379 SLAP Lesion with Glenohumeral Instability 병리및분류 관절와순은해부학적으로관절와의오목함 (concavity) 을증가시킬뿐만아니라다양한관절와상완인대 (glenohumeral ligament) 들의부착부를제공함으로써견관절의안정화구조물

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1 Symposium J Korean Orthop Assoc 2017; 52: Superior Labrum Anterior to Posterior (SLAP) Lesion: Controversial Issue 378 pissn : , eissn : Superior Labrum Anterior to Posterior (SLAP) 병변과관절와상완관절불안정성 김철홍 왕립 동아대학교의과대학정형외과학교실 Superior Labrum Anterior to Posterior (SLAP) Lesion with Glenohumeral Instability Chul Hong Kim, M.D. and Li Wang, M.D. Department of Orthopedic Surgery, Dong-A University College of Medicine, Busan, Korea Role of the superior labrum-biceps complex for the glenohumeral stability is still unclear. Nevertheless, isolated superior labrum anterior to posterior (SLAP) lesion can cause glenohumeral instability in young patient (especially in throwing athletes) and SLAP lesion are a well-known pathology entity in acute or chronic glenohumeral dislocation. Ten types of SLAP lesion have been classified by arthroscopic examination, among them type II and type IV through X SLAP can disturb glenohumeral stability by disrupting the anchoring of biceps. Arthroscopic repair of labrum is the most preferred method for SLAP lesion with glenohumeral instability in younger patient. Surgical treatment, if necessary, should address all aspects of the labral anatomy so that all the roles of the labrum in shoulder stability must be restored. In terms of restoration for glenohumeral instability, the good clinical results have been reported after arthroscopic repair of a SLAP with Bankart lesion. But, it is still a work in progress for long term clinical follow-up and understanding about relationship between SLAP lesion and glenohumeral instability. Key words: superior labrum-biceps complex, superior labrum anterior to posterior lesion, glenohumeral instability 서론 견관절의기능저하와관련되어상부관절와순의역할은여전히 불확실하지만, 관절경과자기공명영상 (magnetic resonance imaging) 기술의발전에힘입어이부위의병변에대한조사혹은진 단은어느정도가능해졌다. 최초에 Andrews 등 1) 은야구선수에 서의 superior labrum anterior to posterior (SLAP) 병변을보고하였 Received April 27, 2016 Revised June 24, 2016 Accepted July 5, 2016 Correspondence to: Chul Hong Kim, M.D. Department of Orthopedic Surgery, Dong-A University Hospital, 26 Daesingongwonro, Seo-gu, Busan 49201, Korea TEL: FAX: kimch@dau.ac.kr *This work was supported by the Dong-A University research fund. 으며 Snyder 등 2) 이현재널리사용되는분류시스템을발표하였다. 이후 SLAP 병변에대한연구가폭발적으로증가하였고, 이러한임상적, 생역학적연구들은경기력이저하된던지기를반복하는운동선수 (throwing athlete) 의원인진단과치료를위하여꾸준히진행되어왔는데, 이러한연구들을통해상부관절와순과상완이두근장두복합체 (superior labrum-biceps complex) 가관절와상완관절 (glenohumeral joint) 의안정성에중요한역할을한다는것을알게되었다. 3-6) SLAP 병변은관절와상완관절의탈구및불안정성의동반병리로이미잘알려져있고, 특히던지기동작을반복하는운동선수의경우 SLAP 병변단독으로도견관절의불안정성을초래할수있다. 