pissn : 1226-2102, eissn : 2005-8918 Instructional Course Lecture J Korean Orthop Assoc 2013; 48: 61-69 http://dx.doi.org/10.4055/jkoa.2013.48.1.61 www.jkoa.org 회전근개파열의치료 광범위회전근개파열의치료 : 관절경적치료를중심으로 Treatment of Massive Rotator Cuff Tears: Focusing on Arthroscopic Approach 이승원 손민수 * 유재철성균관대학교의과대학삼성서울병원정형외과학교실, * 국립의료원정형외과 광범위회전근개파열의치료는다양하지만표준이되는지침은아직알려져있지않다. 따라서본종설에서는현재광범위파열에대해시행되고있는여러치료방법에대해고찰해보고자하였다. 다양한광범위파열의치료방법을선택하기위해봉합가능성에대한평가와생역학적변화에대한이해는필수적이다. 관절경적봉합술중완전봉합술의임상결과가가장우수한것으로보고되고있다. 그외봉합불가능한파열에대한변연절제술, 부분봉합술, 상완이두근장두절제술및건고정술, 대체물을이용한보강술등의구제술역시만족스러운임상결과를보여주고있으나, 이러한방법들에대해장기간관찰한결과는부족한편이다. 광범위파열은봉합불가능파열을포함하며, 재파열률또한높게보고되고있어치료에어려움이있다. 따라서여러가지치료방법의장단점을이해하는것이치료를선택하고그결과를향상시키는데도움이될것으로생각한다. 색인단어 : 회전근개, 광범위파열, 관절경 서론 광범위회전근개파열의치료방법은다양하나크게수술적치 료와보존적치료로구분할수있다. 수술적치료방법으로는단 순변연절제술에서부터부분혹은완전봉합술 (partial or complete repair) 에이르는다양한관절경적방법및관혈적방법, 여 러형태의건이전술 (tendon transfer), 역행성견관절전치환술 (reverse total shoulder arthroplasty) 등을대표적으로들수있다. 최근관절경기술이발전함에따라광범위파열에서도관절경적 봉합술의적응증이점차확대되고있으나, 광범위파열은회전근 개의위축 (atrophy), 섬유화및지방변성 (fatty infiltration) 등을흔 히동반하므로일차건 - 골봉합 (primary tendon to bone repair) 이 어려운경우가많고, 봉합술후재파열률또한작은크기의파열 보다높아그임상결과는다양하게보고되고있는실정이다. 1,2) 접수일 2013 년 1 월 31 일수정일 2013 년 2 월 13 일게재확정일 2013 년 2 월 14 일교신저자유재철서울시강남구일원로 81, 성균관대학교의과대학삼성서울병원정형외과 TEL 02-3410-3501, FAX 02-3410-0061 E-mail shoulderyoo@gmail.com 따라서이글에서는치료의표준이되는지침이명확하게알려져있지않은광범위파열의치료중최근관심이높아지고있는관절경적치료에중점을두고문헌고찰을통해살펴보고자한다. 본론 1. 광범위파열의정의일반적으로광범위파열의정의는파열직경이 5 cm보다크거나변연절제이후 2개이상의건을침범한경우를말하나, 단순한크기나침범한건의개수에따른분류는개인차를반영하지못하는단점이있기때문에이후많은분류법이제안되었다. 3,4) Burkhart 5) 는반월형파열 (crescent-shaped tear), U자형파열 (Ushape tear), L자형파열 (L-shape tear) 과같은회전근개의파열형태와건의유동성 (mobility) 에따른분류를제안하였고, Nobuhara 등 6) 은노출된상완골두의대략적인크기에의한분류를제안하였으며, Tauro 7) 는전-후직경과내-외직경을곱한값을분류의기준으로제시하였다. 대한정형외과학회지 : 제 48 권제 1 호 2013 Copyright 2013 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/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
