Clinical Article The Korean Journal of Sports Medicine 2013;31(2):45-50 http://dx.doi.org/10.5763/kjsm.2013.31.2.45 주관절의외반신전과부하증후군야구선수에서시행한관절경하주두골극절제술 건국대학교의학전문대학원, 건국대학교서울병원정형외과학교실 1, 건국대학교충주병원정형외과학교실 2 박진영 1 ㆍ윤형문 2 ㆍ오경수 1 ㆍ유현열 1 ㆍ방진영 1 ㆍ강대명 2 Arthroscopic Olecranon Osteophyte Resection in the Baseball Players with Elbow Valgus Extension Overload Syndrome Jin-Young Park 1, Hyung-Moon Yoon 2, Kyung-Soo Oh 1, Hyun-Yul Yoo 1, Jin-Young Bang 1, Daemyung Kang 2 1 Glocal Center for Shoulder and Elbow, Department of Orthopedic Surgery, Konkuk University School of Medicine, Seoul, 2 Department of Orthopaedic Surgery, Konkuk University Chungju Hospital, Konkuk University School of Medicine, Chungju, Korea We evaluated the clinical outcome after arthroscopic olecranon osteophyte resection without ligament operation in the elite baseball players who had valgus extension overload syndrome without moderate or severe medial collateral ligament injury. From January 2007 to December 2011, twelve patients underwent arthroscopic osteophyte resection without ligament operation and they were followed for more than 12 months. The mean age was 19.2 years and mean follow-up period was 26 months. The clinical results were evaluated using range of motion, visual analogue scale (VAS) and Mayo elbow performance score (MEPS). After checking osteophyte size and location through 3-dimensional computed tomography, arthroscopic osteophyte resection was performed. Average preoperative extension, flexion, pronation and supination were 2.3 o, 138.2 o, 76.4 o, and 69.1 o. Average postoperative extension, flexion, pronation and supination had been changed into 0.7 o, 137.3 o, 79.1 o, and 77.3 o. Average preoperative pain VAS and MEPS were 5.5 and 67.5. Average postoperative pain VAS and MEPS had been changed into 0.4 (p <0.001) and 97.5 (p<0.001). Eleven patients returned to play. Ten cases returned to their own position. No patients were performed other operation for elbow pain. The arthroscopic osteophyte resection in valgus extension overload syndrome with low grade medial ulnar collateral ligament (MUCL) injury or without MUCL injury was a one of the ideal treatment option for early return to pre-injury levels and relief of pain. Keywords: Valgus extension overload, Posterior impingement, Arthroscopy, Baseball Received: January 10, 2013 Revised: November 17, 2013 Accepted: November 18, 2013 Correspondence: Hyung-Moon Yoon Department of Orthopaedic Surgery, Konkuk University Chungju Hospital, Konkuk University School of Medicine, 82 Gugwon-daero, Chungju 380-704, Korea Tel: +82-43-840-8250, Fax: +82-43-840-3377, E-mail: iulius00@naver.com Copyright 2013 The Korean Society of Sports Medicine CC 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. 제 31 권제 2 호 2013 45
