392 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2017; 52: 392-402 https://doi.org/10.4055/jkoa.2017.52.5.392 www.jkoa.org 변형된 Mac 교량형봉합술 : 건의상태가불량한회전근개파열에서의임상적및영상학적치료결과 천상진 이효열 안성진 부산대학교의과대학정형외과학교실 A Modified Mac Suture Bridge Technique: Clinical and Radiological Outcomes of the Treatment of Rotator Cuff Tear with Poor Tissue Quality Sang Jin Cheon, M.D., Ph.D., Hyo Yeol Lee, M.D., and Sung Jin Ahn, M.D. Department of Orthopedic Surgery, Pusan National University School of Medicine, Busan, Korea Purpose: Base on the concept of the Mac stitch, we designed the modified Mac-suture bridge technique to improve the outcome of arthroscopic repair of rotator cuff tear with poor tissue quality. Moreover, we evaluated both the radiological and clinical outcomes of the surgery to assess the effectiveness of the newly designed technique. Materials and Methods: From January 2010 to December 2014, a total of 52 patients (25 males, 27 females) with rotator cuff tear, with poor tissue quality according to both radiological and intraoperative findings, who underwent arthroscopic rotator cuff repair using the modified Mac-suture bridge technique and followed-up for at least 1 year were included in this study. The mean patient age at the time of surgery was 60 years. The average follow-up period was 20 months. We evaluated the clinical outcomes by checking the range of motion and compared the following, both preoperatively and postoperatively: American Shoulder and Elbow Surgeon (ASES) score, University of California, Los Angeles (UCLA) score, Constant shoulder score (CSS), visual analogue scale (VAS). In addition, we analyzed 42 series of postoperative magnetic resonance imaging by using the Sugaya s classification for the evaluation of the repair integrity. Results: All clinical scores showed significant improvement (ASES score improved from 56.75 to 83.44, UCLA score from 20.52 to 29.23, CSS from 64.04 to 80.90, and VAS from 6.17 to 1.62; p<0.001). The range of motion was also improved; forward flexion improved from 108 to 158, abduction from 109 to 160, external rotation from 27 to 50, and internal rotation from 31 to 57 (p<0.001). Satisfactory radiologic results were noted on postoperative magnetic resonance imaging, consisting of 15 cases (35.7%) type I, 22 cases (52.4%) type II, 3 cases (7.1%) type III, 2 cases (4.8%) type IV, and no type V, according to the Sugaya s method. Conclusion: The modified Mac-suture bridge technique provided satisfactory results both radiologically and clinically for the treatment of rotator cuff tear with poor tendon tissue quality. It could possibly be a good alternative to previous techniques of arthroscopic repair. Key words: rotator cuff tear, poor tissue quality, modified Mac suture bridge technique, Massive cuff stitch, suture bridge repair Received September 19, 2016 Revised December 30, 2016 Accepted March 29, 2017 Correspondence to: Sang Jin Cheon, M.D., Ph.D. Department of Orthopedic Surgery, Pusan National University School of Medicine, 179 Guduk-ro, Seo-gu, Busan 49241, Korea TEL: +82-51-240-7248 FAX: +82-51-247-8395 E-mail: scheon@pusan.ac.kr *This study was supported by a 2016 research grant from Pusan National University Hospital. 