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1 ISSN (Print) ISSN (Online) 대한골절학회지제 27 권, 제 2 호, 2014 년 4 월 J Korean Fract Soc 2014;27(2): Case Report 슬개골골절수술후발생한폐색전증 - 증례보고 - 김용범 최형석 천동일 서정무 이병일 순천향대학교서울병원정형외과 Pulmonary Embolism Complication after Surgical Treatment of Patella Fracture - A Case Report - Yong-Beom Kim, M.D., Hyung-Suk Choi, M.D., Dong-Ill Chun, M.D., Jung-Moo Seo, M.D., Byung-Ill Lee, M.D. Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Seoul, Korea Deep vein thrombosis and pulmonary embolism are serious and fatal complications in orthopedic surgery. Most cases of symptomatic pulmonary embolism in knee surgery have been reported after total knee arthroplasty, but rarely after patella fracture. We report on a case of symptomatic pulmonary embolism after surgical treatment of a patella fracture in a 42-year-old female patient. Key Words: Fracture, Patella, Pulmonary embolism 심부정맥혈전증과폐색전증은정형외과수술후발생할수있는심각하고치명적인합병증으로인공관절치환술이나고관절골절또는다발성골절등에서흔하며, 증상이없는경우가대부분이다. 저자들은정맥혈전색전증발생의위험인자가없는슬개골단일골절환자에서수술후증상이있는폐색전증이발생한 42 세여자환자를경험하였다 년제 9 차미국흉부의학회 (American College of Chest Physicians, ACCP) Received January 22, 2014 Revised February 20, 2014 Accepted March 5, 2014 Address reprint requests to: Hyung-Suk Choi, M.D. Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, 59 Daesagwan-ro, Yongsan-gu, Seoul , Korea Tel: ㆍFax: knee@schmc.ac.kr Financial support: None. Conflict of interest: None. 가이드라인에서는단일하지외상환자에서는증상을동반한정맥혈전색전증은매우드물게발생하기때문에혈전예방약제의사용이권장사항은아니다. 1) 저자들이검색한바로는슬개골단일골절환자에서증상이있는폐색전증의발생을보고한국내외연구가아직없어문헌고찰과함께보고하고자한다. 증례보고 42 세여자환자가넘어지면서발생한좌측슬관절의통증및부종을주소로내원하여시행한단순방사선검사상슬개골골절진단하에입원하였다 (Fig. 1). 술전에시행한혈액응고검사는정상소견이었고, 신장은 169 cm, 체중은 71 kg 으로체질량지수 (body mass index, BMI) 는 kg/m 2 였다. 과거력에서호르몬치료경험이나정맥혈전기왕력은없었고비흡연자였다. 수술은수상후 4 일째관혈 Copyright c 2014 The Korean Fracture Society. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 162

Pulmonary Embolism Complication after Surgical Treatment of Patella Fracture 163 Fig. 3.

the proximal left femoral vein (arrow). Fig. 1.

$42-year-old woman, showing a displaced patella fracture. Fig. 4.$ pulmonary arteries (arrows). Fig. 2.

적정복및장력대강선고정술을시행하였다 (Fig. 2). 수술시간은약 55 분, 지혈대는사용하지않았다. 술후 1 일째부터무릎관절운동및목발을이용한보행을시작하였고술후 4 일째퇴원하였다.

9 로증가되었고, lupus anticoagulant (LAC) 수치가증가된소견이었다.

2 Pulmonary Embolism Complication after Surgical Treatment of Patella Fracture 163 Fig. 3. Lower extremity computed tomography venogram showing a thrombus (poorly defined intraluminal low density) in the proximal left femoral vein (arrow). Fig. 1. A preoperative anteroposterior (A) and lateral (B) 3-dimensional computed tomography images of the knee of a 42-year-old woman, showing a displaced patella fracture. Fig. 4. Chest computed tomography venogram showing an intraluminal low density filing defect in the bilateral pulmonary arteries (arrows). Fig. 2. Postoperative anteroposterior (A) and lateral (B) radiographs after fixation with tension band wire. 적정복및장력대강선고정술을시행하였다 (Fig. 2). 수술시간은약 55 분, 지혈대는사용하지않았다. 술후 1 일째부터무릎관절운동및목발을이용한보행을시작하였고술후 4 일째퇴원하였다. 퇴원후 6 일째인술후 10 일째발생한우측흉통및객혈을주소로내원하여시행한혈액검사상 D-dimer 와 fibrin degradation products 수치가각각 1,127.0 과 6.9 로증가되었고, lupus anticoagulant (LAC) 수치가증가된소견이었다. 컴퓨터단층촬영정맥조영술 (computed tomography venogram) 검사에서좌측대퇴정맥에혈전에의한음영결손소견이보이고 (Fig. 3), 양측폐동맥에서도폐 색전에의한음영결손소견이관찰되었다 (Fig. 4). 환자는급성폐색전증과심부정맥혈전증진단하에 3 일간저분자량헤파린 (enoxaparin sodium 60 mg/0.6 ml) 을 3 일간피하주사치료를하였고, 흉부증상발생 5 일째인술후 15 일째증상호전되었다. 와파린은 6 개월간복용하였다. 고 정맥혈전색전증은심부정맥혈전증과폐색전증을포함하는진단명으로정형외과수술후발생할수있는심각하고치명적인합병증이며인공관절치환술이나고관절골절또는다발성골절등에서흔하다. 정맥혈전색전증발생의후천적위험인자는고령, 비만, 골절, 경구피임약복용, 호르몬치료, 정맥혈전기왕 찰

