슬관절 부분치환술

정영복(Young Bok Jung),이용석(Yong Seuk Lee) 대한정형외과학회 2004 대한정형외과학회지 Vol.39 No.1

슬관절 부분치환술은 1970년 초기에 소개된 이후 최근까지 그 치료 결과에 대하여 이론이 많았다. 환자에 대한 선택, 수술수기의 발달과 보철기구 설계의 개선으로 그 결과가 많이 향상되었다. 수술 후 10년 생존율에서 인공관절 전치환술보다 다소 떨어지는 것이 일반적인 보고이나, 최근 몇몇보고는 전치환술과 비슷한 결과를 보고하고 있으며 15년 이상 생존율에서는 전치환술보다 다소 떨어지나 많이 개선된 상태이다. 부분치환술이 절골술이나 전치환술에 비해 이점이 있으므로 한쪽 부분에 골성관절염 환자 특히 중년 부인에서 이점이 있는 좋은 수술방법으로 사료된다. 최근에 수술수기의 발달로 수술 후 회복이 빠르고 입원 기간의 단축 및 기능상 정상에 가까운 기능 회복 등으로 최근에 다시 각광을 받고 있는 실정이다. 그러나, 수술 전에 술자는 다음과 같은 점을 신중히 고려해야 한다. 첫째, 퇴행성 관절염이 한쪽 관절부분에만 국한된 것인지 확인 해야 되며 이를 임상적, 방사선 사진 및 스트레스 방사선 검사 등으로만 할 것인지 아니면 다른 정밀 검사 즉 동위원소 검사, 관절경 검사 등을 할 것인지 고려해야 한다. 둘째, 한쪽 부분에만 퇴행성 관절염이 있을 경우에 수술의 금기사항은 아닌지 잘 검토 해야 된다. 셋째, 고정된 내반 및 외반 또는 굴곡 변형이 부분 치환술 후 교정이 가능한 것인지, 넷째, 변형을 과도하게 교정을 하면 정상측 관절면이 퇴행성 변화가 촉진되므로 어느 정도 교정하는 것이 좋을 것인지 또한 폴리에틸렌의 두께는 최소한 어느 정도 이상 되어야하는지 등을 잘 검토하여야 된다. Unicompartmental knee arthroplasty has been controversial since its introduction in the early 1970s. Refinements were made in patient selection, surgical technique, and prosthetic design. Ten-year follow up studies were reported that showed survivorship was slightly less than that reported for total knee arthroplasty but acceptable considering the theoretically conservative nature of unicompartmental surgery. Unicondylar knee arthroplasty can be an attractive alternative to osteotomy or total knee arthroplasty especially some middle-aged women. Approximately all studies with followups of 10 years or greater show that unicompartmental knee arthroplasty will have inferior survivorship to total knee arthroplasty whether from loosening, prosthetic wear, or secondary degeneration of the opposite compartment in the second decade. Recently there has been a resurgence of interest in doing unicompartmental knee arthroplasty, which was encouraged by easier recuperation, decreased hospital stays, and good functional results. Before doing a unicompartmental arthroplasty, the surgeon should answer four important questions: Is the disease truly unicompartmental? Can this be determined on a clinical examination and standard radiographs, or are more sophisticated studies such as a bone scan or an arthroscopy required? Second, if the patient does have unicompartmental disease are there any specific contraindications to the surgery? What are the limits of fixed deformity in varus or flexion that can be corrected by a unicompartmental replacement? Overcorrection of angular deformities has in the past led to increased wear of the opposite compartment. Therefore, how much should the knee be corrected? What is the minimal polyethylene thickness that is permissible?

파열된 반월상 연골판의 관절경적 봉합술 - 파열 위치와 동반 손상 여부에 따른 비교 -

정영복,태석기,진휘재,정재원,박철경,Jung, Young-Bok,Tae, Suk-Kee,Jin, Whui-Jae,Chung, Jai-Won,Park, Cheol-Kyoung 대한관절경학회 2001 대한관절경학회지 Vol.5 No.2

