Original Article J Korean Orthop Assoc 2011; 46: doi: /jkoa 저위험군환자에게동시에시행한양측슬관절전치환술의안전성 Postoperative Safety of

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1 Original Article J Korean Orthop Assoc 2011; 46: doi: /jkoa Postoperative Safety of Sequential Bilateral Total Knee Arthroplasty in Low Risk Patients 유주형 김성민 한창동 * 이윤태 오현철 형지호국민건강보험공단일산병원정형외과, * 연세대학교의과대학정형외과학교실 목적 : 저위험군환자에게있어한번의마취하에시행한양측슬관절전치환술의안전성을알아보고자한다. 대상및방법 : 양측에인공슬관절전치환술을시행받은 310 명 (620 예 ) 을대상으로저위험군환자이면서한번의마취하에시행한경우를제 1군 (179 명 ), 2주간격으로시행한경우를제 2군 (97 명 ), 한쪽을수술후재입원하여반대측을시행한경우를제 3군 (34 명 ) 으로구분하여수술후합병증, 수술후총출혈량, 평균수혈량, 수술시간, 입원기간을비교분석하였다. 결과 : 1,2,3 군모두에서주요합병증발생은없었고, 경한합병증이각각 5%, 7.2%, 5.8% 발생하였으나통계적으로유의한차이는없었다. 수술후총평균출혈양은각각 1,442.9 ml, 1,567.4 ml, 1,616.6 ml로각군간에유의한차이는없었으나 (p>0.05), 평균수혈량은각각 1,220.3 ml, ml, ml로 1군에서수혈의양이가장많았다 (p<0.05). 평균수술시간은각각 186 분, 196 분, 211 분으로 1군에서적게소요되었으며 (p<0.05), 총평균입원기간은각각 16.8 일, 28.6 일, 29.8 일로 1군이짧았다 (p<0.05). 결론 : 특별한내과적문제가없는저위험환자에서는한번의마취하에양측을동시에인공슬관절전치환술을시행할수있다고생각된다. 색인단어 : 슬관절, 양측인공슬관절전치환술, 합병증 서론 1971 년 Gunston 의보고이후단기적혹은장기적인임상결과에서 유용한치료방법으로보고되어왔던인공슬관절전치환술은 1) 평균 수명의연장으로수술건수가증가하고있으며이중에양측에인 공슬관절전치환술이필요한경우가많아지고있다. 그런데양 측에인공슬관절전치환술을시행한경우는한측만수술하는 것에비하여수술후사망률이나심혈관계합병증및혈전증의 발생에차이가있다는보고가있으면서, 2-4) 수술시기에따라한 번의마취하에시행하는방법과두번의마취하에수술하는방 접수일 2010 년 2 월 3 일게재확정일 2010 년 4 월 27 일교신저자오현철경기도고양시일산동구백석 1 동 1232 번지 국민건강보험공단일산병원정형외과 TEL , FAX hyuncoh@hanmail.net * 본논문의요지는 2009 년대한정형외과학회추계학술대회에서발표되었음. 법간에장점과단점에대하여여러논란이있어왔다. 5-11) 양측에수술이필요한환자에게수술시기는환자의만족도, 효율성, 경제성및안전성을고려하여결정되어야하는데, 특히한번의마취하에수술하는경우에수술후안전성에부정적인보고가있어 3,4,12-15) 수술시기결정에어려움이있을수있다. 따라서본연구의목적은양측에수술이필요한환자에있어한번의마취하에양측을동시에수술하는환자를내과적으로저위험군환자에게한정하여시행함으로써수술에따른안전성을분석하고자한다. 대상및방법 2003 년 1월부터 2007 년 8월까지양측인공슬관절전치환술을시행받은총 310 명 (620 예 ) 의환자를대상으로하여세군으로분류하여후향적으로분석하였다. 제 1군은한번의마취하에시행한경우로저위험군환자로분류하여 75세이하이면서심각한심혈관혹은뇌혈관질환이없고, 동반된전신질환및환자의신체상 대한정형외과학회지 : 제 46 권제 1 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 ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 55 Table 1. Dermographic Data Sequential Staggered Staged p-value Patients (n) 179 (58%) 97 (31%) 34 (11%) Diagnosis Osteoarthritis (n) Rheumatoid arthritis (n) Gender Women (n) Men (n) Mean Age (year) 66.9 (52-75) 71.5 (53-80) 70.4 (57-85) <0.05 