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1 J Korean Hip Soc 21(3): , 2009 Original Article Total Hip Arthroplasty Using a Large Femoral Head : The Short-Term Follow-up Results and the Early Complications Myung-Rae Cho, MD, Se-Sik Kim, MD, Hyun-Seop Lee, MD Department of Orthopaedic Surgery, School of Medicine, Catholic University of Daegu, Daegu, Korea Purpose: This study evaluated the short-term follow-up results after total hip arthroplasty with using a 36 mm large femoral head. Materials and Methods: Between August 2004 and August 2007, 104 patients were treated with total hip arthroplasties using a 36 mm-cobalt-chrome femoral head with Longevity (Zimmer, Warsaw, IN) as the polyethylene liner. The average age at the time of the index operation was 61.4 years (range: 23 to 87 years), and the mean follow-up period was 27 months (range: 18 to 46 months). The clinical results and early complications after the operation were analyzed. Results: The Harris Hip Scores were more than Good in all cases with an average score of 93, and the Merle d Aubigne and Postel scores were more than Good in 75% of the patients. All the femoral stems that were cemented or cementless had satisfactory fixation. Dislocation developed in one case and only one time, and there were no other complications during the follow-up period Conclusion: Total hip arthroplasty with using a 36 mm large femoral head is a recommendable treatment with a low dislocation rate and high satisfaction, which comes from the lack of restriction of the postoperative hip position and movement. Key Words: Total hip arthroplasty, Large femoral head, HXLPE, Dislocation 서 인공고관절전치환술시행후고관절의불안정성과탈구는삽입물실패의중요한원인으로, 환자로하여금의식적인고관절운동에제한을야기하여일상생활의불편을초래할수있다 2,10,21,22). 이러한불안정성의극복을위해큰대퇴골두를이용한인공고관절치환술이시도되었고, 이는탈구의빈도는줄였으나 3,4,16) 관절면의접촉면증가로인한마모및이로인한골용해등의합병증발생으로인 론 Submitted: April 20, st revision: July 2, nd revision: July 21, rd revision: July 30, th revision: August 26, th revision: September 2, 2009 Final acceptance: September 2, 2009 Address reprint request to Myung-Rae Cho, MD Department of Orthopaedic Surgery, Daegu Catholic University Hospital, , Daemyung-4-dong, Nam-gu, Daegu, , Korea TEL: FAX: cmr0426@cu.ac.kr 해제한적으로사용되어왔다 11,12,13,14,17). 최근관절면을구성하는재질 ( 세라믹, cobalt chrome, 폴리에틸렌 ) 의발달로큰대퇴골두를이용하여인공고관절전치환술을시행하는추세가증가되고있는데, 특히금속 - 폴리에틸렌의관절면을사용한증례들의경우중기추시까지발표되고있는데발표되는문헌들의양상이양호한결과들이많지만여러가지단점에대한보고도있어논란이많으며이에대한연구는아직국내에는보고된바가없다. 이에저자들은 36 mm 의 cobalt-chrome 대퇴골두및 highly cross-linked polyethylene (HXLPE) 를이용한인공고관절전치환술시행후초기결과부터보고하는바이다. 1. 인구통계학적특성 대상및방법 환자들의동의하에본원윤리위원회에서승인된 2004 년 8 월부터 2007 년 8 월까지연속적으로큰대퇴골두를 232

