07-06한창동

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1 대한고관절학회지제 20 권제 1 호 Vol. 20, No. 1, March, 2008 연세대학교의과대학정형외과학교실 목적 : 비만도가심한고관절골관절염환자에서인공고관절치환술시행직후합병증발생에미치는영향을알아보고자하였다. 대상및방법 : 1987년 4월부터 2007년 4월까지심한고관절골관절염으로인공고관절치환술을시행받은 272명의환자들을대상으로체질량지수가 25 kg/m 2 이상이었던 117명의환자를비만군, 체질량지수가 25 kg/m 2 미만이었던 155명의환자를대조군으로설정하고후향적인의무기록검토를시행하여두군에서재원일수, 수술시간, 실혈양및수혈양을조사하였고합병증의발생빈도를수술합병증및내과적합병증으로나누어비교하였다. 결과 : 재원기간, 수술시간, 실혈양및수혈양은모두비만군과대조군에서통계학적인차이를보이지않았다 (p>0.05). 합병증의발생빈도에있어서는수술합병증의발생빈도는두군에서유의한차이가없었으나 (p>0.05) 내과적합병증의발생빈도는비만군에서유의하게높게나타났다 (p<0.05). 결론 : 비만환자군에서심한고관절골관절염으로인공고관절치환술을시행한후재원기간, 수술시간, 실혈양과수혈양및수술합병증의발생빈도는대조군과비교하여차이가없었으나내과적합병증의발생빈도는높게나타났다. 색인단어 : 고관절, 골관절염, 비만, 체질량지수, 합병증, 인공고관절치환술 서 비만은당뇨병이나심장질환뿐만아니라퇴행성관절질환의발생과도밀접한관계가있고, 인공고관절치환술을시행받는환자들중많은수의환자들이비만과관련이있음이보고되고있다 2,9,11,21,23). 또한비만은수술시간의증가와이로인한술후감염및심부정맥혈전증등합병증의발생위험을높인다고생각되어왔고실제로이를뒷받침하는연구결과가발표되기도하여 13,15,17,20) 수술전비만환자들에게체중감량을권유하고있다. 반면, 한편에서는이와반대로비만도가인공고관절치환술시행후합병증의발생에큰영향을끼치지않는다고발표하기도하였다 1,8,12,18,19). 그러나지금까지국내에서인공고관절치환술과비만과의관계에대한보고는없고, 국내환자들의경우외국환자들과평균신장및평균체중등에서차 론 통신저자 : 한창동서울특별시서대문구신촌동 134 연세대학교의과대학정형외과학교실 TEL: FAX: cdhan@yuhs.ac 이가있기때문에외국의보고를우리나라의환자들에게동일하게적용하는데에는문제가있다. 실제로비만도를판정할때인체내의총지방량과밀접한관련이있다고알려져있는 3) 체질량지수 (body mass index, BMI) 를흔히사용하는데서구에서는세계보건기구 (world health organization, WHO) 에서제시한기준으로체질량지수 25~29.9 kg/m 2 를과체중, 30 kg/m 2 이상을비만으로정의하고있는반면 2,13,16), 우리나라를포함한일부아시아국가에서는체질량지수 23~24.9 kg/m 2 를위험체중, 25 kg/m 2 이상을비만으로정의하고있다 22). 그러므로서구에서발표된논문들의결과를우리나라환자들에게그대로적용하는것은합당하지않다고사료된다. 이에저자들은국내의고관절골관절염환자들을대상으로비만과인공고관절치환술후수술직후합병증발병과의상관관계를알아보기위하여본연구를시행하였다. 대상및방법 1987 년 4 월부터 2007 년 4 월까지고관절골관절염으로인공고관절치환술을시행받은환자들중심한발달성고관절이형성증 (dysplasia), 화농성고관절염, Legg- Calve-Perthes 병및고관절외상후후유증등 Kellgren 42