JY Park, et al. Arthroscopic Olecranon Osteophyte Resection in the Baseball Players with Elbow Valgus Extension Overload Syndrome 서론주관절의외반신전과부하증후군 (valgus extension overload syndrome) 은던지는동작을하는운동선수에서주로발생하며, 특히야구선수에서흔히관찰된다. 발생기전은공을던지는도중감속기시기에주두돌기의후내측부위와주두와사이에서외반회전력, 전단력및충돌이발생한다. 이로인하여주두돌기나주두와에는골극이형성되며, 내측측부인대손상과굴곡근약화등이발생하게된다 1). 발생한골극은투구동작시에주두후내측에통증을유발하며, 이학적검사상주관절을회외전, 외반, 신전시키는신전충돌검사상통증을호소하는경우가많다 2). 이경우단순방사선 (X-ray) 촬영또는컴퓨터단층 (computed tomography, CT) 영상으로주두돌기와주두와부위의골극과골의과성장, 유리체등을관찰할수있다. 외반신전과부하증후군에대한수술적치료는골극에대하여는골극절제술을시행하고, 내측측부인대손상이동반된경우에는주관절내측측부인대재건술을같이시행한다. 이중골극절제술만시행한경우는수술후골극의재형성으로인한재수술이나수술후발견된내측측부인대손상으로내측측부인대수술을추가적으로해야한다는보고가있다 3). 이전연구에서는내측측부인대손상에대하여신체검사를통하여진단을하였지만내측측부인대에대한영상학적결과에대해서는보고된바가없다 4,5). 이에저자들은외반신전과부하증후군으로수술적치료가 필요한야구선수환자중영상학적검사상 ( 자기공명영상 [magnetic resonance imaging] 및초음파검사 ) 내측측부인대손상이없거나, 50% 미만의부분파열인경우에관절경하골극절제술만을시행하고그임상결과를보고하고자한다. 연구방법 1. 연구대상본연구는 2007년 1월부터 2011년 5월까지팔꿈치통증을주소로내원한야구선수중컴퓨터단층검사상주두돌기에골극이관찰되어수술을시행한환자를대상으로하였다. 총 29예환자중불안정성이관찰되지않으면서자기공명영상검사또는초음파검사상내측측부인대에중등도파열이나완전파열이관찰되거나이전에내측측부인대수술을시행한환자는제외하였다. 영상검사상내측측부인대손상이없거나내측측부인대전층의 1/2 이하의부분파열을가진환자중 1년이상추시관찰이가능하였던 12예를대상으로후향적연구조사를시행하였다. 수술적응증은투구동작에서주관절후내측에통증을호소하고이전 3개월이상의약물치료및물리치료등보존적치료에도통증의호전이없고, 영상검사검사상주두돌기또는주두와에골극이관찰된경우를대상으로하였다. 증상발현부터수술까지는평균 10.9개월 ( 범위, 1개월 3년) 이었고, 환자의나이는평균 19.2세 ( 범위, 15 31세 ) 였으며, 운동지속기간은평균 9년 ( 범위, 1 21년 ) 이었다. 수비위치는 Table 1. Detailed data of patient history and medial ulnar collateral ligament state Case No. Age (y) Career (y) Duration (mo) Preoperative Postion Postoperative Medial unlar collateral ligament state 1 15 7 12 P O Partial tear 2 31 21 24 P P Partial tear 3 15 6 24 I I Normal 4 15 8 3 C C Partial tear 5 17 7 2 P P Normal 6 19 9 6 O O Normal 7 19 9 1 I I Normal 8 15 1 10 O O Partial tear 9 26 10 12 P Fail* Normal 10 15 5 36 P P Partial tear 11 22 12 24 O P Partial tear 12 16 7 1 I I Partial tear Duration: period of pain onset to surgery, position: position of baseball player, P: pitcher, O: outfielder, I: infielder, C: catcher. *Case No.9: fail due to shoudler operation (superior labrum anterior to posterior lesion). 46 대한스포츠의학회지