서론 회전근개파열의관절경적봉합술은점차보편화되고있으나기술의발전에도불구하고재파열에대한보고가끊이지않고있다. 1) 이에따라재파열을줄이기위한노력들이저자들에의해이루어지고있다. 많은연구에서재파열에영향을미치는요소로나이, 성별, 증상지속시기, 지방변성정도, 파열의크기, 건의상 The Journal of the Korean Orthopaedic Association Volume 52 Number 5 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 (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
393 A Modified Mac Suture Bridge Technique 태등이언급되고있다. 2,3) 이중특히건의상태가불량한경우는재파열률을높이는불량한예후인자로알려져있다. 4,5) 사회의고령화가진행함에따라건과뼈의상태가불량한환자들이증가하고있어이런환자들의예후를개선하기위해다방면적인접근이필요하다. 수술전환자요소나술후관리에대한개선도중요한문제이며이와더불어봉합술자체에대한재고도충분히이루어져야할것이다. Denard와 Burkhart 6) 는건의상태가불량한회전근개파열환자들에게적용할수있는여러가지관절경적회전근개파열복원술에대해고찰한바있다. Meier와 Meier 7) 는회전근개상완골대결절부착부 (footprint) 를늘리고윤활낭액을효과적으로차단하는봉합법을사체연구를통해연구하였다. 그들은이연구에서이열봉합술에서가장우수한성적을보임을보고하였다. Shin 8) 은봉합의성공에있어서건-골간압력접촉면적과균등한건-골간압력의분포가중요함을언급하였고이연구를통해단열봉합술, 이열봉합술, 경골봉합술에비해교량형봉합술이우수한생역학적특성을나타냄을보고하였다. 이외에도많은저자들이봉합술을고안하고있으나가장좋은봉합법이무엇인가에대한질문은여전히난제로남아있다. 저자들은봉합의고정유지력에서우수성을보이는 Mac 봉합술에서아이디어를착안하여교량형봉합술의장점을취하는봉합술을고안하였고이른바 변형된 Mac 교량형봉합법 이라명명하였다. 9) 그리고봉합법의유용성을평가하기위해건의상태가불량하여재파열경향성이높은회전근개파열환자들에서선택적으로변형된 Mac 교량형봉합법을적용한후임상적기능회복정도를평가하고및해부학적치유결과를영상학적방법을통해분석하였다. 대상및방법 1. 연구대상불량한건의상태 (poor tendon quality) 에대한객관적인기준은확립되어있지않다. 저자들은본연구에서건이세동 (fibrillation) 혹은층상분리 (delamination) 된상태, 파열단의두께가현저히얇아 진상태등건의질자체가불량하여봉합시건이쉽게찢어지는 (tendon cutout) 경향성을띨때임상적으로불량한건의상태로정의하였다. 파열의크기나형태는불량한건의상태와어느정도양의상관관계가있을것으로예상되나정의에서는배제하였다. 2010년 1월부터 2014년 12월까지부산대학교병원에서회전근개파열로진단후 6개월이상보존적치료를시행하였으나호전이없어수술을시행한환자를대상으로하였다. 우선수술전시행한자기공명영상검사를통해건의상태가불량한환자들을영상학적으로진단하였다. 건병증의정도가중등도 (2단계) 이상이면서파열단의건의두께가근-건접합부 (musculotendinous junction) 에비해얇아진상태를보이는환자를대상에포함시켰다. 10) 파열의크기가소파열 (small size tear) 이하이거나부분층파열 (partial thickness tear) 인경우연구대상에서제외하였다. 기간내시행된 788건의관절경적회전근개봉합술중 110예의환자에서수술전영상학적으로건의상태가불량한것으로진단되었다. 이들중관절경수술중건에조작을가하여건의두께와근섬유간의결합력, 해어진정도 (fraying) 를평가하였고수술소견에서도건의상태가불량하다고최종판단되는환자들에서변형된 Mac 교량형봉합술을시행하였다. 견인시장력 (repair tension) 이과도히걸려교량형봉합술을적용할만큼건이충분히견인되지않는경우는단열봉합술등을이용하였으며연구대상에서제외되었다. 신경학적증상이동반된경우, 변형된 Mac 교량형봉합술외에추가적인봉합이시행된경우도연구대상에서제외하였다 (Table 1). 수술후최소 1년이상추시를시행한 52예 ( 중파열 18 예, 대파열 30예, 광범위파열 4예 ) 환자에서결과를후향적으로분석하였다. 남자는 25명, 여자는 27명이었으며평균연령은 60세였다. 평균추시기간은 20개월이었다. 전체환자중 2예에서상완이두근의완전파열, 2예에서부분파열이동반되었고부분파열병변에대해서는이두건절단술을시행하였다. 전체환자의 8 예에서상부관절와순파열 (superior labral anterior to posterior lesion) 병변이관찰되었고관절와순부분절제술을시행하였다. 23 예에서견갑하건파열이관찰되었고이중봉합이필요한것을판단되는 18명의환자에서봉합술을시행하였다. 중등도의유착성 Table 1. Inclusion and Exclusion Criteria Inclusion criteria Rotator cuff tear with tendinopathy same or more than grade 2 Marked thinning of tear margin compared to the tendon thickness at musculotendinous junction Intraoperatively findings showing poor tendon quality (fibrillation, tendon cutout) Exclusion criteria Small size tear Partial thickness tear Excessive repair tension that is not adequate for suture bridge repair Multiple repair methods used in addition to suture bridge repair Associated neurologic symptom
