노인무릎관절염수술언제할것인가? 유재두 이화여자대학교의학전문대학원목동병원정형외과학교실 슬관절관절염은퇴행성관절염, 류마치스성관절염, 후외상성관절염등으로분류할수있고, 우리나라에서는 60세이상의인구에서슬관절의퇴행성관절염은증가하고있고, 특히중년기여성에서호발하고있다. 무릎의연골은혈관과신경이분포하지않기때문에무릎관절염이있는경우통증의원인은다양하다. 활액막염, 근육통, 연골하골소주의미세골절, 골막신경의자극, 골변형으로인한인대의긴장, 연골하골의재형성으로인한정맥성울혈등이통증의원인으로생각되고있다. 1) 이중활액막염은진행된관절염에서의가장흔한통증의원인으로, 활액막염이통증의주된원인인경우에는스테로이드등의항염증성약물로치료할수있지만활액막염을일으키는원인에대한보다근본적인치료가필요하다. 무릎관절의퇴행성관절염에대한다양한비수술적인치료가시도되고있고, 수술은비수술적치료로효과가없는경우에시행한다. 수술적치료로는내시경적세척술및변연절제술, 재정렬절골술 (realignment osteotomy), 슬관절전치환술 (knee arthroplasty) 등이있다. 2) 슬관절의통증을호소하지만슬관절의병변이없이고관절이나척추에서유래하는연관통일경우도있고, 슬관절주위의점액낭염, 인대손상, 건염등을감별하는것도필요하다. 무릎의퇴행성관절염은방사선사진상의관절염의진행정도와환자가느끼는통증의정도가반드시일치하지않는다. 상당히진행된퇴행성관절염을가지고있지만체중이적은환자중에는증상은심하지않은경우가있는가하면, 무릎관절의내측구획만을침범한중등도의관절염을가지고있지만체중이많이나가는경우에는심한통증을호소하는경우도있을수있다. 따라서환자의현재통증이슬관절의퇴행성관절염으로인한것인지를명확히하는것이중요하고, 방사선사진소견만을기준으로수술의시기를결정하는것은항상적절한것은아니다. 즉슬관절관절염에행해지고있는수술방법들은관절염의진행정도, 나이, 활동도, 수술에대한기대치, 동반질환여부등여러가지요소를종합적으로분석하여수술방법을결정하게된다. 내시경적세척술및변연절제술의통증을완화하는정확한치료기전은알려져있지않지만, 수술이기계적자극을일으키는불안정한반월상연골파열이나관절연골조각등을제거하고, 관절내를세척함으로써통증을유발하는염증성물질을제거함으로써증상을호전시킨다고알려져있다. 2) 적응증은잠김현상 (Locking) 이나 Catching 등의기계적증상이최근에발생한경우, 방사선사진상관절증이심하지않고하지의부정정렬 (misalignment) 이심하지않은경우에서좋은치료효과를기대할수있다. 3-13) 그러나, 관절경을이용한변연절제술및세척술은증상의호전이영구적인것은아니므로좋은치료결과를얻기위해서는환자의생활습관의교정을통하여슬관절에무리가가지않도록하는환자의교육도치료의중요한부분이다. - 317 -
경골의근위부에절골술을한후에하지의변형을교정함으로통증을완화하는수술인재정렬절골술의적응증은 60세이전의비교적젊은환자에서활동과관계된슬관절의내측또는외측단일구획성관절증, 안정성이있는슬관절에서내반변형이 12도이하인경우, 굴곡구축이없으면서최대굴곡이 90도이상인경우에시행할수있다. 14,15) 재정렬절골술은대개 5년성공률은 90% 이며 10년성공률은 45% 정도로알려져있다. 16,17) 그러나, 재정렬절골술이향후실패하여슬관절전치환술로전환하는경우수술시어려움이있다. 일반적인인공슬관절치환술에비하여수술시야확보가어렵고, 내측및외측인대의균형을얻기가어려운점등수술수기상문제점이있으므로재정렬수술을하기전에충분한고려가있어야한다. 17) 부분인공슬관절치환술도이런환자에서치료방법으로선택될수있다. 인공관절수술은앞에서소개한치료방법으로좋은효과를기대하기어려운진행된관절염을앓고있는비교적고령의환자에서시행된다. 인공관절수술은환자의생존여부를결정하는암수술과는달리환자의기능의호전을위한수술이므로, 인공관절치환술의적절한시기를결정하는것은의사만의결정이아니라환자와의상의가필요하다. 인공관절수술중슬관절전치환술은진행된관절염에서물리치료, 약물치료등의보존적치료에반응하지않는통증에대한가장효과적인치료방법이다. 이는관절내주사등의관절을보존하는치료로호전되지않는진행된관절염환자에서통증을완화하여삶의질을향상시키는수술이다. 적절한수술의시기가언제인지에대한통일된지침을기대하기는어렵다. 왜냐하면환자의수술전방사선사진의진행정도가통증과약한상관관계를보이기때문이다. 1,18) 따라서가장중요한요소는환자가느끼는통증과일상생활또는직업활동에서느끼는제한의정도이다. 인공관절수술의결과에영향을주는여러요소중환자의수술전증상의정도가심할수록수술후결과가불량하다고알려져있다 19,20) Fortin 등은불량한수술전상태인환자가수술후 6개월에더불량한결과를얻었으며, 이결과는수술후 24개월까지지속되었다고하였다. 20) FitzGerald 등도수술전기능이불량한환자가수술후결과도불량하였다고한다. 21) 환자의수술당시의나이가고령일수록수술의기능적결과가불량하였고, 술전 WOMAC 점수가불량할수록수술후결과가불량하였다. 그러나방사선소견상퇴행성관절염의정도와수술결과와는상관관계가없었다. 18) 인공관절수술을가능한조기에하는것이좋은가? 인공고관절치환술을시행한 167명을분석한스웨덴의결과는좀더젊은환자가수술후기능회복이더좋았지만, 수술까지 3개월을기다린군과 3개월미만을기다린군사이에는수술후결과사이에차이가없었다고하였다. 22) 이렇게인공관절수술이필요한환자에서수술의시기가문제가되는것은수술에사용되는인공관절의수명이아직까지는영구적이지않기때문이다. 23-41) 인공슬관절치환술의결과는 15년추시할때약 92% 는만족한다고한다. 그러나최근에는기계공학과금속공학의발달로과거보다더개선된제품의사용이가능하고, 수술수기도더많이발전하여기존의보고보다는좀더좋은성공률을기대할수있을것이다. 그러나특히만약 60세미만에서인공관절치환술을받게되는경우에는여명기간동안에재치환수를받을가능성이있다. 아직까지는적절한수술시기에관한충분한무작위전향적연구 (randomized prospective study) 의부족으로정확한가이드라인을제시하기에어려움이있다. 단순방사선사진상관절염소견을보이는환자에서통증, 특히휴식시통증이있는경우슬관절전치환술의적응증이된다고하였지만, Dieppe 등은통증의정도와함께 걸을수없으며, 일할수없고, 잘수없는경우 가인공관절술의적응증이된다고하였다. 42) 슬관절전치환술의금기로서는최근에화농성관절염이나슬관절근처의골수염등의감염이있었던경우, 동일절개를할수없는 6개월이내의관혈적수술병력이있거나, 동맥협착성질환이있는경우, - 318 -
유재두 : 노인무릎관절염수술언제할것인가? 젊은노동자, 전신상태가나쁜사람, 수술을해도걷지못하는환자등이며상대적인금기증으로는신경병성관절증이있거나, 무릎의신전기전이충분하지못할때, 건선등으로인해피부의상태가나쁠때, 병적인비만등이며최근에침이나뜸을뜬경우에는감염이없다는확인후에시행한다. 모든경우에적용될수있는지침을제시하기어렵고, 수술을결정하기전에환자에연관된요소와수술에관련된요소를잘저울질하여수술시기를결정하여야한다. 가장결정적인요소는환자가느끼는통증의정도이다. 환자요소로는관절염의진행정도, 증상의정도, 동반질환의위험도, 환자의수술후기대치를고려해야하고, 수술요소로는 morbidity, 합병증, 수술결과의지속기간등을고려해야한다. 방사선소견상관절염의진행이내측또는외측에국한되어있고, 60세미만으로나이가젊으며, 활동적인경우에는절골술이적절하고, 연골판파열등이동반된관절염증상이있는경우에는관절세척술과변연절제술을하고, 방사선소견상진행된관절염이고보존적치료로통증의완화를기대할수없는경우에는인공관절수술이선택된다. 80세이상의고령인경우에는환자의건강상태를고려하여야하며, 통증이심하고, 방사선사진상심한관절염이있는경우에만수술을시행한다. 43) 수술전환자와면담시에슬관절전치환술의목적은걸을때통증해소와층계오르내리기를가능하게하고자전거, 가벼운등산등운동을할수있게하는것이궁극적인목표이며심한노동, 장시간보행, 쪼그려앉는자세등은피해야한다는것을주지시켜야한다. 참고문헌 1. Creamer P. Osteoarthritis pain and its treatment. Curr Opin Rheumatol 2000;12(5):450-5. 2. Gunther KP. Surgical approaches for osteoarthritis. Best Pract Res Clin Rheumatol 2001;15(4):627-43. 3. Jackson RW, Dieterichs C. The results of arthroscopic lavage and debridement of osteoarthritic knees based on the severity of degeneration: a 4- to 6-year symptomatic follow-up. Arthroscopy 2003;19(1):13-20. 4. Krystallis CT, et al. Arthroscopic debridement of the osteoarthritic knee under local anaesthesia. Acta Orthop Belg 2004;70(3):260-7. 5. Kuzmanova SI. Treatment of knee osteoarthritis by arthroscopic synovectomy and debridement of cartilage lesions--late results. Folia Med (Plovdiv) 2003;45(3):66-72. 6. Linschoten NJ, Johnson CA. Arthroscopic debridement of knee joint arthritis: effect of advancing articular degeneration. J South Orthop Assoc 1997;6(1):25-36. 7. McLaren AC, et al. Arthroscopic debridement of the knee for osteoarthrosis. Can J Surg 1991;34(6);595-8. 8. Schonholtz GJ. Arthroscopic debridement of the knee joint. Orthop Clin North Am 1989;20(2):257-63. 9. Sprague NF 3rd. Arthroscopic debridement for degenerative knee joint disease. Clin Orthop Relat Res 1981;(160):118-23. 10. Su JY, et al. Arthroscopic debridement for osteoarthritis of the knee: a seven years follow-up study. Gaoxiong Yi Xue Ke Xue Za Zhi 1995;11(12):667-72. 11. Waddell JP. Arthroscopic debridement of the knee. Can J Surg 1991;34(6):532. 12. Wai EK, Kreder HJ, Williams JI. Arthroscopic debridement of the knee for osteoarthritis in patients fifty years of age or older: utilization and outcomes in the Province of Ontario. J Bone Joint Surg Am 2002;84-A(1):17-22. 13. Wei N, Delauter SK, J.B. S. Arthroscopic debridement and visco-supplementation: a minimally invasive treatment for symptomatic osteoarthritis involving the base of the thumb. J Clin Rheumatol 2002;8(3):125-9. 14. Coventry MB. Upper tibial osteotomy for gonarthrosis. The evolution of the operation in the last 18 years and long term results. Orthop Clin North Am 1979;10(1):191-210. 15. Coventry MB, Bowman PW. Long-term results of upper tibial osteotomy for degenerative arthritis of the knee. Acta - 319 -
Orthop Belg 1982;48(1):139-56. 16. Haslam P, et al. Total knee arthroplasty after failed high tibial osteotomy long-term follow-up of matched groups. J Arthroplasty 2007;22(2):245-50. 17. van Raaij TM, et al. The effect of high tibial osteotomy on the results of total knee arthroplasty: a matched case control study. BMC Musculoskelet Disord 2007;8:74. 18. Chang C, Kim T, S SC. Key factors indetermining surgical timing of total knee arthroplasty in osteoarthritic patients: Age, radiographic severity, and symptomatic severity. in 2007 Triannual meeting of Asia Pascific Orthopedic Association. 2007. Seoul. 19. Joshy S, et al. Ethnic differences in preoperative function of patients undergoing total knee arthroplasty. Int Orthop 2006;30(5):426-8. 20. Fortin PR, et al. Timing of total joint replacement affects clinical outcomes among patients with osteoarthritis of the hip or knee. Arthritis Rheum 2002;46(12):3327-30. 21. Weng HH, Fitzgerald J. Current issues in joint replacement surgery. Curr Opin Rheumatol 2006;18(2):163-9. 22. Nilsdotter AK, Lohmander LS. Age and waiting time as predictors of outcome after total hip replacement for osteoarthritis. Rheumatology (Oxford) 2002;41(11):1261-7. 23. Rand JA, Coventry MB. Ten-year evaluation of geometric total knee arthroplasty. Clin Orthop Relat Res 1988;(232): 168-73. 24. Ritter MA, et al. The survival of total knee arthroplasty in patients with osteonecrosis of the medial condyle. Clin Orthop Relat Res 1991;(267):108-14. 25. Kristensen O, et al. Long-term results of total condylar knee arthroplasty in rheumatoid arthritis. J Bone Joint Surg Br 1992;74(6):803-6. 26. Ranawat CS, et al. Long-term results of the total condylar knee arthroplasty. A 15-year survivorship study. Clin Orthop Relat Res 1993;(286):94-102. 27. Ritter MA, et al. Total knee arthroplasty effectiveness in patients 55 years old and younger: osteoarthritis vs. rheumatoid arthritis. Knee 2007;14(1):9-11. 28. Santini AJ, Raut V. Ten-year survival analysis of the PFC total knee arthroplasty-a surgeon s first 99 replacements. Int Orthop 2007. 29. Gioe TJ, et al. Knee Arthroplasty in the Young Patient: Survival in a Community Registry. Clin Orthop Relat Res 2007. 30. Langlais F, et al. The long-term results of press-fit cemented stems in total knee prostheses. J Bone Joint Surg Br 2006; 88(8):1022-6. 31. Tai CC, Cross MJ. Five- to 12-year follow-up of a hydroxyapatite-coated, cementless total knee replacement in young, active patients. J Bone Joint Surg Br 2006;88(9):1158-63. 32. Sharma S, et al. Long-term results of the uncemented low contact stress total knee replacement in patients with rheumatoid arthritis. J Bone Joint Surg Br 2005;87(8):1077-80. 33. Price AJ, et al. Ten-year in vivo wear measurement of a fully congruent mobile bearing unicompartmental knee arthroplasty. J Bone Joint Surg Br 2005;87(11):1493-7. 34. Wright RJ, et al. Patient-reported outcome and survivorship after Kinemax total knee arthroplasty. J Bone Joint Surg Am 2004;86-A(11):2464-70. 35. Haleem AA, Berry DJ, Hanssen AD. Mid-term to long-term followup of two-stage reimplantation for infected total knee arthroplasty. Clin Orthop Relat Res 2004;(428):35-9. 36. Gioe TJ, et al. Why are total knee replacements revised? analysis of early revision in a community knee implant registry. Clin Orthop Relat Res 2004;(428):100-6. 37. Berend ME, et al. Total joint arthroplasty in the extremely elderly: hip and knee arthroplasty after entering the 89th year of life. J Arthroplasty 2003;18(7);817-21. 38. Huang CH, et al. Long-term results of low contact stress mobile-bearing total knee replacements. Clin Orthop Relat Res 2003;(416):265-70. - 320 -
유재두 : 노인무릎관절염수술언제할것인가? 39. Ito J, et al. 15-year follow-up study of total knee arthroplasty in patients with rheumatoid arthritis. J Arthroplasty 2003; 18(8):984-92. 40. Worland RL, et al. Ten to fourteen year survival and functional analysis of the AGC total knee replacement system. Knee 2002;9(2):133-7. 41. Khaw FM, Kirk LM, Gregg PJ. Survival analysis of cemented Press-Fit Condylar total knee arthroplasty. J Arthroplasty 2001;16(2):161-7. 42. Dieppe P, et al. Knee replacement surgery for osteoarthritis: effectiveness, practice variations, indications and possible determinants of utilization. Rheumatology (Oxford) 1999;38(1):73-83. 43. Joshi AB, Markovic L, Gill G. Knee arthroplasty in octogenarians: results at 10 years. J Arthroplasty 2003;18(3):295-8. - 321 -