Symposium J Korean Orthop ssoc 2019; 54: 100-109 https://doi.org/10.4055/jkoa.2019.54.2.100 www.jkoa.org Revision after Shoulder Surgery 100 견관절인공관절재치환술의원인과치료 김영규 정규학 가천대학교의과대학가천대길병원정형외과 pissn : 1226-2102, eissn : 2005-8918 Etiology and Treatment of Revision Shoulder rthroplasty Young-Kyu Kim, M.D., Ph.D. and Kyu-Hak Jung, M.D. Department of Orthopaedic Surgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea The rapidly increasing rate of shoulder arthroplasty is certain to increase the number of revision arthroplasties because of parallel increases in complication numbers. It has been widely reported that the causes of revision shoulder arthroplasty include rotator cuff deficiency, instability, glenoid or humeral component loosening, implant failure, periprosthetic fracture, and infection. Revision arthroplasty can be technically challenging, and surgical options available for failed shoulder arthroplasty are limited, especially in patients with glenoid bone loss or an irreparable rotator cuff tear. Furthermore, the outcomes of revision arthroplasty are consistently inferior to those of primary arthroplasty. ccordingly, surgical decision making requires a good understanding of the etiology of failure. Here, we provide a review of indications of revision arthroplasty and of the surgical techniques used by failure etiology. Key words: total shoulder replacement, revision surgery, complication, treatment failure, risk factors 서론 견관절의회전근개질환이나퇴행성질환이최근빠른속도로 증가함에따라견관절인공관절성형술이점차적으로증가하고 있으며이에따른합병증으로인해재치환술이요구되는경우도 종종발생하게된다. 일부학자들에의해견관절인공관절성형 술후 5 년생존율은 92%, 10 년생존율은 88% 로보고되고있다. 1) 일차적인공관절성형술후재치환술은여러원인에의해발생 하게되며폴리에틸렌마모, 치환물의재질이나해부학적디자인 의문제, 치환술의크기와위치선택의잘못, 연부조직의손상이 나결손, 경험부족에의한기술적문제등그원인이다양하고동 일하지않아이에따른치료방침을정하는데어려움이많다. 따 Received September 3, 2018 Revised November 30, 2018 ccepted December 3, 2018 Correspondence to: Young-Kyu Kim, M.D., Ph.D. Department of Orthopaedic Surgery, Gachon University Gil Medical Center, 21 Namdong-daero 774beon-gil, Namdong-gu, Incheon 21565, Korea TEL: +82-32-460-3384 FX: +82-32-423-3384 E-mail: kykhyr@gilhospital.com ORCID: https://orcid.org/0000-0001-5672-505x 라서재치환술시행시복합적요인을고려하여이를결정하여야한다. 일차적인공관절성형술의실패는임상적증상보다방사선적변화가먼저나타나는경우가흔하며성형술의실패의원인에따라서도증상이나방사선소견이다양하여재치환술여부나시기를결정하기위해서는통증, 기능소실, 명백한병리소견이있어야한다. 2,3) 따라서본논문은실패한견관절인공관절성형술후재치환술의적응증및각각의원인에따른술기에대해논의하고자한다. 적응증및금기증 1. 적응증일차견관절인공관절성형술후실패의주된원인은크게연부조직결손, 골조직결손, 치환물마모, 감염으로분류할수있다. 1,4) 이중상완골반관절성형술후재치환술의흔한원인은관절와마모에따른관절염으로관절와파괴가진행되어불량한결과를보일경우전치환으로의전환이통증을완화시키는최선의방법이다 (Fig. 1). 5) 또한골절치료로상완골반관절성형술을시행시 The Journal of the Korean Orthopaedic ssociation Volume 54 Number 2 2019 Copyright 2019 by The Korean Orthopaedic ssociation This is an Open ccess article distributed under the terms of the Creative Commons ttribution 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.