박진영외. 주관절의외반신전과부하증후군야구선수에서시행한관절경하주두골극절제술 투수 6명, 내야수 3명, 외야수 2명, 포수 1명이었다. 수술후평균추시기간은 26.2개월 ( 범위, 15 47개월 ) 이었다 (Table 1). 2. 수술방법수술은전신마취하에서복와위자세로수술을시행하였다. 마취하에방사선투시영상을이용하여주관절의내ㆍ외반 불안정성검사를시행하였다. 주관절의이상소견을확인하기위하여관절경을이용하여전방에서후방구간을차례로검사를하였다. 수술전 3차원전산화단층촬영 (3-dimensional CT) 을통하여주두돌기및주두와의골극의위치및크기를측정하였다 (Fig. 1). 측정한주두돌기의골극을관절경적시야에서확인하고측정한길이만큼 Burr를이용하여골편제거, 주두및주두와성형술과골극절제술을시행하였다 (Fig. 2). 주관절전후방에있는활액막염과관절내유리체가있는경우절제술을시행하였다. 골극절제시과도한절제가일어나지않도록주관절의굴곡- 신전을통하여주두돌기의윤곽을확인하면서절제를시행하였다. 절제후관절경시야에서주관절을신전하여주두돌기가주두와에충돌되는지를확인하였으며, 주두와에골극이있는경우는주두와성형술도동시에시행하였다. 수술후 3차원전산화단층촬영을통하여주두돌기골극의제거를최종적으로확인하였다 (Fig. 1). 3. 수술후처치방법수술후주관절의부종을감소시키기위하여압박드레싱을시행하였으며, 수술후 1일부터능동적관절운동을시행하였고, 수술후 4주까지관절운동범위를회복한다음주관절의근력강화운동을시작하였다. 수술후 8주에쉐도우피칭을시작하고, 수술후 3개월에팀에복귀하여운동을다시할수있도록허용하였다. 4. 평가방법수술전주관절굴곡신전범위와최종추시시주관절신전, 굴곡, 회내, 회외범위를비교하였다. 기능평가를위하여통증 visual analogue scale (VAS) 와 Mayo elbow performance core (MEPS) 를사용하였으며, 수술전과최종추시시각각재평가하여결과를비교하였다. 수술전과수술후결과비교를위한통계학적검사는대응표본 T 검정법 (paired sample T-test) 을사용하였으며유의수준은 0.05 미만으로하였다. 통계프로그램은 SPSS ver. 12.0 통계프로그램 (SPSS Inc., Chicago, IL, USA) 을이용하였다. 결 과 Fig. 1. Preoperative sagittal section image (A) and 3 dimensional reconstructed images (C, E) there are osteophyte in posteromedial side of olecranon (white arrow). Postoperative sagittal section image (B) and 3 dimensional reconstructed images (D, F). It was observed resected osteophyte after surgery. 관절경하골극절제술후주관절운동범위의변화및통증 VAS, MEPS를수술전과비교하였다 (Table 2). 운동범위는수술전과수술후각각, 신전은 2.3 o 에서 0.7 o 로, 굴곡은 138.2 o 에서 137.3 o 로, 회내는 76.4 o 에서 79.1 o 로, 회외는 69.1 o 에서 제 31 권제 2 호 2013 47
JY Park, et al. Arthroscopic Olecranon Osteophyte Resection in the Baseball Players with Elbow Valgus Extension Overload Syndrome Fig. 2. It is seen preoperative olecranon osteophyte (A) and resected osteophyte is seen after surgery (B) in arthroscopic views. Table 2. Visual analogue scale (VAS) and Mayo elbow performance score (MEPS) changes were statistically significant (p<0.05) between preoperation and postoperation Characteristic Preoperative Postoperative p-value Range of motion Flexion contracture 2.3±4.1 0.7±1.7 0.19 Further flexion 138.2±6.0 137.3±6.8 0.73 Supination 69.1±12.2 77.3±4.7 0.39 Pronation 76.4±9.2 79.1±3.0 0.55 Pain VAS 5.5±1.1 0.4±0.7 0 MEPS 67.5±13.2 97.5±2.6 0 Values are presented as mean±standard deviation. 77.3 o 으로측정되었으나통계학적으로유의하지않았다. 통증 VAS는수술전 5.5점에서수술후 0.4점으로유의하게감소하였고, MEPS 또한 67.5점에서 97.5점으로유의하게증가하였다. 1년이상추시가능하였던 12예중 11예에서투구동작을할수있었고, 10예에서이전수준의운동복귀가가능하였다. 1예는수비위치가투수에서외야수로변경되었다. 1예는동반된 superior labrum anterior to posterior 병변수술로인하여복귀가불가능하였다 (Table 1). 추시기간동안골극제거후내측불안정성이증가한예는없었다. 12예모두투구동작시에주관절에통증을호소하고있지않았다. 고찰주관절통증은야구선수등투구동작을하는운동선수에서흔히관찰되며특히청소년기에서성인에이르기까지대부분의투수들에서매우흔한통증이다. Tullos와 King 6) 에따르면절반정도의투수들이주관절및견관절통증의경험이있다고하였다. 특히주관절은투구동작시의빠른움직임과과도한운동범위에때문에손상의가능성이높다. 투구동작시후기거상단계 (late cocking phase) 와가속단계 (acceleration phase) 에서주관절에큰각속도 (5,000 o /s) 가발생하게되며, 주관절신전시그힘이그대로전달되어외반력으로작용하여내측에는신전력, 외측에는압박력, 후방에는전단력이작용하게된다 3). 이로인하여주관절에서나타나는증상들에대하여 1959년 Bennett 1) 이처음으로보고하였으며, 1968년 Slocum 7) 은이러한증상들의원인이외반-신전-과부하 (valgus extension overload, VEO) 라고하였다. 외반신전과부하증후군은결국내측측부인대손상과굴곡근약화를유발하고그결과주두돌기끝과주두와사이에후내방충돌이일어나골극을형성하게된다. 이러한외반신전과부하증후군의신체검사는주관절의운동범위를측정하고, 주관절후내측에압통을확인한다. 이후내측측부인대의손상을확인하기위해외반부하검사 (valgus stress test) 를시행하고, 내측측부인대중전방다발이상을확인하기위해서용출검사 (milking test) 와운동외반검사 (moving valgus test) 를시행한다 8). 하지만이러한검사의민감도및특이도에대해서는보고된바없다 2). 따라서 48 대한스포츠의학회지