62 이승원 손민수 유재철 2. 광범위파열의병태생리광범위파열은견관절생역학의심각한변화를초래한다. 그중하나의예로짝힘 (force couple) 의소실을들수있다. Inman 등 8) 은관상면에서짝힘을강조하여삼각근의힘과극하근 (infraspinatus), 소원근 (teres minor), 견갑하근 (subscapularis) 및상완의무게가균형을이루어야한다고주장하였다. 이후 Lo와 Burkhart 9) 는관상면에서만이아니라, 수평면에서의짝힘도중요함을강조하여전방의견갑하근과후방의극하근및소원근이서로균형을이루어야한다고주장하였다. Burkhart 5) 의분류중반월형파열은상완골대결절 (greater tuberosity) 에서건이견열된가장흔한형태이며, L자형혹은역 (reverse)l 자형파열은건의전방혹은후방경계에서부터파열이시작되어내측으로파급된형태이다. 이들파열은시간이지나면서건의파열된피판 (flap) 이퇴축 (retraction) 되어 U자형의광범위파열로진행한다. 광범위파열이발생하면건의소실부위를통한상완골두의상방전이가일어나므로회전근개의축이상완골두의중심보다아래쪽으로이동하게되어짝힘의소실이발생하게되므로팔의거상시상완골두를누르는힘이감소하게된다. 몇몇의광범위파열에서견봉 (acromion) 이상완골두에대해받침점 (fulcrum) 을형성하여비교적좋은움직임을보이는경우가있는데이를차양효과 (awning effect) 라한다. 이경우는일시적으로움직임이좋고기능소실이적을수있으나외상등에의해파열이진행될경우보상기전이쉽게소실되고, 급격한증상의변화를초래하게되므로주의해야한다. 결국광범위파열이만성화되면건의퇴축및물리적특성의소실, 근육의지방변성및위축, 상완골두의상방전이에의한견봉- 상완간격 (acromio-humeral distance) 의감소를보이고결국회전근개파열관절병증 (cuff tear arthropathy) 과관절와 -상완관절의골관절염으로진행하게된다. 광범위파열에서회전근개의퇴축으로인한견갑상신경 (suprascapular nerve) 의견인이발생할수있으며이는광범위파열의증상에대한원인중하나이다. 견갑상신경이원위부 (distal branch) 에서견인되는경우에는극하근에영향을주게되며, 견갑절흔 (scapular notch) 에서견인되는경우는극상근과극하근모두에영향을주게된다. 10) 회전근개의퇴축으로인한견갑상신경의견인이원인이되는통증은부분혹은완전봉합술에의해해소될수있기때문에견갑상신경의손상이의심되는경우에는근전도및신경전도검사를시행하는것이수술적치료를결정하는데도움을주기도한다. 11) 3. 광범위파열의증상및이학적검사광범위파열의증상발생은주로급성, 만성, 만성화중급성악화 (acute on chronic) 로구분할수있다. Gerber 등 12) 의연구에서건의영구적변화는수상후약 3개월부터시작된다는보고가있어급성기요소가포함된파열은조기치료가바람직하며이를위해 증상의발생시기를환자에게물어보는것이중요하다. 광범위파열의증상은다른크기의회전근개파열과유사하여어깨의전외측부에서삼각근을따라상완중간부위까지이르는통증을호소하는경우가많은데, 이는 Gerber 등 13) 의연구에서식염수를견봉하공간에주입하였을때삼각근을따라상완중간부위까지통증이유발되는것과유사하다. 통증은야간에심해지고, 거상운동에서악화됨과동시에근력약화도보이게되는데근력의감소는운동범위의감소를초래하고결과적으로스포츠활동과신체활동에영향을주어결국삶의질에도영향을미치게된다. 회전근개의근력은저항검사 (resisted maneuver) 나지연징후 (lag sign) 등으로평가할수있다. 견갑하근의경우 lift-off 와 belly press 검사를이용하여평가할수있으며, 후상방회전근개의경우 Jobe 검사 (empty can 검사 ) 로극상근을, 저항하외회전검사 (resisted external rotation test) 로극하근을평가할수있다. 광범위파열에서근력의약화는더욱심화되어나타나는데외회전의극심한소실은광범위파열의특징적인증상에해당한다. 14) 그외광범위파열에의한근력의광범위한소실을시사하는특징적인이학적소견으로는가성마비 (pseudoparalysis), 상완낙하징후 (drop arm sign), 외회전지연징후및 horn blower 징후등을들수있다. 전방거상시가성마비는수동적관절운동제한및다른신경학적이상이없는상태에서전방거상이불가능한근력약화를의미하며, 이와유사하게외회전시가성마비는외회전근력의중등도약화를의미한다. 4) 상완낙하징후는팔을최대한들어올린상태에서서서히내릴때갑작스러운팔의떨어짐이발생하거나통증이유발되는경우양성이다. Walch 등 15) 은상완낙하징후가극하근의 Goutallier 분류 3기혹은 4기에해당하는변화에대해 100% 의민감도와특이도를나타내는것으로언급하였으나최근의문헌고찰을통한 Alqunaee 등 16) 의연구에서는상완낙하징후가약 21% 의민감도와 92% 의특이도를보이는것으로보고하고있다. 