218 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2018; 53: 218-225 https://doi.org/10.4055/jkoa.2018.53.3.218 www.jkoa.org 관절경하회전근개봉합술시윤활낭절제정도에따른통증및파워도플러초음파결과 : 전절제술과최소절제술시초기 3 개월간의비교 최창혁 곽병훈 이성호 대구가톨릭대학교병원정형외과 Pain and Power Doppler Ultrasonographic Evaluation according to Bursal Preservation after Arthroscopic Rotator Cuff Repair: Comparison between Complete and Minimal Bursectomy in Early 3 Months Chang Hyuk Choi, M.D., Byung Hoon Kwack, M.D., and Sung Ho Lee, M.D. Department of Orthopaedic Surgery, Daegu Catholic University Medical Center, Daegu, Korea Purpose: The purpose of this study was to compare the clinical and power Doppler ultrasonographic results of arthroscopic rotator cuff repair (ARCR) between using a complete and a minimal bursectomy. Moreover, we aimed to evaluate the pain-relief and neoangiogenesis according to bursal preservation. Materials and Methods: Between December 2015 and August 2016, we performed a retrospective review of 78 consecutive patients who underwent ARCR due to full thickness rotator cuff tear (small-large sized tear). Thirty-six patients received ARCR using minimal bursectomy (Group A), while 42 patients received ARCR via complete bursectomy (Group B). The mean age was 57.8 years and the average symptom duration period was 20.3 months. Clinical result was assessed using a visual analogue scale (VAS) pain score due to evaluate the pain-relief and power Doppler ultrasonographic result was classified according to the modified Newman classification due to evaluate the neoangiogenesis. Results: There was no statistically significant difference in operation time, pain-relief, and neoangiogenesis in accordance with bursal preservation between the two groups. Compared to the preoperative values, pain was significantly increased two weeks postoperatively in both groups (Group A: -1.8±1.4, p=0.000; Group B: -1.4±1.7, p=0.000). Compared to the preoperative values using the power Doppler ultrasound, neoangiogenesis was significantly improved at the postoperative 6 weeks (Group A: 0.7±0.9, p=0.000; Group B: 0.9±1.1, p=0.000) and 3 months (Group A: 0.9±1.0, p=0.000; Group B: 1.0±1.1, p=0.000) in both groups. Conclusion: Serial follow-up by power Doppler ultrasound before and after ARCR showed a neoangiogenesis of up to 3 months in both groups, but there was no difference in pain-relief and neoangiogenesis between the two groups. Key words: shoulder, rotator cuff, bursal preserving procedure, Doppler ultrasound, neoangiogenesis Received February 22, 2017 Revised June 13, 2017 Accepted August 26, 2017 Correspondence to: Byung Hoon Kwack, M.D. Department of Orthopaedic Surgery, Daegu Catholic University Medical Center, 33 Duryugongwon-ro 17-gil, Nam-gu, Daegu 42472, Korea TEL: +82-53-650-4054 FAX: +82-53-626-4272 E-mail: kwackbyunghoon@nate.com ORCID: https://orcid.org/0000-0003-4795-8294 The Journal of the Korean Orthopaedic Association Volume 53 Number 3 2018 Copyright 2018 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.
