Original Article J Korean Knee Soc, Vol. 22, No. 3, September 2010 Clinical Relevance of the Femoral Intercondylar Notch Width and the Posterior Tibial Slope for ACL Rupture Seung Suk Seo, M.D., Chang Wan Kim, M.D., Kyung Whan Kim, M.D. 1 and Young Kyoung Min, M.D. Department of Orthopedic Surgery, Busan Paik Hospital, Inje University College of Medicine, 1 Saha Central U Hospital, Busan, Korea Purpose: The purpose of this study was to evaluate the relationship between the femoral intercondylar notch width (ICW), the posterior tibial slope angle (PTS), rupture of the anterior cruciate ligament (ACL) and the ruptured site. Materials and Methods: We retrospectively reviewed 105 cases of ruptured ACL (105 patients), and 91 cases of intact ACL (91 patients). The ICW and PTS were measured from the plain knee radiographs. The ratio of the ICW and the femoral intercondylar notch height (ICH) was also measured. As for the site of ACL rupture, the patients with a ruptured ACL were divided into 3 groups (group 1: femoral attach site, 2: mid-substance, 3: tibial attach site), and the correlations between the ICW and the PTS of each group were analyzed. Results: The mean ICW of the ACL ruptured group was 15.51±4.30 mm (95% confidence interval: 15.48 15.53), that of the ACL intact group was 24.49±3.86 mm (24.47 24.52), and the mean PTS of the ruptured ACL group was 7.68±3.78 o (7.65 7.70) and that of the intact ACL group was 6.12±3.85 o (6.10 6.13). A narrow ICW was a significant risk factors for ACL rupture (odds ratio=0.661 [0.602 0.720], p<0.01). But we did not get any statistically significant results for the increase PTS (odds ratio=1.073 [1.062 1.134], p=0.197). According to the ruptured site, the analysis of variance of the ICW and PTS had no significant correlation. Conclusion: A narrow ICW is a significant risk factor for ACL rupture. Key Words: Rupture of anterior cruciate ligament, Femoral intercondylar notch width, Posterior tibial slope angle 서 론 Received: June 29, 2010 Revised: (1st) July 11, 2010, (2nd) August 4, 2010 Accepted: August 9, 2010 Corresponding author: Chang Wan Kim, M.D. Department of Orthopedic Surgery, Busan Paik Hospital, Inje University College of Medicine, Gaegeum 2-dong, Busanjin-gu, Busan 633-165, Korea TEL: 82-51-890-6129, FAX: 82-51-892-6619 E-mail: kcw8737@gmail.com 무릎의해부학적인접근을통해전방십자인대파열의원인을밝히기위한연구는많이진행되어왔다. 무릎을구성하고있는여러구조물중 LaPrade 와 Burnett 15) 은대퇴과간절흔폭과전방십자인대파열과의상관관계에대해연구하였으며, 좁은대퇴과간절흔폭과전방십자인대파열사이에연관관계가있다고주장하였다. 또다른원인으로후방경골경사각의정도가전방십자인대에미치는정도에대한연구가활발히이루어지고는있으며, 후방경골경사각이슬관절의운동및대퇴경골안정성에미치는 208