2 과 Lawrence 14) 의분류상 4 단계이상의이차성고관절염환자 272 명을대상으로하여체질량지수가 25 kg/m 2 이상이었던 117 명의환자를비만군, 체질량지수가 25 kg/m2 미만이었던 155 명의환자를대조군으로설정하여재원기간중임상적결과및합병증발생빈도를비교하였다. 모든환자들에게한명의수술의에의해단측무시멘트형인공고관절치환술이시행되었다. 비만환자군의평균체질량지수는 27.5±2.5 kg/m 2 ( 범위, 25.11~33.15 kg/m 2 ) 이었고대조군환자들의평균체질량지수는 22.1 ±2.0 kg/m 2 ( 범위, ~ kg/m 2 ) 이었다. 비만군및대조군환자들의평균나이및성별구성및수술전 Harris hip score 는모두통계학적인차이를보이지않았다 (p>0.05)(table 1). 두군모두고관절이형성증의후유증에의한 2 차성고관절염이가장흔하였고 ( 비만군 47%, 대조군 51%), 화농성고관절염, Legg-Calve-Perthes 병및외상후관절염의빈도는두군에서모두차이를보이지않았다. 각환자군에서술전의당뇨병의이환정도는비만군에서 9%, 대조군에서 5% 였으나유의한차이를나타내지는않았으나 (p>0.05) 고혈압의경우비만군에서 41%, 대조군에서 23% 로비만군에서의미있게높은빈도의이환율을나타내었다 (p=0.002)(table 1). 모든환자들에있어재원기간, 수술시간, 출혈양및수혈양을후향적인의무기록검토를통해조사하였고역시의무기록검토를통하여수술후재원기간중의합병증발생여부를탈구, 신경마비및상처감염등수술과관련된합병증과쇽, 심부정맥혈전증, 심근경색및뇌경색등내과적합병증으로구분하여조사하여비교하였다. 통계학적분석은 t- 검정, 카이제곱 (qui square) 검정및로지스틱회귀분석을사용하여시행하였고 p-value 가 0.05 미만인경우를통계학적으로유의한차이가있는것으로해석하였다. 결 재원기간은비만군에서평균 8.6±4.1 일, 대조군에서 8.5±3.6 일로유의한차이를보이지않았고, 수술시간역시비만군에서 96.5±24.7 분, 대조군에서 95.7±30.5 분으로유의한차이가없었다 (Table 2). 출혈양과수혈양에있 과 Table 1. Patient Demographics and medical comorbidities for non-obese and obese patients Non-obese Group Obese Group P value BMI* (kg/m 2 ) 22.1± ±2.5 <0.001 Age (years) 56±12 057±11 <0.590 % Women (n) 62% (96) 71% (83) <0.120 Preop. HHS 59.7± ±14.1 <0.510 Comorbidities Diabetes 08 (05%) 10 (09%) <0.270 Hypertension 36 (23%) 48 (41%) <0.002 *: Body mass index, : Pre-operative, : Harris hip score Table 2. Outcomes for non-obese and obese patients Non-obese Group Obese Group P value Hospital length of stay (day) 8.5± ± Operation time (min) 95.7± ± Total blood loss (cc) 1409± ± Total blood replacement (cc) 705± ± Surgical complications 2 (1.3%) 3 (2.6%) 0.44 Nerve palsy Acute dislocation Acute wound infection Medical complications 1 (0.6%) 5 (4.3%) 0.04 Shock Deep vein thrombosis 0 1 Myocardial infarction Brain infarction

