대한정형외과학회지 : 제 42 권제 4 호 2007 J Korean Orthop Assoc 2007; 42: 505-514 동일인에서슬관절전치환술및단일구획치환술후보행분석비교 최원식ㆍ김하용ㆍ김갑중ㆍ감병섭 을지대학교의과대학정형외과학교실 A Comparison of Gait Analysis after Total Knee Arthroplasty and Unicompartmental Knee Arthroplasty in the Same Patient Won-Sik Choy, M.D., Ha-Yong Kim, M.D., Kap-Jung Kim, M.D., and Byung-Sup Kam, M.D. Department of Orthopaedic Surgery, Eulji University College of Medicine, Seoul, Korea Purpose: To compare the gait characteristics of unicompartmental knee arthroplasty (UKA) with total knee arthroplasty (TKA) performed on the same patient. Materials and Methods: Twelve female patients with advanced degenerative arthritis of both knee joints were enrolled for the study group. The mean age was 70.3 (64-74) years old. One side of the knee joint had been replaced with UKA and the other side with TKA. The mean follow-up period was 11.8 months for the UKA side and 14.8 months for TKA side. The clinical and radiographic evaluations were performed. The gait features of the study group were assessed using computerized gait analysis. Seven age-matched healthy female volunteers (14 knees) were included as the normal control group. Results: The clinical and radiographic results improved after joint replacement in both groups. The postoperative gait was almost normalized regardless of the type of surgery performed, with the exception of some parameters including the walking speed, mean pelvic tilt, knee flexion at initial contact, peak knee flexion, knee flexion between initial contact and loading response, knee flexion between initial swing phase and mid-stance phase and ankle 3rd rocker. Knee flexion at the initial contact of UKA and TKA groups was similar, and was different from that of the normal control group. At the loading response, the amount of knee flexion was similar between the three groups. Kinetic data of the first peak vertical ground reaction force and hip extension moment at loading response were better in the UKA group. Conclusion: The gait features were normalized in both groups. The UKA group was better normalized than the TKA group in terms of the aspect of the gait features, whereas TKA group showed better correction of deformities. Key Words: Knee, Arthritis, Gait analysis, TKA, UKA 서론퇴행성슬관절염의치료로인공관절치환술은전치환술 (TKA, Total knee arthroplasty) 과단일구획치환술 (UKA, Unicompartmental knee arthroplasty) 이시행되고있으며, 관절전체가이환된경우에는전치환술이, 그리고관절의내측구획만이환된경우에는내측부분만을선택적으로치환하는단일구획치환술 (UKA, 통신저자 : 김하용대전광역시서구둔산동 1306 을지대학교의과대학정형외과학교실 TEL: 042-611-3280 ㆍ FAX: 042-259-1289 E-mail: hykim@eulji.ac.kr Unicompartment knee arthroplasty) 이권장될수있다. 단일구획치환술기법은과거 80년대이전의초기모델에서다양한실패가보고 5,13,17,19,24) 되어자취를감추었으나, 최근디자인의변화, 재료의발달, 그리고수술술기의개선으로성공률이높아지면서다시수술이시행되고있다. 단일구획치환술은전치환술에비해외측구획의관절연골과십자인대를보존하여, 수술후회복 Address reprint requests to Ha-Yong Kim, M.D. Department of Orthopaedic Surgery, Eulji University College of Medicine, 1306, Dunsan-dong, Seo-gu, Daejeon 302-120, Korea Tel: +82.42-611-3280, Fax: +82.42-259-1289 E-mail: hykim@eulji.ac.kr 505
