24-조남수/

대한견 주관절학회지제 13 권제 1 호 J. of Korean Shoulder and Elbow Society Volume 13, Number 1, June, 2010 광범위회전근개파열에대한변연절제술및결절성형술 경희대학교동서신의학병원정형외과학교실, 경희대학교의과대학정형외과학교실 * 조남수 오현섭 이용걸 * Debridement or Tuberoplasty for Massive Rotator Cuff Tear Nam Su Cho, M.D., Hyun Sup Oh, M.D., Yong Girl Rhee, M.D.* Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, Kyung Hee University East-West Neo Medical Center, Seoul, Korea Department of Orthopaedic Surgery, Kyung Hee University School of Medicine, Seoul, Korea* Purpose: The purpose of this article was to review the effectiveness of arthroscopic debridement and tuberoplasty, and to evaluate the clinical and radiologic results of our series for irreparable massive rotator cuff tears in the elderly. Materials and Methods: We reviewed articles that focused on the treatment options and decision making for irreparable massive rotator cuff tears. In particular, we summarized the reported results of arthroscopic debridement and tuberoplasty for irreparable massive rotator cuff tears in the elderly. Among consecutive patients who had arthroscopic tuberoplasty for irreparable massive rotator cuff tears in our series, thirty-two patients available for clinical and radiological evaluation at a mean follow-up of 29 months (range, 13-52 months) were enrolled and reviewed for the analysis. Results: At the last follow-up, the range of active forward flexion increased significantly with excellent pain relief and improvement in the ability to perform the activities of daily living. However, the group with less than 2 mm in preoperative acromiohumeral distance showed inferior postoperative results. Conclusion: Arthroscopic tuberoplasty may be an alternative option in irreparable massive rotator cuff tears for pain relief and improvement of range of motion. However, good results can not be expected if the acromiohumeral distance is less than 2 mm preoperatively and decreases postoperatively, or when the preoperative range of motion is less than 90 on flexion and abduction. Key Words: Shoulder, Rotator cuff, Massive tear, Irreparable, Arthroscopic, Debridement, Tuberoplasty 통신저자 : 조남수서울시강동구상일동 149 번지경희대학교동서신의학병원정형외과학교실 Tel: 02) 440-6154, Fax: 02) 440-7498, E-mail: nscos1212@empal.com 접수일 : 2010 년 5 월 10 일, 게재확정일 : 2010 년 6 월 16 일 146

조남수 : 광범위회전근개파열에대한변연절제술및결절성형술 서론회전근개파열환자에서의주된문제는통증및견관절운동능력의저하이다 3). 나이가들어감에따라회전근개는점진적으로노화에따른퇴행성변화가심해지기때문에그만큼파열의위험은증가하게되고또한파열될경우그크기또한커지게된다. 회전근개의광범위파열이라함은대개파열부위의최대직경이 5 cm 이상인경우를말하지만 33), 2개이상의건이파열된경우를광범위파열로정의하는저자들도있다 15). 일반적으로만성퇴행성변화가동반된근육의작용으로내측으로퇴축되며, 근위축과함께지방변성이진행된경우가대부분이다. 회전근개가광범위파열된경우에도견갑하근과극하근에의한횡단면상의회전근개의짝힘 (force couple) 이유지된경우통증없는견관절기능이가능하기도하나 7), 파열이진행되어짝힘의균형이깨질경우증상이유발되며, 이에대해서는보존적치료및수술적치료를고려해야한다. 증상을유발하는광범위파열에서는적절한보존적치료에도호전되지않는경우가있어수술적치료를고려할수밖에없다. 역사적으로광범위파열은개방수술이선호되어왔으나근래관절경기기나술식이발달되면서관절경적봉합술이점차증가하고있는추세이다 2,21,28). 그러나, 광범위파열의경우파열의크기가클뿐만아니라퇴축정도가심하고근육의지방변성으로심한위축을보여제위치에봉합하는것이어렵고 1,4,18,37), 봉합하였다하더라도다시파열되는경우가적지않아치료에어려움이많다 20). 광범위파열에대한개방적및관절경적일차복원술시근에가해지는장력이증가하게되고이로인한재파열의빈도가소파열및중파열에비하여높게보고되는경향이다. 회전근개를충분히유리한후가동성을증가시켜파열부에대한일차복원술을통해회전근개와상완골간의해부학적복원을얻는것이장기적인결과에있어서좋지만 7,24,28,29), 퇴축이심해제자리로장력이없는해부학적복원이힘든경우건-건봉합을통한부분복원술을시행하거나 6,11,41), 내측전이술 26,27) 등을고려해볼수도있다. 물론간격활주 (interval slide) 방식을통한봉합이나 10,25) 건이전술 9,16,22,39,40), 혹은인공관절치환술 32) 을시행할수도있지만어느방법하나결과를예측하기가힘들고수술또한부담이되는것이사실이다. 충분한유리술에도불구하고고령의봉합이불가능한파열의경우에는봉합술을포기하고단순감압술및변연절제술 8,14,23,24,35) 또는결절성형술 12,36,38) 을시행하기도한다. 광범위파열에관절염이동반된근개파열관절병증 (cuff rear arthropathy) 에대해서는역행성견관절인공관절전치환술 (reverse total shoulder arthroplasty) 을시행함으로써삼각근의근력을통한능동적외전기능회복을기대하기도한다 13,19). 이에광범위회전근개파열에대한여러가지수술방법중고령의봉합이불가능한파열에대해시행하는단순변연절제술 (Debridement) 및결절성형술 (tuberoplasty; reversed arthroscopic subacromial decompression [RASD]) 에대해알아보고자한다. 광범위회전근개파열의치료방법의선택 (Decision making in massive rotator cuff tear) 회전근개파열의치료는크게보존적치료및수술적치료로대별되며, 퇴행성변화에의한파열의경우일차적으로보존적치료를시도하여 6개월이상의치료에도호전이되지않거나기존의파열이확대되어증상이심해진경우수술적치료를고려할수있다. 일반적으로노년층에서발생한광범위파열의경우청장년층에비해활동력이나근력의회복은제한되더라도통증의완화및일상생활기능의회복을목표로한보존적치료가도움이되며 Gerber 등 15) 은광범위회전근개파열의경우근의퇴축, 주위조직과의유착, 근조직의지방화등으로인해수술적봉합및유지가힘들어환자의기능적욕구가크지않을경우보존적치료를권하였다. 그러나회전근개의전파열이있을경우보존적치료로는파열의진행및상완골두의상방전위를막을수없어장기적으로증상의반복및악화가예상되므로최근에는보다적극적으로수술적치료를권하는경향이다. 특히젊고활동성이있는환자의경우조기에수술적치료를고려할수있다. Goldberg 등 17) 의연구에의하면보존적치료와수술적치료의결과를비교한바수술적치료가통증의완화및기능회복면에서우수하다고하였으며, 수술방법에따른치료결과는최근큰차이가없는것으로보고되어개방적술식이나관절경적술식의선택은술자의기호도및숙련도에따라선택되어질수있다 3,30). 그러나최근에는소, 중파열뿐만아니라대파열및광범위파열의경우에도관절경적술식에대한선호도가높아지고있으며, 이는개방적술식시삼각근의분리에따른문제및최소절개시무리한삼각근견인손상으로인해삼각근의위축이나수술후강직의문제를피할수있는장점이있을뿐만아니라관절경시야에서파열의상태를좀더정확하게확인하여부분복원및일차봉합등을결정할수있는이점이있기때문이다. 그외에도수술시동반손상에대한치료가가능하며적은반흔, 짧은입원기간과수술후통증이적은상태에서조기에재활치료가가능한점등의다양한장점이있다. 하지만개방적술식에비해수술에필요한장비를충분히갖추고 147

대한견 주관절학회지제 13 권제 1 호 오랜숙달기간을거쳐야만만족할만할결과를얻을수있는다양한관절경적술기를습득할수있다는점이여전히한계점이되고있다 5,25,34,41). 광범위복원불가능회전근개파열의수술적치료 (Surgical treatment for irreparable massive rotator cuff tear) 광범위복원불가능회전근개파열은근조직의위축및지방변성이심하여퇴축된건을상완골의부착부에적절한근긴장하에봉합할수없는경우를말하며 (Fig. 1), 근파열의양상은후상방병변 (posterosuperior lesion), 전상방병변 (anterosuperior lesion) 및전체병변 (global lesion) 의양상으로나타나게된다 15,40). 이에대한치료방법의선택은단순변연절제술 8,14,23,24,35) 또는결절성형술 12,36,38), 국소및원위건이전술 9,16,22,39,40), 동종건이식술 (tendon allograft) 및 synthetic fabrics를이용한재건술 31) 등을시행할수있다. 변연절제술의경우고령의통증을주증상으로하는환자에대해개방적혹은관절경적으로시행하며, 통증완화및일상기능회복에는효과적이나근력회복은기대하기힘들며시간경과에따라증상악화의가능성이높아질수있다. 건이전술은광범위회전근개파열에대해일차적복원술의대상이되지않는경우인접한건혹은원위근-건단위를회전근개결핍부에이전함으로써기능회복을기대하고자하는방법으로이전공여근은견갑하건및소원형근, 전방삼각근, 승모근, 대원형근, 광배근및대흉근등을이용할수있다. 이중현재까지비교적널리쓰이는방법으로써복원불가능한후상방파열에대한광배근이전 Fig. 1. 봉합이불가능한광범위회전근개파열을보이는관절경사진. 술 (latissimus dorsi transfer) 16) 은통증완화및상지의거상을효과적으로회복시킬수있는반면, 재수술의경우에시행하거나삼각근의근력이불량하거나환자의재활의지가약한경우에는그결과가좋지못한경향이다. 복원불가능한전상방파열에대해서는대흉근이전술을통해통증완화및안정효과를기대할수는있으나근기능의생역학적변화가유발됨으로써기능회복은제한적인것으로보고되고있다. 동종건이식술 (tendon allograft) 및 synthetic fabrics 를이용한재건술은주로근고정 (tenodesis) 효과로써현재까지는만족할만한효과를기대하기는힘든것으로보고되고있다 31). 단순변연절제술 (Debridement) 및결절성형술 (Tuberoplasty; reversed arthroscopic subacromial decompression [RASD]) 봉합이불가능한광범위파열의경우파열로발생한모든결손부위를해결해야만기능적인회복을얻을수있는것은아니다. Rockwood 등 35) 은봉합이불가능한광범위파열에서관혈적변연절제술및감압술에대해처음기술하였고, 수술후평균 6.5 년추시에서 83% 가수술결과에만족하였다고보고하였다. Gartsman 등 14) 은 33예의환자에대하여관혈적변연절제술및감압술을시행하여 79% 에서견관절기능의향상을얻었다고보고하였고, Kempf 등 23) 도관절경적견봉성형술을시행한환자중 89% 에서만족할만한결과를얻었다고보고하였다. 하지만이러한단순견봉성형술의장기추시결과가봉합술을병행한경우와비교해기대에미치지못하고시간이경과하면서좋았던단기추기결과가점점나빠졌다는보고들도있다. Melillo 등 28) 은견봉하감압술및파열된회전근개의변연절제술만시행한경우관혈적으로봉합한경우에비해시간이경과함에따라임상적결과가나빠진다고보고하였고, Montgomery 등 29) 은 88 명의환자를관혈적봉합술및견봉하성형술을시행한군과관절경적변연절제술및견봉하감압술을시행한군으로나누어시행한전향적연구보고에서 6~9 년추시시관혈적봉합술및견봉하성형술을시행한군은 87% 에서만족한결과를얻었으나관절경적변연절제술과견봉하감압술을시행한군에서는단지 8% 만이결과에만족하였다고하였다. Zvijac 등 42) 도 25 예의회전근개전층파열에대하여관절경적견봉하감압술을시행하여추시한결과초기추시에는 84% 를보였던만족할만한결과가시간이경과하면서 68% 로떨어졌다고보고하였다. 물론, 이들연구에서봉합이가능한회전근개파열에대하여변연절제술만시행한경우까지포함시켰다는제한점은있으 148

조남수 : 광범위회전근개파열에대한변연절제술및결절성형술 나파열된회전근개를봉합하지않아도되지않는가하는의문에대해서는논란의여지가많은것이사실이다. Fenlin 등 12) 은 Rockwood 등 35) 이시행한견봉성형술과반대로상완골대결절부위의관혈적결절성형술을소개하였다 (Fig. 2). 그들은대결절부위를직접만져가면서제거해야할골조직의두께와모양을확인해야하기때문에관혈적방식을강조하였다. Scheibel 등 36) 은관혈적방법이아닌관절경적결절성형술을시행한후 22 명환자의 40 개월추시보고에서통증이효과적으로감소하였다고보고하였고, 관절경적인방법으로안전하고정확하게결절성형술을시행할수있었다고주장하였다. 최근 Verhelst 등 38) 도 32 예 (31명) 의관절경적결절성형술시행후평균 38 개월간추시한결과수술전거상범위에관계없이훌륭한중기임상결과를얻을수있었다고보고하였다. 이들은결절성형술을시행할때이두장건절제술을함께시행하였으나오구-견봉궁은보존하였다고하였다. 하지만이술식으로도결과에영향을주지는않았지만경과에따른견봉- 상완간격의감소및관절염의악화를막지는못한다고하였다. 본저자의교실에서도봉합이불가능한광범위파열이있는환자들중수술전통증은있으나능동적 전방거상운동이 90 도이상가능하면서방사선사진상상완골두와견봉사이간격이소실되지않은환자를대상으로결절성형술을시행하고있다. 수술방법진단적관절경술을통해관절내이상소견유무와회전근개파열및상완이두장건병변의유무를확인한다음다시관절경을후방삽입구에서견봉하공간으로삽입하고, 세척액흡입과관절경술작업을위한외측삽입구를만든다. 외측삽입구를통해파열된회전근개의파열양상을확인하고, 수술전방사선사진에서견봉이갈고리형태이거나관절경소견상심한세동이보이는경우견봉성형술을통해감압술을시행한다. 견봉하공간의넓은조망이가능한 Grand Canyon view를얻기위해견봉의후외방 1 cm 정도에후외측삽입구를만든다. 관절경하에절삭기 (shaver) 를이용하여상완골대결절부위의연부조직을제거한다음고속연마기 (high-speed burr) 로대결절부의돌출된뼈를연마한다. 이때팔이어떤자세에있더라도견봉과대결절이충돌하는현상이생기지않도록세심 A B C Fig. 2. 결절성형술. (A) 상완골대결절에반응성으로생긴외골증 (exostoses). (B) 연마기 (burr) 를이용하여돌출된뼈을제거하며결절면을부드럽게다듬는결절성형술의모습. (C) 결절성형술후돌출되었던대결절의소실및매끈한견봉-상완관절면을보여주고있다. A B C Fig. 3. 관절경적결절성형술. (A) 관절경적결절성형술시행후상완골대결절이매끈한구형태를보이고있다. (B) 수술전과비교하여 (C) 수술후의방사선사진에서돌출되었던대결절이소실된소견을볼수있다. 149

대한견 주관절학회지제 13 권제 1 호 하게둥근모양을만들어주어야한다 (Fig. 3). 수술직후부터견관절의수동적전방거상운동을시작하며, 수술후 6주까지는수동적운동을통해정상적인견관절운동범위를얻으려하고, 6주후부터능동적관절운동및근력강화운동을시작한다. 치료결과본저자의교실에서광범위회전근개파열로진단받은환자들중회전근개의심한퇴축으로도저히봉합이불가능하였던 32 예를대상으로관절경적결절성형술을시행한후평균 29 개월 (13~52개월 ) 추시한결과통증의감소와능동적거상의경우통계적으로의미있는운동범위의증가를확인할수있었으며기능적향상을얻을수있었다. 하지만수술전견봉-상완간격이 2 mm 미만으로좁았던경우에는수술후불량한결과를보였다. 결론광범위회전근개파열에대한치료방법의선택은환자의증상및전신상태를감안하여개별화된치료목표에따라보존적치료및수술적치료방법이선택될수있으며, 수술적치료또한환자의선호도및술자의숙련도에따라개방적술식과관절경적술식을선택할수있다. 수술시파열된건조직의상태및파열의정도에따라모서리맞춤형복원술, 이열봉합및교량형봉합을통한부착부재건술 (footprint reconstruction) 등의다양한복원방법이시도되고있으며, 건이전술및역행성인공관절전치환술등의다양한술기의개발을통해보다향상된치료결과가보고되고있다. 수술적치료를시행하는경우파열의크기, 퇴축정도, 건및근육의상태등내적요인뿐만아니라환자의전신건강상태, 직업및취미, 예상되는활동수준, 회복에대한의욕등외적요인을종합적으로고려하여달성가능한치료목표를설정하고방법을선택하는것이중요하다고할것이다. 광범위파열의관절경적치료에있어, 일단회전근개유리술후봉합이가능한경우는최대한봉합술을시도해볼수있으며, 봉합이불가능한광범위파열의경우에는무리하게일차복원술을시도하기보다는수술전에통증은있으나 90 도이상능동적전방거상이가능하고방사선사진상견봉과상완골두사이간격이 2 mm 미만으로좁아지지않은경우에는견봉성형술을포함한관절경적결절성형술을고려해보아야할것이다. REFERENCES 1) Adamson GJ, Tibone JE: Ten-year assessment of primary rotator cuff repairs. J Shoulder and Elbow Surg, 2: 57-63, 1993. 2) Bennett WF: Arthroscopic repair of full-thickness supraspinatus tears (small-to-medium): A prospective study with 2- to 4-year follow-up. Arthroscopy, 19: 249-256, 2003. 3) Bishop J, Klepps S, Lo IK, Bird J, Gladstone JN, Flatow EL: Cuff integrity after arthroscopic versus open rotator cuff repair: a prospective study. J Shoulder Elbow Surg, 15: 290-299, 2006. 4) Blevins FT, Warren RF, Cavo C, Altchek DW, Dines D, Palletta G, Wickiewicz TL: Arthroscopic assisted rotator cuff repair: results using a mini-open deltoid splitting approach. Arthroscopy, 12: 50-59, 1996. 