18-고상훈

대한견 주관절학회지제 12 권제 1 호 J. of Korean Shoulder and Elbow Society Volume 12, Number 1, June, 2009 골결손이동반된전방견관절불안정성에서관절경적인수술술기 울산대학교의과대학울산대학교병원정형외과학교실 고상훈 박기봉 Arthroscopic Technique of Bone Defect in Anterior Shoulder Instability Sang-Hun Ko, M.D., Ki-Bong Park, M.D. Department of Orthopedic Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, South Korea Purpose: The bone defects that are associated with shoulder anterior instability may be the causes of failure of arthroscopic surgery. For the treatment of traumatic shoulder instability, we tried to determine the arthroscopic techniques that can be used for the bone defect of the glenoid and the humeral head. The purpose of this study is to assess the surgical techniques for the arthroscopic reconstruction of the shoulder with anterior instability and bone defects. Materials and Methods: We analyzed the articles that have been recently published on anterior shoulder instability and we assessed the arthroscopic surgical techniques. We compared the articles and the methods of arthroscopic surgical techniques for treating bone defects of the anteroinferior glenoid and the posterolateral humeral head, which were considered as the causes of recurrence of shoulder instability. Results: There are the anteroinferior bone defects of the glenoid and Hill-Sachs lesions in the bone defects that appear in patients with anterior shoulder instability. These bone defects are currently the causes of failure of arthroscopic surgery. Conclusion: Open shoulder surgery may be the treatment of the choice for a shoulder with instability and significant bone defects of the glenoid and the humeral head. But efforts are being made to overcome the weaknesses of open surgery by the use of arthroscopy. Key Words: Shoulder, Anterior dislocation, Arthroscopy 서론전방불안정성에서발생하는골결손에는관절와의전하방골결손과상완골두의후외방골결손으로지칭되는 Hill-Sachs 병소가있다. 1890년 Broca 와 Hartmann 은결손된관절와에서상완골두의후외방에발생한 Hill-Sachs 병소가진입 (engaging) 되는현상을인식하였고, Burkhart등은관절경적인술식의실패의원인 통신저자 : 박기봉울산광역시동구전하동 290-3 울산대학교병원정형외과 Tel: 052) 250-7129, Fax: 052) 235-2823, E-Mail: shkoshko@hanmail.net 접수일 : 2009년 5월 1일, 게재확정일 : 2009년 6월 1일 * 이논문의요지는 2009년춘계대한견주관절학회심포지움에서구연발표되었다. 102

고상훈 : 골결손이동반된전방견관절불안정성에서관절경적인수술술기 으로골결손을강조하였다 3,17). 현재까지도골결손이견관절불안정성의관절경술식에서실패의원인으로알려지고있다. 의미있는관절와의골결손과상완골두의골결손을가진견관절불안정성에대하여가장좋은치료방법은아직까지의문점으로남아있다. 몇몇저자들은외회전과외전을제한하는방법으로진입 Hill-Sachs 병소를치료하기위하여어떤방법의개방적관절낭이동술을시행하고관절와상완관절의운동범위를제한하는술식을시행하여왔다 13). 그러나개방적방법은견갑하근건을절단하여야하고운동장애가동반될수있으며재활에시간이소요되는단점이있어, 일부저자들은관절경적인접근법을모색하기위하여노력해왔다 3,13). 이에저자들은외상성으로발생하는견관절불안정성의치료에서관절와의골결손과상완골두의골결손에대한관절경술식을이용한해결방법에대하여알아보고자한다. 1. 외상성골결손전방불안정성에서는상완골근위부나관절와의골절이나다양한골결손이발생할수있으며, 관절와및상완골두를포함해모두에서골결손이발생할수있다. 근위상완골의관절면은연골, 연골하골및해면골로구성되어있으며젊은운동선수에서상대적으로강하지못하다. 관절와의관절면도역시근위상완골의관절면과일치하는형태를가진다 17). 관절와는전체적으로배형태 (pear shape) 이며관절와의아래쪽하위부분은완벽한원의형태와근접하고있다 18). 관절와혹은상완골두의골결손병소를가지고있는견관절은연부조직봉합술에대한요구를더크게할수있고견관절의재발성전방탈구를야기시킬수있는것으로생각되어진다 2,10,15,17). 2. 상완골결손전통적으로 Hill-Sach 병소의중요성은관절와의골결손에비해서덜주목을받아왔다. 그러나 1948년상당한크기의 Hill-Sachs 병소가있는견관절탈구에서관절낭과관절순봉합만시행한후재발성탈구가발생함을인식하였다 12). 이것은어깨를외전, 외회전하면 Hill- Sach 병소가관절와의앞면에진입되어상완골두를앞쪽으로빠지게하는지렛대의역할을함을의미한다 13). Burkhart 등 3) 은견관절의재발성불안정성에서진입 Hill-Sachs 병소가중요한역할을한다는점을다시주목해야한다고주장하였다. 194 명의환자를봉합나사못을이용하여치료하였을때, 21명 (10.8%) 에서재발이발생하였다고하였다. 의미있는골결손이없는환자 에서는오직 4% 에서만재발이발생하였고, 재발한 21 명중 14 명인 67% 에서큰크기의 Hill-Sachs 병소나전하방관절와의골결손의형태로의미있는골결손을가지고있었다고하였다. 큰크기의 Hill-Sachs 병소에대해서개방적동종골이식술이보고되었고 5), 견갑하근건과관절낭의개방적이전술이 Connolly 등에의하여보고되었으며 6), 이것은역 McLaughlin 술식이라고하였다. 최근에는관절경적인접근법을통하여전방의상완골두의압흔골절에대한견갑하근건을고정시키는방법이보고되고있다. 이술식은봉합나사못을이용하여역 Hill-Sachs 병소에견갑하근건을이전하는방법이다 9). 12 명의환자를대상으로단기추시결과가발표되었다. Hill-Sachs 병소는상완골에서발견되며대부분상완골두의후외방에위치하게된다. 상완골이전방으로탈구되면서전방관절와에충돌하기때문에야기되는압흔골절이 Hill-Sachs 병소이다. Burkhart와 DeBeer는진입 (engaging) Hill-Sachs 병소를기술하였으며, 이것은견관절이운동을시행할때기능적위치인외전과외회전위치에서충격이가해지면발생하는병소라고정의하였다 3). 진입 Hill-Sachs 병소의장축은관절와와평행하며관절와의전방부위에진입 (engage) 하게된다. 비진입 (nonengaging) Hill- Sachs 병소는견관절신전및외전이 70 도미만인비기능적인위치에전완부가위치할때충격으로발생하는압흔골절이다. 비진입 Hill-Sachs 병소는견관절이외회전의위치에있으면전방관절와를대각선으로지나기때문에진입이발생하지않아서재발되는탈구를피할수있다. 이러한비진입 Hill-Sachs 병소의견관절은관절경하 Bankart 봉합술의합리적인대상이될수있다 3). 탈구가발생할때의전완의위치에의해 Hill-Sachs 병소가발생하는기전을이해하는것이중요하다. 전완부가몸쪽에위치하면서견관절이약간신전될때발생하는비진입 Hill-Sachs 병소는견관절이외전되고외회전될때발생하는진입 Hill-Sachs 병소에비해좀더수직방향과상방에위치하게된다. 팔이몸통에붙어서발생하는 Hill-Sachs 병소는일반적으로비진입병소이다. Burkhart와 DeBeer는진입 Hill-Sachs 병소에치료적으로접근할수있는세가지방법을보고하였다 3). 첫째는외회전을제한하면서병소가 engage되는것을허용하지않는개방적관절낭이전술 (open capsular shift procedure) 이다. 두번째접근방법은 Hill- Sachs 병소의커다란골결손을채우기위한방법으로, 상완골관절이종골이식술 (size-matched humeral osteoarticular allograft) 를이용하여압흔골절을고정하는것이다. 세번째는상완골의관절면을내회전시키는회전근위상완절골술 (rotational proximal 103

대한견 주관절학회지제 12 권제 1 호 humeral osteotomy) 이다. 일부저자들은 Hill-Sachs 병소에대하여개방적방법으로관절낭과견갑하근건의이전술을시행하고있으며 1), 최근에는진입 Hill-Sachs 병소를치료하는더새로운방법들이보고되고있다 5,8,9,11,14). 최근크기가큰 Hill-Sachs 병소에대하여관절경술식을이용한해결방법으로관절경을이용한후방관절낭고정술과하견갑근건고정술로서 Remplissage 술식이보고되고있다 13). 이술식은회전근개의관절내부분파열에대한관절경봉합술과유사한술식이며 13), 본저자들은회전간격축소술 (Rototor interval closure) 의술식이나관절경진입구봉합술 (Portal closure) 과유사한술기를이용하여시행하고있다. Remplissage 술식은 Hill-Sachs 병소의표면을마멸시켜이식된건과관절낭이치유되어붙을수있도록하고, 후방관절낭과견갑하근건을관절경적인방법으로고정시켜서관절외에서봉합을하는방법으로구 성된다 13). 본저자들이시행하는 Remplissage 술식의방법은다음과같다. 측와위에서병소의위쪽중앙에상완골두둥근부분의외측연을따라서후방진입구 (posterior portal) 를만들고, 이어서전하방진입구와전상방진입구를만들수있다. 후방진입구를이용하여 Hill- Sachs 병소에대하여역돌기 (reverse mode) bur나전동절삭기 (motorized shaver) 를이용하여표면을갈아서치유력을높여줄수있다. 진입관 (cannula) 를후방진입구에삽입하고 Hill-Sachs 병소에봉합나사 (suture anchor) 를박기가가장적당한부위라고생각되는곳에 18G 척추바늘을삽입하여본다 (Fig 1A). 이바늘을따라서 6 mm정도의절개를가하고 6mm 진입관을삽입한후병소의아랫부분에봉합나사를삽입하기위하여골펀칭을시행한다 (Fig. 1B). 생체흡수성봉합나사를삽입하여 (Fig. 1C), 두가닥의봉합사를병소의하방부에위치시킬수있다 (Fig. 1D). A B C D E F G Fig. 1. (A) Posterior portal placement is appropriate if it is located directly over the Hill-Sachs lesion and at an angle that will allow the placement of 2 anchors. If the posterior portal is not appropriate, its location is optimized with the assistance of a spinal needle at this time. (B-D) The anchor is placed in the center area of the Hill-Sachs lesion. (E) Arthroscopic view of remplissage just before completion by tying sutures in subdeltoid space. (F) The inferior suture is tied first with the knots remaining extraarticular in the subdeltoid space. (G) Completed remplissage repair with posterior capsule and infraspinatus tendon well apposed to Hill-Sachs lesion. 104

고상훈 : 골결손이동반된전방견관절불안정성에서관절경적인수술술기 진입관을약간빼내어서후방관절낭과견갑하건의바깥쪽과삼각근사이에진입관을위치시킨다. 뚫는집개 (penetrating grasper) 를이용하여봉합나사삽입부위 (initial portal entry) 의 1 cm 하방에서후방관절낭과건을통과시키고봉합나사에달려있는봉합사를한개끄집어내어봉합준비를완성한다. 1 cm 상방에서역시같은방법으로관절낭과건을뚫는집개를이용하여통과시켜서다른하나의봉합사를끄집어내어 서봉합준비를한다 (Fig. 1E). 필요하다면병소의위쪽에추가로하나더봉합나사를박아서같은방법으로봉합준비를완성한다. 가장아래쪽의봉합사부터관절외에서봉합 extra-articular knot tying) 을시행한다 (Fig. 1F). Hill-Sachs 병소의위와아래에두개의매트리스봉합이완성되며, 치유력을높이기위해마멸된 Hill-Sachs 병소에후방관절낭과견갑하근건을붙일수있게된다 (Fig. 1G). 이어서통상적인방법으로 A B C D E F G H I Fig. 2. (A) The Arthroscopic finding shows anterior labrum tear viewed from posterior portal. (B) The MRI shows anterior labrum detatchment. (C) The Arthroscopic finding shows detatchment of anterior labrum until subscapular fascia reveals. (D) Repaired anterior labrum and capsular ligament viewing from posterior portal. (E) Repaired anterior labrum and capsular ligament viewing from anterior superior portal. (F) The Arthroscopic finding is more close-up picture which shows the repaired anterior labrum and capsular ligament viewing from anterior superior portal. (G) The Arthroscopic finding shows capsular redundancy on posterior inferior corner of the glenohumeral joint. (H) Plication of posterior inferior corner of the glenohumeral joint. (I) The Arthroscopic finding shows closure of posterior portal viewing from anterior superior portal. 105

대한견 주관절학회지제 12 권제 1 호 Bankart병소와관절낭이완을봉합한다. 3. 관절와골결손전통적으로전방불안정성에서는전하방관절순 (labrum) 과하방와상완인대 (inferior glenohumeral ligament) 의파열및소성변형 (plastic deformation) 에의하여발생하는 Bankart병변 (Fig. 2A) 의역할이중요하다고하였다. 이러한병변은술전에촬영한 MRA (Magnetic Resonance Arthrography) 에서잘인식될수있다 (Fig. 2B). 관절경적치료로서수술을시행할때 Bankart병변을박리 (Fig. 2C) 하여관절와의가장자리에원래의해부학적인위치로잘붙여주는것이일반적인방법이다 (Fig. 2D, E). 저자들 A B C D Fig. 3. (A) The Arthroscopic finding shows glenoid bone loss of anterior inferior corner. (B) The preoperative MRI shows anterior bony Bankart lesion. (C) The Arthroscopic finding shows anterior inferior bony bankart lesion. (D) The Arthroscopic finding shows anterior repair of bony Bankart lesion using by nonabsorbable suture. (E) The MRI is post-operative finding which shows healing of bony Bankart lesion. E 106

고상훈 : 골결손이동반된전방견관절불안정성에서관절경적인수술술기 은전상방진입구에관절경을진입시켜서전방과후방을관찰하며전하방의관절낭봉합술을전상방진입구에서관찰하면서시행할수있다 (Fig. 2F). 이때후하방관절낭의이완 (Fig. 2G) 이동반되어있는경우필요에따라서후하방관절낭중첩술 (Fig. 2H) 을시행할수있으며, 회전간격봉합술이나삽입구의관절낭의벌어짐이심할경우에는삽입구봉합 (Fig. 2I) 을시행하는경우도있다. 많은저자들은견관절전방불안정성의재발에대하여관절와골결손이상당한역할을가지고있음을인식하였다 3,17). 두가지종류의병소가관절와의전하방에발생할수있다 17). 압흔골절과견열골절이다. 압흔병소는관절와의전하방골관절또는상완골두의압박에의해발생하는것이다 (Fig. 3A). 반복적으로발생하는불안정성은 inverted pair 병소뿐만아니라전형적인골성 Bankart(Fig. 3B, C) 를만든다. 전형적인골성 Bankart병변이 25% 를넘지않는다면관절경하에서봉합을시도하여 (Fig. 3D) 골유합을얻을수있다 (Fig. 3E). 과거에는관절와변두리골절이관절와의전방및후방지름의 25% 를넘을경우오구돌기이전을추천하였다 7). Burkhart 등은두개의기하학적요소의결과를통해관절와에의해상완골두의억제에대해의견을서술하였다 4). 첫째는오목한표면의더큰호에기인하는 wire 관절와의 deepening 효과이다. 둘째는관절와자체의호길이이다. 골조각이절제된다면또는 inverted pair 형태의관절와라면, 골결손을보강하지않는다면관절경하재건술이실패하는원인이될것이라고그들은경고하였다. 이것을관절경으로진단하기위해, 관절경은전상방삽입구에위치해야하며관절와를아래쪽으로관찰해야한다. 관절와의 bare spot은관절와의중심부에대략적으로위치하며, 측정하는탐침을사용하여관절와의전방변두리에서 bare spot 까지의거리뿐만아니라, bare spot 에서부터관절와변두리의후방까지의거리를측정한다. Bare spot부터후방관절와까지의거리와비교해서전방관절와부터 bare spot까지의길이에서 25% 감소가있다면골술기의적응이된다 4). Chapovsky 5) 등은골관절동종골이식을사용하여결손부를채우는방법으로관절경적인방법을발표하였다. 또한 Lafosse 등 11) 은전방관절와의결손이있는전방불안정성의치료에서관절경적인 Latarjet 술식을발표하였다. 44명의환자에서의미있는단기추시결과를보고하고있다. 4. 전위및저형성병소증가된관절와의후굴 (retroversion) 과관절와저형 성은후방또는다방향성불안정성과관련이있다전통적으로개방적인방법에의해치료되고있다. 5. 관절순 / 골이형성 견관절불안정성은관절와그리고상완골두이형성에의해야기될수있다. 관절와의 en face면을볼때, 관절와의정상형태는배모양과유사하며아래절반은위절반보다확실히넓다. 커다란골성 Bankart 병소혹은연관된골조각은없지만중요한압흔결손이있는 Bankart 병소를가진경우관절와형태는 inverted pear 로변하며, 관절와의위절반이아래절반보다더넓다. 정상관절와에서 bare spot 은관절와의전방과후방변두리의사이에서등거리에위치한다. 관절경하에서관찰하여쉽게 bare spot을결정할수있으며, 관절경으로골소실의양을측정할때유용하게사용할수있다. 유사하게, inverted pear 형태는커다란골성 Bankart 조각이제거되는경우나관절낭-관절순복합체가남아있는관절와와봉합되는경우에보여지게되기도한다. 전방관절순은전방불안정성에주요역할을한다. 그러나, 후방관절순의역할은잘정의되지않는다. 일반적으로 Harryman 등은견관절안정에기여하기위해전체관절순을확인한후, 관절와의함몰부분을깊게함으로써안정성의 10% 를제공한다고하였다 7). 결 전방불안정성에서발생하는골결손에는관절와의전하방골결손과 Hill-Sachs 병소가있다. 이러한골결손은현재까지견관절불안정성에서관절경적인수술의실패의원인이다. 의미있는관절와의골결손과상완골두의골결손을가진견관절불안정성에대하여가장좋은치료방법은개방적수술이라고할수있으나, 관절경적인접근법으로개방적수술의단점을극복하기위한노력이지속적으로새롭게시도되고있어주목되고있다 3,13). 론 REFERENCES 01) Bacilla P, Field LD, Savoie FH: Arthroscopic Bankart repair in a high demand patient population. Arthroscopy, 13: 51-60, 1997. 02) Bigliani LU, Pollock RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC: Tensile properties of the inferior glenohumeral ligament. J Orthop Res, 10: 187-197, 1992. 03) Burkhart SS, De Beer JF: Traumatic glenohumeral 107

대한견 주관절학회지제 12 권제 1 호 bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the invertedpear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy, 16: 677-694, 2000. 04) Burkhart SS, Debeer JF, Tehrany AM, Parten PM: Quantifying glenoid bone loss arthrocopically in shoulder instability. Arthroscopy 18: 488-491, 2002. 05) Chapovsky F, Kelly JD: Osteochondral allograft transplantation for treatment of glenohumeral instability. Arthroscopy, 21: 1007, 2005. 06) Connolly JF: Humeral head defects associated with shoulder dislocation?their diagnostic and surgical significance. Instr Course Lect, 21: 42-54, 1972. 07) DeBerardino TM, Tenuta JJ, Arciero RA: Combined Bankart and unstable superior labral lesions associated with acute initial anterior shoulder dislocations: evaluation, treatment, and early results. Presented at the 66th annual meeting of the American Academy of Orthopedic Surgeons, Anaheim, CA, February 7, 1999. 08) Kropf EJ, Sekiya JK: Osteoarticular allograft transplantation for large humeral head defects in glenohumeral instability. Arthroscopy, 23: 322, 2007. 09) Krackhardt T, Schewe B, Albrecht D, Weise K: Arthroscopic fixation of the subscapularis tendon in the reverse Hill-Sachs lesion for traumatic unidirectional posterior dislocation of the shoulder. Arthroscopy, 22: 227, 2006. 10) Itoi S, Newman SR, Kuechle DK, et al.: Dynamic anterior stabilizers of the shoulder with the arm in abduction. J Bone Joint Surg Br, 76: 834, 1994. 11) 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, 2007. 12) Palmer I, Widen A: The bone block method for recurrent dislocation of the shoulder joint. J Bone Joint Surg Br, 30: 53-58, 1948. 13) Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC: Hill-sachs remplissage : an arthroscopic solution for the engaging hill-sachs lesion. Arthroscopy, 24: 723-726, 2008. 14) Re P, Gallo RA, Richmond JC: Transhumeral head plasty for large Hill-Sachs lesions. Arthroscopy, 22: 798, 2006. 15) Rowe CR, Zarins B: Recurrent transient subluxation of the shoulder. J Bone Joint Surg Am, 63: 863-872, 1981. 16) Sugaya H, Moriishij J, Dohi M, Kon Y, Tsuchiya A: Glenoid rim morphology in recurrent anterior glenohumeral instability. J Bone Joint Surg Am, 85: 878-884, 2003. 17) Warner JJP, Iannotti JP, Flatow EL: Complex and revision problems in shoulder surgery. 2nd ed, Philadelphia, Lippincott Williams and Wilkins: 3-22, 2007. 초록 목적 : 견관절전방불안정성에서골결손에동반되면관절경하재건술에서실패요인이될수있다. 외상성으로발생하는견관절불안정성의치료에서관절와의골결손과상완골두의골결손에대한관절경술식을이용한해결방법에대하여알아보고자하였으며, 골결손이동반된견관절전방불안정성에서관절경재건술의수술술기에대하여고찰하는것이이논문의목적이다. 대상및방법 : 견관절전방불안정성에서최근발표된논문을분석하여관절경적수술방법에대하여고찰하였고, 재발의원인으로간주되는전하방관절와의골결손과후외방견관절두의골결손에대한관절경수술방법에대하여논문고찰과저자의방법을비교하였다. 결과 : 전방불안정성에서발생하는골결손에는관절와의전하방골결손과 Hill-Sachs 병소가있다. 이러한골결손은현재까지견관절불안정성에서관절경적인수술의실패의원인이다. 결론 : 의미있는관절와의골결손과상완골두의골결손을가진견관절불안정성에대하여가장좋은치료방법은개방적수술이라고할수있으나, 관절경적인접근법으로개방적수술의단점을극복하기위한노력이주목되고있다. 색인단어 : 견관절, 전방불안정성, 관절경적수술방법 108