박진영외. 주관절의외반신전과부하증후군야구선수에서시행한관절경하주두골극절제술 저자들은상기검사에서양성이나올경우자기공명영상검사또는초음파검사를추가로시행하였다. 외반신전과부하증후군의치료는먼저휴식과함께약물치료및투구동작의역학적교정을시행하며주관절주위근육의균형및근력강화를포함하는재활등의비수술적치료를먼저시행한다. Aguinaldo와 Chambers 9) 는몸의회전이빠를수록, 어깨의외회전이많을수록, 주관절의굴곡이적을수록주관절의외반력이더크게측정되었다고하였다. 즉, 3/4이나체상투구동작보다사이드암투구동작에서주관절외반력이더크게작용하기때문에투구동작의교정을통하여주관절의외반력을감소시킬수있다고하였다. 외반신전과부하증후군에서비수술적치료에반응하지않거나이전수준의기량회복을원하는환자는수술적치료를시행할수있다고알려져있다 2). 수술적치료는주두돌기의골극절제술과내측측부인대재건술이많이시행된다. 수술적치료는 1983년 Wilson 등 5) 이처음으로보고하였으며 5명의투수에게개방적주두돌기내측골극절제술을시행하여모두이전수준으로운동에복귀하였다고하였다. 1995년 Andrew 와 Timmerman 4) 은 72명의야구선수에서중 47명 (65%) 에서후내측골극이관찰되어관절경하골극절제술을시행하였으나 19명 (41%) 에서골극이다시발생하여재수술을시행하였고, 10명 (25%) 에서는내측측부인대재건술을시행하였다. 따라서만성손상이있는경우는만족할만한결과를얻기힘들다고하였지만수술전내측측부인대에대한도수검사외에영상학적평가는보고되지않았다. 이후 2000년 Reddy 등 10) 은 178명의환자에서시행한주관절관절경수술결과, 야구선수 55명중 47명 (85%) 의선수는이전수준으로회복이되었다고하였으나이전과마찬가지로수술전내측측부인대에대한영상평가는언급되지않았다. 이전연구에서골극절제술시행전에내측측부인대에대한영상학적평가에대한언급이없어서저자들은외반신전증후군으로진단되어수술이필요한환자중내측측부인대에대한영상검사를시행하여파열이없거나, 1/2 이하의부분파열을보인환자에서관절경하골극절제술만시행한결과를확인하였다. 수술후주관절의굴곡과신전의변화는통계학적으로는유의하지않았다. 하지만 VAS 점수를이용한통증정도는향상되었고, MEPS 도유의하게증가하였다 (Table 1). 주관절외반력에대한주두돌기와내측측부인대의역할은여러연구에서확인되었다 11-18). An 등 15) 은주두돌기의절제가외반불안정성을증가시킨다고보고하였다. 또한내측측부 인대재건술또는봉합술을시행받은환자가과거에주두돌기의골극절제술을시행받았던비율은 36% 19), 44% 20), 86% 21) 로보고되고있다. 또한내측측부인대손상시주두돌기의골극이관절의접촉면을늘려서안정성에기여를하기때문에골극절제로인하여내측측부인대통증이발현되거나심해질수있다는보고도있다 2). Kamineni 등 11,13) 은사체에서내측측부인대긴장과주두돌기후외측절제간의연구를통하여정상주두돌기보다후외측이 6 mm 이상절제시내측측부인대의부하가증가하며, 3 mm 이하절제시내측측부인대의기능변화가생기나 3 mm 이하절제시에는내측측부인대에변화가없었다고보고하였다. 저자들은주두돌기골극의과다한절제를예방하기위해서절제전 3차원컴퓨터단층영상촬영을시행하여절제부위를수술전에측정하였으며, 수술시에도주관절굴곡-신전으로관절윤곽을확인하면서절제하여정상주두돌기의절제를방지하였다. 수술후추시기간중추가적으로발생한내측측부인대손상으로수술을시행한환자는없었다. 외반신전증후군에서관절경하골극절제술은최소침습적이며, 수술후통증이적고, 수술후조기재활이가능한장점이있다. 야구선수가경도의내측측부인대부분파열이나파열이없는외반신전과부하증후군이있는경우전산화단층촬영을이용한적절한관절경하절제술로경기에복귀할수있는유용한수술방법이라생각된다. 본연구의제한점은비교적증례의수가적고, 장기추시결과가아니라는점, 후향적연구인점을들수있으며향후장기추시연구를비롯한지속적인연구가필요할것으로생각된다 22). References 1. Bennett GE. Elbow and shoulder lesions of baseball players. Am J Surg 1959;98:484-92. 2. Ahmad CS, Conway JE. Elbow arthroscopy: valgus extension overload. Instr Course Lect 2011;60:191-7. 3. Dugas JR. Valgus extension overload: diagnosis and treatment. Clin Sports Med 2010;29:645-54. 4. Andrews JR, Timmerman LA. Outcome of elbow surgery in professional baseball players. Am J Sports Med 1995;23:407-13. 5. Wilson FD, Andrews JR, Blackburn TA, McCluskey G. Valgus extension overload in the pitching elbow. Am J Sports Med 1983;11:83-8. 6. Tullos HS, King JW. Throwing mechanism in sports. Orthop 제 31 권제 2 호 2013 49
