전방십자인대 재건술 후 잔류조직 보존술식과 비보존술식의 자기공명영상을 이용한 연구

이병일(Byung-Ill Lee),김병민(Byoung-Min Kim),고덕환(Duk-Hwan Kho),권세원(Sai-Won Kwon),김환배(Hwan-Bae Kim) 대한정형외과학회 2015 대한정형외과학회지 Vol.50 No.6

목적: 전방십자인대 재건술 시 잔류조직 보존술식과 비보존술식 간 차이를 안정성 검사와 기능적 평가, 이차관절경 소견 및 자기공명영상을 이용하여 비교하고자 한다. 대상 및 방법: Outside-in 술식하에 자가 슬괵건을 이용한 재건술을 시행받고 12개월 이상 경과하여 이차관절경과 자기공명영상을 시행한 환자 23명 중 보존군 12예와 비보존군 11예로 나누어 두 군 간에 안정성 검사, 임상적 기능평가점수, 이차관절경 소견과 자기공명영상에서 signal to noise quotient (SNQ) ratio를 비교하였다. 결과: 안정성 검사와 International Knee Documentation Committee 점수, Lysholm 점수에서는 두 군 간에 차이를 보이지 않았으나 외발뛰기 검사에서 보존군에서 더 우수하였고(p<0.05), 보존군에서 유의하게 SNQ ratio가 더 낮았다(p<0.05). 이차관절경 평가는 두 군 간에 유의한 빈도 차이를 보이지 않았다. 이식건의 활액막 형성정도와 이식건의 상태는 SQN ratio와 연관성이 없었다(p>0.05). 결론: 잔류조직 보존술식은 1년 이상 추시 시 자기공명영상에서 비보존군에 비해 낮은 신호강도를 보였다. 잔류조직 보존술식이 인간대상연구에서 생물학적 차이를 보임을 자기공명영상을 이용하여 간접적으로 확인할 수 있었다. Purpose: The purpose of this study was to clarify the difference between the remnant-preserving and remnant-sacrificing techniques in anterior cruciate ligament (ACL) reconstruction using stress test, functional score, 2nd look arthroscopy and magnetic resonance imaging (MRI). Materials and Methods: Among 66 patients having anatomical ACL reconstruction with the fourstrand hamstring autograft using outside-in technique (FlipCutter®) for the femoral tunnel from April 2012 to April 2014, 23 patients who underwent 2nd look arthroscopy and MRI were included. The remnant-preserving group included 12 patients and the remnant-sacrificing group included 11 patients. The two groups were compared and analyzed with regard to stability (Stress test using GNRB<SUP>®</SUP>, pivot shift test), functional assessment (International Knee Documentation Committee [IKDC] scale, Lysholm score, one leg hoop test), and the result of second-look arthroscopy and signal to noise quotient (SNQ) ratio of the graft in MRI. Results: The two groups did not differ significantly in the stability test, IKDC scale, and Lysholm test. The remnant-preserving group showed significant improvement in one leg hoop test compared with the remnant-sacrificing group (p<0.05). The SNQ ratio of the grafted tendon in the remnant-preserving group was significantly lower than those in the remnant-sacrificing group in all regions (p<0.05). In second-look arthroscopy, no significant difference in tension, synovialization, and status of the bundle was observed between the two groups. The grade of synovialization and the status of the bundle in second-look arthroscopy did not influence the signal intensity of the graft in MRI (p>0.05). Conclusion: More than 12 months after surgery, the graft of the remnant-preserving group showed lower signal intensity compared to that of the remnant-sacrificing group by MRI evaluation. The remnant preserving technique has biological difference compared with the remnant sacrificing technique in human study.