본종설은관절와상완관절의불안정성에관여하는 SLAP 병변의병리, 치료및그결과에관하여문헌고찰을통하여논의하고자한다. The Journal of the Korean Orthopaedic Association Volume 52 Number Copyright 2017 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 379 SLAP Lesion with Glenohumeral Instability 병리및분류 관절와순은해부학적으로관절와의오목함 (concavity) 을증가시킬뿐만아니라다양한관절와상완인대 (glenohumeral ligament) 들의부착부를제공함으로써견관절의안정화구조물로작용한다. 상완골두와관절와사이에서접촉압력 (contact pressure) 을비교적균일하게배분하는역할을하고, 근육과인대의부착부을제공하면서이들의긴장도를유지하는역할을하는데, 7) 그런연유로골성구조의위치가변하는고속의회전운동과높은압력에대하여견관절의안정성을도모하게된다. 그러므로정상적인관절와순이존재하여야회전운동시부드러운견관절의운동, 관절자체의안정성, 힘전달등이가능한것이다. 8,9) 그중상부관절와순은상완이두근장두, 관절낭, 관절막인대 (capsular ligament) 등이부착하여역시안정화구조물로작용하게되지만상부관절와순과상완이두근장두가형성하는복합체의정확한역할은완전히밝혀져있지는않다. 상부관절와순의견관절안정성에대한역할을추론해볼수있는몇몇사체연구들이밝히고있는내용은다음과같다. 1) 상완이두근장두는견관절의전방안정화에기여하며, 하관절와상완인대 (inferior gleno-humeral ligament) 에가해지는스트레스를줄여준다. 10) 2) 실험적으로만든사체의 II형 SLAP 병변은관절와상완관절의전-후방전위 (translation) 와전-하방전위를증가시켰다. 11,12) 3) 이러한전-후방전위의증가는상부관절와순파열이상완이두근장두의부착부까지확장될때만발생하였다. 13) 4) 실험적으로만든 SLAP 병변을봉합하면증가된관절와상완관절의전-후방전위가회복되었다. 14) 즉상부관절와순의손상은관절와상완관절의불안정성을초래할수있으며이의봉합을통하여불안정성을줄여줄수있다고주장하는것이다. 임상적으로관절와상완관절의불안정성을위한신체검진중하나인전방불안 (anterior apprehension) 검사와 Jobe검사 (Jobe relocation test) 가임상적으로의미있는 II형 SLAP 병변에서도높은특이도와민감도를가지고양성으로나타나며, 15) 급성혹은만성관절와상완관절탈구의경우 SLAP 병변은잘동반되는병적병변중의하나로이미알려져있다. 16,17) 또한탈구의횟수가많을수록 SLAP 병변이 Bankart 병변과동반되어있을가능성이높다고알려져있으며, 18) 일부에서는재발성관절와상완관절불안정성 (recurrent glenohumeral instability) 에서발견되는 SLAP 병변은불안정발생을초래하는원인이되는시작점이아닌재발성불안정성마지막단계의병리로보고있다. 17) 이러한불안정성은 Snyder 등 2) 이최초분류한기본 4개형과이후 II형의확장정도에따라추가된 6 개형을 19-21) 포함총 X형으로표시되는분류 (Table 1) 중에서 I형과 III형에서는발생하지않는다고알려져있는데, 특히 III형은상완이두근장두자체와부착부는손상되지않기때문에마찰에의한기계적인증상만생기는것으로여기고있다. 2) 그러나최근후방불안정성과관련된 III 형 SLAP 병변에대한증례도보고되었다. 22) 이둘을제외한나머지 SLAP 병변들은상부관절와순과상완이두근장두복합체가직접적으로손상되므로관절와상완관절의불안정성발생에관여하게되는것이다. 수술적치료와결과 관절불안정성이동반된 SLAP 병변의경우현재관절경적검사가진단및치료의원칙적인수단으로인정되고있으며, 관절경하봉합수술은지속적인통증과불안정성이동반될때고려하며, 관절와상완관절관절염, 관절구축, 노령환자의회전근개파열과동반된경우등은와순봉합의상대적인금기이다 ) 특히불안정성과동반된 SLAP 병변의기본형인 II형의경우관절경상에서상부관절와순의명백한기능소실이확인되는지가상 Table 1. Classification of SLAP Lesion Type Type I Type II Type III Type IV Type V Type VI Type VII Type VIII Type IX Type X SLAP, superior labrum anterior to posterior. Morphology Fraying of superior labrum (usually degenerative changes) Superior labrum-biceps anchor pulled off from superior glenoid Bucket-handle like detachment (no extension to biceps-labral attachment) Bucket-handle tears of superior labrum extend into biceps tendon Bankart lesion in continuity with type II SLAP lesion Type II lesion with unstable labral flap lesion (anterior or/and posterior) Type II lesion with extension to MGHL (middle gleno-humeral ligament) Type II lesion with extension to posterior labrum Circumferential labral tear (pan-labral lesion) Type II lesion combined with postero-inferior labral tear (reverse Bankart lesion)