394 Sang Jin Cheon, et al. 관절낭염을보이는 1예의환자에서는관절낭유리술을시행하였다. 2. 수술방법모든수술은동일시술자에의해이루어졌으며전신마취하에측와위 (lateral decubitus position) 로시행하였다. 출혈을최소화하기위해저혈압마취를시행하고 1:1,000 epinephrine 1 ml를 3,000 ml 세척용생리식염수에혼합하여사용하였다. 펌프를이용하여 40-60 mmhg 압력을유지하고도르래를이용해 5-6 kg 추를매달아상지를견인하여견관절내수술시야를확보하였다. 마취하견관절의수동적운동범위를확인한후견봉의후외측연하방및내측에후방삽입구를만들어도관삽입후관절경을삽입하여관절내이상유무를확인하였다. 전방삽입구를통해탐색침을삽입하여상완이두장건의병변과상부관절와순의상태를관찰하고, 관절내연골과관절활액막, 견갑하건의이상유무를확인하였다. 이후관절경을점액낭측 (bursal side) 으로옮겨견봉하공간을관찰하였다. 건의해어진정도를시진을통해확인하였고건에관절경겸자 (tendon grasper) 를이용하여건에조작을가하여건의두께와근섬유간의결합력을평가하여건의상태를종합적으로사정하였다 (Fig. 1). 건의상태가불량하여재파열의경향성이높다고판단되는경우변형된 Mac 교량형봉합술을적용하였다. 변형된 Mac 교량형봉합술을시행하기위해우선상완골두관절면상방연바로외측의대결절부위에네가닥의봉합사가달린봉합나사못 (suture anchor) 을단단히고정한다음네가닥중찢어짐방지봉합 (rip-stop stitch) 으로활용될두가닥을봉합갈고리 (suture passer) 를이용해회전근개의파열된외측연으로부터약 10 mm 내측에서건을통과시킨후수평고리 (horizontal loop) 를형성하였다. 여기서형성된수평고리를바로매듭지어버리면이후교량형봉합술에사용될봉합사를적절한위치로통과시 킬수없게되기때문에수평고리를완전히매듭짓지않은상태에서교량형봉합술에이용될두가닥의봉합사를수평고리의바로내측지점에서건을통과시켰다. 네가닥의봉합사가모두적절한위치를통과하는게확인이되면봉합사의전체적인위치관계를다시확인하면서수평고리를천천히매듭지어수평매트리스봉합을시행하였다. 이때매듭을조이는강도를너무세게할경우감돈을야기할수있으므로건과골간에고정이유지가되는범위내에서회전근개가대결절에편안하게접촉할수있을정도로매듭을시행하였다. 찢어짐방지봉합의매듭을짓고남는봉합사부분은결찰하지않고이전에교량형봉합술을위해수평고리안을통과시킨봉합사두가닥과한가닥씩짝지어두었다. 이러한과정을동일하게반복하여대결절부위의평행한곳에내측열봉합을추가로실시하면여덟개의봉합사가네쌍을이루게된다. 이중가운데에있는두쌍의봉합사는서로교차시키면서외측열로이동시키고, 바깥의두쌍의봉합사들은찢어짐방지봉합과수직하게외측열로이동시킨후비매듭나사못을이용하여교량형봉합술을시행하였다 (Fig. 2, 3). 내측열에사용된나사못은 4.5 mm Bio-Corkscrew FT (Suture- Tak; Arthrex, Inc., Naples, FL, USA) 71개, 2.8 mm Y-knot RC All-Suture Anchor System (ConMed Linvatec, Largo, FL, USA) 9개, 2.9 mm JuggerKnot Soft Anchor (Biomet Sports Medicine, Warsaw, IN, USA) 8개, 4.5 mm Genesys CrossFT Biocomposite Fully Threaded Anchors (ConMed Linvatec) 가 34개, 5.0 mm Super REVO full threaded metal anchor FT (ConMed Linvatec) 는 2개사용되었다. 외측열에사용된나사못은 3.5 mm 혹은 4.5 mm Bio- PushLock (SutureTak; Arthrex, Inc.) 45개, 3.5 mm 혹은 4.5 mm PopLok Knotless Suture Anchor (ConMed Linvatec) 32개가사용되었다. 사용한나사못의종류는환자의병변과는무관하게수술당시집도의의선호에따라사용되었다. Figure 1. Manipulating tendon to evaluate the quality of tendon tissue. Edematous torn tendon is grasped with a retriever, which is oversusceptible to the tension due to severe tendinopathy.
395 A Modified Mac Suture Bridge Technique A B C D Figure 2. Schematic illustration of modified Mac-suture bridge technique. (A) Penetrate suture fiber in appropriate site. (B) Rip-stop stitch. (C) Anchor-lock fixation. (D) Final outcome. SSp HH A B C D Figure 3. Modified Mac-suture bridge technique. (A) Rip-stop stitches at the medial row (black arrow: rip stop stitch, white arrow: traction fiber for suture bridging, SSp: supraspinatus tendon, HH: humeral head). (B) Lateral migration of two pairs of suture fibers. (C) Suture anchor fixation at the medial row. Note that one pair is consisted of one green fiber and one white fiber. (D) Grand canyon view at the end of the repair.