Height (m) 1.5 ( ) 1.5 ( ) 1.5 ( ) >0.05 Weight (kg) 62.8 (43-98) 62.4 (30-95) 63.2 (45-100) >0.05 BMI (kg/m 2 ) 27.3 ( ) 27.4 ( ) 27.4 ( ) >0.05 BMI, body mass index. Table 2. Comorbidities of Patients Sequential (n) Staggered (n) Staged (n) Cardiovascular condition Hypertension CAOD Arrhythmia CHF Cerebrovascular condition Stroke TIA Parkinson Endocrine condition Diabetes mellitus Hypothyroidism Hyperthyroidism Hypoparathyroidism Asthma Renal failure CAOD, coronary artery obstructive disease; CHF, congestive heart failure; TIA, transient ischemic attack. 태에따른 American Society of Anesthesiologists (ASA) 분류상 1,2 등급에해당하는경우에환자가동시에수술받기를원하는경우 로하였고 (179 명, sequential group), 제 2 군은저위험군환자이지 만환자가동시에수술을원하지않거나, 75 세이상이면서심각 한심혈관혹은뇌혈관질환이있고, ASA 분류상 3 등급이상인경 우 (97 명, staggered group) 로하였고, 제 3 군은한쪽을수술한후환 자가충분한회복기간을원하거나반대측의증세가심하지않은 경우에일단퇴원하였다가재입원하여반대측을수술한경우 (34 명, staged group) 로분류하였다. 전체 310 명환자중남자가 12 명, 여자가 298 명이었으며, 전체평균연령은 68.7 세 ( 최저 56 세, 최고 Table 3. Comparison of ASA PS Classification System Sequential Staggered Staged ASA PS ASA PS ASA PS ASA PS ASA PS ASA PS ASA PS, American Society of Anesthesiologists physical status. 85 세 ) 였고, 퇴행성슬관절염이 306 명, 류마티스관절염이 4 명이 었다. 각군간의수술전비교에서연령은제 1 군이 2 또는 3 군에 비하여의미있게낮았으나 (p<0.05), 키, 몸무게, body mass index (BMI), 수술전슬관절점수에서는각군간에차이가없었다 (p> 0.05)(Table 1). 수술전동반된전신질환은전체환자중 72% 에서있었고, 그 중에고혈압이 1 군에서 104 예 (58%), 2 군에서 65 예 (67%), 3 군에 서 22 예 (65%) 였으며, 당뇨병은 1 군에서 39 예 (21%), 2 군에서 26 예 (27%), 3 군에서 7 예 (21%) 였고, 심근경색과거력을가지고있는환 자는 2 군에서 9 예 (9%), 3 군에서 1 예 (3%) 였으며, 뇌출혈과거력을 가지고있는환자는 2 군에서 3 예 (3%), 3 군에서 2 예 (6%) 였다 (Table 2). ASA 분류상등급은제 2 군에서는 3 등급이상의환자가 11 명 (11%), 제 3 군에서는 3 명 (9%) 이었다 (Table 3). 주요한합병증의정의는수술후 8 주이내사망, 심근경색, 폐색 전증, 뇌졸중, 심부감염으로하였고, 경한합병증의정의는수술 중에발생한합병증, 요로감염, 심부정맥혈전증, 폐렴, 천부감 염, 조기관절운동장애로하였다. 제 1 군에서는양측다리를동시에소독하여수술준비를하였으 며, 한측의피부봉합을완료한후에반대측수술을진행하였다. 전례에서제 1 저자에의하여진행되었고전례에서동일한 Nex-