Remnant preserving augmentation using an adjunct anterolateral portal in anterior cruciate ligament reconstruction

Su-Keon Lee,Beom-Seok Lee,Chae-Chul Lee,이창욱 대한정형외과 스포츠의학회 2017 Arthroscopy and Orthopedic Sports Medicine Vol.4 No.2

Anterior cruciate ligament (ACL) tears are rarely found without remnant tissue. Remnant tissue is usually found either attached to the posterior cruciate ligament (PCL) or bridging the femoral and tibial footprints. Keeping the remnant tissue intact during ACL reconstruction has been favored because it has been thought to promote revascularization of the graft and recovery of joint position sense. However, in our experience, we found that using the remnant preserving technique for ACL reconstruction led to unexpected complications such as blockage of the arthroscopic view by the remnant tissue itself and separation of the remnant tissue during tunnel formation. To overcome these complications associated with the remnant-preserving technique, we developed a novel technique using an adjunct anterolateral portal and a polydioxanone suture to stabilize remnant ACL tissue in place.

잔류조직보존술을 이용한 전방십자인대 재건술과 잔류조직을 제거한 재건술에 따른 근력과 고유수용감각의 비교

김도경 ( Do Kyung Kim ),박원하 ( Won Hah Park ) 대한스포츠의학회 2011 대한스포츠의학회지 Vol.29 No.2

Reconstruction of the anterior cruciate ligament (ACL) restores knee stability. The remnant preserving technique was developed to preserve mechanoreceptor function, promote revasularzation and facilitate ligamentation. The purpose of this study was to analyze the clinical results of ACL reconstruction with remnant preserving. Between October in 2008 and September in 2009, 40 patients underwent ACL reconstruction using auto graft-hamstring tendon. On the basis of the ACL`s condition patients were divided into 2 groups. In the trial group (preserved remnant group, PRG; n=20), there were 20 males with an average age of 26.2 years. In the control group (no remnant group, NRG; n=20) were 20 males with an average of age 27.1 years. We measured concentric peak torque of the knee extensors and flexors at 60o/s and 180o/s on an Isokinetic dynamometry. Proprioceptive functions have been assessed using Joint position sense and threshold to detection of passive motion. Dynamic postural stability was measured as a stability index in the anterior-posterior and medial-lateral planes with the Biodex Stability System. All tests were measured post-operative 1year. We found significant difference between the PRG and NRG for Joint position sense at 15o (2.40o±1.00o vs. 3.36o±0.95o; p=0.0145) and threshold to detect passive motion at 45o (2.02o±0.59o vs. 3.12o±0.94o; p=0.0213). But, we found no significant difference between the groups for the test results of the dynamic postural stability and knee strength. Therefore, preservation of the remnant ACL reconstruction is helpful in preserving the proprioception and function to stabilize the knee.

Outcome Differences of Remnant-Preserving versus Non-Preserving Methods in Arthroscopic Anterior Cruciate Ligament Reconstruction: A Meta-analysis with Subgroup analysis

원성훈,Byung-Il Lee,Su Yeon Park,Kyung-Dae Min,김준범,권세원,김용범,서기원,Jae-Hyung Kim,최형석 대한슬관절학회 2020 대한슬관절학회지 Vol.32 No.-

Purpose: To analyze differences in clinical outcomes of arthroscopic anterior cruciate ligament reconstruction between remnant-preserving and non-preserving methods. Methods: International electronical databases PubMed, Embase, and the Cochrane central database from January 1966 to December 2017 were searched for randomized controlled trials (RCTs) and observational studies that compared differences of clinical outcomes of ACL reconstruction with and without remnant preservation. A metaanalysis of these studies was performed to compare clinical outcomes. Subgroup analyses were conducted to evaluate the role of methodological quality in primary meta-analysis estimates. Results: Five RCTs and six observational studies were included in this meta-analysis and subgroup analysis. The remnant-preserving method in arthroscopic ACL reconstruction showed a statistically significant difference compared to the non-preserving method regarding arthrometric evaluation (side-to-side difference). Lachman test, Lysholm scores, and IKDC subjective scores showed statistically minor difference in meta-analysis, but showed no significant difference in subgroup analysis. Remained parameters including pivot shift test, IKDC grades, incidence of cyclops lesion showed no statistically differences in meta-analysis or subgroup analysis. Conclusions: This meta-analysis with subgroup analysis showed that arthroscopic remnant-preserving ACL reconstruction provided statistically significant but limited clinical relevance in terms of arthrometric evaluation. Results of Lachman test, Lysholm scores, and IKDC subjective scores demonstrated statistically minor differences.