396 Sang Jin Cheon, et al. 3. 수술후재활수술후재활은환자들마다수술방내소견에맞춰개개인마다달리시행했으나큰흐름은다음과같았다. 수술후약 6주간외전보조기를착용하였다. 수술직후부터주관절, 수근관절의능동적운동과견관절의으쓱거림 (shrugging) 운동을장려하였다. 수술 1주후부터는상지를전방으로기울인상태에서몸전체를가볍게움직여견관절의수동적인진자운동 (pendulum) 을시작하였다. 수술 2-3주후부터는수동적전방거상운동, 외회전및내회전운동을시작하였고수술후 4-6주부터정상적인견관절운동범위를확보하기위해능동적보조적관절가동범위운동 (active assisted range of motion exercise) 을시행하였다. 8주이후부터는능동적관절운동을시작하고 12주째부터 6개월간근력강화운동을시작하였다. 4. 기능적평가및해부학적평가술전모든환자에대해 American Shoulder and Elbow Surgeon (ASES) score, University of California, Los Angeles (UCLA) score, Constant shoulder score (CSS), visual analogue scale (VAS) 설문을실시하였고관절운동범위측정을이용하였다. 그리고최종추시때동일한검사를시행하여하여기능적평가및추시를시행하였다. 한편해부학적평가를위해모든환자에서술전견관절전후및측면방사선검사, 자기공명영상검사를시행하였고건병증및건의파열단의상태를조사하였다. 또 Goutallier 분류법을통해극상건근위부의지방변성정도간의연관성여부를조사하였다. 11) 수술후에는회전근개회복정도를평가하기위해모든환자에게추시자기공명영상검사를권유하였고이중동의한 42 예 ( 중파열 14예, 대파열 24예, 광범위파열 4예 ) 의환자에서자기공명영상촬영을시행하였다. 이영상에대해 Sugaya 분류를이용하여술후구조적상태를분석하여영상학적평가를시행하였다. 12) T2 조영증강관상면에서회전근개건이균질한저강도의충분한두께를보일때 I형, 부분적으로고강도를보이는충분한두께를보일때 II형, 불연속성은없으나불충분한두께를보일때 III형, 약간의불연속성을보일때 IV형, 두드러진불연속성이보이는경우 V형으로분류하여회전근개건의회복상태를분석하였다. 자기공명영상촬영평균추시간격은 27.7주 ( 약 7개월 ) 이었다. 5. 통계적분석통계적분석은 SAS ver. 9.3 (SAS Institute, Cary, NC, USA) 통계분석프로그램을이용하였고, p-value가 0.05 미만인경우를유의한것으로판단하였다. 수술전, 후의신체검사상관절운동범위, 임상적지표로서 ASES, UCLA, CSS, VAS 점수를전산화하였고자료가정규성을만족하지않아윌콕슨부호순위검정 (Wilcoxon signed rank test) 을이용하여 95% 의신뢰구간에서통계적유의성 을검증하였다. 회전근개파열외의다른병변들이치료결과의해석에교란변수로작용했을가능성에대해전체환자를동반된견관절병변없이회전근개파열이단독으로존재하는군 (Group A, n=31) 과회전근개파열외의견관절병변 ( 이두박건파열, 관절와순파열, 유착성관절낭염, 중증의윤활낭염등 ) 이동반되어회전근개봉합술시행과함께동반병변을치료한군 (Group B, n=21) 으로나누어윌콕슨순위합검정 (Wilcoxon rank-sum test) 으로통계적분석을시행하였다. 결과 최종추시결과 ASES score는 56.75±13.52점에서 83.44±8.39점으로호전되었으며 UCLA score는 20.52±6.50점에서 29.23±5.19점으로, CSS는 64.04±16.18점에서 80.90±7.97점으로, VAS score는술전 6.17±1.20점에서술후 1.62±0.82점으로모두의미있는호전을보였다. 견관절운동범위의평균치는전방거상은 108 ±28 에서 158 ±17, 외전 109 ±34 에서 160 ±15, 외회전 ( 외전 ) 27 ± 21 에서 50 ±17, 내회전 ( 외전 ) 31 ±12 에서 57 ±18 로회복되었다. Group A와 Group B의치료성적을분석한결과두군에서모두통계적으로유의한호전을보였다 (Table 2). 동반병변의존재와치료여부는결과에유의한영향을미치지않는것으로나타났다 (Table 3). 술전자기공명영상에서극상건근위부의지방변성의정도는 Goutallier 분류상 1단계 13명, 2단계 24명, 3단계 14명, 4단계 1명이었으며회전근개파열의크기나건병증과는서로연관성이없는것으로나타났다. 수술후평균 7개월째시행한추적자기공명영상상치유정도는 Sugaya 분류법상 I형은 15명 (35.7%), II형은 22 명 (52.4%), III형은 3명 (7.1%), IV형은 2명 (4.8%) 이었으며 V형은없었다. I, II, III형으로병변의회복상태에해당하는환자는 40명으로전체의 95% 에해당하였다. 재파열 (IV, V형 ) 은 2명 (5%) 에서관찰되었다. 수술소견상재파열환자 2명중 1명은대파열, 1명은광범위파열환자였다. 수술후창상감염, 신경손상, 봉합나사못실패등의합병증은발생하지않았다 (Fig. 4). 고찰 저자들은건의상태가불량한회전근개파열환자에서재파열을줄이기위해변형된 Mac 교량형봉합술을고안하였고이를임상에적용해임상적및영상학적으로우수한결과를얻을수있었다. 지금까지많은연구에서회전근개건의상태를평가하는등급체계가제시되고그효용성이연구되어왔다. Goutallier 등 11) 은자기공명영상시상단면상에서지방변성정도를등급화하여건의상태를평가하였다. 그리고그들은지방변성으로대표되는건