506 최원식ㆍ김하용ㆍ김갑중외 1 인 이빠르고, 조기재활이가능하며입원기간을줄일수있다. 또한, 삽입물의마모나해리가발생하더라도재수술이용이하다는장점이있다. 인공관절수술에대한결과평가로는방사선학적계측, 임상적결과, 장기생존율등여러지표가이용될수있으며, 가장기능적인검증방법으로는보행분석기법이이용되고있다. 전치환술후의보행분석에대하여는많은연구보고 1,4,7,15,23) 있었지만, 단일구획치환술후의환자의보행형태에대한연구는상대적으로적다 6,20,25,28). 이에, 본연구는동일환자에서일측은슬관절단일구획치환술을받았고, 다른일측은전치환술을받은환자군을대상으로보행분석을실시하여정상보행의회복정도를비교분석하고자하였다. 대상및방법 1. 연구대상이환의정도가다른양측의퇴행성슬관절염으로좌ㆍ우측중한쪽은전치환술을, 다른한쪽은단일구획치환술을받은환자로 2003년이후본원에서수술받고, 연구에자발적참여에동의한 12예 24슬관절을대상으로하였다. 평균연령은 70.3세 (64-74) 이었고, 대상환자는모두여성이었다. 슬관절단일구획치환술로 Oxford Uni Knee system (Biomet Inc., Warsaw, IN, USA) 을, 슬관절전치환술로는 LCS Knee system(depuy Orthopaedics Inc., Warsaw, IN, USA) 을사용하였다. 저자들의슬관절단일구획치환술의적응증은 MRI 검사상전방십자인대가온전하고, 15 o 미만의슬관절내반변형, 10 o 미만의슬관절굴곡구축, 내반-외반스트레스방사선사진상슬관절의외측구획이온전한경우로하였으며, 슬관절전치환술의적응증은슬관절의내ㆍ외측구획모두에심한퇴행성관절염이있고, 보존적치료에반응하지않는심한슬관절통증이있는경우로하였다. 대상환자군의보행분석시점은슬관절전치환술후평균 14.6 개월 (6-47) 에단일구획치환술후평균 11.8 개월 (6-34) 에시행하였다. 비교분석을위하여단일구획치환술을받은슬관절을 UKA 군 (n=12), 전치환술을받은슬관절을 TKA군 (n=12) 으로분류하였다 (Table 1). 정상대조군으로는대상환자군과비슷한연령대의건강한여자 7예로하였다. 평균연령은 64.6세 (60-73) 였다. 2. 연구방법 1) 임상적및방사선학적평가임상적평가로 HSS 점수, WOMAC (The Western Ontario and MacMaster Osteoarthritis Index) 점수, 슬관절의운동범위, 내반불안정성, 선호슬관절 (preferred knee), 우세슬관절 (dominant knee on upstairs & downstairs), 쪼그려앉기 (squatting) 가능여 Table 1. Demographics of the Patients and Clinical and Radiographic Results No. Age OP Preop TFA ( o ) Postop TFA ( o ) Preop ROM ( o ) Postop ROM ( o ) R L T U T U FC (T/U) FF (T/U) FC (T/U) FF (T/U) Postop HSS score (T/U) Postop WOMAC score (T/U) 1 72 T U 5 5 +6 +6 10/5 135/135 4/0 145/155 93/95 16/13 2 74 T U 15 +3 +7 +4 15/5 90/130 6/2 145/150 92/95 16/14 3 64 T U 9 6 +6 +4 10/5 130/140 5/3 145/155 93/94 15/12 4 70 U T 0 +3 +6 +3 5/5 140/140 0/0 145/155 93/95 16/13 5 69 T U 6 7 +5 +4 10/5 135/135 4/0 150/155 93/95 15/13 6 65 U T 10 0 +6 +3 10/5 135/135 5/2 150/150 95/96 16/13 7 76 U T +5 0 +6 +4 15/10 130/135 6/3 145/150 95/96 16/13 8 67 T U 0 +1 +4 +7 0/0 135/135 0/0 150/145 98/93 12/15 9 69 T U 10 6 +6 +4 20/10 130/135 4/2 150/155 95/96 15/12 10 76 T U 5 2 +6 +3 20/10 135/135 5/0 145/150 94/95 16/11 11 69 T U 1 +2 +5 +3 10/5 135/140 0/0 145/150 94/94 15/13 12 73 T U 1 1 +6 +3 20/10 125/145 5/0 150/150 93/96 16/12 No., number; OP, operation; T, Total knee arthroplasty; U, Unicompartmental knee arthroplasty; Preop, Preoperative; Postop, Postoperative;, varus; +, valgus; FC, Flexion contracture; FF, Further flexion; R, Right; L, Left.