외회전지연징후는극상근과극하근전체의근력의연속성을평가하는것으로양성은상완을몸옆에두었을때외회전자세를유지하지못하는것을의미한다. Horn blower 징후는손을입에가져가라고지시했을때상완을외전시키지않고서는가져가지못하는경우양성이며, 이는소원근의 Goutallier 분류 3기혹은 4기의지방변성에대해 100% 의민감도와 93% 의특이도를가지는것으로보고되었다. 15) 광범위파열을시사하는특징적인이학적소견이있으나그민감도와특이도는연구에따라다양한결과를보여주고있으므로광범위파열에서는여러가지이학적검사를통해회전근개의기능을종합적으로판단하는것이중요하다. 4. 광범위파열에대한관절경적치료광범위파열에대한보존적치료는질환에대한교육에서부터비스테로이드성소염제, 스테로이드국소주사등을이용한통증
63 광범위회전근개파열의치료 조절, 유연성회복, 견갑- 흉곽 (scapulothoracic) 운동, 견갑- 상완관절운동및회전근개강화운동등의재활치료를포함하며, 최근까지광범위파열에서초기치료로인식되어왔다. 보존적치료로도장기적인통증의조절, 기능의회복이가능함이보고되어왔으나최근에는비교적젊은연령이나활동적인사람에서는장기적인증상완화에실패하는경우가많고증상이조절되더라도만성퇴행성변화, 견봉- 상완간격의감소혹은관절와 -상완관절의골관절염변화등의구조적인변화는예방하지못하는것으로보고되고있어최근에는수술적치료가많이권장되고있다. 그중최근관절경기술의발달에힘입어다양한시도가이루어지면서광범위파열에대한관절경적치료는점차증가하는추세에있다. 9) 관절경적치료를결정하기전에가장먼저시도되어야하는것은봉합가능성에대한평가이다. 봉합불가능파열은간격활주방법 (interval sliding) 을사용한가동 (mobilization) 및유착의박리등으로가동성이증가되었음에도불구하고파열의크기가크고지방변성과퇴축이심해상완골대결절로일차건-골봉합을할수없는파열을의미한다. 17,18) 특히건의탄력성이소실되지않은젊은연령에서외상이후의급성파열은그크기가광범위파열에해당하더라도일차봉합이가능한경우가많고, 반대로고령에서만성으로발생한파열은건의위축, 섬유화, 지방변성이심하여크기가작더라도봉합이불가능한경우가발생하기때문에봉합불가능파열은광범위파열과같은의미가아니다. 광범위파열에서봉합가능성은수술도중내측으로퇴축된건을직접상완골대결절까지이동시켜서판단하는것이가장정확하겠으나치료방침의결정을위해봉합가능성에대한수술전평가또한필요하며이에대해다양한방법이제시되고있다. 2) 단순방사선검사소견으로는관절와상완관절및견봉- 쇄골관절의퇴행성변화나상완골대결절의낭성변화, 견봉하방의경화소견등을들수있으며특히전-후방촬영에서견봉- 상완간격이 7 mm 미만인경우극하건의완전파열및심한지방변성을동반하는경우가많아봉합가능성이낮아진다는보고가있다. 4) Goutallier 등 19) 은전산화단층촬영에서파열된회전근개의근위축과지방변성정도에따라파열을분류하였고근위축과지방변성이심할수록봉합가능성이낮아짐을언급하였다. 이러한지방변성은전산화단층촬영뿐아니라자기공명영상을이용하여더욱정확하게확인할수있으며, 현재자기공명영상을이용해봉합가능성을평가하려는다양한시도가이루어지고있다. Thomazeau 등 20) 은자기공명영상검사를이용해극상근와에대해서극상근이차지하는면적의비를이용하여 (occupation ratio) 극상근의위축정도를판단하려하였으며, Davidson 등 21) 은전-후크기와내-외측크기가모두 2 cm 이상인경우일차건-골봉합이불가능해부분봉합을시행하거나활주방법을이용해가동성 을늘려야한다고보고하였으며, 파열의크기가큰 U자형파열은봉합이불가능할수있다고하였다. Sugihara 등 22) 은수술전시행한자기공명영상검사상파열길이와넓이가 40 mm 이상이면서, 관절와위치에서극상근이 5 mm 이하로얇아져있고, 극하근에고신호음영이관찰될때일차봉합이가능하지않은경우가많다고주장하였다. Zanetti 등 23) 은회전근개가극상와에의해나누어지는시상면단면에서극상와의상측부를서로연결하는선인 tangent 선과극상근의관계를이용하여극상근의위축정도를평가하였으며, 극상근이 tangent 선을넘지못할때양성으로봉합이힘들다고보고하였다. Yoo 등 24) 은봉합나사를이용한관절경적봉합술에서관상면상파열길이가 32 mm 이상, 시상면상파열길이가 31 mm 이상이면서극하근의지방변성이 2기이상, 극상근의지방변성이 3기이상인경우는불완전복원이이루어질가능성이높음을밝힌바있다. 