101 Etiology and Treatment of Revision Shoulder rthroplasty Figure 1. () ipolar humeral hemiarthroplasty complicated by superior migration of humeral head and erosion of superior glenoid due to cuff deficiency. () Revision to reverse arthroplasty. Figure 2. () Loose glenoid component (arrow) after anatomical total shoulder arthroplasty. () Loosening and substantial subsidence of the humeral component (arrow) and loosening of the glenoid component. Figure 3. nterior instability after anatomical total shoulder arthroplasty. nterior subluxation (arrow) visible on lateral axillary view is typically a sign of subscapularis rupture. ny signs of loosening of glenoid are not observed. 결절부불유합, 부정유합, 골흡수가실패의흔한원인이다. 견관절인공관절성형술후재치환술의가장흔한원인은치환물의해리이며관절와치환물이상완골두치환물보다더흔히발생한다 (Fig. 2). 6) 관절와치환물의재치환술의적응증은동통성해리, 비정상위치, 불안정성을야기시키는치환물의마모등이있다. 반면에상완골치환물의해리는상완골치환물주변에방사선적변화가많이발생함에도불구하고상완골치환물의해리 가재수술의원인이되는경우는흔치않다. 7,8) 견관절인공관절성형술후초기재치환술및상완골반관절성형술후재치환의가장흔한원인으로는불안정성이있다 (Fig. 3). 불안정성이존재하면관절강직, 회전근개파열, 관절와해리, 상완골해리, 그리고폴리에틸렌마모등으로인한광범위골흡수등이발생하여재치환술이필요할수밖에없으며, 상완골두전방탈구, 견갑하건의파열, 관절와해리는전치환후발생할수
102 Young-Kyu Kim and Kyu-Hak Jung 있는심각한삼징후로여겨진다. 회전근개파열관절병증으로인해반관절성형술을시행한경우상부불안정성이발생할수있으며이러한경우종종나타나는동통과운동제한은심한일상생활의장해를초래할수있다. 징후가심한경우재수술적치료로역행성치환술로의전환을고려하여야한다. 재치환술의다른적응증으로는치환물의부정위치, 치환물주위골절, 감염등이있다. 특히치환술후감염은재치환술을고려하게하는가장심각한합병증중하나로여겨진다. 9) 2. 상대적금기증봉합이불가능한회전근개광범위파열이있는경우인공관절성형술로의재치환은금기시되고있다. 회전근개파열로인해상완골두치환물을관절와중심에유지하기어려워흔들목마현상이발생하고관절와해리를유발하게된다. 만일인공관절성형술후관절와해리가발생된경우에는상완골반성형술을고려할수있으나관절와골이충분하거나관절와구면에서관절와치환물의기저판이고정될수있다면역행성치환술로전환할수있다. 10) 관절와골결손이심한경우에는관절와표면치환 (resurfacing) C D Figure 4. () Painful loosening of the glenoid component (arrow) without cuff deficiency. () Moderate bone loss in the glenoid cavity after removal of polyethylene-glenoid. (C) Glenoid cancellous bone grafting with an iliac crest. (D) cemented polyethyleneglenoid is reimplanted with bone graft. C D Figure 5. () Loose glenoid component (arrow) with rotator cuff deficiency and loose humeral component after anatomical total shoulder arthroplasty. (, C) Cancellous and cortical bone grafts in the glenoid cavity for large bone defect after removal of polyethylene-glenoid and humeral component. (D) Revision to a reverse shoulder replacement.