서승석외 : 전방십자인대파열에있어대퇴과간절흔폭과후방경골경사각의임상적의의 209 영향에대해서는많은연구를통해밝혀졌다 7,11). Ahn 등 2) 에따르면전방십자인대는경골의전방으로작용하는힘의 80 90% 를지지하고있으며, 후방경골경사각이증가하게되면체중이부하되어서있는자세에서대퇴골이전방으로전위하려는힘이증가하여전방십자인대에그만큼의부하가증가하여파열을받을확률이증가하게된다고주장하였다. 이와같이대퇴과간절흔폭및후방경골경사각의구조적이상은전방십자인대파열의중요한위험인자로생각해볼수있다 11). 대퇴과간절흔폭이전방십자인대파열에미치는영향에대한연구는어느정도이루어져왔으며, 후방경골경사각이증가시경골의전방전위가일어남을보고하는연구은많으나전방십자인대손상여부와관련하여직접적으로알아보며, 특히이두가지를동시에연구하여각각의전방십자인대파열에미치는영향에대해분석한연구는부족한실정이다. 또한전방십자인대의단면은원형및타원형이아닌불규칙한형태를하고있으며, 전방십자인대의경골부착부위가대퇴골부착부위에비해넓고더강하게부착되어있어파열시경골부착부위에비해대퇴골부착부위의파열이더쉽게일어나는것으로알려져있으나 1), 이런골부착부위의특성이외에파열부위와대퇴과간절흔폭과후방경골경사각등이관련이있는지에대한연구는없었다. 이에저자들이경험한전방십자인대파열군및비파열군에서대퇴과간절흔폭및후방경골경사각을분석하여이두위험요소와전방십자인대파열과의상관관계를보고하고자한다. 24.8 kg/m 2 이었다. 전방십자인대파열을받지않은대조군은본원외래및응급실을방문한단순전방슬관절통증, 슬관절좌상등에의해무릎의전방, 측면단순방사선사진을촬영한환자를대상으로하였으며파열군과비교를위해나이및성별 BMI 등을체크하였다. 의무기록및영상사진등을검토하여동반된인대파열이있거나이전에슬관절수술을받은과거력이있는환자는제외하였다. 평균나이 31.4 세 (13 54 세 ) 이었으며남자 71예, 여자 20예이었고, BMI 는 25.2 kg/m 2 이었다. 두군의평균나이및 BMI 를 T-test 로측정한결과나이는 p=0.90, BMI 는 p=1.97 로서두군간의유의한차이를보이지않았다. 2. 방법대퇴과간절흔폭은 Rosenberg 등 19) 이기술한체중을부하하여서있는상태에서무릎을 45 o 굴곡시킨후뒤쪽에서앞쪽으로촬영한슬관절단순방사선영상을이용하여측정하였으며 (Rosenburg view), 내측대퇴과간의반월상연골경계부에서대퇴과간꼭대기까지의대퇴과간절흔높이의절반에해당하는지점에서양대퇴과간사이의거 대상및방법 1. 대상 본연구는 2002 년 2월부터 2009 년 7월사이에입원치료를받은전방십자인대파열을받은환자군 105 예 (105 명 ) 및대조군으로전방십자인대비파열군 91예 (91 명 ) 에대하여연구를시행하였다. 환자군에서교통사고와같은무릎에직접적인외력에의한손상을받은외상성환자 13예는제외하였으며, 전방십자인대파열이재발한 5예에대해서도본연구에서제외하였다. 전방십자인대파열군 87예의환자들은스포츠활동도중수상을입었으며나이는평균 32.4 세 (14 62 세 ) 이었으며남자 74예, 여자 13예이었고평균신체질량지수 (body mass index, BMI) 는 Fig. 1. Femoral intercondylar notch width (A B): A first line is drawn across lateral edge of the articular margin of the medial femoral condyle. Second line is drawn palleral to first line at the level of the apex of the intercondylar notch. The femoral intercondylar notch width (distance from point A to point B) is measured at one-half of notch height (distance from point C to point D).