1) 관혈적봉합술 (open repair) 및소절개봉합술 (mini-open repair) 전통적으로관혈적회전근개봉합술은비교적범위가큰파열이거나관절경적봉합방법에익숙하지않은경우사용되어왔다. 관혈적수술방법은관절경적수술방법에비해대부분의수술자에게친숙한방법이면서육안으로파열의형태를쉽게관찰할수있다는장점이있으나삼각근의손상이발생할수있고, 관절내병변을관찰하기어려우며, 절개가커서미용상의문제를보이기쉽다는단점이있다. 관혈적수술방법에서는삼각근의부분적인분리가필요한데, 이때삼각근의분리는일반적으로견봉으로부터 5 cm를넘지않아야액와신경 (axillary nerve) 손상을피할수있다고알려져있으나가깝게는 3.1 cm 위치까지존재하는것으로보고된적도있다. 25) 삼각근의손상은직접손상뿐아니라수술기구의견인으로인해서도발생할수있으며매우심각한결과를초래하는것으로보고되고있으며, 관혈적봉합술후수술후강직 (postoperative stiffness) 을보이는환자의경우이러한삼각근의손상이원인이된다는보고도있다. 26) 하지만최근에는관혈적방법에서도유착의박리와가동성을늘리는과정에서관절경을부분적으로사용하는방법이소개되면서이러한손상의발생가능성은점차줄고있는추세이다. 소절개봉합술은관절경으로관절내병변을확인후관절경적견봉성형술을시행하고관절경에사용되었던외측삽입구 (lateral portal) 를연장하여회전근개를봉합하는방법이다. 관절내병변을관찰하기어려우며삼각근의손상가능성이높은관혈적회전근개봉합술에비해소절개봉합술은이를보완할수있는장점이있으며, 관절경적봉합술과비교하여도임상결과가나쁘지않다고보고되고있다. 따라서소절개봉합술은관절경적봉합술에관한수술기술이부족한경우좋은대안이될수있다. 광범위파열에대한관혈적혹은소절개봉합술후의경과는
64 이승원 손민수 유재철 대체로우수한것으로보고되고있다. Bigliani 등 27) 은 61예의광범위파열에대한관혈적봉합술후 7년간관찰한결과약 85% 에서만족스러운결과를보였다고하였으며, Cofield 등 28) 역시장기간관찰한결과 80% 에서만족스러운결과를보였다고하였다. Musil 등 29) 은소절개봉합술과관절경적수술방법을비교하였을때, 환자의만족도나임상결과에는차이가없으며, 두방법모두양호한결과를보여준다고하였다. Bartl 등 30) 은 25예의광범위파열에대한관절경적치료와관혈적치료방법을조합하여사용한결과 80% 에서우수이상의결과를보였다고보고하였다. 관혈적봉합술후재파열률은관절경적봉합술과유사한정도로보고되고있으며 37% 에서부터 94% 까지보고되고있다. 31,32) 2) 관절경적완전봉합술관절경적봉합술은관절내병변의관찰에유리하며, 삼각근의손상이적다는장점이있으나수술방법이어렵다는단점이있다. 광범위파열의경우대부분유착을박리하고, 회전근개를가동시킨후봉합술을시행하게되는데이때봉합술의구체적인방법은다양하게소개되어있으며, 주로단열 (single row), 이열 (double row) 혹은경골봉합술과유사한 (transosseous equivalent) 봉합술형태인교량형봉합술 (suture-bridge technique) 등이흔히사용된다. 봉합술의차이를비교한생역학적연구들은단열봉합술보다는교량형봉합술이극상건의족적 (footprint) 에더넓은부착면적을제공하고, 파열부하 (load to failure) 가커서더튼튼한구조적특성을보인다고보고하고있다. 33,34) 그러나많은연구에서생역학적특성이아닌임상결과는봉합방법에따른차이가거의없는것으로보고하고있어최근에는관절경적봉합술의재파열률및임상적결과는관혈적수술방법과비교해동등한결과를보인다는견해가보편적으로받아들여지고있다. 35,36) Galatz 등 37) 은 18예의광범위파열에대한관절경적봉합술후 2년간관찰한결과약 17예에서재파열이있었으나외회전범위와기능적결과는향상되었으며모든환자에서높은주관적만족도를보였다고보고하고있다. Denard 등 1) 도광범위파열인경우최초수술의 80%, 재수술의 29% 에서완전한일차건-골봉합이가능하였고, 각각 90% 와 43% 에서가성마비가회복되었음을보고하였다. 광범위파열에서회전근개가가동성이떨어지는경우에는간격활주방법을사용하여봉합을시도할수있다. 