동일인에서슬관절전치환술및단일구획치환술후보행분석비교 507 부를측정하고, 단순전후면기립방사선사진에서대퇴-경골각 (Tibiofemoral angle, TFA) 을측정하였다 (Table 1). 중앙부에두개설치하였고, 여기서얻어진자료는역동역학 (inverse dynamics) 방법으로소프트웨어처리하였다. 2) 보행분석검사보행검사를통해대상군과대조군의보행선형지수, 운동형상학, 운동역학자료를구하였다. 운동형상학자료를위한표식자 (passive reflective marker) 부착은 Modified Helen-Hayes 방법으로하였고, 피검자는 7 m의포착공간 (capture volume) 을본인에게편안한속도로걷도록하였다. 3차원운동포착 (3-D motion capture) 은 6대의카메라 (Eagle system, Motion A- nalysis, Santa Rosa, CA, USA) 를이용하였고, 카메라는 1초당 120 frame 의속도 (120 Hz) 로각표지의이동을추적하였다. 자료의처리는 EvaRT와 Orthotrak (Motion Analysis, Santa Rosa, CA, USA) 소프트웨어를이용하였다. 운동역학자료를얻기위한힘판 (AMTI force plate, Watertown, Mass, England) 은보행로의 3) 자료처리및분석보행분석자료는매우많은결과물이산출되어어떠한자료가일차적인병적보행인지파악하기가쉽지않으며, 회복의정도를나타내는지표로어떠한지표를검토해야할지일치된의견이없다. 현재쓰이고있는방법들로는첫째그래프의시각적비교, 둘째정상지수 (normalcy Index) 10), PCA (Principle component analysis), KJF (knee joint function) 과같은특정보행분석지수를이용하는방법, 셋째는퇴행성관절염의알려진보행특징지표를분석하는방법들이다. 시각적비교는정량화가되지못하는단점이있으며, 지수를이용하는방법들은주로뇌성마비등의소아보행분석기법이다. 알려진퇴행성슬관절염환자의 1차보행이상은하지의내반정렬, 슬관절의굴곡구축, 체중부하의제한 ( 수직 Table 2. Gait Parameters for Analysis and Results of Each Group Parameters TKA UKA Control 1. Walking speed (cm/sec) 83.9 (±17.0) 73.6 (±8.3) 109.3 (±8.7) 2. Cadence (steps/min) 105.2 (±16.2) 105.2 (±16.2) 117.1 (±6.3) 3. Stride length (cm) 89.9 (±14.3) 89.9 (±14.3) 112.6 (±6.95) 4. Time to toe off (%cycle) 62.8 (±4.7) 63.3 (±2.6) 61.5 (±1.0) 5. Mean Pelvic tilt ( o ) 9.0 (±5.3) 9.0 (±5.3) 14.5 (±2.0) 6. Min hip flexion ( o ) 2.7 (±10.7) 2.3 (±9.8) 2.4 (±2.8) 7. HEM at LR (J) 0.4 (±0.1) 0.5 (±0.3) 0.7 (±0.2) 8. Knee flexion at IC ( o ) 14.7 (±7.3) 12.8 (±4.6) 8.8 (±3.0) 9. Knee flexion at LR ( o ) 22.2 (±5.3) 23.5 (±4.7) 23.0 (±4.9) 10. Knee extension at MST ( o ) 15.9 (±7.4) 16.5 (±5.1) 14.0 (±4.2) 11. Knee flexion at ISW ( o ) 59.0 (±5.6) 59.8 (±5.3) 67.1 (±5.1) 12. ROM (IC-LR) ( o ) 8.1 (±3.6) 10.9 (±3.4)* 15.5 (±2.8) 13. ROM (MST-ISW) ( o ) 46.1 (±7.6) 46.5 (±6.8) 56.1 (±4.4) 14. Knee valgus ( o ) 2.6 (±3.6) 2.0 (±4.9)* 2.7 (±3.7) 15. Knee rotation ( o ) 9.5 (±5.7)* 14.6 (±6.3) 7.2 (±5.7) 16. Max KEM during MST (J) 0.001 (±0.026) 0.019 (±0.018) 0.004 (±0.028) 17. Max KVM during MST (J) 0.000 (±0.049) 0.008 (±0.014) 0.026 (±0.014) 18. Ankle 2 nd rocker ( o ) 16.9 (±2.7) 17.5 (±2.8) 15.6 (±2.3) 19. Ankle 3 rd rocker ( o ) 5.5 (±6.0) 3.9 (±5.3) 10.4 (±4.5) 20. Push-off moment (J) 1.01 (±0.16) 1.14 (±0.21)* 1.10 (±0.18) 21. 1 st peak of v-grf (J) 1.02 (±0.10) 1.07 (±0.85)* 1.08 (±0.14) 22. 2 nd peak of v-grf (J) 1.03 (±0.05) 1.05 (±0.05) 1.01 (±0.12) Parameter 1-4 for the linear parameters, 5-7 for the hip and pelvis, 8-17 for the knee, 18-20 for the ankle and 21-22 for the ground reaction force. *, statistical significance between the TKA group and UKA group., statistical significance between the TKA group and control group., statistical significance between the UKA group and control group., statistical significance between both groups and the control group. Max, maximum; min, minimum; IC, initial contact; LR, loading response; MST, midstance; ISW, initial swing; HEM, hip extensor moment; KEM, knee extensor moment; KVM, Knee varus moment; v-grf, vertical ground reaction force.