103 Etiology and Treatment of Revision Shoulder rthroplasty 이금기증이다. 관절와골결손에대해골이식을시행한후상완골반관절성형술이나전치환성형술을시행하여야한다. 11,12) 연부조직의결손이심한경우에도인공관절성형술로의전환은어렵다. 재치환과동시에근이전술이나근-건보강술을시행하거나역행성치환술로의전환을고려하여야한다. 13,14) 감염발생시 6주이내에발생한급성의경우는치환물을남겨둔채세척및변연절제만으로감염이조절될수있으나 6주이상경과된만성감염의경우는치환물제거후지연성치환술이고려되어야한다. 9,13,15) 수술전계획 단순방사선사진과전산화단층촬영을통해치환물의해리나침강정도, 관절와치환물의경사나상완골치환물의후경사를확인하고관절와골소실의위치나정도, 견갑골의깊이를파악한다. 양측상완골의단층촬영을통해상완골치환물의높이와침강정도를측정한다. 관절와나상완골골소실의정도에따라골이식을시행하여야하므로자가해면골이나피질-해면골공여부를준비하여야한다. 근전도와신경전도검사는재치환술전에근육및신경의상태를파악하고예후를판정하는데도움이될수있다. 재치환술을시행시재치환할치환물의선택은매우중요하다. 해부학적인공관절성형술후관절와치환물의이완이있으나회전근개가온전한경우에는관절와에골이식과함께치환물을교체하면된다 (Fig. 4). 회전근개파열이있어상완골두치환물이회전중심축을유지하지못할경우에는역행성치환술로전환하 여야한다 (Fig. 5). 16,17) 역행성인공관절치환술후관절와치환물의이완이있으나관절와골결손이골이식으로재건될수있다면새로운관절와기저판으로교체하면되나관절와골결손이심하여관절와재건이어려운경우에는상완골두반치환물로교체하여야한다. 16,18) 술기 1. 외과적접근환자를 30도각도로해변의자자세를유지하고환측의팔을자유롭게움직일수있도록지지대를설치한다. 피부절개는삼각대흉근간도달법을이용한다. 인공관절성형술이실패한대부분의경우삼각대흉근간격이유착되어있으므로오구돌기첨부를촉지하여조심스럽게박리를시행한다 (Fig. 6). 관절강직및연부조직유착이심하므로견봉하와삼각근하공간을유착된반흔조직으로부터유리한후연합건을찾아박리하여내측으로견인하여공간을확보한다. 오구견봉인대는상완골치환물의전상방전위를막아주기때문에최소한의절개만시행한다. 견갑하건을결절부로부터절개하여박리하고하관절막을상완골으로부터유리한다. 이때액와신경을촉지하여신경손상에주의하여야한다. 상완골치환물을관절와로부터탈구시켜신전하면서관절내유착된반흔조직을유리하고상완골을충분히노출시킨다. 2. 상완골재치환상완골치환물은제거를용이하게하기위해유연하면서도단단한절골기를사용하거나초음파시멘트제거시스템등을이용하 C D Figure 6. () Fibrotic scar tissue is removed through the deltopectoral approach from the first approach. () Exposure of primary prosthesis after release of the subscapularis tendon from the lesser tuberosity. (C) Easy extraction of the humeral stem or cement removal and polyethylene-glenoid due to loose humeral stem. (D) Sufficient exposure of glenoid using retractors.
104 Young-Kyu Kim and Kyu-Hak Jung 여근위고정을해리시킨후타격쇠망치가부착된기구로상완골치완물의스템을잡고치환물을적출한다. 상완골치환물이원위부에서고정이견고하다면치환물을적출하기위해쇠망치로무리하게상완골치환물을가격하면상완골간부에분쇄골절이발생할수있다. 이경우에는측면절개연마기 (side cutting saw) 를이용하여상완골간부의이두구바로외측부에선상으로절골을하거나창문형식으로절골을시행한후 Midas Rex와같은고속연마기를이용하여골시멘트를제거하면치환물을적출하기용이해진다 (Fig. 7). 19) 상완골재치환시긴상완골치환물을사용하여치환물하단이절골부를상완골직경의 2-3배정도의길이로충분히지나가도록삽입하고환상강선케이블로절골피질골을고정한다. 상완골재치환시상완골근위부에해면골결손이있을경우자가또는동종해면골이식을시행하고, 상완골근위부에골결손이심한경우는맞춤형치환물을사용하거나피질동종이식지지골 (cortical allograft strut) 로보강한후상완골재치환을시행하면된다. 10) 3. 관절와재치환관절와치환물은해리나폴리에틸렌마모가있으면치환물을제거하여야한다. 관절와골소실이적은경우에는골편이식후관절와재치환을시행하면된다. 관절와에중심부골결손이경도나중등도의경우는자가또는동종해면골이식술을시행후관절와재치환을시행하고, 변연부골결손의경우에는피질-해면 골을이용한국소적골이식편을남아있는관절와면에피질골나사못으로고정한후관절와재치환을시행한다. 11) 중심부와변연부골결손이복합된관절와골결손의경우는피질-해면골로관절와강을충분히충전한후역행성인공관절관절와기저판으로압박하여고정한다 (Fig. 8). 20) 그러나해리가진행되어골용해가심해져관절와천장이소실된경우에는재치환술은상당히어렵다. 만일관절와골이충분하지않다면형성된섬유조직과시멘트를철저히제거하고자가또는동종이식골편을관절와강에단단히채워넣고관절와재치환은시행하지않는다. 21) 흔하지는않으나상완골두만재치환한후통증이지속되는경우에는 6-12개월후에새로운관절와치환물로관절와를재표면화할수있다. 4. 연부조직결손치료인공관절성형술후흔한합병증중하나인회전근개파열은연부조직불균형을가져와치환물의불안정성을야기할수있다. 전방불안정성은대개견갑하건파열로발생하며이는치료가어렵다. 따라서파열의조기인식을통한봉합이치료의중요한열쇠이다. 봉합이어려울시대흉근이전술이나동종건을이용한재건술이요한다. 그러나이러한술식은대개좋은결과를보이지않는다. 22) 상부회전근개대범위파열은상완골두의상방전위를야기시킨다. 회전근개봉합이시도되기는하나술기상어려움이있으며삼각근의손상을줄수있다. 후방회전근개파열은대개상 C Figure 7. () If a cemented implant without any lucency or an uncemented implant with a long ingrowth surface has been placed, tensile forces imparted on the humerus during implant extraction may result in humeral fracture in areas of cortical thinning. () Osteotomy (arrow) or cortical window should be used in order to gain access to cement. (C) high-speed burr and flexible osteotomes are used to disrupt implant fixation. Prosthesis can be malleted out with the use of long bone clamp placed underneath the implant collar.