219 Comparison between Complete and Minimal Bursectomy in Early 3 Months 서론 회전근개봉합술시견봉하윤활낭절제술은수술시야확보, 염증성및괴사조직을제거하여통증경감및치유능력개선, 봉합된조직에가해지는장력감소를위하여시행되고있다. 윤활낭절제술은봉합하기에약하고괴사된건조직과윤활낭 (falciform edge) 을제거하여회전근개의파열단부위가튼튼한봉합이가능하도록도와주며, 윤활낭내부에존재하는통증감각과관련된신경말단을제거함으로써통증완화에도도움이되는것으로알려져있다. 1,2) 반면에 Uhthoff와 Sarkar 3) 는견봉하윤활낭에외인성치유과정에서중요한역할을하는섬유혈관 (fibrovasular) 세포들이많이존재함을보고하면서봉합된조직의재생력을높이기위해서윤활낭절제술을최소화할것을주장하였다. 건치유는힘줄내에존재하는힘줄세포 (tenocyte) 의증식에의한내인성 (intrinsic) 치유와활액막과같은힘줄주위조직에서세포들의이동에의한외인성 (extrinsic) 치유로구분되며이러한과정들은동시에진행되는것으로알려져있다. 4) Chillemi 등 5) 은회전근개의치유과정에서젊은환자들의경우에는내인성치유가활발히이 루어지나나이가들어감에따라서윤활낭이관여하는외인성치유의기여도가증가함을보고하면서윤활낭의신생혈관형성 (neoangiogenesis) 이활발히이루어짐을보고하였다. 그러나회전근개의치유과정에대한이러한연구들은조직학적연구결과로서실제임상적의의를확인하기에는한계가있었다. 최근초음파기술및프로그램발달로초음파의해상도가개선되어진단에대한신뢰도가개선되고있으며파워도플러초음파의경우에는관절의정상혈류를감지할수있을정도로기술이개선되었다. 6) 이로인하여류마티스환자들의활액막염에대한평가에사용되던파워도플러초음파도작은관절에서어깨로적용범위가확대되고있으며혈관신생도확인해볼수있게되었다. 7) 이에저자들은윤활낭절제술의양에따라통증및외인성치유와관련된염증성조직의제거에차이가발생할수있으며이로인하여통증및신생혈관형성의결과에도변화가있을것으로가정하였다. 본연구의목적은윤활낭전절제술과최소윤활낭절제술로회전근개봉합술을받은환자들에대하여윤활낭절제술의양에따른통증경감정도및파워도플러초음파상신생혈관형성의차이를평가해보고자하였다. A B C D E F Figure 1. Representative arthroscopic images of the rotator cuff repair using a minimal bursectomy on the right shoulder (A C) and a complete bursectomy on the left shoulder (D F).
220 Chang Hyuk Choi, et al. 대상및방법 1. 연구대상본연구는대구가톨릭대학교병원생명의학연구윤리위원회 (institutional review board) 로부터연구승인을받고시행되었다 (CR- 17-020-L). 2015년 12월부터 2016년 8월까지본원에서회전근개전층파열 ( 소파열-대파열 ) 로관절경하회전근개봉합술을시행한 81예를대상으로후향적연구를시행하였다. 회전근개전층파열로관절경하회전근개봉합술을시행한환자중 3개월간연속적인외래초음파추시관찰이가능하였던환자를대상으로하였다. 부분층파열및광범위파열환자, 견봉성형술및오구견봉인대절제술을동시에시행한환자, 류마티스관절염등과같은염증성질환의과거력이있는환자, 추시관찰중재파열이확인된환자는배제하였다. 최소윤활낭절제술 (Group A) 은수술시야확보를위해서견봉쇄골관절과오구견봉인대아래부위및파열된부위 (tear margin and foot print) 주위만윤활낭절제술을시행한경우로정의하였고, 윤활낭전절제술 (Group B) 은내측으로는견봉쇄골관절아래에서시작하여후방으로견갑극 (scapular spine) 을확인하고후내측구석까지, 외측으로는견관절전측구 (gutter) 에서시작하여후방으로후측구까지윤활낭절제술을시행하는경우로정의하였다 (Fig. 1). 수술순서에따라윤활낭절제술의방법을번갈아가면서시행하여표집편향 (sampling bias) 을줄이려고노력하였으나최소윤활낭절제술을시행하기로계획하였던 12예가회전근개의안정적인봉합을위하여건의가동을위한유착박리술 (adhesiolysis) 을하는과정에서불가피하게전절제술이되어이경우윤활낭전절제술로전환되었다. 정기적인외래추시관찰이나초음파검사가불가능하였던 3예를제외한 78예 (96.3%) 가연구에포함되었으며, Group A가 36예, Group B는 42 예였다. 환자의평균나이는 57.8세 (35-80세) 였고남성이 47명, 여성이 31명이었다. 우측이 54예, 좌측이 24예였고과거력상당뇨가있는환자가 8예, 흡연중인환자가 11예였다. 평균신체질량지수는 24 kg/m 2 (18.9-33.6 kg/m 2 ) 였고평균증상이환기간은 20.3개월 (2-120개월) 이었다. 윤활낭절제술방법에따른환자의인구통계학적자료에서유의한차이는보이지않았다 (Table 1). 2. 