508 최원식ㆍ김하용ㆍ김갑중외 1 인 지면반발력의감소 ) 등이며, 이에대한보상기전은보행속도와단하지지지기의감소, 관절안정성을증가시키기위한슬관절신전근과굴곡근의동시수축, 밸런스를유지하기위한족배굴곡과고관절굴곡등이지적되고있다. 이에본연구에서는분석을위한변수로슬관절염과관련이있는 22개의변수를설정하여분석하였으며 (Table 2), UKA 군과 TKA군간의상관관계는 Independent T-test 로통계처리하였다. 통계적유의수준은 95% 신뢰구간으로하였다. 결과 1. 임상적및방사선학적결과 (Table 1) 최종추시시평균 HSS 점수는 UKA 군이 95±0.95 점, TKA군이 94±1.60 점이었고, WOMAC 점수는 UKA군은 12.8±1.03 점, TKA 군은 15.3±1.15점이었다. 양군간 HSS 점수는통계학적으로의미있는차이가없었으나 (p>0.05), WOMAC 점수는 UKA 군이 TKA 군에비하여우수하였다 (p<0.05). 수술후평균굴곡구축은 UKA군이 1.0±1.28 o, TKA 군은 3.7±2.31 o 였고, 수술전과비교해볼때각각 UKA군이평균 5.25 o, TKA 군이평균 8.4 o 의굴곡구축이개선되었다. 평균최대굴곡은 UKA 군이 151.7±3.26 o, TKA 군은 147.1±2.57 o 였고, 수술전과비교해볼때각각 UKA군이평균 15 o, TKA 군이평균 17.5 o 의개선을보였다. 선호슬관절은 UKA군은 9예, TKA 군은 1예, ' 좌우간차이없음 ' 이 2예였고, 우세슬관절은선호슬관절과동일하였다. 또한, 전예에서쪼그려앉기자세가가능하였으며, 내반불안정성도전예에서개선되었다. 수술전평균대퇴- 경골각은 UKA군이내반 1.9± 4.08 o, TKA 군이내반 5.6±6.27 o 였고, 수술후평균대 퇴-경골각은 UKA군은외반 4.0±1.28 o, TKA 군은외반 5.8±0.75 o 였으며통계학적인차이는없었다 (p> 0.05). 수술을통한 UKA 군은평균 5.5 o, TKA 군은평균 10.5 o 의변형교정이되었으며이는양군간통계학적인차이가있었다 (p<0.05). 2. 보행분석결과 1) 보행선형지수 (Parameter 1-4 of Table 2) UKA군과 TKA군의보행선형지수를측정하여정상대조군과비교하였다 (Table 2). 보행속도 (walking speed) 는양군의평균치가정상대조군의평균치에미치지못하였지만 (p<0.05), 일반적으로받아들여지는보행속도의평균값에는도달되었다. 8) 분속수 (cadence) 는대상환자군이 105.2 (steps/min), 정상대조군이 117.1 (steps/min) 로 100 (steps/min) 이상측정되어대상환자군과정상대조군사이에특별한이상이없는것으로나타났으나, 통계학적으로는의미있는차이가있었다 (p <0.05). Chung 등 8) 의정상한국인보행의표준치중해당연령군의표준치와비교해볼때정상인에비하여보행속도가다소감소되었으며, 이는수술후분속수 (cadence) 는정상에가깝게회복되었지만, 활보장 (stride length) 이정상에미치지못하여보행속도가적게회복된것으로나타났다. 2) 운동형상학및운동역학 (1) 골반및고관절 (Parameter 5-7 of Table 2)(Fig. 1, 2) 양군모두에서수술후골반의운동형상학과운동역학은정상화되었다. 즉, 관상면, 시상면, 횡단면에서골반움직임은정상적인사인파를보였다 (Fig. 2). 골반전경사가수술전및동일연령정상대조군의평균치와 Fig. 1. Pelvic kinematics of the UKA and TKA groups. The pelvic motions of both groups showed a normal sinusoidal pattern.