간격활주방법에는전방활주 (anterior sliding) 와후방활주 (posterior sliding) 가있는데전방활주는후방삽입구에서관절경을이용해관찰하면서외측삽입구로기구를넣어극상건의전방을회전근간격 (rotator interval) 으로부터상완이두근장두의방향을따라서오구돌기하방까지분리시키는것이다. 7,11) 전방활주는극상건의내-외측가동역 (excurtion) 을약 1-2 cm 정도늘려주는것으로보고되고있다. 38) Debeyre 등 39) 은최초로회전근간격과오구- 상완인대 (coraco-humeral ligament) 를관절와및오구돌기에서박리하여퇴축 되고유착되어있는극상건을외측으로가동시켜봉합을시행하는전방간격활주방법을제시하였고, 이후의여러연구에서도만족스러운임상결과들이보고되고있다. 9,38) 전방활주이후에도가동성이떨어지면후방활주를추가로시행하게되는데, 이는극상건과극하건사이를유리하는방법이다. Warner 40) 는후방활주시극상건을 3 cm까지가동시켰을때에도신경손상이없었음을보고한바있다. Lo와 Burkhart 9) 는관절와로부터약 2 cm 이상내측으로너무과도하게가동시키는경우견갑상신경의손상가능성이있다고보고하였으며, Zanotti 등 41) 역시극상건의가동범위가 2.5-4 cm 정도일때견갑상신경손상이발생할가능성이있음을보고하였다. 또한후방활주는견갑극 (scapular spine) 내측으로시행할경우견갑상동맥 (suprascapular artery) 의손상및이로인한건의탈혈관화 (devascularizatoin) 의위험이있으며, 봉합시건이부족해지는문제등도추가로발생시키게되므로주의를요한다. 2,9,11,38) 최근에는간격활주방법등의가동화에도불구하고완전봉합이불가능한경우절단된상완이두근장두혹은동종이식물이나합성물을이용하여결손간격을보강하는시도가이루어지고있다. 42,43) Cho 등 42) 은절단된상완이두근장두를이용하여광범위파열을봉합한결과구조적실패가줄고, 기능적향상을얻을수있었다고보고하였고, Bond 등 43) 은이식물을이용한보강술후 16 예중 15예에서만족스러운결과를보였다고보고하였다. 3) 관절경적부분봉합술광범위파열에서봉합불가능한파열로인해관절경적으로일차건-골봉합을시행하지못하는경우부분봉합을시행하여통증을줄이고기능을향상시키려는시도를할수있다. 관절경적부분봉합술은봉합불가능파열에서회전근개를해부학적위치로복원시키지는못하나짝힘이유지될수있도록봉합하여견관절생역학을복원시키고기능적회전근개파열 (functional cuff tear) 로전환시켜주는방법이다 (Fig. 1). 44,45) Burkhart 5) 와 Burkhart 등 45) 은봉합불가능한파열에서상완골두의중간까지만이라도봉합하면현수교 (suspension bridge) 효과가발생하여짝힘이균형을찾게되고, 따라서삼각근에의한전방거상이가능하게된다고언급하면서부분봉합술의중요성을강조하였다. 또이들은변연수렴술식이광범위파열에서도움이된다고언급하였는데, 변연수렴술식은 U자형파열이나 L자형파열에서전방피판과후방피판을측면봉합을이용해봉합함으로써파열의크기와전체적인긴장도를줄여상완골대결절에건을쉽게봉합할수있게한다고언급하였다. 이러한부분봉합후결과는대체로만족스러운것으로보고되고있으며 Burkhart 등 46) 은 Goutallier 분류의 3기와 4기에해당하는극하근의지방변성이있는 22예를대상으로부분봉합후임상적, 기능적결과가향상됨을보고하였다. Yoo 등 24) 도봉합불가능파
65 광범위회전근개파열의치료 Figure 1. (A) Pre-operative magnetic resonance imaging shows a massive rotator cuff tear with severe tendon retraction and (B) fatty degeneration. (C) Arthroscopic finding of the same patient shows severe retraction of tendons. (D) Rotator cuff tendons could not be restored to the original footprint, despite of mobilization; therefore partial repair was performed. H, humeral head; G, Glenoid; SS, supraspinatus; SC, subscapularis; IS, infraspinatus; TM, teres minor. 