359 pissn : , eissn : Symposium J Korean Orthop Assoc 2015; 50: M

359 pissn : 1226-2102, eissn : 2005-8918 Symposium J Korean Orthop Assoc 2015; 50: 359-364 http://dx.doi.org/10.4055/jkoa.2015.50.5.359 www.jkoa.org Medial Meniscus Posterior Root Tear 퇴행성내측반월연골판후방기시부파열의비수술적치료 배지훈 김한주 고려대학교의과대학구로병원정형외과학교실 Non-Operative Treatment of the Degenerative Medial Meniscus Posterior Root Tear Ji-Hoon Bae, M.D., Ph.D. and Han-Ju Kim, M.D. Department of Orthopedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea Degenerative medial meniscus posterior root tear is commonly seen in middle or old age populations. Because the biomechanical status of the meniscus root tear is similar to total menisectomy state, medial meniscus posterior root tear can cause early osteoarthritis. Treatment options for the medial meniscus posterior root tear include non-operative treatment, meniscectomy, repair, and high tibia osteotomy. There is still debate regarding the exact indication of each treatment, because the natural course of the medial meniscus posterior root tear and long-term results of each treatment is not known. However, non-operative treatments provide symptomatic relief and functional improvement in patients who are not indicated for operative treatment or before operative treatment. Key words: knee, medial meniscus, root tear, degeneration 서론 내측반월연골판후방기시부파열은후방경골부착부 1 cm 이 내의횡파열로정의할수있으며스포츠활동중외상이나퇴행 성변화로인해파열이발생할수있다 (Fig. 1). 1-5) 퇴행성파열인 경우, 중년이후의여성에서비교적흔한파열이다. 6) 내측반월연 골판후방기시부파열은생역학적으로반월연골판의완전절제 와같은상태라할수있으며원주테장력의소실로인하여반월 연골판의기능이소실될수있다. 7) 퇴행성내측반월연골판후방 기시부파열의자연경과가정확히밝혀지지않았지만골관절염 Received June 29, 2015 Revised September 30, 2015 Accepted October 2, 2015 Correspondence to: Ji-Hoon Bae, M.D., Ph.D. Department of Orthopedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea TEL: +82-2-2626-3296 FAX: +82-2-2626-1164 E-mail: osman@korea.ac.kr 환자들에서흔히관찰되고퇴행성내측반월연골판후방기시부파열환자들에게서골관절염의조기발병과진행을보고하고있어슬관절의기능을최대한보존하도록가능한조기에적극적인치료가필요하다. 8-10) 치료방법으로보존적방법과수술적방법이있으며증상의정도, 이환기간, 동반손상, 퇴행성변화의정도, 직업, 활동력, 환자의전신상태등을고려하여가장적합한방법을선택해야한다. 2) 본종설에서는중년이후에발생한퇴행성내측반월연골판후방기시부파열의보존적치료방법과임상결과에대해기술하고자한다. 본론 1. 보존적치료의적응증수술적치료가부적합한환자나수술을시행하기전슬관절기능 The Journal of the Korean Orthopaedic Association Volume 50 Number 5 2015 Copyright 2015 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.