380 Chul Hong Kim and Li Wang 부관절와순에대한봉합술여부를결정하는중요한인자이다.

4,26-28) 관절불안정성과동반된 SLAP 병변의수술법은병변형태, 연령, 환자의기대수준, 동반된병변유무등을고려하여결정한다. 예를들면, 임상적으로의미있는 II형 SLAP 병변의경우젊은환자에서는상부관절와순을관절와에부착시키는봉합술이우선고려되나중년이후는건절제술 (tenotomy) 이나건고정술 (tenodesis) 을고려하게된다.

31) IV형의경우양동이형태 (bucket-handle) 파열부분을제거하거나봉합할수있는데이는환자의연령에따라결정하게된다.

25,32,33) V형부터 X형은손상된관절와순, 중관절와상완인대 (middle gleno-humeral ligament), 그리고상부관절와순상완이두근장두복합체를관절와에재부착시키는봉합술을시행하게된다 (Fig. 1).

일반적으로 V형에있어서 Bankart 병변과 SLAP 병변을동시에봉합할경우관절운동제한 ( 특히외회전 ) 이생길가능성이높다는우려가있어왔지만최근 Bankart 병변만있는관절불안정성과 V 형관절불안정성환자에서각각관절경하봉합술후의결과를비교한후향적연구들은 Bankart 병변만있는환자군과 SLAP

3 380 Chul Hong Kim and Li Wang 부관절와순에대한봉합술여부를결정하는중요한인자이다. 즉 1) 명백한분리 (detachment) 소견, 2) peel-back 현상유무, 3) 상부와순부착부연골의손상 ( 골노출 ) 또는연골연화증, 4) 관절낭긴장도의감소로인한 drive-through 징후혹은하관절와상완인대의후방긴장소실, 5) 후하방관절낭의과도한비후나섬유화등의소견이보일때봉합술을고려하게된다. 4,26-28) 관절불안정성과동반된 SLAP 병변의수술법은병변형태, 연령, 환자의기대수준, 동반된병변유무등을고려하여결정한다. 예를들면, 임상적으로의미있는 II형 SLAP 병변의경우젊은환자에서는상부관절와순을관절와에부착시키는봉합술이우선고려되나중년이후는건절제술 (tenotomy) 이나건고정술 (tenodesis) 을고려하게된다. 24,29,30) 다만, 던지기를반복하는운동선수의경우건고정술은일부방향 ( 후방, 외전, 최대외회전등 ) 의미끄러짐불안정성 (translational instability) 을초래할수있으므로일차치료로서선택시는주의를요한다. 31) IV형의경우양동이형태 (bucket-handle) 파열부분을제거하거나봉합할수있는데이는환자의연령에따라결정하게된다. 남아있는상완이두근장두의손상정도에따라수술법을결정하는데파열정도가건의굵기 1/3 미만이고미미하다면변연절제술만으로도충분하지만 1/3 이상인경우는건절제술이나건고정술을시행하게되며, 이의결정은환자의나이와기능적요구정도를고려하여결정한다. 25,32,33) V형부터 X형은손상된관절와순, 중관절와상완인대 (middle gleno-humeral ligament), 그리고상부관절와순상완이두근장두복합체를관절와에재부착시키는봉합술을시행하게된다 (Fig. 1). 관절불안정성과동반된 SLAP 병변의장기추시연구결과는많지않은데, 18,34-37) 그나마도임상에서흔히볼수있는 Bankart 병변과동반된 V형에대한연구들에국한되어있다 (Table 2). 일반적으로 V형에있어서 Bankart 병변과 SLAP 병변을동시에봉합할경우관절운동제한 ( 특히외회전 ) 이생길가능성이높다는우려가있어왔지만최근 Bankart 병변만있는관절불안정성과 V 형관절불안정성환자에서각각관절경하봉합술후의결과를비교한후향적연구들은 Bankart 병변만있는환자군과 SLAP 병변이동반된환자군에서시행한봉합술은임상적결과나관절운 A B C D E F Figure 1. A circumferential tear (type IX) of the glenoid labrum in the right shoulder. (A) Posterior labral tear viewed from the anterosuperior portal. (B) Anterior labral tear viewed from the anterosuperior portal. (C) Superior labral tear viewed from the posterior portal. (D) Arthroscopic view of a repaired posterior labral lesion with double horizontal mattress suture. (E) Arthroscopic view of a repaired anterior labral lesion with double horizontal mattress suture. (F) Arthroscopic view of a repaired superior labral lesion a horizontal mattress suture (posterior, anterior and superior order using with 6 anchors; anterior-3, posterior-2, superior-1).

