KNEE 스포츠손상과치료 Sports injury Jin-Goo Kim, M.D. Department of Orthopedic Surgery, Seoul Paik Hospital of Inje University 스포츠손상 스포츠손상 근골격계스포츠손상이란? 스포츠손상을일으키는주요원인 : 1. 신체요인 근골격계에가해진지나친운동부하또는반복되는현미경적외상 ( 근육, 건, 근막, 인대, 점액낭, 연골그리고골어디에나발생 ) - 내적요인 : 근력불균형, 하지의부정정렬, 해부학적요소 - 외적요인 : 잘못된트레이닝방법, 옳지못한기법, 맞지않는장비나나쁜설비 체격상의문제점 근력의불균형 유연성결핍 컨디션난조 스포츠손상 스포츠손상 스포츠손상을일으키는주요원인 : 2. 운동요인 스포츠손상을일으키는주요원인 : 3. 환경요인 손상의주원인 지나친운동 운동기구, 보호장구, 운동장등의시설 조명상태, 기온, 기압, 습도, 풍속등의일기조건 등이적절하지않은경우 외상성손상 준비운동및정리운동부족 1
스포츠손상 인대손상 스포츠손상형태 1) 급성손상 - 골절, 골막 ( 뼈를싸고있는막 ) 손상, 연골손상, 인대손상, 근육손상등외부적요인 : 직접적인타격, 타인이나운동기구내부적요인 : 인대나근육염좌등 인대손상 근육손상 1 도, 2 도 3 도 응급치료 전기치료요법관절운동연부조직마사지 수술봉합 or 재건혹은보호적보조기 근력강화고유체위감각훈련기능적훈련 급성인대염좌의치료 Injury mechanism Injury mechanism Mechanism of anterolateral quadrant injuries. Diagram shows a fall forward with the knee in varus angulation and the tibia in internal rotation. Method of visualizing knee instability. Diagram shows the tibial plateau divided into quadrants 2
Injury mechanism 스포츠손상 A Mechanisms of posterolateral quadrant injuries A : Diagrams show a direct blow with the knee flexed while the tibia is externally rotated. B 1) 급성손상골절, 골막손상, 연골손상, 인대손상, 탈골, 근육이나인대의염좌등급성손상의원인 1) 외부적요인 : 직접적인타격, 타인이나운동기구 2) 내부적요인 : 인대나근육염좌등 B : fall with the knee in hyperextension and the tibia internally rotated 스포츠손상 스포츠손상 2) 과사용손상 피로골절, 골막염, 활액막염, 골기염, 관절주위염, 인대염증, 근육통힘줄손상, 신경및피부손상등 신체조직이회복할수있는능력을넘어선미세손상반복 염증반응 구조적변화 과사용손상유발요인외부적요인잘못된운동방법, 불량운동장, 운동화, 운동기구, 기후, 심리적요인, 불충분한영양등내부적요인정렬이상, 다리길이불균형, 근육불균형, 근력약화, 유연성감소, 과다체중등 정확한치료를위해손상의정도와종류를파악하기위한검사가선행되어야 1] 손상즉시검사실시 2) 시진, 촉진, 이학적검사 ( 신체검사 ) 3) 필요시방사선검사, 초음파, CT, MRI, 근전도검사등실시 스포츠상황에서발생할수있는무릎손상종류 과거력 (History) 병력청취시중요한부분정확한부상의과정, 통증과무력감같은추후증상부상시가해졌던힘의방향 급성손상시 부상기전 부상시통증과장애의정도 종창의시작시점과현재정도 임상의에게호소하는장애의정도 통증의위치 -십자인대손상과관련된통증은주로위치가모호하고경골고평부외측에서증상이느껴진다. 그러나측부인대손상시에는위치가비교적명확하다. 통증의정도 -주로전방십자인대손상은부상후즉시상당한통증이있지만, 일반적으로통증의정도가항상손상의정도와연관되지는않는다. 3
종창발생시간과진단관계 잠김증상 (Locking) 딸깍 하는소리와잠김증상 (locking) 은주로 반월상연골손상과연관. 혈관절증의원인 주인대파열 (major ligament rupture) - 전방십자인대 (ACL) - 후방십자인대 (PCL) 슬개골탈구 (patellar dislocation) 골연골골절 (osteochondral fracture) 반월상연골변연부파열 ( 주로내측 ) Hoffa s 증후군 ( 급성지방체충돌 ) 출혈성소질 ( 드물다 ). ( 유리체및반월상연골파열과관계 ) 무력감 (Giving way) 전방십자인대손상과같은불안정성이있을때나타날수있으며반월상연골파열, 관절연골손상, 슬개대퇴관절통증또는심각한슬관절통증이있을때도나타날수있다. 신체검사 (Examination) A. 관찰 (observation) 1. 서기 2. 걷기 3. 앙와위 B. 능동운동 (active movements) 1. 굴곡 2. 신전 3. 일자로다리들기 (straight leg raise) C. 수동운동 (passive movements) 1. 굴곡 2. 신전 D. 촉진 (palpation) 1. 슬개대퇴관절 ( 슬개골과사두근힘줄을포함하여 ) 2. 내측측부인대 (MCL) 3. 외측측부인대 (LCL) 4. 내측관절선 (medial joint line) \ 5. 외측관절선 (lateral joint line) 6. 복와위 신체검사 (Examination) E. 특수검사 (special tests) 3. 굴곡 / 회전 (McMurray's) 검사 1. 종창의유무 4. 슬개골불안검사 2. 안정성검사 5. 슬개대퇴관절 (a) 내측측부인대 6. 기능검사 (b) 외측측부인대 (a) 쪼그려앉기검사 (squat (q test) (c) 전방십자인대 (b) 뛰기검사 (hop test) (i) Lachman s 검사 (ii) 전방전위검사 (iii) 축이동검사 (d) 후방십자인대 (i) 후방전위 (ii) 역 Lachman's 검사 (iii) 후방전위검사 : (iv) 외회전검사-능동적및수동적 (e) 슬개골 (i) 내측과외측슬개골전위 ( 또는이동성 ) 임상검사 (Investigations) 무릎급성손상시 X-ray 검사의 90% 이상이정상이기때문에임상의는종종 X-ray 검사를시행해야할것인지에대해고민한다. 이에 1990년도중반성인응급의학에서 Ottawa 슬관절법칙이라고알려진방사선검사결정기준이확립되었다 4