동일인에서슬관절전치환술및단일구획치환술후보행분석비교 509 Fig. 2. Kinematic and kinetic results of the hip joint in the sagittal plane. The hip motion in the sagittal plane (A) were normalized in both UKA and TKA groups. The amount of extensor moment (B) and power generation (C) at the loading response were still less than those in the normal control group. Fig. 3. Knee joint kinematics of the UKA and TKA group. The knee joints of the UKA and TKA groups were not fully extended at the initial contact compared with the normal control group, but rather flexed about 14 o (A). Knee joint alignment in the coronal plane was corrected in the TKA group (B). The knee joint of the UKA group still shows slight varus alignment (B). Tibial external torsion was well corrected in the TKA side than in the UKA side (C). 비교하여통계학적으로유의하게감소하였다 (p<0.05). 고관절굴곡의정도는정상화되었다. 퇴행성슬관절염환자는시상면에서고관절이굴곡된자세로보행을하므로고관절신전모우멘트 (internal hip extension moment) 가과도하게걸리는것으로보고되고있다. 본연구에서는수술후 UKA군이나 TKA군의고관절신전모우멘트는양군간통계학적인차이는없었으나 (p> 0.05), 정상대조군과 TKA군과는통계학적으로의의있는차이를보였다 (p<0.05). (2) 슬관절 (Parameter 8-17 of Table 2)(Fig. 3) 초기입각기에슬관절굴곡정도는 TKA군이평균 14.7 o, UKA 군이평균 12.8 o 로양군간유사하였으나 (p>0.05), 정상대조군의슬관절굴곡정도 8.8 o 와비교할때양군모두초기입각기에굴곡위를보였다 (p <0.05). 하중반응기의슬관절의굴곡정도는 UKA군이평균 23.5 o, TKA 군이평균 22.2 o (p>0.05) 이었으며, 중간입각기에슬관절의신전은 TKA군이평균 15.9 o, UKA군이평균 16.5 o (p>0.05) 이었다. 초기입각기와하중반응기사이의슬관절운동범위는 TKA군이평균 8.1 o 로 UKA 군 (10.9 o ) 에비해유의하게감소되어있었고 (p<0.05), 또한양군모두정상대조군 (15.5 o ) 에비하여유의하게감소되어있었다 (p<0.05). 초기유각기의슬관절굴곡 (peak knee flexion) 은 TKA 군과 UKA군모두평균 59.0 o, 59.8 o 로거의비슷하였지만 (p>0.05), 정상대조군 (67.1 o ) 에비하여는감소되어있었다 (p<0.05). 중간입각기의슬관절내-외반각도는 TKA 군이평균외반 2.6 o, UKA 군이평균내반 2.0 o 였으며, 양군간통계학적으로유의하게 TKA 군에서내반변형의교정정도가좋았다 (p<0.05). 중간입각기에슬관절최대신전모우멘트와슬관절내반모우멘트는 UKA군과 TKA군모두에서정상화되었으며, 정상대조군과통계적유의성을보이지않았다 (p>0.05). 횡단면상에서슬관절회전 ( 경골염전 ) 은 TKA군이 9.5 o 로 UKA군의 14.6 o 에비하여
510 최원식ㆍ김하용ㆍ김갑중외 1 인 Fig. 4. Kinematic and kinetic results of the ankle joint in the sagittal plane. The first and second rockers were quite similar in the three groups, but the third rockers of the UKA and TKA group were less than the normal control group (A). The ankle push off moment (B) and power generation (C) of TKA group were UKA group. Fig. 5. Ground Reaction Force (GRF) of the UKA and TKA groups. The vertical GRF (A) showed two peaks during the loading response and push-off period. The first peak of the vertical GRF was almost normalized in the UKA side. The second peak of the vertical GRF was similar in both groups. 