353 pissn : 1226-2102, eissn : 2005-8918 Symposium J Korean Orthop Assoc 2015; 50: 353-358 http://dx.doi.org/10.4055/jkoa.2015.50.5.353 www.jkoa.org Medial Meniscus Posterior Root Tear 내측반월연골판후방기시부파열의진단과최신지견 신영수 이대희 * 이현민 한승범 이화여자대학교의과대학정형외과학교실, * 성균관대학교의과대학정형외과학교실, 고려대학교의과대학정형외과학교실 Diagnosis and Current Trends of Medial Meniscus Posterior Root Tear Young-Soo Shin, M.D., Dae-Hee Lee, M.D.*, Hyun-Min Lee, M.D., and Seung-Beom Han, M.D. Department of Orthopaedic Surgery, Ewha Womans University School of Medicine, *Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Department of Orthopaedic Surgery, Korea University College of Medicine, Seoul, Korea Medial meniscal root tears with extrusion result in the loss of transmission of circumferential hoop stresses, leading to significantly increased tibiofemoral contact pressure and changes in knee biomechanics and kinematics. Therefore, medial meniscal root tears have attracted attention in recent years with regard to their early diagnosis. With the remarkable development of magnetic resonance imaging and arthroscopy, early diagnosis of medial meniscal root tears is on the rise. This report includes diagnosis and current trends of medial meniscal root tears. Key words: medial meniscus, root tear, magnetic resonance imaging 서론 초승달모양의섬유연골구조인내측반월연골판은슬관절접촉 면의일치성 (congruity), 안정성, 충격흡수와고유감각 (proprioception) 을보존하는데필수적인것으로알려져있다. 1,2) 내측반 월연골판은슬관절의굴곡과신전시슬관절의축하중을버팀테 응력 (hoop stress) 으로전환할수있는특별하게만들어진콜라겐 섬유 (collagen fibers), 프로테오글라이칸 (proteoglycans) 과당단백 질 (glycoproteins) 의교차네트워크로구성되어있다. 1,3) 내측반월 연골판후방기시부의파열은연골판의생역학과운동학에영향 을미치고이로인해슬관절내에퇴행성변화를가속화시킨다. 또한생역학적연구에서도내측반월연골판전절제술을시행한 Received July 2, 2015 Revised July 24, 2015 Accepted July 27, 2015 Correspondence to: Seung-Beom Han, M.D. Department of Orthopaedic Surgery, Korea University Anam Hospital, 73 Inchon-ro, Seongbuk-gu, Seoul 02841, Korea TEL: +82-2-920-5692 FAX: +82-2-924-2471 E-mail: oshan@korea.ac.kr 군과내측반월연골판후방기시부가파열된군사이에슬관절의최대접촉응력을비교한결과차이를보이지않았다고보고한바있다. 4) 내측반월연골판의후방기시부는두꺼운부착부인대로손상받기쉬운부분으로알려져있고, 고령환자에서비교적흔하고반복적인외상혹은퇴행성변화로발생한다. 내측반월연골판의후방기시부파열의임상적진단은어려운것으로알려져있지만, 자기공명영상 (magnetic resonance imaging, MRI) 과관절경으로진단의민감도와특이도가향상되고있다. 따라서본종설에서는내측반월연골판후방골기시부파열의진단에대한최신지견을살펴보고자한다. 본론 1. 내측반월연골판후방기시부의해부학내측반월연골판후방기시부는연골판의후각부를뼈에부착시키기때문에대퇴골에서경골로전해지는부하가원주콜라겐다 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.
