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1 178 pissn : , eissn : Case Report J Korean Orthop ssoc 2016; 51: 양측성슬와낭종내통풍결절의수술적치료 김주오 안기용 박봉주 민웅배 광주보훈병원정형외과 Ju-Oh Kim, M.D., Ki-Yong n, M.D., ong-ju Park, M.D., and Woongbae Min, M.D. Department of Orthopaedic Surgery, Gwangju ohun Hospital, Gwangju, Korea Gout often occurs in the first metatarsophalyngeal joint, and also in the ankle joint and posterior foot. Knee joint gouty arthritis is commonly reported, but gouty tophi in bilateral popliteal cysts, such as this case, are rare. We report on a case treated by cystectomy of gouty tophi in bilateral popliteal cysts and review. Key words: knee, gout, baker cyst, popliteal cyst, cystectomy 요산의축척에의해발생하는통풍은퓨린대사의이상에의한질환으로주로제1 중족족지관절에많이발생한다. 또한중족관절등여타족부관절및후족부의주위에발생할수있으며, 견관절및슬관절부혹은수지관절등여러관절에이환된다. 이중통풍성슬관절염의보고는국내에서있었으나슬와낭종내통풍결절은국내에보고가없었다. 이에저자들은양측성슬와낭종내통풍결절에대해수술적치료를시행하고이를보고하는바이다. 증례보고 57세남자환자로 6년전부터양측슬관절부위통증을호소하였다. 2-3년전부터는점차크기가커졌으며, 내원 3-4개월전타병원에서여러차례천자를시행했었으나실패하였다. 양측슬관절운동범위는양측모두 0-120도였으며, 양측슬와부위에 mm 가량의낭성종괴가촉지되었다. 양측슬와부위의종괴는육안상각각양측무릎후방으로튀어나와있었으며촉진시단단하고경계가분명했고압통은심하지않았다. 우측슬와부위 Received ugust 27, 2015 Revised October 12, 2015 ccepted November 4, 2015 Correspondence to: Ki-Yong n, M.D. Department of Orthopaedic Surgery, Gwangju ohun Hospital, 99 Cheomdanwolbong-ro, Gwangsan-gu, Gwangju 62284, Korea TEL: FX: girong@naver.com 에는내측부위에피하출혈의흔적이보였다 (Fig. 1). 우측제5 수지근위지간관절에도 mm 가량의낭조직이관찰되었으며하얀결절조직이낭바깥으로노출되었다. 촉진시단단하고경계가분명했으며압통은존재했다 (Fig. 1). 환자의기저질환으로당뇨병이있어약물복용중이었으며다른내과적인질환은없었다. 6년전타병원에서통풍진단을받았으나환자스스로약을복용하지않았다. 내원당시시행한혈액학적검사상백혈구 10,500/mm 3, C 반응성단백질 8.26 mg/l ( 정상범위, 0-5 mg/l), 적혈구침강속도 67 mm/h ( 정상범위, -15 mm/h), 요산 9.1 mg/dl, 혈청크레아티닌 0.98 mg/dl, 류마티스인자 <0.5 IU/ml ( 정상범위, <14 IU/ml) 였다. 이낭성조직에대해단순방사선검사 (Fig. 2) 및자기공명검사를시행하였다 (Fig. 3). 단순방사선검사상슬관절후방으로피하조직의음영증가가관찰되었으며, 자기공명검사상우측과좌측슬관절내삼출액이관찰되었다. 관절낭의전반적인석회화및비후가관찰되었고, 각각장축이 60 mm와 75 mm 가량의석회화된종괴가관찰되었다. 손가락등전신의기타부위통증을호소하여 Tc-99m hydroxydiphosphonate whole body scan을시행하였다 (Fig. 4). 양측슬관절후방으로섭취증가된연부조직종양이관찰되었고양측슬관절, 왼쪽발목관절, 우측주관절, 우측족부, 양측제1 중족족지관절, 좌측제2 중족족지관절, 양측제1 수근중수관절, 우측제2 중수수지관절, 우측제5 수지근위지간관 The Journal of the Korean Orthopaedic ssociation Volume 51 Number Copyright 2016 by The Korean Orthopaedic ssociation This is an Open ccess article distributed under the terms of the Creative Commons ttribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

179 절, 제4, 5 흉추, 제9 우측늑추관절, 제3 요추우측에서섭취증가가관찰되었다. 이에통풍으로진단, 커진낭성조직에대해수술적처치를시행하였다.