2 Myung-Rae Cho et al.: Total Hip Arthroplasty Using a Large Femoral Head: The Short-Term Follow-up Results and the Early Complications 사용하여일차고관절전치환술을시술받은 104 명, 104 예를대상으로하였다. 수술당시평균연령은 61.4 세 (28~87), 평균추시기간은 27 개월 (18~48) 였으며, 남자 51 명, 여자 53 명이었다. 원인질환으로대퇴골두무혈성괴사 40 예, 대퇴골경부골절 39 예, 퇴행성관절염 11 예, 류마티스관절염 6 예, 발달성고관절이형성증 4 예, 강직성척추염 2 예및감염후유증 2 예였다. 수술은전예에서 1 인 (MRC) 에의해시행되었으며임상적, 방사선학적평가는독립된전문의에의해시행하였다. 통계는 Statistical Package for the Social Sciences (SPSS) 프로그램을이용하여 student t-test 와 chi-square test 를사용하였다. 2. 수술방법및삽입물 전례에서 Hardinge 접근법을변형한측방도달법을사용하였으며, 비구부품은 Triology (Zimmer, Warsaw, IN, USA) 컵과 Longevity (Zimmer, Warsaw, IN, USA) 폴리에틸렌을, 대퇴부품은 36 mm Cobalt-Chrome 대퇴골두와시멘트형은 Versys (Zimmer, Warsaw, IN, USA) 대퇴주대를, 무시멘트형은 FMT (Zimmer, Warsaw, IN, USA) 를사용하였으며 59예는무시멘트를, 45예는시멘트성대퇴부품을사용하였다. 수술후고관절의자세나운동에제한을두지않았고, 수술다음날부터대퇴사두근및중둔근강화운동을시행하였으며배액관을제거한날부터부분체중부하보행을허용하였다. 3. 임상적및방사선적평가 modified Merle d Aubigne and Postel 7) 방법을사용하였다. 방사선적평가는삽입된비구및대퇴주대에대하여단순방사선사진에서전후방경사각및전방각을측정하였으며, 삽입된대퇴주대의고정에대한평가는무시멘트성대퇴주대의경우 Engh 등 8) 의평가기준을, 시멘트성대퇴주대의경우 Barrack 등 1) 의평가기준을사용하였다. 환자는술후 1 개월, 3 개월, 6 개월, 1 년간격으로외래에서임상적인기능및방사선학적인관찰을하였고특히수술후탈구, 감염등의초기합병증발생에대해면밀히관찰하였다. 결 최종추시시 HHS 는술전평균 53 점에서평균 93 점으로향상되었고 (p<0.05), Merle d Aubigne and Postel s global evaluation 은최종추시시우수 26 예 (25%), 매우양호 31 예 (30%), 양호 21 예 (20%), 보통 26 예 25%) 로향상되었다 (P<0.05) (Table 1, 2). 비구부품의전후방경사각은평균 48 도 (39~59), 전방각은평균 19.4(8~32) 였고, 대퇴주대의전경각은평균 21.2(4~30) 였다. 무시멘트성대퇴주대의고정은 38 예 (72%) 에서골성내성장 (bony ingrowth) 을, 16 예 (28%) 에서섬유성내성장 (fibrous ingrowth) 을보였으며시멘트성대퇴부품의경우는 39 예 (78%) 에서 Grade A, 7 예 (14%) 에서 Grade B, 4 예 (8%) 에서 Grade C 로평가되었다. 술후합병증으로탈구가 1 예관찰되었으나 (Fig. 1-4), 추시기간중감염, 신경마비, 삽입물주위골절등의다른합병증은없었다. 과 임상적인기능평가는 Harris Hip Score (HHS) 9) 와 Table 1. Clinical Results According to Harris Hip Score System Result (Range of Point) Initial Last Follow-up Excellent (90~100) 0 73 (70%) Good (80~89) 0 20 (19%) Fair (70~79) 25 (24%) 11 (11%) Poor (0~69) 79 (76%) 0 Table 2. Clinical Result According to Merle d Aubigne and Postel Global Classification Result Initial Last Follow-up Excellent 0 26 (25%) Very Good 0 31 (30%) Good 0 21 (20%) Fair 27 (26%) 26 (25%) Poor 53 (51%) 0 Bad 24 (23%) 0 233

J Korean Hip Soc 21(3): 232-237, 2009 고 인공고관절전치환술의눈부신발전에도불구하고탈구의빈도는일차치환술후 1.0~4.9%, 재치환술후 4.8~20% 로여전히높고중요한문제이다 3,4,5,16,20).

큰대퇴골두를사용하는경우작은대퇴골두에비해탈구가일어나기위해서는더많은거리의전이 Fig. 1. Plain radiograph of a 65-year-old man shows the advanced osteoarthritis in right hip.

3 J Korean Hip Soc 21(3): , 2009 고 인공고관절전치환술의눈부신발전에도불구하고탈구의빈도는일차치환술후 1.0~4.9%, 재치환술후 4.8~20% 로여전히높고중요한문제이다 3,4,5,16,20). 불안정성의극복을위해큰대퇴골두를이용한인공고관절치환술의역사는 1960 년대로거슬러올라가나, 당시가용할수있는플라스틱재질의한계및마모에의한높은실패율로사용이제한되어져왔다 6). 최근관절구성면의재질학적발전, 특히마모에강한저항을가지는 HXLPE 의개발로금속 - 폴리에틸렌관절면에큰대퇴골두가사용되고있다 4,10,15,18). 큰대퇴골두를사용하는경우작은대퇴골두에비해탈구가일어나기위해서는더많은거리의전이 Fig. 1. Plain radiograph of a 65-year-old man shows the advanced osteoarthritis in right hip. 찰 (jump distance) 가필요하고, 대퇴골두를대퇴삽입물의경부에안착시키기위한 skirt 가필요없으며, 대퇴골두 - 경부비 (head-neck ratio) 가증가하므로충돌의빈도가낮아탈구에보다안정적이다 3,4). 또한큰대퇴골두를사용한경우작은골두에비해고관절운동범위의증가가관찰되는데 Scifert 등 19) 은대퇴골두의 1 mm 증가당운동범위 의증가가관찰되며, 탈구에저항하는 peak moment 는 3.6% 증가한다고보고하였고, Burroughs 등 3,4) 은 38 mm 와 42 mm 대퇴골두는 32 mm 대퇴골두의비해각각 6 와 16 의운동범위가증가한다고보고하였다. 큰대퇴골두사용시이러한안정성향상및운동범위의증가는일상생활, 특히한국인의생활양식적특성인극한고관절자세를가능하게하여환자만족도및삶의질을향상시킬수있다는장점이있는데본연구에서도기존에 28 m 대퇴골두를사용할때는수술중안정성검사를위해서또는수술후고관절탈구방지를위하여과도한고관절자세에제한을두었는데 36 m 대퇴골두를사용한경우는수술중안정성검사시에일반적으로통용되는각도이상에서도안정성검사확인이가능하였고또한수술후탈구방지를위한침상안정이나과도한고관절자세에제한을두지않았다. 또한한국인의흔한자세인 cross-leg sitting (tailor position) 이수술전에가능한환자의 96% 에서수술후에도가능하였다. 저자들의경우추시기간이짧은관계로술후초기합병증, 특히고관절탈구의발생여부를면밀히관찰하였으나, 본연구에서는 1% 이하의빈도로관찰되어기존의작은대퇴골두사용후발생되는빈도와비교해볼때상대적으로높은안정성향상을경험할수있었고, 특히술후자세및운동에제한을두지않아환자의초기만족도도높았다. A B Fig. 2. (A) Postoperative radiographs show the anteroposterior inclination of 45 degrees (B) and anteversion of 15 degrees. 234

Myung-Rae Cho et al.: Total Hip Arthroplasty Using a Large Femoral Head: The Short-Term Follow-up Results and the Early Complications Fig. 3. A dislocation developed at postoperative 11 days.

탈구된 1 예는수술후 11 일째발생하였는데비구부품의전후방경사각및대퇴주대의전경각, 비구부품의전방각등이정상범위에있으나침상에서내려오면서과도한굴곡, 내전상태에서발생한것으로,

