Original Article J Korean Orthop Assoc 2010; 45: 243-248 doi:10.4055/jkoa.2010.45.4.243 www.jkoa.org 견관절충돌증후군과동반된제 2 형 SLAP 병변봉합의추시결과 Follow-up Result in Repairing a Type II Superior Labrum Anterior and Posterior (SLAP) Lesion when Associated with Shoulder Impingement Syndrome 이상명 박재철 송석환 김상일 박보연 이승구가톨릭대학교의과대학정형외과학교실여의도성모병원 목적 : 충돌증후군과동반된제2형 SLAP 병변환자를대상으로 SLAP 병변봉합및견봉성형술을시행한 (S+A) 군과견봉성형술만시행한 (A) 군을비교하여 SLAP 병변봉합술이필수적인치료인지에대하여검정하려한다. 대상및방법 : 2003 년부터 2008 년까지제2형 SLAP 병변이확진된 40세이상의충돌증후군환자중술후 12개월이상관찰이가능하였던 75예를대상으로하였다. 전환자에서견봉성형술을시행하였으며이중 39예는 SLAP 병변을봉합하였고 36예는봉합하지않았다. 결과는 American Shoulder and Elbow Surgeons (ASES) 설문지및운동범위로평가하였다. 결과 : 술후평균 33개월이경과한후 ASES 점수는두군모두술전에비하여술후에유의하게증가하였으나 (p<0.001) 두군간유의한차이는없었다 (p=0.278). 그러나과격한운동을시행하는군에서는 (S+A) 군이 (A) 군에비하여높은 ASES 점수를보였다 (p=0.014). 운동범위는 (S+A) 군이 (A) 군에비해술후외회전이유의하게제한되었다 (p=0.026). 결론 : 40세이상의충돌증후군을동반한제2형 SLAP 병변환자에게 SLAP 병변봉합술을시행하는경우임상적결과는시행하지않는경우와유의한차이를보이지않았다. 또한과격한운동을시행하는환자는 SLAP 병변을봉합하는것이임상적결과가좋으나증상호전을위해서는과격한운동을자제하여야한다. 색인단어 : SLAP 병변, 관절경적 SLAP 병변봉합술, 충돌증후군, 견봉성형술 서론 Snyder 에의해분류된 1) 제 2 형상부관절와순병변 (Superior Labral Anterior Posterior Lesion, 이하 SLAP 병변 ) 은충돌증후군과동반 되어나타나는경우가 41-47% 로비교적흔하다. 2-4) 하지만 SLAP 병변은고유의증상을갖지않으며이학적검사역시충돌증후 군과구별하기쉽지않아충돌증후군과동반되는경우환자의 통증이 SLAP 병변에의해발생하였는지분명치않을때가많다. 2) 단독 SLAP 병변의관절경적치료에관한문헌은많이보고되어 있지만 5-7) 대부분젊고역동적인스포츠활동을하는환자를대 접수일 2009 년 12 월 30 일게재확정일 2010 년 5 월 6 일교신저자이승구서울시영등포구여의도동 62, 가톨릭대학교여의도성모병원정형외과 TEL 02-3779-1192, FAX 02-783-0252 E-mail skrhee@catholic.ac.kr 상으로한연구이며견관절내다른질환을동반한고령의환자에게서발견된 SLAP 병변이통증을유발하는지에대하여는거의알려진바가없다. Coleman 등 8) 은 SLAP 병변봉합술및견봉성형술을동시에시행하여좋은결과를보고한바있는데 SLAP 병변을봉합하지않은경우는연구에포함시키지않았다. 저자들은충돌증후군을동반한제2형 SLAP 병변을가진환자에서견봉성형술후 SLAP 병변을봉합한군과봉합하지않은군을비교하여 SLAP 병변봉합술이필수적인치료인지, 그리고 SLAP 병변봉합술이나이또는스포츠활동의정도에따라술후견관절통증에영향을미치는지에대해알아보고자한다. 대상및방법 1. 연구대상 2003 년 3월부터 2008 년 5월까지자기공명영상검사 (Magnetic 대한정형외과학회지 : 제 45 권제 4 호 2010 Copyrights 2010 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/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