초음파검사방법모든초음파검사는동일술자에의해이루어졌으며 Philips iu22 (Philips Healthcare, Bothell, WA, USA) 의 12-5 MHz 선형탐촉자 (linear array tranducer) 를사용하였다. 환자는의자에앉고검사자가환자의뒤에서서전반적인어깨초음파검사를시행하였으며, 극상건을최대한노출시키기위해서환자의상태에따라 Crass 자세나변형 Crass 자세를적용하였다. 8) 수술부위에대한전반적인검사를시행한후 7.5 MHz 파워도플러모드로전환하여견봉하윤활낭에대한검사를시행하였으며, 신호강도가가장강하게나오는부위의장축및단축에대하여 5초간동영상을녹화하였다. 견봉하윤활낭에대한혈류를반정량적으로평가하기위하여 Newman의분류 9) 를변형하여 4단계로정의하였다. 0 단계를신호가없거나암적색의신호강도를보이는상태로, 1단계를암적색에서적색의단일혈관신호가보이는상태로, 2단계를적색에서오렌지색의혈관들이융합하는신호가보이는상태로, 3단계를오렌지색에서노란색의융합하는혈관들의길이가 5 mm 이상인상태로정의하였으며장축및단축에서강한신호강도가나오는영상으로단계를결정하였다 (Fig. 2). 3. 수술및재활과통증조절방법모든수술은동일술자에의해시행되었으며사각근간마취하 Table 1. Demographic Data Variable Group A (n=36) Group B (n=42) p-value Age (yr) 58.4±8.1 57.2±9.1 0.553 Sex (male:female) 23:13 24:18 0.554 Position (right:left) 24:12 30:12 0.650 Presence of diabetes 0.134 Yes 6 2 No 30 40 Presence of smoking 0.100 Yes 8 3 No 28 39 Body mass index (kg/m 2 ) 23.8±3.3 24.2±3.0 0.548 Symptom duration (mo) 20.1±23.3 20.5±23.7 0.935 Values are presented as mean±standard deviation or number only. Group A, using minimal bursectomy; Group B, using complete bursectomy.
221 Comparison between Complete and Minimal Bursectomy in Early 3 Months A B C Figure 2. Power Doppler ultrasound image of the repaired rotator cuff at the peritendinous region. The vascularity was classified according to the modified Newman classification. (A) Power Doppler signal (PDS) grade 1 (arrow). (B) PDS grade 2 (arrow). (C) PDS grade 3 (arrow). 에반좌위에서시행되었다. 견봉하윤활낭절제술을제외한나머지수술과정은동일하게진행되었다. 전층파열의크기분류는 Cofield 분류 10) 를이용하였다. 모든환자는술후 6주간외전보조기를착용하였으며술후다음날부터술후 2주사이에수술부위의상태에따라서시계추운동및수동적견관절운동을시작하였다. 술후 6주부터보조적인능동적관절운동 (active-assisted exercise) 을시행하였다. 술후 3개월에는일상적인활동및가벼운운동복귀를허용하였다. 수술시유치한견봉하공간유치도관을통한일회성의 bupivacaine 국소주사와다중통증조절법을통하여수술후통증조절을시행하였다. 11) 4. 임상및초음파평가환자들은본원외래에서수술후 3개월까지연속적추시경과관찰이시행되었으며임상평가는동일술자에의해평가되었다. 모든환자의의무기록 ( 입원및외래의무기록, 수술기록, 초음파사진및영상 ) 은후향적으로분석되었으며, 파워도플러를이용한 Modified Newman 분류에따른신생혈관형성에대한관찰자내및관찰자간신뢰도를확인하기위하여임상결과를숨긴채초음파동영상을이용하여 2명의정형외과전문의에의해독립 적으로측정되었다. 임상결과는수술전과술후 6, 12, 24, 48, 72시간, 2, 6주, 3개월의추시결과에서시각통증등급 (visual analogue scale, VAS) 을이용하여통증의차이를비교평가하였다. 파워도플러초음파결과는수술전과술후 6주, 3개월의추시결과에서측정한 modified Newman의분류로신생혈관형성의차이를비교평가하였다. 5. 통계분석통계적인분석은 SPSS ver. 12.0 (SPSS Inc., Chicago, IL, USA) 프로그램을이용하여연속형변수에대해 independent t-test와 Paired t-test, 범주형변수에대해카이제곱검정이나 Fisher의정확검정을사용하였다. 모든분석의통계적유의수준은 p값이 0.05 미만인경우로하였다. 관찰자간신뢰도는 Cronbach α 계수를사용하였고관찰자내신뢰도는동일인에의해 1주일간시간차를두고측정한 1차및 2차계측치를 Pearson 상관계수를사용하여분석하였다.