3 56 유주형 김성민 한창동외 3 인 gen LPS-flex total knee system (Zimmer R, Warsaw, IN) 을사용하였다. 모두슬개골치환을하였으며, 모든삽입물은시멘트를이용하여고정하였다. 마취방법은제1군에서 107 예는전신마취, 72 예는척추마취를시행하였고, 제 2군에서 5예는전신마취, 92예는척추마취를하였으며, 제3군에서전신마취는 1예, 척추마취는 33 예로제1군에서전신마취의비율이높았다. 수술시간은피부절개시작에서피부봉합종료까지의시간으로하였으며, 피부봉합후에지혈대를이완하였다. 총실혈량은수술후 2일째아침에배액관을제거하여이기간동안의실혈량의총합으로하였다. 총수혈량은입원기간중자가수혈과동종수혈을합하여측정하였는데, 자가수혈은혈색소수치가 11.0 gm/dl 이상인경우수술전 30일이내에서한번혹은두번의자가헌혈을시행하여얻은혈액을사용하였는데 1군은 81.2%, 2군은 50.5%, 3군은 67.2% 에서자가헌혈을하였다. 혈전증에의한합병증을예방하기위하여모든환자에게수술당일부터수술후 3일까지족부펌프를시행하였고, 수술후 6주 간하지압박스타킹을착용하였으며, 빠른재활을위하여수술후 2일째부터보행을시작하였다. 수술전 aspirin 을복용하던환자는수술후 5일째부터재투여를하였으며, 수술전환자의동의하에전례에서수술후에추가적인혈전용해제는사용하지않았다. 수술후심부정맥혈전증및폐색전증의가능성평가는 Well 16,17) 의예측모형에따라수술후입원기간동안관찰하여중등도의가능성이상인경우에도플러초음파를시행하여확진하고자하였다. 입원기간은수술후피부의봉합사를제거하는 14일을원칙으로하였으며, 환자의요구에따라입원기간을연장하였다. 모든환자에서수술중발생한합병증, 수술후 8주이내에발생한합병증, 출혈량및수혈량, 수술시간, 입원기간을조사하였다. 각군간자료들의통계학적분석은 Statistical Product and Service Solution 13.0 ps.exe (SPSS Inc., Chicago, IL, USA) 를이용하여변수의일원배치분산분석 (one-way ANOVA test) 과카이제곱검정을사용하였고, 유의수준은 0.05 로하였다. Table 4. Post-operative Complications after Total Knee Arthroplasty Major complication Sequential Staggerd Staged Death Myocardial infarction Pulmonary embolism Cerebral infarction Deep wound infection Minor complication Intraoperative complication 1* 0 0 Urinary tract infection Deep vein thrombosis Pneumonia Delayed wound healing Recurrent hemarthrosis Early ROM limitation ROM, range of montion. *Medial collateral ligament rupture. 결과 본연구에서주요합병증은세군모두에서발생하지않았으며이기간동안임상적으로하지에혈전증이의심되어진단을위한추가검사를시행한경우도없었다. 경한합병증은 1군에서수술중내측인대손상이 1예 (0.5%) 있었고, 피부봉합부위에 1 cm 미만의부분적인피부괴사로입원기간이지연된경우가 1군에서 3예, 2군에서 2예, 3군에서 2예가있었는데모두국소적인변연절제술후후유증이없이치료되었다. 입원기간중관절운동이원활하지않아척추마취하도수조작을한경우는 1군에서 1예 (0.5%), 2군에서 2예 (2%), 3군에서는없었다 (Table 4). 수술후이틀간의배액량을합산한총실혈량은제1군에서평균 1,443 ml, 제2군에서평균 1,567 ml, 제3군에서평균 1,617 ml 로측정되어, 3군에서출혈량이가장많았으나통계적으로의의는없었다 (p>0.05). 입원기간동안수혈을받은경우는 1군에서 173 명 (96.6%), 2군에서 93예 (95.8%), 3군에서 32예 (94.1%) 였고, 이때수혈받은양은자가수혈및동종수혈을합하여 1군은 1,220.3 ml, 2군은 ml, 3군은 ml으로 1군에서수혈의양이가장많았다 (p<0.05)(table 5). 수술하는데소요된시간은 1군에 Table 5. Comparison of Total Blood Loss and Transfusion Sequential Staggered Staged p-value Total blood loss (ml) 1,442.9±279.2 (425-2,985) 1,567.4±333.4 (390-2,990) 1,616.6±334.3 (471-3,215) >0.05 Transfusion* (ml) 1,220.3±504.2 (400-2,400) 680.1±348.4 (400-1,600) 692.2±384.1 (400-2,000) <0.05 Operation time (min) 186 ( ) 196 (60-195) 211 (65-270) <0.05 Admission period (day) 16.8±5.7 (11-31) 28.6±10.9 (19-37) 29.8±4.6 (19-42) <0.05 *Pack RBC transfusion+autologous transfusion.