105 Etiology and Treatment of Revision Shoulder rthroplasty C D E Figure 8. () central deficit (arrow) in the glenoid surface is grafted with cancellous bone graft from iliac crest. () If asymmetric defect of the peripheral aspect of the glenoid is existed, subchondral graft fixed with 2 screws (arrow) can be used for recontoured glenoid surface. (C) Then, anatomical total shoulder arthroplasty is reimplanted. (D) If bone deficit complicated in central and peripheral aspect is existed, glenoid cavity is filled with corticalcancellous bone grafts (arrow). (E) Then, baseplate of reverse prosthesis is firmly reimplanted to stabilize the bone graft and increase the potential of healing bone. C D Figure 9. () periprosthetic fracture at the tip of a humeral component. () plating and wiring for fixation. (C) periprosthetic fracture at the distal portion of a humeral component. (D) Fixation using plate and screw with fibular strut allo-graft. 방회전근개파열이진행되면서발생하며봉합술을시행시견갑하건봉합술보다는성공률이높다. 22) 봉합이불가능할경우에는광배근이나대원형근의이전술이도움을줄수있다. 그러나인공관절성형술후전, 후방불안정성이지속되고교정이어려운경우에는역행성인공관절로의재치환을고려하여야한다. 16,23) 5. 치환물주위골절치환물주위골절은수술도중발생할수있으며특히상완골골 수강을확공하는과정이나상완골치환물을과도하게삽입하는과정에서발생할수있고관절와치환물삽입을위한견인도중상완골에과도한염전력으로골절이발생할수있다. 24) 수술도중발생한골절은긴스템치환물로교체한후철선이나케이블로고정하거나상완골치환물에중복하여금속판으로고정하여골절부에안정성을제공한다. 수술후골절이발생한경우는골절부가치환물의하단끝에서근위부에위치해있으면비수술적치료로도골유합을얻을수있
106 Young-Kyu Kim and Kyu-Hak Jung 으나안정성이없으면추가적인고정이필요하다. 치환물의끝이나하방에서의골절은금속판내고정을시행하여야하나금속판고정을위해강선케이블만을사용시골절부가견인되어불유합의가능성이높아반드시나사못고정이요하며필요시동종이식지지골로보강이요한다 (Fig. 9). 골절의발생과함께치환물이해리되어있으면긴스템의치환물을이용한재치환술이필요하며골결손이동반된경우는동종이식지지골로고정을강화해주어야한다 (Fig. 10). 24,25) 6. 감염견관절은주변연부조직에둘러싸여있어급성감염의경우감염여부를확인하는데어려운점이있다. 일반적으로감염을의심하는징후로는견관절통증으로동반한전신증상과관절내에화농이있는경우, 또는적혈구침강속도 30 mmhg/h 이상, C-반응성단백 (C-reactive protein) 10 mg/l 이상, 술전관절천자에서세균이배양된경우, 동결절편에서고배율소견다형핵백혈구가 5 개이상인경우, 술중세균배양검사에서세균이배양된경우이다. 견관절인공관절성형술후감염의흔한균주로 Staphylococcus C D Figure 10. () periprosthetic fracture at the tip of a humeral component and implant loosening (arrow) after reverse arthroplasty. () Comminuted fracture of humeral meta-diaphysis occurred during the extraction of humeral component. (C, D) Revision to a reverse shoulder replacement with a long-stem component to bypass the fracture and strut allo-graft. C D Figure 11. () Late infection after rotator cuff repair. () Septic joint and osteomyelitis of the humeral head and the glenoid. (C) Insertion of PROSTLC after resection of the humeral head and debridement. (D) Conversion to anatomical total shoulder arthroplasty.