열이있는 16명의환자에서부분봉합술을시행하여통증의감소와기능적향상을보였음을보고하였다. Duralde 와 Bair 47) 역시완전봉합만큼우수하지는못하나부분봉합술로향상된임상결과를보였음을보고하였다. Moser 등 48) 은단순변연절제와비교하였을때부분봉합이외회전범위의증가를가져옴을, Berth 등 44) 역시단순변연절제와의비교에서부분봉합이더나은결과를보였다고보고하였다. Porcellini 등 49) 은약 5년간관찰한결과부분봉합이임상적결과의향상과함께견봉상완간격의감소의발생을줄였다는보고를하였다. 현재관절경적부분봉합술은통증과기능의만족스러운향상을가져오는것으로보고되고있으나부분봉합후높은재파열률을보이는등장기적결과는아직불투명하다. 따라서관절경적부분봉합은일차건-골봉합이불가능한경우중역행성견관절전치환술을시행하기에상대적으로젊은나이이거나내과적문제등으로시행이어려운경우에시도될수있는구제술의한방법으로고려해야한다. 4) 관절경적변연절제술및견봉하감압술관절경적변연절제술의장점은수술시간이짧으며, 재활이용이하고, 합병증이낮다는점등을들수있다. 관혈적변연절제술및감압술에대하여처음기술한 Rockwood 등 17) 은광범위파열 에서견봉하감압술과변연절제술을시행한경우 83% 에서만족스러운결과를얻었음을보고하고있으며, Gartsman 50) 역시견봉하감압술및변연절제술을시행한 33명의환자중 26명에서통증의감소및생활능력의향상을가져왔음을보고하였다. 그러나변연절제술및견봉하감압술을단독으로사용하는경우는통증완화에일시적인효과를거둘수있으나, 시간이지나면서통증이악화될가능성이높고, 광범위파열에서기능적인호전은기대하기힘들며, 이차적으로발생하는상완골두의상방전위및골관절염변화를막기에는부족하다는보고도있다. 51) 따라서관절경적변연절제술및견봉하감압술의단독사용은구제술의한방법으로적용되는것이바람직하다. 5) 관절경적결절성형술결절성형술은 Fenlin 등 52) 에의해소개되었고, 이후 Scheibel 등 53) 은이러한결절성형술이역행성관절경적견봉하감압술 (reversed arthroscopic subacromial decompression) 의역할을하여오구- 견봉궁의손상을최소화하여좋은결과를얻었음을보고하였다. Lee 등 54) 역시 32예의봉합불가능파열에대하여상완골대결절부위의돌출된뼈에대하여고속연마기를이용하여어떤자세에서도견봉과충돌하는현상이생기지않도록세심하게둥근모양으로연마하는관절경적결절성형술을시행한후평균 40개월간관찰
66 이승원 손민수 유재철 한결과의미있는통증의감소및능동적거상운동범위의개선을가져왔다고하였으나수술전견봉- 상완간격이 2 mm 이하이고수술후에더좁아지거나수술전운동범위가굴곡및외전에서 90 o 미만인경우라면좋은결과를기대하기어렵다고보고하였다. 최근 Verhelst 등 55) 도 32예의관절경적결절성형술을시행하여수술전거상범위에관계없이우수한중기임상결과를얻을수있었다고보고하였으나이러한수술방법으로도견봉- 상완간격의감소및관절염의악화를막지는못한다고보고하였다. 6) 관절경적상완이두근장두절단술및건고정술상완이두근장두는상완골두의상방전위를막고어깨를안정화시키는데있어동적요소와정적요소모두에기여한다고보고되어있다. 56,57) 그러나근전도를이용한연구에서광범위파열인경우상완이두근장두가정적요소에주로기여한다는보고도있는등광범위파열에서상완이두근장두의구체적인기능에대해서는아직논란이많다. 58) 하지만상완이두근장두의병변은회전근개파열과자주동반되며, 통증의원인중하나일수있다는사실은비교적명백하여고령이면서활동이적은경우에는상완이두근장두절단술을, 젊고활동적인환자에서는건고정술을시행하는것이통증을완화시킬수있는치료의하나로자리잡고있다. Walch 등 59) 은광범위파열에서시행한 307 회의절단술을 57개월간관찰한결과평균 Constant 점수가 48 점에서 68 점으로향상되었음을보고하였고, Boileau 등 60) 은봉합불가능파열에서상완이두근장두의절단술및건고정술이모두좋은결과를보였으며특히후방회전근개가보존된경우더나은결과를보였다고하였다. 또다른다기관연구 (multicenter study) 에의하면광범위파열환자 210 명을관찰한결과상완이두근장두의절단술이광범위파열에서확실한이득이있다고보고하였다. 61) 5. 수술후재활수술후에는봉합된회전근개의긴장을줄여건-골치유를도모하기위해외전보조기를착용하는것이좋으며수술후재활은크기가작은파열에서는 4-6 주정도, 광범위파열에서는 6-8 주정도능동적운동 (active exercise) 을피하며저항하근력강화운동은약 3개월째시행한다. 