397 A Modified Mac Suture Bridge Technique Table 2. Clinical Results of Modified Mac-Suture Bridge Technique Variable Group Preoperative Postoperative Diff. p-value* ASES score Total 56.75±13.52 83.44±8.39 26.69±12.28 <0.001 Group A 57.87±13.79 83.23±9.62 25.35±12.03 <0.001 Group B 55.10±13.27 83.76±6.36 28.67±12.66 <0.001 UCLA score Total 20.52±6.50 29.23±5.19 8.71±5.50 <0.001 Group A 20.10±7.09 28.77±5.67 8.68±5.69 <0.001 Group B 21.14±5.63 29.90±4.44 8.76±5.35 <0.001 CSS Total 64.04±16.18 80.90±7.97 16.87±11.08 <0.001 Group A 62.94±17.15 80.13±8.42 17.19±11.49 <0.001 Group B 65.67±14.90 82.05±7.30 16.38±10.71 <0.001 VAS Total 6.17±1.20 1.62±0.82-4.56±1.24 <0.001 Group A 6.10±1.30 1.65±0.91-4.45±1.23 <0.001 Group B 6.29±1.06 1.57±0.68-4.71±1.27 <0.001 FF ( ) Total 108.37±28.45 158.27±16.54 49.90±23.65 <0.001 Group A 110.32±28.92 158.71±18.93 48.39±21.62 <0.001 Group B 105.48±28.19 157.62±12.61 52.14±26.77 <0.001 ABD ( ) Total 109.33±34.04 160.10±15.00 50.77±33.17 <0.001 Group A 112.74±36.47 160.00±17.61 47.26±35.00 <0.001 Group B 104.29±30.26 160.24±10.43 55.95±30.36 <0.001 ER at ABD ( ) Total 27.31±21.32 50.10±17.28 22.79±13.45 <0.001 Group A 26.29±21.75 47.42±15.86 21.13±14.87 <0.001 Group B 28.81±21.09 54.05±18.88 25.24±10.89 <0.001 IR at ABD ( ) Total 30.87±12.40 56.73±17.82 25.87±20.04 <0.001 Group A 31.77±14.23 58.55±17.52 26.77±19.39 <0.001 Group B 29.52±9.21 54.05±18.35 24.52±21.38 <0.001 Values are presented as mean±standard deviation. *Wilcoxon signed rank test. Diff., difference; ASES, American Shoulder and Elbow Surgeon; UCLA, University of California, Los Angeles; CSS, Constant shoulder score; VAS, visual analogue scale; FF, forward flexion; ABD, abduction; ER, external rotation; IR, internal rotation; Group A, isolated rotator cuff lesion; Group B, rotator cuff lesion with associated shoulder lesion. Table 3. Comparison of Clinical Results Depending on the Existence of Other Shoulder Lesions Variable Group A Diff. Group B p-value* ASES score 25.35±12.03 28.67±12.66 0.336 UCLA score 8.68±5.69 8.76±5.35 0.911 CSS 17.19±11.49 16.38±10.71 0.831 VAS -4.45±1.23-4.71±1.27 0.463 FF ( ) 48.39±21.62 52.14±26.77 0.772 ABD ( ) 47.26±35.00 55.95±30.36 0.311 ER at ABD ( ) 21.13±14.87 25.24±10.89 0.257 IR at ABD ( ) 26.77±19.39 24.52±21.38 0.674 Values are presented as mean±standard deviation. *Wilcoxon signed rank test. Diff., difference; Group A, isolated rotator cuff lesion; Group B, rotator cuff lesion with associated shoulder lesion; ASES, American Shoulder and Elbow Surgeon; UCLA, University of California, Los Angeles; CSS, Constant shoulder score; VAS, visual analogue scale; FF, forward flexion; ABD, abduction; ER, external rotation; IR, internal rotation.