4 381 SLAP Lesion with Glenohumeral Instability Table 2. Summary of Clinical Reports of Repair for SLAP and Bankart Lesion Author (year) Study type Design Warner et al. Retrospective 7-athletes (1994) 37) (AS repair SLAP V) Lo and Burkhart Retrospective 7 patients (2005) 36) (AS repair type IX) Takase (2009) 34) Retrospective; case series Tokish et al. Retrospective; (2009) 38) multicenter Bankart alone (n=55) vs. Bankart & SLAP repairs (15 type II and 5 type IV) 39 patients; AS repair circumferential (360 ) labral tear Cho et al. Retrospective Bankart repairs (2010) 35) (n=15) vs. type V SLAP repairs (n=15) Follow-up duration Procedure >1 year Absorbable anchor; SLAP repair preceded Bankart repair 41 months Absorbable suture anchors (mean number 7.1); Bankart repair preceded SLAP repair 2.25 years SLAP repair was performed only if the SLAP lesion did not communicate with the Bankart lesion, otherwise débridement 31.8 months Absorbable or polyethylethylketone (PEEK) anchors (mean number 7.1); posterior, anterior and superior order 15 months Absorbable suture anchors (mean number 5.2); SLAP repair preceded Bankart repair Result Significant improvement in score; 2 complications (one recurrent dislocation/one stiff shoulder); no restriction of ER compared with other side arm Significant improvement of modified Rowe scores; 75% returned to preinjury Significant improvement in scores in all groups; significant restriction of ER in the group with combined SLAP repair and Bankart repair compared with the group treated with débridement of SLAP tear and Bankart repair alone Significant improvement in scores; all patients returned to their preinjury activity level; six revision (2 recurrent dislocation/2 tightness/2 LHB tendinitis) Significant improvement in scores; no significant difference ROM & scores: but ROM recovery was slower in the SLAP type V repair group SLAP, superior labrum anterior to posterior; AS, arthroscopic; ER, external rotation; LHB, long head of the biceps; ROM, range of motion. 동범위차이가유의하지않았고, 다만 V형에서관절운동의늦은회복을보고하고있다. 18,35) 반면에 Takase 34) 는 V형병변에서 Bankart 병변은봉합하고, 상부관절와순파열은이파열이 Bankart 병변과연결되지않은경우만봉합하고연결되어있는경우는변연절제술만시행하여그결과를보고하였는데재탈구나임상적경과는유의한차이가없었으나 SLAP 병변을봉합하지않은경우에서외회전운동범위가유의하게높았다고보고하였다. 관절와순전체가 360도파열된 IX형의경우 Tokish 등 38) 이 39 명의환자에대한관절경하봉합술결과를보고하였는데, 전환자에서손상이전의기능을회복하였다고밝히고있으며, 수술시후방및후하방관절와순, 전방관절와순, 상부관절와순순서로봉합할것을추천하고있다. V형의경우 Bankart 병변과 SLAP 병변중에어느부위를먼저봉합할것인가에대하여는술자들간에공용되는합의점은없는상태인데, 많은술자들은 SLAP 병변을먼저봉합하면전-하방와순으로의접근이어려운점으로인해 Bankart 병변을먼저봉합하는쪽을선호한다. 18,36,39) 그러나일부는 SLAP 병변을먼저봉합하는것이 Bankart 병변의해부학적정복 (reduction) 에유리하다고주장하기도한다. 35) 봉합한관절와순이치유되는데는약 6주이상의기간이필요 하며이를고려하여수술후재활이계획되고, 4주에서 6주간은견관절보조기착용이필요하다. 통상적으로이시기이후견갑골평면 (scapular plane) 에서의보조하능동적 (active assisted) 전방거상과외회전을시작하여다른평면으로확대해가며 3개월에서 4개월사이에등척성 (isometric) 근력운동부터시작하고스포츠활동의복귀는 6개월이후로결정한다. 요약 장기적인추시를가지는전향적연구와실험을통한관절불안정성과동반된 SLAP 병변봉합술의정확한효과에대한확인과상부관절와순-상완이두근장두복합체의관절안정성에대한정확한역할규명은아직남아있는과제이지만현재까지대부분의임상적결과보고는이를함께복원하는것이급성혹은만성불안정성의치료에서좋은결과를제공하는것으로되어있다. CONFLICTS OF INTEREST The authors have nothing to disclose.