정상에가깝게교정된것을보였다 (p<0.05). (3) 족관절 (Parameter 18-20 of Table 2)(Fig. 4) 시상면상에서의족관절의입각기최대족배굴곡 ( 제 2 차호 (2 nd rocker)) 은세군간에유사하였다. 입각기최대족저굴곡 ( 제 3차호 (3 rd rocker)) 은 TKA군 (-5.5 o ) 과 UKA군 (-3.9 o ) 모두에서족저굴곡의정도가정상대조군 (-10.4 o ) 에는미치지못했다 (p<0.05). 운동역학그래프상에서발들림 (push-off) 모우멘트는양군간통계학적차이가있었으며 (p<0.05), UKA 군이정상대조군에가까운결과를보였다. (4) 수직지면반발력 (Parameter 21-22 of Table 2)(Fig. 5) 수직지면반발력은입각기동안두번의봉우리를보이는데, 제1차봉우리 (1 st peak of vertical GRF) 는하중반응기 (loading response) 에, 제2차봉우리 (2 nd peak of vertical GRF) 는발들림기 (push-off) 에나타난다. 수직 지면반발력의 1 차봉우리는 UKA 군 (1.1) 에서 TKA 군 (0.9) 에비하여더욱정상에가까운결과를보였다 (p< 0.05). 제 2 차봉우리는세군간에유사하게측정되었다. 고찰퇴행성슬관절염이단일구획에만제한된경우이환된구획만을치환하는단일구획치환술이수술적적응이될수있다 2,13). 슬관절의내, 외측모두를치환하는전치환술에비해단일구획치환술은환자들의골변형과연부조직의구축이상대적으로덜심하므로수술도중뼈의절제나연부조직의유리술면에서수술의범위가적고, 전방십자인대등의지지구조물을유지할수있다. 많은저자들이수술후임상적인비교에서단일구획치환술이전치환술에비하여양호하다고보고하고있다 2.6,26). Laurencin 등 18) 은임상적으로수술후최대굴곡이 UKA군은 123 o, TKA 군은 110 o, 선호슬관절은 UKA군 44%, TKA군 12% 를보였다고보고하였다. 본
동일인에서슬관절전치환술및단일구획치환술후보행분석비교 511 연구에서는굴곡구축은양군에서거의교정되었고, 최대굴곡은 Laurencin 등 18) 의보고와같이 UKA군에서좀더좋은결과를보였다. 선호슬관절과우세슬관절의평가에서도 UKA군에서 75% (9예) 로 TKA군보다많았다. 슬관절전치환술후환자는보행능력의회복이라는측면에서일반적으로좋은결과를보이는것으로보고되고있다. 본연구에서 TKA군과 UKA군모두에서수술후정상에가까운보행양상을보였다 (Table 2). 그러나 Murray 등 21), Skinner 등 27), Collopy 등 9) 과 Olsson과 Barck 22) 는슬관절전치환술후보행능력은향상되었지만, 그형태는정상보행과는일정부분다르다고보고하였다. 정상보행의형태에비하여활보장 (stride) 이작고, 입각기에슬관절굴곡의감소, 슬관절굴곡- 신전모우멘트값의비정상적인보행패턴을보인다고알려져있다 12,21). 본연구에서도인공슬관절치환술후이와유사한보행패턴을보였으나, 모우멘트값은정상과유사하게측정되었다. Mattsson 등 20) 에의하면 UKA 후보행속도 (walking speed) 가향상되며, 그정도는수술후치료척도 (parameters) 로도이용될수있다고보고하였다. Mattsson 등 20), Weidenhielm 등 29) 은단일구획치환술후보행속도, 단일하지지지 (single limb support), 보장 (step length) 은증가하는것으로보고하였다. 이러한보고는수술전과후를비교한것으로, 본연구에서이에대한조사는제외되었다. 수술후환자들은단일하지지지등많은지표가정상화되었지만, 활보장은정상보다짧았고 (UKA 93%, TKA 90%), 이로인해보행속도는정상의 84% 정도이었다. 활보장이여전히짧은것은수술후잔여변형으로서의슬관절굴곡구축과연관이있으리라사료된다. 시상면상의운동형상학적인측면에서퇴행성슬관절염환자는고관절굴곡, 슬관절굴곡, 족관절과도배굴 (hyper-dorsiflexion) 이라는엉거주춤한자세 (crouching position) 가특징적이다 14). 본연구에서 TKA 군과 UKA군모두에서입각기의골반전경사, 고관절굴곡, 슬관절굴곡구축, 족관절의제2호 (second rocker) 가호전되어중간입각기에는곧은자세를보여정상대조군과비교하여많은변수에서통계적으로유의한차이를보이지않았다. 통계적차이를보인것은네가지였는 데, 첫째는 TKA군과 UKA군모두에서대조군에비교하여초기입각기에슬관절이굴곡경향을보였다. 이는잔여굴곡구축이보행동안에불리하게작용함을단적으로보여준것이다. 둘째는 TKA군이 UKA군에비교하여초기입각기 -하중반응기간의관절운동범위가적었다는점이다. 