210 리를측정하였다 (Fig. 1) 22). 또한환자개개인의키에따른대퇴과간절흔폭의차이를교정하기위해대퇴과간절흔폭및높이의비를측정하여비교하였다. 후방경골경사각은 Bae 등 4) 에의해기술된무릎의측면단순방사선영상에서경골근위부피질골의전연을이은선의수직선과경골내과고평부를이은선이이루는각으로정의하였다 (Fig. 2). 전방십자인대파열의위치는수술시슬관절관절경소견으로확인하였으며, 전방십자인대파열위치에따라서대퇴골부착부위, 중간부위, 경골부착부위파열군세군으로분류하여, 각군에서대퇴과간절흔폭및후방경골경사각이미치는영향및상호관계에대하여알아보았다. 영상의학사진들은 picture archiving and communicating system (PACS, Maroview R 5.4, Marotech, Seoul, Korea) 를이용하여수상후최초로촬영된단순방사선영상을이용하여대퇴과간절흔폭및후방경골각을측정하였다. 통계학적분석방법은단순상관분석 (simple correlation analysis) 및로지스틱회귀분석 (logistic regression analysis), 평균비교 (one-way ANOVA) 를이용하였으며 p-value 가 0.05 이하일때유의한것으로분석하였다. Fig. 2. Posterior tibial slope angle (A): The measure method of the proximal tibial anterior cortex-referenced posterior slope. Proximal tibial anterior cortex line is drawn parallel to the anterior cortex below the tibial tuberosity. And posterior slop line is drawn a tangent line parallel to the tibial plateau. 대한슬관절학회지 : 제 22 권제 3 호 2010 Volume 22, Number 3, September 2010 결과전방십자인대파열군에있어서대퇴과간절흔폭및후방경골경사각사이의관계에대하여단순상관분석을이용하여분석해본결과전방십자인대파열군의대퇴과간절흔폭의평균은 15.51±4.30 mm (95% confidence interval: 15.48 15.53) 이었으며, 비파열군 24.49±3.86 mm (24.47 24.52) 이었다. 후방경골경사각은파열군은평균 7.68±3.78 o (7.65 7.70) 비파열군 6.12±3.85 o (6.10 6.13) 이었다. 대퇴과간절흔폭및후방경골경사각이전방십자인대파열에미치는영향에대하여로지스틱회귀분석을이용하여분석해본결과, 교차비 (odds ratio) 는대퇴과간절흔폭은그값이 0.661 (0.602 0.720, p< 0.01) 로체크되어, 폭이넓어질수록파열이생길위험도는 0.662 배증가한다 (p<0.01). 즉, 감소한다는의미이다. 또한환자의골격에따른대퇴과간절흔폭의차이를교정하기위해대퇴과간절흔높이에대한폭의비를측정하였으며, 이를비교한결과교차비는 0.907 (0.884 0948, p<0.01) 로비가커질때마다파열이생길위험도는 0.907 배증가한다. 반면에후방경골경사각은교차비가 1.073 (1.062 1.134, p=0.197) 이므로각도가커질때마다파열이생길위험도는 1.083 배로증가함을알수있으나, p=0.194 이므로통계적으로유의하지는않았다. 대퇴과간절흔폭및후방경골경사각이전방십자인대파열위치에영향을주는지알아보기위해파열위치에따라서대퇴과간절흔폭및후방경골경사각의평균비교 (one-way ANOVA) 를시행한결과, 대퇴골부착부위파열은 56예로가장많았고, 대퇴과간절흔폭은 15.80± 4.40 mm (14.63 16.99), 후방경골경사각은 7.92±3.77 o (6.91 8.93) 였으며, 중간부위파열은 14예로, 대퇴과간절흔폭은 15.11±4.55 mm (12.48 17.74), 후방경골경사각은 5.94±3.68 o (3.81 8.06) 였으며, 경골부착부위파열은 17예로대퇴과간절흔폭은 14.87±3.93 mm (12.85 16.89), 후방경골경사각은 8.31±3.72 o (6.40 10.22) 였다. 각군간에대퇴과간절흔폭과후방경골경사각에따라서는통계적으로의미있는결과를관찰할수는없었다. 본연구에서는대퇴과간절흔폭및후방경골경사각이전방십자인대파열부위를결정하는요소로작용하지않는다는것을알수있다.
서승석외 : 전방십자인대파열에있어대퇴과간절흔폭과후방경골경사각의임상적의의 211 고찰전방십자인대는대퇴골에대하여경골의전방전위를막아주고무릎의과신전및내회전시무릎의안정화에기여하는주요구조물로서 3), 이미많은연구에서전방십자인대파열과연관된위험요소에대하여연구되어왔으며, 밝혀진전방십자인대의위험요소로는비만, 성별 ( 남성에서호발 ), 인대의느슨한정도 (ligamentous laxity), 무릎의전반 (knee recurvatum) 정도, 호르몬수치의변화, 신경근육조절의저하 (poor neuromuscular control), 거골하관절의회내 (subtalar pronation) 및대퇴과간절흔폭의감소등이있다 5,12,13,15,17,20,22-24,26,27). 또한이러한위험요소가있는경우전방십자인대파열후재발의위험성역시높다 23). 본연구는무릎자체의구조적요인에의해전방십자인대의파열이더욱잘일어나는지에대해알아보고임상에적용하고자하였다. 대퇴과간절흔폭은전방십자인대를담아두는저장공간역할을하고있으며, 대퇴과간절흔폭이좁을수록전방십자인대의직경이좁아지게되고 6,8), 이는같은외력으로충격을받았을경우전방십자인대파열이좀더쉽게일어날수있음을의미한다 10,14,16,18,21,24). 