107 Etiology and Treatment of Revision Shoulder rthroplasty aureus, S epidermidis가알려져있으나최근균배양에천천히배양되는 Cutebacterium acnes가가장흔한원인균으로알려지면서미생물검사를위해 3-5군데에서배양액을채취하여최소 10일이상배양을해야한다. 26) 특히 C. acnes는일반적인감염징후가잘나타나지않으며통증을주증상으로하고있어수술후지속적인어깨통증시감염을의심해보아야한다. 27) 급성감염의치료로조기에세척및변연절제를시행하고, 역행성인공관절성형술의경우에는추가로폴리에틸렌라이너를교체한후정맥내항생제를투여한다. 만성의경우는보통치환물을제거하고항생제가혼합된골시멘트 (PROSTLC) 를이용하여공간을확보하고최소 6주이상정맥내항생제투여후지연성재치환술을시행한다 (Fig. 11). 25,28) 지연성치환을위해수술중시행한체액과조직표본채취에서감염징후로고배율소견삼다핵백혈구가 5개이상인경우에는이차변연절제후시멘트재삽입을시행한다. 시멘트에사용할수있는항생제는 gentamycin, tobramycin, cefoxitin, vancomycin 등이있다. 예후 견관절재치환술후중장기결과의문헌상보고는많지않으나비교적만족스러운결과가보고되고있다. 11,12) 그러나재치환술의결과및예후는일차적진단및재치환을하게되는원인에따라많은차이를보이며높은합병증도보고되고있다. 29-31) 상완골근위부골절의치료로시행한상완골반관절성형술의실패로인한재치환은다른원인에의해시행된상완골반관절성형술의재치환보다결과가불량하다. 그리고인공관절성형술후골결손으로인해재치환을하는경우가연부조직결손으로인한재치환술보다결과가훨씬양호한것으로알려져있다. 관절와재치환술의예후는관절와에남아있는골의양과질이중요한요소이다. 관절와해리는골용해와조기해리가있어도골이광범위하게파괴되기전까지는증세가뚜렷하지않아관절와치환을위한적절한골이존재하지않는경우가흔히발생한다. 이러한경우새로운관절와치환물을골이식과함께재삽입한경우가관절와절제후골이식만을시행한경우나역행성인공관절성형술을시행한경우보다더좋은결과를보였다고보고되고있다. 11,32) 반면에관절와절제술만을시행한경우가동통완화에더만족스러운결과를보였거나관절와재치환을시행한경우와특별한차이가없었다고보고하는학자들도있어두술식간의결과비교에는추후더많은연구가필요해보인다. 1,13) 상완골치환물의해리는관절와치환물의해리보다흔하지않다. 특히재치환에이르게하는증상이동반된치환물해리는흔치않다. 상완골재치환술은비교적좋은결과가보고되고있으며 10년생존율도 89% 에이른다. 15,33) 최근실패한인공관절성형술후재치환으로역행성인공관절 성형술이증가하고있으며결과도 64%-83% 까지만족스럽게보고되고있어실패한인공관절성형술을해결할수있는유용한방법으로알려져있다. 16) 그러나수술후불안정성, 관절와치환물의이완, 치환물주위골절, 감염등의합병증이있어주의깊은선택이요한다. 16,34) 요약 재치환술의결과는재치환의원인에의존되는경우가많으므로인공관절성형술의실패원인을정확히판단하는것이중요하며골및연부조직상태를정확히파악하여야한다. 그리고수술이어려울수있는관절와재치환술이나자가골이식후상완골인공관절성형술도비교적좋은결과를보이므로동통이지속되는관절와해리는적극적인재수술로문제를해결하려는노력이필요하다. 반면인공관절성형술후불안정성이나회전근개결손이발생한경우는치료도어려울뿐만아니라예후도불량하므로연부조직재건이나역행성인공관절치환술이요할것으로생각된다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Cofield RH, Edgerton C. Total shoulder arthroplasty: complications and revision surgery. Instr Course Lect. 1990;39:449-62. 2. itzer, Rojas J, Patten IS, Joseph J, McFarland EG. Incidence and risk factors for aseptic baseplate loosening of reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2018;27:2145-52. 