244 이상명ㆍ박재철ㆍ송석환외 3 인 Resonance Arthrography, 이하 MRA) 상제 2 형 SLAP 병변이확인 된충돌증후군환자중수술후최소 12 개월이상추시관찰이 가능하였던환자는 101 예였으며이중불안정성이있거나회전 근개전층파열이있는경우, 그리고상완이두근파열이동반되 었던 15 예의환자는제외하였다. 회전근개부분층파열이있으 나경미하여봉합이필요없는경우는포함시켰으나수술후제 2 형 SLAP 병변이아닌것으로판명된경우는제외시켰으며젊은 환자나너무고령인환자도제외하기위해표본집단의나이를 40 세이상, 79 세이하로제한하여총 75 명의환자를대상으로연구 를시행하였다. 남자가 44 예, 여자가 31 예였고, 수술시평균나이 는 55 세 (40-76 세 ), 평균추시기간은 33 개월 (13-109 개월 ) 이었다. 수 술전모든환자는견관절통증이있었으며충돌징후양성소견 (Neer s impingement sign, Hawkins sign) 을나타내었고, 수술전 MRA 상제 2 형 SLAP 병변및견봉전외측의골극 (osteophyte) 을 확인하였다. 환자들은수술전 3 개월이상물리치료, 항소염제 복용, 견봉하스테로이드주사등의보존적치료를시행하였으 며이에실패한환자에게서수술을시행하였다. 환자들은두명 의집도의에배정되어한집도의는 SLAP 병변을봉합하고견봉 성형술을시행하였으며, 다른집도의는견봉성형술만을시행하 였다. SLAP 병변을봉합한군은 39 명, 봉합하지않은군은 36 명 이었다 (Table 1). 2. 수술방법 수술은전신마취하에몸통이뒤쪽으로 15 o 가량기울도록측와 위로위치시켰다. 환측팔은 30 o 외전, 20 o 전방굴곡시켜 6-8 파운 드의무게로종적으로견인을하였다. 우선후방삽입구를견봉 의후방가장자리에서 2 cm 하방, 1 cm 내측에형성한후관절경 검사를시행하였으며 MRA 상에서관찰되었던제 2 형 SLAP 병변 인지를확인하였다. SLAP 병변봉합을시행한군에서는전방삽입구를형성하고삽 입관 (cannula) 을삽입한후대패기 (shaver) 를이용하여불안정한 관절와순을다듬고연마기 (burr) 를이용하여연골하골을노출시 킨후고정나사봉합 (anchor suture) 을관절외에 45 o 각도로삽입 하여 SLAP 병변을봉합하였다. 이후개방술기로전환하여견봉 성형술을시행하였으며회전근개는부분파열인경우변연절제 Table 1. Summary of Demographic Data Group 1 (SLAP repair and acromioplasty) Group 2 (acromioplasty only) p-value Case (M/F)* 39 (23/16) 36 (21/15) 0.955 Age 54.5±7.3 56.0±9.7 0.457 Follow-up 32±18.0 35±23.4 0.503 *M, Male; F, Female, Calculated by Chi-square and student t-test, Values are expressed as mean±sd. 술만실시하였다. SLAP 병변의봉합을시행하지않은군에서는상완와관절은관찰하지않고개방술기로견봉성형술만을시행하였다. 3. 평가방법대상환자의결과평가는수술전과수술후최소 12개월이상지난뒤, American Shoulder and Elbow Surgeons' Assessment ( 이하 ASES) 설문지 9) 및관절운동범위정도를측정하였다. 집도의의편견이결과에영향을미치지않도록술전, 술후결과측정은제 3의연구자에의해시행되었다. ASES 설문지는 0점에서 100 점까지로측정되며통증에관한항목 50점, 일상생활활동에관한항목 50점으로구분되어있으며점수가높을수록기능과통증의호전상태가높다는것을의미한다. 관절범위는전방굴곡, 신전, 외전, 내전, 외회전, 내회전으로나누어수술전과최종추시에측정하였다. 수술결과가스포츠활동정도에따라영향을받는지확인하기위해나누어결과평가를하였다. 스포츠활동정도는과격한운동, 가벼운운동, 운동을거의하지않음의 3단계로나누었고축구, 농구, 테니스, 골프, 배드민턴등은과격한운동범주로, 조깅, 등산, 에어로빅등은가벼운운동범주로하였으며특별한운동을시행하지않는사람은운동을거의하지않는군으로나누었다. 