3 어서도비만군에서는각각 1421±1044 cc, 641±475 cc 였고대조군에서는각각 1409±612 cc, 705±468 cc 로모두통계학적으로유의한차이를나타내지않았다 (Table 2). 수술후재원기간내의합병증발생은수술관련합병증의경우비만군에서총 3 예 (2.6%), 대조군에서총 2 예 (1.3%) 발생하였으나두군간의발생율의차이를보이지는않았다 (Table 2). 각각세분하여살펴보면수술후대퇴신경이나좌골신경마비가발생한경우가비만군에서 2 예, 대조군에서 1 예있었고수술직후고관절의탈구가발생한경우는대조군에서만 1 예있었던반면수술후급성상처감염이생긴경우는비만군에서만 1 예있었다 (Table 2). 내과적합병증이발생한경우는전체적으로비만군에서 5 예 (4.3%), 대조군에서 1 예 (0.6%) 발생하여비만군에서유의하게높은발생율을나타내었고 (Table 2), 특히심부정맥혈전증, 심근경색및뇌경색등혈전관련합병증의경우비만군에서 5 예발생한반면대조군에서는한예에서도발생하지않았다 (Table 2). 연령, 성별, 고혈압및당뇨병의유무를보정한다항로지스틱회기분석결과에서도체질량지수가높을수록내과적합병증의발생확률이높아지는결과를나타내었다 (p<0.05). 고 비만이심장질환, 악성종양의발생률및사망률을높인다는사실은이미증명되었으며 10), 마취와관련되어호흡기관련합병증의발생위험이비만환자군에서높은것으로보고되고있다 4,6). 이러한이유로비만도가높을수록인공고관절치환술후합병증의발생위험이높아질것이라고생각되지만실제로이에관해서시행된연구는그수가그리많지않을뿐아니라이러한연구들마다서로상반된결과를보고하고있다 1,8,12,13,15,17-20). 또한서구에서의비만도의기준과동아시아지역에서의비만도의기준이서로다르고실제로국내환자들중체질량지수가 30 kg/m 2 이상인환자들은상대적으로드물어서본연구대상인 272명의환자들중체질량지수가 30 kg/m 2 이상인환자는 13명 (4.8%) 에불과하였으며이환자들에서의수술결과가체질량지수 25 kg/m 2 이상인환자들과크게다르지않았다. 그러므로국내환자들을대상으로한비만과인공고관절치환술후합병증발생의상관관계에대한연구가실제인공고관절치환술을계획함에있어수술전계획수립에도움이될수있을것으로사료된다. 본연구는 Kellgren과 Lawrence의분류상 4단계이상의변형이심한이차성고관절골관절염환자들을대상으로연구를진행하였는데이는정도가경한고관절골관절 찰 염환자들을연구에포함시킬경우두군간의환자구성이차이가남으로써이러한요인이결과에영향을끼쳐비만도외의다른요인, 즉골관절염의정도의차이에의해수술시간, 출혈량및재원기간등의결과에영향을미치는것을방지하기위해서였다. 결과에서비만군과대조군에서재원일수, 수술시간및출혈과수혈양에있어서통계학적으로유의한차이를나타내지않았는데 Soballe 등 18) 은적정체중의 20% 이상을초과하는비만군에서재원일수및수술시간은대조군과차이가없었으나출혈양은비만군에서더많았다고발표한바있으며, Jiganti 등 8) 은역시적정체중의 20% 이상을초과하는비만군과그대조군간의연구에서출혈양은두군에서유의한차이가없으나수술시간에서는비만군에서대조군에비하여유의하게길게나타났다고보고한바있다. 탈구, 신경마비및상처감염등수술과관련된합병증의경우본연구에서는두군간의유의한차이를나타내지않았는데 Nanba 등 13) 의연구에서도인공고관절치환술후체질량지수 35 kg/m 2 이상인비만군과그이하인대조군과의비교에서감염이나탈구등의합병증의발생빈도가두군에서차이가나지않았다고발표한바있다. 비만과인공고관절치환술후심부정맥혈전증발생과의연관관계에대한연구에서비만환자들의경우심부정맥혈전증의발생이더많다고하였지만 7,18), 그와반대되는보고나 5,17) 연관성이없다는보고가있다 1,8,13). 본연구에서는심부정맥혈전증, 심근경색및뇌경색등의혈전발생과관련된합병증이대조군에비해비만군에서더높은발생율을보였다. 그러므로비만환자들의인공고관절치환술을고려시에이러한점을염두에두고수술전후항혈전예방치료에더주의를기울여야할것으로사료된다. 결 본연구에서비만환자군 ( 체질량지수 25 kg/m 2 ) 에서심한고관절골관절염으로인공고관절치환술을시행한후재원기간, 수술시간과실혈양및수혈양은대조군 ( 체질량지수 <25 kg/m 2 ) 과비교하여차이가없었고, 수술합병증의발생빈도역시대조군에비하여차이가없었으나내과적합병증의경우비만군에서높은빈도의발생율을나타내었다. 론 REFERENCES 01) Anderson L, Kammerer WS, Greer RB: Risk factor assessment in 101 total hip arthroplasties: a medical perspective. Clin Orthop, 141: 50-54, ) Bostman OM: Prevalence of obesity among patients 44

