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 to Posterior (SLAP) 병변봉합후실패시치료 박진영 이제형 이준규 네온정형외과 pissn : 1226-2102, eissn : 2005-8918 Problem Solving for Failed Superior Labrum Anterior to Posterior (SLAP) Repair Jin-Young Park, M.D., Ph.D., Jae-Hyung Lee, M.D., and Joon-Gyu Lee, M.D. Center for Shoulder, Elbow and Sports, Neon Orthopaedic Clinic, Seoul, Korea Stiffness and pain are major causes of failed superior labral anterior to posterior (SLAP) repair. The term, failed SLAP repair, can be defined as stiffness or pain without rotator cuff tears, acromio-clavicular pathology, arthritis, impingement syndrome, and other shoulder diseases. Moreover, it does not respond to conservative management. Generally, for failed SLAP repair, the initial conservative management includes physical therapy, strengthening exercise, oral medications, and injections. In addition, with failed conservative treatment, surgical intervention can be carried out. Surgical indications must be in consideration with patients age, mechanism of injury, stability of the lesion, activity, former history of sports activity, and types of sports. Surgical treatments include debridement, SLAP repair, biceps tenodesis and tenotomy. However, each type of surgical method is controversial on both indications and prognosis. Surgical treatment on SLAP lesion is increasing, and studies on failed SLAP repair are expanding. The recommended first line therapy for failed SLAP lesion is conservative management, and with limited and thorough indications, surgical treatment yields good results, depending on concurrent lesions. However, authors recommend that it is important to seek for adjacent lesions prior to the initial SLAP repair to decrease failed SLAP repair. Key words: superior labral anterior to posterior, failed superior labral anterior to posterior repair, tenotomy, tenodesis 서론 상부관절와전후방 (superior labral anterior to posterior, SLAP) 병 변은상부관절와순이전방에서부터후방까지파열되는질환으 로주로견인손상이나압박손상, 혹은상지거상동작이반복되 는경우발생하게되며이때이두장두건의손상이동반될수있 다. 1) 이는 1985 년 Andrews 등 2) 에의해언급된이후 1990 년 Snyder Received April 18, 2016 Revised March 3, 2017 Accepted August 23, 2017 Correspondence to: Jae-Hyung Lee, M.D. Center for Shoulder, Elbow and Sports, Neon Orthopaedic Clinic, 8 Seolleung-ro 131- gil, Gangnam-gu, Seoul 06059, Korea TEL: +82-2-540-3200 FAX: +82-2-540-2299 E-mail: medos97@naver.com 등 3) 에의해 SLAP으로명명되고파열의위치와양상에따라네가지종류로분류되었다. 이후 Maffet 등 4) 과 Powell 등 5) 에의해추가로세가지형태가추가되었으며 Morgan 등 6) 에의해서는 2형이다시세가지아형으로분류되었다. 일반적으로초기치료는도수치료를비롯한근력운동, 경구약복용, 주사치료등의보존적치료를시행하게되며보존적치료에반응하지않는경우수술적치료를고려해볼수있다. 수술은환자의나이와수상기전, 병변의불안정성, 활동수준, 이전의운동과거력과운동의종류등을고려하여결정하여야하며, 수술적치료는각각의수술적응증과예후에대해서많은논란이있어왔다. 7) 이전연구에따르면, 2형 SLAP 병변의복원술을시행한후환 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.