354 Young-Soo Shin, et al. 발의늘어짐을통해충격흡수기능을할수있게해준다. 또한원주섬유에의한버팀테응력의분포는상대적으로관절접촉면을가로질러축하중을전달하면서과도한부하및관절연골의파괴를방지하는데도움을준다. 5,6) 내측반월연골판전방기시부는경골고평부에간단한평면삽입부를가지고있는반면, 내측반월연골판후방기시부는상대적으로복잡한 3차원삽입부를가지고있다. 7) 따라서내측연골판후방골기시부의특정해부학에대한지식은진단및치료에있어굉장히중요하다하겠다. Johannsen 등 7) 은내측반월연골판후방기시부의정량적인경계를밝혀냈는데내측경골융기의정점으로부터대략후방 9.6 mm와외측 0.7 mm에있다고보고했다. 또한내측경골고평부관절연골의변곡점에서외측으로 3.5 mm와후방십자인대경골부착부의최고점으로부터전방 8.2 mm에위치한다고하였다. 기존연구에서내측연골판후방골기시부의전체면적은대략 47 mm 2 와 80 mm 2 정도로큰차이를보이고있는데, 5,8) 이는 Ziegler 등 9) 이언급한내측연골판후각과완전히분리되어있지않고, 후방골기시부와연속성을유지하는후방에기반을둔보조섬유인 반짝흰색섬유 (shiny white fibers) 때문인것으로보여진다. Johannsen 등 7) 도후방골기시부의가장중심부부착면적이평균 30.4 mm 2 였으나, 반짝흰색섬유를포함시키면부착면적이평균 77.7 mm 2 로증가한다고하였다. 따라서기존연구에서내측반월연골판후방기시부의면적에반짝흰색섬유를포함시킨다면내측반월연골판후방기시부의정확한면적을알지못하게될수있다고하였다. 2. 내측반월연골판후방기시부파열의역학및병인최근내측반월연골판후방기시부파열의발생빈도는이전에관절경하연골판봉합술혹은제거술시보였던약 10%-20% 보다훨씬흔하다고알려져있고, MRI에서내측반월연골판후방기시부에근접해있는횡파열은대략 1/3 정도에서진단되지못하고있는실정이다. 10,11) 기존연구에서내측반월연골판후방기시부파열의위험요인에대해서보고하였는데증가된나이, 여성, 증가된체질량지수와감소된스포츠활동의정도등이내측반월연골판후방기시부파열의높은발생빈도와연관이있다고하였다. 10,12) 3. 생역학내측반월연골판후방기시부는연골판의버팀테응력 (hoop stress) 을유지하고, 연골판돌출을방지하는데필수적이라하겠다. 13,14) Allaire 등 4) 은내측반월연골판후방기시부파열이정상적인상태와비교했을때내측구획의최대접촉응력을 25% 증가시킨다고하였으며, Marzo와 Gurske-DePerio 15) 도내측반월연골판후방기시부견열시접촉면이급격히감소하고, 최대접촉응력은증가한다는동일한결과를보고하였다. 또한내측반월연골 판후방기시부의손상시경골의외회전과외측전위가증가되며, 이러한변화는궁극적으로하지의내반정렬을초래하게된다. 4) 4. 진단 1) 임상적진단내측반월연골판후방기시부파열의임상적진단은일반적으로어려운것으로알려져있다. 환자들은내측관절면의통증, 종창및슬관절굴곡의소실등을호소하며, 연골판손상에서전형적으로양성반응을보이는 McMurray 검사에서도기계적걸림없이양성소견을보일수있고, 16) 내반스트레스검사는내측반월연골판후방기시부견열의임상적진단에유용하다. 또한내반스트레스검사시환자의내측관절면을촉지하면서연골판의돌출소견을확인할수있고, 스트레스를주지않은상태에서는연골판의돌출소견이보이지않게된다. 17) 특히중년이후아시아인에서통증을동반한터지는느낌 (popping sensation) 이단일이벤트로존재할때내측반월연골판후방기시부파열을강하게예측할수있는것으로알려져있고, 이러한임상적사인이있을때에는환자들의연골마모상태가나쁘지않음을시사하기도한다. 18) 관절경적인방법으로서는겸자를이용한후각부의 리프트오프 (lift-off) 검사로병변을식별하는데도움을줄수있다. 2) 자기공명영상진단내측반월연골판후방기시부파열의효과적인이학적검사의부재로인해 MRI가내측반월연골판후방기시부파열의진단에사용이증가되고있는추세이다. 그러나기존연구에서관절경적으로확인된내측반월연골판후방기시부파열환자 67명을대상으로술전 MRI 소견을확인한결과 72.9% 에서만양성소견을보였기때문에 MRI의정확한진단에는영상의질과방사선사의숙련도가많은영향을미친다고할수있겠다. 11) (1) 관상면 (coronal plane) 영상 : 축면영상이높은민감도와특이도를제공하긴하지만일반적으로내측반월연골판후방기시부파열병변은내측경골부에부착되어있는섬유연골띠로서연속된두개의관상면 MRI 영상에서가장쉽게관찰되며, 수직선형결함 (sign of truncation) 으로나타난다. 특히 T2-강조영상이최대특이도및민감도를가지기때문에가장좋은영상으로받아들여지고있다. 19) 하지만내측반월연골판후방기시부파열이상대적으로크기가작을때에는파열을진단하기어려워이차적으로내측반월연골판의돌출은후방골기시부파열이존재함을강하게시사한다하겠다. 20) 내측반월연골판의돌출은경골고평부경계에비하여연골판의부분전위혹은완전전위된상태로정의할수있다 (Fig. 1). 기존연구에따르면중간관상면영상에서 3 mm 이상의돌출은관절연골및연골판의변성을초래하며후방골기시부를침범하는연골판파열과크게관련이있다고알려져있
355 Diagnosis and Current Trends of Medial Meniscus Root Tear Figure 1. Coronal T2-weighted image showing medial meniscus extrusion with left arthroscopic panel. Figure 2. Axial image showing a high signal in the region of the posterior horn with a radial root tear (arrow). Figure 3. Sagittal image showing a ghost sign (arrow). 다. 21) (2) 축면 (axial plane) 영상 : 내측반월연골판후방기시부파열과관련된중요한징후로는축면영상에서발견되는연골판후방골기시부의방사상선형결함이다 (Fig. 2). 22) 축면영상은연골판후방골기시부파열에있어서때로는관상면혹은시상면영상보다진단이잘되는것으로알려져있는데, 이는횡파열의방향이반월상연골판의방향축에수직이기때문이다. (3) 시상면 (sagittal plane) 영상 : 내측반월연골판후방기시부파열과관련된또다른중요한징후로는시상면영상에서연골판식별의부재및정상적인연골판의저강도신호가고강도신호로전환된고스트사인 (ghost sign) 이라하겠다. 