과격한운동을하는군은 33명, 가벼운운동을하는군은 23명, 운동을거의하지않는군은 19명이었다. 자료분석은수술전수술후비교는 Paired t-test 를, 수술후각군간의비교는 Student t-test 를이용하였으며유의수준은 0.05 였고, 통계프로그램은 SPSS 12.0 통계프로그램 (SPSS for Windows Release 12.0, Chicago, IL, USA) 을이용하였다. 결과 추시관찰기간은평균 33개월이었으며 SLAP 병변봉합술을시행한군은남자 23명, 여자 16명이었고평균연령은 54.5±7.3 세였다. SLAP 병변봉합술을시행하지않은군은남자 21명, 여자 15 명이었고평균연령은 56.0±9.7 세였다. 두군간의성비, 나이및추시기간의차이는유의하지않았다 (Table 1). SLAP 병변봉합술을시행하지않은군의 ASES 점수는수술전 27점에서수술후 80점으로향상되었으며 (p<0.001), SLAP 병변봉합술을시행한군의 ASES 점수는수술전 29점에서수술후 84 로향상되었다 (p<0.001, Fig. 1). 그러나술후두군간의 ASES 점수는유의한차이를보이지않았다 (p=0.278). 스포츠활동정도에따른술후 SLAP 병변봉합술의결과는과격한운동을시행하는군에서 SLAP 병변을봉합한군이봉합하지않은군에비하여유의하게높은 ASES 점수를보였으며 (p=0.014), 가벼운운동이나운동을하지않는군에서는 SLAP 병변봉합술을시행한군과봉합하지않은군간의유의한차이는
245 견관절충돌증후군과동반된제 2 형 SLAP 병변봉합의추시결과 Figure 1. Mean ASES before and after surgery of acromioplasty with or without SLAP repair. After surgery, ASES increased, but there was no significant difference between SLAP repair group and no SLAP repair group postoperatively. Table 2. Summary of Range of Motion Preoperative Group 1 (SLAP repair and acromioplasty) Group 2 (acromioplasty only) p-value* Flexion 138±29 136±34 0.776 Extension 47±37 39±12 0.133 Abduction 122±44 126±41 0.724 Adduction 47±25 48±20 0.887 Internal rotation 79±20 75±36 0.688 External rotation 67±22 54±31 0.067 Postoperative Flexion 162±21 166±33 0.606 Extension 41±10 44±18 0.566 Abduction 157±27 163±37 0.491 Adduction 30±12 43±25 0.391 Internal rotation 77±19 77±24 0.932 External rotation 69±17 80±15 0.026 *Calculated by student t-test, Values are expressed as mean±sd. Figure 2. There was significant difference between SLAP repair group and no SLAP repair group in competitive sports group. However, the other groups showed no significant difference. 없었다 (p=0.257, p=0.810, Fig. 2). 관절운동범위는술전 SLAP 병변봉합술을시행하지않은군 과봉합한군간의통계적유의성은보이지않았다. 그러나수술 후 SLAP 병변을봉합한군에서외회전의제한이유의하게관찰 되었다 (p=0.026, Table 2). 