386 Jin-Young Park, et al. 자들이수술후통증, 강직을비롯하여결과에불만족을느끼고재수술을필요로하는경우가있으며, 8,9) SLAP 병변복원술후재수술을시행하는환자의수가지속적으로증가하고있다고보고되고있다. 10,11) 또한운동선수의경우 SLAP 병변복원술이후에경기로의복귀율이제한적이며상지거상운동선수의경우, 특히야구선수에서의복귀율은현저히낮은것으로알려졌다. 12,13) 회전근개파열이동반된경우또한 SLAP 복원술의실패확률이높아재수술이필요한경우가증가한다. 14,15) 이에저자들은통증혹은강직을수반하는 SLAP 병변의봉합후실패, 즉 SLAP 병변의봉합후지속되는증상이있는경우의이학적검사, 방사선검사및적절한치료법에대해알아보고자하였다. 본론 1. 상부관절와전후방병변복원술이후의실패의증상및원인 SLAP 병변복원술후실패에영향을미치는요인에대해서명확히밝혀지지는않았으나상부관절와순주위의원활하지못한혈류공급과충분하지못한수술후고정기간, 과도한치료및연령등이영향을미칠것으로보고되고있다. 11) SLAP 병변복원술실패의증상에는술후통증혹은술후강직이주된원인이다. 10,11) 술후통증은수술의기술적인문제혹은병변의효과적인봉합이이루어지지않아발생하는경우가흔하며, 동반병변을적절하게치료하지못한경우에도빈번하게일어난다. 또한봉합부위가너무강한 (tight) 경우와적절한재활이이루어지지않은경우에술후관절강직이동반될수있다. 11,12) 이증상들이이두장두건손상이나회전근개파열, 견봉쇄골관절병변, 관절염, 충돌증후군등의병변과연관이없으면서보존적치료에반응하지않는경우일때 SLAP 복원술후실패로정의할수있다. Weber 16) 는 SLAP 병변복원술후통증이지속된 24예를분석한결과 7예에서만 SLAP 복원술후실패를발견하였고, 14예에서는연골의손상, 10예에서는수술후강직을보고하였다. 이러한실패를일으키는원인중에는술기와 anchor의성분도관련이있는데 poly-l/d-lactic acid anchor의경우다른재질보다흡수 (resorption) 율이높아실패율이증가하는것으로밝혀졌다. 17) Knotless anchor의경우그렇지않은것에비해초기고정력은비슷하면서견관절에과도한긴장을주지않는장점이있으며 18) 봉합방법에있어서도단순봉합보다는매트리스봉합법의경우더큰장력에견딜수있는장점이있었다. 19) 또한한개의 anchor에서두개의봉합을하는방법과두개의 anchor에서각각하나씩봉합을하여총두개의봉합을하는방법에있어서는큰차이가없는것으로나타났다. 20) 결론적으로 SLAP 복원술이후실패시에는통증및강직이주된증상으로나타나며, 술후고정기간, 과도한치료, 효과적이지못한봉합및동반병변의간과등이원인이될수있다. 2. 상부관절와전후방병변복원술실패후진단방법 SLAP 병변의복원술실패후진단방법은 SLAP 병변초기의이학적검사와비슷하다. 외래에서시행할수있는이학적검사는재파열혹은통증을동반한경우 SLAP 병변초기의이학적검사와마찬가지로능동적압박검사 (O Brien test) 및제2 이두근건부하검사 (Biceps load 2), 압박회전검사 (compression rotation test), 역동적관절와순전단검사 (dynamic labral shear test, O Driscoll test), Speed 검사, 관절와순긴장검사 (labral tension test) 등이있으며, 관절강직등은관절가동범위 (range of motion) 검사만으로도쉽게구별이가능하다. 21) SLAP 재파열병변은파열양상이다양하고증상이모호하며다른견관절병변을동반하는경우도많기때문에이학적검사를통해이를잘감별할필요가있다. Cook 등 21) 은위에소개된이학적검사의유용성을검사하여제2 이두근건부하검사만이 SLAP 단독병변을진단하는데있어유의한검사로보고하였으나 Pandya 등 22) 과 Meserve 등 23) 은위검사의정확성을밝힌바있다. 하지만강직과동통이수반되는 SLAP 재파열병변의경우이학적검사를통해정확하게진단하기가힘든경우가있다. 방사선검사역시 SLAP 병변초기진단과비슷하게자기공명영상 (magnetic resonance imaging, MRI) 과자기공명영상조영술 (magnetic resonance angiography, MRA) 을통해더정확한진단을할수있다. Connolly 등 24) 은 244예의 MRI를시행하였으며이중 144예에서관절경을통해 2형 SLAP 병변을확진하였다. 이연구에서 MRI의민감도는 38% 였고특이도는 94% 로서 2형 SLAP 병변을확진하는검사로는적합하지않았다. Amin과 Youssef 25) 는 MRA를통해민감도 93.8%, 특이도 85.7% 로진단의정확성을높일수있다고하였다. 또한비슷한증상을야기할수있는감염에대해서는혈액검사와천자검사를통해반드시배제해야한다. 일반적으로 SLAP 병변봉합이실패한경우 MRA에서 SLAP 병변의초기와마찬가지로상부관절와순 (superior labrum) 으로조영제가새어들어가 (leaking), 고강도의신호 (high signal) 를보이는경우가대부분이다. 관절강직의경우관절막의유착 (capsular thickening) 및관절강내의용적감소 (intra-articular volume decrease) 가보인다 (Fig. 1). 3. 상부관절와전후방병변복원술실패후치료 1) 보존적치료 SLAP 병변의초기치료에서와마찬가지로 SLAP 복원술후실패의치료에있어서도보존적치료는도움이된다. 특히동반된병변을정확히찾아낸후이에맞는적절한보존적치료를선행한