3 164 Yong-Beom Kim, et al. 력, 임신, 산욕기, 암, 항인지질증후군 (antiphospholipid syndrome) 등이고, 선천적위험인자로는혈액응고인자의이상, 즉 anti-thrombin III, protein C, protein S, Factor V Leiden and prothrombin G20210A mutation 등이다. 2) 이러한위험인자를가지고있거나 hyperhomocysteinemia 와 fibrinogen 수치가높은사람은경미한외상이나간단한수술에의해서도혈전증이생길수있다고보고되고있다. 2) 외상환자에서정맥혈전색전증의위험인자는 45세이상이거나정맥혈전색전증의과거력, 척추골절, 골반골절, 혼수상태, 사지마비혹은하지마비, 하지의중요정맥의봉합, 수상후 48시간동안수혈, 3일이상의침상안정, 장시간의수술시간, 수상후골절부위고정까지의시간등이다. 3-5) 본증례의경우 42세로고령이아니고 BMI kg/m 2 로비만이아니었으며흡연이나호르몬치료, 정맥혈전의과거력도없었다. 또한지혈대의사용이 60분을넘는경우혈전증의위험성이증가한다는보고 6) 가있으나, 수술시에지혈대는사용하지않았으며, 수술후 1일째관절운동과목발을이용한보행을시행하였다. 하지만휴일때문에수술이지연이되어수상후 4일째에수술을시행하였는데, 술전목발을이용한보행으로완전침상안정은아니었으나수상후수술이지연기간이 3일이었던점은정맥혈전색전증의위험요소중하나라생각된다. 선천적위험인자여부에대한검사에서도 anti-thrombin III, protein C, protein S는정상소견이었으나 LAC 검사수치가증가되어있었다. LAC는항인지질증후군을진단하기위한검사로, 항인지질증후군은동정맥혈전증이나산과적합병증이있는환자에서 negative charged phospholipids (cardiolipin, phosphatidylserine) 에대한항체가존재하는자가면역질환으로 anticardiolipin antibody, anti-β 2 glycoprotein I antibody, LAC 를이용하여검사한다. 7) 본예의경우동정맥혈전증환자면서초기검사에서 anticardiolipin antibody 는음성이었으나 LAC 검사수치가증가되어있어서항인지질증후군으로판단하였으나 12주이후검사에서는 LAC 검사수치가정상소견보이고있어서항인지질증후군의진단기준 7) 에는적합하지않았다. 동양인에서는서양인보다낮은심부정맥혈전증과폐색전증유병률을보이는데이는비만율과고지혈증의빈도가낮은임상적요인과함께 Factor V Leiden 으로알려진활성형 C 단백질저항성이서양의정맥혈전증환자 30%- 50% 에서발견되지만동양인에서는발견되지않으며, prothrombin의수치를높이는역할을하는 promoter G20210A 돌연변이가없고, 정상적인 anti-thrombin III 수치를유지하는등의혈액응고인자유전자의다형성의부재가원인으로알려져있다. 8) 한국인에서의심부정맥혈전증은그동안비교적낮은유병률이보고되어서양인에비하여발 생빈도가낮은것으로알려져왔으나최근식생활의서구화나인구의고령화등으로점차발생빈도가증가하는것으로보고되고있어, 9) 점차수술전의심부정맥혈전증예방에대해관심이높아지고있다. 인공관절이나고관절골절환자이외의단순골절환자에서의심부정맥혈전증예방에대해서는아직체계적인가이드라인이없으며, 슬관절보다원위부의하지골절환자를대상으로한연구 10) 에서는혈전예방을위한약제를사용한군과예방약제를사용하지않은군에서의심부정맥혈전의발생률의차이가없다고하였다. 정형외과의사들이혈전예방약제사용후발생하는부작용을고려하지않고과한용량과기간을권고하고있는 2012년제9차 ACCP 가이드라인에서도하지의단순골절에서는혈전예방약제의사용이권장사항은아니다. 1) 따라서슬개골골절과같은하지의단순골절의경우지혈대사용의제한이나시간감축또는조기보행및관절운동등의예방이우선시되어야할것으로보인다. 폐색전증이발생할경우심각한합병증이남거나사망으로까지이어질수있다는것을고려할때인공관절및다발성골절환자뿐만아니라정맥혈전색전증의위험요소가없는단순골절환자에서도폐색전증발생가능성에대한술전및술후환자교육과함께수상후가능한빨리수술을해야할것이며혹시수술이지연될경우보행을독려하고수술후에흉통이나객혈, 수술부위이외의하지통증등을유심히살펴보아야할것이다. 수술시지혈대의사용및사용시간을줄이고, 술후조기보행및관절운동등을통해정맥혈전색전증의발생을낮추려는노력이필요할것으로생각되며폐색전증이의심되는경우원인질환의감별과함께적극적인치료가필요할것으로생각한다. References 1) Guyatt GH, Akl EA, Crowther M, Schünemann HJ, Gutterman DD, Zelman Lewis S; American College of Chest Physicians: Introduction to the ninth edition: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence- Based Clinical Practice Guidelines. Chest, 141: 48S-52S, ) Franco RF, Reitsma PH: Genetic risk factors of venous thrombosis. Hum Genet, 109: , ) Abelseth G, Buckley RE, Pineo GE, Hull R, Rose MS: Incidence of deep-vein thrombosis in patients with fractures of the lower extremity distal to the hip. J Orthop