고찰 충돌증후군과동반된 SLAP 병변은비교적흔하며단독 SLAP 병변의유병률은 12% 로낮게보고되고있다. 10) Snyder 등 3) 은 SLAP 병변으로진단된 140 명의환자중 66 명 (47%) 에서충돌증 후군이동반된다고하였으며, Samani 등 4) 은 SLAP 병변이있었던 43명의환자중 18명 (41%) 에서충돌증후군이있었다고보고하였다. 그런데이경우 SLAP 병변이통증을일으키는지, 그리고기능의장애를일으키는지에대해평가하기는어렵다. 11-13) 단독제2형 SLAP 병변은젊고활동적인사람이나운동선수에게발생하지만, 충돌증후군이동반된제2형 SLAP 병변은좀더나이든사람에게서발생하며증상이모호하고진찰소견역시정확하지않아단독제2형 SLAP 병변과같은질환군으로분류하는데문제가있다. Kim 등 10) 은제2형 SLAP 병변이 40세이하에서는 Bankart 병변과흔히동반되지만 40세이상에서는극상건의파열 (supraspinatus tear) 및상완골두의골관절염과흔히동반된다고하였으며, Coleman 등 8) 은나이든환자에게서발견된 SLAP 병변의진찰소견이충돌증후군과구분하기힘들다고하였고, Pandya 등 14) 도수술전에시행한 MRI 상 SLAP 병변과충돌증후군이동시에관찰되는경우통증의원인을구분하기힘들다고하였다. 고정나사봉합 (anchor suture) 을이용한 SLAP 병변봉합수술의결과는좋은것으로보고되고있으나 5,15-20) 대부분젊은환자를대상으로한단독 SLAP 병변에대한연구이다. 40세이상의환자는상부관절순의퇴행성변화로인해정상보다관절순의움직임이더많이일어날수있으며, 이를봉합하는것은본연구결과환자의통증경감이나일상생활능력의개선에영향을주지못할수있다. 그러나과격한운동을시행하는군에서는 SLAP 병변봉합술을시행한것이시행하지않는것에비해좋은결과를보였는
246 이상명ㆍ박재철ㆍ송석환외 3 인 데그이유는팔을머리위로올려외전- 외회전을하면상부관절순이벗겨지는힘이가해지며 (peel back mechanism) 21) 과격한운동으로인해빈도및강도가증가하는경우통증의원인으로작용할수있기때문이다. SLAP 병변에의한통증은운동과관련이있으며따라서젊은연령군은물론격렬한운동을하는고령군의경우 SLAP 병변을봉합하여안정화시키는것이통증완화및기능향상에도움이될것이다. 그러나수술후과격한운동을자제하는것이보다좋은결과를가져올수있음을본연구결과에서유추할수있다. 한편, SLAP 병변을봉합한군은 SLAP 병변을봉합하지않은군에비해외회전운동범위가유의하게낮았다. 이는 SLAP 병변을봉합하지않은군은견봉성형술로인해통증이경감되어운동범위가늘어난것으로생각되며 SLAP 병변을봉합하는경우관절와순이안정되어관절운동에제한을가져올수있을것이다. 그외에 SLAP 병변봉합후에는외회전운동을하지않도록교육하기때문에술후관절강직이발생하여외회전제한이올수있을것이나이연구만으로는정확한원인을확인할수없다. 하지만외회전이감소하더라도일상활동및대부분의스포츠활동에무리가없는운동범위를확보할수있으므로외회전제한을염려하여 SLAP 병변봉합술을주저할필요는없을것으로사료된다. 본연구결과충돌증후군과동반된제2형 SLAP 병변을봉합하는것이최종추시결과에영향을주지않는다면 SLAP 병변을봉합하지않음으로써수술시간을단축시킬수있고관절낭및관절내구조물에손상으로인한합병증을줄일수있다. 또한고정 (immobilization) 기간없이바로관절운동을시행할수있어이차동결견의발생을낮출수있으며입원및재활기간을단축시켜빠른회복을기대할수있다. 향후잘계획된전향적연구가필요할것으로생각되나본연구가임상적으로시사하는점은크다고하겠다. 본연구의한계점으로는후향적분석이므로무작위화 (randomization) 가되지않았고두집도의에의해환자가두군으로분리되어선택편견 (selection bias) 이발생할수있다는것이다. 하지만제 3의연구자에의해대상환자의선택및결과평가를시행되어집도의의편견이결과에영향을주지않도록하였고예상할수있는편견요소들, 즉, 연령, 성별, 추시기간등은두군간에차이가없었으므로연구결과는의의가있을것으로판단된다. 그외 ASES 평가법으로는주관적인통증평가와만족도및일상생활기능평가만을측정할수있었으며, 객관적인근력, 안정성, 지구력등은측정하지못한한계점이있다. 