고스트사인은내측연골판후방골기시부와부분변성을가지는후방십자인대사이에단절된간격을나타낸다 (Fig. 3). 또한이러한영상이후방십자인대내측에서관찰되는이유는내측연골판후각부의경골삽입부가경골고평부의후방과간와 (posterior intercondylar fossa) 전내중간부위에부착되어있고, 후방십자인대는관절선에서대략 1-1.5 cm 하방으로과간와 (intercondylar fossa) 후외측중간부위에부착되어있기때문이다. 21,23) 결론 내측반월연골판후방기시부파열을가진환자를치료할때술자는적절한치료방법을선택하기위해중심주위후각부횡파열과후방골기시부파열을구분해야만하며, 이는후방골기시부파열보다중심주위후각부횡파열에서제한된혈관공급으로인해더낮은치유결과를보이기때문인것으로알려져있다. 2) 또한내측반월연골판후방기시부파열은흔히내측구획에반월상연골판전절제술과비슷한결과를초래하는연골판돌출을야기하기때문에최근에알려진다양한임상적진단및 MRI 영상에서관상면상 truncation sign, 축면상선형결함, 시상면상고스트
356 Young-Soo Shin, et al. Table 1. Clinical Diagnosis and MRI Evaluation of Medial Meniscus Root Tears Clinical diagnosis Patients with posterior knee pain Assess for effusion and painful flexion MRI, magnetic resonance imaging; MCL, medial collateral ligament. MRI evaluation Assess for meniscal extrusion >3 mm at level of the MCL Assess for ghost sign on sagittal MRI Assess for vertical linear defects on coronal MRI Differentiate root tear from posterior horn radial tear Ascertainment for the presence of bony edema or insufficiency fractures of the ipsilateral knee 사인을종합적으로이해하고평가한다면내측반월연골판후방기시부파열을가진환자에게있어정확한조기진단및치료에많은도움이될것이다 (Table 1). CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Fithian DC, Kelly MA, Mow VC. Material properties and structure-function relationships in the menisci. Clin Orthop Relat Res. 1990;252:19-31. 2. Koenig JH, Ranawat AS, Umans HR, Difelice GS. Meniscal root tears: diagnosis and treatment. Arthroscopy. 2009;25: 1025-32. 3. Kopf S, Colvin AC, Muriuki M, Zhang X, Harner CD. Meniscal root suturing techniques: implications for root fixation. Am J Sports Med. 2011;39:2141-6. 4. Allaire R, Muriuki M, Gilbertson L, Harner CD. Biomechanical consequences of a tear of the posterior root of the medial meniscus. Similar to total meniscectomy. J Bone Joint Surg Am. 2008;90:1922-31. 5. Johnson DL, Swenson TM, Livesay GA, Aizawa H, Fu FH, Harner CD. Insertion-site anatomy of the human menisci: gross, arthroscopic, and topographical anatomy as a basis for meniscal transplantation. Arthroscopy. 1995;11:386-94. 6. Jones AO, Houang MT, Low RS, Wood DG. Medial meniscus posterior root attachment injury and degeneration: MRI findings. Australas Radiol. 2006;50:306-13. 7. Johannsen AM, Civitarese DM, Padalecki JR, Goldsmith MT, Wijdicks CA, LaPrade RF. Qualitative and quantitative anatomic analysis of the posterior root attachments of the medial and lateral menisci. Am J Sports Med. 2012;40:2342-7. 8. Kohn D, Moreno B. Meniscus insertion anatomy as a basis for meniscus replacement: a morphological cadaveric study. Arthroscopy. 1995;11:96-103. 9. Ziegler CG, Pietrini SD, Westerhaus BD, et al. Arthroscopically pertinent landmarks for tunnel positioning in singlebundle and double-bundle anterior cruciate ligament reconstructions. Am J Sports Med. 2011;39:743-52. 10. Bin SI, Kim JM, Shin SJ. Radial tears of the posterior horn of the medial meniscus. Arthroscopy. 2004;20:373-8. 