또한대퇴과간절흔폭이좁을수록무릎의과신전시전방십자인대가대퇴과간절흔사이에끼일가능성이높아지며전방십자인대의파열가능성역시높아진다 9). 또한운동과정중에서갑자기무릎이회전하거나꺾이는동작을행하는경우대퇴외과가전방십자인대의파열을유발할수있는것으로알려져있다 1). 이에 Souryal 와 Freeman 23) 은대퇴과간절흔폭이좁은환자가다른어떤이유로무릎관절내시경을이용한수술을받는경우에는예방적으로대퇴과간절흔성형술 (notchplasty) 을시행할수있다고하였으며, 비접촉성전방십자인대파열을받은젊은환자중대퇴과간절흔폭및대퇴과와대퇴과간절흔의비가좁은경우, 파열받지않은반대쪽무릎의전방십자인대역시파열의위험도가높다고보고하였다. 특히 Lund-Hanssen 등 16) 은대퇴과간절흔폭이 17 mm 이하인경우전방십자인대파열의위험이임상적으로의미있게증가한다고하였으며, 본연구에서전방십자인대파열군의대퇴과간절흔폭의평균이전방십자인대파열군이 15.51 mm 및대조군은 24.49 mm로서 Lund-Hanssen 등 16) 의연구에합당한결과 를얻을수있었다. 후방경골경사각은후방경골경사와평행한선과경골의골간을양분하는선이교차하여이루는각을의미하며, Shoemaker 과 Markolf 22) 는사체연구를통해전방십자인대및내측반월상연골이절단되었을경우축성압력이가해지면경골이전방으로전위함을증명하였다. Dejour 와 Bonnin 7) 은전향적인연구를통해환자가한발로체중을부하하여서있는경우후방경골경사각이 10 o 증가함에따라경골의전방전위가 6 mm 정도증가함을보여졌고, 이런관계는전방십자인대파열이있는경우경골의전방전위가더심하기는했으나전방십자인대파열군및비파열군모두에서전방전위가증가함을발견하였다. Giffin 등 11) 도후방경골경사가증가할수록대퇴골에대하여경골이전방전위를더발생한다고보고하였으며, 개방성절골술등을통해후방경골경사각이증가하는경우무릎을굴곡시키면서각각의각도에서전방으로압력을가했을경우, 경골의전방전위를관찰할수있었으며, 전방전위가최고로측정된경우는그크기가 3.6 mm로서무릎이완전히신전된경우에서측정되었다. 또한 Todd 등 25) 은전방십자인대파열군의환자가비파열군에비해후방경골경사각이크다고보고하였다. 본연구에서는전방십자인대파열군의후방경골경사각은 7.68 o 이며대조군의후방경골경사각의평균은 6.12 o 로서 Todd 등 25) 의연구에합당한결과를얻었으나통계적유의성은없었다. 결 본연구에서전방십자인대파열에있어서대퇴과간절흔폭은의미있는위험요소임을알수있었으나, 후방경골경사각에대해서는통계적으로유의한결과를얻지는못하였다. 대퇴과간절흔폭및후방경골경사각은전방십자인대파열위치를결정하는요소는아닌것으로생각된다. 따라서, 대퇴간절흔폭은전방십자인대파열을일으킬수있는위험인자로서활용될수있다. 론 REFERENCES 1. Agneskirchner JD, Hurschler C, Stukenborg-Colsman C, Imhoff AB, Lobenhoffer P: Effect of high tibial flexion osteotomy on cartilage pressure and joint
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214 대한슬관절학회지 : 제 22 권제 3 호 2010 Volume 22, Number 3, September 2010 전방십자인대파열에있어대퇴과간절흔폭과후방경골경사각의임상적의의 인제대학교의과대학부산백병원정형외과, 1 부산중앙 U 병원 서승석ㆍ김창완ㆍ김경환 1 ㆍ민영경 목적 : 대퇴과간절흔폭과후방경골경사각이전방십자인대파열및파열위치에미치는영향에대하여알아보고자하였다. 대상및방법 : 2002 년 2 월부터 2009 년 7 월사이에본원에서전방십자인대파열로치료받은환자 105 예 (105 명 ) 및대조군으로전방십자인대비파열군 91 예 (91 명 ) 에대하여단순방사선사진을이용하여대퇴과간절흔폭과후방경골경사각을측정하였다. 또한전방십자인대의파열위치에따라서대퇴골부착부위, 중간부위, 경골부착부위파열군으로분류하여각군에서의상관관계를분석하였다. 결과 : 대퇴과간절흔폭의평균은전방십자인대파열군 15.51±4.30 mm (95% confidence interval: 15.48 15.53), 비파열군 24.49±3.86 mm (24.47 24.52) 이었으며, 후방경골경사각은파열군평균 7.68±3.78 o (7.65 7.70), 비파열군 6.12±3.85 o (6.10 6.13) 이며, 대퇴과간절흔폭과전방십자인대파열사이에는연관성이있었다 ( 교차비 =0.661 [0.602 0.720], p<0.01). 후방경골경사각과는연관성이없었다 ( 교차비 =1.073 [1.062 1.134], p=0.197). 파열위치에따른분산분석에서는통계학적으로의미있는결과를관찰할수는없었다. 결론 : 전방십자인대파열에있어서대퇴과간절흔폭의감소는의미있는위험요소임을알수있었다. 색인단어 : 전방십자인대파열, 대퇴과간절흔폭, 후방경골경사각