아킬레스 동종건을 이용한 전방십자인대 재건술에서 잔류조직 보존술식과 비보존술식의 임상적 결과 및이차 관절경 소견의 비교

전근철(Keun Churl Chun),황재선(Jae Sun Hwang),김광미(Kwang Mee Kim),김다희(Da Hee Kim),전철홍(Churl Hong Chun) 대한정형외과학회 2013 대한정형외과학회지 Vol.48 No.5

목적: 잔류조직 보존술을 이용한 전방십자인대 재건술이 임상적으로 나은 결과를 보일 것으로 생각하여 전방십자인대 재건술에서 잔류조직 보존술식과 비보존술식을 이차 관절경 소견과 기능 안정성을 비교, 분석하였다. 대상 및 방법: 2008년 1월부터 2010년 12월까지 24개월 이상 추시 관찰 가능하였던 전방십자인대 재건술을 시행한 환자 48명 중 잔류조직 보존 여부에 따라 보존군 26명, 비보존군 22명으로 나누었다. 슬관절 안정성 평가(International Knee Committee, Lysholm 슬관절 점수, Tegner 활동 점수, Lachman 검사, Pivot shift 검사) 및 이차 관절경에서 비교 분석하였다(study design: prospective cohort study). 결과: 최종 추시상 슬관절 안정성 평가에서 두 군 간 유의한 차이는 없었으나(p>0.05), 기능적 평가에서 보존군이 비보존군보다 유의하게 향상된 결과를 보였다(p<0.05). 이차 관절경상 이식건의 긴장도는 유의한 차이는 없었고 활액막 형성은 보존군에서 더 형성된 결과를 보였다. 결론: 아킬레스 동종건을 이용한 전방십자인대 재건술 시 잔류조직 보존군이 기능성 평가와 이차 관절경 소견에서 우수한 결과를 보였다. Purpose: This study was conducted for evaluation of clinical uses of anterior cruciate ligament (ACL) reconstruction with an Achilles allograft using the remnant technique by comparison and analysis stability, functional assessment and results of second-look arthroscopy between the remnant technique and the non-remnanat technique. Materials and Methods: A total of 48 patients who underwent ACL reconstruction using an Achilles allograft were selected and divided into two groups depending on the presence of remnant. The preserving group included 26 patients and non-preserving group included 22 patients. The two groups were compared and analyzed with regarding to stability (Stress view Lachman test, pivot shift test), functional assessment (International Knee Documentation Committee, Lysholm score, Tegner score, single hoop test, shuttle turn, carioca test), and the result of second-look arthroscopy (study design: prosepective cohort study). Results: In the final result, the remnant group showed significant improvement in the Tegner and carioca tests compared with the non-remnant group (p<0.05). In second-look arthroscopy, the remnant group showed better coverage of synovium (p<0.05). Conclusion: ACL reconstruction with an Achilles allograft using the remnant technique showed better results in functional assessment and finding in second-look arthroscopy compared with the non-remnant technique group.

A Comparative Study of Clinical Outcomes and Second-Look Arthroscopic Findings between Remnant-Preserving Tibialis Tendon Allograft and Hamstring Tendon Autograft in Anterior Cruciate Ligament Reconstruction: Matched-Pair Design

김유근,안종현,유재두 대한정형외과학회 2017 Clinics in Orthopedic Surgery Vol.9 No.4

Background: This study aimed to compare stability, functional outcome, and second-look arthroscopic findings after anterior cruciate ligament reconstruction between remnant-preserving tibialis tendon allograft and remnant-sacrificing hamstring tendon autograft. Methods: We matched two groups (remnant-preserving tibialis tendon allograft group and hamstring tendon autograft group) in terms of demographic characteristics, associated injury, and knee characteristics. Each group consisted of 25 patients. Results: Operation time was longer in the remnant-preserving tibialis tendon allograft group, but there was no significant intergroup difference in stability, clinical outcome, and second-look arthroscopic findings. Conclusions: When an autograft is not feasible in anterior cruciate ligament reconstruction, the remnant-preserving technique can produce comparable results in terms of restoration of function, stability of the knee, and degree of synovium coverage at second-look arthroscopy compared to remnant-sacrificing hamstring autograft.