360 Ji-Hoon Bae and Han-Ju Kim A B C Figure 1. (A) Coronal magnetic resonance (MR) image showing the medial meniscus posterior root tear (arrow). (B) Marginal osteophytes, full thickness cartilage defect in the medial femoral condyle and medial tibia plateau are seen in same patient. (C) Sagittal MR image showing effusion and a full thickness cartilage defect in the weight bearing area of the medial femoral condyle and medial tibia plateau. 개선을위해보존적치료를먼저시행할수있다. 퇴행성내측반월연골판후방기시부파열의치료방법을결정하기위하여현재환자가호소하는증상이반월연골판파열과관련이있는지판단하고, 파열된반월연골판후각근이봉합술의적응증이되는지를판단하여야한다. 보존적인치료로는파열된부위의치유와반월연골판의기능회복을기대하기는어렵기때문에봉합을시도하여치유를유도할수있다고판단되면반월연골판의기능회복을위해봉합술을선택할수있다. 11,12) 봉합술의적응증은반월연골판의심한퇴행성변화가없는급성파열, 내, 외측구획의관절연골의상태가정상이거나 Outerbridge grade 2 이하인경우, 관절간격이정상의 1/2 이상유지되어있고 5도이내의내반변형이며체질량지수가정상인경우이다. 1,2,13) 최근봉합술의여러술기들이소개되고단기및중기추시의양호한임상결과가보고되고있지만반월연골판의정상적인기능을회복할수있는지는명확하지않으며장기추시결과가없어봉합술이골관절염의발병이나악화를예방할수있는지는불확실하다. 14-26) 또한수술술기상퇴행성내측반월연골판후방기시부의해부학적위치에봉합이쉽지않고적절한장력을유지하는것이어렵기때문에봉합이불완전하게이루어지고골기시부에서치유가잘되지않아재파열되거나수술도중인접한관절연골의손상등이발생하면활액막염과같은증상이지속적으로남을수있게된다. 27-30) 따라서봉합술은매우선택적으로이루어져야하고그외의경우에는대부분보존적치료를먼저시행할수있다. 퇴행성내측반월연골판후방기시부파열로인한기계적증상이 3개월이상지속되는경우에는부분절제술을, 31,32) 내반변형이동반되어있으면서내측구획의관절연골의퇴행성변화가진행이되어있는경우에는근위경골절골술이나인공슬관절부분치환술을고려해볼수있지만이러한수술의적응증이되는환자들도수술전슬관절기능개선을위해보존적치료를먼저선택할수있다. 33-35) 2. 보존적치료방법보존적치료의목적은통증을감소시키고, 염증을완화하고, 슬관절의기능을향상시키는데있다. 보존적치료방법에는국소관절안정, 약물요법, 운동요법등일반적인반월연골판파열이나골관절염의보존적치료방법과동일하다. 36-38) 보존적인치료로는파열된부위의치유와반월연골판의기능회복을기대하기는어렵고퇴행성내측반월연골판후방기시부파열은퇴행성골관절염발병과진행을유발할수있다. 특히하지의내반정렬, 비만, Outerbridge grade 3-4의관절연골퇴행성변화등이동반되어있는경우, 조기에골관절염이발병하거나악화될수있기때문에보존적치료를선택하는경우 8) 치료의목적과질환의경과및예후에대하여환자및가족이이해하도록충분히설명을하는것이매우중요하다. 1) 관절안정상당수의환자에서파열급성기에 뚝 하는탄발음과함께슬관절후방부또는후내측부에극심한통증을느끼고무릎주변근육의경직과관절가동범위 (range of motion, ROM) 가제한이되어일상적인활동이힘들다고호소한다. 39) 적절한휴식과국소부위의안정은통증과염증반응을완화할수있기때문에파열급성기에일시적으로부목고정이나보조기착용등이도움이된다. 하지만장기간의고정은근위축이나관절구축이발생할수있기때문에극심한통증이완화되는시기에제거하고관절운동을시작해야한다. 관절안정을위해체중부하를제한할필요는없으나급성파열시기에극심한통증으로인하여체중부하가어려운경우목발이일시적으로도움이된다. 2) 약물요법급성파열시기에통증조절을위해단순진통제나비스테로이드성항염증약물을사용할수있다. 골관절염같은동반질환이나

361 Non-Operative Treatment of the Degenerative Medial Meniscus Posterior Root Tear 관절연골손상없이퇴행성내측반월연골판후방기시부파열만있는경우에는장기간복용할필요는없다. 환자의증상에따라 6-12주까지투여하여증상의호전을기대할수있다. 40,41) 만성파열인경우에는대개관절연골의결손이나골관절염이동반되어있고이로인한증상이주증상이기때문에이시기에치료는내측반월연골판후방기시부파열보다는관절연골의결손이나골관절염의증상완화를위한약물요법을시행한다. 36,42) 이러한경우약물복용의목적과치료대상을정확히환자에게이해시켜야한다. 급성파열후지속적인통증과부종으로관절가동운동 (ROM exercise) 이어렵고단순진통제나비스테로이드성항염증약물복용에도통증완화가없을때, 스테로이드제재를관절내에국소주사하면수시간또는수일이내에통증과부종이경감되고운동범위가많이호전될수있다. 삼출액이많아불편을느끼는경우에도삼출액을천자하고스테로이드를관절내국소주사하면염증을완화하고삼출액을감소시키는데도움이될수도있다. 하지만반복적으로사용하는것은관절연골의손상을줄수있기때문에주의를요한다. 43) 3) 운동요법운동요법은퇴행성내측반월연골판후방기시부파열의보존적치료에가장핵심이되는방법이다. 운동요법의목적은관절의운동범위를유지하여관절구축을예방하고, 근력을강화하여슬관절기능을보존하는것이다. 44-46) 급성파열의시기에는극심한통증이완화되는시점부터, 만성파열의시기에는진단직후부터운동요법을교육하고시행하는것이좋다. 급성파열후 1-2주후극심한통증과부종이감소하면부목을제거하고관절구축을예방하기위해 ROM exercise와슬개골운동 (patella mobilization) 을시행하고근위축을예방하기위하여대퇴사두근세트운동, 하지직거상운동을시행한다. 