업무나스포츠로의복귀는운동범위와근력이회복되는 6-9 개월째시행하는것이일반적이며, 그이후에도 12-18 개월까지기능적향상을얻을수있다. 14) 결론 광범위파열이진행하면결국건의퇴축과근육의지방변성및위축을초래하고짝힘의소실로인한상완골두의상방전이를가져와결국에는회전근개파열관절병증을일으키게되므로최근 에는보다적극적인치료가선호되고있다. 하지만많은광범위파열은봉합불가능파열에해당하고, 봉합을하더라도재파열률이높으며그임상결과또한다양하기때문에그기준이되는치료는아직명확하지않다. 따라서광범위파열에대한치료방법의결정은많은주의를필요로하며환자개인별로여러가지요소를고려한후이루어져야한다. 다양한치료방법중관절경적치료는최근관절경기술이발전하고이를바탕으로한다양한시도가이루어짐에따라더욱향상된결과를보이고있어광범위파열에대한중요한치료방법중하나로생각된다. 참고문헌 1. Denard PJ, Lädermann A, Jiwani AZ, Burkhart SS. Functional outcome after arthroscopic repair of massive rotator cuff tears in individuals with pseudoparalysis. Arthroscopy. 2012;28:1214-9. 2. Shin SJ. Massive rotator cuff tear repair. J Korean Shoulder Elbow Soc. 2010;13:167-74. 3. Post M, Silver R, Singh M. Rotator cuff tear. Diagnosis and treatment. Clin Orthop Relat Res. 1983;173:78-91. 4. Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am. 2000;82:505-15. 5. Burkhart SS. Arthroscopic treatment of massive rotator cuff tears. Clinical results and biomechanical rationale. Clin Orthop Relat Res. 1991;267:45-56. 6. Nobuhara K, Hata Y, Komai M. Surgical procedure and results of repair of massive tears of the rotator cuff. Clin Orthop Relat Res. 1994;304:54-9. 7. Tauro JC. Arthroscopic rotator cuff repair: analysis of technique and results at 2- and 3-year follow-up. Arthroscopy. 1998;14:45-51. 8. Inman VT, Saunders JB, Abbott LC. Observations of the function of the shoulder joint. 1944. Clin Orthop Relat Res. 1996;330:3-12. 9. Lo IK, Burkhart SS. Arthroscopic repair of massive, contracted, immobile rotator cuff tears using single and double interval slides: technique and preliminary results. Arthroscopy. 2004;20:22-33. 10. Albritton MJ, Graham RD, Richards RS 2nd, Basamania CJ. An anatomic study of the effects on the suprascapular nerve due to retraction of the supraspinatus muscle after a rotator cuff tear. J Shoulder Elbow Surg. 2003;12:497-500. 11. Abrams JS. Arthroscopic approach to massive rotator cuff