이러한부족한점을보완하기위해관절범위는측정하여제시하였다. 충돌증후군과동반되는제2형 SLAP 병변의치료는아직정립되어있지는않으나, 본연구를통하여 SLAP 병변의봉합없이견봉성형술만으로도양호한결과를얻었기에 SLAP 병변봉합술은필수적이지않은것으로판단된다. 결론 40세이상의충돌증후군을동반한제2형 SLAP 병변환자에게 SLAP 병변봉합술을시행하는경우임상적결과는시행하지않는경우와유의한차이를보이지않았다. 또한과격한운동을시행하는환자는 SLAP 병변을봉합하는것이임상적결과가좋으나증상호전을위해서는과격한운동을자제하여야한다. 참고문헌 1. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy. 1990;6:274-9. 2. Maffet MW, Gartsman GM, Moseley B. Superior labrumbiceps tendon complex lesions of the shoulder. Am J Sports Med. 1995;23:93-8. 3. Snyder SJ, Banas MP, Karzel RP. An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg. 1995;4:243-8. 4. Samani JE, Marston SB, Buss DD. Arthroscopic stabilization of type II SLAP lesions using an absorbable tack. Arthroscopy. 2001;17:19-24. 5. Rhee YG, Lee DH, Lim CT. Unstable isolated SLAP lesion: clinical presentation and outcome of arthroscopic fixation. Arthroscopy. 2005;21:1099. 6. Paxinos A, Walton J, Rütten S, Müller M, Murrell GA. Arthroscopic stabilization of superior labral (SLAP) tears with biodegradable tack: outcomes to 2 years. Arthroscopy. 2006; 22:627-34. 7. O'Brien SJ, Allen AA, Coleman SH, Drakos MC. The transrotator cuff approach to SLAP lesions: technical aspects for repair and a clinical follow-up of 31 patients at a minimum of 2 years. Arthroscopy. 2002;18:372-7. 8. Coleman SH, Cohen DB, Drakos MC, et al. Arthroscopic repair of type II superior labral anterior posterior lesions with and without acromioplasty: a clinical analysis of 50 patients. Am J Sports Med. 2007;35:749-53. 9. Michener LA, McClure PW, Sennett BJ. American shoulder and elbow surgeons standardized shoulder assessment form, patient self-report section: reliability, validity, and responsiveness. J Shoulder Elbow Surg. 2002;11:587-94. 10. Kim TK, Queale WS, Cosgarea AJ, McFarland EG. Clinical features of the different types of SLAP lesions: an analysis of one hundred and thirty-nine cases. J Bone Joint Surg Am. 2003;85-A:66-71.