387 Problem Solving for Failed SLAP Repair Figure 1. Magnetic resonance angiography finding of the re-torn site after superior labrum repair; a contrast material leakage in superior labrum and showing high signal intensity between superior labrum and superior glenoid. Figure 3. Removal of loose stitch. 가많다. 보존적치료는 6개월이상복합적으로시행한뒤환자의증상이경감하지않으면수술적치료를고려할수있다. 이에대한연구로 Katz 등 10) 은 SLAP 병변복원술을시행한후실패한사람들에게보존적치료를시행하였으나 71% 에서만족스러운결과를얻지못하였음을발표하였고, 따라서 SLAP 병변복원술실패후치료시보존적치료보다는수술적치료가더높은만족도를줄것으로보고이를권유하였다. Figure 2. Loose stitch after failed superior labral anterior to posterior repair. 다면통증을많이해소할수있다. SLAP 병변과함께수술후강 직이동반된경우 cortisone 을이용한주사치료를통해술후강 직과통증을감소시킬수있으며적절한도수치료를통해정상 적인관절범위를얻을수있다. 수술후강직을동반한충분하지못한재활과관절막유착의 경우는보존적치료로잘해결되는반면에, 동반된다른병변을 적절히치료하지못한경우와새로운병변이발생한경우혹은 수술의기술적인문제가발생한경우에는재수술을요하는경우 2) 수술적치료 SLAP 병변복원술실패후시행해볼수있는수술적치료방법은 SLAP 병변에대한첫치료와마찬가지로관절경하변연절제술을비롯하여 SLAP 재복원술, 이두장두건고정술, 이두장두건절제술이있다. 치료방침이명확히확립되지는않았으나환자의상태와병변의양상, 술자의선호도를고려해치료방법을선택할수있다. SLAP 복원술실패후관절경을시행할때는이전에시행한수술의종류에상관없이병변의부위와함께이전수술에서놓친부분이없는지도면밀히살펴보아야한다. SLAP 재복원술은대개 35세이하의젊고활동력이있는환자에서명확한이두장두건의병변이없는상황에서고려해볼수있다. 수술에는 anchor의개수와봉합방법에따라재실패의가능성에영향을줄수있으므로올바른봉합사의선택, 이두박건전후방부의 anchor 삽입위치, vertical 혹은 horizontal 봉합을잘고려하여시행하여야한다. 17-20) 또한이전에사용하였던 anchor는가능한한제거하여야하며관절와순의회복에도움을줄수있는환경을위해철저한피질제거술 (decortication) 을통하여 bleeding bone bed를만들어야한다 (Fig. 2-5). Park과 Glousman 26) 은 SLAP 재복원술을시행한 12예를대상으로평균 50.5개월간추시한결과수술후통증이가장많은불
388 Jin-Young Park, et al. Figure 4. Complete removal of the loose stitch and insertion of suture anchor after decortication of the superior glenoid. Figure 5. Arthroscopic finding after repair of failed superior labral anterior to posterior lesion. 편사항이었으며이전수준으로의일복귀율은 57.8%, 경기복귀율은 42.2% 로보고하였다. 그중상지거상운동선수의복귀율은 41.3% 이었으며특히 4명의야구선수들은모두복귀하지못하였다. SLAP 재복원술의경우일반인과운동선수모두에서, 1차복원술에비해수술후결과가더좋지않은것으로보고되고있다. 이두장두건고정술은최근 SLAP 복원술실패후의수술적치료로서좋은결과를보여주며많이시행되고있다. 나이제한이있는것은아니나 60세이하의경우많이시도하며일반적으로중년의여성이나이두장두건에명확한병변을동반한젊은환자에서도선택적으로시행할수있다. 16,27) McCormick 등 27) 은관절경으로 2형 SLAP 병변복원술을시행한후실패한 42예의환자 ( 평균나이 39.2세, 남자 85%, 평균관찰기간 3.5년 ) 에서이두장두건고정술을시행한후최소 2년간추시하였다. 