JY Park, et al. Arthroscopic Olecranon Osteophyte Resection in the Baseball Players with Elbow Valgus Extension Overload Syndrome Clin North Am 1973;4:709-20. 7. Slocum DB. Classification of elbow injuries from baseball pitching. Tex Med 1968;64:48-53. 8. Chen FS, Rokito AS, Jobe FW. Medial elbow problems in the overhead-throwing athlete. J Am Acad Orthop Surg 2001; 9:99-113. 9. Aguinaldo AL, Chambers H. Correlation of throwing mechanics with elbow valgus load in adult baseball pitchers. Am J Sports Med 2009;37:2043-8. 10. Reddy AS, Kvitne RS, Yocum LA, Elattrache NS, Glousman RE, Jobe FW. Arthroscopy of the elbow: a long-term clinical review. Arthroscopy 2000;16:588-94. 11. Kamineni S, ElAttrache NS, O'Driscoll SW, et al. Medial collateral ligament strain with partial posteromedial olecranon resection: a biomechanical study. J Bone Joint Surg Am 2004;86:2424-30. 12. Ahmad CS, Park MC, Elattrache NS. Elbow medial ulnar collateral ligament insufficiency alters posteromedial olecranon contact. Am J Sports Med 2004;32:1607-12. 13. Kamineni S, Hirahara H, Pomianowski S, et al. Partial posteromedial olecranon resection: a kinematic study. J Bone Joint Surg Am 2003;85:1005-11. 14. Andrews JR, Heggland EJ, Fleisig GS, Zheng N. Relationship of ulnar collateral ligament strain to amount of medial olecranon osteotomy. Am J Sports Med 2001;29:716-21. 15. An KN, Morrey BF, Chao EY. The effect of partial removal of proximal ulna on elbow constraint. Clin Orthop Relat Res 1986;(209):270-9. 16. Morrey BF, An KN. Functional anatomy of the ligaments of the elbow. Clin Orthop Relat Res 1985;(201):84-90. 17. Andrews JR. Bony injuries about the elbow in the throwing athlete. Instr Course Lect 1985;34:323-31. 18. Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med 1983; 11:315-9. 19. Azar FM, Andrews JR, Wilk KE, Groh D. Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med 2000;28:16-23. 20. Conway JE, Jobe FW, Glousman RE, Pink M. Medial instability of the elbow in throwing athletes. Treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg Am 1992;74:67-83. 21. Thompson WH, Jobe FW, Yocum LA, Pink MM. Ulnar collateral ligament reconstruction in athletes: muscle-splitting approach without transposition of the ulnar nerve. J Shoulder Elbow Surg 2001;10:152-7. 22. Bennett GE. Shoulder and elbow lesions distinctive of baseball players. Clin Orthop Relat Res 2012;470:1531-3. 50 대한스포츠의학회지