Fig. 1. Flap tear REFERENCES Fig. 2. Microfracturing of the debrided subchondral bone bed 01. Ferkel RD, Hommen JP: Arthroscopy of the ankle. In: Coughlin MJ, et al., eds. Surgery of The Foot And Ankle. vol II. 8th ed. Philadelphia, Mosby: , O Loughlin PF, et al: Current Concepts in the Diagnosis and Treatment of Osteochondral Lesions of the Ankle. Am J Sports Med, Ferkel R, et al: Arthroscopic treatment of osteochondral lesion of the talus: long term result. Orthop Trans: , Taranow WS, et al: Retrograde drilling of osteochondral lesions of the medial talar dome. Foot Ankle Int, 20: , Flick AB, Gould N: Osteochondritis dissecans of the talus (transchondral fractures of the talus): review of the literature and new surgical approach for medial dome lesions. Foot Ankle, 5: ,

49 Hip & Ankle Arthroscopy 06. Canale ST, Belding RH: Osteochondral lesions of the talus. J Bone Joint Surg Am, 62:97-102, Muir D, et al: Talar dome access for osteochondral lesions. Am J Sports Med, 34: , Giannini S, Vannini F: Operative treatment of osteochondral lesions of the talar dome: current concepts review. Foot Ankle Int, 25: ,

50 제 2 회관절경수술심포지엄 관절경적발목관절고정술 (AS assisted ankle fusion) 가톨릭대학교의과대학정형외과학교실 안재훈 서 론 발목관절은주된체중부하관절의하나임에도불구하고원발성골관절염이비교적드물며, 대부분골절이나연골및인대손상등외상의후유증으로관절염이발생하게된다. 관절염의수술적치료중하나인관절고정술은발목관절의경우비교적그결과가만족스러워현재도많이시행되고있으며, 그구체적인술기로는전통적인관혈적방법외에도최소절개를이용하거나관절경을이용하는방법등이많이시행되고있다. 이중관절경적관절고정술은관혈적방법에비해불유합이나신경손상등의합병증이비교적적게발생하는좋은방법으로그시술이점점늘어나고있으나관절의변형이심한경우에는기술적으로어려운단점이있다. 관절경적관절고정술의술기 1. 기기및준비 (Instrumentation and setup) 성공적인관절경술을위해서는발목관절의견인이충분히되어관절간격이확보되어야하며이를위해중족부와발뒤꿈치에 strap을감아서사용하는 non-invasive 견인기구가많이이용된다. Non-invasive 견인은보통앙와위에서 1) 슬관절을신전하거나 2) thigh holder를이용하여고관절과슬관절을굴곡시키거나 3) 슬관절을침대의끝에위치시킨후굴곡시키는등의자세에서행할수있다. 사용되는관절경은 2.7 mm 직경의 30 경사를가진짧은관절경이주로사용되며, 족관절의불안정성이동반된경우처럼견인이충분히되는경우는 4.0 mm 관절경을사용할수도있는데관절고정술의경우는관절연골의손상이이미심한상태이므로 4.0 mm 관절경을사용하는것이술기상더용이할수있다. 그외의기기로전동절삭기및 burr, curette 등이관절면의처치를위해사용된다. 2. 삽입구 (Portal) 및술기 (Technique) 생리식염수 10~15 ml 를관절내로주사하여관절강을팽창시킨후 portal 을만들게되는데 46

51 Hip & Ankle Arthroscopy anteromedial, anterolateral 및 posterolateral의세 portal을통해서관절고정술을시행하게된다. 발목의관절경술시에는특히천비골신경등신경분지의손상을피하는것이중요하며 nick & spread 기법이도움이된다. Anteromedial portal은비교적만들기쉬우면서도주요한신경이나혈관들을피할수있기때문에가장먼저만들며전경골건의바로내측에위치한다. 그다음 anterolateral portal은제3 비골건의외측으로천비골신경분지들을피하여만들며이 anteromedial 및 anterolateral portal을통해대부분의작업이행해진다. Posterolateral portal은비골외과말단부의 1~1.5 cm 근위부에서아킬레스건의바로외측에만들며관절고정술중에주로 inflow portal의기능을담당하여시야를확보하게해주는역할을한다. 실제술기상은 anteromedial 및 anterolateral portal을통해한쪽으로관절경을넣어관절안쪽을보면서다른 portal로는전동절삭기, burr, curette 등을삽입하고이를이용하여활액막, 관절연골및연골하골등을절제하게된다. 관절면의절제가이루어지고나면 Microvector나다른 ACL guide 등을이용하여 6.5 mm 유관나사 (cannulated screw) 의 guide pin을원위경골의내측및외측으로삽입한후관절경및기기등을제거한다. 다음술자가관절의위치를시상면에서는중립위, 관상면에서는 0도에서 5도사이의외반, 그리고 5도정도의외회전상태를유지하면서압박하여최대한관절면을잘접촉시킨상태에서 guide pin을거골로삽입하면 temporary fixation이이루어진다. 마지막으로 C-arm fluroscopy로관절의위치및 guide pin의위치를확인하고 screw를삽입하면최종 fixation이이루어진다. 보통두개의나사를삽입하나안정성에문제가있는경우는세개의나사를이용하여내고정할수도있다. 술후치료는 6주간의비체중부하단하지석고고정후방사선사진상유합이완료될때까지체중부하석고고정을시행하게되는데대부분의경우 8~10주사이에유합이이루어지게된다. REFERENCES 01. Myerson M, Quill G. Ankle arthrodesis: a comparison of an arthroscopic and an open method of treatment. Clin Orthop Relat Res. 1991;268: Ogilvie-Harris D, Lieberman I, Fitsialos D. Arthroscopically assisted arthrodesis for osteoarthrotic ankles. J Bone Joint Surg Am. 1993;75: Schneider D. Arthroscopic surgery of the ankle, arthroscopic abrasion arthroplasty, ankle fusion. Arthroscopy Video Journal. 1983;3(2): Stone JW. Arthroscopic ankle arthrodesis. Foot Ankle Clin. 2006;11(2): Winson I, Robinson D, Allen P. Arthroscopic ankle arthrodesis. J Bone Joint Surg Br. 2005;87(3): Zvijac J, Lemak L, Schurhoff M, et al. Analysis of arthroscopically assisted ankle arthrodesis. Arthroscopy. 2002;18(1):

52 제 2 회관절경수술심포지엄 Arthroscopic treatment of intraarticular hip lesion - Acetbabuloplasty. labral repair and femoroplasty around surgical technique- 서울부민병원 김필성 서 론 고관절의관절경적술식이최근들어비약적으로발전되고있으며적응대상도확대되고있다. 대퇴비구충돌및비구순파열등이주된적응이지만원형인대파열, 화농성관절염, 관절내유리체제거, 활액막성골연골종등의관절내질환뿐만아니라내측및외측발음성고관절, 대전자부통증증후군, 이상근증후등의관절외질환에대해서도관절경적치료가확대되고있다. 국내에서도과거에비해고관절관절경적치료법에대해관심이증가되고있으며수술적치료도증가되고있는현실이다. 이에저자는고관절관절경의주된질환인대퇴비구충돌및비구순파열의수술의치료법인비구성형술, 비구순봉합술, 대퇴골성형술의수술과정을설명하고술전고려해야할사항과수술적치료기법에대해논하고자한다. 고관절경의수술적기법 1. 수술전고려할점 고관절관절경의가장중요한문제는환자의선별부터시작되어야한다. 비구순파열을가지고있는환자의주된주소는서혜부통증과관절운동시악화되는통증으로일상적인보행에서는통증을호소하지않으나과도한관절굴곡의동작에서서혜부통증을호소한다. 환자들은 양반다리가안된다., 바닥에앉기힘들다., 쪼그려앉기힘들다., 운전석에오르고내릴때아프다., 계단오르내릴때찌르는듯한느낌이든다. 등으로표현하며통증부위를서혜부에영역화 (localization) 하면서표시한다. 그러나, 장요근과내전근건병증, sports hernia 등도서혜부통증을호소할수있으므로여러가지요건을고려해야하며충분한보존적치료에도반응하지않지않고통증이지속될경우관절내병변을의심하여검사를진행하며, 관절내병변과전술한질환과의감별을위해진단적 lidocaine 차단을시행해볼수있으며자기공명검사나초음파등을통해방사선적평가가요구되기도한다. 또한, 고관절부위의통증은척추질환요인을배제할수없으므로척추에대한이학적 / 신경학적검사가반드시시행되어야한다. 48

53 Hip & Ankle Arthroscopy 이학적검사가통증의양상을이해하는데매우중요하며, 여기에는고관절충돌검사 (impingement test), Patrick 검사, Log rolling 검사, Hip apprehension test 등을이용한관절내검사와관절외질환을배제하기위해대전자부의압통검사, Gaenslen 검사, snapping의유무확인, Piriformis 검사등을시행해야한다. 고관절의운동범위를측정하여구축의유무를확인하고내전 / 외전제한이있는지검사해야하며이러한증상을보이는환자들은관절견인시에신경이나근육손상을줄수있기때문에유의해야하며견인이실패할경우도발생할수있음을인지해야한다. 방사선학적검사에서단순촬영은고관절전후사진, 고관절측면사진, frog-leg 측면사진, false profile 영상, cross table 측면사진을반드시확인하여 pincer형의증거인비구의전경사 (crossover sign; figure of eight sign) 나과도한덮힘 (coxa profunda, acetabluar protrusio) 등의충돌의증거가있는지확인해야하며 cam 형의증거인대퇴골두-경부접합부의 offset의감소소견, 골성융기 (bump), 충돌반흔 (herniation pit) 등이있는지확인해야한다. 이러한방사선적증거와이학적검사의추정진단이일치할게될때대퇴비구충돌및비구순파열을의심할수있으며이를확인하기위해컴퓨터단층촬영 (CT), 자기공명관절조영술 (MRA) 등의검사를시행하고역동학적검사를위해고관절초음파를시행할수있다. 컴퓨터단층촬영에서단순촬영에서의심되었던방사선적증거를확인할수있으며관절경수술시에수술부위의위치를정하기위해단순 CT보다는 3차원컴퓨터단층촬영을권유한다. 또한, 자기공명관절조영술에서는비구순파열의위치와파열의형태, 원형인대손상의유무, 활액막염의정도, 동반되는관절내병변을확인한다. 2. 수술방법 고관절관절내병변의관절경적치료가주제이므로중심구획의선접근후변연구획으로전환하는수술적방법에대해논하고자한다. 고관절관절경을시행하기위해서는관절견인이필요한데통상적으로골절테이블을이용되며견인정도를확인하기위해방사선투시기가필요하며고관절관절경세트가필요하다. 고관절관절경세트에는 17 gauge long spinal needle과긴가이드와이어, 이를통해관절경삽입구를제작할수있는 obturator와관절경을삽입할수있는 4.5/5.0/5.5 mm 배관 (cannnula), 30 /70 관절경이필요하다. 관절절개술에필요한관절경용칼 (arthroscopic knife), 굴곡형고주파가열프로브 (flexible radiofrequency probe), Arthrocare 고주파가열기, 통상적인관절경에서사용되는것보다긴 shaver가필요하며, 비구순봉합을위해큐렛, 드릴, 드릴가이드, 흡수형봉합나사, 비구순봉합기구등이필요하다. 환자의자세는앙아위 (supine position) 와측와위 (lateral position) 이있는데앙아위에서는환자를골절테이블에위치시킨후회음신경보호를위해솜붕대를이용하여두껍게패딩한회음부기둥을세우고환자의회음부와회음부기둥이접촉되었는지확인하다 (Fig. 1). 양쪽발목에전경골신경의압박을방지하기위해발목을솜붕대를이용하여두껍게패딩한후환측의발목을중립및약간내회전위치로고정한후슬개골의위치를확인하여고관절의회전정도를방사선투시기를이용하여확인한다 (Fig. 2). 수술전외과적소독하기전에관절의견인정도를확인해야한다. 먼저건측의하지를고정한후건측방향으로약간견인하여환측고관절이이완되지않도록한후환측하지를견인한다. 적절하게견인이되었을때방사선투시 49

54 제 2 회관절경수술심포지엄 기에서관절속음압차이로인해 vaccum seal 현상이나타나게된다 (Fig. 3). 관절의구축이나관절낭이비후되어있는환자들에서는견인이되지않을수있는데이러한경우환자의위치가정확이위치되었는지재확인한후다시견인을시도한다. 이러한경우에도관절견인이되지않는경우, 환측의다리를 30도정도외전한상태에서다리를견인하고이상태에서다리를내전시킬경우회음기둥의지렛대효과로견인력을더얻을수있으나신경의견인손상에유의해야한다. 관절의견인이확인된경우, 견인을풀고외과적소독 (surgical drape) 을시행해야삽입구제작시에 vaccum seal 현상을이용할수있으며견인된상태에서소독이진행된경우정작삽입구를제작할때에는 vaccum seal 현상이사라지게된다. 이러한과정을통해서도견인을얻을수없을경우에는외과적소독을시행한후삽입구제작시에견인을얻도록한다. 삽입구제작을위해환측다리를재견인하고 vaccum seal 현상이나타났을경우 17 guage 척추바늘을천자하면, 음압경사로인해공기가관절내로유입되면서공기관절사진 (air arthrogram) 을얻을수있다. 준비과정에서견인이되지않았던관절에서도환측하지를견인한상태에서관절천자를하는경우공기가유입되면서 vaccume seal과함께견인을얻을수있다. 견인은대퇴골의인성손상을주지않을정도로이루어져야하는데 8~10 mm( 관절경두께의 2배정도 ) 가되어야한다 (Fig. 4). 측와위 (lateral position) 를이용하여관절의견인을얻을수있는데일반적으로널리사용되지않으나전방비구병변이있는경우, 후방유리체제거, 비만으로견인을얻을수없는경우에사용된다. Fig. 1. Fig

55 Hip & Ankle Arthroscopy Fig. 3. Fig. 4. 견인을한후삽입구를제작하는데, 고식적삽입구 (classic portal) 로전방, 전외측, 후외측삽입구가있다 (Fig. 5). 대부분의비구순파열및비구성형술및대퇴골성형술이고관절전방과전외측에위치하기므로전방삽입구와전외측삽입구가 viewing portal과 working portal로주로이용되게된다. Fig. 5. 전방삽입구 (anterior portal) 는치골결합부위에서측면으로수평선을긋고전상방장골극 (anterosuperior iliac spine) 에서원위부로수직선을내렸을때만나는교차점으로보통전상방장골극에서평균 6.3 cm에위치하게되는데외측대퇴비구신경의손상에주의해야한다. 그러나, 최근의관절경적비구순봉합술을위해서는변형된전방삽입구 (modified anterior portal) 를제작하게되는데저자의경우방사선투시기에서척추천자바늘로대전자부의첨단부위를확인하고내측으로수평선을긋고전상방장골극에서원위부로수직선을그었을때만나는점에서외측 1 inch, 원위부 1 inch에전방삽입구를제작한다 (Fig. 6). 고식적전방삽입구의위치가근위부에위치하기때문에봉합나사를삽입할경우 drill guide 51

56 제 2 회관절경수술심포지엄 의각도가수직에가깝게서기때문에비구관절내천공을유발할가능성이높은반면, 변형된전방삽입구의경우 drill 삽입각도를줄일수있어천공발생가능성을낮출수있다. 전외측삽입구 (anterolateral portal) 는대퇴골의대전자부의첨부에서전방 1 cm에위치하게제작하게되는데중둔근을뚫고관절난의외측을관통하게되며상둔부신경의손상에유의해야한다. 후외측삽입구 (posterolatearl portal) 는대전자부의첨부에서후방으로대전자부를만지면움푹들어간연한지점 (soft spot) 을찾을수가있게되는데이지점을이용한다. 관절낭의두껍지않고척수바늘의삽입이용이하여제작이비교적쉬우나병변의위치가주로전방부에위치하므로관절액배수구로이용된다. 저자는전방과전측방삽입구의두삽입구를주로이용하는데삽입구제작방법은다음과같다. 견인력을얻은이후에전외측삽입구의위치에척추바늘을삽입한후천자의느낌 (feeling) 을느끼게되는데부드럽게천자되는경우관절낭을통과한것이며척추바늘에저항이느껴지는경우는비구순이나비구연골을천공한경우일수있어저항이느껴지지않는위치에척수바늘을재천자해야한다. 천자가이루어진후에이를통해가이드와이어를관절내로주입한후방사선투시기를확인하면가이드와이거가비구의벽에닿았을경우휘어지게되는데이를통해관절내천자되었음을확인할수있다 (Fig. 7). 전외측삽입구에관절경을삽입하여전방부를관찰할때. 비구순의경계, 대퇴골두그리고관절막의삼각형부위를관찰할수있게관절경을위치시켜야한다 (Fig. 8). 척추바늘을전방삽입구위치에삽입한후방사선투시기에서관절경의끝부위와척추바늘의끝부위가만나도록위치시켜관절경상에서비구순을천공하지않고관절낭을통과할수있게천자할수있다 (Fig. 9). Fig. 6. Fig

57 Hip & Ankle Arthroscopy Fig. 8. Fig. 9. 그러나, 삽입구제작시에환자가혈관절증이있는경우나비구의전외측부에골극이있는경우후외측삽입구를만들어야하는데, 혈관절증이있어관절내가관찰되지않을경우는후외측삽입구위치에척추바늘로관절천자를하여피를제거한후충분한시간동안세척하면관절내를관찰할수있게된다. 전외측부에골극이있어전외측삽입구를제작하기어려울경우후외측삽입구를 viewing portal로만들고이를통해골극을피해전외측삽입구주위에추가적삽입구를만들어 working portal로사용하여절삭기들을이용하면전외측삽입구를만들수있게된다. 그러나, 삽입구의제작은고식적위치를지키지않아도술자가원하는곳에대퇴골이나비구의관절연골, 비구순의손상을주지않는다면안전영역 (safe zone) 어느곳이라도제작이가능하다 (Fig. 10). Fig