247 견관절충돌증후군과동반된제 2 형 SLAP 병변봉합의추시결과 11. Baysal D, Balyk R, Otto D, Luciak-Corea C, Beaupre L. Functional outcome and health-related quality of life after surgical repair of full-thickness rotator cuff tear using a mini-open technique. Am J Sports Med. 2005;33:1346-55. 12. Gartsman GM, Khan M, Hammerman SM. Arthroscopic repair of full-thickness tears of the rotator cuff. J Bone Joint Surg Am. 1998;80:832-40. 13. Jost B, Pfirrmann CW, Gerber C, Switzerland Z. Clinical outcome after structural failure of rotator cuff repairs. J Bone Joint Surg Am. 2000;82:304-14. 14. Pandya NK, Colton A, Webner D, Sennett B, Huffman GR. Physical examination and magnetic resonance imaging in the diagnosis of superior labrum anterior-posterior lesions of the shoulder: a sensitivity analysis. Arthroscopy. 2008;24:311-7. 15. Cohen DB, Coleman S, Drakos MC, et al. Outcomes of isolated type II SLAP lesions treated with arthroscopic fixation using a bioabsorbable tack. Arthroscopy. 2006;22:136-42. 16. Lim MH, Chan BK, Low CO. Arthroscopic management of superior labral anterior and posterior (SLAP) and associated lesions: clinical features and functional outcome. Ann Acad Med Singapore. 2008;37:44-8. 17. Ozbaydar MU, Tekin C, Kocabas R, Yalaman O. Arthroscopic treatment of type 2 superior labrum anterior posterior lesions. Acta Orthop Traumatol Turc. 2006;40:349-55. 18. Panossian VR, Mihata T, Tibone JE, Fitzpatrick MJ, McGarry MH, Lee TQ. Biomechanical analysis of isolated type II SLAP lesions and repair. J Shoulder Elbow Surg. 2005;14:529-34. 19. Park JH, Lee YS, Wang JH, Noh HK, Kim JG. Outcome of the isolated SLAP lesions and analysis of the results according to the injury mechanisms. Knee Surg Sports Traumatol Arthrosc. 2008;16:511-5. 20. Yung PS, Fong DT, Kong MF, et al. Arthroscopic repair of isolated type II superior labrum anterior-posterior lesion. Knee Surg Sports Traumatol Arthrosc. 2008;16:1151-7. 21. Huffman GR, Tibone JE, McGarry MH, Phipps BM, Lee YS, Lee TQ. Path of glenohumeral articulation throughout the rotational range of motion in a thrower's shoulder model. Am J Sports Med. 2006;34:1662-9.
248 이상명ㆍ박재철ㆍ송석환외 3 인 Follow-up Result in Repairing a Type II Superior Labrum Anterior and Posterior (SLAP) Lesion when Associated with Shoulder Impingement Syndrome Sang-Myung Lee, M.D., Jae-Chul Park, M.D., Seok-Whan Song, M.D., Sang-Il Kim, M.D., Bo-Youn Park, M.D., and Seung-Koo Rhee, M.D. Department of Orthopedic Surgery, Yeouido St. Mary s Hospital, The Catholic University of Korea School of Medicine, Seoul, Korea Purpose: Type II superior labral anterior posterior (SLAP) lesions can occur in the setting of impingement syndrome. The authors compared the clinical results of patients who had undergone either an isolated acromioplasty or a combined type II SLAP repair and acromioplasty. Materials and Methods: Between 2003 and 2008, a total of 75 cases of SLAP II lesions associated with impingement syndrome were recruited. In 39 patients, the type II SLAP lesion was repaired and acromioplasty was performed. In the other 35 patients, acromioplasty was performed alone. All patients were evaluated using the American Shoulder and Elbow Surgeons (ASES) questionnaire and range of motion. Results: At an average of 33 months postoperatively, the ASES scores significantly increased in both groups (p<0.001) but the ASES score was similar in the 2 groups (p=0.278). However, there was a significant difference in the ASES scores when the competitive sports activity of the 2 groups of patients postoperatively were compared (p=0.014). The SLAP repair patients showed limited external rotation motion compared to the acromioplasty alone patients (p=0.026). Conclusion: There are no advantages in repairing a type II SLAP lesion when associated with impingement syndrome. However, type II SLAP lesions should be repaired in patients involved with competitive sports activity but the competitive sports activity should be limited for a better result. Key words: SLAP lesion, arthroscopic SLAP repair, impingement syndrome, acromioplasty Received December 30, 2009 Accepted May 6, 2010 Correspondence to: Seung-Koo Rhee, M.D. Department of Orthopedic Surgery, Yeouido St. Mary s Hospital, The Catholic Univrsity of Korea School of Medicine, 62, Yeouido-dong, Youngdeungpo-gu, Seoul 150-713, Korea TEL: +82-2-3779-1192 FAX: +82-2-783-0252 E-mail: skrhee@catholic.ac.kr