4 Pulmonary Embolism Complication after Surgical Treatment of Patella Fracture 165 Trauma, 10: , ) Geerts WH, Code KI, Jay RM, Chen E, Szalai JP: A prospective study of venous thromboembolism after major trauma. N Engl J Med, 331: , ) Hak DJ: Prevention of venous thromboembolism in trauma and long bone fractures. Curr Opin Pulm Med, 7: , ) Demers C, Marcoux S, Ginsberg JS, Laroche F, Cloutier R, Poulin J: Incidence of venographically proved deep vein thrombosis after knee arthroscopy. Arch Intern Med, 158: 47-50, ) Miyakis S, Lockshin MD, Atsumi T, et al: International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost, 4: , ) Kim YH, Yoo JH, Kim JS: Factors leading to decreased rates of deep vein thrombosis and pulmonary embolism after total knee arthroplasty. J Arthroplasty, 22: , ) Jang MJ, Bang SM, Oh D: Incidence of venous thromboembolism in Korea: from the Health Insurance Review and Assessment Service database. J Thromb Haemost, 9: 85-91, ) Goel DP, Buckley R, devries G, Abelseth G, Ni A, Gray R: Prophylaxis of deep-vein thrombosis in fractures below the knee: a prospective randomised controlled trial. J Bone Joint Surg Br, 91: , 2009.

5 ISSN (Print) ISSN (Online) 대한골절학회지제 27 권, 제 2 호, 2014 년 4 월 J Korean Fract Soc 2014;27(2): Case Report 슬개골골절수술후발생한폐색전증 - 증례보고 - 김용범 최형석 천동일 서정무 이병일 순천향대학교서울병원정형외과 심부정맥혈전증과폐색전증은정형외과수술후발생할수있는심각하고치명적인합병증이다. 슬관절수술이후에발생한증상이있는폐색전증은대부분인공관절치환술후발생한예들이보고되었고, 슬개골골절에서발생한예는드물다. 저자들은슬개골골절수술후증상이있는폐색전증이발생한 42세여자환자를경험하여보고하고자한다. 색인단어 : 골절, 슬개골, 폐색전증 접수일 수정일 게재확정 책임저자최형석서울시용산구대사관로 59, 순천향대학교서울병원정형외과 Tel , Fax , knee@schmc.ac.kr Copyright c 2014 The Korean Fracture Society. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 166

317 pissn : , eissn : Original Article J Korean Orthop Assoc 2019; 54:

317 pissn : , eissn : Original Article J Korean Orthop Assoc 2019; 54: 317 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2019; 54: 317-326 https://doi.org/10.4055/jkoa.2019.54.4.317 www.jkoa.org 정맥혈전색전증고위험군에서시행한혈전색전예방요법 (American College of Chest