4 admitted for elective orthopedic surgery. Int J Obes Relat Metab Disord, 18(10): , ) Bray GA: Overweight is risking fate. Definition, classification, prevalence, and risks. Ann NY Acad Sci, 31: 14-28, ) Damia G, Mascheroni D, Croci M, Tarenzi L: Perioperative changes in functional residual capacity in morbidly obese patients. Br J Anaesth, 60(5): , ) Davis FM, Laurenson VG, Gillespie WJ, Wells JE, Foate J, Newman E: Deep vein thrombosis after total hip replacement. A comparison between spinal and general anaesthesia. J Bone Joint Surg Br, 71(2): , ) Fox GS, Whalley DG, Bevan DR: Anaesthesia for the morbidly obese. Experience with 110 patients. Br J Anaesth, 53(8): , ) Jense HG, Dubin SA, Silverstein PI, O Leary-Escolas U: Effect of obesity on safe duration of apnea in anesthetized humans. Anesth Analg, 72(1): 89-93, ) Jiganti JJ, Goldstein WM, Williams CS: A comparison of perioperative morbidity in total joint arthroplasty in the obese and nonobese patient. Clin Orthop, 289: , ) Karlson EW, Mandl LA, Aweh GN: Total hip replacement due to osteoarthritis: the importance of age, obesity, and other modifiable risk factors. Am J Med, 114: 93-98, ) Kral JG, Heymsfield S: Morbid obesity: Definitions, epidemiology, and methodological problems. Gastroenterol Clin North Am, 16(2): , ) Marks R, Allegrante JP: Body mass indices in patients with disabling hip osteoarthritis. Arthritis Res, 4: , ) McLaughlin JR, Lee KR: The outcome of total hip replacement in obese and non-obese patients at 10- to 18- years. J Bone Joint Surg Br, 88-B: , ) Namba RS, Paxton L, Fithian DC, Stone ML: Obesity and perioperative morbidity in total hip and total knee arthroplasty patients. J Arthroplasty, 20(7 suppl 3): 46-50, ) Lawrence JS: Rheumatism in populations-osteoarthritis. London, William Heinemann Medical Books Ltd.: , ) Sadr Azodi O, Bellocco R, Eriksson K, Adami J: The impact of tobacco use and body mass index on the length of stay in hospital and the risk of post-operative complications among patients undergoing total hip replacement. J Bone Joint Surg Br. 88(10): , ) Sikorski JM, Hampson WG, Staddon GE: The natural history and aetiology of deep vein thrombosis after total hip replacement. J Bone Joint Surg Br, 63-B(2): , ) Smith DM, Oliver CH, Ryder CT, Stinchfield FE: Complications of Austin Moore arthroplasty. Their incidence and relationship to potential predisposing factors. J Bone Joint Surg Am, 57(1): 31-33, ) Soballe K, Christensen G, Luxhoj T: Hip replacement in obese patients. Acta Orthop Scand, 58: , ) Stickles B, Phillips L, Brox WT, Owens B, Lanzer WL: Defining the relationship between obesity and total joint arthroplasty. Obes Res, 9(3): , ) Strauss RJ, Wise L: Operative risks of obesity. Surg Gynecol Obstet, 146(2): , ) Sturmer T, Gunther KP, Brenner H: Obesity, overweight and patterns of osteoarthritis: the Ulm osteoarthritis study. J Clin Epidemiol, 53: , ) Tseng CH: Body mass index and blood pressure in adult type 2 diabetic patients in Taiwan. Circ J, 71(11): , ) Wendelboe AM, Hegmann KT, Biggs JJ, et al.: Relationships between body mass indices and surgical replacements of knees and hip joints. Am J Prev Med, 25: ,

5 ABSTRACT Obesity and Perioperative Morbidity after Total Hip Arthroplasty in Osteoarthritis Patients Chang-Dong Han, M.D., Chang-Wook Han, M.D., Ik-Hwan Yang, M.D. Department of Orthopedic Surgery, Yonsei University, College of Medicine, Seoul, Korea Purpose: To evaluate the effect of obesity on perioperative morbidity following total hip arthroplasty in patients with severe osteoarthritis. Materials and Methods: Between April 1987 and April 2007, 272 patients with severe osteoarthritis underwent total hip arthroplasty. One hundred seventeen patients were obese (body mass index, BMI 25 kg/m 2 ), and 155 were not obese (BMI<25 kg/m 2 ). Through retrospective medical record research we were able to determine length of hospital stay, operation time, total blood loss and replacement, and surgical and medical complication rates for the two groups. Results: The obese and non-obese groups were similar in terms of length of hospital stay, operation time, total blood loss and replacement, and surgical complication rate (p>0.05). However, the medical complication rate was significantly higher in the obese group compared to the non-obese group (4.3% vs. 0.6%, p<0.005). Conclusion: In severe osteoarthritis patients undergoing total hip arthroplasty, obesity (BMI 25 kg/m 2 ) has no observable effect on perioperative morbidity in terms of length of hospital stay, operation time, total blood loss and replacement, or surgical complication rate, but is associated with a higher medical complication rate. Key Words: Hip joint, Osteoarthritis, Obesity, Body mass index, Complication, Total hip arthroplasty 46

황지웅

황지웅 Comparison of Laparoscopy and Exploration in the Distal Pancreatectomy BACKGROUND: To determine the benefits of laparoscopic surgery compared with exploration, the clinical outcomes of open and laparoscopic