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Case Report pissn : 1226-4962 eissn : 2233-9841 J Korean Bone Joint Tumor Soc 2012; 18: 89-93 http://dx.doi.org/10.5292/jkbjts.2012.18.2.89 www.kbjts.or.kr 반건양건내에발생한근육경색및석회화 : 증례보고 Muscle Infarction and Calcification of the Semitendinosus Tendon: A Case Report 조진호인제대학교의과대학일산백병원정형외과학교실 석회화건염은주로견관절이가장많이호발하고고관절, 슬관절등다른부위의관절에발생하는것으로알려져있다.

1 Case Report pissn : eissn : J Korean Bone Joint Tumor Soc 2012; 18: 반건양건내에발생한근육경색및석회화 : 증례보고 Muscle Infarction and Calcification of the Semitendinosus Tendon: A Case Report 조진호인제대학교의과대학일산백병원정형외과학교실 석회화건염은주로견관절이가장많이호발하고고관절, 슬관절등다른부위의관절에발생하는것으로알려져있다. 근육내에허혈로인한근육경색또한주로당뇨병환자에서빈번한합병증인폐쇄성혈관병변에의한하지원위부에주로발생하는것으로알려져있다. 본저자는고령의환자에서당뇨병같은기존질환이없고관절부위가아닌하퇴후방부순수건내에생긴근육경색과석회화가같이동반된종괴병변을경험하였기에이를보고하고자한다. 색인단어 : 대퇴하퇴부, 반건양건, 근육경색, 석회화 일반적으로상하지에생길수있는석화화건염은견관절극상건에오는것이대표적이며, 이는전형적인증상및방사선검사로쉽게진단을할수있으며, 그외고관절, 슬관절, 완관절, 주관절에가끔생기는것으로되어있다. 그리고주로하퇴에많이생기는근육경색은장기간인슐린의존성당뇨병환자로다발성장기합병증이있는환자에서주로발현되는당뇨병합병질환으로거의대퇴부와드물게하퇴부에서발생하고심한국소적통증과종창을동반한종괴양병변으로나타나며대부분중재적시술없이수주에서수개월후자연적으로관해되는것으로알려져있으나임상양상이비특이적이며유병률이적어비슷한증상을일으킬수있는질병, 특히감염성질환이나연부조직육종과의감별진단이필수적이다. 본저자는고령의환자에서근육내발생할수있는연부조직종양과구별되며, 석회화와근육괴사두질환이병합된하퇴부순수반건양건내에종괴양병변을경험하였기에이를보고하고자한다. 하였으며, 환자는무릎을많이구부리는자세를취할때종괴로인한심한압박감을호소하였다. 과거력상당뇨는없었고, 고혈압외엔지병이없었다. 이학적검사상무릎관절슬와부상방에호두크기정도의종괴가만져졌으며, 동반된피부병변은없었고, 만졌을때압통을호소하였다. 시행한피검사에선특이소견이없었다. 시행한단순방사선검사에선무릎후방부에석회화가동반된연부조직음영이관찰되었고 (Fig. 1), MRI 에선반건양건을따라서비교적경계가명확한 cm크기의 fusiform shape 의연부조직종괴가관찰되었으며, T1WI 상근육과비교하여약간 high signal intensity 을보이고 T2WI 상 heterogeneous-iso 증례보고 66 세남자환자로서내원 8 년전심하게넘어진적이있고그후 잘지내다우연히촉지된우측무릎뒤쪽에종괴를주소로내원 접수일 2012 년 4 월 27 일심사수정일 2012 년 11 월 15 일게재확정일 2012 년 11 월 19 일교신저자조진호경기도고양시일산서구대화동 2240, 인제대학교의과대학일산백병원정형외과학교실 TEL , FAX osd07@paik.ac.kr Figure 1. Lateral radiograph of right knee show calcified lesion (arrow) on posterior area of distal femur. 대한골관절종양학회지 : 제 18 권제 2 호 2012 Copyrights 2012 by The Korean Bone and Joint Tumor Society 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.

90 조진호 Figure 2. Magnetic resonance images shows well-defined soft tissue mass along semitendinosus tendon, posterior aspect of distal thigh.

Gross examination reveals tendon (right white portion) with skeletal muscles (left cut view). signal intensity 을보였다.

환자 는척추마취하에복와위자세로수술을받았는데, 수술소견은 우측무릎슬와부 6 cm 상방에 1.6 1.5 5.1 cm 크기의종괴가순 수반건양건내에위치해있었으며, 주위조직으로의침범은없었 다. 수술은단순종괴부위절제술을시행하였고, 술후다음날부 터체중부하보행및관절운동을시행하였다. 병리학교실에서시 행한육안적소견 (Fig.

2 90 조진호 Figure 2. Magnetic resonance images shows well-defined soft tissue mass along semitendinosus tendon, posterior aspect of distal thigh. (A) T1-weighed image: slightly high signal intensity (B) T2-weighed image: heterogeneous iso signal intensity. Figure 3. Gross examination reveals tendon (right white portion) with skeletal muscles (left cut view). signal intensity 을보였다. T1WI 와 T2WI 모두에서동일한두께의 가장자리에 dark signal intensity rim 을가지고있고내부에도 dark signal intensity focus 가보이는데이는단순방사선사진과연계하 여비교시석회화로진단되었다 (Fig. 2). 조영제검사에선특이소 견은없었다. 이종괴와인접한부위에특이소견은없었다. 환자 는척추마취하에복와위자세로수술을받았는데, 수술소견은 우측무릎슬와부 6 cm 상방에 cm 크기의종괴가순 수반건양건내에위치해있었으며, 주위조직으로의침범은없었 다. 수술은단순종괴부위절제술을시행하였고, 술후다음날부 터체중부하보행및관절운동을시행하였다. 병리학교실에서시 행한육안적소견 (Fig. 3) 현미경하조직검사에선건내부에석회 화및퇴행성변화가보이고, 근육경색이동반된골격근육조직 을관찰할수있었다 (Fig. 4). 고 찰 석회화건염의발생기전은아직명확하게규명되지않았으나극 상건의석회화건염에서의연구로서 Uhthoff 등 1) 이제시한국소 허혈에의한섬유연골로의변성과석회침착, 뒤이어서미세혈관 이자라들어가면서대식세포에의한흡수기전을거쳐서산소공급의회복과인대구조의정상화를이룬다고하였으며 Gärtner 와 Simons 2) 에의하면석회침착물흡수에의한급성기는무기질의화학적용해가아니라유기질에의해유지되던 Hydroxyapatite 간의접착력의변화에서기인한다고하였다. 주로견관절에생기며, 그외고관절, 손목관절, 주관절등에생길수있으며, 무릎관절에서도생길수있는데, 이는주로슬개건, 대퇴이두근, 대퇴직근, 내측측부인대 (Pelligrini-Steida disease) 등에서보이며, 드물게슬와건에서도생길수있다는증례보고가있다. 대퇴직근의석회화건염과관련해서는수상력과관련하여발생한경우를대퇴직근의파열에이은외상성골근부착부병증 (enthesopathy), 전하장골극의견열골절후발생한외골종으로보고한예가있다. 3) 본예에서는내원 8년전심한외상당시근육의손상이있었고그후근육의괴사와석회화가같이동반된것으로사료된다. 일반적인발생원인은확실하진않으나외상, 만성신부전증, 종양성석회화증, 당뇨병등과연관이있다고알려져있다. 4) 하퇴골격근육내에생길수있는근육경색은하퇴부혈관의죽상경화및폐쇄성질환으로인해생기는것으로보고있으며, 이는당뇨병을오래앓은경우에주로오는것으로알려져있다. 주로대퇴부의사두근, 대퇴내전근, 대퇴이두근에서호발하며, 드물게비복근에서도발생한다고알려져있고, 상지에서는거의발생안하는것으로알려져있다. 따라서당뇨병환자에서하지골격근에심한급성통증을동반하는종괴가발현시당뇨병성근육경색을의심하게되나비슷한증상을일으킬수있는봉와직염, 농양, 골수염및화농성근염등의감염성질환, 양성이나악성종양, 출혈이나심부정맥, 혈전증등의혈관성질환, 드물게염증성질환이나신경원성질환들과감별진단하는것이필요하다. 5-9) 특히그중에서도근육내발생할수있는연부조직종양들과의감별이중요한데, 이는증상발현이급성이나아급성으로생기거나진찰시심한통증또는만졌을때압통을호소하는경우, 초음파나 MRI 같은영상검사에서종괴주위로정상조직으로의침범여부등으로두질환을구분할수있겠다.

$(B) Degeneration with infract (arrows) was noted in muscle portion ( 200, H&E). (C) Degeneration with calcification (arrows) was noted in tendon portion ( 100, H&E).$ (D) Tendinitis with foreign body reaction (arrows).

(D) Tendinitis with foreign body reaction (arrows).

이는원인을정확히알수는없지만최초의심한외상이있었고그후반복되는외상에의한것으로사료된다. 고령의환자에서하퇴부순수반건양건내에술전시행한영상학적검사에서양성또는악성종양으로생각되었으나술후조직학적으로근육과건의결합부위가아닌순수건내부에서석회화및근육경색이함께동반된드문경우를경험하였다. 참고문헌 1. Uhthoff HK, Sarkar K, Maynard JA.

Clin Orthop Relat Res. 1990;(254):111-20. 3. Baudrillard JC, Lerais JM, Segal P, et al. Enthesopathy of the upper insertion of the musculus rectus femoris.

3 91 반건양건내에발생한근육경색및석회화 Figure 4. Microscopic findings of tendinitis with muscle infarct. (A) Low power view reveals tendon (T) and skeletal muscle (M) ( 40). (B) Degeneration with infract (arrows) was noted in muscle portion ( 200, H&E). (C) Degeneration with calcification (arrows) was noted in tendon portion ( 100, H&E). (D) Tendinitis with foreign body reaction (arrows). 본증례는당뇨병의과거력이없고, 내원당시에도심한통증을호소하지않아서당뇨로인한근육경색은감별할수있었고, 시행한 x-ray 및 MRI 에서석회화가동반된양성종양으로생각되어종괴절제술겸조직검사를시행하였으나수술소견및조직학적검사에서순수반건양건부위에서경색되고퇴행성변화가동반된근육조직및석회화성분이관찰되었다. 이는원인을정확히알수는없지만최초의심한외상이있었고그후반복되는외상에의한것으로사료된다. 고령의환자에서하퇴부순수반건양건내에술전시행한영상학적검사에서양성또는악성종양으로생각되었으나술후조직학적으로근육과건의결합부위가아닌순수건내부에서석회화및근육경색이함께동반된드문경우를경험하였다. 참고문헌 1. Uhthoff HK, Sarkar K, Maynard JA. Calcifying tendinitis: a new concept of its pathogenesis. Clin Orthop Relat Res. 1976;(118): Gärtner J, Simons B. Analysis of calcific deposits in calcifying tendinitis. Clin Orthop Relat Res. 1990;(254): Baudrillard JC, Lerais JM, Segal P, et al. Enthesopathy of the upper insertion of the musculus rectus femoris. A retrospective sign of tendon rupture in sports pathology. J Radiol. 1986;67: Tennent TD, Goradia VK. Arthroscopic management of calcific tendinitis of the popliteus tendon. Arthroscopy. 2003;19:E Aboulafia AJ, Monson DK, Kennon RE. Clinical and radiological aspects of idiopathic diabetic muscle infarction. Rational approach to diagnosis and treatment. J Bone Joint Surg Br. 1999;81: Damron TA, Levinsohn EM, McQuail TM, Cohen H, Stad-

4 92 조진호 nick M, Rooney M. Idiopathic necrosis of skeletal muscle in patients who have diabetes. Report of four cases and review of the literature. J Bone Joint Surg Am. 1998;80: Lauro GR, Kissel JT, Simon SR. Idiopathic muscular infarction in a diabetic patient. Report of a case. J Bone Joint Surg Am. 1991;73: Hinton A, Heinrich SD, Craver R. Idiopathic diabetic muscular infarction: the role of ultrasound, CT, MRI, and biopsy. Orthopedics. 1993;16: Morcuende JA, Dobbs MB, Crawford H, Buckwalter JA. Diabetic muscle infarction. Iowa Orthop J. 2000;20:65-74.

5 Case Report pissn : eissn : J Korean Bone Joint Tumor Soc 2012; 18: Muscle Infarction and Calcification of the Semitendinosus Tendon: A Case Report Jin-Ho Cho Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea The most common anatomic location of calcific tendinitis is the suprasupinatus muscle of the shoulder joint. However, it is known to develop in any joint including the hip, knee. Infarction of skeletal muscle in the distal areas of the limbs due to vascular occlusion is a well recognized systemic condition in patients who have diabetes. The author experienced mass-like lesion combined muscle infarction and calcification within pure semitendinosus tendon without diabetes in posterosuperior area of distal thigh in old age. Key words: distal femur, semitendinosus tendon, muscle infarction, calcification Received April 27, 2012 Revised November 15, 2012 Accepted November 19, 2012 Correspondence to: Jin-Ho Cho Department of Orthopaedic Surgery, Ilsan Paik Hospital, Inje University College of Medicine, 2240, Daehwa-dong, Ilsanseo-gu, Goyang , Korea TEL: FAX: osd07@paik.ac.kr The Journal of the Korean Bone and Joint Tumor Society Vol. 18, No. 2 (December 2012) Copyrights 2012 by The Korean Bone and Joint Tumor Society 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.

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( ) Jkra076.hwp Vol. 11, No. 4, December, 2004 Objective: Ultrasonography (USG) of joints has a unique position for the diagnosis of joint diseases. Bone surface, cartilage, periarticular soft tissue and their pathologic