11. Ozkoc G, Circi E, Gonc U, Irgit K, Pourbagher A, Tandogan RN. Radial tears in the root of the posterior horn of the medial meniscus. Knee Surg Sports Traumatol Arthrosc. 2008; 16:849-54. 12. Hwang BY, Kim SJ, Lee SW, et al. Risk factors for medial meniscus posterior root tear. Am J Sports Med. 2012;40:1606-10. 13. Griffith CJ, LaPrade RF, Fritts HM, Morgan PM. Posterior root avulsion fracture of the medial meniscus in an adolescent female patient with surgical reattachment. Am J Sports Med. 2008;36:789-92. 14. Kim JH, Chung JH, Lee DH, Lee YS, Kim JR, Ryu KJ. Arthroscopic suture anchor repair versus pullout suture repair in posterior root tear of the medial meniscus: a prospective comparison study. Arthroscopy. 2011;27:1644-53. 15. Marzo JM, Gurske-DePerio J. Effects of medial meniscus posterior horn avulsion and repair on tibiofemoral contact area and peak contact pressure with clinical implications. Am J Sports Med. 2009;37:124-9. 16. Lee JH, Lim YJ, Kim KB, Kim KH, Song JH. Arthroscopic pullout suture repair of posterior root tear of the medial meniscus: radiographic and clinical results with a 2-year followup. Arthroscopy. 2009;25:951-8. 17. Seil R, Dück K, Pape D. A clinical sign to detect root avulsions of the posterior horn of the medial meniscus. Knee Surg Sports Traumatol Arthrosc. 2011;19:2072-5. 18. Bae JH, Paik NH, Park GW, et al. Predictive value of pain-
357 Diagnosis and Current Trends of Medial Meniscus Root Tear ful popping for a posterior root tear of the medial meniscus in middle-aged to older Asian patients. Arthroscopy. 2013; 29:545-9. 19. Lee SY, Jee WH, Kim JM. Radial tear of the medial meniscal root: reliability and accuracy of MRI for diagnosis. AJR Am J Roentgenol. 2008;191:81-5. 20. Magee T. MR findings of meniscal extrusion correlated with arthroscopy. J Magn Reson Imaging. 2008;28:466-70. 21. Lerer DB, Umans HR, Hu MX, Jones MH. The role of meniscal root pathology and radial meniscal tear in medial meniscal extrusion. Skeletal Radiol. 2004;33:569-74. 22. Kim SB, Ha JK, Lee SW, et al. Medial meniscus root tear refixation: comparison of clinical, radiologic, and arthroscopic findings with medial meniscectomy. Arthroscopy. 2011;27:346-54. 23. Breitenseher MJ, Trattnig S, Dobrocky I, et al. MR imaging of meniscal subluxation in the knee. Acta Radiol. 1997;38:876-9.
358 pissn : 1226-2102, eissn : 2005-8918 Symposium J Korean Orthop Assoc 2015; 50: 353-358 http://dx.doi.org/10.4055/jkoa.2015.50.5.353 www.jkoa.org 내측반월연골판후방기시부파열 내측반월연골판후방기시부파열의진단과최신지견 신영수 이대희 * 이현민 한승범 이화여자대학교의과대학정형외과학교실, * 성균관대학교의과대학정형외과학교실, 고려대학교의과대학정형외과학교실 돌출 (extrusion) 을동반한내측반월상연골판후방골기시부파열은 원주버팀테응력 (circumferential hoop stress) 전달의소실을가져오며이로인해슬관절의접촉응력 (contact pressure) 이증가하고, 생역학및운동학의변화가발생하게된다. 따라서최근내측반월상연골판후방골기시부파열의조기진단에관심이집중되고있으며, 자기공명영상과관절경의괄목할만한발전으로조기진단이증가하고있다. 본종설에서는내측반월상연골판후방골기시부파열의진단에대한최신지견을살펴보고자한다. 색인단어 : 내측반월상연골판, 후방골기시부파열, 자기공명영상 접수일 2015 년 7 월 2 일수정일 2015 년 7 월 24 일게재확정일 2015 년 7 월 27 일책임저자한승범 02841, 서울시성북구인촌로 73, 고려대학교안암병원정형외과 TEL 02-920-5692, FAX 02-924-2471, E-mail oshan@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.