222 Chang Hyuk Choi, et al. 결과 평균수술시간은 91.1분이소요되었으며전층파열의크기는소파열 15예, 중파열 39예, 대파열 24예였고봉합방법은일렬봉합술 67예, 경골-유사봉합술 11예였다. 양군간에통계적으로유의한차이는확인할수없었다 (Table 2). VAS는수술전, 술후 6, 12, 24, 48, 72시간, 2, 6주, 3개월의평균이각각 2.3, 2.0, 6.3, 3.5, 2.6, 2.2, 0.8, 0.5, 0.2였으며양군간에통계적으로유의한차이는확인할수없었다 (Table 3). 수술전통증과비교해보면양군모두에서술후 48시간 (Group A: 0.2±1.8, p=0.465; Group B: 0.4±1.9, p=0.233), 72시간 (Group A: -0.1±1.9, Table 2. Operative Data Variable Group A (n=36) Group B (n=42) p-value Operation time (min) 89.7±25.9 92.3±20.7 0.628 Rotator cuff tear size 0.621 Small 6 9 Medium 17 22 Large 13 11 Repair technique 0.746 Single row repair 30 37 Transosseous-equivalent repair 6 5 Values are presented as mean±standard deviation or number only. Group A, using minimal bursectomy; Group B, using complete bursectomy. p=0.859; Group B: -0.2±1.8, p=0.556) 에술전통증상태와유사한수준으로통증이감소함을확인할수있었으며술후 2주에술전과비교하여의미있는통증호전을확인할수있었다 (Group A: -1.8±1.4, p=0.000; Group B: -1.4±1.7; p=0.000). 신생혈관에대한 modified Newman 분류는수술전, 술후 6주, 3개월의평균이각각 0.8, 1.6, 1.8 이었으며양군간에통계적으로유의한차이는확인할수없었다 (Table 4). 수술전신생혈관상태와비교해보면양군모두에서술후 6주 (Group A: 0.7±0.9, p=0.000; Group B: 0.9±1.1, p=0.000) 및 3개월 (Group A: 0.9±1.0, p=0.000; Group B: 1.0±1.1, p=0.000) 에신생혈관증가를확인할수있었으나술후 6주와 3개월사이의변화는통계적으로유의한차이를확인할수는없었다 (Group A: 0.2±0.6, p=0.070; Group B: 0.1±0.8, p=0.262). Modified Newman 분류에따른혈관신생에대하여관찰자내및관찰자간신뢰할수있는수준의신뢰도를확인할수있었다 (Table 5). 수술후 3개월까지건의단락이소실된재파열소견을보인예는없었다. 고찰 견봉하윤활낭에는고유수용성감각및통각에관여하는신경말단및건의재생에관여하는다양한세포들이포함되어있는것으로알려져있으나회전근개전층파열시통증을유발하는염증성사이토카인을분비하는중요한역할을하는등상반된조직학적의의를갖는것으로알려져있다. 2,4,12-14) 그러나회전근개봉합술시염증의원인이되는윤활낭에의한통증및봉합된건의장력해소를위해서완전한윤활낭절제술은필수적인과정으로 Table 3. VAS Pain Scores according to the Time Dependent between the Group Time Group A Group B CI of the difference p-value Preoperative 2.5±1.8 2.1±1.5-0.3 1.1 0.297 Postoperative (h) 6 2.1±2.2 1.9±1.9-0.8 1.1 0.786 12 6.7±1.7 5.9±2.3-0.1 1.8 0.070 24 3.9±1.6 3.2±1.7-0.1 1.5 0.060 48 2.8±1.3 2.5±1.4-0.4 0.9 0.415 72 2.5±1.4 2.0±1.2-0.1 1.1 0.096 Postoperative (wk) 2 0.8±0.8 0.8±0.9-0.4 0.4 0.958 6 0.5±0.7 0.5±0.7-0.3 0.3 0.979 Postoperative (mo) 3 0.1±0.3 0.3±0.8-0.4 0.1 0.173 Values are presented as mean±standard deviation. VAS, visual analogue scale; Group A, using minimal bursectomy; Group B, using complete bursectomy; CI, confidence interval.