전방십자인대 잔유물을 남겨둔 방법을 이용한 전방십자인대 재건술의 임상적 평가 : 자가 반건양건 단일 4가닥 이식건을 이용한 방법

경희수(Hee-Soo Kyung),오창욱(Chang-Wug Oh),이현주(Hyun-Ju Lee) 대한정형외과학회 2011 대한정형외과학회지 Vol.46 No.1

목적: 자가 반건양건 단일 4가닥을 이용하여 전방십자인대 잔류 조직을 보존한 관절경적 전방십자인대 재건술의 임상적 및 기능적 평가를 하였다. 대상 및 방법: 자가 반건양건 단일 4가닥을 이용한 전방십지인대 재건술을 받은 환자 70명을 대상으로 하였다. 수술 당시 파열된 전방십자 인대의 1/2 이상의 잔류 조직이 남아 있는 경우를 Ⅰ군(N=34), 거의 남아 있지 않는 경우를 Ⅱ군(N=36)으로 나누어 조사하였다. 수상 후 수술까지의 평균 기간은 Ⅰ군은 5.7개월, Ⅱ군은 6.9개월이었다. 평균 추시 기간은 Ⅰ군은 18.7개월, Ⅱ군은 20.7개월이었다. Lachman검사, pivot-shift 검사, Lysholm 점수, Tegner활동 점수, IKDC점수 등의 임상적 평가 및 고유수용감각 기능적 평가인 한 쪽 다리 지지 검사, 수상전 스포츠 활동으로의 복귀를 분석하였다. 결과: 수술 후 관절 Lachman검사, pivot-shift 검사, KT-2000 관절계 검사를 이용한 전방 전위 정도, Tegner 활동점수는 수술전보다 모두 호전되었으며, 양군간에 통계적인 차이는 없었다. International knee documentation committee (IKDC) 객관적 평가에서 A+B응급비율, 수상 전 스포츠 활동으로의 복귀율은 양군 간에 통계적인 차이는 없었으나, IKDC 주관적 평가(p=0.007) 및 Lysholm 점수(p=0.001)는 최종 추시 시 Ⅰ군에서 더 좋은 결과를 얻었다. 한 쪽 다리 지지 검사를 이용한 고유수용감각 기능 측정에서 양군간에 통제적인 차이는 없었으나 수술 전보다는 호전되는 경향이 있었다. 결론: 전방십자인대의 자가 반건양건 단독4가닥 이식건을 이용한 전방십자인대 재건술 후 양군 모두 좋은 결과를 얻었다. 그러나 잔유물을 남겨둔 경우 Lysholm점수 및 환자의 IKDC 주관적 평가가 더 좋았다. Purpose: We evaluated the functional and clinical results of anterior cruciate ligament (ACL) reconstruction with remnant-preserving technique using an autologous single four-strand semitendinosus tendon. Materials and Methods: We evaluated 70 patients who had undergone ACL reconstruction using autologous single four-strand semitendinosus tendon. Group Ⅰ (n=34) were cases in which more than half of the ACL remnant remained. Group Ⅱ (n=36) included cases in which the ACL was nearly absent. The mean follow-up period was 18.7 months for group Ⅰ cases, and 20.7 months in group Ⅱ cases. We performed clinical evaluation using the following tests: Lachman test, pivot shift test, Lysholm score, Tegner activity score, and IKDC score; functional evaluation was performed using the single limb standing test and ability to return to pre-injury sports activity Results: Lachman test, pivot-shift test, measurement of side-to-side difference using KT-2000 arthrometer and Tegner activity scores were much improved over preoperative evaluations, and there were no statistically significant differences between the 2 groups. The objective IKDC (International Knee Documentation Committee) score and return to pre-injury sports activity showed no statistical difference between the 2 groups, but the subjective IKDC score (p=0.007) and Lysholm score (p=0.001) were better in group Ⅰ than in group Ⅱ. There was no difference in the single limb standing test and there was no difference between the 2 groups, but there was a tendency to have improved over the preoperative evaluation. Conclusion: We obtained good results after ACL reconstruction using the autologous single four-strand semitendinosus tendon. ACL remnant preserving group had better Lysholm score and IKDC subjective score.