4 57 서 186 분, 2군에서 196 분, 3군에서 211 분으로 1군에서수술시간이적게소요되었다 (p<0.05). 총입원기간의비교에서는 1군이 16.8 일, 2군이 28.6 일, 3군이 29.8 일로 1군의입원기간이짧았다 (p <0.05) (Table 5). 고찰 양측에수술이필요한경우는전체의 1/3 이라는보고 18) 가있으나저자의경험상 2000 년 1월부터 7년간본원에서수술받은 750 명중양측을시행받은환자가 650 명 (86.7%) 으로양측에수술이필요한경우가더많았다 (Yoo J.H., unpublished data). 양측슬관절을수술하는시기로분류하면한번의마취하에양측슬관절을두수술팀이동시에하는방법 (simultaneous), 한쪽을끝내고순차적으로반대쪽을수술하는방법 (sequential), 한번의입원기간동안일정시간간격으로두번의마취를통하여시행하는방법 (staggered), 두번의입원으로수술하는방법 (staged) 이있는데, 한번의마취로양측을수술하는경우에환자의만족도, 입원기간및재활기간단축에따른효율성및경제성의장점에대하여수술시간의지연, 수술후출혈의증가, 수술후통증, 지방색전이나혈전에의한사망, 혹은합병증이많이있다는여러부정적인보고가있고 3,4,12,13) 특히기존의내과적질환이중증이거나고령의경우에그위험성이증가한다는보고가있다. 14,15) 수술시기에따른수술결과비교에서가장중요한것은사망률인데 Ritter 등의보고 10) 에의하면수술후처음 3개월동안은한번의마취하에동시에수술한경우가더높았고, 수술 1년후에는두번에나누어수술한경우에사망률이높았으나수술 2년후에는차이가없다고보고하였다. 이때사망률에가장영향을주는요인중에하나는혈전증에의하여발생하는폐색전증으로혈전에대한예방을하지않을경우 40-84% 에서혈전이발생하고이중에폐색전의발생빈도는 2-5% 에서발생하며, 사망에이르는폐색전증은 1-3% 에서발생한다고하였다. 19) 혈전증을예방하는유용한방법으로혈전용해제를사용하는방법과기계적인압박에의한족부펌프가널리사용되고있는데전자의경우는약제사용에따른비용과부작용이있다는단점이있다. 이에반하여족부펌프는환자에게불편감을줄수있고고가라는단점이있지만, 혈류의증가로정맥혈의정체를줄이고심부정맥내판막아래에혈액의소용돌이를유발시키며, 혈관내에일시적인 hypovolemia 를유발시켜 endothelial derived relaxing factor 와 prostaglandin 이혈액내로분비됨으로써섬유소분해를유발하여혈전생성을억제한다고알려져있으며이는약물요법의결과에비교할때대등한효과를보이는유용한방법이라는많은보고가있어왔다. 19,20) 본연구에서는족부펌프를사용하지않은환자가없어비교하기는어렵지만 310 명의환자전례에서임상적으로나타나는혈전증의발생및폐색전증에의한사망이없었던것은 족부펌프가일부기여했을것으로추측된다. 고령의환자에서는내과적인질환을동반하는경우가많아수술시간이길어지는경우폐와심장에합병증발생가능성이높다는보고 14,15) 가있어동시수술을피하는것이좋을것으로사료되며, 본연구에서도 75세이하이면서심혈관질환이나뇌혈관질환이없는저위험군의환자를선별하여동시수술을시행하였기에수술후주요한합병증의발생이없었다고생각한다. Jankiewicz 8) 와 Lane 등 4) 은동시에시행한양측슬관절전치환술에서수혈요구량등이현저히높다고보고한바있으며 Bottner 등 21) 은양측슬관절전치환술에서자가수혈량이많으면많을수록동종수혈의빈도가낮아지므로자가수혈의필요성을언급한바있다. 본연구에서도한번혹은두번의자가헌혈을시행하였으며, 이를통하여양측을동시에수술하는경우동종수혈량을줄일수있었다. 수술시간의비교에서제 1군에서총수술시간이다른군에비하여짧았던이유는수술을연이어했기때문에수술의집중도가높았기때문으로생각된다. 본연구를통하여한번의마취하에양측을수술한경우는한번의마취로비교했을때수술시간이많이소요되었고, 수술후출혈량과평균수혈량이많았지만, 입원기간과재활기간이단축되는장점이있었고, 수술후안전성에있어서본연구에서적용한환자선택기준으로시행했을때임상적으로심각한합병증은발생하지않았다. 결론 양측에인공슬관절전치환술이필요한경우에수술시기에따른장단점을고려하고, 환자의상태, 여건및환자의선호도에따라신중하게수술시기를선택해야할것으로생각되며, 저위험군환자에서는한번의마취하에양측을동시에시행하는것도안전한방법이될수있을것으로생각된다. 참고문헌 1. Forster MC, Bauze AJ, Bailie AG, Falworth MS, Oakeshott RD. A retrospective comparative study of bilateral total knee replacement staged at a one-week interval. J Bone Joint Surg Br. 2006;88: Ritter MA, Harty LD, Davis KE, Meding JB, Berend M. Simultaneous bilateral, staged bilateral, and unilateral total knee arthroplasty. A survival analysis. J Bone Joint Surg Am. 2003;85- A: Gradillas EL, Volz RG. Bilateral total knee replacement under one anesthetic. Clin Orthop Relat Res. 1979;140: Lane GJ, Hozack WJ, Shah S, et al. Simultaneous bilateral ver-