이들은통증점수, 관절가동범위를포함한임상평가에서유의한향상을보였으며, 관절경적 SLAP 병변복원술에실패한환자군에서이두장두건고정술을시행할만한안전하고효과적인수술이라고보고하였다. 다른연구에서도이두장두건고정술을시행한결과통증을비롯한관절가동범위에서모두호전을보여 SLAP 복원술실패후치료의대안으로보고하였다. 28) Boileau 등 29) 은 25예의 2형 SLAP 병변을대상으로 10예에서는복원술을, 15예에서는이두장두건고정술을시행한후추시한결과복원술의경우환자만족도는 40%, 일상운동으로의복귀율은 20% 인데반해이두장두건고정술의경우환자만족도가 93%, 운동복귀율이 87% 로나타나현저히효과적인치료결과를보고하였다. 또한 SLAP 복원술을시행받은환자중 4예에서실패를보여이들을대상으로이두장두건고정술을시행하였고, 이에좋은결과를보여이두장두건고정술은 1차 SLAP 병변과술후실패한 SLAP 복원술모두에 있어효과적인치료가될것으로보고하였다. 결론 SLAP 병변에대한수술적치료는점점증가하고있고복원술후실패한경우도따라서증가하는추세를보이며적절한치료에대한연구가많이진행되고있다. 이에대한치료로먼저보존적치료를생각해볼수있고, 수술적치료에도좋은결과를보여환자의상태와병변의양상, 동반된병변의유무에따라다양한치료를선택할수있다. 하지만술자들은 SLAP 병변에대한첫치료시동반된병변을정확히찾고그에대한적절한치료를선행하여치료효과를높여서 SLAP 복원술후실패를줄이는노력도기울여야하며충분한보존적치료를통한신중한접근이필요할것으로생각하였다. 또한 SLAP 병변봉합후실패의원인및환자의상태에따라서개별화된치료방법설정이필요한상태이다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Keener JD, Brophy RH. Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment. J Am Acad Orthop Surg. 2009;17:627-37. 2. Andrews JR, Carson WG Jr, McLeod WD. Glenoid labrum
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391 pissn : 1226-2102, eissn : 2005-8918 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) 병변 : 쟁점 Superior Labrum Anterior to Posterior (SLAP) 병변봉합후실패시치료 박진영 이제형 이준규 네온정형외과 상부관절와전후방 (superior labral anterior to posterior, SLAP) 병변의수술적치료후의실패는관절강직 (stiffness) 과통증 (pain) 이있으면서회전근개질환 (rotator cuff disease), 견쇄관절병변 (acromio-clavicular lesion), 관절염 (arthritis), 충돌증후군 (impingement syndrome) 및다른견관절병변의동반병변이없으며보존적치료에반응하지않는경우를지칭한다. 일반적으로 SLAP 병변의복원술후실패의치료로물리치료, 강화운동, 경구소염제및주사치료를포함한보존적치료를시행할수있다. 보존적치료에실패할경우수술적치료를시행할수있으며, 반드시환자의나이, 손상기전, 병변의안정성, 환자의활동성과여가생활의다양성을고려하여신중히결정해야한다. 수술적치료는변연절제술 (debridement), 재복원술 (revisional repair), 상완이두박건고정술 (tenodesis) 및건절술 (tenotomy) 이있으며, 각각의방법은적응증과예후에있어서논란이많은실정이다. SLAP 병변에대한수술적치료는점점증가하고있고복원술후실패한경우도함께증가하는추세로이에대한적절한치료에대한연구가많이진행되었다. 이에대한치료로먼저보존적치료를생각해볼수있고, 수술적치료도좋은결과를보여환자의상태와병변의양상, 동반된병변의유무에따라다양한치료를선택할수있다. 하지만술자들은 SLAP 병변에대한첫치료시동반된병변을정확히찾고그에대한적절한치료를선행하여치료효과를높여야한다. SLAP 복원술후실패의경우를줄이는노력도기울여야하며충분한보존적치료를통한신중한접근이필요할것으로생각된다. 또한 SLAP 병변봉합후실패의원인및환자의상태에따라서개별화된치료방법설정이필요한상태이다. 색인단어 : 상부관절와전후방병변, 상부관절와전후방병변치료의실패, 상완이두박건고정술, 상완이두박건건절술 접수일 2016 년 4 월 18 일수정일 2017 년 3 월 3 일게재확정일 2017 년 8 월 23 일책임저자이제형 06059, 서울시강남구선릉로 131 길 8, 네온정형외과 TEL 02-540-3200, FAX 02-540-2299, E-mail medos97@naver.com 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.