재활운동적용이 전방십자인대 재건술 방법에 따른 집단 간 근력, 기능수행능력 및 고유수용감각에 미치는 영향

조승익,신윤아 대한운동학회 2014 아시아 운동학 학술지 Vol.16 No.2

[INTRODUCTION] This study aimed to compare muscle strength, functional fitness, and proprioceptive sensibility in anterior cruciate ligament (ACL) reconstruction with or without preserving remnant tissue. [METHOD] Forty patients who underwent ACL reconstruction between September 2007 and December 2009, twenty each with and without preserved remnant tissue, were evaluated at the 6-month post-operation follow-up. The Lysholm knee score, IKDC subjective score, Tegner activity score, knee joint laxity with KT-2000, isokinetic strength test, and balance test using the Biodex system III were evaluated. For functional performance testing, co-contraction, shuttle run, carioca, one leg hop, and balance tests were performed. The active and passive joint position senses were assessed to evaluate proprioceptive function. [RESULT] In the results of clinical outcomes, namely the AP stability test, isokinetic strength test, and functional performance test, both groups showed no statistically significant difference. The results of active JPS showed significant difference between groups, however, there was no statistically significant difference in the results of passive JPS. [CONCLUSION] We concluded that there was no significant difference in clinical evaluation, isokinetic strength test, and functional performance test in ACL reconstruction with or without preserving remnant tissue, except for in the proprioceptive function test. Therefore, we suggested that patients’ participation in appropriate rehabilitation program can help improve muscle strength and functional performance. However, only the change of joint position sense test was revealed a statistically significant difference in the results between groups. According to the results, the method of ACL reconstruction that preserves remnant tissue may have a positive effect on recovery of proprioceptive function in the knee joint. [서론] 이 연구는 잔류조직 보존술을 이용한 전방십자인대 재건술 후 잔류조직을 제거한 재건술 집단과 재활훈련 후 근력, 기능수행능력과 고유수용감각기능을 비교하고자 실시되었다. [방법] 연구대상은 전방십자인대 재건술을 시행 받고 6개월간 재활운동 프로그램에 참여했던 남자 환자 중 잔류조직을 보존하여 재건술을 시행한 20명과 잔류조직보존 없이 재건술을 시행한 20명을 대상으로 하였다. 임상적 평가 항목으로 Lysholm knee score, internation knee documentation committee (IKDC) subjective score, Tegner activity score를 분석하였고 KT-2000을 이용한 관절이완검사와 등속성 최대근력 평가를 실시하였으며, 기능수행능력평가 항목으로 공동수축 검사, 왕복달리기 검사, 카리오카 검사, 외발뛰기 검사와 균형검사를 실시하였다. 또 고유수용감각 평가로 Active joint position sense(JPS)와 Passive joint position sense 검사를 실시하였다. [결과] 임상적 평가와 전후방 안정성 평가 그리고 근력 평가 및 기능적 평가에 있어서 두 군 간에 통계적으로 의미 있는 차이는 보이지 않았다. 하지만 고유수용 감각 검사로 Active JPS 결과에서 잔류조직을 보존한 재건술 집단과 제거한 재건술 집단 간에 유의한 차이를 나타냈으며 Passive JPS 결과에서 폄 시 차이의 경향을 나타내었다(p=.054). [결론] 전방십자인대 손상 후 잔류조직 보존 재건술 방법에 따른 재활운동 프로그램 후 집단 간의 임상적 평가, 최대근력 및 기능수행능력은 차이가 없는 것으로 나타났다. 따라서 적절한 재활운동프로그램의 참여가 환자들의 근력과 기능수행능력을 향상시키는데 도움이 될 것으로 사료된다. 그러나 고유수용 감각 검사에서는 집단 간에 유의한 차이를 나타내었으므로, 잔류조직 보존술이 무릎관절의 고유수용감각기능 회복에는 긍정적인 영향을 미치는 것으로 사료된다.

