ORIGINAL ARTICLE http://dx.doi.org/10.5371/hp.2013.25.1.44 Print ISSN 2287-3260 Online ISSN 2287-3279 Hemiarthroplasty for Hip Fractures in Elderly Patients over 80 Years Old - Comparative Analysis between Femoral Neck Fracture and Intertrochanteric Fracture - Chae-Hyun Lim, MD, Young-Yool Chung, MD, Jeong-Seok Kim, MD, Chung-Young Kim, MD Department of Orthopaedic Surgery, Kwangju Christian Hospital, Gwangju, Korea Purpose: The purpose of this study is to investigate the relative surgical risk and problems in hip hemiarthroplasty for treatment of an unstable intertrochanteric fracture in elderly patients over 80 years old. Materials and Methods: Between April 2005 and May 2010, 58 patients whose age was over 80 years were available for inclusion in this study. They were divided into two groups: group 1 included 30 patients with femoral neck fracture and group 2 included 28 patients with intertrochanteric fracture. No significant differences in average age, concomitant disease, and walking ability before development of fracture were noted between the two groups. The following factors, including interval from development of fracture to operation, operation time, amount of blood loss, start time of walking after operation, duration of hospital stay, complications, revision rate, and walking ability were compared between the two groups. Results: Operation time was an average of 85.2 minutes in group 1 and 97.5 minutes in group 2(P=0.03). The amount of bleeding was an average of 483 cc in group 1 and 695 cc in group 2(P=0.006). Similar results for walking start and recovery of walking ability after operation were observed in the two groups. No significant differences were observed in duration of hospital stay, complications, and revision rate. While 25 patients in group 1(83.3%) showed restoration of walking ability after operation to the same level of walking before injury, 19 patients in group 2(67.8%) showed restoration of walking ability postoperatively. Conclusion: Even though patients in group 2 showed a longer operation time and a higher amount of blood loss, compared with those in group 1, patients in group 2 had similar surgical risk and complications, compared with those in group 1. Therefore, primary hip hemiarthropalsty could be a good treatment option for intertrochanteric fracture in elderly. Key Words: Intertrochanteric fracture, Hip arthroplasty, Elderly patient, Relative surgical risk Submitted: August 6, 2012 1st revision: October 17, 2012 2nd revision: November 8, 2012 