4 Myung-Rae Cho et al.: Total Hip Arthroplasty Using a Large Femoral Head: The Short-Term Follow-up Results and the Early Complications Fig. 3. A dislocation developed at postoperative 11 days. Under the image intensifier it was managed by a closed method. 탈구된 1 예는수술후 11 일째발생하였는데비구부품의전후방경사각및대퇴주대의전경각, 비구부품의전방각등이정상범위에있으나침상에서내려오면서과도한굴곡, 내전상태에서발생한것으로, 기존의작은골두에서는발생할수있는기전으로판단되지만본연구에서는삽입된부품의각도가상기증례보다탈구의요소가많은상태에서도탈구가발생하지않은것으로그원인을정확히파악할수는없지만큰대퇴골두를사용하더라도정확한각도에서의부품삽입이필요하다는것을암시할수있으며, 본증례의경우는관절의안정성에대한확신으로탈구를정복한후기존의작은대퇴골두의경우외전보조기또는침상안정등여러후속조치가필요하였지만본증례의경우는탈구의정복후즉시보행, 일상생활등에별다른제한을두지않았으며추후탈구는발생하지않았다. 본연구의제한점으로는비교적적은수의환자로통계적유효성이낮고, 짧은추시기간 (bedding -in time 이갓지난상태 ) 으로플라스틱의마모등에대해서는관찰하지않았으며또한 highly cross-linked polyethylene 의인체사용후 15,000 예중 3 예 (0.0002%) 에서플라스틱의파열이있었는데그원인으로는비정상적인비구컵의각도로알려져있지만본연구의경우증례의수가상대적으로너무적고또한추시기간이짧아낮은발생률의플라스틱의피로골절에대하여는의미를두지않았으며, 마모나이완에관련된연구는추후중기관찰에서고려할것으로판단되어논문의복잡성을감안해서이번연구에서는부품의방사선학적측정을시행하지않았다는점이다. 또한인공고관절전치환술시행후결과에대한연구는최소 2 년이상의추시가필요하지만본연구에사용된큰대퇴골두의장점으로인정되는고관절안정성에대한평가는수술후탈구발생빈도가객관적인증명이될수있으며이는수술후초기에발생할가능성이가장큰상태로 Fig. 4. Radiograph two years after the index operation. No dislocation developed during the follow-up period. 수술후초기의추시가필요하다고판단되어본연구를하였으며현재까지발생한증례는적지만폴레에틸렌의변연부골절, 또한대퇴골두의크기증가로인한폴레에틸렌두께감소로야기될수있는마모문제, 새로운폴리에틸렌을인체내에서장기간사용할때에마모율에대한문제등은좀더많은연구가필요하리라판단된다. 결 큰대퇴골두를이용한인공고관절전치환술후초기추시결과에서는환자의고관절자세나운동에제한을두지않아환자의만족도가높았고, 탈구의빈도도 1% 이하로낮아권장할만한수술방법이라판단되지만대퇴골두의크기증가로인한폴리에틸렌의마모및마찰력증가로인한삽입물의이완등에대해서는중장기추시가필요하리라판단된다. 론 REFERENCES 01. Barrack RL, Mulroy RD, Jr., Harris WH. Improved cementing techniques and femoral component loosening in young patients with hip arthroplasty. A 12-year radiographic review. J Bone Joint Surg, 74-B: , Berry DJ. Unstable total hip arthroplasty: detailed overview. Instr Course Lect, 50: , Burroughs BR, Hallstrom B, Golladay GJ, Hoeffel D, Harris WH.: Range of motion and stability in total hip arthroplasty with 28-, 32-, 38-, and 44-mm femoral head sizes. J Arthroplasty, 20: 11-19, Burroughs BR, Rubash HE, Harris WH. Femoral head sizes larger than 32 mm against highly cross-linked polyethylene. Clin Orthop Relat Res, 405: ,