3. oileau P, Melis, Duperron D, Moineau G, Rumian P, Han Y. Revision surgery of reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2013;22:1359-70. 4. Wirth M, Rockwood C Jr. Complications of total shoulder-replacement arthroplasty. J one Joint Surg m. 1996;78:603-16. 5. Levine WN, Djurasovic M, Glasson JM, Pollock RG, Flatow EL, igliani LU. Hemiarthroplasty for glenohumeral osteoarthritis: results correlated to degree of glenoid wear. J Shoulder Elbow Surg. 1997;6:449-54. 6. Rodosky MW, Weinstein DM, Pollock RG, Flatow EL, igliani LU, Neer CS 2nd. On the rarity of glenoid component failure. J Shoulder Elbow Surg. 1995;4 Suppl 1:S13-4.
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109 pissn : 1226-2102, eissn : 2005-8918 Symposium J Korean Orthop ssoc 2019; 54: 100-109 https://doi.org/10.4055/jkoa.2019.54.2.100 www.jkoa.org 견관절수술후재수술 견관절인공관절재치환술의원인과치료 김영규 정규학 가천대학교의과대학가천대길병원정형외과 견관절인공관절성형술의빈도가빠른속도로증가함에따라일차적인공관절성형술과관련된다양한형태의합병증이발생하고, 이로인해재치환술역시증가하고있는추세이다. 견관절인공관절재치환술은여러원인에의해발생되는것으로알려져있는데일차적인공관절성형술후나타난회전근개파열, 관절와상완관절의불안정성, 관절와또는상완골치완물의해리, 인공치환물의실패, 치환물주위골절, 감염등이있다. 재치환술은술기적으로어려운과제이다. 실패한견관절인공관절성형술은해결할수있는외과적선택이많지않다. 특히관절와골결손또는봉합불가능한회전근개파열이있는경우에는더욱어렵다. 또한재치환술의결과는일차적성형술의결과에비해항상좋지않다. 결국외과의는수술을결정하기전에일차적인공관절성형술이실패한원인을잘파악하여야한다. 따라서본논문에서는실패한일차적인공관절성형술후재치환술의적응증에대해살펴보고실패의원인에따른재치환술의술기에대해논의하고자한다. 색인단어 : 견관절인공관절성형술, 재치환술, 합병증, 성형술의실패, 위험요인 접수일 2018 년 9 월 3 일수정일 2018 년 11 월 30 일게재확정일 2018 년 12 월 3 일책임저자김영규 21565, 인천시남동구남동대로 774 번길 21, 가천대길병원정형외과 TEL 032-460-3384, FX 032-423-3384, E-mail kykhyr@gilhospital.com, ORCID https://orcid.org/0000-0001-5672-505x 대한정형외과학회지 : 제 54 권제 2 호 2019 Copyright 2019 by The Korean Orthopaedic ssociation This is an Open ccess article distributed under the terms of the Creative Commons ttribution 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.