이기간은체중흡수기 (weight acceptance) 에해당되며, 이구간동안스프링과같이약간의굴곡을통해충격을흡수한다. 여러저자들은슬관절전치환술후하중반응기에적절한슬관절굴곡을하지못한다고하였다 7,23). 본연구에서도하중반응기에 TKA군이 UKA군에비하여덜굴곡한것으로나타났다. 이에대한설명으로 Dorr 등 11) 은정상연골면간의마찰계수보다, 수술로삽입된금속과플라스틱사이의마찰계수가더크고, 수술전동통으로인한경직된슬관절보행 (stiff knee gait) 이습관화된때문이라고하였다. 반면에다른저자들은대퇴사두근의필요를감소또는회피하려는현상즉, 대퇴사두근회피현상 (quadriceps avoidance pattern) 때문이라고하였다 1,6). 셋째는유각기의슬관절최대굴곡 (peak knee flexion) 의정도로, 양측슬관절염환자를대상으로김 16) 의연구결과 (49 o ) 에비하여상당부분회복되었지만, 정상대조군에비하여는감소되어있었다. Webster 등 28) 은단일구획치환술후 12명환자중 8명에서정상적인슬관절굴곡이회복됨을보고하였다. 좀더장기추시후에굴곡의정도가회복되는지여부는앞으로의과제라고할수있겠다. 넷째는골반전경사각으로수술후평균 9 o 로정상대조군의 14.5 o 보다감소하여, 20대중반의한국인평균치와유사하였다 8). 골변형의교정이라는측면에서관상면상에서슬관절의내반정렬과횡단면상에서의경골염전에대한교정은 TKA군에서더욱정상적으로교정되었다 (p<0.05). 이는수술의범위와밀접한연관이있으리라추정된다. 전치환술의경우수술자의술기에따라골과연부조직의완벽한교정이가능한데반해, 단일구획치환술의경우에는슬관절의내측구획만을치환하므로완전한의미의교정절골술을시행하는데제한이따른다. 이러한잔여골변형, 특히단일구획치환술후내반변형이남아있는경우, 보행도중외적내반모우멘트가걸려인공관절의수명에좋지않은영향을줄수있으므로, 잔존하는내반변형이인공관절의수명에어떠한영향을주는가에대하여는장기추시가필요하리라사료된다.
512 최원식ㆍ김하용ㆍ김갑중외 1 인 운동역학적측면에서하중부하기의수직지면반발력, 초기입각기에고관절신전힘생성, 말기입각기시족관절발들림 (push-off) 힘등은 UKA군에서더대조군과유사한결과보였다. 이런결과가의미하는것은좀더나은입각기의안정성 ( 수직지면반발력 ) 과전방추진력 ( 힘생산근육 - 고관절신전근, 족저굴곡근 ) 의제공이라고할수있다. UKA 군에서운동역학적인면에서좀더낳은이유는전술한운동형상학적이유와많은인체조직을보존하였다는이유외에도, 관절염의이환정도가덜하기때문에, 슬관절자체와근육등의주변구조물이좀더건강한상태에서수술이시행되었다는점도중요한이유가될수있을것으로사료된다. UKA군과 TKA 군의비교연구를통해밝혀진것은, 수술후 UKA 군이관상면상에서의병적내반변형의교정은조금덜되었지만, 시상면상에서의슬관절굴곡- 신전이나, 운동역학적분석에서좀더정상보행에접근되어있었다는점이다. 이러한결과를보인데는여러가지이유가있을수있다. Barrett 등 3) 은골관절염의진행정도에따라위치감각 (proprioception) 이소실된다고하였는데, UKA 군은보존된골및인대조직등으로위치감각의훼손이적다고사료된다. Dennis 등 10) 은정상슬관절역학에서전방십자인대가중요한역할을한다고보고하였으며, 그외여러저자들은단일구획치환술후십자인대보존으로더욱정상에가까운기능을할것으로보고하였다 6,25). 결론만성퇴행성관절염으로수술적치료를받은환자에서단일구획치환술과전치환술후보행의양상이정상에가까운회복을보였다. 골변형교정이라는측면에서대퇴-경골각의교정과슬관절염전교정은슬관절전치환술을받은군에서더욱정상적인정렬을보였다. 그러나기능적인면에서시상면상에서하중반응기의슬관절굴곡의정도와수직지면반발력, 초기입각기의고관절신전모우멘트등에서단일구획치환술이더욱정상에가까운회복을보였다. 본연구가수술후추시기간이 1년여정도로단기연구의한계를가지고있으며, 향후장기적인회복정도에대한연구가필요하리라사료된다. 참고문헌 1. Andriacchi TP: Functional analysis of pre and post-knee surgery: total knee arthroplasty and ACL reconstruction. J Biomech Eng, 115: 575-581, 1993. 2. Argenson JN, Chevrol-Benkeddache Y, Aubaniac JM: Modern unicompartmental knee arthroplasty with cement: a three to ten-year follow-up study. J Bone Joint Surg Am, 84: 2235-2239, 2002. 3. Barrett DS, Cobb AG, Bentley G: Joint proprioception in normal, osteoarthritic and replaced knees. J Bone Joint Surg Br, 73: 53-56, 1991. 