398 Sang Jin Cheon, et al. Figure 4. Preoperative and postoperative outcomes on magnetic resonance imaging findings. Table 4. Criteria Used for the Subjective Evaluation of Intraoperative Findings Tendon quality Description 1: Poor Thin, attenuated, friable tendon with fibrillations±laminations; high likelihood of the suture s cutting through the tendon during repair 2: Fair Thin tendon with fibrillations±laminations 3: Moderate Thick tendon with fibrillations and laminations 4: Good Thick tendon with only some fibrillations 5: Excellent Thick tendon with well-defined tear margins; no fibrillations Repair tension Negligible Minimal Moderate High No tension as tear margin is already sitting on the footprint Some tension needed to pull the cuff onto the footprint Moderate tension needed to pull the cuff on to the footprint after tenolysis is performed (subacromial±intraarticular supraglenoid release); tendon has tendency to retract off footprint after locking the anchor Great tension needed to pull the cuff onto the footprint even after interval-slide release; poor tendon to bone apposition after anchor locking 의상태가치료의예후와밀접한연관이있음을보고하였다. 한편 Sein 등 10) 은자기공명영상의관상단면상에서관찰되는신호강도의소견에따라 4단계로회전근개건병증의정도를등급화하여건의상태를서술하였다. Chung 등 13) 은파열의크기와지방변성의정도가예후에영향을크게미치지않았으며건병증의정도가예후에영향을미치는것으로보고하여기존에알려진결과들을반박하였다. 본연구에서는영상학적으로불량한건의상태를건병증등급과지방변성등급을종합하여평가하였으며추가로자기공명영상의관상단면에서근-건접합부 (musculocutaneous junction) 에비해파열단의건의두께가현저히얇아진경우를본연구대상에포함시켰다. 14) 파열단의건의두께가얇아진경우견인시증가하는장력을이기지못하고건섬유들이찢어져봉합이어려워지는보편적인경험에비추어볼때파열단의두께도건의상태를서술하는데포함되어야한다고판단하였기때문이다. 영상학적검사를통해건의상태를평가하는것은물론환자의병변과치료결과를예측하는데도움이되나수술내소견상관찰되는불량한건의상태를완벽하게반영하는데에는한계가있다. 파열단의두께가얇거나건섬유사이의결합상태가좋지못하여건이쉽게찢어지는상황 ( 세동 ), 봉합바늘을통과시킨후견인을했을때건이찢어지는현상등수술중관찰되는소견이야말로건의상태를가장정확하게반영하는것으로볼수있다. 그러나주관적인집도의의느낌을객관화하는것은쉽지않다. Ahmad 등 15) 은최근연구에서수술중주관적소견에대한평가체계를제시하려고노력하였다. 그들은첫째로수술중건의두께, 건이층이나섬유단위로분리된정도, 파열된건의경계부가명확한지등을관찰하여건의상태를서술하였고둘째로봉합술을위해건을견인할때걸리는장력에대해등급을나누어평가하였다 (Table 4). 그결과건의상태가불량할수록임상적인예후
399 A Modified Mac Suture Bridge Technique 가좋지않았고초음파로측정된구조적연속성또한실제수술시소견과밀접한연관이있는것으로보고되었다. Ahmad 등 15) 과저자들의연구를비교할때수술중건의상태에대한평가를위해관찰한항목이매우유사함을알수있다. 반면 Ahmad 등 15) 은견인시걸리는장력을건의상태의등급화에반영한것과는달리저자들은치료시에적용하는봉합법을달리하기위해참고하였다. 건의상태에대한집도의들의평가방법은이처럼개개인의경험에따라약간의차이가존재하는것으로보이며앞으로저자들간의논의를통해건의상태에대한각자의주관적인평가가통일되어객관화가이루어지는과정이필요할것으로보인다. 건의상태가불량한회전근개파열의경우대부분견인시장력이크게걸리는것에비해건의섬유의저항력이작아수술중에도쉽게찢어지는현상을발견할수있다. 또봉합을시행하더라도건자체의치유능력이떨어져있기때문에재파열을줄이기위해튼튼하고적절한봉합을찾는것은여전히과제로남아있다. 재파열의대부분은복원된회전근개가대결절부착부에서완전치유되기전건-봉합사간의분리가발생하는것에서기인한다. 따라서건과골조직사이의접촉면적을넓히고강한고정력을얻는방법들이연구되고개발되어왔다. 16) 널리알려진봉합법중변형된 Mason-Allen 봉합법은다른기술들에비해건에대한봉합의고정유지력이떨어지지않으면서감돈이적은것으로각광받아왔다. 17) Rhee 등 18) 과 Lee 등 19) 은이봉합법을응용하여고정유지력을향상시키고내측열에서의감돈을막아주기위해 변형된 Mason-Allen 교량형봉합술 을고안하였다. 이봉합법은고정유지력이매우강하며찢어짐방지역할을하는봉합사가있어회전근개를통해봉합사가빠져나오는것을방지해주는 장점이있다. 또한매듭이없어견봉하공간에서매듭충돌등자극이발생할가능성이적다. 그러나내측으로장력이부하될시 Mason-Allen 봉합법에서매듭의특성상자체적으로감돈이발생하여안정성이떨어지게되고결과적으로회전근개의내측전위를유발하게되는현상이보고된바있다. 또내측열에서외측열을향하며교차하는봉합사들에장력이동일하게부하되지않을시내측열고리의불안정성과맞물려상완골대결절부착부의건과골조직사이접촉면 (footprint) 에관절액의침범을막기힘들다는단점이있다. 한편 MacGillivray와 Ma 9) 가제안한 Mac 봉합법은수평고리를사용함으로써봉합의힘을높여주는것과동시에찢어짐방지기능을추가하였다. 이런장점으로인해광범위파열에서도효과적인고정유지력을보인다는점에서광범위근개봉합법 (Massive cuff stitch) 으로불리기도한다. Ma 등 20) 은생체역학적연구를통해찢어짐방지봉합의유용성을고찰하였고찢어짐방지봉합이 2개이상의봉합나사못과함께사용될경우변형된 Mason- Allen 봉합법과맞먹는고정유지력을가지는것으로보고하였다. Ko 등 21) 은중범위의전층회전근개파열에대해변형된 Mason- Allen 수술기법을이용한광범위근개봉합을시행하여 1년이상추시에서좋은결과를얻었다. 그러나이매듭법은내측열매듭의결찰후발생하는자유단 (free end) 이견봉하공간에그대로노출되어자극을일으킬소지가있다. 저자들이제시하는변형된 Mac 교량형봉합법의특징을기존에알려진봉합술기들과비교하여정리하자면다음과같다. (1) 매듭이없는 (knotless) 봉합 : 내측열에서매듭을짓지만결찰없이그대로외측열로당겨교량형봉합술을시행하므로자유단이발생하지않는다. (2) 찢어짐방지봉합 : 내측열의수평봉합 Table 5. Comparison of Postoperative Cuff Integrities Technique Overall retear rate Double row repair 22) 9.8 (4/41) Single row Mason-Allen repair 23) 24.5 (13/53) Conventional SB repair 24) 19 (5/26) TOE/SB repair 25) 12 (3/25) Modified Mason-Allen SB repair 18) 5.9 (3/51) Modified Mac SB repair 5 (2/42) Small tear Medium tear Large tear Massive tear 22 (2/9) N/A (0/0) 0 (0/27) 24 (9/38) 24 (4/17) 33 (2/6) 11 (1/9) 29 (4/14) N/A (0/0) N/A (0/0) N/A N/A N/A N/A N/A N/A N/A N/A N/A (0/0) Retear rates of each technique are subdivided by preoperative tear size. Values are presented as percent (number/total number). SB, suture bridge; TOE/SB, Transosseous-equivalent suture bridge; N/A, not available. 0 (0/14) 4.2 (1/24) 25 (1/4)
400 Sang Jin Cheon, et al. 이찢어짐방지기능을하여건의질이불량한예에서도비교적건이찢어지는현상이발생하지않고동시에윤활낭액의침범을효과적으로차단한다. (3) 교량형봉합 : 기존에알려진교량형봉합술보다수적으로증가된네쌍의봉합사, 총 8개의봉합사를이용해건을골에압착시켜회전근개상완골대결절부착부 (foot print) 에건-골간접촉면적을늘리고고른장력이걸리게하였다. (4) 기술적으로용이함 : 관절경적으로시행하기비교적쉬운술기로관절경술기가익숙하지않은수술의들에게도쉽게행해질수있다. 새로운술기의사활은기존에알려진술기들과비교하여더개선된예후를보이는지여부에달려있다. 본연구는새로운봉합법의유용성을시험해보기위해재파열의경향성이높은건의상태가불량한환자에서선택적으로시행됐고이점에서타연구의봉합법과단순비교를하기에는어려움이있다. 하지만수치만을봤을때술전파열의크기가중파열에해당하는 14예에서 0% 재파열률을보였으며대파열환자 24예에서 4.2%, 광범위파열환자 4예에서 25% 의재파열률을보였고전체재파열률은 4.8% 를보였는데이는타연구에서보고된수치에비해우수한치유결과임을알수있다 (Table 5). 18,22-25) 또한개선된예후뿐만아니라술기가비교적쉬워관절경을시행하는초심자들에게도널리시행될수있겠고수술시간의단축도기대해볼수있다. 이런점을종합해볼때변형된 Mac 교량형봉합술은기존에알려진봉합법들에대해새로운대안으로서제시될수있을것이다. 나아가불량한건의상태를보이는회전근개파열환자군에서뿐만아니라보편적인회전근개파열의치료법으로적용을하여도손색이없을것으로보인다. 한편찢어짐방지봉합마저도적용할수없을정도의심한건병증이있거나파열단이얇아진회전근개파열에서는 Mac 교량형봉합술의시행에제한이있었다. 저자들은이러한경우단열봉합법등을사용하여봉합을시행하였으며병변의양상에따라적절한봉합이시행되어야할것으로보인다. 본연구의제한점으로는저자의다른봉합법과의대조연구가이루어지지않았다는점, 파열분석과정에서골의상태는고려되지않았다는점등이있다. 또구조적평가를위한자기공명영상추시가평균수술후 7개월에이루어져 12개월이후에추시된다른연구들과의비교가어려운점이있다. 그러나봉합의원리와결과를볼때굉장히안정된고정유지력이있을것으로보이며향후추가적으로생체역학적인연구가이루어진다면좋은연구가될것으로보인다. 결론 건의상태가불량한회전근개파열에서변형된 Mac 교량형봉합술은임상적및영상학적회복측면에서기존에알려진봉합법 들에대한유용한대안이될수있을것으로보인다. CONFLICTS OF INTEREST The authors have nothing to disclose. ACKNOWLEDGEMENTS The authors acknowledge Mrs. Seong Eun Kim for preparation of the illustrations. REFERENCES 1. Wilson F, Hinov V, Adams G. Arthroscopic repair of fullthickness tears of the rotator cuff: 2- to 14-year follow-up. Arthroscopy. 2002;18:136-44. 2. Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am. 2000;82:505-15. 3. Oh JH, Kim SH, Ji HM, Jo KH, Bin SW, Gong HS. Prognostic factors affecting anatomic outcome of rotator cuff repair and correlation with functional outcome. Arthroscopy. 2009;25: 30-9. 4. Djurasovic M, Marra G, Arroyo JS, Pollock RG, Flatow EL, Bigliani LU. Revision rotator cuff repair: factors influencing results. J Bone Joint Surg Am. 2001;83:1849-55. 5. Lädermann A, Denard PJ, Burkhart SS. Management of failed rotator cuff repair: a systematic review. J ISAKOS. 2016;1:32-7. 6. Denard PJ, Burkhart SS. Techniques for managing poor quality tissue and bone during arthroscopic rotator cuff repair. Arthroscopy. 2011;27:1409-21. 7. Meier SW, Meier JD. Rotator cuff repair: the effect of doublerow fixation on three-dimensional repair site. J Shoulder Elbow Surg. 2006;15:691-6. 8. Shin SJ. Arthroscopic rotator cuff repair: double rows & suture bridge technique. J Korean Shoulder Elbow Soc. 2008;11:82-9. 9. MacGillivray JD, Ma CB. An arthroscopic stitch for massive rotator cuff tears: the Mac stitch. Arthroscopy. 2004;20:669-71. 10. Sein ML, Walton J, Linklater J, et al. Reliability of MRI assessment of supraspinatus tendinopathy. Br J Sports Med. 2007;41:e9. 11. Goutallier D, Postel JM, Gleyze P, Leguilloux P, Van Driessche S. Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness
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402 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2017; 52: 392-402 https://doi.org/10.4055/jkoa.2017.52.5.392 www.jkoa.org 변형된 Mac 교량형봉합술 : 건의상태가불량한회전근개파열에서의임상적및영상학적치료결과 천상진 이효열 안성진 부산대학교의과대학정형외과학교실 목적 : 저자들은건의상태가불량한회전근개파열환자에서재파열을줄이기위해변형된 Mac 교량형봉합술을고안하였고임상적및영상학적치료결과를분석하여새로운봉합법의유용성에대해알아보고자하였다. 대상및방법 : 2010년 1월부터 2014년 12월까지부산대학교병원에서관절경적회전근개봉합술을시행한환자들중수술전시행한자기공명영상검사와수술중관절경소견을종합평가한결과건의상태가불량하다고판단되는경우변형된 Mac 교량형봉합술을시행하였다. 이중최소 1년이상추시가가능하였던환자 52명을연구대상으로하였다. 남자 25명, 여자 27명, 평균연령은 60 세였다. 평균추시기간은 20개월이었다. 임상적결과는술전그리고최종추시시 American Shoulder and Elbow Surgeon (ASES) score, University of California, Los Angeles (UCLA) score, Constant shoulder score (CSS), visual analogue scale (VAS), 관절운동범위를비교하여평가하였다. 수술후평균 7개월째자기공명영상추적관찰을시행한 42예에서는 Sugaya 분류를이용하여구조적상태를분석하였다. 결과 : 수술후시행한추적자기공명영상상치유정도는 I형은 15명 (35.7%), II형은 22명 (52.4%), III형은 3명 (7.1%), IV형은 2명 (4.8%), V형은없었다. I, II, III형으로병변의회복상태로판단되는환자는 40명으로전체의 95.2% 에해당하였다. 재파열 (IV, V형 ) 은 2명 (4.8%) 에서관찰되었다. 재파열환자 2명중 1명은대파열, 1명은광범위파열환자였다. 최종추시시 ASES score 는평균 56.75 점에서 83.44점으로, UCLA score 는 20.52점에서 29.23점으로, CSS는 64.04점에서 80.90점으로, VAS는술전 6.17점에서술후 1.62점으로유의하게호전되었다 (p<0.001). 관절운동범위는전방거상 108 에서 158, 외전 109 에서 160, 외회전 ( 외전 ) 27 에서 50, 내회전 ( 외전 ) 31 에서 57 로유의한회복을보였다 (p<0.001). 결론 : 건의상태가불량한회전근개파열에서변형된 Mac 교량형봉합술은임상적및영상학적회복측면에서기존에알려진봉합법들에대한유용한대안이될수있다. 색인단어 : 회전근개파열, 불량한건의상태, 변형된 Mac 교량형봉합술, 광범위근개봉합, 교량형봉합술 접수일 2016 년 9 월 19 일수정일 2016 년 12 월 30 일게재확정일 2017 년 3 월 29 일책임저자천상진 49241, 부산시서구구덕로 179, 부산대학교의과대학정형외과학교실 TEL 051-240-7248, FAX 051-247-8395, E-mail scheon@pusan.ac.kr * 본연구는 2016 년부산대학교병원임상연구비지원으로이루어졌음. 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 (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.