5 58 유주형 김성민 한창동외 3 인 sus unilateral total knee arthroplasty. Outcomes analysis. Clin Orthop Relat Res. 1997;345: Hutchinson JR, Parish EN, Cross MJ. A comparison of bilateral uncemented total knee arthroplasty: simultaneous or staged? J Bone Joint Surg Br. 2006;88: Brotherton SL, Roberson JR, de Andrade JR, Fleming LL. Staged versus simultaneous bilateral total knee replacement. J Arthroplasty. 1986;1: Leonard L, Williamson DM, Ivory JP, Jennison C. An evaluation of the safety and efficacy of simultaneous bilateral total knee arthroplasty. J Arthroplasty. 2003;18: Jankiewicz JJ, Sculco TP, Ranawat CS, Behr C, Tarrentino S. One-stage versus 2-stage bilateral total knee arthroplasty. Clin Orthop Relat Res. 1994;(309): McLaughlin TP, Fisher RL. Bilateral total knee arthroplasties. Comparison of simultaneous (two-team), sequential, and staged knee replacements. Clin Orthop Relat Res. 1985;199: Ritter M, Mamlin LA, Melfi CA, Katz BP, Freund DA, Arthur DS. Outcome implications for the timing of bilateral total knee arthroplasties. Clin Orthop Relat Res. 1997;345: Morrey BF, Adams RA, Ilstrup DM, Bryan RS. Complications and mortality associated with bilateral or unilateral total knee arthroplasty. J Bone Joint Surg Am. 1987;69: Samii K, Elmelik E, Goutalier D, Viars P. Hemodynamic effects of prosthesis insertion during knee replacement without tourniquet. Anesthesiology. 1980;52: Sliva CD, Callaghan JJ, Goetz DD, Taylor SG. Staggered bilateral total knee arthroplasty performed four to seven days apart during a single hospitalization. J Bone Joint Surg Am. 2005;87: Parvizi J, Sullivan TA, Trousdale RT, Lewallen DG. Thirty-day mortality after total knee arthroplasty. J Bone Joint Surg Am. 2001;83-A: Adili A, Bhandari M, Petruccelli D, De Beer J. Sequential bilateral total knee arthroplasty under 1 anesthetic in patients > or = 75 years old: complications and functional outcomes. J Arthroplasty. 2001;16: Wells PS, Anderson DR, Rodger M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 2000;83: Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350: Ivory JP, Simpson AH, Toogood GJ, McLardy-Smith PD, Goodfellow JW. Bilateral knee replacements: simultaneous or staged? J R Coll Surg Edinb. 1993;38: Westrich GH, Sculco TP. Prophylaxis against deep venous thrombosis after total knee arthroplasty. Pneumatic plantar compression and aspirin compared with aspirin alone. J Bone Joint Surg Am. 1996;78: Warwick D, Harrison J, Glew D, Mitchelmore A, Peters TJ, Donovan J. Comparison of the use of a foot pump with the use of low-molecular-weight heparin for the prevention of deep-vein thrombosis after total hip replacement. A prospective, randomized trial. J Bone Joint Surg Am. 1998;80: Bottner F, Pavone V, Johnson T, Heitkemper S, Sculco TP. Blood management after bilateral total knee arthroplasty. Clin Orthop Relat Res. 2003;(410):