4. Berman AT, Zarro VJ, Bosacco SJ, Israelite C: Quantitative gait analysis after unilateral or bilateral total knee replacement. J Bone Joint Surg Am, 69: 1340-1345, 1987. 5. Cameron HU, Jung YB: A comparison of unicompartmental knee replacement with total knee replacement. Orthop Rev, 17: 983-988, 1988. 6. Chassin EP, Mikosz RP, Andriacchi TP, Rosenberg AG: Functional analysis of cemented medial unicompartmental knee arthroplasty. J Arthroplasty, 11: 553-559, 1996. 7. Chung CY, Seong SC, Lee MC, Moon YW, Kim TG, Lim ST: Gait analysis after total knee arthroplasty. J Korean Orthop Assoc, 32: 1290-1301, 1997. 8. Chung CY, Park MS, Choi IH, Cho TJ, Yoo WJ, Kim JY: Three dimensional gait analysis in normal Korean: a preliminary report. J Korean Orthop Assoc, 40: 83-88, 2005. 9. Collopy MC, Murray MP, Gardenr GM, DiUlio RA, Gore DR: Kinesiologic measurements of functional performance before and after geometric total knee replacement: one-year follow-up of twenty cases. Clin Orthop Relat Res, 126: 196-202, 1977. 10. Dennis D, Komistek R, Scuderi G, et al: In vivo threedimensional determination of kinematics for subjects with a normal knee or a unicompartmental or total knee replacement. J Bone Joint Surg Am, 83(Suppl 2 Pt 2): 104-115, 2001. 11. Dorr LD, Ochsner JL, Gronley J, Perry J: Functional comparison of posterior cruciate-retained versus cruciate-sacrificed total knee arthroplasty. Clin Orthop Relat Res, 236: 36-43, 1988. 12. Ferkul D, Peat M, Woodbury MG: Changes in temporal characteristics and knee joint angles in total knee arthroplasty patients. Physiotherapy Canada, 34: 313-318, 1982.
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514 최원식ㆍ김하용ㆍ김갑중외 1 인 = 국문초록 = 목적 : 동일환자에서시행한슬관절단일구획치환술 (UKA) 과전치환술 (TKA) 후보행을비교하고자하였다. 대상및방법 : 동일환자에서슬관절전치환술과단일구획치환술을받은 12 예를대상으로하였다. 평균연령은 70.3 세 (64-74) 였다. 보행분석은슬관절전치환술후평균 14.6 개월, 단일구획치환술후 11.8 개월에시행하였다. 임상적, 방사선평가및 3 차원보행분석을시행하였다. 비슷한연령대의여자 7 예를대조군으로하였다. 결과 : 양군모두임상적, 방사선학적으로호전되었다. 보행속도, 골반경사, 초기입각기의슬관절굴곡, 최대슬관절굴곡, 초기입각기에서하중반응기사이의슬관절운동범위와중간입각기에서초기유각기사이의슬관절운동범위및족관절의 3 호족저굴곡을제외하고양군에서정상보행형태를보였다. 시상면상초기입각기에서양군의슬관절굴곡정도가유사했으나정상대조군과차이가있었으며, 하중반응기에서는양군과정상대조군간에차이는거의없었다. 운동역학에서말기입각기의발들림모우멘트, 하중반응기의수직지면반발력, 초기입각기의고관절신전모우멘트및힘값에서 UKA 군이정상에가까운결과를보였다. 결론 : 단일구획치환술과전치환술후보행양상은정상에가깝게회복되었다. 골변형교정은전치환술을시행받은군에서더욱정상적인정렬을보였으며, 운동역학적으로는지면반발력등의측면에서 UKA 군이더욱정상에가깝게회복되었다. 색인단어 : 슬관절, 퇴행성관절염, 보행분석, 전치환술, 단일구획치환술