58 제 2 회관절경수술심포지엄 viewing portal과 working portal이정해지게되면관절경을이용하여관절내병변을관찰하게되는데전외측삽입구와전방삽입구를통해전방부위의비구순파열의유무, 비구연골의손상, 원형인대손상, 대퇴골두의상태, 후방부위의비구순파열및후방비구연골손상, 반충손상 (contre-coup lesion) 이있는지확인한다. 주병변이확인이되고수술계획이수립되었다면원활한수술의진행을위해관절낭절개술 (capsulotomy) 을시행해야하는데고관절관절경을위해익숙해져야하는중요한술식이다. 고관절의해부학적구조가깊은관절이며비구와대퇴골사이가좁기때문에삽입구제작이매우어려워, 초심자의경우삽입구에서관절경이빠져다시재작하게될때시간을허비하는경우가많다. 따라서관절낭절개술이필요한데다음과같은방법으로시행할경우수월하게시행할수있다. 전방삽입구의경우장대퇴인대 (iliofemoral ligament) 가두꺼운관절낭을이루고있으며인대의주행방향이관절낭절개수직방향으로위치하므로절개에어려움이있다. 따라서전외측삽입구를 viewing portal로하고전외측삽입구를통해관절경용칼을위치시켜내측및외측방향으로삽입구를약간확장시킨후 viewing portal을전방삽입구로바꾸고전외측삽입구를통해 working portal로한다. 전외측삽입구의경우장좌골인대 (ilioischial ligament) 에의해쌓이게되는데관절낭절개의방향과인대주행방향이어느정도평행을이루므로전방삽입구에서관절낭절개를하는경우보다수월하게실행된다. 전방삽입구에서시행한관절낭절개와전외측삽입구에서시행된관절낭절개가서로만나게되면만족할만한관절낭절개를얻을수있게되며병변의위치및관절경접근의필요에따라전방및후방으로관절낭절개를연장할수있다 (Fig. 11). 관절낭절개가충분하게이루어져야추후에시행되는변연구획에서의작업을원활하게시행할수있으므로다소시간이걸리더라도반드시정확하게시행해야한다. 그러나과도한관절낭절개는고관절의불안정성이나비구의이형성이있는경우오히려퇴행성변화를유발할수있어저자는비구이형성이있는경우관절낭절개를하지않고관절경술식을시행한다. Fig. 11. 비구순봉합에앞서방사선적평가에서 pincer 형의대퇴비구충돌이있는경우비구성형술 (acetabuloplasty) 을시행해야하는데, 이를위해서는관절낭-비구순접합부의비구순주위공간 54

59 Hip & Ankle Arthroscopy (paralabral space) 의확보가필요하다. 비구순봉합에있어골-건치유를위해서비구의골성부위를노출시켜야하는데 long shaver, 큐렛, 굴곡형고주파가열프로브, arthrocare 등이사용된다. 대퇴비구충돌의증거가없이비구순파열만을보이는환자에서는연부조직만을제거하고, pincer형의대퇴비구충돌이있는경우연부조직제거후절삭기 (burr) 를이용하여비구성형술을시행하게되는데관절경에서비구순-연골접합부과관찰될때까지비구의경계를절삭한다. 이과정이끝나게되면비구순봉합 (labral repair) 를시행하게되는데저자의경우퇴행성변화가진행되어있더라도비구순봉합을시행하고있다. 전술한바와같이대부분의비구순병변은전방혹은전외측에존재하기때문에봉합나사의삽입위치는병변의위치와가깝게위치하게된다. 봉합나사의삽입각도가비구에너무비스듬하게들어갈경우 pull-out의가능성이높다. 따라서, 저자의경우전방비구순봉합은전방삽입구를 working portal로하여봉합나사를삽입하고, 전외측과후외측비구순봉합은전외측삽입구를 working portal로하여봉합나사를삽입한다. 병변이전방 / 전외측에만존재할경우 2개의봉합나사로견고한고정을얻을수있으나비구순의파열이확장되어후외측까지존재하는경우 3개또는 4개의봉합나사를사용한다. 비구순의견고한고정을확인한후비구연골의손상을확인하게되는데비구연골이비구에서찢어지는파열 (flap tear) 을보이는경우연골성형술 (chondroplasty) 와미세천공술 (microfracture) 를시행하고, 비구연골이비구에서들리는연골손상 (debonding injury) 를보이는경우관절경적연골축소술 (arthroscopic thermal shirinkage) 을시행하거나 fibrin glue를이용한재부착술을시도해볼수있다. 이후관절경을좀더심부로위치시켜원형인대 (ligamentum teres capitis) 의손상유무를확인해야하는데, 이때고정된발목을내회전 / 외회전하여원형인대의전방섬유와후방섬유의파열유무와열된인대가비구와대퇴골사이에감입 (ligament teres impingement) 되는지확인한다 (Fig. 12). 이러한경우파열된인대의변연제및고주파를이용한인대퇴축술을시행할수있다. Fig. 12. 이렇게중심구획의관절경적치료가끊나면보조자로하여금환측하지견인을풀도록하고고관절을 60 도정도굴곡시킨다. 수술전에골절테이블에다리받침대를걸어놓고견인후에다리를위치시키면쉽게변연구획의수술자세를얻을수있다. 전외측삽입구를 viewing portal로하고견인을풀게되면비구에 55

60 제 2 회관절경수술심포지엄 서분리되었던대퇴골이비구내로위치하게된다. 전방삽입구에 switching rod나 shaver 또는 Arthrocare를위치시켜절개된관절낭을원위부로밀면서대퇴골두-경부접합부를노출시킨다. 이때 shaver를이용하여관절낭을추가로정리해도되고, Arthrocare로원위부로관절낭을고주파가열을하여변연구획의노출을얻을수있다. 대퇴골두-경부접합부에골성융기 (bump) 가있는지확인하고대퇴골성형술 (femoroplasty) 를시행할위치를정한다. Arthrocare를이용하여두경부접합부의섬유조직과마멸된원위관절연골을정리하여대퇴골성형을시행할골을노출시킨다. 대퇴비구충돌이있는경우충돌반흔 (herniation pit) 을관찰할수있으며충돌의간접적증거이므로이부위는대퇴골성형술을충분히시행해야한다. 대퇴골성형술을시행할경우유의해야할점은대퇴비구충돌의주된충돌부위는대퇴골의전외측부위인데반하여전방삽입구에서대퇴골성형술을시행해야할경우대퇴골의내측부위만을감압하는결과를초래할수있다. 따라서이때는수술전시행했던 3차원컴퓨터단층촬영영상과방사선투시영상을비교하여대퇴골의구조 (geometry) 를이해해야정확한대퇴골성형을통한감압을얻을수있다. viewing portal을전방삽입구로전환하고전외측삽입구에서절삭기를삽입하여대퇴골전외측의대퇴골성형을시행하는데보조자는고관절을약간내회전하여대퇴골의외측면을노출시켜술자가대퇴골의전외측부위를쉽게성형할수있도록도와야한다. 그러나, 관절낭절개가충분히이루어지지않았거나수술전환자의다리위치가중립혹은외회전되어있는경우에서관절낭절개가이루어지는경우에보조자가다리를내회전하면관절낭이꼬이게되어 (kinking) 되면서관절경과절삭기의움직임이제한되게되므로초기위치와관절낭절개에있어유의해야한다. 그리고절삭기가대퇴골의내측면이나외측면으로너무과도하게위치하는경우대퇴내측 / 외측회선동맥 (medial/lateral femoral circumflex artery) 의손상을유발할수있어유의해야하며대부분의충돌위치는전방부에서이루어짐을인지하고과도한감압을시행해서는안된다. 대퇴골성형술이시행된후환자의하지를 frog leg position을취하게한상태에서방사선투시기로적절하게감압이되었는지확인하고, 고관절을 90도정도굴곡시키고관절경하에서봉합된비구순과대퇴골의충돌부위가부딪히는지확인해야하며불충분한경우걸리는부위의대퇴골성형술이추가로시행되어야한다 (dynamic arthroscopy) (Fig. 13). 최근에는관절경적수술후관절낭봉합에대한보고가있으며시행되고있으나필요성에대해서는논란의여지가있다. Fig

61 Hip & Ankle Arthroscopy 결 론 고관절의내시경의적응환자를선별하는데있어충분한보존적치료기간이필요하며정확한진단을바탕으로시행되어야한다. 고관절의관절경은술식을익히는데긴교육곡선 (long learning curve) 이필요하지만, 기본술식을충분히이해하고수술적기법에익숙해지면고관절관절내병변을치료할수있는효과적미세침습수술법이다. 대퇴비구충돌과비구순파열의관절경적치료는비구순의견고한고정과충돌부위의충분한감압을시행해야좋은결과를얻을수있다. REFERENCES 01. Byrd JW. Hip arthroscopy: patient assessment and indications. Instr Course Lect, 52: Byrd JWT. Physical examination. In: Byrd JWT ed. Operative hip arthroscopy. 2nd ed, New York, Springer: 36-50, Khandauja V, Villar RN. Arthroscopic surgery of the hip: current concepts and recent advances. J Bone joint Surg Br. 88: , McCarthy JC. Hip arthroscopy: when it is and when it is not indicate. Instr Course Lect, 53: , Philippon MJ Schenker ML. A new method for acetabular rim trimming and labral repair. Clinics in Sports Medicine, 25(2): Philippon MJ, Schroder e Souza BG, Briggs KK. Labrum: resection, repair and reconstruction sports medicine and arthroscopy review, Sports Med Arthrosc, 18:76-82, Hwang DS, Lee JB. Arthroscopy of the hip joint: diagnosis and treatment. J Korean Hip Soc, 22:27-37,

62 제 2 회관절경수술심포지엄 Arthroscopic treatment: snapping hip & acetabular fracture Dept of Orthopaedic Surgery, College of Medicine Chung-Ang Univ., Korea. Yong-Chan HA 58

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69 제 2 회관절경수술심포지엄 Current update of arthroscopic surgeries: Solution of practical problem, Video Illustration and Case discussion Upper Extremity Arthroscopy 좌장 : 이광진 ( 한국병원 ), 이병일 ( 순천향의대 )

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71 Upper Extremity Arthroscopy Arthroscopic TFCC Repair: Capsular vs. Foveal Tear 성균관의대 박민종 삼각섬유연골복합체 (triangular fibrocartilage complex: TFCC) 병변은손목척측동통의가장흔한원인으로알려져있다. TFCC는기능적으로척골의골두와수근골사이에서수근열에관절면을제공하고수부의하중을척골로전달하는삼각섬유연골 (TFC) 과원위요척관절의주안정화구조물인전후방인대가복합적으로합쳐진구조물이다. TFCC 변연부파열 Palmer는 TFCC의외상성파열을위치에따라중앙부파열, 변연부파열, 전방척수근인대파열, 요골부착부파열의 4가지로분류하였다. 이중척측변연부가파열된 type I-B는가장자리에혈관이있어봉합으로치유를기대할수있기때문에슬관절의반월상연골의변연부파열처럼봉합을하는것이원칙이다 (Fig. 1). Fig. 1. 변연부파열에대한 outside-in 봉합술 최근 TFCC 척측변연부파열 (Plamer classification class 1B) 의치료에대하여표재부파열과심부 fovea 인대부착부파열을구별하여야한다는의견이제시되었다. 일반적으로요수근관절경으로관찰한파열은 TFCC 원위면이척측관절막으로이행하는부위이며, 관절막 ( 주로 ECU tendon sheath에해당하는두꺼운관절막, 또는 ulnar collateral ligament라고하는부분 ) 에 TFC 표재면만봉합을하는것으로만족하였다. 그러나 TFCC의구조가척수근관절의하중을전달하고관절면을연장하는역할을하는중앙 67

72 제 2 회관절경수술심포지엄 의연골구조물 (TFC proper) 뿐만아니라원위요척관절 (DRUJ) 의안정화역할을하는가장자리의인대구조물 (distal radioulanr ligament) 로구성되어있다는점을명심하여야한다. 원위요척인대는요골 sigmoid notch의전후방가장자리에서기시하여삼각형으로모아져원위척골의경상돌기기저부와바로인접한 fovea에부착하고있다. 따라서 TFCC의변연부는원위표재면이관절막으로연결되어있지만심층부는 fovea에인대가붙어있다. 따라서 TFCC 변연부파열은원위부의관절막파열 (caspular tear) 과 fovea detachment를점검하여야한다 1,2). 관절막파열은 DRUJ의안정성이유지된상태에서단순히파열된변연부가척수근관절을자극하여통증이유발되는반면 fovea detachment는근본적으로 DRUJ의탈구또는아탈구에해당하는손상으로인대가파열되는것을의미한다 (Fig. 2A). 그러므로최초외상에대해자세히물어볼필요가있으며신체검사에서 DRUJ의안정성을점검하여야한다. Fovea detachment는 styloid process 바로전방안쪽에압통이있으며전후방스트레스검사를하여정상측과비교하면통증과함께전후방이동이많은것으로의심할수있다 3,4). 방사선검사는최근 MRI의해상도좋아지면서 fovea insertion 부위의신호강도의증가나 defect를확인할수있다. 관절경은요수근관절경으로는 TFC의 defect가없는한 fovea를직접관찰할수는없다. DRUJ 관절경으로확인이가능하나공간이매우좁고 1.5 mm 지름의작은관절경을사용하여야하기때문에자세히관찰하기는어렵다. 요수근관절경으로보면서 probe로변연부를당겨보는 hook test가도움이된다. TFC가안쪽으로쉽게밀려지면변연부파열이없더라도 fovea detachment를의심하여야한다3. Fovea detachment가있고이로인한 DRUJ 불안정, 통증이있다고진단이되면전통적인변연부봉합은충분한치료가되지못하고 fovea에서떨어진 TFCC를직접 fovea에봉합하여야한다. 그러나공간이좁고접근이어려워기술적으로여간어려운것이아니다. 후방또는경상돌기바로전방으로개방하여 suture anchor나 pullout method로봉합을하며이때관절경으로 TFCC의원활한봉합사통과를도와줄수있다 (Fig. 2B) 3-5). A B Fig. 2. 변연부 foveal detachment 는 DRUJ 의불안정성이동반되며 (A) fovea 에직접부착하여야한다 (B). 68

73 Upper Extremity Arthroscopy REFERENCES 1. Moritomo H. Advantages of open repair of a foveal tear of the triangular fibrocartilage complex via a palmar surgical approach. Tech Hand Up Extrem Surg 2009;13: Atzei A. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. J Hand Surg Eur Vol 2009;34: Atzei A, Rizzo A, Luchetti R, Fairplay T. Arthroscopic foveal repair of triangular fibrocartilage complex peripheral lesion with distal radioulnar joint instability. Tech Hand Up Extrem Surg 2008;12: Nakamura T, Nakao Y, Ikegami H, Sato K, Takayama S. Open repair of the ulnar disruption of the triangular fibrocartilage complex with double three-dimensional mattress suturing technique. Tech Hand Up Extrem Surg 2004;8: Moritomo H, Masatomi T, Murase T, Miyake J, Okada K, Yoshikawa H. Open repair of foveal avulsion of the triangular fibrocartilage complex and comparison by types of injury mechanism. J Hand Surg Am 2010;35:

74 제 2 회관절경수술심포지엄 주관절관절경 : 변연절제술과관절낭유리술 (Arthroscopic debridement and capsular release) 고려대 문준규 서 론 주관절에서관절경을이용한변연절제술, 골극제거술및관절낭유리술은퇴행성관절염혹은후외상성강직에서대표적으로적응된다. 따라서이두가지병변을기준으로관절경술식을기술하고자한다. 주관절의퇴행성관절염 (osteoarthritis of elbow) 은팔을과하게사용하는직업을가진중년이상의남자에서발생한다. 최대굴곡또는최대신전시의동통과운동제한이주증상이며, 척골신경병증 (ulnar neuropathy) 을동반하는경우에는제 4, 5수지손저림과근력감소를호소하기도한다. 동통의성격은최대신전시후방통증이특징적인데주두 (olecranon) 및주두와 (olecranon fossa) 의골극의기계적충돌 (mechanical impingement) 로인한증상이다. 신전충돌검사 (extension impingement test) 나 arm bar test는이를유발하는이학적검사이다. 주관절강직은다양한원인이있지만크게외상성 / 비외상성으로나눌수있다. 외상성은골절과탈구같은직접적인외상, 화상및두부외상과연관되어발생된구축 (contracture) 이흔하며수술합병증으로올수도있다. 비외상성으로는퇴행성또는류마티스관절염이흔하며선천성관절구축증, 선천성요골두탈구와같은선천성질환이해당된다. 방사선학적인검사로는단순방사선검사및 CT 가도움이된다. 특히 CT는골극의위치나크기를수술전에파악할수있는유용한검사이다. 3D 및 2D reconstruction view로유리체의위치나골극의충돌을진단할수있다 1). 주관절관절염의주병변은골극생성 (osteophyte formation), 유리체 (loose bodies) 및관절낭구축 (capsular contracture) 으로나눌수있다. 골극은전방에서는구상돌기의첨부 (coronoid tip), 요골와 (radial fossa) 및구상돌기와 (coronoid fossa) 에위치하고후방에서는주두첨부 (olecranon tip) 와주두와 (olecranon fossa) 에생긴다. 유리체는전방및후방에모두존재할수있으며관절낭에붙어있는경우도흔하다. 관절낭구축은후내측관절낭 (posterior medial capsule) 과전방관절낭 (anterior capsule) 구축이동반되는데관절운동제한의병인으로작용한다 2). 70

75 Upper Extremity Arthroscopy Fig. 1. 주관절단순방사선사진과 CT 사진에서전방및후방의골극 (osteophyte) 들을관찰할수있다. 관절경수술 (arthroscopic treatment) 전신마취하에측와위위치 (lateral decubitus) 에서시행하는것이보통이며지혈대를사용하여출혈을줄이는것이좋다. 수술전척골신경병증이동반되어있는경우에는후내측으로 3 cm 정도의최소절개를통한척골신경감압술을먼저시행하는것이권장된다. 이때후내측관절낭의손상이생기면관절경수술시수액이배출되므로조심한다 3). 관절경기법 (arthroscopic technique) 주관절을 4개구역으로나누어유리체제거. 골극제거및관절낭절제술시행한다. 전방 (anterior compartment), 후방 (posterior compartment), 내측구 (medial gutter) 및외측구 (lateral gutter) 으로나눌수있는데전방을처음시행하거나후방을먼저시행할수도있다. 관절경삽입구 (portals) 는전방은근위전내측 (proximal anteromedial portal), 전외측 (anterolateral portal) 및, 근위전외측삽입구 (proximal anterolateral portal) 가주로사용되고후방, 내측방및외측방은후방삽입구 (posterior portal), 후외측삽입구 (posterolateral portal) 및연성관절경삽입구 (soft spot portal) 가주로이용된다 4-6). 1. 전방 (anterior compartment) 2. 후방 (posterior compartment) 3. 외측구 (lateral gutter) 4. 내측구 (medial gutter) 전방관절 (anterior compartment) 은먼저근위전내측관절경구에서관절경을넣고전외측에서 shaver를이용하여시야를확보한다. 전방의유리체는전반관절낭과활액에유착되어있는경우가흔하며 grasper등으로쉽게제거할수있다. 유리체의크기가클때는작게나누어제거할수있다. 골극의제거는 71