6 59 Postoperative Safety of Sequential Bilateral Total knee Arthroplasty in Low Risk Patients Ju-Hyung Yoo, M.D., Seong-Min Kim, M.D., Chang-Dong Han, M.D.*, Yeun-Tae Lee, M.D., Hyun-Cheol Oh, M.D., and Jee-Ho Hyung, M.D. Department of Orthopaedic Surgery, National Health Insurance Corporation Ilsan Hospital, Ilsan, *Yonsei University College of Medicine, Seoul, Korea Purpose: To study the safety of sequential bilateral total knee arthroplasty in low risk patients. Materials and Methods: Those who had received the surgery all at once were grouped as the first group, those who had received the surgery over two weeks interval were the second group and the last group, third group were those who had received the first surgery on only one knee and they were gotten re-hospitalized for the second surgery on the rest of the knee. These groups were compared on the aspects of complication, postoperative bleeding amount, average transfusion amount, operation time and admission period. Results: There were no major complications found in all groups and the minor complication rate of occurrence was 3%, 4%, 6% in each, which did not constitute a significance difference. Each of the total blood loss was ml, ml, ml and which did not constitute a significance difference, either. Each of the average volume of blood transfused was ml, ml, ml, and the first group had the largest volume transfused (p<0.05). The operation time was 186, 196, 211 minutes in each and the first group had the shortest duration (p<0.05). The average admission periods were 16.8, 28.6, 29.8 days and the first group had the shortest period (p<0.05). Conclusion: We suggest that when there are no medical diseases contracted on patients, the sequential bilateral total knee arthroplasty can be performed safely without definite increase in perioperative complications. Key words: knee, bilateral total knee arthroplasty, complication Received February 3, 2010 Accepted April 27, 2010 Correspondence to: Hyun-Cheol Oh, M.D. Department of Orthopaedic Surgery, National Health Insurance Corporation Ilsan Hospital, 1232, Baekseok 1-dong, Ilsandong-gu, Goyang , Korea TEL: FAX: hyuncoh@hanmail.net

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical