Case Report J Korean Orthop Assoc 2011; 46: 152-157 doi:10.4055/jkoa.2011.46.2.152 www.jkoa.org Reverse Shoulder Arthroplasty for Humeral Head Fracture with Massive Rotator Cuff Tear in Elderly Patient 권오수 문창윤 김원유가톨릭대학교대전성모병원정형외과 상완골골두골절은고령에서호발하는외상으로서흔히상완골근위부의골다공증과함께회전근개파열이동반되어있으므로견관절기능을유지하기위해서는적절한치료가필요하다. 이와같이상완골두골절로골두의혈액순환이이미차단된경우에는견관절치환술이고려될수있으나상완결절의불유합, 견갑하근의기능저하또는상완골두의상방전위등을초래하여실패율이상당히높은것으로알려져있다. 역견관절치환술은회전근개기능을소실한관절증환자를위해상완골두의회전중심을내측으로이동시켜삼각근의힘의능률을향상시키도록고안되었으며이미각국에서널리시행되고있다. 고령의상완골근위부골절치료로서이와같은삽입물을이용한보고흔하지않다. 74세고령으로에대해보고하고자한다. 색인단어 : 견관절, 상완골골두골절, 광범위회전근개파열, 역견관절치환술 상완골두골절은고령에서빈번히발생하는외상의한형태로서고령에서는흔히상완골근위부의골다공증및광범위회전근개파열등을동반하고있어이상적인치료방법을결정하기가쉽지않으며환자의나이, 활동정도, 동반질환의유무등이고려되어야하며적절한치료방법의선택이향후견관절기능을회복하는데에무엇보다중요하다. 1) 최근고령인구의증가로이러한골절의발생빈도가꾸준히증가하고있으며역학적연구에의하면 65세이상의골절환자중약 10% 를차지한다고알려져있다. 2) 고령의환자의상완골골두골절에대한치료는보존적치료에서부터견관절치환술까지매우다양한치료방법이제시되어왔으나치료방법의선택에있어서는논란의여지가있다. 1,3-6) 고령의환자에서는골다공증에의한분쇄골편들로인해골절부의고 정이용이하지않으며고정되더라도상완결절이전위되거나흡수되는위험이있으며대부분의경우회전근개파열이동반되어있어통상적인견관절반치환술을시행하더라도만족할만한결과를얻기힘들어새로운치료대안의필요성이제시되고있다. 4,7) 역견관절치환술 (Reverse Shoulder Prosthesis) 은광범위회전근개파열과함께견갑와상완관절에관절염을동반한회전근개관절증에서상완골두의회전중심을내측으로이동하여삼각건의지렛대를늘려효율적인외전을도모하기위해고안되었으며비교적양호한장기추시결과가보고되고있다. 4,8,9) 그러나상완근위부골절에서의역할이나적응증에대해서는명확하게확립되지않은상태이다. 고령의환자의광범위회전근개파열을동반한상완골두골절에서역견관절치환술을시행한증례를보고하고자한다. 접수일 2009 년 5 월 18 일게재확정일 2009 년 8 월 12 일교신저자권오수대전시중구대흥동, 가톨릭대학교대전성모병원정형외과 TEL 042-220-9248, FAX 042-221-0429 E-mail oskn@catholic.ac.kr 증례보고 74 세남자환자가자전거사고로수상후타병원을경유하여자 기공명영상촬영후내원하였다. 이학적검사상우측견관절에 대한정형외과학회지 : 제 46 권제 2 호 2011 Copyright 2011 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.
153 심한동통과함께능동적인관절운동은불가능한상태였으며신경학적검사상특이소견은없었다. 단순방사선촬영상상완근위부해부학적경부골절과골절편의전위및상완골두골절편의전방탈구와함께견갑와에관절염소견을동반하고있었고컴퓨터단층촬영에서오구돌기에비전위성골절선이관찰되었다. 타병원에서촬영된자기공명영상검사상회전근개광범위파열소견을보이고있었다 (Fig. 1-5). 수술은전신마취후해변의자자세에서수술은상외측도달법 (Superolateral approach) 을이용하여삼각근의전방부를견봉에서일부분리하여골절부위를노출시킨후회전근개의광범위파열을확인하고상완골두의골절편을제거하였다. 역견관절치환물 (Aequalis Reverse Shoulder Prosthesis, Tornier, France) 을이용하였으며상완골수강에대한확공을시행하고 100 x 36 mm의주대와직경을가진상완골측가삽입물을일시적으로골수강내에위치시켰다. 견갑와견인기 (Glenoid retractor) 를이용하여견갑와를충분히노출시켜잔존하는회전근개조직및관절낭을제거하고 36 mm 견갑와를확공한후 Glenoid base plate 를 4개의나사를이용하여고정하였다. 상완골삽입물은시멘트고정법을이용하였다. 6 mm의폴리에틸렌삽입물로고정한후관절운동범위를확인하였다. 2주간의팔걸이착용후점진적인수동적관절운동을시작하였으며현재 12 개월추시방사선사진에서삽입물이잘유지되고있으며 (Fig. 5, 6) 전방거상 150 도외회전 50 도의관절운동범위를보이며 Korean Shoulder Score 상 75 점으로평가되었다 (Fig. 6). Figure 2. CT scan demonstrates anteriorly displaced humeral head fragment and arthritic changes on glenoid. Figure 1. (A, B) Plain radiographs show displaced humeral head fracture, subacromial spur and reduced acromiohumeral interval. Figure 3. (A, B) 3D CT reveales humerus head fracture with inferomedial displacement of fractured head fragment.
154 권오수 문창윤 김원유 Figure 4. (A, B) MR images show full thickness rotator cuff tears with retraction and muscle atrophy. Figure 5. (A, B) Plain radiographs taken 12 months after implantation of reverse shoulder prosthesis. Figure 6. (A, B) This patient showed 150 forward elevation and 50 external rotation at side 12 months after surgery. 고찰 상완골두골절의치료에는다양한방법들이제시되어있다. 전 신상태가불량하여수술을시행하기어렵거나기능적요구가낮은환자에서는비수술적치료를시행하여볼수있으나대부분의경우결과는만족스럽지못하다. Compito 등 3) 은비수술적치료를시행한환자중오직 5% 만이만족할만한결과를보였음을
155 보고하였다. 일반적으로상완근위부골절에대한수술적치료는골접합술 (Osteosynthesis) 과견관절반치환술로크게나눌수있다. 현재까지의문헌상치료방법간에임상결과의우열을가리기는힘들며치료방법의선택에도논란이많다. 골유합을도모하기위하여관혈적정복과내고정을시행하고파열된회전근개를봉합하는방법도시도해볼수있으나골다공증이동반되고분쇄골절인경우에골절편의정복및고정자체가힘들며이와같이상완골두골절인경우에는해부학적으로이미상완골두에대한혈액순환이차단되어무혈성괴사와같은합병증의발생에대한우려가매우크다. 6,10) 견관절부분치환술은이러한골괴사의위험성이없으며통증감소에효과적이라는여러연구자들의보고가있으나이러한장점에도불구하고임상적결과는항상만족스러운것은아니다. 5) Boileau 등 10) 에의하면골두골절에대한견관절부분치환술을 75 세이상에서시행한경우임상결과가불량하였으며상완골대결절의불유합과부정유합이원인의하나로제시되었다. 이러한합병증은특히고령에서골다공증을동반한경우에더욱문제가되는데골절골편의정복및고정하는수술수기가어려울뿐만아니라비록해부학적위치에정확히정복이되고골유합이일어나더라도추시상에골흡수에의한결절부불유합을초래하여회전근개의적절한기능을유지하기힘들며상완골두의상방전위등이발생하여결국에견관절기능저하를초래하게된다. 역견관절치환술은 1985 년에프랑스에서 Grammont 에의해서고안되었으며 1991 년도에처음으로회전근개파열관절증에대해수술을시행하였다. 역견관절치환술의장점은디자인상반구속형의볼-소켓형태의관절면을가지고있어회전근개부재시에안정성을확보하며관절와삽입물의기계적실패의위험을줄이고견관절의회전중심을원위부로이동시켜삼각근의 moment arm 을증가시킴으로써회전근개부재시에도견관절의능동적거상을도모하도록고안되었다. 9) 회전근개관절증의치료후장기추시결과는비교적만족스러우나합병증의발생시에재수술의대안을제시하기힘들다는단점이있다. 상완골근위부골절에대한치료로서역견관절치환술의역할은명확히정립되지않았으며급성골절의치료후임상결과에대한문헌도매우드물다. 4,8) 그러나이와같은고령의환자에서일반적인전신상태와상완근위부의골다공증, 골절의분쇄로인한골소실, 불량한회전근개상태등을고려하고기존의다른치료방법에대한대안을찾기힘든경우에선택적으로역견관절치환술이시행될수있을것으로생각된다. 수술적접근방법으로삼각- 흉근접근법 (Deltopetoral approach) 와상외측접근법 (Superolateral approach) 가모두가능하나본증례에서는상외측접근법을사용하였다. 이접근법은삼각- 흉근접근법과는달리비교적작은절개를통해전방의견갑하건에손상을주지않으며견갑와에대한시야 가좋다는장점이있으나삼각근일부를견봉에서분리하여야하며액와신경에대한손상을피하기위해절개를원위부까지연장할수없다는단점이있다 (Fig. 3). 9) 저자의견해로는수술도달법상견갑하건의박리와재부착의과정에서필연적으로속발하는견갑하건의기능저하와관련된합병증의빈도는상당히높은것으로알려져있다. 7) 더구나광범위한회전근개파열이동반된경우에축상면상에서 force couple 을유지하고있는전방의견갑하건의기능이저하될경우에는견관절의역학적인변화를초래하게되어임상결과에영향을주게된다. 따라서견갑하건의처리가견관절치환술시에현재가장주요한이슈의하나로간주되고있음을감안할때에상외측도달법을추천할수있으나술전삼각건의형태또는기능등을고려하여선택적인접근이필요할것으로생각된다. 결론 고령에서회전근개광범위파열과견갑와관절염소견을동반한상완골해부학적경부골절환자에서역견관절치환술은견관절기능을보존할수있는치료방법의대안으로역할을할것으로기대된다. 참고문헌 1. Zyto K, Ahrengart L, Sperber A, Törnkvist H. Treatment of displaced proximal humeral fractures in elderly patients. J Bone Joint Surg Br. 1997;79:412-7. 2. Baron JA, Karagas M, Barrett J, et al. Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age. Epidemiology. 1996;7:612-8. 3. Compito CA, Self EB, Bigliani LU. Arthroplasty and acute shoulder trauma. Reasons for success and failure. Clin Orthop Relat Res. 1994;(307):27-36. 4. Martin TG, Iannotti JP. Reverse total shoulder arthroplasty for acute fractures and failed management after proximal humeral fractures. Orthop Clin North Am. 2008;39:451-7. 5. Prakash U, McGurty DW, Dent JA. Hemiarthroplasty for severe fractures of the proximal humerus. J Shoulder Elbow Surg. 2002;11:428-30. 6. Schai P, Imhoff A, Preiss S. Comminuted humeral head fractures: a multicenter analysis. J Shoulder Elbow Surg. 1995;4:319-30. 7. Edwards TB, Williams MD, Labriola JE, Elkousy HA, Gartsman GM, O'Connor DP. Subscapularis insufficiency and the risk of shoulder dislocation after reverse shoulder arthroplas-
156 권오수 문창윤 김원유 ty. J Shoulder Elbow Surg. 2009;18:892-6. 8. Tischer T, Rose T, Imhoff AB. The reverse shoulder prosthesis for primary and secondary treatment of proximal humeral fractures: a case report. Arch Orthop Trauma Surg. 2008;128:973-8. 9. Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Molé D. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. Results of a multicentre study of 80 shoulders. J Bone Joint Surg Br. 2004;86:388-95. 10. Boileau P, Krishnan SG, Tinsi L, Walch G, Coste JS, Molé D. Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg. 2002;11:401-12.
157 Reverse Shoulder Arthroplasty for Humeral Head Fracture with Massive Rotator Cuff Tear in Elderly Patient Oh Soo Kwon, M.D., Ph.D., Chang Yoon Moon, M.D., and Weon Yoo Kim, M.D., Ph.D. Department of Orthopedic Surgery, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daejeon, Korea There are several methods to treat anatomic neck fracture of humerus in elderly patients. It is not easy to obtain optimal clinical or radiological results because of unstable fixaton of fractured site attributed to multifractured osteoporotic tuberosities and combined massive rotator cuff tears in these patients. These factors often lead to high failure rate of implantation. Alternative methods of treatment have been proposed to reduce complications and improve shoulder functions. Reverse shoulder prosthesis was originally designed for patients with cuff tear arthropathy. Indications for reverse shoulder arthroplasty have expanded with initial success. However, there are few reports to perform reverse shoulder prosthesis in proximal humerus fracture. We performed reverse shoulder arthroplasty in a 74-year-old man with right anatomic neck fracture of humerus and concomitant massive rotator cuff tear. Key words: shoulder, anatomic neck fracture, massive rotator cuff tear, reverse prosthesis Received May 18, 2009 Accepted August 12, 2009 Correspondence to: Oh Soo Kwon, M.D., Ph.D. Department of Orthopedic Surgery, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daehueng-dong, Jung-gu, Daejeon 301-723, Korea TEL: +82-42-220-9248 FAX: +82-42-221-0429 E-mail: oskn@catholic.ac.kr