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7 384 pissn : , eissn : Symposium J Korean Orthop Assoc 2017; 52: Superior Labrum Anterior to Posterior (SLAP) 병변 : 쟁점 Superior Labrum Anterior to Posterior (SLAP) 병변과관절와상완관절불안정성 김철홍 왕립 동아대학교의과대학정형외과학교실 견관절안정성에있어서관절와순상완이두근장두복합체의역할은명확하지는않지만젊은환자, 특히운동선수의경우 superior labrum anterior to posterior (SLAP) 단독병변만으로불안정성이야기될수있고, 급성혹은만성견관절의탈구에서 SLAP 병변은흔한동반병리중하나인것은잘알려진사실이다. SLAP 병변은 X형까지분류되어있는데 II형, 그리고 IV형부터 X 형까지가관절불안정성과관련이있다. 관절불안정성이동반된젊은환자에서관절경수술이선호되는진단및치료수단이며, 수술시관절안정성에필요한관절와순의모든해부학적문제를복구하고자노력해야한다. 관절안정성회복의측면에서 SLAP 및 Bankart 병변에대한관절경적봉합술의좋은임상적결과들을보고하고있으나장기적인경과관찰이더필요하고, SLAP 병변과관절와상완관절불안정성간의관계에대한연구가더요구된다. 색인단어 : 관절와순상완이두근장두복합체, 상부관절와순전후병변, 관절와상완관절 접수일 2016 년 4 월 27 일수정일 2016 년 6 월 24 일게재확정일 2016 년 7 월 5 일책임저자김철홍 49201, 부산시서구대신공원로 26, 동아대학교병원정형외과 TEL , FAX , kimch@dau.ac.kr * 본연구는동아대학교의연구비지원을받아진행되었음. 대한정형외과학회지 : 제 52 권제 5 호 2017 Copyright 2017 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Symposium J Korean Orthop Assoc 2017; 52: Superior Labrum Anterior to Posterior (SLAP)

Symposium J Korean Orthop Assoc 2017; 52: 385-391 https://doi.org/10.4055/jkoa.2017.52.5.385 www.jkoa.org Superior Labrum Anterior to Posterior (SLAP) Lesion: Controversial Issue 385 Superior Labrum Anterior