5) Burkhart SS, Athanasiou KA, Wirth MA: Margin convergence: a method of reducing strain in massive rotator cuff tears. Arthroscopy, 12: 335-338, 1996. 6) Burkhart SS, Nottage WM, Ogilvie-Harris DJ, Kohn HS, Pachelli A: Partial repair of irreparable rotator cuff tears. Arthroscopy, 10: 363-370, 1994. 7) Burkhart SS: Arthroscopic treatment of massive rotator cuff tears. Clinical results and biomechanical rationale. Clin Orthop Relat Res, 267: 45-56, 1991. 8) Burkhart SS: Arthroscopic debridement and decompression for selected rotator cuff tears. Clinical results, pathomechanics, and patient selection based on biomechanical parameters. Orthop Clin North Am, 24: 111-123, 1993. 9) Cofield RH: Subscapular muscle transposition for repair of chronic rotator cuff tears. Surg Gynecol Obstet, 154: 667-672, 1982. 10) Debeyre J, Patie D, Elmelik E: Repair of Ruptures of the Rotator Cuff of the Shoulder. J Bone Joint Surg Br, 47: 36-42, 1965. 11) Duralde XA, Bair B: Massive rotator cuff tears: the result of partial rotator cuff repair. J Shoulder Elbow Surg, 14: 121-127, 2005. 12) Fenlin JM, Jr., Chase JM, Rushton SA, Frieman BG: Tuberoplasty: creation of an acromiohumeral articulation-a treatment option for massive, irreparable rotator cuff tears. J Shoulder Elbow Surg, 11: 136-142, 2002. 13) Frankle M, Siegal S, Pupello D, Saleem A, Mighell M, Vasey M: The Reverse Shoulder Prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum two-year follow-up study of sixty patients. J Bone Joint Surg Am, 87: 1697-1705, 2005. 14) Gartsman GM: Massive, irreparable tears of the rotator cuff. Results of operative debridement and subacromial decompression. J Bone Joint Surg Am, 79: 715-150

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대한견 주관절학회지제 13 권제 1 호 초록 목적 : 광범위회전근개파열에대한여러가지수술방법중고령의봉합이불가능한파열에대해시행하는단순변연절제술및결절성형술에대해알아보고자하였다. 대상및방법 : 봉합불가능한광범위회전근개파열에대한여러수술방법및치료방법의선택에대하여문헌을검토하고정리하였다. 특히고령의봉합이불가능한광범위회전근개파열에시행할수있는단순변연절제술및결절성형술에대해연구발표된논문을조사하여요약하고정리하였다. 또한본저자들의교실에서회전근개의심한퇴축으로도저히봉합이불가능하였던 32 예를대상으로시행된관절경적결절성형술의수술방법을소개하고임상적및방사선학적결과를분석하였으며그결과에미치는요인들을조사하였다. 결과 : 평균 29 개월 (13~52개월 ) 추시한결과통계적으로의미있는통증의감소와능동적거상운동범위의증가를확인할수있었으며기능적향상을얻을수있었다. 하지만수술전견봉-상완간격이 2 mm 미만으로좁았던경우에는수술후불량한결과를보였다. 결론 : 광범위파열의관절경적치료에있어, 일단회전근개유리술후봉합이가능한경우는최대한봉합술을시도해볼수있으며, 봉합이불가능한광범위파열의경우에는무리하게일차복원술을시도하기보다는수술전통증은있으나 90 도이상능동적전방거상이가능하고방사선사진상견봉과상완골두사이간격이 2 mm 미만으로좁아지지않은경우에는견봉성형술을포함한관절경적결절성형술을고려해보아야할것이다. 색인단어 : 견관절, 회전근개, 광범위파열, 봉합불가능한, 관절경적, 변연절제술, 결절성형술 152