자기공명영상촬영 (MRI) - 특히임상적평가만으로진단이불확실한경우진단에도움을줄수있는유용한방법. 초음파검사 (Ultrasound examination) Sports injury of ACL - 고화질의초음파검사는슬개건의부분파열을구별하는데좋은방법. - 완전파열은임상적으로확연함. 또한활액낭종창의크기와위치를알수있으며관절내외의종창여부를알아볼수있음. 관절경 (Arthroscopy) - 관절경은검사와치료모든부분에서사용됨. - 임상적소견이불명확하거나치료후에도환자가회복되지않고지속적인통증을호소할경우진단적관절경시술이시행됨. ACL Injury ACL Injury 과도한전방전위및내회전을방지하여슬관절의안정성을유지. 임상적특징 (Clinical features) 대부분의전방십자인대파열은점프에서착지를하는순간이나회전동작혹은감속운동과같은비접촉상황에서많이일어난다 환자는주로 pop, crack 같은소리를듣거나무엇인가빠졌다가돌아오는느낌을받는다고한다. 대부분의심각한전방십자인대파열은부상후몇분동안통증이심하다. 운동선수는부상초기에는활동을못한다. 가장흔한인대손상이며또다른이차적인손상을유발하여장기적으로슬관절기능을감소시키고손상시동반손상이많으므로수상초기세심한 스포츠활동을다시시작하려고할때불안정성이나무릎상태에대한자신감이떨어지는것을느낄수있다. 이학적검사와관절경하에서철저한조사및치료가필요하다. ACL Injury ACL Injury 상태를검사하기가장좋은때는검사를방해하는심각한혈관절증이나타나기전인부상후한시간이내이다. 전방십자인대파열의검사소견은다음과같다. 운동선수는슬관절운동범위 ( 특히신전제한 ) 에제한이있다. 환자는넓은부위에서가벼운압통이있을수있다. 전방전위시외측관절막이늘어나면서외측관절선압통이종종관찰된다. 다음과같이몇개의요인을고려하여결정한다. 환자의나이 안정성의정도 동반손상 ( 예. 내측측부인대파열, 반월상연골파열 ) 환자가회전운동을하는지에대한여부 내측반월상연골손상이있다면내측관절선압통이관찰될수있다. 치료비용이나시간적여유와같은사회적요인 5
ACL Injury ACL Injury (16 y.o.high school athlete) 전방십자인대손상초기의치료되지않은반월상연골손상의자연경과는 정상적으로보이지만만성으로진행할수록슬관절의지속적인통증, 불안정성을야기하고반월상연골의손상의빈도도증가시킨다. ACL Injury (17 y.o.high school athlete) ACL Injury ACL injury Most common, serious sport injury Female ACL injury 3-9 times more than male Why the gender gap? Neuromuscular in nature Hence, neuromuscular prevention program ACL Injury ACL injury mechanism ACL Injury paradigm shift 75% of ACL injuries are non-contact Treatment & Rehabilitation Injury mechanism & Prevention Activities Surgical & rehabilitative costs ; $35,000 per injury Loss of sports participation Scholarship funding Long-term disability Up to 100 times greater risk of osteoarthritis Landing a jump Deceleration to stop Pivoting or cutting to change directions 6
ACL injury mechanism ACL injury mechanism Mechanism : landing Knee slightly flexed on landing Quad pulls tibia forward Mechanism : Pivot Importance of ground-shoe surface interface in pivot mechanism Shoe surface interface ACL injury mechanism Risk factors Mechanism : Contact Hit on outside of leg Foot planted Twisting of fknee Poor landing + pivot style Stronger quads than hamstrings Female gender Risk factors Risk factors Landing / Pivoting with knee slightly bent Places ACL in vulnerable position Additional torsion/twisting can injury Hamstring/Quadriceps imbalance Poor hamstring strength Hamstrings protect ACL Quads stretch/stress ACL Slow activation of hamstring muscles with pivot / landing 7