수술당시양측슬와낭종내로흰색의분필가루와치약과비슷한양상의물질이관찰되어절제후충분한변연절제술및세척술을시행하였다. 수술후낭종은제거되었으며감염등의합병증은없었다.

() Gross finding on both popliteal areas.

() Gross finding on the right 5th finger.

고찰 통풍은퓨린대사의장래로요산의과다생성혹은배설이상으로인한고요산혈증으로관절의활액막, 관절, 주위조직에요산결절 Figure 2.

2 179 절, 제4, 5 흉추, 제9 우측늑추관절, 제3 요추우측에서섭취증가가관찰되었다. 이에통풍으로진단, 커진낭성조직에대해수술적처치를시행하였다. 환자는전신마취하에복와위에서양측대퇴부근위부에지혈대를감고슬와후방접근법을이용하여신경과혈관등의구조물에주의하여양측슬관절개방적낭종절제술을차례로시행하였다 (Fig. 5). 수술당시양측슬와낭종내로흰색의분필가루와치약과비슷한양상의물질이관찰되어절제후충분한변연절제술및세척술을시행하였다. 수술후낭종은제거되었으며감염등의합병증은없었다. 수술장에서제거하였던조직의검사소견상요산일나트륨결정 (monosodium urate crystal) 을확인하여 (Fig. 6) 양측슬와낭종내통풍결절을확진하였다. Figure 1. () Gross finding on both popliteal areas. pproximately mm sized firm and round masses are palpated on both popliteal areas. () Gross finding on the right 5th finger. pproximately mm sized firm and whitish mass on the right 5th proximal interphalangeal joint. 고찰 통풍은퓨린대사의장래로요산의과다생성혹은배설이상으로인한고요산혈증으로관절의활액막, 관절, 주위조직에요산결절 Figure 2. () Preoperative lateral radiograph of the right knee. () Pre operative lateral radiograph of the left knee. Soft tissue masses are seen. Figure 3. () Magnetic resonance imaging (MRI) of the right knee with T2-weighted fat suppression sagittal view shows diffuse calcified synovial thickening in the knee joint, with large calcified mass formation (approximately 6 cm in the long axis) in popliteal fossa. () MRI of the left knee T2-weighted. Sagittal view shows diffuse calcified synovial thickening in the knee joint, with large calcified mass formation (approximately 7.5 cm in the long axis) in popliteal fossa.

180 Ju-Oh Kim, et al. nterior Tc-99m HDP whole body bone scan IV SITE:LT.elbow Posterior nterior Posterior Figure 4.

Increased uptake is shown on both knee joints, left ankle joint, right elbow joint and other multiple joints. C Figure 5.

Whitish chalk and toothpaste-like materials were seen in both popliteal cysts. 의침착으로인한통증이발생하는질환이다.

2,3) 모든통풍환자에서결절을보이지는않고, 통풍환자의약 10%-25% 에서결절이있었으며, 그중족부에서 60% 정도, 슬관절은그중 7% 에서결절이보인다고보고하였다.

3 180 Ju-Oh Kim, et al. nterior Tc-99m HDP whole body bone scan IV SITE:LT.elbow Posterior nterior Posterior Figure 4. Tc-99m hydroxydiphosphonate (HDP) whole body bone scan showed a soft tissue mass with faint increased uptake behind both knee joints. Increased uptake is shown on both knee joints, left ankle joint, right elbow joint and other multiple joints. C Figure 5. () Operative findings. Gross findings of the mass left () and right (C). Whitish chalk and toothpaste-like materials were seen in both popliteal cysts. 의침착으로인한통증이발생하는질환이다. 1) 국내및미국에서는 76% 이상의환자에서첫발작시통증이발현되는관절로제1 중족족지관절에 76%, 족근관절 13%, 무릎 5%, 수근관절 5%, 주관절 1% 등으로보고되었다. 2,3) 모든통풍환자에서결절을보이지는않고, 통풍환자의약 10%-25% 에서결절이있었으며, 그중족부에서 60% 정도, 슬관절은그중 7% 에서결절이보인다고보고하였다. 2) 슬와낭종은무릎뒤쪽에점액낭과슬관절과의연결로관절액의유출이나후방관절낭의활액막의돌출로발생한다. 4) 슬와낭종은낭종자체로는증상이없는경우가많으나종괴자체로운 동제한및압박으로인한증상이유발되며이로인해주위신경의압박, 슬와동맥의압박으로인한허혈성동통및파행, 심부정맥혈전증과비슷한증상혹은낭종의파열등이유발될수있다. 5,6) 슬와낭종은 one-way valve 기전 4) 에의해관절내액이낭종내로들어가는것으로, 이때통풍결절이슬관절내에서슬와낭종으로들어가고점차나오지못하면서관절액내에존재하는통풍결절이슬와낭종내에침착된것으로생각된다. 국내의보고로슬관절내의통풍결절의경우슬개골부위혹은대퇴사두근내등슬관절내측혹은경골결절에발생하였다

4 181 통풍에대한자각이없었던것으로보인다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES Figure 6. Histological images of masses. Deposition of monosodium urate crystals (arrow) were seen (H&E, 400). 는보고가있었다. 7-9) 슬와낭종의경우대한류마티스학회에서 mm 크기의통풍성관절염이동반된슬와낭종의파열을약물로호전을보였다는보고 10) 가있으나일측성으로수술적치료가필요치않은작은크기였다. 본사례의경우환자는양측슬관절부위와양측수지관절에다발성통풍성결절이있는상황으로여러차례의천자를타병원에서시행하여파열의가능성과크기가매우커서슬와동맥및신경의압박가능성이높고관절운동에장애를주고있어수술적처치를고려하였으며, 낭종의크기가매우커서관절경적절제술로는불가할것으로생각되어개방적낭종절제술을시행하기로하였다. 슬관절내의통풍결절침착및혈중요산수치조절을위해하루 1회 febuxostat 160 mg을투약하고통증발생시 colchicine 600 μg 을이용한약물치료를시행하기로하였다. 시행후관절운동에호전을보였으며현재추시 2개월후에도슬관절부위의슬와낭종의재발은없었으며통증도호전되었다. 본환자의경우오랜기간통풍약의복용이없었고환자또한 1. Weselman KO, gudelo C. Gout basics. ull Rheum Dis. 2001;50: Chung TG, Kim HG, Song YS, et al. Clinical manifestations of gout in Korea. Korean J Med. 1997;53: gudelo C, Wise CM. Gout: diagnosis, pathogenesis, and clinical manifestations. Curr Opin Rheumatol. 2001;13: ickel WH, urleson RJ, Dahlin DC. Popliteal cyst; a clinicopathological survey. J one Joint Surg m. 1956;38: Nakano KK. Entrapment neuropathy from aker's cyst. JM. 1978;239: Scott WN, Jacobs, Lockshin MD. Posterior compartment syndrome resulting from a dissecting popliteal cyst. Case report. Clin Orthop Relat Res. 1977;122: Hong KD, Ha SS, Shim JC. Tophaceous gout involving the bipartitle patella: a case report. J Korean Knee Soc. 2000;12: Lim HC, Shim JH, Nam HW, Choi S, Hong MP. Pathologic quadriceps tendon rupture in patients with chronic renal failure: case report. J Korean Knee Soc. 2000;12: Jeong JC, Park CH, Cho HK, et al. Gouty tophus on the tibial tuberosity with accompanied chemical cellulitis localized at the upper tibia. J Korean Rheum ssoc. 2004;11: Park RY, Nam SY, Lee JH, et al. case of ruptured popliteal cyst in gouty arthritis. J Korean Rheum ssoc. 2002;9:

5 182 pissn : , eissn : Case Report J Korean Orthop ssoc 2016; 51: 양측성슬와낭종내통풍결절의수술적치료 김주오 안기용 박봉주 민웅배 광주보훈병원정형외과 통풍은제1 중족족지관절에서많이발생하며족근관절및후족부에서발생하기도한다. 통풍성슬관절염은흔히보고되지만, 본증례와같이양측성슬와낭종내통풍결절은드물다. 저자들은양측성슬와낭종내통풍결절을진단하고낭종절제술을시행한증례를문헌고찰과함께보고하고자한다. 색인단어 : 무릎, 통풍, 베이커낭종, 슬와낭종, 낭종절제술 접수일 2015 년 8 월 27 일수정일 2015 년 10 월 12 일게재확정일 2015 년 11 월 4 일책임저자안기용 62284, 광주시광산구첨단월봉로 99, 광주보훈병원정형외과 TEL , FX , girong@naver.com 대한정형외과학회지 : 제 51권제 2호 2016 Copyright 2016 by The Korean Orthopaedic ssociation This is an Open ccess article distributed under the terms of the Creative Commons ttribution 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