5 J Korean Hip Soc 21(3): , Chandler DR, Glousman R, Hull D, et al. Prosthetic hip range of motion and impingement. The effects of head and neck geometry. Clin Orthop, 166: , Charnley J. Total hip replacement by low-friction arthroplasty. Clin Orthop, 72: 7-21, d Aubigne R, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J bone Joint Surg, 36- A: , Engh CA, Bobyn JD, Glassman AH. Porous-coated hip replacement. The factors governing bone ingrowth, stress shielding, and clinical results. J Bone Joint Surg Br, 69-B: 45-55, Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg, 51-A: , Harris WH, Muratoglu OK. A review of current crosslinked polyethylenes used in total joint arthroplasty. Clin Orthop, 430: 46-52, Kabo JM, Gebhard JS, Loren G, Amstutz HC. In vivo wear of polyethylene acetabular components. J Bone Joint Surg, 75-B: , Lee PC, Shih CH, Chen WJ, Tu YK, Tai CL. Early polyethylene wear and osteolysis in cementless total hip arthroplasty: the influence of femoral head size and polyethylene thickness. J Arthroplasty, 14: , Livermore J, Ilstrup D, Morrey B. Effect of femoral head size on wear of the polyethylene acetabular component. J Bone Joint Surg, 72-A: , Mai MT, Schmalzried TP, Dorey FJ, Campbell PA, Amstutz HC. The contribution of frictional torque to loosening at the cement-bone interface in Tharies hip replacements. J Bone Joint Surg, 78-A: , Manning DW, Chiang PP, Martell JM, Galante JO, Harris WH. In vivo comparative wear study of traditional and highly cross-linked polyethylene in total hip arthroplasty. J Arthroplasty, 20: , Morrey BF. Instability after total hip arthroplasty. Orthop Clin North Am, 23: , Morrey BF, Ilstrup D. Size of the femoral head and acetabular revision in total hip-replacement arthroplasty. J Bone Joint Surg, 71-A: 50-55, Muratoglu OK, Greenbaum ES, Bragdon CR, Jasty M, Freiberg AA, Harris WH. Surface analysis of early retrieved acetabular polyethylene liners: a comparison of conventional and highly crosslinked polyethylenes. J Arthroplasty, 19: 68-77, Scifert CF, Brown TD, Lipman JD. Finite element analysis of a novel design approach to resisting total hip dislocation. Clin Biomech (Bristol, Avon), 14: , Turner RS. Postoperative total hip prosthetic femoral head dislocations. Incidence, etiologic factors, and management. Clin Orthop, 301: , Woo RY, Morrey BF. Dislocations after total hip arthroplasty. J Bone Joint Surg, 64-A: , Yamaguchi M, Akisue T, Bauer TW, Hashimoto Y. The spatial location of impingement in total hip arthroplasty. J Arthroplasty, 15: ,

6 Myung-Rae Cho et al.: Total Hip Arthroplasty Using a Large Femoral Head: The Short-Term Follow-up Results and the Early Complications 국문초록 큰대퇴골두를사용한인공고관절전치환술 : 초기합병증에관한단기추시결과 조명래 김세식 이현섭 대구가톨릭대학교정형외과학교실 목적 : 36 mm 대퇴골두를사용한인공고관절전치환술후초기추시결과를알아보고자한다. 대상및방법 : 2004년 8월에서 2007년 8월까지 Longevity (Zimmer, Warsaw, IN, USA) 폴리에틸렌과 36 mm Cobalt-Chrome 대퇴골두를사용하여인공고관절전치환술을시행한 104례를대상으로하였다. 수술당시평균연령은 61.4세 (28~87), 평균추시기간은 27개월 (18~46) 이었다. 임상적평가와술후발생가능한초기합병증에대하여관찰하였다. 결과 : Harris Hip Score는전예에서양호이상으로, 평균 93점이었다. Merle d Aubigne and Postel score도 75% 에서양호이상을보였다. 무시멘트및시멘트성대퇴부품전예에서수술후방사선사진상만족할만한고정을보였다. 1예에서 1회의탈구가관찰되었으며추시기간동안다른합병증은발생하지않았다. 결론 : 큰대퇴골두를이용한인공고관절전치환술후환자의고관절자세나운동에제한을두지않아환자의만족도가높았고탈구의빈도도낮아권장할만한수술방법이라판단된다. 색인단어 : 인공고관절전치환술, 큰대퇴골두, HXLPE, 탈구 237

세라뉴스-2011내지도큐

세라뉴스-2011내지도큐 2 2 8 17 18 22 23 24 Heinrich Wecker 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 예정된 이벤트 증례2 : 세라믹-폴리에틸렌 고관절 치환술후 발생한 비구-대퇴 해리로 세라믹-세라믹 관절면을 사용하여 재수술 진단 : 고관절 통증으로 내원한 65세 여자환자, 20년전 세라믹-폴리에틸