Proprioception and Clinical Results of Anterolateral Single-Bundle Posterior Cruciate Ligament Reconstruction with Remnant Preservation

( Dung Chul Lee ),( Oog Jin Shon ),( Byung Hoon Kwack ),( Sung Jun Lee ) 대한슬관절학회 2013 대한슬관절학회지 Vol.25 No.3

Purpose: To evaluate the clinical and radiological results and proprioception following anterolateral single-bundle posterior cruciate ligament (PCL) reconstruction with remnant preservation for PCL injury. Materials and Methods: Twenty patients with an isolated PCL injury (16 males and 4 females) were included in this study. The mean follow-up period was 61 months (≥24 months) and the mean age of the patients was 36 years. Knee joint instability was evaluated using posterior drawer stress radiography. Knee function, level of activities, and individual satisfaction were assessed using the Lysholm knee score, Tegner activity score, and 2000 International Knee Documentation Committee (IKDC) score. Knee proprioception was assessed using an isokinetic machine. Results: The mean ligament laxity assessed using the posterior drawer stress radiography was improved from 10.8-3.2 mm. The mean Lysholm knee score was improved from 70.0-88.9 points, and the mean Tegner activity score was improved from 2.7-6.2 points. Individual satisfaction assessed using the IKDC score was improved from 62.7-85.4 points (p<0.05). Knee proprioception was not significantly different between the treated and the uninjured knees. Conclusions: Single-bundle PCL reconstruction with remnant preservation for PCL injury exhibited satisfactory outcomes regarding functional outcome, joint stability, and proprioception.

Arthroscopic augmenting reconstruction of the anterolateral bundle in isolated posterior cruciate ligament injuries using the remnant bundle-preserving technique

Sang Bok Lee,Jae Ang Sim,Yong Seuk Lee,Beom Koo Lee 대한정형외과 스포츠의학회 2014 Arthroscopy and Orthopedic Sports Medicine Vol.1 No.2

Background: The purpose of this study was to report the outcomes of arthroscopic reconstruction of posterior cruciate ligament (PCL) using the remnant bundle preserving technique, augmenting specifically the anterolateral bundle of PCL. Methods: Thirty-seven patients who underwent an arthroscopic anterolateral bundle reconstruction with the remnant preserving technique of PCL between February 2001 and August 2010 were enrolled in this study. There were 29 male and 8 female patients with an average age of 41 years (range, 19 to 67 years). Mean follow-up period was 41 months (range, 12 to 103 months). The clinical outcomes were assessed by the Lysholm knee score and the International Knee Documentation Committee (IKDC) score. The radiological outcomes were assessed using the stability and stress radiograms, measured by the Telos device. Results: The preoperative Lysholm knee score improved significantly from a mean 75.3 ± 12.8 value to a postoperative mean of 91.2 ± 5.8 (P < 0.05). Likewise, the preoperative IKDC subjective score improved from a mean value of 72.0 ± 11.6 to a postoperative mean of 87.8 ± 5.0 (P < 0.05). Further, stress radiographs showed a decrease in the average side to side difference of posterior tibial translation from 8.4 ± 4.1 mm to 4.0 ± 2.8 mm, before and after the operation (P < 0.05). Conclusion: The clinical and stability results improved in patients with isolated PCL injury after arthroscopic augmenting PCL reconstruction using the remnant preserving technique.