223 Comparison between Complete and Minimal Bursectomy in Early 3 Months Table 4. Neoangiogenesis according to Modified Newman Classification between the Group Time Group A Group B CI of the difference p-value Preoperative 0.7±0.8 0.9±0.9-0.5 0.2 0.476 Postoperative 6 weeks 1.4±0.9 1.8±1.0-0.8 0.1 0.103 Postoperative 3 months 1.6±1.0 1.9±0.8-0.7 0.1 0.144 Values are presented as mean±standard deviation. Group A, using minimal bursectomy; Group B, using complete bursectomy; CI, confidence interval. Table 5. Reliability of Vascularity according to Modified Newman Classification Reliability Intra-observer* Inter-observer Preoperative 0.913 0.923 Postoperative 6 weeks 0.890 0.953 Postoperative 3 months 0.906 0.930 *Pearson correlation coefficient (p<0.05). Cronbach α (p<0.05). 여겨져왔다. 하지만윤활낭의절제정도에따른혈관신생효과및회전근개치유과정에미치는영향을확인하기위한연구는없었다. 저자들은회전근개봉합술시시행한견봉하윤활낭절제술의정도에관계없이양군모두에서통증감소및신생혈관형성을확인할수있었으나차이점을확인할수는없었다. Boss 등 15) 은회전근개봉합술후 48시간이내에수술후심한통증이발생함을보고하였다. 이러한수술후초기통증조절을위해견봉하일회성 bupivacaine 국소주사와다중통증조절법의안정성과유용성이보고된바있다. 11) 본연구에서도동일한방법을적용하여양군모두에서수술후초기통증을효과적으로조절할수있었으며술후 2주이후에는술전에비해의미있는통증호전을얻을수있음을확인할수있었다. 파워도플러는움직이는혈구의속도대신신호의크기만을보여주므로영상의노이즈가작아서일정한혈류의흐름보다는혈액이정체된곳의미세한혈류를관찰하는데유용한방법으로알려져있으며, 이러한특성으로인하여조직의관류 (perfusion), 염증, 신생혈관의확인에이용되고있다. 16) Kitchen과 Kane 17) 은건강한사람들을대상으로시행한정상관절에대한초음파검사상견관절에서는 60예전체예에서 0단계의파워도플러검사결과를보고하였다. 본연구에서는수술전시행한파워도플러검사상평균 0.8의변화를양군모두에서확인할수있어서통증의원인이되는견봉하윤활낭염을파워도플러검사를통하여반정량적으로확인할수있었다. Fealy 등 18) 은회전근개봉합술후견봉하윤활낭주위의혈류형성이가장활발하게진행되며이러한혈관신생반응은수술후가장강하게형성되고, 시간이경과함에따라줄어드는양상을보임을보고하였다. 그러나 Urita 등 19) 은경골-유사봉합술을시행한환자의윤활낭주위혈류신생이 3개월까지증가한이후 감소하는양상을보임을보고하였다. 본연구에서도양군모두에서수술전과비교하여술후 6주와 3개월째의미있는신생혈관증가를확인할수있었으나술후 6주에비해 3개월째증가된신생혈관의변화에대한통계적차이를확인할수는없었다. 본연구는다음과같은한계를가진다. 첫째, 전향적연구보다비뚤림가능성이큰후향적연구라는점이다. 둘째, 최소윤활낭절제술을시행하던중환자의건유착정도및윤활낭상태에따라서윤활낭전절제술로전환한환자들이포함되어있어서선택의비뚤림을배제할수없다는점이다. 셋째, 혈류를반정량적으로평가하기위하여 Newman 의분류를변형하여적용하였으나류마티스활액막염에대한평가기준을정상적인치유과정의염증반응에적용하였다는점이다. 