Risk factors Risk factors (female gender) Female Gender 2-8x more common in girls Poor ham:quad strength Activate hams more slowly Land with knees slight bent Boys land with knees more bent 1) Knee anatomy Smaller intercondylar notch ACL may get stretched across bone and torn Athletes with bilateral ACL injuries have smaller ICN Risk factors (female gender) Risk factors (female gender) 2) Hormonal Influences 3) Biomechanical ACL has estrogen receptors Estrogen ligament looseness Estrogen levels in girls compared to boys Estrogen d at specific times in menstrual cycle Studies VERY inconsistent Every phase of cycle has been implicated in at least 1 study Risk factors (female gender) 3) Biomechanical 3) Biomechanical Position of Vulnerability Safety Position Lower extremity alignment Women more knock-kneed May allow quad to exert more stress on ACL Data not great 8
Gastrocnem ius Risk factors (female gender) Risk factors (female gender) Time to Peak Torque Hamstrings Females have a longer electromechanical delay then males Males hamstring muscles fire faster Male athletes: Hamstrings Quadriceps Gastrocnemus Female athletes: Quadriceps Hamstrings Gastrocnemius Recruitment Order Male athletes vs male non-athletes 328-443 msec Female athletes vs male non- athletes 430-443 msec (Huston & Wojlys AJSM 1996) Huston & WojlysAJSM 1996 Risk factors (female gender) Muscle Strength 전방십자인대손상예방 (Prevention of ACL injury) 전방십자인대손상예방 구기스포츠에서두가지주요기전에의해전방십자인대가파열된다. 1. 끼어드는운동 (a cutting maneuver) 2. 한발착지 (one leg landing) 전형적인전방십자인대손상은운동선수가땅에밀착된 Female athletes = female controls Huston & WojlysAJSM 1996 Quad/hamstring ratio 47% in females Quad/hamstring ratio 67% in males 발을띄고급작스러운방향전환을위해내회전할때무릎이 10~30도의굴곡및외반상태에있으면서외회전이일어날때발생한다 전방십자인대손상예방 전방십자인대손상예방 왜여성의전방십자인대파열의발생율이남성의경우보다 3배가높은가? 1. 해부학적 더작은크기와다른형태의대퇴과간절흔 (intercondylar notch) 더넓은골반과더큰 Q 각도 (Q angle) 더큰인대이완성 (greater ligament laxity) 끼어드는동작이나점프에서의착지활동과같이간단한움직임에서신경근의형태를더안전하게반응할수있도록훈련. 2. 호르몬적 에스트로겐은여성에서더높은전방십자인대손상의요인으로알려져왔다. 에스트로겐수용기는전방십자인대에서발견되었고최근에는릴랙신수용기 (relaxin receptors) 가여성의전방십자인대에서만발견되었다. 생리주기와전방십자인대손상의관계에대해서는여러가지상반된결과들이있다. 9
전방십자인대손상예방 전방십자인대손상예방 3. 신발표면접촉면 왜여성의전방십자인대파열의발생율이 남성의경우보다 3 배가높은가? 전방십자인대손상예방프로그램 (Prevention program) 1. 균형운동 2. 슬관절과고관절의굴곡을증가시키며착지 3. 신체움직임, 특히감속과회전운동조절 4. 연습중피드백 평평하지않은경기장 비, 잔디의상태가신발의표면접촉면을변화시킴. 4. 신경근요인 (Neuromuscular factors) 사두근수축은 10~30도사이의굴곡에서전방십자인대의변형율을증가시킨다. 신장성사두근 (eccentric quadriceps) 수축은전방십자인대를파열시킬수있다 My Preference of ACL-R Case Single semitendinosus graft Transtibial method Anatomic femoral tunnel Double Fixation Accelerated Rehabilitation 20/ 남, 축구선수 축구도중 pivot-injury 진단명 : 전방십자인대파열 후방십자인대 후방십자인대는일차적으로후방전위를방지하고, 이차적으로외회전을방지한다. Sports injury of PCL 후방십자인대를절단하였을때는경골의후방전위가증가한다. 전위정도는완전신전위에서비교적작고 90도굴골위에서가장크다. 후방인대단독손상시회전이나외반 / 내반불안정성은경미하다. 10