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69 pissn : 1226-2102, eissn : 2005-8918 Instructional Course Lecture J Korean Orthop Assoc 2013; 48: 61-69 http://dx.doi.org/10.4055/jkoa.2013.48.1.61 광범위회전근개파열의치료 www.jkoa.org Management of Massive Rotator Cuff Tear Treatment of Massive Rotator Cuff Tears: Focusing on Arthroscopic Approach Seung Won Lee, M.D., Min Soo Shon, M.D.*, and Jae Chul Yoo, M.D. Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, *National Medical Center, Seoul, Korea There are no standard guidelines for treatment of massive rotator cuff tears. In this article, we reviewed the various modalities for treatment of massive rotator cuff tears, especially focusing on arthroscopic treatment. Selection of one of a variety of treatment modalities is essential for understanding pathogenesis, biomechanics and reparability of massive rotator cuff tears. The best clinical results have been reported with arthroscopic complete repair of massive rotator cuff tear. Satisfactory results have also been reported with other various arthroscopic treatment methods, including simple debridement, partial repair, biceps tenotomy or tendesis, and augmentation using a tissue substitution. However few long-term follow up results are available with these salvage options. Treatment of massive rotator cuff tears is difficult due to high incidence of irreparable tears and re-tear rate. Thus, understanding the advantages and disadvantages of various treatment modalities is thought to be helpful to improving the outcome of treatment of massive rotator cuff tears. Key words: rotator cuff, massive tear, arthroscopy Received January 31, 2013 Revised February 13, 2013 Accepted February 14, 2013 Correspondence to: Jae Chul Yoo, M.D. Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 135-710, Korea TEL: +82-2-3410-3501 FAX: +82-2-3410-0061 E-mail: shoulderyoo@gmail.com The Journal of the Korean Orthopaedic Association Volume 48 Number 1 2013 Copyright 2013 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/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.