76 제 2 회관절경수술심포지엄 요골와, 구상돌기와및구상골기순으로 burr 또는 osteotome을이용하여시행한다. 구상돌기쪽골극을제거할때는전외측관절경구에서보면서근위전내측에서기구가들어오는것이수월하다. 이때시야를좋게하기위해서근위전외측관절낭구를통해 retractor를이용할수있다. 제거할골극와정상피질골과의경계는구분이가능하며술전 CT를통한정보를이용하면도움이된다. 마지막으로전방관절낭 (anterior capsule) 을 punch 등을이용하여내측부터외측방향으로절제한후 shaver로제거한다. 전외측관절낭절제술에는후골간신경 (posterior interosseus nerve) 의손상을주의해야한다. A B Fig. 2. (A) 전외측관절경구에서유리체를제거하는장면. (B) 요골와와구상돌기와골극을 burr 로제거하는장면 후방관절 (posterior compartment) 은후방관절경구 (posterior portal) 와후외측관절경구 (posterolateral portal) 를번갈아가면서이용한다. 주관절을 30~40도신전시킨상태에서시행하는것이관절공간을얻기가편하다. 활액막제거와유리체제거를통해시야를확보한다. 주두와주두와의골극을 burr와 osteotome 등을통해제거한다. 이때시야를좋게하기위해서근위후외측관절낭구를만들어 retractor를이용할수있다. 주관절을굴곡 / 신전해보면골극의충동을관찰할수있고절제범위를선정에도움이된다. A B Fig. 3. (A) 주두첨부골극을 osteotome 으로제거하는장면과 (B) 제거후사진 72

77 Upper Extremity Arthroscopy 외측구 (lateral gutter) 는후외측관절경구로시야를유지면서근위요철관절 (proximal radioulnar joint) 의후면까지볼수있다. 유리체의제거, 골극제거및후외측관절낭을절제할수있으나외측척골측부인대 (lateral ulna collateral ligament) 손상을주의해야한다. 연성삽입구 (soft s potportal) 를통해서 shaver등을이용하면활액막제거및유리체를제거하기가용이하다. 내측구 (medial gutter) 는척골신경의인접성으로주의를요한다. 후내측관절낭 (posteromedial capsule) 의비후로인한굴곡운동의제한이초래되므로이부분의관절낭절제술이필요하지만 shaver등을이용하는것은고도의경험자를제외하고는위험할수있다. 이를경우는관절경수술이후에최소절개를통해척골신경을박리한후후외측관절낭을절제하는방법을쓸수있다. A B Fig. 4. (A) 후내측골극의제거는척골신경의손상의위험성이높다. (B) 최소절개를통하여후내측관절낭절제술을시행할수있다. 관절경수술이끝난후에는전후방에각각삽입관을넣어배액시킨다. 주관절을신전상태에서압박드레싱을시행하고술후 2~3일부터조기관절운동을시행한다. CPM (continuous passive motion) 을이용하거나보조기또는부목을이용하여술후 1개월정도까지관절운동의유지및향상에대한재활을유지한다 7). REFERENCES 01. Kokkalis ZT, Schmidt CC and Sotereanos DG. Elbow arthritis: current concepts. J Hand Surg Am. 2009;34: Gramstad GD and Galatz LM. Management of elbow osteoarthritis. J Bone Joint Surg Am. 2006;88: Gallo RA, Payatakes A and Sotereanos DG. Surgical options for the arthritic elbow. J Hand Surg Am. 2008;33: O Driscoll SW. Arthroscopic treatment for osteoarthritis of the elbow. Orthop Clin North Am. 1995;26: Steinmann SP, King GJ and Savoie FH, 3rd. Arthroscopic treatment of the arthritic elbow. J Bone Joint Surg 73

78 제 2 회관절경수술심포지엄 Am. 2005;87: Norberg FB, Savoie FH, 3rd and Field LD. Arthroscopic treatment of arthritis of the elbow. Instr Course Lect. 2000;49: Cheung EV, Adams R and Morrey BF. Primary osteoarthritis of the elbow: current treatment options. J Am Acad Orthop Surg. 2008;16:

79 Upper Extremity Arthroscopy 주관절외상과염의관절경적유리술 좋은삼선병원정형외과 조형래 주관절외상과염은주관절외측부에동통을야기하는가장흔한질환중에하나로, 단요수근신건의기시부에퇴행성변화및불완전재생과정으로인해미세혈관및섬유모세포의증식이일어나는것으로알려져있다. 일반인구중 1~3% 정도이환되며, 70% 이상에서직업과관련된과사용증후군의하나이다. 40~60세 ( 평균연령 42 세 ) 사이에호발하고남녀발생비는같으며우세수에더흔하다. 대개보존적치료에잘반응하여 90% 정도는비수술적치료로호전되는경향이있다. 그러나최소 6개월이상비수술적치료를시행하여도지속되는통증과기능제한이있는경우, 또는비수술적치료에반응하였으나자주재발하는경우는수술적치료의적응증이된다. 단요수근신건의개방적유리술을비롯한많은수술적치료방법이알려져있으나최근관절경하단요수근신건유리술의좋은결과가많이보고되고있다 1-5). 관절경적유리술은총수지신건의건막을손상시키지않으며외상과염시흔히동반되는관절내이상을확인할수있고재활기간을단축시킬수있다는장점이있다. 해부학 주관절외측에있는단요수근신건, 장요수근신건, 상완요골근으로구성되는세가지근육다발이존재하며이를헨리의가동성뭉치라고한다. 이중단요수근신건과장요수근신건은각각제 3 중수골기저부와제 2 중수골기저부에부착하여수근관절을신전시키는역할을하고이중단요수근신건은수근관절신전, 주관절약한굴곡, 파악동작시수근관절안정화에중요한역할을한다. 해부학적으로장요수근신건이단요수근신건의근위부를덮고있기때문에단요수근신건을노출시키기위해서는장요수근신건을박리하여야한다 (Fig. 1A). 장요수근신건은상완골외상과상부에서완전히근육으로기시하며건으로기시하는단요수근신건과차이를보인다. 단요수근신건의기시부는다이아몬드형태로길이는 13±2 mm, 너비는 7±2 mm이며, 면적은 93±33 mm 2 이다 (Fig. 1B). 외상과부위에서기시하는신전건중에단요수근신건의기시부에퇴행성병변이잘발생하는이유는주관절신전시단요수근신건의밑면이소두의외측경계에마찰되는위치적특성과동시에장요수근신건이단요수근신건을아래쪽으로압박하는기계적인요인이있다 6). 또한수근관절신전을일으키는단요수근신건의반복적인수축은건내에긴장을증가시켜미세한건파열을유발한다. 75

80 제 2 회관절경수술심포지엄 A B Fig. 1. Anatomical relationship (A) between extensor carpi radialis longus, brevis and digitorum communis and (B) lateral collateral ligament. 진 단 외상과의다소전방원위부에최대압통을보이고, 저항성수근관절신전운동시에통증을유발하며주관절을 90도굴곡하면단요수근신건에더특이적이다. 일반방사선학적검사상외상과의골경화소견및진행된질환에서석회화를발견할수있으며이는외상과염의 20% 정도에서발견된다. 초음파는주관절 90도굴곡회내전상태에서시행되며, 건기시부에서국소적인저반향이나건실질내파열, 건주위삼출액및공통수지신건의비후등을관찰할수있다. 김등 7) 에따르면외상과염시에초음파상단요수근신건의두께를측정한결과정상측에서 3.2±1.1 mm 보이며외상과염에서는 4.9±0.9 mm로증가된소견을보인다고하였으며 MRI상에서단요수근신건은 T1 영상에서두꺼워보이며 T2 영상에서는건파열로인한높은신호강도를보인다 (Fig. 2A, B). 외상과염과비슷한증상을보일수있는질환으로요골관증후군, 경부신경근증, 요골-소두골연골병변, 주관절후외측추벽증후군, 후외방불안정성등이있으므로감별이필요하다. A B Fig. 2. (A-B) A high T2 signal focus was found in the origin of the extensor carpi radialis brevis in the coronal and axial planes. 76

81 Upper Extremity Arthroscopy 치료방법의선택 보존적치료는휴식, 소염진통제, 스테로이드및보톡스주사, 물리치료, 보조기, 체외충격파치료, 혈소판풍부혈장주사등이있다. 스테로이드주사는높은재발율을보이는데이는건실질내주사로인한역효과나통증경감으로인한과사용의결과로생각된다. 스테로이드주사후 3개월후예후는비슷하거나오히려악화되는경향을보이며, 색소침착이상, 지방위축, 건파열등의합병증이발생할수있다 8,9). 물리치료는전완부근력과유연성, 지구력을증가시킨다. 특히편심성근력강화는근건단위의비대, 건의신장강도를증가시키며, 건에가해지는긴장을줄이고건세포의콜라겐생성을촉진하며혈관신생을감소시킨다. 보조기는전완근위부에밴드를착용하거나수근관절신전을유지하는부목등이있다. 전완밴드의경우근육의팽창을제한하며, 새로운근기시부를형성하고근육의수축방향을재조정한다. 체외충격파치료는동통수용체를차단하여진통효과를증가시키며, 건세포의투과성을증가시키고건치유를돕는다. Speed 등 10), Wilner 등 11) 에따르면시술후 6~12주에유익한결과를보였다고하였지만 Buchbinder 등 12) 의체계적검토논문에서는체외충격파치료와대조군을비교한 9개의논문, 1006개증례에서이점이거의없었다고보고하였다. 혈소판풍부혈장주사 (PRP) 는자가혈액에서혈소판을추출한농축액으로혈소판풍부혈장에존재하는성장인자들은조직의치유와재생을자극및촉진시키는역할을하는것으로알려져있다. Peerbooms 등 13,14) 의전향적이중맹검연구에서는 50명의혈소판풍부혈장치료군과스테로이드를사용한대조군을 1년추시한결과혈소판풍부혈장치료군의경우 73%, 스테로이드군은 51% 호전을보였으며, 이는시술 2년째까지유지됨을보고하였다. 외상과염은대부분보존적치료에잘반응하지만 5~10% 에서만성화되며, 6개월간의보존적치료에반응이없고심한동통으로일상생활에지장이큰경우수술적치료의적응증이될수있다. 수술적치료방법에있어서는 1933년 Hohmann 15) 이외상과염에대한수술적치료를처음도입한이후로여러술자들이각기다른방법을발표해왔는데이러한고식적수술방법으로는외상과부의부분적절제, 탈신경화, 신경감압술, 이환된건의연장술등이있다 16-18). 전통적인개방적절제술은단요수근신건내의회색의퇴행성조직을육안적으로확인후제거하는방법으로하부의외상과피질골에박피술을동시에시행하는것으로 Nirschl법으로알려져있다 19). 최소절개 Nirschl 단요수근신건유리술은외상과위를따라서 1.5~3 cm 절개를가하고공통수지신건과장요수근신건사이의근간중격사이로접근하여병변부를제거한후단요수근신건을재부착시키지않고, 골천공술도시행하지않으므로술후구축방지나통증감소에효과적이다. 경피적신전건유리술은외래에서간단히시술될수있으며상대적으로적은통증과상처를줄이는미용적효과등효율적방법이나병변조직을남겨놓으며, 건절제정확성의미흡으로현재널리사용되고있지는않다. 수술방법 : 관절경적단요수근신건유리술 관절경적단요수근신건유리술은관혈적인방법에비해미용적으로우수하며, 빠른통증완화와조기 77

82 제 2 회관절경수술심포지엄 재활, 정확한관절내동반병변에대한평가및치료가가능한장점이있다. Baker 등 3) 은외상과염의 69% 에서관절내병변을동반하고있으며이중에는활액막염또는활액막비대가 55%, 골극이 12%, 관절내유리체가 7% 를차지하였다고하였다. 또한외상과염의관절경소견을관절막손상여부에따라분류하였는데관절막이온전한경우를 Type I, 선상파열이있는경우를 Type II, 관절막이완전히파열된경우를 Type III로정의하였다. 1. 자세와준비 전신마취혹은부위마취로시행하고술자의편의에따라복와위나측와위를선택할수있으며저자는복와위를선호한다 (Fig. 3A) 장골극과같은골돌출부에압박이가해지지않도록패드를삽입하고지혈대는가능한한근위부로감아야시야확보나술중상지의조작이쉽다. 상지받침대를사용하여상박부가지면과수평이되도록하고주관절이 90도정도굴곡되도록자세를잡는다. 주관절을 90도이상굴곡조작할때수부가수술대에부딪히지않도록공간을확보하도록한다. A B C Fig. 3. (A-C) Patient positioning, anatomical landmark and portals. (A) Prone position and anatomical landmark of (B) medial aspect and (C) lateral aspect of right elbow. (AM: anteromedial portal, ME: medial epicondyle, UN: ulnar nerve, OL: olecranon, DL: direct lateral portal, RH: radial head, LE: lateral epicondyle, AL; anterolateral portal) 2. 기구와삽입구 4.0 mm, 30 의고식적인관절경을사용하며 3.5 mm 전경연부조직절삭기 (shaver) 와열전도장비 (VAPER ) 를준비한다. 2.7 mm 관절경을사용하는술자도있으나수술시야가좁아어려움이있을수있다. 술중연부조직의부종으로시야확보에어려움이있을때연부조직을들어올리는데필요한 switching stick도준비한다. 척추마취바늘보다 21 G 바늘을사용하는편이조작이쉽다. 마취후자세를잡고국소부위소독이끝나면피부표식펜으로내측근간막, 내상과, 외상과, 주두, 요골두, 척골신경등주요 landmark와삽입구를표시한다 (Fig. 3B, C). 외상과염의관절경적단요수근신건유리술에사용되는삽입구는전내측삽입구와후내측삽입구가주된삽입구이며술전후방구조물의충돌이의심되는경우는후 78

83 Upper Extremity Arthroscopy 방삽입구와직외측삽입구를사용할수있다. 전내측삽입구는주된시야삽입구 (viewing portal) 로내상과상방 2 cm, 전근간막의약 1 cm 전방에표시하고주된시술삽입구 (working portal) 인전외측삽입구는외상과에약 1 cm 전방에표시하지만전내측삽입구로관찰하면서외측에서내측으로 (outside-in) 만드는편이나으므로병변의범위나위치에따라조금씩변할수있다. 표식이끝나면상지를압박붕대로감아올린후지혈대는 250 mmhg로맞춘다. 3. 수술의진행 외상과, 요골두, 내상과가이루는삼각형의중앙부인연점 (soft spot) 을 21 G 주사기로천자하여관절내를약 20~30 cc 정도의식염수로팽창시킨다. 먼저전내측삽입구에 No. 11 blade를이용하여 nick and spread 방식으로삽입구를확보한다. 끝이무딘삽입기 (blunt trocar) 를이용하여소두를향하여관절내로진입한후식염수의누출을확인하고관절경을삽입한다. 전내측삽입구로진단적관절경을시행하여관절내이상을확인하고요골-소두추벽이나활액막의상태를관찰한다. 관절경의시야방향을조절하여소두부위로시야를옮기면소두와요골두사이에서단요수근신건을덮고있는관절막의상태를관찰할수있다 (Fig. 4A). 전내측삽입구로관찰하면서 21 G 바늘을삽입하여전외측삽입구를만드는데이때삽입구는되도록이면절제를염두해두고관절선에서위로올라오도록만드는것이시술하기에편하다 (Fig. 4B). A Fig. 4. (A-B) Arthroscopic photograph of left elbow showing (A) the status of joint capsule overlying extensor carpi radialis brevis and (B) 21 G needle from joint line for anterolateral portal (CT: Capitellum) B 해부학적으로소두관절연골의상단은단요수근신건의근위경계와일치한다는점을염두에두어야한다 (Fig. 5A, B). 79

84 제 2 회관절경수술심포지엄 A B Fig. 5. (A) Anatomic illustration depicting common extensor tendon origins and (B) Arthroscopic photograph showing relationship between capitellar cartilage margin and upper border of ECRB tendon origin. (Arrow indicates capitellar cartilage margin and dotted line indicates upper border of ECRB tendon. CT: Capitellum) 단요수근신건의기시부는관절외 (extraarticular) 구조물이므로전외측삽입구로 3.5 mm 절삭기를삽입한후관절막을절제해야관찰할수있다 (Fig. 6A). 단요수근신건의기시부를노출시킨후열전도장비를이용하여단요수근신건의절제를시작하는데소두상부의근위부착부부터시작하여원위부로진행해나간다 (Fig. 6B). 때때로부착부가이미파열된경우도있으며이때는부착부의변연절제를한다. 근위부에서건의절제가완성되면장요수근신건기시부를확인할수있다 (Fig. 6C). A B C Fig. 6. (A-C) Arthroscopic photograph of left elbow showing (A) ECRB origin after capsular resection and (B) ECRB release from proximal to distal direction with VAPER and (C) ECRL after release. (ECRB: extensor carpi radialis brevis, ECRL: extensor carpi radialis longus, CT: Capitellum) 원위부로절제를해나가면서단요수근신건절제시상완골소두또는요골두를가로지르는가상의중앙선을표식으로삼아이선의상방에서만건절제가이루어져야하며만약하방으로절제가내려갈경우외측척측측부인대손상을통한후외방불안정성을야기시킬수있다 (Fig. 7). 80