후외측구조물손상 후방십자인대손상 60% 정도에서후외측구조의손상을동반한다. 후외측구조물의일차안정화구조는외측측부인대 (lateral collateral ligament) 와슬와복합체 (popliteal complex) 이다. 후방십자인대와후외측구조가모두절단되었을때 임상적특징 (Clinical features) 후방십자인대손상의기전은주로슬관절굴곡위에서경골부의직접타격에의해일어난다. 과신전역시후방십자인대및후방관절막의손상을초래한다. 후방불안정성은상당한정도로증가한다. 1도손상 : 경골은여전히대퇴내과앞쪽에위치하지만약간의후방전위를보인다 2도손상 : 경골은대퇴내과와같은위치에있다. 3도손상 : 더이상내측스텝 (medial step) 을가지고있지않거나대퇴내과보다경골이더후방에위치해있다. PCL Injury PCL Injury Injury mechanism Less frequent injury : 5-10% Lack of science 10 years behind ACL Unknown natural history Still evolving entity Constant posterior force on the proximal tibia Motor vehicle accident (50%) : dashboard injury Sports injury (40%) Fall to the ground with the knee flexed and the foot plantarflexed PCL Injury PCL Injury Injury mechanism Hyperextension and valgus or varus stress combined with leg rotation Natural history of PCL-injured knee ACL posterior capsule PCL (30 hyperextension) Popliteal artery (50 hyperextension) - Multi-ligament injury Controversial o Grade 1 and 2 injuries - good Px. Grade 3 injuries - late chondrosis PCL & PLC injuries - poor Px. 11
2 Pathomechanics: PCL Deficiency Tibiofemoral contact shifts anteriorly Posterior horn medial menisci unloaded Increase wear of articular cartilage Technique of PCL reconstruction Single Bundle PCL Reconstruction with Transtibial Technique 1 3 Force in the PLC Posterior tibial translation Seoul Paik Hospital Technique of PCL reconstruction 21/ 남, 축구선수 3주전골키퍼와부딪힘. 진단명 : 후방십자인대파열 후방전위 : 11mm Sports injury of MCL,LCL MCL Injury MCL Injury 내측측부인대단독손상은보전적치료를요구하지만십자인대반월상연골 손상이동반되면기능장애가크기때문에수술적치료를해야한다. 1도손상대퇴내과나내측경골고평부의내측측부인대위로부분적압통을보이지만부종은잘나타나지않는다. 30도슬관절굴곡위에서외반력을주었을때통증은있으나인대이완소견은없다. 2도손상보다심한외반력에의해생긴다. 뚜렷한압통이있고종종부분적으로부종이보인다. 인대는손상되었지만인대의길이는유지된다. 3도손상인대섬유의심한파열을야기할정도로의심한외반력에의해생긴다. 12
LCL Injury Meniscus Injury 외측측부인대파열은내측측부인대파열보 Sports injury of Meniscus 다빈도가낮다. 이는높은에너지의직접적내반력이무릎에가해졌을때일어나고내측측부인대와비슷한기준으로손상의정도를측정한다. 반월상연골기능 반월상연골기능 Circumferential hoop tension Helps to distribute the load across the tibia MM: transmit 50% of joint load in MC LM : transmit 70% of joint load in LC Circumferential hoop tension 50% of joint load in extension 85 90% in flexion Removal of 16-34% of the meniscus : 350% increase in contact stress 반월상연골손상 반월상연골손상 손상기전 손상기전 - 무릎이굴곡또는신전한상태로내회전또는외회전이동반되어체중지지시에발생한다. -내측반월상연골판손상의대다수는커팅동작이나점프후착지동작같이발은지면에고정되었을때대퇴골의강한굴곡과내회전이동반되었을때일어난다. - 이런동작시내측반월상연골판은대퇴골상과사이에찍히거나부딪히게된다. - 내측또는외측측부인대를손상시킬 충분한외반또는내반력은전방십자인대및반월상연골판의동반손상도유발시킬 -반월상연골판병변은세로, 대각선, 가로로일어난다. 반월상연골판의앞이나뒤쪽각이스트레칭되면양동이손잡이모양의찢어짐을유발한다. 수있다. 13