3rd revision: November 23, 2012 4th revision: January 9, 2013 Final acceptance: January 10, 2013 Address reprint request to Young-Yool Chung, MD Department of Orthopedic Surgery, Kwangju Christian Hospital, 264 Yangrim-dong, Nam-gu, Gwangju 503-715, Korea TEL: +82-62-650-5060 FAX: +82-62-650-5066 E-mail: paedic@chol.com This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons. org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 44 Copyright c 2012 by Korean Hip Society
Chae-Hyun Lim et al.: Hemiarthroplasty for Hip Fractures in Elderly Patients over 80 Years Old 서 론 평균수명의연장과더불어급속한노령화가진행되고있는가운데노령인구의고관절부골절도빠른속도로증가하고있다 1-3). 노인에서발생하는고관절주위골절은골절자체도문제이지만장기간의입원과국소적및전신적인합병증으로인한사망률의증가로사회경제적손실이막대하다. 특히초고령노인은많은기저질환을가지고있어골절치료과정에서내과적합병증을유발하므로조기보행이가능한치료방법을선택하여빠른시일내에기능을회복시키는것이치료의목표이다. 그러므로노인에서발생하는고관절골절은대부분고정술이나인공관절치환술같은수술적방법을선택하게된다. 그러나 80 세이상의초고령노인에서시행하는불안정골절에대한고정술은불량한골질로인하여견고한고정을할수없는경우가있고이로인하여수술후체중부하까지의시기가지연되어합병증이증가하고보행능력의회복이늦어질수있다. 또한불유합이나무혈성괴사등불량한결과를보인경우재수술이필요하나수술의위험도가높아불가능한경우가많다 4-7). 반면인공고관절반치환술은골질에관계없이초기의안정된고정을얻을수있어조기보행이가능하여고령의환자에서성공적인일차적치료중한가지로받아들여지고있다 8). Kim 등 9) 은고령환자의불안정성대퇴골전자간분쇄골절에대해시멘트를사용한인공관절반치환술을시행한후 2 년추시에서대부분만족할만한임상적및방사선적결과를얻었다고보고하였다. 이에저자들은 80 세이상의대퇴골경부골절과전자간골절에서무시멘트형인공고관절반치환술을시행한후임상적및방사선학적결과를통해전자간골절에서 1 차치료로써인공관절반치환술의적용가능성을알아보고자하였다. 대상및방법 2005 년 4 월부터 2010 년 5 월까지고관절부위골절로본 원에입원한환자중 80세이상환자에서인공고관절반치환술을시행한환자를대상으로대퇴골경부골절을 I군, 대퇴골전자간골절을 II군으로분류하여조사하였다. I군은총 30명 30예중남자 4명, 여자 26명이었으며평균연령은 84.2세 (80-92세) 이었고, II군은총 28명 28예중남자 3명, 여자 25명이었으며평균연령은 85.1세 (80-93세) 이었다. 두군모두에서최소 1개이상의내과적기저질환을갖고있었고두군간의통계적으로의미있는차이는보이지않았다. 수상부터수술까지걸린평균시간은 I군에서 5.1일, II군에서 5.0일소요되었으며통계적으로의미있는차이는보이지않았다 (Table 1). 수술은한명의수술자에의해시행되었으며후외측도달법을사용하였다. I군은전례에서무시멘트형 M/L taper (Zimmer, Warsaw, USA) 대퇴골삽입물을이용하여양극성반치환술을시행하였으며 (Fig. 1A), II군은무시멘트형 Versys beaded fullcoat collared (Zimmer, Warsaw, USA) 대퇴골삽입물을사용하였다 (Fig. 1B). 대퇴골전자간골절의 II군에서는대전자와소전자를강선혹은전자부재부착금속판 (Cable system, Zimmer, USA) 을이용하여고정하였다. 두그룹간재활은차이를두지않았으며모든환자에서가능하면술후이틀째부터보행기를이용하여보행을시작하도록하였다. 수술후 3개월까지는 1개월간격으로외래추시를하여방사선사진촬영과임상적결과를조사하였으며 1년이후는 6개월간격으로추시하였다. 평균추시기간은 35.2개월로서최소 24개월부터최대 57개월이었다. 두군을비교하기위한평가방법은두군간의수상전보행상태및기저질환, 수상후부터수술시행까지소요된시간, 수술시간, 출혈량, 수술후보행시작까지시간, 재원기간, 합병증, 보행상태등을이용하여임상적평가를하였으며, 방사선학적평가는삽입물의고정상태와해리를이용하여평가하였다. 출혈량은수술중발생한양과수술후헤모벡 (hemovac) 에서측정한양을합한것으로하였다. 보행상태는외래추시및전화설문으로평가하였다. 고령임을고려하여보행의회복정도는수술후 1년이내가장좋은보행상태를기준하여평가하였다. 보행에제한이없 Table 1. Demographics of Two Groups Group 1 Group 2 P-value Age 84.2 85.1 0.35 Concomitant Disease (Person) 0.12 Hypertension 16 16 Diabetes Mellitus 04 08 Pneumonia 05 03 COPD* 06 01 Dementia 04 03 Cancer 02 00 CHF 03 00 *: Chronic Obstructive Pulmonary Disease, : Congestive Heart Failure. www.hipandpelvis.or.kr 45
는경우 3 점, 지팡이보행은 2 점, 보행에제한이있으며보행기사용한경우 1 점, 보행이불가능한경우 0 점으로평가하였다 (Table 2). 수술의상대적위험도는수술에의해발생하는사망률과합병증을비교하여평가하였다. 통계학적분석은 SPSS 12.0 를이용하여 Independent t-test 와 chi square test 를사용하였으며 P 값이 0.05 이하일때를유의한결과로하였다. 결 과 수술시간은 I 군평균 85.2 분, II 군평균 97.5 분으로 II 군에서더긴수술시간이소요되었고, 출혈량도 I 군평균 483 cc, II 군평균 695 cc 로 II 군에서통계적으로의미있게출혈량이많았다 (P=0.006). 수술후보행까지소요된평균시간은 I 군 4.8 일, II 군 4.8 일로통계적으로의미있는차이는보이지않았고, 재원일수도 I 군평균 25.9 일, II 군은평균 24.7 일로차이가없었다. 수상전보행상태는 I 군평균 Table 2. Walking Ability Walking Ability Score Independent Ambulatory 3 Ambulator with Cane 2 Dependant Ambulator with Crutch 1 Non-ambulator 0 2.7 점, II 군평균 2.6 점으로큰차이를보이지않았으나수술후추시중보행상태는 I 군 2.5 점, II 군 2.0 점으로 I 군에서더좋은결과를보였다. 추시중보행상태를술전보행상태와비교했을때 I 군은 30 명중 25 명 (83.3%) 에서술전보행상태로회복하였고, II 군은 28 명중 19 명 (67.8%) 에서술전보행상태로회복되어경부골절환자군에서보행상태의회복은통계학적으로좋았다 (P=0.03). 최종추시에서사망률은 I 군에서 10 명 (33.3%), II 군에서 5 명 (17.8%) 이었으나통계학적으로차이는없었다 (Table 3). I 군에서 2 명은호흡기질환으로인하여수술후 1 개월이내에사망하였으나나머지사망환자는수술과상관없었다. 방사선검사상인공삽입물의해리는양군에서관찰할수없었으며삽입물의재치환술도없었다. 합병증으로는 I 군에서인공삽입물주위골절 1 예, 표재성감염 4 예이었으며, II 군에서삽입물주위골절 1 예, 표재성감염 2 예, 고관절탈구 2 예를보였다. 표재성감염은항생제치료로해결되었으며, 수술후발생한삽입물주위골절은강선고정으로치료하였다. 탈구는정복후외전보조기를 6 주간착용시켰다. 고 찰 노령인구가급속하게증가하면서고령인구에서발생하는골다공증성고관절부골절도빠른속도로증가하고있으며 80 세이상의초고령환자에서발생한고관절부골절도증가하는추세이다. 저자들의연구기간에 80 세이상의 A B Fig. 1. (A) M/L taper prosthesis was used for femoral neck fracture and (B) Versys beaded fullcoat collored femoral stem for intertrochanteric fracture. 46 www.hipandpelvis.or.kr
Chae-Hyun Lim et al.: Hemiarthroplasty for Hip Fractures in Elderly Patients over 80 Years Old 고관절골절이전체고관절골절의 24% 를차지하였다. 특히대퇴골전자간골절은나이가증가함에따라경부골절보다그빈도가높아진다고알려져있으며, 80 세이상의고관절부골절에서특히관절외골절인전자간골절이더많다고보고되고있다 10,11). 고령노인의고관절골절은조기보행으로합병증을줄이고수상전보행능력을회복하기위해수술적치료가권장되고있는데 10,12), 일반적으로 70 세이상의대퇴골경부전위골절에서는인공고관절치환술이일차치료로시행되고있으나 13-15) 대퇴골전자간골절에서는대부분내고정술을시행하고있다 16-19). 그러나 80 세이상의초고령환자에서발생한대퇴골전자간골절에서시행한인공고관절반치환술은조기보행을가능하게함으로써빠른재활치료를할수있어보행능력의회복이우수하다는점이보고되어불안정성전자간골절에서인공관절반치환술이일차치료중하나로시도되고있다 8,19-22). Haentjen 등 19) 은 100 예의불안정성전자간골절을인공고관절반치환술로치료하였는데술후평균 4 일부터전체중 부하보행이가능하였으며 78% 에서양호이상의임상결과를얻을수있어서 75 세이상의고령의환자에서발생한불안정성전자간골절에인공고관절반치환술이추천할만한좋은방법이라고보고하였다. 또한 Kim 등 9) 은고령환자의불안정전자간골절에서시행한양극성반치환술후평균 2.8 년추시에서 88% 의우수및양호한결과를얻었다고보고하였다. 그런데아직까지대퇴골전자간골절에서인공관절치환술에대한적응증이확실하게정립되어있지않고수상후사망률이대퇴경부골절보다더높은것으로알려져있으나 3) 초고령환자에서시행하는인공고관절반치환술의안전성에대한자세한조사가없는실정이다. 본연구에서수술시간이 1 군에서평균 85.2 분, 2 군에서평균 97.5 분 (P=0.03) 으로전자간골절에서길었으며, 출혈량도 1 군에서평균 483 cc 2 군에서평균 695 cc 로전자간골절군에서의미있게출혈량이많았다. 골질이나쁜초고령환자의불안정성전자간골절에서인공고관절치환술은소전자부와대전자부의골절로수술시해부학적구조의 Table 3. Clinical Results of Two Groups Group 1 Group 2 P-value Time from Fracture to Operation (day) 05.3 5 0.82 Operation Time (min) 85.2 97.5 0.03 Bleeding Amount (cc) 483 695 00.006 Walking Start (day) 04.8 04.8 0.98 Hospital Stay (day) 25.9 24.7 0.76 Complications (person) Periprosthetic Fracture 01 1 Superficial Infection 04 2 Hip Dislocation 00 2 Recovery of Pre-injury Walking Ability (%) 83.3 67.8 0.03 Mortality (person) 10 5 0.23 A B C Fig. 2. (A) Preoperative radiograph of 84 years old female with unstable intertrochanteric fracture in the right hip. (B) Cementless hemiarthroplasty was done after 3 days from injury. Wire & non-absorbable suture were used for fixation of greater and lesser trochanter. Ambulation using walker began 5 days after operation. (C) At last follow up, the patient restores the walking ability before injury without complication. www.hipandpelvis.or.kr 47
이해가쉽지않고동반된소전자부와대전자부의정복과고정이필요한경우가많아단순한대퇴골경부골절과비교하여출혈과수술시간이많은것은당연한결과로생각된다. 전자간골절군에서수술시간이길고출혈량이많았지만수술후보행시작은경부골절군과같았으며합병증에서도양군에차이가없었으며통계학적으로의미는없지만사망률은오히려경부골절에서더높았다. 그러나내과질환이있는 80 세이상의초고령환자에서수술이길고출혈량이많다는것은수술자와환자에게큰부담이되는것은분명할것으로생각된다. 전자간골절에서인공관절치환술은골절의형태와골질에상관없이전신상태가허락되면모든환자가수술후 5 일이내에부분체중부하보행이가능하여장기간침상안정으로인하여발생하는내과적합병증을예방할수있어서경부골절군과비교하여수술에의한위험도를증가시키지않았던것으로생각된다. 수술후재활치료도경부골절과비교하여차이없이진행할수있어서재원기간도두군은같았다 (Fig. 2). 두군에서삽입물의해리로재수술은없었으나경부골절군에서삽입물주위골절로 1 예에서수술적치료를시행하였다. 전자간골절에서탈구가 2 예발생하여정복후외전보조기를착용시켰다. 경부골절군과비교하여통계학적으로의미는없었지만전자간골절에서 2 예의탈구가발생한이유가경부골절과비교하여더광범위한골과근육및연부조직의손상이발생하고수술중더많은연부조직의손상이아닌가생각된다. 초고령환자에서발생하는탈구는환자의재활에심각한문제를일으키고골질이불량한환자에서정복중골절을일을킬수있어수술후탈구에각별한주의를하여야한다. 탈구의위험도가높은환자에서는수술후외전보조기착용하고재활치료를시작하는것도탈구를예방하는하나의방법으로생각된다. 초고령환자에서의수술의주된목적은수상전보행능력을회복시키는것인데, 일반적으로고관절부골절이있는노인환자에서수상전기능회복은매우어렵고나이가들수록더어렵다고보고되고있다 23-25). 본연구에서수술전보행상태가비슷하였던두군을비교하였을때수술후보행시작일이평균 4.8 일로차이가없었으나수술후보행상태는경부골절군에서통계적으로의미있게더좋은결과를보였다. 전자간골절군에서수술후빠른보행시작을하였음에도불구하고보행상태의회복에제한이발생한원인으로대전자및소전자고정실패, 긴대퇴골삽입물에의한대퇴부통증, 서혜부통증등을생각할수있었다. 1 예에서만대전자고정실패가발생하여골절된전자고정실패가보행상태의회복에영향을주지않았을것으로생각하였으며, 또서혜부통증은양군에서양극성반치환술을하였으므로원인으로생각할수없었다. 고령의환자에서골절후발생하는보행능력의감소는여러가지원인이복합적으로발생한것으로생각된다. 특히골절이심 한전자간골절군에서추시중보행능력의회복에제한이발생한정확한원인을위해추후이에대한자세한연구가필요할것으로생각된다. 본연구에서퇴원후요양병원에입원한환자들이많았지만보행능력의회복에는도움이안되어퇴원후재활의중요성을고려하여고령환자의보다적극적인재활프로그램이필요할것으로생각된다. 본연구는초고령노인의고관절골절에서인공고관절치환술을시행하고그결과를비교한것으로대퇴골전자간골절에서시행한인공관절치환술은대퇴골경부골절에서시행한인공관절과비교하여수술에의한위험성은비슷하였으며, 수술후조기보행이가능하여합병증발생률도증가하지않았다는것을보여주는데의의가있다. 그러나대상수가 58 예로비교적적은수의후향적연구이며초고령노인인구를대상으로하여오랜추시후결과를확인하기힘들었다는제한점이있다. 결 론 대퇴골전자간골절에서시행한인공관절반치환술은대퇴골경부골절에서시행한인공관절반치환술과비교하여수술에의한위험성이비슷하였고수술후조기보행이가능하여합병증발생률도증가하지않았다. 