22-김명선/

대한견 주관절학회지제 13 권제 1 호 J. of Korean Shoulder and Elbow Society Volume 13, Number 1, June, 2010 광범위회전근개파열에서관절성형술 전남대학교의과대학정형외과학교실 김명선 문은선 Massive Rotator Cuff Tears: Arthroplasty Myung-Sun Kim, M.D., Eun-Sun Moon, M.D. Department of Orthopaedic Surgery, Chonnam National University School of Medicine, Gwangju, Korea Purpose: Surgical treatment of massive rotator cuff tear is challenging and there are various surgical options. The purpose of this article is to describe arthroplasty for the treatment of massive rotator cuff tear. Materials and Methods: We reviewed all publications that focused on and/or mentioned arthroplasty as a treatment option for massive rotator cuff tear. Results: Arthroplasty can be used as primary treatment and represents a salvage option for irreparable rotator cuff tear. Hemi-arthroplasty can provide satisfactory results by Neer s limited goals criteria in patients with intact coracoacromial arch. In addition, reverse total shoulder arthroplasty can be a salvage option for pain relief and restoration of active flexion in elderly patients with pseudoparalysis. Conclusion: In patients with massive rotator cuff tear, proper selection of arthroplasty can provide pain relief and restoration of functional range of motion in shoulder joints. Key Words: Shoulder, Massive rotator cuff tear, Arthroplasty 서론회전근개파열환자의주요한문제는견관절통증과기능의저하이며, 치료의궁극적목표는통증이없는견관절의정상기능을회복하는일이다. 광범위회전근개파열 (massive rotator cuff tear) 이란일반적으로전층파열된단면부위의최대직경이 5 cm 이상인경우 26) 와 2개이상의건이전층파열된경우 14) 로문헌 상정의되고있다. 증상이있는광범위회전근개파열에서적극적이고충분한보존적치료에도증상의호전이없을경우수술적치료를고려하게되지만, 큰파열크기, 건의심한퇴축, 근위축을동반한지방변성등으로인해수술적치료에상당한어려움이따른다. 또한, 치료방법의선택시에는정확한진찰과영상의학적소견을토대로여러생물학적인자와환자요소등을고려하여판단하여야한다. 통신저자 : 문은선광주광역시동구학동 8 전남대학교의과대학정형외과학교실 Tel: 062) 227-1640, Fax: 062) 225-7794, E-mail: esmoon@chonnam.ac.kr 접수일 : 2010 년 6 월 11 일, 게재확정일 : 2010 년 6 월 16 일 132

김명선 : 광범위회전근개파열에서관절성형술 이러한광범위회전근개파열의수술적치료방법으로는단순변연절제술 (debridement) 및견봉하감압술 4,13,29), 결절성형술 (tuberoplasty) 10,31), 다양한형태의회전근개봉합술 3,6), 건이전술 (tendon transfer) 37), 동종건및합성물을이용한재건술 23), 관절성형술 (arthroplasty) 24) 등다양한방법들이소개되고있지만, 그어떤방법도결과를예측하기란쉽지가않다. 저자들은광범위회전근개파열에대한여러가지수술방법중관절성형술에대하여문헌고찰과함께알아보고자한다. 인공삽입물디자인의역사 (History of implant design) 회전근개파열관절병증 (rotator cuff tear arthropathy) 은봉합이불가능한회전근개파열의마지막단계이다. 역사적으로볼때, 회전근개파열로인해이차적으로발생하는관절염에대한치료로써대부분의의사들이연부조직에대한시술보다는고식적인 (conventional) 관절성형술을주로선택하였다 33). 그러나, Neer 등 20) 은고식적인견관절전성형술을 시행하였을경우, 회전중심 (center of rotation) 의상하방이동에대한적절한조절의실패로관절와표면에서의흔들목마 (rocking horse) 기전으로인해조기에관절와부품해리가발생되는문제가있다고하였다. 구속형 (constrained) 인공관절은회전근개파열관절병증의본질적인불안정성의문제를보완하고자고안되었다. 상완골두부분이관절와부품안에서벗어나지않고그안에서만움직이는형태로, 관절의회전중심이고정되는효과로인해높은일치도 (conformity) 및구속력 (constraint) 을갖는특징이있다. 그러나, 이디자인은매우높은 hardware 실패율과불안정성의발생, 그리고높은재수술율의문제로인해현재는더이상사용되지않고있다 (Fig. 1) 25). 또다른형태로는덮개 (hood) 가있는관절와부품이특징인반구속형 (semiconstrained) 인공관절이개발되었는데, 이디자인은상완골두를관절와부품내의중심에위치하게하는데는보다효과적이지만관절운동범위가만족스럽지않은문제점을안고있다 (Fig. 2). Fig. 1. Constrained total shoulder arthroplasty. (Post M, Silver R, Singh M: Rotator cuff tear: Diagnosis and treatment. Clin Orthop Relat Res, 173: 78-91, 1983.) 25) Fig. 2. Semiconstrained Dana shoulder prosthesis. (Amstutz HC, Thomas BJ, Kabo JM, Jinnah RH, Dorey FJ: The Dana total shoulder arthroplasty. J Bone Joint Surg Am, 70: 1174-1182, 1988.) 1) 133

대한견 주관절학회지제 13 권제 1 호 또한, 관절와부품상부에는압박력이, 하부에는신연력이가해지는특징적인효과로인해흔들목마현상이발생하게되고, 역시관절와부품해리가문제가된다 22). 견관절의양극성반관절성형술 (bipolar hemiarthroplasty) 은고관절에서와마찬가지로인공관절의불안정성의문제의해결방안으로고안되었다 (Fig. 3) 35). Worland 등 40) 은회전근개파열관절병증환자에대해양극성반관절성형술을시행한후 Neer 의제한적목표 (Neer s limited goals; 20 external rotation and 90 forward elevation) 21) 를기준으로평가하여양호한단기추시결과를보고한바있다. 그러나, 이러한디자인은회전중심이외측으로이동하게되고, 상당한양의폴리에틸렌파편이발생하며, 관절와상부내측으로의마모 (wear) 가발생하는문제점을가지고있다. 또한, 최근방사선투시기 (fluoroscope) 를이용한연구보고에의하면, 대부분의움직임이바깥쪽골-삽입물접촉면에서발생한다고하였다. 그러나, 임상적으로고전적인단극성반관절성형술 (un-ipolar hemiarthroplasty) 보다특별한우세는보이지않았다 33). 최근치료경향광범위회전근개파열환자의수술적치료의적응은활동조절, 소염진통제복용, 물리치료및재활치료등을포함하는충분하고적절한보존적치료에도반응 하지않는경우가해당된다. 회전근개질환에대한인공관절성형술은크게비구속형 (unconstrained) 견관절전성형술, 반관절성형술, 역형견관절전성형술로구분할수있으며, 치료방법의선택시에는환자의연령및요구도, 상완골두의상방전이정도, 그리고회전근개의상태등을고려하여야한다. 비구속형견관절전성형술 (Unconstrained total shoulder arthroplasty) 전통적인비구속형견관절전성형술은관절와상완관절의관절염을가진환자중극상건 (supraspinatus) 만단독으로파열되어있으며, 상완골두의상방이동이경미한경우에시행할수있다. Edwards 등 7) 은일차성관절염과함께회전근개파열을동시에갖고있는환자들에대한견관절전성형술의치료결과를분석한결과, 극상건파열만있었던환자군은회전근개가정상이었던환자군과임상적결과에차이가없었으나, 파열이극하건 (infraspinatus) 까지확대된환자군에서는더불량한결과를보였다고하였다. 또한, 비구속형견관절전성형술을시행한환자가비록소형파열을갖고있는경우라도만약파열이광범위파열로진행된다면결국상하짝힘 (force couple) 의균형이소실되게되고, 결국흔들목마현상으로인한관절와부품의해리가발생할수도있다. 하지만, 극상건단독파열이있는환자에서시행한비구속형견관절전성형술의장기추시결과에대한보고는아직까지없는실정이다 33). 반관절성형술 (Hemiarthroplasty) Fig. 3. The bipolar shoulder implant allows motion between a distal extremity and a proximal part through two moving interfaces. The ball of the intramedullary stemmed humeral component articulates with a polyethylene bearing within the glenoid cup component. The glenoid component has the advantage of not being fixed to bone. (Swanson AB, de Groot Swanson G, Sattel AB, Cendo RD, Hynes D, Jar-Ning W: Bipolar implant shoulder arthroplasty. Long-term results. Clin Orthop Relat Res, 249: 227-247, 1989.) 35) 역사적으로견관절에대한반관절성형술은진행된회전근개파열관절병증의구제술로서사용되어져왔으며, 역형인공관절을사용하기에는인공관절의수명이걱정되는젊은환자나 90 이상능동적전방거상이가능한고령의환자에대한치료에는아직도그역할이유효하다. 특히, 오구견봉궁 (coracoacromial arch) 의건재여부가반관절성형술의결과에환자의연령에관계없이매우중요한영향을미친다. Sanchez-Sotelo 등 30) 은회전근개파열관절병증을가진 33 명의환자에대해반관절성형술을시행한평균 5년추시결과, 술후통증과관절운동범위의의의있는호전을보였으며, 과거력상견봉하감압술시오구견봉궁의손상이있었던 7예에서술후전상방불안정성이발생하였다고보고하였다. 134

김명선 : 광범위회전근개파열에서관절성형술 Zuckerman 등 41) 은고령의진행된회전근개파열관절병증을가진 15 명의환자에대해반관절성형술을시행한평균 28 개월추시결과, 통증이의의있게감소하였고, 능동적거상이술전69 에서술후86 로호전되었으며, 능동적외회전도술전 15 에서술후 29 로호전되었다고보고하였다. 광범위회전근개파열환자에게반관절성형술의시행시에는술후통증이완전히소실되지않을수있고, 관절운동범위의회복이적을수있으며, 격렬한노동의수행은어려울수있고, 관절와마모나불안정성으로인해초기임상적결과가영구적이지않을수있다는사실을환자에게주지시키는것또한중요하다. 반관절성형술후불안정성이발생하거나통증이지속될경우역형견관절전성형술로의전환이구제술로사용될수도있다. 추가적으로, 회전근개파열관절병증환자에서반관절치환술의결과를향상시키기위한시도로서대결절부위로인공상완골두의크기를연장시켜크고특이한모양의인공상완골두를디자인하였는데, 이를 CTA head (cuff tear arthropathy head, Fig. 4) 라고한다. 기존에비해좀더커다란인공상완골두는관절와를포함하여견봉과오구견봉궁의하면과관절면을이루면서보다큰운동반경을가능하게한디자인으로서, 최근회전근개파열관절병증환자에게시행되어지고있다 8). 역형견관절전성형술 (Reverse total shoulder arthroplasty) 광범위회전근개파열등심한회전근개의기능부전이동반된경우에견관절의정상적인동역학적운동을수행하는데중요한역할을하는짝힘의소실이발생하게되는데, 이는팔의능동적전방거상의소실을초래할수있으며, 어떤경우에는상방불안정성과도연관이있게된다 2,19). 결국, 광범위회전근개파열이동반된경우에견관절전성형술은관절의회전중심이상방으로이동하게되고이로인해팔의거상시삼각근이수축하는동안관절에가해지는부하가회전의중심부에서멀어지게되어수술후관절와부품해리의발생이심각한문제가된다 11,19). 그러므로, 회전근개파열이광범위한경우에는고식적인인공견관절전성형술을통해수술후동통의호전은기대할수있으나원활한상지의능동적거상등의견관절기능향상을크게기대하기가어렵다 28,39). 이러한회전근개광범위파열환자의치료에있어고식적인인공견관절전치환술의문제를해결하기위해반관절성형술이권장되기도하지만, 이술식또한견관절기능과운동범위의향상에는한계가있는것으로보고되고있다 17,33). 고식적인인공견관절술식으로효과적으로치료되지않는여러견관절질환에대한해결방법으로 1980년대중반 Grammont 에의해소개된역형 (reversed type) 인공관절은어깨관절의정상적인해부학적모 B Fig. 4. Hemiarthroplasty with a laterally extended cuff tear arthropathy (CTA) head. (A) CTA prosthesis, (B) Diagram of installed prosthesis. A 135

대한견 주관절학회지제 13 권제 1 호 양을뒤집은형태를통해관절안정성을보다높인새로운디자인의인공관절이다. 이렇게볼과소켓을서로뒤바꾸는디자인의변화는견관절의해부학적회전중심을내측과하방으로, 상완골을하방으로이동시키는효과를초래하는데, 결국이러한생역학적변화는기존의삼각근섬유에긴장과장력을증가시키게되며, 전, 후방삼각근이외전에관여하는효과를초래한다. 추가로, 삼각근의지렛대길이의증가는기존삼각근의기능을극대화하여회전근개의도움없이도팔을능동적으로거상할수있게한다 (Fig. 5). 역형인공관절을이용한인공견관절전성형술은견관절통증을효과적으로감소시키고, 가성마비에대해능동적거상이가능하게되는등, 감소된견관절기능을상당부분향상시킴으로써가성마비를동반한회전근개파열관절병증과광범위회전근개파열, 그리고, 심한회전근개기능부전을동반한관절와상완관절의골관절염등으로인해견관절통증과견관절의기능부전을호소하는환자들에게효과적인치료로보고되고있다 (Fig. 6) 5,16-18,27). 국내에서도 2007년부터역형인공관절이도입되어최근시술이급속히증가하고있는실정이다. 역형견관절전성형술의단기추시결과들은술후능동적거상의회복면에서는고무적이었다. Sirveaux 등 34) 은다기관비교연구를통해, 회전근개파열관절병증환자에대한치료로서역형견관절전성형술이반관절성형술에비해 Constant 점수면에서 20 점, 능동적거상도 40 더향상되었으며, 통증완화면에서도훨씬우세하다고보고하였다. Frankle 등 12) 은회전근개결손을가진관절와상완관절관절염환자 60 명 (60 예 ) 을대상으로역형인공 관절삽입물을이용한전성형술의약 2년의단기추시결과, 능동적거상면에서는술전 55 에서술후 105.1 로, 통증에대한주관적시각척도 (visual ana-logue scale, VAS) 는술전 6.3 에서술후 2.2 로호전되어동통의완화및기능향상에상당한효과가있는것으로보고하였고, 환자역시수술후 60 명중 57 명이만족하였고, 3명이불만족하였다고하였다. 합병증은 17% 에서발생하였다. Wall 등 36) 은역형견관절전성형술을시행받은 240 명의환자의술전원인을분석한결과, 광범위회전근개파열, 회전근개파열관절병증, 회전근개파열을동반한관절염이원인이었던경우가다른원인이었던경우에비해, 술후 Constant 점수나기능회복면에서보다양호하였다고보고하였다. 추가로, 최소 2년추시한결과, 재수술을시행받았던군의합병증발생율이 37% 로서일차수술만시행받았던군의 13% 에비해합병증발생율이상대적으로높음을알수있었다. 역형견관절전성형술의제한점으로는통증완화와팔의능동적거상의회복은가능할수있지만, 능동적외회전회복은어렵다는점이다. 술후능동적외회전의부전때문에능동적거상이가능함에도불구하고불량한견관절의기능을보일수도있다. Simovitch 등 32) 은술전 MRI상소원근 (teres minor) 의지방변성 (fatty infiltration) 이존재했던군에서, 술후평균 7 의외회전감소를보였다고하였다. 이는감소된후하방회전근개 (posterosuperior rotator cuff) 기능을역형인공관절디지인으로향상된삼각근의기능만으로는보상되지않음을시사한다. 결국, 술전후하방회전근개의기능을평가하는것은매우중요하며, 진찰소견상외회전지연징후 (exter- A B Fig. 5. (A) A reverse total shoulder prosthesis. (B) Reversing the ball and socket changes the mechanics of the shoulder joint in order to improve active range of motion and deltoid muscle strength. This is due to the increased force (F) of the deltoid muscle by moving the center of rotation of the joint medially and distally compared with the anatomic center of rotation. The lever arm of the deltoid (d) and the strength of the deltoid are increased because of the lowering of the humerus (L) which lengthens the deltoid fibers. So this retensioned deltoid muscle has an improved mechanical advantage to raise the arm. 136

김명선 : 광범위회전근개파열에서관절성형술 A B C D Fig. 6. Anteroposterior (A) Radiograph of 71-year-old male patient with a pseudoparalytic painful shoulder (B) Show cuff tear arthropathy. At 13 months after surgery, anteroposterior (C) Radiograph shows good alignment of reverse prosthesis. The patient shows active forward flexion in nearly full range (D) And the functional results was excellent. nal rotation lag sign) 나호른부는사람징후 (hornblower s sign) 가양성일경우는소원근의기능부전을고려하여, 역형견관절전성형술과함께광배근이전술을동시에시행하는것이권유되기도한다 9,15,16,38). 역형견관절전성형술의합병증은감염, 관절와절흔, 불안정성, 탈구, 부품해리, 견봉골절등다양하며, 이를줄이기위해서는술자의상당한학습곡선 (learning curve) 이요구된다. Wall 등 36) 에의하면숙련된의사에의해수술이시행되었음에도불구하고, 재수술율이 40%, 합병증발생율은 50% 로매우높게보고하고있다. Guery 등 17) 에의한 5년중기추시의 80 예의다기관연구결과, 인공삽입물의생존율은 90% 이상이었으며, 5년추시상관절와부품해리는 15% 이하에서발생하 137

대한견 주관절학회지제 13 권제 1 호 였다. 그러나, 흥미로운점은술후 1년에서 3년사이에인공삽입물의생존율의갑작스런감소가발생하였으며, 이는부품의불량한위치, 류마티스성관절염환자, 감염과관련한인공삽입물의조기해리때문일것으로추정하였다. 그리고, 술후 6년경일부환자들에게서견관절기능이감소가발생하였는데, 그이유는아직알수없다고하였다. Singh 등 33) 은역형견관절전성형술의인공삽입물의수명에대한문제가아직명확히규명되지않은관계로 65 세미만의젊은환자에게는권하지않는다고하였다. 또한, 부득이젊은환자에게사용하게될경우에는, 높은재수술율의가능성에대해설명을하여야하며, 술자자신도복잡한재수술에대한수행능력을충분히갖추고있어야한다고하였다. 추가로, 광범위회전근개파열에대해역형견관절전성형술을선택할때는다른치료대안이없는경우로한정되어야하며, 높은합병증발생율과충분한학습곡선이필요함을항상고려해야한다고하였다. 요 관절성형술은봉합이불가능한광범위회전근개파열환자에서일차적치료법또는구제술로도사용될수있으며, 반관절성형술은오구견봉궁이건재할경우 Neer의제한적기준을목표로삼는다면만족스런결과를얻을수있다. 또한, 역형견관절전성형술은가성마비를동반한고령의환자에서동통완화와능동적거상을회복할수있는구제술이며, 소원근기능부전에의한외회전지연이존재할경우추가적인광배근이전술을통해보다좋은임상적결과를얻을수있을것으로사료된다. 결론적으로, 치료가어려운광범위회전근개파열환자에서적절한관절성형술의선택은견관절의동통완화와기능적관절운동범위회복을가능케할수있는주요한치료방법중하나라고생각된다. 약 REFERENCES 1) Amstutz HC, Thomas BJ, Kabo JM, Jinnah RH, Dorey FJ: The Dana total shoulder arthroplasty. J Bone Joint Surg Am, 70: 1174-1182, 1988. 2) Burkhart SS, Danaceau SM, Pearce CE Jr: Arthroscopic rotator cuff repair: analysis of results by tear size and by repair technique-argin convergence versus direct tendon-to-bone repair. Arthroscopy, 17: 905-912, 2001. 3) Burkhart SS, Nottage WM, Ogilvie-Harris DJ, Kohn HS, Pachelli A: Partial repair of irreparable rotator cuff tears. Arthroscopy, 10: 363-370, 1994. 4) Burkhart SS: Arthroscopic debridement and decompression for selected rotator cuff tears. Clinical results, pathomechanics, and patient selection based on biomechanical parameters. Prthop Clin North Am, 24: 111-123, 1993. 5) Cuff D, Pupello D, Virani N, Levy J, Frankle M: Reverse shoulder arthroplasty for the treatment of rotator cuff deficiency. J Bone Joint Surg Am, 90: 1244-1251, 2008. 6) Duralde XA, Bair B: Massive rotator cuff tears: the result of partial rotator cuff repair. J Shoulder Elbow Surg, 14: 121-127, 2005. 7) Edwards TB, Boulahia A, Kempf JF, Boileau P, Nemoz C, Walch G: The influence of rotator cuff disease on the results of shoulder arthroplasty for primary osteoarthritis: Results of a multicenter study. J Bone Joint Surg Am, 84: 2240-2248, 2002. 8) Ekelud A & Seebauer L: Advanced evaluation and management of glenohumeral arthritis in the cuff-deficient shoulder. In: Rockwood CA, Matsen FA, ed. The Shoulder, WB Saunders, Philadelphia: 1257-1270, 2009. 9) Faver P, Loeb MD, Helmy N, Gerber C: Latissimus dorsi transfer to restore external rotation with reverse shoulder arthroplasty: A biomechanical study. J Shouler Elbow Surg, 17: 650-658, 2008. 10) Fenlin JM, Chase JM, Rushton SA, Frieman BG: Tuberoplasty: creation of an acromiohumeral articulation-a treatment option for massive, irreparable rotator cuff tears. J Shoulder Elbow Surg, 11: 136-142, 2002. 11) Franklin JL, Barrett WP, Jackins SE, Matsen FA 3rd: Glenoid loosening in total shoulder arthroplasty. Association with rotator cuff deficiency. J Arthroplasty, 3: 39-46, 1998. 12) Frankel M, Siegal S, Pupello D, Saleem A, Mighell M, Vasey M: The Reverse Shoulder Prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: A minimum two-year follow-up of sixty patients. J Bone Joint Surg Am, 87: 1697-1705, 2005. 13) Gartsman GM: Massive, irreparable tears of the rotator cuff. Results of operative debridement and subacromial decompression. J Bone Joint Surg Am, 79: 715-721, 1997. 14) Gerber C, Fuchs B, Hodler J: The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am, 82: 505-515, 2000. 15) Gerber C, Maquieira G, Espinosa N: Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears. J Bone Joint Surg Am, 88: 113-120, 2006. 16) Gerber C, Pennington SD, Lingenfelter EJ, Sukthankar A: Reverse Delta-III total shoulder replacement combined with latissimus dorsi transfer: A preliminary report. J Bone Joint Surg Am, 89: 940-947, 2007. 138

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대한견 주관절학회지제 13 권제 1 호 초록 목적 : 광범위회전근개파열에대한수술적치료는매우어려우며, 다양한수술방법이알려져있다. 여러수술방법중광범위회전근개파열에서적용될수있는관절성형술에대해고찰하고자한다. 대상및방법 : 광범위회전근개파열에대한수술방법중하나인관절성형술에관한문헌들을조사하여요약하고정리하였다. 결과 : 봉합이불가능한광범위회전근개파열환자에서관절성형술은일차적치료법또는구제술로사용될수있으며, 반관절성형술은오구견봉궁이건재할경우 Neer의제한적기준을목표로삼는다면만족스런결과를얻을수있다. 또한, 역형견관절전성형술은가성마비를동반한고령의환자에서동통완화와능동적거상을회복할수있는구제술이다. 결론 : 치료가어려운광범위회전근개파열환자에서적절한관절성형술의선택은견관절의동통완화와기능적관절운동범위회복을가능케할수있을것으로사료된다. 색인단어 : 견관절, 광범위회전근개파열, 관절성형술 140