1. Bucket handle tear 2. Vertical Longitudinal tear En bloc ( > piecemeal ) Step 15 23 4 : reduction inspection dividing partially removal the of transsect and of fragment anterior peripheral fixation the attachment posterior of rim, the fragment attachment contouring and balancing Anterior horn en bloc > piecemeal Middle and posterior horn piecemeal > en bloc Greater than 3 to 4mm in depth Radial tears in the midportion of the meniscus basket or duck-billed forceps 3. Radial tear 4. Oblique tear Usually require resection that tear extends into the avascular zone of the meniscus Oblique tears extend deeply into the vascular zone require a combination of partial resection and repair Commonly displace, if large, underneath the normal meniscus, sometimes missed from the contralateral portal 5. Horizontal tear Does it make the symptom and should I resect it or leave it? Usual cleavage plane is fairly central, leaving two distinct leaves of tissue Often the superior and inferior i surface of the meniscus are relatively well preserved 6. Complex and Degenerative tear Most often seen in older individuals, also be seen in young individuals after significant traumatic events In the younger age groups, consideration of salvage of complex tears should be made(meniscus tissue is often of good quality) - combined partial meniscectomy and repair 14
Types of Meniscal Excision (meniscectomy) 반월상연골봉합술적응증 Partial Total meniscectomy ( ( C A )) Subtotal leave a meniscectomy stable and intact ( B ) remove all meniscus peripheral partial rim, excision at least 2-3 of peripheral mm rim, no longer hoop stress Vertical longitudinal tears in the peripheral 3mm 1cm, unstable Around tissue : normal condition Vascular zone (red zone) 40 yr, active 10-15% tear Acute, traumatic Radial, root tear in middle age 반월상연골봉합술종류 Inside-to-outside suture Inside to outside Zone specific cannular system Henning system Outside to inside Lanny johnson technique Landsiedl technique All inside Out-side in repair 반월연골판이식술 (Meniscus allograft transplantation) MAT: 소실된반월연골판의기능을회복시켜관절연골의퇴행성변화를 지연시키기위한목적으로고안된치료방법 1989 년 Milachowski 와 Wirth 처음시도함. 현재는성공률이 85% 이상으로알려짐. 아직관절연골보호효과는모르는상태임. 15
반월연골판이식술적응증 Surgical Techniques of MMAT MM transplantation - Technically demanding - Difficult to prepare the anatomic location of post. horn - Difficult to pass the graft into the joint Surgical Techniques of LMAT MAT Case Bridge-in-Slot Technique 28/ 여, 축구선수 외측원판형연골파열 6개월전외측반월상연골아전절제술시행받음. MM root tear MM root repair technique 16
MM root repair technique Complete radial tear Preparation of fibrin clot Complete radial tear Complete radial tear Repair with fibrin clot Additional procedures to promote healing Engaging 2 nd suture Fibrin 1 st to clot horizontal hold to Final the fibrin radial suture clot tear Multiple Trephination Medullary stimulation 17