넷째, 본연구는혈류증가소견이치유와관련되는지에대해서확인하고자하는것이아니라초기통증과의관련여부를확인하는데있는바, 수술이후통증영향이큰첫 3개월로추시기간을설정하여짧은추시기간으로인하여초기통증및신생혈관형성에대한비교는가능하였으나신생혈관형성의정도에따른재파열및임상평가를비교할수없었다는점이다. 다섯째, 제거되는윤활낭의양을정량화하기위하여소파열-대파열이하로환자들을제한하였으나명확하게수치로정량화할수없었다는점이다. 그러나동일기관에서동일술자에의해윤활낭절제술을제외한동일한방법으로수술및추시관찰이진행되어결과도출과정에서발생할수있는비뚤림을최소화할수있었다고생각하며이점이본연구의강점으로생각된다. 요약하자면윤활낭절제술의양에따른수술시간, 통증경감, 신생혈관형성에차이는없었으나양군모두에서술후 48시간에술전통증상태와유사한정도로통증이호전되었으며 2주에의미있는통증호전을확인할수있었다. 파워도플러초음파를이용하여술후 6주와 3개월에신생혈관증가소견을확인할수있었으나회전근개치유에대한연관성을확인하기위해서는장기간추적관찰이필요할것으로판단된다. 결론 파워도플러초음파를통하여수술전과비교하여술후에양군모두에서의미있는신생혈관증가소견을확인할수있었으나
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225 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2018; 53: 218-225 https://doi.org/10.4055/jkoa.2018.53.3.218 www.jkoa.org 관절경하회전근개봉합술시윤활낭절제정도에따른통증및파워도플러초음파결과 : 전절제술과최소절제술시초기 3 개월간의비교 최창혁 곽병훈 이성호 대구가톨릭대학교병원정형외과 목적 : 윤활낭전절제술과최소윤활낭절제술로회전근개봉합술을받은환자들의임상및파워도플러초음파결과를평가하여윤 활낭절제정도에따른통증경감및신생혈관형성에대한차이를평가해보고자하였다. 대상및방법 : 2015 년 12 월부터 2016 년 8 월까지대구가톨릭대학교병원에서회전근개전층파열 ( 소파열 - 대파열 ) 로관절경하회전 근개봉합술을시행한 78예를대상으로후향적연구를시행하였으며최소윤활낭절제술 (Group A) 을이용한회전근개봉합술은 36 예, 윤활낭전절제술 (Group B) 을이용한회전근개봉합술은 42예였다. 환자의평균나이는 57.8세였고평균증상이환기간은 20.3 개월이었다. 임상결과는시각통증등급을이용하여통증의차이를비교평가하였으며파워도플러초음파결과는 modified Newman 의분류를이용하여신생혈관형성의차이를비교평가하였다. 결과 : 양군간에견봉하윤활낭절제정도에따른수술시간, 통증경감, 신생혈관형성에차이는없었다. 양군모두에서술후 2 주에술전통증상태와비교하여의미있는통증호전을확인할수있었다 (Group A: -1.8±1.4, p=0.000; Group B: -1.4±1.7, p=0.000). 파워도플러초음파를이용하여양군모두에서술전에비해서술후 6주 (Group A: 0.7±0.9, p=0.000; Group B: 0.9± 1.1, p=0.000) 및 3개월 (Group A: 0.9±1.0, p=0.000; Group B: 1.0±1.1, p=0.000) 에신생혈관증가소견을확인할수있었다. 결론 : 관절경하회전근개봉합술전후파워도플러초음파를통한연속추시관찰상양군모두에서 3개월까지신생혈관증가소견을확인할수있었으나두군간에통증경감및신생혈관형성정도의차이는확인할수없었다. 색인단어 : 견관절, 회전근개, 윤활낭보존술식, 도플러초음파, 신생혈관형성 접수일 2017 년 2 월 22 일수정일 2017 년 6 월 13 일게재확정일 2017 년 8 월 26 일책임저자곽병훈 42472, 대구시남구두류공원로 17 길 33, 대구가톨릭대학교병원정형외과 TEL 053-650-4054, FAX 053-626-4272, E-mail kwackbyunghoon@nate.com ORCID https://orcid.org/0000-0003-4795-8294 대한정형외과학회지 : 제 53권제 3호 2018 Copyright 2018 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.