85 Upper Extremity Arthroscopy Fig. 7. Diagram of the safe zone for débridement in the management of lateral epicondylitis. The safe zone is defined by an area superior to the dashed line bisecting the radial head. 마지막으로단요수근신건보다표재부에위치하는후하방부의총수지신건의기시부골능 (ridge) 를확인하며절제를마치는데총수지신건의기시부를절제하면단요수근신건과총수지신건모두원위부로퇴축되어주관절외측부에심한연부조직약화를초래할수있다. 외상과에박피술이필요한지여부에대해서는논란에여지가있다. 박피술시에도외측척측측부인대와총수지신건의기시부에주의하면서시행하여야한다. 4. 수술후재활 술후 2~3일간압박드레싱과장상지부목으로고정하고 icing을시행한다. 이후부목을제거하면서주관절의수동적가동역회복운동을시작하고전완부신근근육군의마사지와온열요법을시행한다. 술후 3 주경관절운동영역이회복되면등척성근력운동을시작하고 6주경부터저항성운동, 8주부터활동의제한없이사용할수있도록허용한다. 결과와합병증 보존적치료에반응하지않는주관절외상과염의수술적인치료는시술방법과관계없이대부분의환자가수술후만족스러운결과를보인다. 그러나개방적절개를통한방법은절개반흔이있고총신전근건막을손상시킴으로써재활및운동복귀지연유발하고동반되는관절내이상을파악하기어려우며 20,21) 경피적유리술역시간단히외래에서국소마취하에서시행할수있는장점은있으나병변부건이그대로남아있고건절제여부를정확히판단하기가쉽지않다 22,23). 여러저자들이관절경적유리술의효과적인결과를보고하고있는데 Owens 등 5) 은 16 예의외상과염환자에대해관절경적유리술후전례에서증상호전을보였고평균수술 6일후활동에복귀할수있었다고하였고, Lattermann 등 24) 은 36 예중 34(94%) 예에서호전을보여평균 3.8주에일상복귀가가능하다고하였다. 최근 Baker 등 2) 은외상과염을관절경적유리술을시행한 42명의환자를평균 130개월간 ( 범위 106~173개월 ) 추시관찰하여 77% 가매우호전되었고 20% 는호전, 단지 3% 만이증상호전이없으며 26예 81

86 제 2 회관절경수술심포지엄 (87%) 에서수술에만족을보여관절경적유리술의장기적효과도우수함을보고하였다. 관절경적유리술은총신전근건막을보존하여술후주관절의잠재적불안정성등의합병증을줄일수있으며미용적효과와함께빠른일상복귀가가능하다는장점이있다. 이러한장점에도불구하고과연관절경하에서건의절제가충분히이루어지는가에대한의문이생길수있다. Smith 등 25) 의해부학적연구에의하면관절경적수술법은주관절주위의신경과혈관을보존하면서단요수근신건기시부의 100%, 총수지신건의 90% 를절제할수있다고도하였고, Cummins 26) 도술기터득에시간은걸리지만관절경상절제된건을개방적절개로확인해본결과육안적또는현미경적으로건절제이루어졌음을확인할수있었다고하였다. 그러나주관절관절경수술은주관절주위의복잡한신경과혈관분포로인해관절경삽입구의해부학적위치를충분히숙지해야하고건의절제시외측척측측부인대손상을유발하여술후의인성후외방불안정성이발생할수있으므로상완골소두또는요골두를가로지르는가상의중앙선을표식으로삼아이선의전방에서만건절제가이루어져야한다 4). 또한단요수근신건의잔여건절제시나절제후건의고유부착부를관찰시 70 도관절경을이용하여보다직접적시야를얻을수있으며장요수근신근의노출과수술진행에따른주관절부종으로시야가좁아지는경우가는 Wissinger 막대를이용하여근육을전방으로견인함으로써시야확보에도움을얻을수있다. 관절경적유리술은원인병소제거뿐만이아니라신전건막을손상시키지않고동반된관절내병변을동시에치료할수있는장점이있다. 또한건부착부의관절낭상태를파악하고분류할수있다. 외상과염의관절경수술시동반된관절내이상은 19~44% 로보고되고있으나 5,27) Baker 등 3) 은 69% 까지보고하여개방적절제술시 Nirschl과 Pettrone 19) 이보고한 11% 보다상당히높은빈도로발견됨을알수있다. 물론이러한관절내이상에대한처치가술후결과에영향을준다고단정짓기는어려우나술후잔여증상의원인이될수있을가능성은항상염두에두어야할것으로판단된다. 관절경적단요수근신건유리술을시행시박피술을시행한군과하지않은군을비교한연구에따르면박피술을시행한군에서술후통증이증가했으며장기적인이점은없었다고보고하였다 28). 관절경술의단점으로는술기터득에시간이걸리고관절경상에서건의절제가충분히이루어지는가에대한의문이생길수있으며, 주관절주위의복잡한신경과혈관분포로인해관절경삽입구의해부학적위치를충분히숙지해야신경혈관합병증을예방할수있다. 결 론 주관절외상과염은 90% 환자에서비수술적치료로호전될수있는자기제한적경과를보이나보존적치료에반응하지않는경우에는개방적, 경피적, 관절경적수술방법을통하여좋은결과를기대할수있다. 관절경적수술의경우단요수근신건절제술뿐만아니라관절내병변을함께치료할수있고조기재활의장점이있으나술기와관련된 learning curve를요할수있다. 82

87 Upper Extremity Arthroscopy REFERENCES 01. Baker CL. Arthroscopic versus open techniques for extensor tenodesis of the elbow. Tech Shoulder Elbow Surg 2000;1: Baker CL Jr, Baker CL III. Long-term follow-up of arthroscopic treatment of lateral epicondylitis. Am J Sports Med 2008;36: Baker CL Jr, Murphy KP, Gottlob CA, Curd DT. Arthroscopic classification and treatment of lateral epicondylitis: two-year clinical results. J Shoulder Elbow Surg 2000;9: Cohen MS, Romeo AA, Hennigan SP, Gordon M. Lateral epicondylitis: anatomic relationships of the extensor tendon origins and implications for arthroscopic treatment. J Shoulder Elbow Surg 2008;17: Owens BD, Murphy KP, Kuklo TR. Arthroscopic release for lateral epicondylitis. Arthroscopy 2001;17: Bunata RE, Brown DS, Capelo R. Anatomic factors related to the cause of tennis elbow. J Bone Joint Surg Am. 2007;89: Kim BS, Min GD, Cha JG, Lee JS. Ultrasonographic Measurement of Thickness of Extensor Carpai Radialis Brevis Tendons for Lateral Epicondylitis, J Korean Orthop Assoc 2009;44: Hay EM, Paterson SM, Lewis M, Hosie G, Croft P. Pragmatic randomized controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ 1999; 319: Smidt N, van der Windt DA, Assendelft WJ, Devillé WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002;359: Speed CA. Extracorporeal shock-wave therapy in the management of chronic soft-tissue conditions. J Bone Joint Surg Br 2004;86: Wilner JM, Strash WW. Extracorporeal shockwave therapy for plantar fasciitis and other musculoskeletal conditions utilizing the Ossatron-an update. Clin Podi Med Surg. 2004;21(3): Buchbinder R, Green SE, Youd JM, Assendelft WJ, Barnsley L, Smidt N. Systematic review of the efficacy and safety of shock wave therapy for lateral elbow pain. J Rheum. 2006;33(7): Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med 2010;38: Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year followup. Am J Sports Med. 2011;39(6): Hohmann G. Das wesen und die behandlung des sogennanten tenniss ellenbogens. Munch Med Wochenschr. 1933;80: Kaplan EB. Treatment of tennis elbow (epicondylitis) by denervation. J Bone Jonit Surg. 1959;41A: Wilhelm A. Treatment of theraphy refractory epicondylitis lateralis humeri by denervation. On the pathogenesis. Handchir Mikrochir Plast Chir. 1999;31(5): Garden RS. Tennis elbow. J Bone Joint Surg. 1961;43B: Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 83

88 제 2 회관절경수술심포지엄 1979;61: Dunn JH, Kim JJ, Davis L, Nirscle RP. Ten-to 14-year follow-up of the surgical technique for lateral epicondylitis. Am J Sports Med. 2008;36: Verhaar J, Walenkamp G, Kester A, van Mameren H, van der Linden T. Lateral extensor release for tennis Elbow: A prospective long-term follow-up study. J Bone Joint Surg Am. 1993;75: Yerger B, Turner T. Percutaneous extensor tenotomy for chronic tennis elbow: an office procedure. Orthopedics. 1995;8: Gundberg AB, Dobson JF. Percutaneous release of the common extensor origin for tennis elbow. Clin Orthop Relat Res. 2000;376: Lattermann C, Romeo AA, Anbari A, et al. Arthroscopic debridement of the extensor carpi radialis brevis for recalcitrant lateral epicondylitis. J Shoulder Elbow Surg. 2010;19: Smith AM, Castle JA, Ruch DS. Arthroscopic resection of the common extensor origin: anatomic considerations. J Shoulder Elbow Surg. 2003;12: Cummins CA. Lateral epicondylitis: in vivo assessment of arthroscopic debridement and correlation with patient outcomes. Am J Sports Med. 2006;34: Szabo SJ, Savoie FH III, Field LD, Ramsey JR, Hosemann CD. Tendinosis of the extensor carpi radialis brevis: an evaluation of three methods of operative treatment. J Shoulder Elbow Surg. 2006;15: Kim JW, Chun CH, Shim DM, Kim TK, Kweon SH, Kang HJ, Bae KH. Arthroscopic treatment of lateral epicondylitis: comparison of the outcome of ECRB release with and without decortications. Knee Surg Sports Traumatol Arthrosc. 2011;19:

89 Upper Extremity Arthroscopy Arthroscopic SLAP Repair: Should We Repair? Sports Medicine & Shoulder and Elbow Service, Gachon University, Gil Medical Center Young-Kyu Kim 85

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96 제 2 회관절경수술심포지엄 Remplissage: When I can do? Department of Orthopaedic Surgery, Ewha Womans University College of Medicine, Seoul, Korea Sang-Jin Shin, M.D. 서 론 전방골성관절와병변 ( 골성 Bankart 병변 ) 과후외방상와골두의압흔골절 (Hill-Sachs 병변 ) 은재발성전방불안정이있는환자에서자주발견된다. 관절와와상완골의골결손은견관절면과정적견관절안정화구조물의변형을유발하기때문에재발성탈구의원인이될수있다. Broca와 Hartmann은 1890년 Hill- Sachs 병변의관절와연 (glenoid rim) 에진입 (engagement) 을최초로언급한이후, Burtkart와 De Beer 등은 2000년관절경안정술의실패의원인으로골결손에관심을기울였으며그이후오늘날까지골결손의역할에대한관심은지속되고있다. 본 론 재발성견관절불안정과관절와와상완골의골결손의연관성을밝히기위하여여러연구가진행되었으며나름대로의분류도시도되어왔다. Taylor 등은첫번째전방탈구환자에서관절와결손은 22% 에서발견되었으며상완골골결손은 70% 에서발견되었다고하였으며, Bollier 등은재발성전방탈구환자에서관절와연의미란 (erosion) 이나골절이포함된관절와골결손이 48~86% 의환자에서발견되었다고하였다. Antonio 등과 Kim 등은재발성탈구환자의모든환자에서상완골압흔골절을보였다고하였다. 견관절불안정성이재발하는환자들은 Hill-Sachs 병변이크고깊을수록불안정성의위험이증가한다고알려져있다. 그러나, 관절와와상완골의골결손을수술적으로치료해야하는가는아직논란의여지가있으며, 또한치료를한다면어떻게치료할것인가의문제도아직확실히정해지지않았다. 여러생역학연구에서견관절불안정성에서골결손의중요성이밝혀졌지만임상적상황을고려할때골결손자체의중요성만을강조하기에는논란이될수있다. 그래서최근제시되는개념은관절와경로 (glenoid rim track) 를고려하여팔을올림에따라상완골두와관절와연의접촉면을밝히는것에더중요성이있다고인정되고있다. Burkhart와 De Beer 등이제시한진입 Hill-Sachs 병변 (Engaging Hill- Sachs lesion) 은팔을외전, 외회전함에따라관절와연이골결손의가장자리를넘어진입 (engagement) 하기에충분한크기의상완골두의압흔골절이라고설명하였다. 또한진입 Hill-Sachs 병변이관절경적 Bankart 봉합이후유발되는견관절불안정성의높은비율과연관되어있다고보고하였다. 92

97 Upper Extremity Arthroscopy Other surgical techniques 여러연구에서견관절불안정성과동반된상완골의골결손을해결하기위해여러시도들이있어왔다. 외전과외회전을제한시키는개방적관절낭이동술 (open capsular shift) 을시행하기도하고동종골연골이식술 (osteochondral allograft transplantation), 상완골통과성형술 (transhumeral head plasty), 장골능선골이식술 (iliac crest bone graft), 관절경을이용한 Latarjet 술식, 상완골절골술 (humeral osteotomy), 견관절치환술등이시도되고있다. 그러나이런방법들에는여러문제점이발생할수있는데장골능선골이식술의경우고관절통증과같은이식부위의합병증이발생할수있고, 상완골절골술의경우불유합, 부전유합, 내고정장치의이완, 주위근육역학의변형, 술후내회전의결여로인한견관절회전의변형등의문제가있을수있다. 또한동종골이식술 (structural allograft) 의경우정상해부학의변형을최소화하며복원시킬수있지만견갑하근의건절제술과관절낭절개 (capsulotomy) 를위해광범위한삼각흉근도달법 (deltopectoral approach) 이필요하며, 이식물흡수 (graft resorption), 불유합, 내고정장치의실패를걱정해야한다. 상완골통과성형술은덜침습적이고해부학적재건술이지만큰상완골결손이있는환자에서적절하지않을수있고심한골감소증 (osteopenia) 가있는환자에서적절한연골하고정 (subchondral support) 이어려울수있다. Remplissage procedure 1972년 Connly는술후재탈구를줄이기위해 Hill-Sachs 병변에극하건과관절낭을개방적이전 (open transfer) 시키는술식을시행하였다. 이는상완골두결손을채움으로서병변이관절외부에있게하고관절와연에상완골의진입을예방한다. 또한후방관절낭건고정술 (posterior capsulotenodesis) 는상완골두의전방전위를줄이고수술후재탈구를감소시키는역할을하게된다. 2004년 Wolf 등은이전에시행했던개방적수술법을관절경을이용하여시행하는것으로 Remplissage 술식을제시하였는데이는관절경을이용하여극하근건과관절낭을이전시켜 Hill-Sachs 병변에고정시키는술식이다. Patient evaluation 1. History 외상성전방어깨관절불안정의전형적인병력은팔의외전, 외회전그리고신전등에서간접적인손상으로인한경우가많다. 환자의병력청취는탈구로인한기능장애정도, 탈구의횟수, 정복의어려움정도, 신경혈관계문제, 수상전방사선검사결과, 수상전의치료력등이있다. 그리고재발의빈도를증가시키는요인으로경련, 넘어지는경향, kayaking과같은팔을외전, 외회전시키는활동여부, 알코올중독, 약물의존성등이있다. 93

98 제 2 회관절경수술심포지엄 2. Examination 환자에게처음수상시의자세를취해보라고하고, 어깨불안정을유발시키는자세를취해보도록한다. 삼각근과회전근개근력의문제가있는지알아봄으로서액와신경과회전근개의문제를파악할수있다. 그리고 load shift test를통해관절와오목면 (glenoid concavity) 의적절성을평가할수있다. 3. Imaging 적절한방사선검사로먼저기본적인견갑골면에대한전후방단순방사선, 액와 (axillary) radiograph, Apical oblique radiograph, Garth view 등을시행한다. 이런검사는무부하 (resting) 상태에서의관절와상완골관계 (relationship) 을파악할수있으며상완골과관절와의골결손, 상완결절 (tuberosity) 골절, 관절협착, 골극, 상완골의상방전이등을알수있다. 그밖에 Hill-Sachs 병변의존재와크기, 방향등을파악할수있는 Stryker notch view, 관절와연의이상여부를알수있는 West point axillary view 등을시행해볼수있다. 컴퓨터단층촬영은단순방사선으로파악하기어려운골결손을파악하는데유용하며 oblique coronal, sagittal, 3D reconstruction image를통해정확한골결손의정도를파악할수있다. 자기공명영상은불안정한어깨관절에서회전근개나다른인대의이상여부, 관절순파열을알수있다. 4. Surgical Technique 전신마취및사각근간신경차단 (interscalene nerve block) 후좌체위 (beach chair position) 에서전후방삽입구와 remplissage 삽입구로불리는부후위방삽입구 (accessory posterolateral portal) 를이용하여상완골골결손에직각으로봉합나사못 (suture anchor) 를삽입할수있다. 수술의지연이나어려움을줄이기위해 4단계의전략으로시행할수있다. Step 1: 관절와준비, 관절순과관절낭의전방으로견인봉합실의통과후방삽입구를통해관절순과하관절와상완인대 (inferior glenohumeral ligament) 는상외방으로움직일수있어야한다. 견인봉합실을한개나두개바깥쪽으로옮긴다음전방관절와연 2~6시를 shaver나 burr를이용하여변연절제술시행한다. Step 2: Hill-Sachs 준비, 상완골 anchor 삽입상완골두를전방으로전위시키면서 spinal needle을후외방삽입구에위치시킨다. 상완골두를 spinal needle이골결손에수직이되도록회전시키고 shaver를통해상완골결손을변연절제술을시행한다. 봉합나사못을하나는위쪽하나는아래쪽경계에위치시킨다. 94

99 Upper Extremity Arthroscopy Step 3: 봉합실통과, 상완골결손채움관절경을전상방으로옮기고 cannula를후외방삽입구에삼각근하공간 (subdeltoid space) 까지집어넣는다. 그리고 grasper (cleverhook 등 ) 을이용하여각각의봉합실을관절낭과극하건을통과시킨다. 상완골을정복한뒤, 팔을 neutral rotation 시키고두가닥의봉합실을회전근개활액낭편 (bursal side) 에서매듭을시행하여관절낭건고정술을시행한다. Step 4: 전방관절순 (Bankart) 복원술관절경을후방삽입구로옮기고전방관절순복원술을시행한다. Biomechanical study Giles 등은 Hills-Sachs 병변의 3가지치료방법에대한생역학를비교하였다. Remplissage, 상완골두동종이식술, 부분표면관절성형술 (partial resurfacing arthroplasty) 한세그룹의안정성과관절운동범위를비교하였다. 8 cadaver를통한실험결과 remplissage 그룹에서안정성은증가하고진입병변은제거되었으나관절운동범위의감소가있었고, 상완골두동종이식술그룹과부분표면관절성형술그룹에서는관절운동범위변화는없었으나부분표면관절성형술그룹에서 Hill-Sachs 병변의진입을완전히예방하지는못하였다. Clinical results Nourissat 등은 Remplissage 술식후 Bankart 복원술단독으로시행한그룹에비해관절운동범위의변형은차이가없었지만, 후상방통증을 30% 의환자에서경험하였다고하였으며, Zhu 등은 49명을대상으로 Remplissage 술식후 29 개월추시결과심각한기능장애없이어깨관절불안정의회복을보였으며, Park 등은 85% 의환자에서기능의회복및통증감소, 만족도의향상을보였다고보고하였다. 또한 Boileau 등은 47명의환자를대상으로평균 24개월추시결과약간의외회전의제한은있었지만스포츠로돌아가는데영향을주진않았고, 98% 의환자에서어깨관절불안정의회복을보였다고하였다. 결 론 Bankart 복원술와함께시행한관절경을이용한 Remplissage 술식은진입 Hill-Sachs 병변을동반한전방어깨관절불안정성의치료에효과적이며임상적으로약간의관절운동범위의제한이있을수있지만만족스런결과를보였다. 그러나아직까지확실한적응증은정해지지않았다. 95

100 제 2 회관절경수술심포지엄 REFERENCES 01. Beran, M. C.; Donaldson, C. T.; and Bishop, J. Y.: Treatment of chronic glenoid defects in the setting of recurrent anterior shoulder instability: a systematic review. J Shoulder Elbow Surg, 19(5): , Boileau, P.; O Shea, K.; Vargas, P.; Pinedo, M.; Old, J.; and Zumstein, M.: Anatomical and functional results after arthroscopic Hill-Sachs remplissage. J Bone Joint Surg Am, 94(7): , Elkinson, I.; Giles, J. W.; Boons, H. W.; Faber, K. J.; Ferreira, L. M.; Johnson, J. A.; and Athwal, G. S.: The shoulder remplissage procedure for Hill-Sachs defects: does technique matter? J Shoulder Elbow Surg, Elkinson, I.; Giles, J. W.; Faber, K. J.; Boons, H. W.; Ferreira, L. M.; Johnson, J. A.; and Athwal, G. S.: The effect of the remplissage procedure on shoulder stability and range of motion: an in vitro biomechanical assessment. J Bone Joint Surg Am, 94(11): , Giles, J. W.; Elkinson, I.; Ferreira, L. M.; Faber, K. J.; Boons, H.; Litchfield, R.; Johnson, J. A.; and Athwal, G. S.: Moderate to large engaging Hill-Sachs defects: an in vitro biomechanical comparison of the remplissage procedure, allograft humeral head reconstruction, and partial resurfacing arthroplasty. J Shoulder Elbow Surg, 21(9): , Longo, U. G.; Loppini, M.; Rizzello, G.; Romeo, G.; Huijsmans, P. E.; and Denaro, V.: Glenoid and humeral head bone loss in traumatic anterior glenohumeral instability: a systematic review. Knee Surg Sports Traumatol Arthrosc, Lynch, J. R.; Clinton, J. M.; Dewing, C. B.; Warme, W. J.; and Matsen, F. A., 3rd: Treatment of osseous defects associated with anterior shoulder instability. J Shoulder Elbow Surg, 18(2): , Nourissat, G.; Kilinc, A. S.; Werther, J. R.; and Doursounian, L.: A prospective, comparative, radiological, and clinical study of the influence of the remplissage procedure on shoulder range of motion after stabilization by arthroscopic Bankart repair. Am J Sports Med, 39(10): , Park, M. J.; Tjoumakaris, F. P.; Garcia, G.; Patel, A.; and Kelly, J. D. t.: Arthroscopic remplissage with Bankart repair for the treatment of glenohumeral instability with Hill-Sachs defects. Arthroscopy, 27(9): , Purchase, R. J.; Wolf, E. M.; Hobgood, E. R.; Pollock, M. E.; and Smalley, C. C.: Hill-sachs remplissage : an arthroscopic solution for the engaging hill-sachs lesion. Arthroscopy, 24(6): 723-6, Zhu, Y. M.; Lu, Y.; Zhang, J.; Shen, J. W.; and Jiang, C. Y.: Arthroscopic Bankart repair combined with remplissage technique for the treatment of anterior shoulder instability with engaging Hill-Sachs lesion: a report of 49 cases with a minimum 2-year follow-up. Am J Sports Med, 39(8): ,

101 제 2 회관절경수술심포지엄 Current update of arthroscopic surgeries: Solution of practical problem, Video Illustration and Case discussion Shoulder Arthroscopy 좌장 : 김정만 ( 동작경희병원 ), 김성재 ( 연세의대 )

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103 Shoulder Arthroscopy AS Bankart Repair 동아의대 김철홍 Operative pearls 1. Appropriate preoperative evaluation: glenoid / humeral head bone loss. 2. Evaluation under anesthesia: confirm the preoperative plan and assist with amount of capsular shift to perform. 3. Patient positioning: lateral decubitus ease of access to the superior, posterior, inferior, and anterior labrum and capsule (it is surgeon preference) 4. Anterosuperior portal 1 to avoid missing ALPSA lesions 2 better to evaluate anteroinferior glenoid bone loss 3 to assess extent of tear posteriorly. 5. Glenoid preparation: soft tissue is removed from the intended repair site a bleeding bed of bone (to enhance healing) Visualization of the posterior subscapularis muscle fibers indicates an adequate preparation of the labrum and capsular attachments to the glenoid and allows for sufficient mobilization for repair The axillary nerve is closest at the 6-o clock position, between 12.5 to 15 mm, and should be avoided. 6. Labral preparation: an elevator device release subperiosteally the capsulolabral tissue to easily float up to the glenoid face 7. Suture anchor placement: anchors are placed at the articular cartilage margin avoid non anatomic medial scapular neck placement. 8. Number of suture anchor: most anteroinferior labral tears a minimum of three suture 99

104 제 2 회관절경수술심포지엄 anchors should be used (3?6 o clock on a right shoulder; 6?9 o clock on a left shoulder). A standard repair is three anchors below 3 o clock (the equator). 9. Capsular plication: Abrasion of the capsule plication can be performed to an intact labrum (if there is healthy labral tissue) If there is any question, a suture anchor is preferred. Pearls for portals Proper portal placement is essential standard posterior and anterior-superior portals (high in the rotator interval) an anterior mid-glenoid portal: 3-o clock position on the glenoid (just superior to the subscapularis tendon) or trans-cuff working portal 4- to 6-o clock labral pathology: difficulty to appropriately repair through these standard portals. 7-o clock portal (2 to 3 cm lateral and 1 cm inferior to the posterior portal) Pearl/pitfalls of portal placement anterosuperior portal: high in the rotator interval. mid-glenoid portal: in the rotator interval, just superior to the subscapularis tendon. not always used, a 7-o clock (posterolateral) portal: * made for percutaneous anchor placement * small cannula may be inserted to facilitate glenoid anchor placement * repair inferiorly. axillary nerve: is closest at the 6-o clock position on the glenoid (12.5 mm~15 mm), which increases with abduction. Pearls for labrum preparation the surgeon spend time preparing and mobilizing the labrum-bone interface before anchor insertion and fixation A small bone-cutting type of shaver (3.0 to 3.5 mm) is useful to prepare the anterior glenoid neck on a high-speed reverse setting, 100

105 Shoulder Arthroscopy Anchors & capsular plication The standard arthroscopic Bankart repair typically three anchors placed below 3 o clock ideal anchor placement on the glenoid rim at a 45 angle relative to the glenoid surface 2 to 3 mm inside the anterior glenoid rim Additional anchors: 7 mm apart depending on the sizet of the labral defect not medially on the glenoid neck. Some have advocated a balanced repair, which includes repair of the anterior tear and posterior plication sutures to the intact posterior labrum if a balanced repair is desired and the posterior labrum is intact, it has been shown biomechanically that an intact labrum provides similar fixation strength to a suture anchor Tension the capsulolabral structures with the arm in slight external rotation. Pull on sutures before knot tying Suture tying knot should not be between articular interface REFERENCES 01. Kim S.H., Ha K.I.: Bankart repair in traumatic anterior shoulder instability: open versus arthroscopic technique. Arthroscopy 18.(7): Bottoni C.R., Smith E.L., Berkowits M.J., et al: Arthroscopic versus open shoulder stabilization for recurrent anterior instability: a prospective randomized clinical trial. Am J Sports Med 34.(11): Kim S.H., Ha K.I., Park J.H., et al: Arthroscopic posterior labral repair and capsular shift for traumatic unidirectional recurrent posterior subluxation of the shoulder. J Bone Joint Surg Am 85.(8): Freedman K.B., Smith A.P., Romeo A.A., et al: Open Bankart repair versus arthroscopic repair with transglenoid sutures or bioabsorbable tacks for Recurrent Anterior instability of the shoulder: a meta-analysis. Am J Sports Med 32.(6): Levine W.N., Flatow E.L.: The pathophysiology of shoulder instability. Am J Sports Med 28.(6): Ferrari D.A.: Capsular ligaments of the shoulder. Anatomical and functional study of the anterior superior capsule. Am J Sports Med 18.(1): Bigliani L.U., Newton P.M., Steinmann S.P., et al: Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. Am J Sports Med 26.(1): Burkhart S.S., De Beer J.F.: Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs 101

106 제 2 회관절경수술심포지엄 lesion. Arthroscopy 16.(7): Bushnell B.D., Creighton R.A., Herring M.M.: Bony instability of the shoulder. Arthroscopy 24.(9): Boileau P., Villalba M., Héry J.Y., et al: Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am 88.(8): Tauber M., Resch H., Forstner R., et al: Reasons for failure after surgical repair of anterior shoulder instability. J Shoulder Elbow Surg 13.(3): Snyder S.J., Karzel R.P., Del Pizzo W., et al: SLAP lesions of the shoulder. Arthroscopy 6.(4): Williams M.M., Snyder S.J.: A sublabral foramen must not be confused with a Bankart lesion. Arthroscopy 10.(5): Williams M.M., Snyder S.J., Buford, Jr., Jr.D.: The Buford complex-the cord-like middle glenohumeral ligament and absent anterosuperior labrum complex: a normal anatomic capsulolabral variant. Arthroscopy 10.(3): Howell S.M., Galinat B.J., Renzi A., et al: Normal and abnormal mechanics of the glenohumeral joint in the horizontal plane. J Bone Joint Surg Am 70.(2): Garth W.P., Slappey C.E., Ochs C.W.: Roentgenographic demonstration of instability of the shoulder: the apical oblique projection. J Bone Joint Surg Am Arciero R.A.,Taylor D.C.:Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am 80.(2): Bigliani L.U., Kelkar R., Flatow E.L., et al: Glenohumeral stability. Biomechanical properties of passive and active stabilizers. Clin Orthop Relat Res Huysmans P.E., Haen P.S., Kidd M., et al: The shape of the inferior part of the glenoid: a cadaveric study. J Shoulder Elbow Surg 15.(6): Lo I.K., Parten P.M., Burkhart S.S.: The inverted pear glenoid: an indicator of significant glenoid bone loss. Arthroscopy 20.(2): Detterline A.J., Provencher M.T., Ghodadra N., et al: A new arthroscopic technique to determine anteriorinferior glenoid bone loss: validation of the secant chord theory in a cadaveric model. Arthroscopy 25.(11):

107 Shoulder Arthroscopy AS reverse Bankart repair 충북의대 박경진 Posterior instability 1. Epidemiology/overview 1) Posterior shoulder instability is much less common than anterior instability, accounting for 2% to 5% of all unstable shoulders. 2) Approximately half of presenting cases are caused by traumatic injury. 3) Posterior shoulder dislocation can occur after a seizure or electrical shock. 4) Up to 50% of traumatic posterior shoulder dislocation go undiagnosed when patients are examined in hospital emergency departments. 2. Pathoanatomy 1) The primary stabilizers of the posterior shoulder are the superior glenohumeral ligament, the coracohumeral ligament, and the posterior portion of the IGHL. 2) The labrum deepens the glenoid and serves as a static restraint to posterior humeral head translation. 3) Repetitive episodes of subluxation may produce a marginal crack or erosion of the posterior labrum, a labral tear, and an incomplete and/or concealed avulsion of the posterior labrum. 4) Posterior shoulder dislocations that do not readily reduce are associated with humeral impression fractures (reverse hill-sachs). 5) Less common causes of posterior shoulder instability include retroversion or hypoplasia of the glenoid. 103

108 제 2 회관절경수술심포지엄 3. Evaluation 1) History (1) A history of trauma with the arm in the flexed, adducted, and internally rotated position may be the inciting event. (2) In patients with undiagnosed dislocations, the posterior shoulder is locked in an internally rotated position. (3) Voluntary dislocation of the shoulder must be ruled out before surgical repair is considered. 2) Physical examination (1) A patient with an acute or undiagnosed posterior dislocation may have a prominent posterior shoulder and anterior coracoid and a limited ability to rotate the shoulder externally. (2) Posterior instability may lead to compensatory scapular winging. (3) Specialized tests to assess posterior stability. ㄱ. Posterior stress test ㄴ. Jerk test 4. Treatment 1) Nonsurgical (1) Nonsurgical treatment should always be attempted first. (2) The arm should be immobilized in neutral rotation with elbow at the side. A short period of immobilization is followed by rotator cuff strengthening and periscapular stabilization. 2) Surgical (1) Indications - surgical intervention is indicated for patients who have symptoms that interfere with daily or sports activities, and for patients in whom nonsurgical treatment fails. (2) Contraindications - Surgery is contraindicated for voluntary dislocators. 3) Surgical procedures (1) Soft-tissue procedures ㄱ. Open or arthroscopic labral repair and capsular shift 104

109 Shoulder Arthroscopy ㄴ. Some authors recommend plication of the rotator interval as part of an arthroscopic procedure (controversial). (2) Procedures for engaging reverse Hill-Sachs lesions. ㄱ. Structural bone graft to humeral head ㄴ. McLaughlin procedure: Transfer of lesser tuberosity into the defect 5. Surgical complications 1) Recurrence is the most common complication. Rates range from 7% to 50%. 2) Generalized stiffness or adhesive capsulitis 3) Overtightening the posterior capsule can lead to anterior subluxation or coracoid impingement. 4) Axillary or suprascapular nerve injury 6. Surgical pearls and pitfalls 1) For arthroscopic posterior labral work, a high lateral portal is better than the standard posterior portal. 2) For arthroscopic stabilization, the lateral decubitus position provides increased visualization. 7. Rehabilitation 1) Postoperatively, the shoulder should be placed in a rigid immobilizer with the arm abducted to 30 and in neutral rotation. The elbow should be posterior to the plane of the body to limit stress on the repair. 2) After a short period of immobilization, range of motion and strengthening exercises should begin. 3) The patient may return to full heavy labor or contact sports 6 months after surgery. Multidirectional instability 1. Epidemiology/overview 1) Multidirectional instability (MDI) has variable presentations and is difficult to quantify. 105

110 제 2 회관절경수술심포지엄 2) It is characterized by global laxity (anterior, posterior, and inferior) with reproducible symptoms inferiorly and in at least one other direction. 3) Incidence - MDI peaks in the second and third decades of life. 2. Pathoanatomy 1) The two classic lesions of MDI are a patulous inferior capsule (which contains the anterior and posterior bands of the IGHL) and a functional deficiency of the rotator interval. 2) Patients often have generalized ligamentous laxity. 3) Although patients with classic MDI do not have labral pathology, repeated subluxations or a traumatic event may lead to a Bankart lesion or a bony erosion of the glenoid. 3. Evaluation 1) History (1) Symptoms include pain, weakness, paresthesia, popping or clicking of the shoulder, instability of the shoulder during sleep, difficulty with throwing, and discomfort in the shoulder when carrying objects. (2) Differential diagnoses include unidirectional instability of the shoulder, cervical disease, brachial plexitis, and thoracic outlet syndrome. (3) Trauma superimposed upon intrinsic laxity may lead to pathologic instability of the shoulder. 2) Physical examination (1) To assess for generalized ligamentous laxity, ability to abduct the thumb to reach the forearm, and genu recurvatum. (2) Tests ㄱ. The sulcus sign assesses the rotator interval. ㄴ. Additional tests described previously (posterior instability) (3) Rotator cuff tendinitis or impingement in a young individual (age <20 years) should raise suspicion for MDI. 106

111 Shoulder Arthroscopy 4. Treatment 1) Nonsurgical (1) A physical therapy regimen that includes rotator cuff strengthening and a focus on scapular kinematics should be the first line of treatment for at least 3 to 6 months after injury. (2) A complete nonsurgical treatment program for MDI should include scapular kinematics and proprioceptive training. 2) Surgical (1) Indications ㄱ. Pain and instability that interferes with daily or sports activities. ㄴ. Pain and instability that does not respond to nonsurgical treatment. (2) Contraindications ㄱ. Surgery is contraindicated for voluntary dislocators. ㄴ. Nonsurgical treatment options should be maximized before considering surgery. 3) Surgical procedures (1) Arthroscopic - Pancapsular plication with or without tightening of the rotator interval. If labral pathology is encountered, anterior or posterior Bankart repair is indicated. To avoid asymmetric tightening, capsulorraphy should address the inferior redundancy in a balanced fashion. (2) Open - Anteroinferior capsular shift 5. Complications 1) Recurrence of MDI 2) Axillary nerve injury 3) Stiffness and loss of motion (rare) 4) Subscapularis insufficiency (after open procedure) 6. Rehabilitation 1) Postoperative immobilization through the use of a sling or rigid arthrosis for 4 to 6 weeks (may vary) 107

112 제 2 회관절경수술심포지엄 2) Minor activities of daily living may be allowed 6 to 10 weeks after surgery, with abduction and external rotation of the shoulder limited to 45. 3) Gradual range of motion exercises should begin 10 to 16 weeks after surgery. 4) Rotator cuff and scapular strengthening may begin approximately 16 weeks after surgery. 5) The patient may resume sports activities when normal strength and motion are achieved, but contact sports should be avoided for approximately 10 months after surgery. 108

113 Shoulder Arthroscopy 골성 Bankart 병변 Bony Bankart lesion 건국대학교병원정형외과 박진영 전승협 서 론 견관절은구형의상완골두와접시모양의견갑골관절와 (glenoid) 로이뤄진관절로서고관절에비해골성구속이약해큰운동범위를가지는반면에안정성은낮은관절이다 2). 따라서견관절에서는관절낭과인대및회전근개와같은연부조직이안정성의유지에큰역할을한다. 이러한해부학적특징때문에견관절은외상성탈구가빈발하며급성탈구가재발성불안정성으로진행하는비율이사지의관절중에서가장높은것으로알려져있다 1,2,4). 외상성견관절전방탈구의필수병변으로알려져있던 Bankart 병변은전하방관절와순의파열로서이는견관절의외전-외회전상태에서관절안정성에가장중요한역할을하는하관절와상완인대 (inferioir glenohumeral ligament) 의기능상실을의미한다 3). 전방불안정성에서발생하는골결손에는관절와 (glenoid) 의전하방골결손인골성 Bankart 병변과상완골두의후외방골결손으로지칭되는 Hill-Sachs 병변이있다. 외상성탈구또는지속적인불안정시에관절와의골절또는골성미란이발생할수있는데, 이를골성 Bankart 병변이라일컫는다. 관절와골은견관절의안정성에중요한역할을갖기에, 골성 Bankart 병변의골소실은주의깊게치료하지않으면재발성탈구의가능성이높아질수있다 15,23,27). 골성 Bankart 병변은외상성탈구과함께상완골두를통한관절와에강한힘이가해지거나팔의내전과함께탈구가발생하는경우발생한다. 전방탈구와동반되어약 5.4~44% 에서골성 Bankart 병변이발생된다 25). 최근젊은남성에서그빈도가증가하고있어그치료에대해많은연구가이루어지고있다. 본장에서는골성 Bankart 병변의치료에대하여알아보고자한다. 본 론 1. 관절와골결손 (Glenoid bone loss) 의평가 관절와골결손은오목압박기전에영향을미쳐견관절의전방이동에대한불안정증을야기할수있으며, 실제로여리문헌에서보고되고있듯이관절와의골결손정도는견관절불안정증치료의성공여부에 109

114 제 2 회관절경수술심포지엄 매우큰영향을미친다 9,15,26-28). 즉, 관절와골결손의크기및상태는수술방법을결정하는데매우중요하며, 골결손을정확히평가하여적절한치료방법을선택하는것은치료의성공을위한핵심이라할수있으며, 이에많은저자들이관절와골결손의형태및크기를파악하고재발성불안정증과관련을연구하려는시도를해왔다. Rowe 등 27) 은처음으로관절와골결손의크기와 Bankart 복원술의결과의상관관계를연구하였는데, 관절와표면의 1/6에서 1/3까지의골결손은수술결과에큰영향을미치지않는다고하였다. 전방관절와의골결손이심할수록연부조직재건술만으로는술후재발및불량한결과를초래한다고알려져있다. Bigliani 등 5) 은재발성불안정성및전방관절와병변이있는 25명의환자를병변의특징에따라관절와골결손을 Type I ( 전위된견열골절 ), type II( 부정유합된견열골절 ), type III( 관절와연의미란 ) 의 3가지그룹으로나누고, 다시 type III는 25% 이하의관절와골결손형태인 IIIa와 25% 이상의 IIIb로세분하였다. IIIb형의경우는큰골결손으로인하여오구돌기이전술과같은골이식이필요하다라고하였으며, 이후 Itoi 등은 15) 골결손을만들어생체역학을조사한카데바연구에서골결손부의길이가관절와길이의 21% 에상응하면탈구가쉽게생긴다고하였고골결손의크기가커질수록안정성이감소한다고하였다. 그의연구결과는비교적쉬운방법으로골결손의정도를측정하여골이식술의시행필요성을결정할수있어의미가있다고할수있다. 그리고 3D CT 이미지의발전으로이를이용한골결손정도측정이용이해졌다. Burkhart 등 9) 은관절경적측정과비교하여수술전 3차원재현컴퓨터전산화단층촬영 (3D CT scan) 이골이식술시행을결정할수있는지연구하였다. 상당한크기의골결손을지닌관절와를 Inverted pear 모양의관절와 라고명명하면서, 연부조직술식을시행한 194예를후향적으로조사한결과 inverted pear 모양의관절와의경우 61% 가재탈구되었으나, 그렇지않은예에서는 4% 만이재탈구를일으켜, 골결손이큰경우연부조직에대한술식만으로는부족하다고하였으며, 관절경소견상골결손이 25% 이상인경우골이식이별도로필요하다고하였다. 최근 Park 등은 22) 관절조영제를투여한후시행한컴퓨터전산화단층촬영을통하여 Bankart 재건술후관절와순높이 (labral height) 가술후임상적결과에중요한인자라는것을보고하였다. 3차원재현컴퓨터전산화단층촬영 (3D CT scan) 이나관절조영제를투여한후시행한컴퓨터전산화단층촬영 (CT arthrogram) 을통하여골결손병변의진단및술전골결손크기의평가가용이해졌으며, 수술전수술의계획과환자설명등에추가적진단방법으로정확하고유용한방법으로사용되고있다. 2. 골성 Bankart 병변의치료 술전에관절와병변의위치와크기를명확히진단하고, 적절한치료계획을세우는것이예후에중요한영향을미치기때문에병변의양상과위치를파악하는것이중요하다. Boileau 등은 8) 재발성불안정증환자의 49% 에서골성관절와병변이있었음을보고하였고전방관절와의견열골절 (avulsion fracture) 형태와압박골절 (compression fracture) 형태로구분하였다. 여기서두번째형태인압박골절형태에서 Bankart 재건술후재발성불안정증이더많이일어난다고보고하였다. 따라서, 골성 Bankart 병변치료의실패의주된요인이골소실로인한관절와의버팀목기능감소임을 110

115 Shoulder Arthroscopy 감안할때, 골편의소실을최소화하도록유의하는것이필요하다. 대부분에서병변의위치는주로관절와전하방에있으며, 골결손이나골절의크기에따라치료방법이결정되어야한다. 그리고수술의결과에영향을미치는인자들 - 자발적탈구, 전반적인인대이완성, 다방향성불안정성, 상완골두나관절와의골결손등-을모두파악하고치료계획을세워야한다 9,13,15). 골성 Bankart 병변에대한수술적치료는관혈적혹은관절경적술식으로이루어진다. 관절와골결손의크기와상관없이관절경적수술이좋은결과를나타낸다는보고도있으나 8,30), 대다수에서골결손의크기가큰경우오구돌기이전술이나장골이식과같은골이식을동반한관혈적방법으로의수술이바람직하다고보고되고있다 8,21,31). 최근견관절병변에대한관절경적치료가발전하면서골성 Bankart 병변의관절경적치료에대한연구가활발히이루어지고있고좋은결과가보고되고있으며점차관절경적봉합수술이보편화되는추세이다 25,32). Porcellini 등은 24) 관절와 25% 이하의급성외상성골성 Bankart 병변을가진운동선수환자 25명을대상으로 suture anchor를이용한관절경적고정술을시행하여불안정성의재발없이좋은결과를보고하였다. Sugaya 등 17,30) 역시골결손이있는경우에도관절경적수술이시도되었는데, 골성 Bankart 병변이나심지어전하방관절와가압박된골결손병변에서도골편을이용하여관절경적관절와재건이가능하다고하였다. 전통적인관절경적 Bankart 재건술, 즉일열봉합법은비록좋은임상결과를나타내지만몇가지한계점이있다. 봉합나사가골절절편을압박하지못하며단일점의고정이기때문에골편이전위될수있고, 골편을통과시킬때골편이깨질염려도있다. 이러한단점을보완하기위해이열봉합술이제안되었다. Millett 등은 20) 골성방카르트병변의치료로관절경을이용한 Bony Bankart bridge procedure를소개하였다. 이열고정술 (double-row) 및교량형봉합술 (suture-bridge) 에착안하여두점고정 (2-point fixation) 을만들어골편에압박을가하여고정하였다. 골편에압박을가할수있어추가적인골편회전을막을수있는것이기존의일열봉합과의큰차이점이다. 하지만, 관절와아래로봉합나사못을위치시킬때기술적으로어려움이많으며견갑하근을뚫어봉합나사못을삽입해야하므로견갑하근의손상이불가피하게발생할수있는문제점이있으며, 비흡수성봉합사가골병변부위의관절면을가로질러위치하기때문에매듭과함께관절와혹은상완골두에부식 (erosion) 과같은합병증을야기할가능성이있다. 또다른이열봉합법으로 Lafosse 등 18) 은전방관절순과관절낭의중요성을강조하면서관절낭-순복합체를보다견고하게고정하기위하여 W모양의이열봉합을시도하였다 (Fig. 1). W 모양의별자리이름에서 cassiopeia라고명명하였고, 먼저관절와경부내측에두개의봉합나사로관절낭을고정한후관절와경계부에세개의봉합나사를이용하여관절순을고정하여보다넓은관절낭- 순복합체와골과의접촉면을확보하여본래의해부학적부착부위 (footprint) 를재건하였다. 또한 Kim 등은 16) 관절경적 three-point double-row repair을소개하였고, 세점의고정으로효과적이고단단한고정력을얻을수있을뿐만아니라관절와공간을통과하는봉합사없이고정할수있어비흡수성봉합사에의한합병증을가능성을낮출수있지만, 기술적인어려운점과증례수 (6명) 가부족하고추시기간이짧은한계점이있다 (Fig. 2). 111

116 제 2 회관절경수술심포지엄 Fig. 1. Principle of Cassiopeia double-row technique (Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 22, No 2 (February), 2006) A B C D Fig. 2. Three - point double - row repair (Knee Surg Sports Traumatol Arthrosc (2009) 17: ) 최근더욱견고한고정과해부학적복원을위한이점, 삼점고정술, 그리고일열보다이열로고정하려는시도들이이뤄지고있지만, 아직수술법의소개정도이며많은증례를통한임상결과보고는미흡한실정이다. 관혈적수술은일단술자가관절경적술기에익숙치못하고개방적수술에탁월한능력이있다면이를먼저고려하여야할것이며, 일반적으로관절와의골결손이 25% 이상인경우와 Hill Sachs 병변이큰경우, 이전의수술이실패한경우, 환자가수술후재활등순응도가좋지못한경우등이그적응증이될수있을것이다 11). 112

117 Shoulder Arthroscopy 전술했듯이, 골결손이큰환자에서는오구돌기이전술이나장골이식과같은골이식이요구된다 4,5,8,31). 최근엔오구돌기이전술의일종인 Bristow-Latarjet 수술법이주로쓰인다 (Fig. 3). 이수술법은상완이두근단두건및오구상완건을부착한채로오구돌기를절단하여견갑경부전하방에이전고정하는자가생골이식술식으로, 크게세가지효과를갖는장점을갖고있다. 첫째, 관절와의전후방직경이증가하는골성효과, 둘째, 관절막에오구견봉인대를부착할수있는인대효과, 셋째, 하부견갑하근에대한단두건및오구상완건의해먹효과가관절와상완관절의안정성을증가시킨다 10). 하지만정상관절와의오목함을재건할수없는비해부학적술식으로해부학적인관절와의깊이와관절면의일치를가져오기힘들고, 관절운동의제한, 관절염의발생, 나사못의파괴및불유합등의합병증이보고되기도한다. 여러문헌에따르면, 술후탈구나아탈구와같은견관절불안정증의재발율은 0% 에서 12% 까지보고되었다 10,12,14,29). 이러한골이식및오구돌기이전술도 Boileau 등과 6,7) Lafosse 등 19) 이보고한바와같이최근에는관절경적방법을사용하여좋은결과를보고하고있는것이사실이나, 아직장기추시관찰이이루어지지않았고기술적으로매우어렵기때문에관절경적술식에대한동의가이루어지지않은상태이다. Fig. 3. Bristow-Latarjet procedure 결 론 외상성견관절탈구또는지속적인불안정성으로인해발생하는골성 Bankart 병변은 3차원재현컴퓨터전산화단층촬영이나관절조영제를투여한후시행한컴퓨터전산화단층촬영을통하여골결손병변의진단및술전골결손크기의평가가용이해졌다. 13) 술전관절와골결손의크기및환자의직업, 운동강도등을고려하여적절한치료계획을수립해야한다. 주로관절경하 Bankart 수술로치료가가능하나, 일반적으로 25% 이상의큰관절와골결손이나레슬링, 격투기와같은격렬한운동을하는환자에있어서는관혈적 Bankart 수술또는골이식술을고려해야한다. 수술적치료방법역시수술기구와수술방법의급속한개발로인해해를거듭할수록다양해지고진화하고있지만, 여러가지새로운수술방법은앞으로더욱많은증례와장기간의추시를통하여그결과가입증되어야할것으로생각된다. 113

118 제 2 회관절경수술심포지엄 REFERENCES 01. Abboud JA, Soslowsky LJ: Interplay of the static and dynamic restraints in glenohumeral instability. Clin Orthop Relat Res: 48-57, Bahk M, Keyurapan E, Tasaki A, Sauers EL, McFarland EG: Laxity testing of the shoulder: a review. Am J Sports Med, 35: , Bankart AS: RECURRENT OR HABITUAL DISLOCATION OF THE SHOULDER-JOINT. Br Med J, 2: , Bigliani LU, Kelkar R, Flatow EL, Pollock RG, Mow VC: Glenohumeral stability. Biomechanical properties of passive and active stabilizers. Clin Orthop Relat Res: 13-30, Bigliani LU, Newton PM, Steinmann SP, Connor PM, McLlveen SJ: Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. Am J Sports Med, 26:41-45, Boileau P, Mercier N, Old J: Arthroscopic Bankart-Bristow-Latarjet (2B3) Procedure: How to Do It and Tricks To Make it Easier and Safe. Orthop Clin North Am, 41: Boileau P, Mercier N, Roussanne Y, Thelu CE, Old J: Arthroscopic Bankart-Bristow-Latarjet procedure: the development and early results of a safe and reproducible technique. Arthroscopy, 26: Boileau P, Villalba M, Hery JY, Balg F, Ahrens P, Neyton L: Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am, 88: , Burkhart SS, De Beer JF: Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy, 16: , Burkhart SS, De Beer JF, Barth JR, Cresswell T, Roberts C, Richards DP: Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss. Arthroscopy, 23: , Cole BJ, Romeo AA: Arthroscopic shoulder stabilization with suture anchors: technique, technology, and pitfalls. Clin Orthop Relat Res: 17-30, Dossim A, Abalo A, Dosseh E, Songne B, Ayite A, Gnandi-Pio F: [Bristow-Latarjet repairs for anterior instability of the shoulder: clinical and radiographic results at mean 8.2 years follow-up]. Chir Main, 27:26-30, Griffith JF, Antonio GE, Tong CW, Ming CK: Anterior shoulder dislocation: quantification of glenoid bone loss with CT. AJR Am J Roentgenol, 180: , Hart R, Svab P, Krejzla J: [Modified Latarjet procedure for recurrent shoulder dislocation in elderly patients]. Acta Chir Orthop Traumatol Cech, 77: Itoi E, Lee SB, Berglund LJ, Berge LL, An KN: The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg Am, 82: 35-46, Kim KC, Rhee KJ, Shin HD: Arthroscopic three-point double-row repair for acute bony Bankart lesions. Knee Surg Sports Traumatol Arthrosc, 17: , Kon Y, Shiozaki H, Sugaya H: Arthroscopic repair of a humeral avulsion of the glenohumeral ligament lesion. Arthroscopy, 21:632, Lafosse L, Baier GP, Jost B: Footprint fixation for arthroscopic reconstruction in anterior shoulder instability: 114

119 Shoulder Arthroscopy the Cassiopeia double-row technique. Arthroscopy, 22: 231 e e236, Lafosse L, Lejeune E, Bouchard A, Kakuda C, Gobezie R, Kochhar T: The arthroscopic Latarjet procedure for the treatment of anterior shoulder instability. Arthroscopy, 23: 1242 e , Millett PJ, Braun S: The bony Bankart bridge procedure: a new arthroscopic technique for reduction and internal fixation of a bony Bankart lesion. Arthroscopy, 25: , Montgomery WH, Jr., Wahl M, Hettrich C, Itoi E, Lippitt SB, Matsen FA, 3rd: Anteroinferior bone-grafting can restore stability in osseous glenoid defects. J Bone Joint Surg Am, 87: , Park JY, Lee SJ, Lhee SH, Oh JH: Change in labrum height after arthroscopic Bankart repair: correlation with preoperative tissue quality and clinical outcome. J Shoulder Elbow Surg, 21: Pollock RG, Bigliani LU: Glenohumeral Instability: Evaluation and Treatment. J Am Acad Orthop Surg, 1:24-32, Porcellini G, Campi F, Paladini P: Arthroscopic approach to acute bony Bankart lesion. Arthroscopy, 18: , Porcellini G, Paladini P, Campi F, Paganelli M: Long-term outcome of acute versus chronic bony Bankart lesions managed arthroscopically. Am J Sports Med, 35: , Rowe CR: Prognosis in dislocations of the shoulder. J Bone Joint Surg Am, 38-A: , Rowe CR, Patel D, Southmayd WW: The Bankart procedure: a long-term end-result study. J Bone Joint Surg Am, 60:1-16, Rowe CR, Sakellarides HT: Factors related to recurrences of anterior dislocations of the shoulder. Clin Orthop, 20:40-48, Schroder DT, Provencher MT, Mologne TS, Muldoon MP, Cox JS: The modified Bristow procedure for anterior shoulder instability: 26-year outcomes in Naval Academy midshipmen. Am J Sports Med, 34: , Sugaya H, Moriishi J, Kanisawa I, Tsuchiya A: Arthroscopic osseous Bankart repair for chronic recurrent traumatic anterior glenohumeral instability. Surgical technique. J Bone Joint Surg Am, 88 Suppl 1 Pt 2: , Warner JJ, Gill TJ, O Hollerhan J D, Pathare N, Millett PJ: Anatomical glenoid reconstruction for recurrent anterior glenohumeral instability with glenoid deficiency using an autogenous tricortical iliac crest bone graft. Am J Sports Med, 34: , Wolf EM: Arthroscopic capsulolabral repair using suture anchors. Orthop Clin North Am, 24: 59-69,

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121 제 2 회관절경수술심포지엄 Current update of arthroscopic surgeries: Solution of practical problem, Video Illustration and Case discussion Shoulder Arthroscopy Case Panel Discussion moderator 박태수 ( 한양의대 ) 노규철 ( 한림의대 ), 유재철 ( 성균관의대 ), 김양수 ( 가톨릭의대 )

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123 Shoulder Arthroscopy Case Panel Discussion Shoulder Arthroscopy Case Panel Discussion 노규철 ( 한림의대 ), 유재철 ( 성균관의대 ), 김양수 ( 가톨릭의대 ) 119

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125 제 2 회관절경수술심포지엄 Current update of arthroscopic surgeries: Solution of practical problem, Video Illustration and Case discussion Knee Arthroscopy & Osteotomy 좌장 : 배대경 ( 경희의대 )

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127 Knee Arthroscopy & Osteotomy Posterior cruciate ligament reconstruction -Arthroscopic trans-tibial single bundle PCL reconstruction 중앙대흑석동병원 정호중 Exam under general anesthesia Lachman test - DDx combined PLRI 1-3) Posterolateral drawer test - reduced and unreduce position 4) Varus stress test - DDx Gr3 PLRI Arthroscopic examination posterolateral drive through sign - PFL, POP, Post-sup popliteomeniscal fascicle Empty wall sign - melting out of PCL remnant consider the DB PCLR ACL pseudolaxity - definite sign of PCL rupture Tibial tunnel preparation trans-septal technique lateral side of posterior capsule release (using 90 curved rasp) tibial tunnel point - Just lateral to the remnant PCL 15 mm below the LFC 50 PCL angle guide through the AM portal-between ACL & PCL (over the PCL) Guide pin insertion (5~6 cm) without fluoroscopy Diameter 8~9 mm reaming with reamer Femoral tunnel preparation Out-side in technique - under the Vastus medialis, ant to the adductor tubercle, proximal 1.5~2 cm to distal articular surface femoral tunnel point - 11:30(Rt), 12:30(Lt) contact to the articular cartilage 5-7) 123

128 제 2 회관절경수술심포지엄 Preparation for Rigid-fix for tibial tunnel fixation Flush the Guide to the posterior orifice of tibial tunnel 1 cm pull-out the guide rigid fix sheath insertion (Just anterior above the fibular head tip) confirm inside location of the sheathe Graft passage Femoral tunnel Pull-out through the AL portal intra-articular (over the PCL) 8) tibial tunnel (to avoid difficult passage of acute bending angle) Femoral tunnel fixation same diameter of bioscrew Pretension (passive range of motion 20 times) to settle down femoral fixation (60~70% in 20 cycle) Isometry check Usually shortening in deep flexion Tibial tunnel fixation Usually 90 flexion, full tension Rigid fix fixation REFERENCES 01. Li G, Gill TJ, DeFrate LE, Zayontz S, Glatt V, Zarins B: Biomechanical consequences of PCL deficiency in the knee under simulated muscle loads--an in vitro experimental study, J Orthop Res 2002, 20: Pearsall AWt, Hollis JM: The effect of posterior cruciate ligament injury and reconstruction on meniscal strain, Am J Sports Med 2004, 32: Race A, Amis AA: Loading of the two bundles of the posterior cruciate ligament: an analysis of bundle function in a-p drawer, J Biomech 1996, 29: Jung YB, Lee YS, Jung HJ, Nam CH: Evaluation of posterolateral rotatory knee instability using the dial test according to tibial positioning, Arthroscopy 2009, 25: Burns WC, 2nd, Draganich LF, Pyevich M, Reider B: The effect of femoral tunnel position and graft tensioning technique on posterior laxity of the posterior cruciate ligament-reconstructed knee, Am J Sports Med 1995, 23:

129 Knee Arthroscopy & Osteotomy 06. Galloway MT, Grood ES, Mehalik JN, Levy M, Saddler SC, Noyes FR: Posterior cruciate ligament reconstruction. An in vitro study of femoral and tibial graft placement, Am J Sports Med 1996, 24: Mannor DA, Shearn JT, Grood ES, Noyes FR, Levy MS: Two-bundle posterior cruciate ligament reconstruction. An in vitro analysis of graft placement and tension, Am J Sports Med 2000, 28: Jung HJ, Kim JH, Lee HJ, Koo S, Chang SH, Jung YB, Lee SH: The isometry of two different paths for remnant-preserving posterior cruciate ligament reconstruction, Knee Surg Sports Traumatol Arthrosc

130 제 2 회관절경수술심포지엄 Medial Patellofemoral Ligament Reconstruction 고려대학교의과대학안산병원정형외과 배지훈 Anatomy of Medial Patellofemoral Ligament Layer 2 (Warren and Marshall) of medial side of the knee Flat, fan-shaped structure that is larger at its patellar attachment than at its femoral origin Femoral attachment: Saddle area between the medial epicondyle and the adductor tubercle Patellar attachment: Proximal half to third of the medial aspect of the patella Legth average 58 mm (47~70 mm) Fig. 1. Bony attachments of medial structures of the knee (From Noyes Knee Disorders, 1 ST edition) 126

131 Knee Arthroscopy & Osteotomy A Fig. 2. (A) Anatomy of medial patellofemoral ligament (MPFL) and medial aspect of knee, showing points A through F on MPFL. (B) Frontal view showing vertical distance from superior pole of patella (SP) to superior edge of MPFL (A) and inferior edge of MPFL (C) (From Steensen RN et al, AJSM 2004; 32:1509) B Function of Medial Patellofemoral Ligament Primary static stabilizer of lateral patellar subluxation at low flexion angle of knee (0~20 degree) During the first 20 degree of knee flexion, the MPFL guides the patella into the trochlear groove Indication of MPFL Reconstruction Symptomatic recurrent lateral subluxation or dislocation Skeletally mature patients Failed non operative treatment Q-anlge < 20 degrees TT-TG < 15 mm Preoperative Considerations Assess the risk factors of recurrent patellar instability Patellar alta 127

132 제 2 회관절경수술심포지엄 Trochlear dysplasia Increased Q-angle Genu valgum Excessive femoral anteversion Increased TT (tibia tuberosity) - TG (trochlear groove) distance (> 20 mm) generalized ligament laxity Table 1. Determining factors for surgical treatment options Physical Examinations Evaluate the limb alignment with standing and walking Identify tender point along the course of the MPFL in acute dislocation: the location of MPFL tear Check cruciate and collateral ligament Patellar compression test with flexion and extension: articular crepitus or pain Patellar tracking (J sign) Apprehension test Quantify the amount of the patellar translation: pushing the medial side of the patellar at full extension, MPFL incompetence if the patellar translates greater than 50% of its width form the center of the sulcus Feel the end point during patellar translation: soft end point if MPFL incompetence Assess the lateral retinaculum tightness: patellar tilting test Measure the Q-angle Rule out other sources of pain 128

133 Knee Arthroscopy & Osteotomy Radiographic Evaluation Evaluate the lower limb coronal, sagittal & rotational alignment Both knee AP in supine and standing, Lower extremity AP in standing Both knee tunnel: osteochondral loose body, OCD lesion Both knee lateral in 30 degree of flexion: patellar height, trochlear dysplasia Dynamic Merchant view (20, 30, 45, 60 degree of knee flexion angle): patellar tracking and alignment CT (20 degrees of knee flexion), MRI : Patellofemoral alignment, Trochlear dysplasia, TT- TG distance Anteversion CT: femur anteversion, femur & tibia torsion MRI: cartilaginous structures, better anatomic approximation of the trochlear articular cartilage groove, meaningful information about all of the soft tissue structures about the knee joint Surgical Steps Diagnostic arthroscopy Graft harvest (semitendinous autogaft) and preparation Patella tunnel preparation Femoral tunnel preparation Graft passage, tensioning & fixation 1. Patient positioning & Exam under anesthesia Supine position on the operative table with or without C-arm (lateral view) General or spinal anesthesia Check patellar stability, translation (amount & consistency of the endpoint), tilt at 0 and 30 degrees of knee flexion, compared to contralateral knee 2. Arthroscopy patellar tracking through superolateral portal Hemorrhage in the soft tissue adjacent to the medial edge of the patella in patients who 129

134 제 2 회관절경수술심포지엄 have sustained a recent dislocation osteochondral fragment (most in the lateral gutter) cartilage lesion meniscus patholoty lateral reticular release if excessive lateral reticular tightness 3. Incision Incision for graft harvest: 2~3 cm vertical incision over the pes anserinus Incision for tunnel placement (one or two incision), One incision for tunnel placement: midway between medial edge of the patella and the medial epicondyle Two incisions: medial edge of the patella, over the medial epicondyle 4. Graft harvest Gracilis tendon autograft Semitendinous tendon autograft (preferred) Medial 1/3 patella tendon autograft Quadriceps tendon autograft Tibialis anterior allograft Fig. 3. Single bundle and double bundle MPFL reconstruction using semitendinous tendon autograft (From Wang et al, International Orthopaedics 2013;37: ) 130

135 Knee Arthroscopy & Osteotomy Fig. 4. MPFL reconstruction using a quadriceps tendon autograft. (From Steensen et al, Arthroscopy 2005;21: ) Fig. 5. MPFL reconstruction using a patellar tendon autograft. (From Bitar et al, AJSM 2012;40: ) 5. Patella tunnel Single tunnel: superior half of the patella Two tunnels: superior half or two thirds of the patella, just above the equator of the patella Not to violate the anterior cortex or posterior articular surface 131

136 제 2 회관절경수술심포지엄 A B C D E Fig. 6. Different techniques of anatomical two patellar tunnels (From Hinterwimmer et al, Knee Surg Sports Traumatol Arthrosc 2013;e-pub) 6. Femoral tunnel Between medial epicondyle and adductor tubercle Distal to adductor tubercle, anterior to medial epicondyle Radiographic landmark: slight anterior (0.5 mm) to distal posterior cortex, just proximal (3 mm) to apex A common error is too far proximal tunnel placement. Even 5 mm too far proximal results in increased graft force and pressure Check isometric point: looping the graft around the guide pin and assessing graft length and tension through a range of motion Fig. 7. MPFL attachment is defined in relation to the size of the medial femoral condyle: if the anterior-posterior size is 100%, then the MPFL attachment is 40% from the posterior, 50% from the distal, and 60% from the anterior outline. (From Stephen et al, AJSM :1871-9) 7. Graft passage, tensioning & fixation Graft passage: underneath the medial retinaculum and remaining MPFL Not to overconstrain the graft Appropriate tension of the graft should allow approximately one to two quadrants lateral passive glide at 30 degrees flexion 132

137 Knee Arthroscopy & Osteotomy Grafts should have minimal tension as the knee is flexed past 45 degrees Patellar side first and then femoral side Patella side: endobutton, bioabsorbable interference screw Femoral side: bioabsorbable interference screw, suture anchor, a spiked stable, screw & spike washer, direct suture at soft tissue Fixation at 20~30 degree of knee flexion angle Augmenting suture the graft to the adjacent soft tissue Finally confirm the patellar stability and check graft length, tension, patellar tracking, translation, tilt during flexion and extension 8. Postoperative Rehabilitation Postop: Touchdown weight bearing in brace locked in extension, quadriceps sets, and straight leg raises Week 1: knee range of motion, partial wt bearing, and strengthening Week 4: 90~120 degree knee range of motion Week 6: Discontinue brace Week 8: Full range of motion Week 12: Jogging Week 16: Sports specific drills Week 20: Return to sports when strength and agility allow 9. Complications Loss of motion (flexion deficit) Recurrent instability Patellar fracture Saphenous nerve injury Arthritis Summary Assess the risk factors of recurrent patellar instability Avoid techniques that do not allow fine tuning of length and tension If the graft is fixed too proximally on the femur, it will tighten in flexion and may limit 133

138 제 2 회관절경수술심포지엄 postoperative knee flexion Overconstraint of the MPFL will lead to premature patellofemoral?arthritis MPFL reconstruction is an instability operation only, it is not an operation for pain Avoid large transverse tunnels through the patella that can lead to fracture This procedure does not correct malalignment, that is it is not meant to pull the patella into a centered location. This should be performed, if necessary, by adding a tubercle osteotomy, especially if the TT-TG is >20 mm, and there is fixed lateral subluxation and/or rotation on the imaging studies REFERENCES 01. Bitar AC, Demange MK, D Elia CO, Camanho GL (2012) Traumatic patellar dislocation: nonoperative treatment compared with MPFL reconstruction using patellar tendon. Am J Sports Med 40: Ellera Gomes JL, Stigler Marczyk LR, César de César P, Jungblut CF (2004) Medial patellofemoral ligament reconstruction with semitendinosus autograft for chronic patellar instability: a follow-up study. Arthroscopy: The Journal of Arthroscopic & Related Surgery 20: Goyal D (2013) Medial patellofemoral ligament reconstruction: the superficial quad technique. Am J Sports Med 41: Hinterwimmer S, Imhoff AB, Minzlaff P, Saier T, Rosenstiel N, Hawe W, Feucht MJ (2013) Anatomical twobundle medial patellofemoral ligament reconstruction with hardware-free patellar graft fixation: technical note and preliminary results. Knee Surg Sports Traumatol Arthrosc 05. Kang H, Cao J, Yu D, Zheng Z, Wang F (2013) Comparison of 2 different techniques for anatomic reconstruction of the medial patellofemoral ligament: a prospective randomized study. Am J Sports Med 41: Nomura E, Inoue M, Kobayashi S (2007) Long-term follow-up and knee osteoarthritis change after medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 35: Noyes FR, Albright JC (2006) Reconstruction of the medial patellofemoral ligament with autologous quadriceps tendon. Arthroscopy 22:904 e Panagopoulos A, van Niekerk L, Triantafillopoulos IK (2008) MPFL reconstruction for recurrent patella dislocation: a new surgical technique and review of the literature. Int J Sports Med 29: Panni AS, Alam M, Cerciello S, Vasso M, Maffulli N (2011) Medial patellofemoral ligament reconstruction with a divergent patellar transverse 2-tunnel technique. Am J Sports Med 39: Ronga M, Oliva F, Longo UG, Testa V, Capasso G, Maffulli N (2009) Isolated medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 37: Shah JN, Howard JS, Flanigan DC, Brophy RH, Carey JL, Lattermann C (2012) A systematic review of complications and failures associated with medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 40: Sillanpaa P, Mattila VM, Visuri T, Maenpaa H, Pihlajamaki H (2008) Ligament reconstruction versus distal realignment for patellar dislocation. Clin Orthop Relat Res 466:

139 Knee Arthroscopy & Osteotomy 13. Steensen RN, Dopirak RM, Maurus PB (2005) A simple technique for reconstruction of the medial patellofemoral ligament using a quadriceps tendon graft. Arthroscopy 21: Steiner TM, Torga-Spak R, Teitge RA (2006) Medial patellofemoral ligament reconstruction in patients with lateral patellar instability and trochlear dysplasia. Am J Sports Med 34: Stephen JM, Lumpaopong P, Deehan DJ, Kader D, Amis AA (2012) The medial patellofemoral ligament: location of femoral attachment and length change patterns resulting from anatomic and nonanatomic attachments. Am J Sports Med 40: Wang CH, Ma LF, Zhou JW, Ji G, Wang HY, Wang F, Wang J (2013) Double-bundle anatomical versus single-bundle isometric medial patellofemoral ligament reconstruction for patellar dislocation. Int Orthop 37: Yercan HS, Erkan S, Okcu G, Ozalp RT (2011) A novel technique for reconstruction of the medial patellofemoral ligament in skeletally immature patients. Arch Orthop Trauma Surg 131:

140 제 2 회관절경수술심포지엄 Medial Opening wedge HTO 인제대학교일산백병원정형외과 나경욱 HTO 역사및원리 - Medial opening HTO는 1951년프랑스의 Debeyre가처음수술을시작하였고그제자인 Hernigou 가 1987년 JBJS (Am) 에 10~13년추적논문을발표하여많이알려지게되었다. 그리고 2000년이후미국, 유럽을비롯해서전세계적으로이수술의장점이다시부각이되면서많이사용되고있읍니다 1). - 이수술의원리는내측퇴행성관절염을체중부하의축을내측에서외측으로옮겨서아픈쪽내측관절에하중을줄여주어통증을감소시키는방법입니다 1-4). - Open HTO의단점은 1) 골이식을해야하고 2) 교정손실로인한재발성내측변형입니다. 과거에쓰던금속판의고정력이떨어져이러한현상을극복하고자근위부에 4개의금속핀을고정하는금속판을개발하여최근많이사용하고있습니다 3). 즉이것은기존에 one plane osteotomy 가아니라 4개의금속핀을고정하기위해서 biplane osteotomy를사용하고있습니다 (Fig. 1). Fig. 1. One plane vs Biplane technique - 개인적으로는어느방법을사용해도무방하다고생각합니다. 저는 one plane method를사용하면서 autotricortical BG 를시행하므로 biplane ostetomhy를사용하는것과비슷한축성강도를얻는다고생각합니다. One plane 은수술이쉽고좋으나고정할공간이적어서현재사용이적었으나고정력을확보할수있다면 ( 즉 autotircortical bone graft 나견고한금속판의사용 ) Biplane 보다장점이많은 136

141 Knee Arthroscopy & Osteotomy 수술입니다. Biplane 수술은수술이약간복잡하나근위부고정공간을만들어금속고정력을확보하기가유리합니다. 두군간의골유합율에는차이가없습니다. - 즉 TKA가뼈및연골을모두절제후금속및플라스틱로대치하는술기인데반해 HTO는자기관절을보존하면서퇴행성관절염이발생하는체중부하의위치를바꾸어주어통증을치료하는방법입니다. 임상적결과 : Survivorship (survival rate) 1. Comparison of survival rates 5) (*survivorship - HTO 수술후 TKA 로전환된기간 ) Table 1. Study 5 year survival(%) 10 year survival(%) 15 year survival(%) Coventry (1993) Gstottner M (2008) Schallberger A (2011) 위표에서보시다시피과거 1970년대 10 year survivorship은 51~66% 였으나또한 2008년일본의 Akizuki 등도 6) 15년생존율을 90% 까지보고하고또한 Schallberger A는 7) 10yr survivorship은약 92% 로증가하는추세를보인다고보고하였읍니다. - 저자도 10년간이수술을시행하여아직 TKA로전환한경험이없습니다. 이러한결과는수술테크닉의변화라기보다는과거보다는환자를잘선택해서시술을하면좋은결과를보여주는연구결과라고생각합니다. - 그래서 TKA의수명을평균 15년으로보았을때 60~65세이전의인공관절술은 2차수술시어려움과나쁜예후를생각해보면 HTO을이용하여자기관절을이용하여퇴행성관절염을치료한후나중에 TKA로치료하는것이올바른방법으로생각됩니다. 술전계획 - 술전에내반되어있는무릎을외측면 62~65% 에갖다놓아야임상적결과가좋다고알려져있읍니다. 그러나이것은쉽지않읍니다. 그래서 undercorrection or overcorrection을많이초래합니다. 기존의 conventional method은 C-arm을보면서수술시에 cable line (or Bovi line) 등을이용하여측정하거나최근에 Navigation method를이용하여절골술후 62% line에위치하는방법을쓰나이것은 non-weight bearing system으로실제상황을반영하지못한다고생각합니다 8,9) ( 비체중부하에서는 medial joint space widening 현상이일어납니다 ). 그래서저자는 both low extremely weight bearing scanography를찍어 100% 로프린트하면실제체중부하의상황과같은도면을얻을수있읍 137

142 제 2 회관절경수술심포지엄 니다. 그후가위로실제가상선의절골술부위를자르고 WBL 62% 에같다놓고내측공간을자 (ruler) 로측정하여뼈이식을몇 mm 할것인지를미리측정하고있읍니다. 이것이기존의방법보다더욱정확하다고생각합니다 10) (Fig. 2). Fig. 2. Scanography method - template was cut through the osteotomy site and the tibia was rotated until the weight bearing line passes through the 62% coordinate. Medial open HTO 수술의원칙 1. keys to success in HTO 1) proper select patients 2) proper preoperative planning 3) precise surgical technique 2. 수술상의 3 대원칙 1) Osteotomy - safe zone in lateral cortex 11) (prevent the lateral cortex Fracture) (Fig. 3) 2) Juxtacortical position of 2 Stainmann pins, and than osteotomy approximately 10 mm from lateral cortex, and use 3 chisel technique. (prevent the tibia plateau Fracture) (Fig. 4) 3) Anterior to Posterior gap - 2/3 (auto tricortical BG) 4) (maintain the post slope) (Fig. 5) 138

143 Knee Arthroscopy & Osteotomy Fig. 3. Safe zone osteotomy for preventing lateral cortex fracture. (from A fibular tip to B circumference line) Fig. 4. Juxtacortical position of 2 Steinmann pins. Osteotomy approximately 10 mm from lateral cortex. And use 3 Chisel technique for preventing tibia plateau fracture. Fig. 5. Anterior to posterior gap around 2/3 to maintain post slope 139

144 제 2 회관절경수술심포지엄 뼈이식종류 1. 이식골종류 Autograft - Cancellous (Puddu) Bicortical (Noyes, Hernigou) Tricortical (my method) Allograft - many surgeons Ca ++ phosphate - Takewuchi, None - Sawakuchi ** Medial opening HTO는절골술후빈공간을골이식술로채워야하므로어떠한물질로채우냐에따라금속판의강도가결정됩니다. 만일 auto-cancellous or bicortical bone or Allograft or Ca ++ Phosphate 등으로채운다면내부가약하므로, 견고하고단단한금속판으로고정이필요하고, autotricortical-bone으로채운다면골이식자체가 medial buttress support가좋기때문에일반적인 plate로도충분합니다. Autotricortical iliac bone graft 의장점은 4,12) 1) 골채취시자연적으로 iliac crest의두께가달라서앞뒤 2/3비율로조절이쉽고 2) iliac crest가 medial buttres support가되어서조기체중부하가가능하며 3) iliac crest가 metal block의역할을하므로 Dual plate or Puddu plate를사용하지않아도되며 4) 감염되었을경우골이식자체가붕괴되지않으므로금속판을제거하고감염에대한치료를하여도되는장점이있읍니다. Fig

145 Knee Arthroscopy & Osteotomy * 즉 autotricortical iliac bone graft를사용하면술후장골의동통을호소하고드물게 pelvic linear Fx가발생할수가있는단점이있읍니다. 그래서장골에시멘트를채워넣으면동통감소효과가있읍니다 12). 결 론 Medial opening HTO는내측퇴행성관절염 ( 혹은골괴사 ) 으로아파하는 60~65세이하의젊고활동적인환자에게 10 yr survivalship이약 80~90% 를보이는좋은수술로서 3대원칙을잘지키면성공적인근위경골절골술을시행할수있으며퇴행성관절염의환자에서인공관절술을지연시키는환자가만족할만한좋은치료법입니다. REFERENCES 01. Hernigou P, Medevielle D, Debeyre J, Goutallier D. Proximal tibial osteotomy for osteoarthritis with varus deformity FU study. JBJS Am 1987;69: Coventry MB et al. Proximal tibia osteotmy. A critical long tern study of 87 cases. JBJS Am : Staubli AE, De simony C, Lobenhoffer P. Tomofix : a new LCP concept for Open HTO. Injury ; suppl 2 B Nha KW Chae DJ et al. Tibial slope and patellar height after opening wedge high tibia osteotomy using autologous tricortical iliac bone graft. Knee 2008;15: Gstottner M et al. Long term outcome after HTO. Arch Orth Trauma Sug. 2008;128: Akizuki S et al: The long term outcome of HTO: FU. JBJS br 90: Schallberger A et al: HTO in unicompartmental medial osteoarthritis of the knee: yr FU. KSSTA. 19: Lee DH, Nha KW, Han SB. Preop and Postop comparisons of navigation and radilologic limb alignment measurements after open HTO. Arthroscopy. 28: Reising K, et al. Computer assisted navigation for open HTO can avoid outliers compared with conventional technique. KSSTA. 21: Nha KW, Lee DH, Han SB et al. The Weight-bearing scanogram technique provides better coronal limb alignment than navigation technique in open HTO. Knee in pubmed Nha KW Han SB, Lee DH et al. A safe zone in medial HTO to prevent lateral cortex fracture (cadaver study). KSSTA. 21: Nha KW, Chae DJ et al. Early complications of medial opening wedge high tibial osteotomy using autologous tricortical iliac bone graft and T-plate fixation. Knee :

146 제 2 회관절경수술심포지엄 Lateral Closed Wedge High Tibial Osteotomy 서울대학교병원정형외과 이상훈 Closing wedge osteotomy는내반변형이있는내측골관절염이적응증이다. 55세이하, 너무높지않은 BMI, 15-90이상의슬관절굴곡범위, intact vascularity가상대적인적응증이라고할수있다. 반면염증성관절염, 광범위하고불분명한관절통증, 굴곡구축및관절운동범위제한이심한경우, 비만의경우등에는 contraindication이된다. Open wedge osteotomy와달리술후 patella alta의가능성이있을수있으며반대로 patella baja가생기는경우가보고된바도있다. 경골후방경사각이감소할수있고, 비골절골등이필요하고, 이에따라비골신경의마비가올수도있다는점이단점이다. 까다로운술기도걸림돌일수있다. 반면좀더큰각도의교정이가능하고 graft material이필요없고빠른재활이가능하며치유의속도도빠르고 MCL의 transection 등의합병증이없어젊고활동적인환자뿐아니라골다공증등으로골질이저하된노령의환자에서도매우좋은절골술이라고할수있다. 현재보고된바로는 10년정도에약 75~80% 의 survival rate를보이고있다. 술전준비 하지전장을포함하는weight-bearing view를찍고가상의 osteotomy를하여경골외측부의 wedge size 를예상한다. Dicom image viewer를사용하는경우 photoshop을이용하여실제필름을이용하지않고좀더간편하게측정할수있다. Osteoarthritis환자에서가상의 osteotomy를시행하는경우 weight-bearing line은경골고평부의 62~66% 를지날수있게한다. 대개 Fujisawa line, Jakob 의관절간경을이용하는방법, Dugdale 등무수히많은방법이보고되어있다. 수술술기 Mechanical symptom이있는 meniscus tear 등의제거가필요하거나 grade 4 chondral lesion에대한 microfracture를시행하게되는경우관절경을이용한수술을하기도한다. 대부분의경우관절경적인검사를꼭시행하지는않는다. 피부의절개는경골결절의약 1 cm 상단외측에서비골골두 1 cm 하부까지 5 cm 가량의직선절개를하거나경골고평부외측에서전면으로이어지는부드러운 L자절개를하기도한다. Anterior tibial muscle group을경골전면에서 periosteal dissection하고후방으로 retract한다. Muscle의 retraction은 mutilation되지않도록조심스럽게해야하나 peroneal nerve를따로박리하여 142

147 Knee Arthroscopy & Osteotomy 확인하지는않는다. Patellar tendon의뒤쪽도조심스럽게 blunt dissection하여시야를확보하며 osteotomy시에는확실히보호하여 fibrosis나 tendon contracture 등가능한합병증의발생과악화를자극하지않도록신경써야한다. Fibular shaft osteotomy나 proximal tibiofibular joint division을시행해야한다. Tibiofibular joint division은술후 FCL의 laxity나있을수있으며 fibular shaft osteotomy 의경우nonunion이있을수있고 peroneal nerve injury를주의해야하나 osteoarthritis환자에서실제임상결과에대한영향은미미한것으로보인다. 다만 sports trauma 환자에서 ligament laxity의치료와병행하는경우 tibiofibular joint division은 posterolateral instability의가능성때문에 contraindication으로여겨진다. Fibular shaft osteotomy는 incision을넣어 lateral peroneal muscle을대개앞으로 retract한후 microsaw와 osteotomy를이용하여 oblique하게하는데 neck근처의 proximal part에서하는경우에는 dissection하여 peroneal nerve를육안확인후에해야한다. 경골에서 osteotomy 위치를확인후그후방에 retractor를넣어후방구조물을보호한다. Osteotomy위치의 proximal과 distal에 Steinmann pin을하나씩 insert 한다. Fluoroscope으로두개의 pin이경골의내측에서만나게되도록한다. 만나는지점이경골내측 cortex에서바깥쪽이나안쪽으로지나치게치우쳐서는안된다. 상하두개의핀에접하여 (Proximal pin의 distal에서그리고 distal pin의 proximal에서 ) saw blade를이용하여 osteotomy를시행한다. Blade는경골의내외측전장보다짧아야하는데대개의경우훨씬더짧기때문에끝까지 insert하고 osteotome 으로마무리한다. Osteotome은 cortex에서약 1 cm 모자라게한다. 외측에서볼때절골선의방향이경사지게하여약간후하방에서전상방으로향하도록하여슬개건의경골부착부위의상방을지나도록하며때로약간의 step cutting이필요하기도하다. Closed wedge osteotomy의경우대개 tibial slope가감소하므로감안하여 posterior bone wedge 가약간커지도록자른다. Tibial slope 의변화를최소화하기위해경골후면부의 dissection과 clearing도적당히시행하는것은물론이다. 나중에 correction시도움이될수있도록 osteotomy시골질상태를염두에두어둔다. 절골이된경골은하지를잡고 axial방향으로 compression force와 valgus stress를주면서 correction을한다. 이때너무 leverage를많이하여 medial cortex가깨지지않도록하며반대로너무 stiff하면 Steinmann pin으로 medial cortex에구멍을뚫고 correction을하기도한다. 고정전 coronal, sagittal plane에서각도를확인한다. Coronal plane에서는 closure가잘되었는지, mechanical axis가원래의도했던고평부를지나는지, medial cortex가깨지지않았는지 fluorosopy와 cautery line 등으로확인하며 undercorrection이되지않도록주의하는것이중요하다. Sagittal plane 에서는 hyperextension되지않도록주의해야한다. Coventry staple, rigid stepped plate, aescula plate, conventional anatomical plate 등으로고정하며 correction각도가고정시술과정중달라지지않도록주의한다. Anterior tibia의 muscle 을 repair하고환부를 close한다. 143

148 제 2 회관절경수술심포지엄 Distal Femoral Osteotomy 순천향대학교부천병원 민경대 대퇴원위부절골술은보통 60세이하의활동도가높은환자에서대퇴-경골각이 15도이상의외반변형이있을때와관절의정렬이 10도이상의외반경사를보일때적응이되는술기이다 1). 교정술을필요할정도의외반변형은내반변형에비하여흔하지않으며성장이상, 외상, 대사성질환 ( 구루병등 ), 소아마비나인대의불안정성과동반되는경우에는치료가용이하지않다 2). 외반변형에대한경골근위부의내반절골술은그결과가다양하고, 실패와합병증의빈도가비교적높은것으로알려져있으며 3), 특히관절선이상외측으로경사진경우경골근위부내반절골술로는잘교정하기어렵다. 따라서관절면경사가 10도이상이거나외반변형이 12~15도를넘으면대퇴과상부에서의절골술이필요하다. 대퇴과상부절골술은경골근위부절골술에비하여쐐기를효과적으로잘라내기어렵고, 폐쇄절골면의안정화및적절한교정을위한쐐기의크기를예측하는데보다어려움이있어정확성을요하는술기이다 3). 대퇴원위부절골술방법들은내측폐쇄형또는외측개방형내반절골술, 과상부천장형절골술, V 절골술, 과간절골술등 1-6) 이있으며내측폐쇄형내반절골술 (medial closing wedge varus osteotomy) 이가장흔히이용되고있고있어그술기를간략히기술하고자한다. 슬관절외반변형의생역학적기초 슬관절의외반변형은내반변형보다관용도가좋고관절염으로의진행도늦게나타나는데이는보행중내측구획에중력이보다많이작용하는내전모멘트 (adduction moment) 때문이다. 내반슬에서는내전모멘트가외측근육의수축을유발하여관절에보다많은부하가걸리게되나외반슬에서는외측근육의활동도가줄어관절사이의압박력이보다적게작용하기때문이다. 내반슬에서는보행중내반모멘트때문에과교정이필요하지만, 외반슬에서과교정이필요없는데그이유는슬관절의중립정렬에서중력의대부분이내측구획으로전달되기때문이다. 내반절골술에서는고관절-슬관절-족관절의정렬각을 0도에가깝게목표로해야한다 2). 동측고관절의병변이있는경우슬관절의외측구획에응력이증가하게되는데이는장경인대나대퇴이두근등고관절과슬관절에작용하는근육이고관절을안정시키기위해활성화되면동시에슬관절의외측구획에압박력이증가하고고관절이반대쪽으로의골반경사등으로인해보행의입각기에외전되면중력의중심이외측으로전위되기때문에슬관절외측의응력이증가하게된다. 따라서가능하면동측고관절의 144

149 Knee Arthroscopy & Osteotomy 병변이있는경우슬관절의절골술전에먼저확인하고해결해야한다. 수술적응증 (surgical indication) 환자의나이와활동도는근위경골절골술에비해유합시간과부분체중부하기간이길기때문에보다신중하게선택되어야한다. 대퇴과상부절골술은약 10~15도이상의외반변형을교정하기위한술기로외측구획의관절증, 통증및불안정성등이동반되는경우에적응이된다. 심한불안정성이있는경우는특히내측불안정성에동적안정화물이없으므로선택에주의를요하고, 굴곡변형이 20도이상이거나 90도이하의운동범위인경우, 세구획의관절증, 염증성관절질환, 골다공증이심한경우는추천되지않는다 4). 술전계획 (preoperative planning) 고관절에서족관절까지의직립체중부하방사선사진이변형을평가하고교정을계획하는데중요하다. 교정목표는해부학적각도가약 0도정도가권장되며, 내반해부학적축은피해야한다. 교정이필요한각도측정의가장손쉬운방법은고관절에서슬관절까지의기계적축 ( 대퇴골두와슬관절의중심을이은선 ) 을그은후족관절에서슬관절까지의기계적축과만들어지는각도 ( 알파각 ) 를이용한다 (Fig. 1). B Fig. 1. The desired angle of correction is most easily determined from the angle (alpha) formed by proximal and distal mechanical axis 145

150 제 2 회관절경수술심포지엄 수술술기 (surgical technique) 환자를앙와위로눕힌후전상방장골극을촉지할수있게하여수술중정렬을확인할수있도록한다. 피부절개는내측관절면에서상방으로내측광배근의후연을따라약 10~15 cm 정도절개후내측광배근후면의근간격막 (intermuscular septum) 을절개하여내측광배근을전방으로제치고대퇴골내측을노출시킨다. 아래쪽으로는내전근결절 (adductor tubercle) 부위의골막에분지하는골단혈관을소작하고, 아래쪽으로약 2~3 cm 정도를금속판원위부가위치할수있게추가로박리해놓는다. 영상증폭기 (c-arm) 감시하에내전근결절에서원위대퇴를가로질러유도핀을삽입한다. 두번째유도핀을계획된절골위치에넣고확인한다. 원위유도핀을따라절골도 (osteotome) 을삽입후제거한후근위부유도핀에서전동톱을이용하여절골한다. 술전계획된쐐기의크기를확인하면서제거하는데이때대퇴골후면의골막을박리하여 Homan 등의견인기를넣어신경혈관을다치지않게보호하고절골진행시전동톱이반대쪽피질골을침범하지않게주의한다. 외측피질골은얇은절골도를이용하여약화시킨후쇄골 (osteoclasis) 한다. 절골부의고정은전통적으로 blade plate나 DCS plate가이용되어왔으나최근잠김나사못금속판의역학적장점과수술의수월성으로그이용이증가하고있다. 수술후관리 (postoperative management) 수술직후압박드레싱하고수일내관절운동은시작한다. 6~8주간부분체중부하를하고적극적근력강화운동과함께정기적방사선사진으로유합을확인한다. 증례 (Case presentation) 53세남자로 10세때외상력이있으며외반슬로인한파행과통증을주소로내원하였다. 방사선사진상대퇴원위부에서부정유합으로인하여약 30 도의외반변형을보이고있다. 내측대퇴원위부절골술과잠김나사금속판을이용하여대퇴경골각 0도를얻었다 (Fig. 2). Fig. 2. Preoperative and postoperative scanogram show correction of mechanical axis 146