목 적 : 반월상 연골판의 관절경적 봉합술후 파열 위치나 동반 손상 여부에 따라 어떠한 결과의 차이가 있었는지 알아보고자 하였다. 대상 및 방법 : 1994년부터 관절경적 봉합술을 시행 후 1년 이상 추시가 가능했던 73례를 대상으로 하였다. 위치에 따라서는 red-red zone이 29례, red-white zone이 36례 그리고 white-white zone이 8례이었다. 26례에서 동반 손상이 있었고 동측 전방 십자 인대 파열이 17례가 있어 동시에 치료하였다. 결과는 OAK system에 의한 기준을 사용하여 평가하였다. 결과 : 양호 이상의 결과를 나타낸 것은 연골판 단독 손상인 경우 $94\%$, 동반 손상이 있었던 경우 $88\%$이었는데, 특히 전방십자인대 파열후 재건술을 동시에 한 경우는 $94\%$로 좋았다. 연골판 파열의 위치에 따른 결과에서는 red-red zone은 $90\%$, red-white zone은 $91\%$, white-white zone은 모든례에서 양호 이상의 결과를 보였다. 결론 : 전방 십자 인대 파열이 동반된 경우는 동시에 치료하는 것이 좋고, white-white zone의 봉합도 가능한 것으로 사료되었다. Purpose : The purpose of this study was to determine the clinical outcome of meniscal repairs according to tern location and combined injury. Materials and Methods : From 1994, 73 meniscal repairs were underwent by arthroscopy and followed more than 1 year. The locations of torn meniscus were 29 red-red Bone, 36 red-white zone, 8 white-white zone. Twenty-six patients also had combined lesion including ACL injury 17 cases and treated simultaneously. Clinical result was evaluated by OAK system. Result : Healing rates(above good) were $94\%$ in isolated injury and $88\%$ in combined injury, especially $94\%$ in ACL injury. The result according to tern location were $90\%$ in red-red zone, $91\%$ in red-white zone, all in white-white zone. Conclusion : Meniscus tear with ACL injury should be repaired by arthroscopy, simultaneously. The meniscal tear of white-white zone could be healed by arthroscopic meniscal suture.

후방 십자 인대 손상의 치료

정영복,정호중,Jung, Young Bok,Jung, Ho Joong 대한관절경학회 1998 대한관절경학회지 Vol.2 No.1

The distinction between isolated and combined injuries is crucial both for treatment and prognosis. For most combined injuries, surgical treatment continues to be favored over nonoperative treatment. It is generally agreed that isolatel PCL injuries do well without surgery. There has been an interest by many authors to fix the graft directly to the posterior aspect of the tibia(tibial inlay). With this procedure, tibial graft fixation will be more direct and theoretically reduce the bending effects of the graft with a fixation site far away from the tibial insertion. Modified tibial inlay technique, which is the posterior approach does not require the patient to be in the prone or lateral decubitus position during the operation. Use of a double-bundle reconstructive technique is attractive and has been performed by some surgeons. At this time, this procedure is still being investigated and should not be routinely used in the clinical setting until studies have indicated an advantage over current single-bundle techniques. However theologically, double-bundle reconstructive technique is more useful in severe posterior unstable knee. Recent advances have increased our knowledge of the anatomy and mechanical characteristics of the PCL. Basic science research has further increased our awareness of the interaction of the posterolateral structures with the PCL. To achieve restoration of normal posterior laxity, it is critical to address the posterior as well as the postero-lateral structures. Surgical treatment is often complex and requires a wide range of surgical techniques and skills to treat associated injuries. When the PCL is reconstructed, most surgeons choose to reconstruct the anterolateral component using a graft of sufficient size and strength. The initial postoperative rehabilitation should be addressed cautiously in an effort to avoid excessive forces on delicate repairs and reconstructions in these complex injuries. Further research is necessary to evaluate new surgical approaches such as double-bundle reconstructions and tibial inlay techniques as well as improved techniques for capsular and collateral ligament injuries.

슬관절 후외측 인대 재건술에서의 비골두 터널 방법과 경골 터널 방법의 비교

정영복(Young Bok Jung),이용석(Yong Seuk Lee),정호중(Ho Joong Jung),진호선(Ho Sun Jin),태석기(Suk Kee Tae) 대한정형외과학회 2006 대한정형외과학회지 Vol.41 No.5

목적: 슬관절 후외측 만성 불안정성에 대한 치료로 비골 두 터널과 경골 터널 방법의 결과를 비교 분석하여 그 장단점을 알아보고자 하였다. 대상 및 방법: 1999년에서 2003년까지 본원에서 후방십자인대 긴장술 및 전외측 다발 재건술을 시행하고, 2도의 후외측 불안정성이 동반된 경우에 후외측 재건술을 시행받은 환자 중 1년 이상 추시가 가능하였던 비골 두 터널 방법 20예와 경골 터널 19예를 대상으로 비교 분석을 시행하였다. 결과: 비골 두 터널의 수술 시간이 36.5±7.5분으로 경골 터널 방법이 68.4±12.8분인데 비하여 통계학적으로 유의하게 더 짧았다(p<0.0001). 회전 안정성에 있어서도 비골 두 터널은 85%에서 반대쪽 다리에 비하여 같은 정도의 긴장 이상을 보여서 63%인 경골 터널에 비하여 더 안정적이었다(p=0.0018). IKDC (타각적 점수)에서 비골 두 터널이 85%에서 B 이상의 결과를 나타내어 79% 인 경골 터널에 비하여 더 우수하였다(p<0.0001). 그러나, 전후방 안정성 및 IKDC (주관적 점수), OAK score는 두 군 간에 유의한 차이가 없었다. 결론: 후 외측 회전 불안정성이 있으며 내반 불안정성이 경하거나 거의 없는, 즉 2도 이하의 만성 손상의 경우 특히 후방십자인대와 동반 손상 시 후외측부 재건술 방법으로 비골 두 터널 방법이 경골 터널에 비하여 효과적이었다. Purpose: This study compared the surgical results of various posterolateral corner sling methods performed through either the fibula head tunnel or tibia tunnel in patients with chronic PLRI (Posterolateral Rotatory Instability). Materials and Methods: Between January 1999 and October 2003, 20 and 19 patients who had undergone surgery for PCL (posterior cruciate ligament) tensioning and an ALB (anterolateral bundle) reconstruction through the fibula head tunnel or tibia tunnel, respectively and were followed up more than 1 year were enrolled in this study. Results: The fibular head tunnel was found to be superior compared with the tibia tunnel method in terms of the operation time (36.5±7.5 versus 68.4±12.8) (p<0.0001), rotational stability (p=0.0018) and IKDC objective score (p<0.0001). In the fibula head tunnel group, 85% of patients had an equal to normal or tighter than normal rotational stability in the tibial tunnel group with 63% having an equal to normal or tighter than normal side at the last evaluation. In the IKDC objective score, 85% of patients in the fibula head tunnel group had a rating B or higher at the last evaluation compared with 79% in the tibial tunnel group (p<0.0001). However there were no significant differences in anteroposterior stability and OAK score. Conclusion: The modified posterolateral corner sling through the fibula head tunnel produces better results in terms of a posterolateral rotational stability of grade Ⅱ chronic PLRL in a combined PCL injury than that using the tibia tunnel method.

후십자인대 재건술의 임상적 고찰 - 골슬개건골을 이용한 -

정영복,강수용,서정환 ( Young Bok Jung,Soo Yong Kang,Jung Hwan Seo ) 대한슬관절학회 1991 대한슬관절학회지 Vol.3 No.1

The posterior cruciate ligament(PCL) is the most important ligament of the knee joint because of its cross section area, tensile strength and location in the central axis of the knee(Hughston et al. 1976, Kennedy 8r, Grainger 1967). Butler et al. (1980) demonstrated that it provides 95 % of the total restraint to posterior displacement of the tibia. We diagnosed and reconstructed sixteen cases with the injury of the PCL by the modified Clancy method. Twelve of sixteen patients with a follow up of eight months to five years(average twenty three months) were evaluated. Seven patients were augmented with Kennedy LAD. The subjective, objective and functional assessment of the knee made according to the criteria of Hughston and Degenhardt(1982). The incidence of the injury af the PCL was 25 % in one hundred seventy one knee ligament injuries. The injuries of medial collateral ligament were combined most fre- quently. 1. The objective and functional results were good in nine and fair in three. 2. The instability of the knee was measured as difference between the injured side and the opposite one. The difference is 7 to 8 mm in three and less than 5 mm in nine of twelve patients. 3. Seven patients were augmented with Kennedy LAD. Three patients were received arthroscopic adhesiolysis due to limitation of motion of the knee. Six patients were examined by arthroscopy and all of them had synovial avergrowth and well vascularization at intercondylar notch. We suggest that the reconstruction of the PCL is necessary when the posterior displacement is more than 1 or 1.5 cm, ache on descending stairs and some discomfort in usual life of the young patients. Augmentation of Kennedy LAD helps early motion of the knee and takes up part of the load to the grafted patellar tendon. But further follow up is required to evaluate the stress shielding effect of Kennedy LAD and the grafted patellar tendon.

퇴행성슬관절염 환자에 있어서 관절경수술의 효과

정영복,강수용,최호림 ( Young Bok Jung,Soo Yong Kang,Ho Rim Choi ) 대한슬관절학회 1991 대한슬관절학회지 Vol.3 No.2

Recently arthroscopic examination and operation have replaced open arthrotomy surgery end become one of good treatment modahties in osteoarthritis of the knee which daes not reapond to coneervstive treatment. Afthroscopic debridement was camed aut in 52 knees of 48 patients who had a primary d noiis of osteoarihritie at Chung-Ang University Yong-San Hospital from January 1988 to September 1990. The patients ranged in age from 34 to 83 years with mean age of 54.9 years (male: female= 1: 1.8) and the average follow up period was 16.5 months from 12 to 36 months. Followiog results were obtained; l. Arthroscopic lavage, meniscectomy, synovectomy, cartilage driUing and loose body removal were peiformed with overall resU1ts of 3 excellent (6%), 28 good (54%), 14 fair (27 %) and 7 fail (13 %). 2. The result of gynovectomy was most satisfactory for 2 excellent, 7 good and 2 fair. In conclusion, arthroscopic debridement can be one of the good alternative treatment methods of osteoarthritis and a time saving procedure before arthroplastic surgery of the knee.

후방십자인대의 경골부착부 손상에 대한 간단한 수술적 도달법 - 증례보고 2례 -

정영복,강기서,김기성 ( Young Bok Jung,Ki Ser Kang,Ki Seong Kim ) 대한슬관절학회 1991 대한슬관절학회지 Vol.3 No.2

The standard approach thro the poplitea1 fossa to the tibial attachment of the posterior Cruciate Ugament (PCL) can be time-consuming and is regarded as harXafdous. The simplified approaah does not trensect or expose neurovascular structures as in oger procedures. With dissectiom on the medial border of the medial head of the gatrocnemius and by lateral retraqtion, the posterior capsule is safely exposed. The approach is ideal for internal fixation of an avulsed tibial attachment of the PCL. The authoirs repart two cases of avulsed tibial aftachment of the PCL which was treiated with open reduction and intemaI fixation through the simplified posterior approach.

슬개대퇴관절 부정정렬증후군

정영복,박용준 ( Young Bok Jung,Yong Jun Park ) 대한슬관절학회 1992 대한슬관절학회지 Vol.4 No.1

Fortunately, most young people with patellofemoral pain respond favorably to conservative treatment, including quadriceps strengthening, anti-inflammatory medication, reassuarance and physical therapy. However after failure of conservative treat- ment for painful patellofemoral malalignment, we should carefully evaluate the cause of the anterior knee pain, then we decided to do some surgery or not depend on the cause of the anterior knee pain. There are soft tissue realignment surgery, such as Roux-Goldthwait, Galeazzi operation and bony surgery in distal realignment of the treatment patellofemoral malalignment. There are tibial tubercle anterization(Maquet) and anteromedialization of tibial tubercle in distal realignment bony surgery. If there is severe articular degeneration and with or without malalignment, a straight forward Maquet procedure or a very steep anteromedial tibial tubercle transfer may be more appropriate when all other treatment modalities have failed. Lateral retinacular release may not be, by itself, an adequate procedure for patellar arthrosis alone. Lateral release should be viewed as a means of denervating a painful retinacuium, minimizing mild malaligninent, and reducing a pathologically tilted patella. Maquet and Ferguson and assaciates have emphasized the importance of relieving stress in the degenerated patellofemoral joint by anteriorization of the tibial tubercle, and consequently, anteromedial tibial tubercle transfer may be most desirable when realigning the extensor mechanism of a mature patient with resistant patellofemoral pain related to subluxation, elavated Q-angle, and patellofemoral degeneration with or without abnormal patella tilt. Since most patients have significant patellar arthrosis by the time realignment is undertaken, anteromedial tibial tubercle transfer may be the best procedure for most patients.

후방 십자 인대 손상 치료의 개관(over view)

정영복,Jung, Young Bok 대한관절경학회 1998 대한관절경학회지 Vol.2 No.1

The PCL reconstruction in chronic isolate PCL reconstruction was still controversy. 1) In isolate PCL deficient knee, functionally not so bad as like ACL deficient knee. 2) The result of the PCL reconstruction was not as good as ACL reconstruction. Therefore, isolate PCL injuries has been treated as nonoperatively. Hey Grovere, who was the first to attempt an intra-articular reconstruction of the PCL, utilized the semi-tendinous tendon other static procedures have been described in only a few cases with very limited follow-up. Dynamic procedures utilizing the medial head of the gastrocnemius has been reported by Hugston and Degenhardt, Kennedy and Grainger, and Insall and Hood. These procedures did not improve static stability. Dr Clancy, who was introduce the use of BPTB for the PCL reconstruction transtibial and femoral tunnel. From 1995, untill early 1990 PCL reconstruction was done as tend as placement of the isometric point. Physiometic placement of Anatomical placement of the femoral tunnel in PCL reconstruction were introduced in 1995. Tibial Inlay Technique was reported by Dr Berg in 1995. The main advantage of the tibial Inlay Technique was to avoid fraying of the graft at the posterior tibial tunnel orifice. In complete PCL ruptured and severely posterior unstable knee, dual femoral tunnel technique will be to get better result than one bundle technique. To achieve restoration of normal posterior laxity, it is critical to address the posterior as well as the posterolateral structures. Futher research is necessary to evaluate new surgical approches such as double-bundle reconstructions and tibial inlay techniques as well as improved techniques for capsular and collateral ligament injuries.

슬관절 후외측 회전 불안정성의 적합한 수술적 방법

정영복,이용석,송광섭,진호선,이종석,Jung Young Bok,Lee Yong Seuk,Song Kwang Sup,Jin Ho Sun,Lee Jong Seok 대한정형외과스포츠의학회 2004 대한정형외과스포츠의학회지 Vol.3 No.1

목적: 후외측 불안정성에 대하여 시행한 여러 수술 방법 등을 비교 분석함으로써 불안정성의 정도에 따른 적합한 수술적 방법들을 제시하고자 한다. 연구대상 및 방법: 1998년에서 2002년 10월까지 85명의 환자가 후외측 회전 불안정성으로 후외측 재건술을 시행하였으며 이중에서 2년 이상 추시가 가능하였던 61 명 환자를 대상으로 임상적 평가(OAK, IKDC)와 후외측 전위 검사 및 경골 외회전(dial test)를 이용하여 회전 안정성을 평가 하였다. 결과: 변형된 비골 두 터널을 이용한 후외측 재건술이 회전 안정성면에서 가장 좋은 결과를 나타내었으며 Hughston-jacobson 방법과 대퇴 이두건 고정술은 불량한 결과를 나타내었다. 비골 두 터널은 경골 터널에 비하여 유의하게 안정적 이었다. 결론: 변형된 비골 두 터널을 이용한 후외측 재건술은 grade II 이하의 불안정성에서는 좋은 결과를 나타내었고, grade III 이상의 불안정성에는 비골 두 터널과 경골 터널의 동시 해부학적 재건술이 필요하다. 또한, 내반 불안정성이 동시에 존재하는 경우는 외측 측부 인대 재건술이 필요할 것으로 판단된다. Purpose: we would like to suggest the proper surgical methods according to the severity of instability by analyzing the results. Materials and Methods: Between January 1998 and August 2002, eighty five patients have been operated on because of posterolateral rotatory instability (PLRI). The materials were included the patients who had followed-ups for over 2 years in sixty one patients and the patient's assessments were done by clinical score (OAK, IKDC) and posterolateral drawer and dial test. Results: Through our results, the fibular tunnel turned out to be superior compared to the tibia tunnel method in rotational stability. Hughston-Jacobson methods and biceps tenodesis showed poor results. Fibula head tunnel was superior to tibia tunnel in rotational stabiliaty Conclusion: The surgical technique that passes the modified posterolateral corner sling through the fibula head tunnel may provide good clinical results in grade II PLRI. It is necessary to reconstruct both tibia and fibula tunnel in grade III PLRI. When there is combined varus instability, a positive result may be obtained if an additional LCL reconstruction is performed.