이에초고령의환자에서발생한전자간골절의 1 차적치료로써인공관절반치환술은하나의좋은선택이될것으로생각된다. REFERENCES 01.Kim KH, Kho DH, Yang JH, Kim DH. Treatment of intertrochanteric fractures with bipolar hemiarthroplasty in the elderly. J Korean Soc Fract. 2001;14:174-80. 02.Johnell O, Nilsson B, Obrant K, Sernbo I. Age and sex pattern of hip fracture - - changes in 30 years. Acta Orthop Scand. 1984;55:290-2. 03.Chang JD, Kang ST, Lee EJ, Choi SJ, Chang HK, Lee CJ. A study of the factors which influence on the one-year mortality rate after hemiarthroplasty in older patients with hip fracture. J Korean Hip Soc. 1998;10:225-32. 04. Bickel WH, Jackson AE. Intertrochanteric fractures of the femur: an analysis of the end results of 126 fractures treated by various methods. Surg Gynecol Obstet. 1950; 91:14-24. 05.Cobelli NJ, Sadler AH. Ender rod versus compression screw fixation of hip fractures. Clin Orthop Relat Res. 1985;(201):123-9. 06.Kang CN, Kim JO, Kim DW, Koh YD, Ko SH, Lee KW. Comparison of hemiarthroplasty and compression hip screw on elderly unstable intertrochanteric fractures. J Korean Soc Fract. 1997;10:738-45. 07.Park MS, Choi SS. Bipolar hemiarthroplasty for the treatment of femoral neck and unstable intertrochanteric fracture in elderly patients. J Korean Orthop Assoc. 1991; 26:482-8. 48 www.hipandpelvis.or.kr
Chae-Hyun Lim et al.: Hemiarthroplasty for Hip Fractures in Elderly Patients over 80 Years Old 08.Khan RJ, MacDowell A, Crossman P, et al. Cemented or uncemented hemiarthroplasty for displaced intracapsular femoral neck fractures. Int Orthop. 2002;26:229-32. 09. Kim YH, Park GC, An SC, Choi IY. Bipolar hemiarthroplasty using cement for the treatment of intertrochanteric femoral fracture in elders - 2 to 5 year results. J Korean Hip Soc. 2001;13:330-7. 10.Alarcòn T, Gonzālez-Montalvo JI, Bārcena A, Saez P. Further experience of nonagenarians with hip fractures. Injury. 2001;32:555-8. 11.van de Kerkhove MP, Antheunis PS, Luitse JS, Goslings JC. Hip fractures in nonagenarians: perioperative mortality and survival. Injury. 2008;39:244-8. 12.Ooi LH, Wong TH, Toh CL, Wong HP. Hip fractures in nonagenarians--a study on operative and non-operative management. Injury. 2005;36:142-7. 13.LaVelle DG. Fractures and dislocations of the hip. In: Campbell WC, Canale ST, Beaty JH, ed. Campbell s operative orthopaedics. 11th ed, Philadelphia: Mosby/ Elsevier; 2008. 3237-62. 14.Lee SH, Kim JH. Operative treatment of femoral neck fracture. J Korean Hip Soc. 2007;19:271-6. 15.Leighton RK. Fractures of the neck of the femur. In: Rockwood CA Jr, Green DP, eds. Rockwood and Green s fracture in adults. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. 1753-91. 16.Kim BS, Lew S, Ko SH, Cho SD, Yang JH, Park MS. Treatment of femoral intertrochanteric fracture with proximal femoral nail. J Korean Fract Soc. 2004;17:1-6. 17.Kim CK, Jim JW, Ahn BW, et al. Intertrochanteric fractures of femur treated with a proximal femoral nail. J Korean Hip Soc. 2005;17:99-105. 18.Ko SB, Cho MR, Kim TH, Chang IW. Nailing in the patients with intertrochanteric fractures of the femur: comparison gamma nail and proximal femoral nail. J Korean Fract Soc. 2004;17:295-300. 19.Haentjens P, Casteleyn PP, Opdecam P. Primary bipolar arthroplasty or total hip arthroplasty for the treatment of unstable intertrochanteric and subtrochanteric fractures in elderly patients. Acta Orthop Belg. 1994;60 Suppl 1:124-8. 20.Choi IY, Kim YH, Kim BH, Lee HS. Cemented bipolar hemiarthroplasty for the femoral neck or cervicotrochanteric fracture in patients older than 85 years. J Korean Hip Soc. 2002;14:83-9. 21.Sierra RJ, Timperley JA,Gie GA. Contemporary cementing technique and mortality during and after Exeter total hip arthroplasty. J Arthroplasty. 2009;24:325-32. 22.Ereth MH, Weber JG, Abel MD, et al. Cemented versus noncemented total hip arthroplasty--embolism, hemodynamics, and intrapulmonary shunting. Mayo Clin Proc. 1992;67: 1066-74. 23.Zuckerman JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg Am. 1995;77:1551-6. 24.Koval KJ, Zuckerman JD. Functional recovery after fracture of the hip. J Bone Joint Surg Am. 1994;76:751-8. 25.Formiga F, Lopez-Soto A, Sacanella E, Coscojuela A, Suso S, Pujol R. Mortality and morbidity in nonagenarian patients following hip fracture surgery. Gerontology. 2003;49:41-5. www.hipandpelvis.or.kr 49
국문초록 80 세이상노인의고관절골절에서시행한인공고관절반치환술 - 대퇴골경부골절과전자간골절의비교 - 임채현 정영율 김정석 김충영광주기독병원정형외과 목적 : 80 세이상노인의불안정대퇴골전자간골절에서시행한인공고관절반치환술의상대적수술적위험도와문제점들을알아보고자하였다. 대상및방법 : 2005 년 4 월부터 2010 년 5 월까지 80 세이상의고관절골절환자 58 명을대상으로하였다. 1 군은경부골절환자 30 명, 2 군은전자간골절환자 28 명이었다. 두군에서나이, 내과적질환, 골절전보행상태에는차이가없었다. 각군의외상에서수술까지기간, 수술시간, 출혈량, 보행시작시기, 입원기간, 합병증, 재수술율, 보행상태를조사하여비교하였다. 결과 : 평균수술시간은 1 군이 85.2 분, 2 군이 97.5 분이었으며 (P=0.03), 평균출혈량은 1 군이 483 cc, 2 군이 695 cc 이었다 (P=0.006). 수술후보행시작과초기보행능력의회복은양군에차이가없었으며, 입원기간, 합병증, 재수술률에도차이가없었다. 그러나추시에서수상전보행회복은 1 군이 30 예중 25 예 (83.3%) 이었으며, 2 군은 28 예중 19 예 (67.8%) 이었다. 결론 : 2 군에서 1 군보다수술시간이길고출혈량은많았지만수술적위험도나합병증의발생률은두군에서비슷하였다. 따라서고령의환자에서발생한전자간골절의일차적치료로인공고관절반치환술은하나의좋은방법이될수있을것으로생각된다. 색인단어 : 전자간골절, 인공고관절반치환술, 고령환자, 수술적위험도 50 www.hipandpelvis.or.kr