하지근육과관절의유연성을향상시키기위한스트레칭운동은슬관절주위근육뿐만아니라고관절, 족관절, 허리와관련된근육모두를스트레칭하는것이좋다. 굴곡구축이나굴곡제한등 ROM이제한이되지않도록 ROM exercise와스트레칭운동은반드시시행해야한다. 47) 이시기에쪼그려앉기등과같이무릎이과굴곡이되는자세는증상을악화시킬수있으므로피하는것이좋다. 급성파열후 4-6주에부종과통증이사라지고비교적전범위의관절운동을회복하고완전체중부하가가능해지는데이시기부터는 mini-squat, leg press 등과같은등장성근력강화운동등을시행한다. 근력강화운동의모든동작들은 5-10초간유지, 10번반복, 3세트를시행한다. 41) 3. 보존적치료의임상결과퇴행성내측반월연골판후방기시부파열의보존적치료후임상결과는 6-12개월까지증상과기능이호전되고비교적만족스러웠으나일부환자에서골관절염의진행을보고하였다. Lim 등 41) 은 내측반월연골판후방기시부파열환자 30명을대상으로 8주간의운동요법과약물요법의병행치료후최소 2년추시 (24-51개월) 에서양호한임상결과를보고하였다. 대상환자의 77% 에서 6개월이내증상은완화되었고통증점수와 Lysholm score는 1년후까지호전되었다가이후최종추시까지 (24-51개월) 감소하였으나치료전과비교하였을때의미있게호전된결과를보였다. Kellgren- Lawrence (KL) grade 2 환자에서임상결과가불량하였고 10명중 2명에서 KL grade 3으로진행하였다고보고하였다. Neogi 등 40) 은퇴행성내측반월연골판후방기시부파열환자 37명을대상으로 12주간의운동요법과약물요법의병행치료후평균 35개월추시 (26-49개월) 에서양호한임상결과를보고하였다. 임상증상은 6 개월까지호전되었다가이후최종추시까지 (26-49개월) 감소하였으나치료전과비교하였을때의미있게호전된결과를보였으며, 높은체질량지수가골관절염의진행에연관이있다고보고하였다. Ahn 등 48) 은내측반월연골판후방기시부파열 25명의봉합술을시행한환자군과 13명의보존적치료를시행한환자군을비교한연구에서평균 18개월추시에서봉합술의임상결과가더양호하였으나하지의내반변형이 5도이상, Outerbridge grade 3 이상인경우에는봉합술의경우에도예후가불량하였다고보고하였다. 결론 퇴행성내측반월연골판후방기시부파열은중년이후의연령군에서흔히관찰되는반월연골판파열이다. 생역학적으로내측반월연골판후방기시부파열은반월연골판완전절제와같은상태라할수있으며이로인해조기에골관절염이발병할수있다. 보존적치료방법에는국소관절안정, 약물요법, 운동요법등이있으며보존적인치료로파열된부위의치유와반월연골판의기능회복을기대하기는어렵지만증상의개선과슬관절의기능을향상시킬수있다. 치료를시작하기전질환의경과에대해환자에게충분히설명하고보존적치료의목적을정확히이해시키는것이중요하다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Petersen W, Forkel P, Feucht MJ, Zantop T, Imhoff AB, Brucker PU. Posterior root tear of the medial and lateral meniscus. Arch Orthop Trauma Surg. 2014;134:237-55. 2. Lee DW, Ha JK, Kim JG. Medial meniscus posterior root tear: a comprehensive review. Knee Surg Relat Res. 2014;26:125-34.

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364 pissn : 1226-2102, eissn : 2005-8918 Symposium J Korean Orthop Assoc 2015; 50: 359-364 http://dx.doi.org/10.4055/jkoa.2015.50.5.359 www.jkoa.org 내측반월연골판후방기시부파열 퇴행성내측반월연골판후방기시부파열의비수술적치료 배지훈 김한주 고려대학교의과대학구로병원정형외과학교실 퇴행성내측반월연골판후방기시부파열은중년이후의연령군에서흔히관찰되는연골판파열이다. 반월연골판후각근파열은생역학적으로반월연골판의완전절제와같은상태라할수있으며이로인해조기에골관절염이발병할수있다. 치료방법으로보존적방법, 반월연골판부분절제술, 반월연골판봉합술, 근위경골절골술등이있다. 이질환의자연경과가확실히밝혀지지않았고각각의치료방법에대한장기추시결과가없어각치료방법에대한정확한적응증에대해서는아직이견이있지만수술적치료가부적합한환자나수술을시행하기전보존적인치료로증상완화와슬관절의기능개선을기대해볼수있다. 색인단어 : 슬관절, 내측반월연골판, 근파열, 퇴행 접수일 2015 년 6 월 29 일수정일 2015 년 9 월 30 일게재확정일 2015 년 10 월 2 일책임저자배지훈 08308, 서울시구로구구로동로 148, 고려대학교의과대학구로병원정형외과학교실 TEL 02-2626-3296, FAX 02-2626-1164, E-mail osman@korea.ac.kr 대한정형외과학회지 : 제 50 권제 5 호 2015 Copyright 2015 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.