172 pissn : , eissn : Case Report J Korean Orthop Assoc 2019; 54: 슬

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1 172 pissn : , eissn : Case Report J Korean Orthop ssoc 2019; 54: 슬관절후방십자인대에발생한동통성석회침착 정환용 박상준 성승용 가톨릭관동대학교의과대학정형외과학교실 Symptomatic Calcific Deposition in Posterior Cruciate Ligament of the Knee Whan-Yong Chung, M.D., Sang Jun Park, M.D., and Seung-Yong Sung, M.D. Departments of Orthopedic Surgery, College of Medicine, Catholic Kwandong University, Incheon, Korea Calcium deposition disease, including calcific tendinitis, rarely affects the knee joint. Only a few cases can be found in the literatures and there is no case report of symptomatic calcific deposition arising from the posterior cruciate ligament in Korea. The authors encountered a case of symptomatic calcific deposition arising from the posterior cruciate ligament, which was excised arthroscopically and confirmed pathologically. This paper reports this case with a review of the relevant literature. Key words: calcinosis, posterior cruciate ligament 석회화건염을포함한석회침착성질환은특징적으로인산칼슘 세라믹결정체가관절주위근육혹은인대의부착부위에침착되 어발생하는질환으로주로견관절의회전근개에서호발하는것 으로알려져있다. 1,2) 그러나이는슬관절내에는드물게발생하는 병변으로이를보고하는문헌도제한되어있으며, 특히후방십자 인대에발생한동통성석회침착의국내보고는없었다. 저자들은 슬관절후방십자인대에발생한동통성석회침착 1 예를관절경하 에서절제후병리학적으로확진하였으며임상적으로좋은결과 를보였기에문헌고찰과함께보고하고자한다. 증례보고 53 세여자환자가 1 년전부터좌측슬관절부의묵직함을느꼈으 나별다른처치및치료를하지않고지내왔다고하며내원 1 개월 Received November 10, 2017 Revised February 20, 2018 ccepted March 19, 2018 Correspondence to: Seung-Yong Sung, M.D. Department of Orthopedic Surgery, Catholic Kwandong University Intrnational St. Marys Hospital, 25 Simgok-ro 100beon-gil, Seo-gu, Incheon 22711, Korea TEL: FX: sysung@ish.ac.kr ORCID: 전부터특이외상력없이갑자기발생된좌측슬관절부의찌르는듯한동통및간헐적잠김증상을주소로내원하였다. 환자는전업주부로외상의과거력이없었고슬관절의반복적부하나미세손상을의심할만한사항도없었다. 과거력상당뇨, 갑상선및부갑상선질환등의기저질환은없었으며, 가족력상특이사항은없었다. 신체검사상슬관절부의경미한부종과전방부위의압통이있었으며, 슬관절신전시동통을호소하였으나슬관절의불안정성은관찰되지않았다. 혈액검사상염증반응검사및류마토이드인자는정상소견이었다. 단순방사선검사상슬관절전방부의약 1 1 cm 크기의석회성병변이관찰되었고, 병변주변의골침식소견이나골파괴소견은관찰되지않았으며, 관절간격도정상이었다 (Fig. 1). 자기공명영상의시상면 T2 강조영상에서저등도신호강도의약 cm 의일부활액막에둘러싸인연부조직종물이후방십자인대의대퇴골부착부위전방에관찰되었다 (Fig. 2). 관절경하에서후방십자인대의활액막에둘러싸인타원형종물이관찰되었으며종물제거시석회화건염의특징적인흰색혹은크림색의치약같은물질을볼수있었다. 물질은후방십자인대전연과연결되어있었고이를관절경하에서제거하였다 (Fig. 3). 수술직후추시방사선검사상석회성병변의완전소실을확인하였다 (Fig. 4). 조직검사결과비특이적염증 The Journal of the Korean Orthopaedic ssociation Volume 54 Number Copyright 2019 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.

173 Symptomatic Calcific Deposition in Posterior Cruciate Ligament

Plain anteroposterior () and lateral () radiographs of the left knee

round mass with well circumscribed intermediate signal intensity was

() low signal intensity mass was noted in the posterior aspect of

() On the anterolateral portal view, there were calcific deposits

2 173 Symptomatic Calcific Deposition in Posterior Cruciate Ligament of the Knee Figure 1. Plain anteroposterior () and lateral () radiographs of the left knee demonstrating a calcific lesion just below intercondylar notch (arrows). Figure 2. () Sagittal magnetic resonance imaging, T2-weighted of the left knee. round mass with well circumscribed intermediate signal intensity was observed just inferior to the posterior cruciate ligament (PCL). () low signal intensity mass was noted in the posterior aspect of the PCL in T1-weighted image. Figure 3. () On the anterolateral portal view, there were calcific deposits with a tooth-paste consistency arising from the posterior cruciate ligament. () fter excising the mass from the anteromedial portal with the shaver, it was removed completely by an arthroscopic technique.

174 Whan-Yong Chung, et al. Figure 4. Postoperative plain anteroposterior radiograph of the left knee demonstrating that a calcific lesion has disappeared. 반응및석회침착물소견을관찰할수있었다 (Fig. 5).

발생원인은명확하게규명 되지않았으나만성외상, 염증, 혈액공급의장애나고령에의한 퇴행성변화, 석회가흡수되고재생되는과정에서발생하는섬유 연골화생 (fibrocartilage metaplasia), 갑상선호르몬및부갑상선호 르몬이상및골대사이상등다양한가설이제기되고있고, 최근 에는 HL-1 과의연관성도거론되면서유전적인요소또한관 여할것으로추정하고있다.

3 174 Whan-Yong Chung, et al. Figure 4. Postoperative plain anteroposterior radiograph of the left knee demonstrating that a calcific lesion has disappeared. 반응및석회침착물소견을관찰할수있었다 (Fig. 5). 관절경하 석회화건염의제거후증상의소실과함께 12 개월간의추시관 찰동안임상증상의재발없이정상적인소견을보였다. 고찰 건, 근육, 및관절주변의석회침착은수산화인회석저장질환 (hydroxyapatite deposition disease) 의일종으로서관절주위건조직 등에칼슘수산화인회석결정이침착되어이로인한극심한동통 및관절운동장애를일으킬수있다. 발생원인은명확하게규명 되지않았으나만성외상, 염증, 혈액공급의장애나고령에의한 퇴행성변화, 석회가흡수되고재생되는과정에서발생하는섬유 연골화생 (fibrocartilage metaplasia), 갑상선호르몬및부갑상선호 르몬이상및골대사이상등다양한가설이제기되고있고, 최근 에는 HL-1 과의연관성도거론되면서유전적인요소또한관 여할것으로추정하고있다. 1,2) 발생위치상주로견관절에발생하 며극상건을침범하는경우가가장흔하며, 다음으로는고관절, 주관절, 수근관절, 슬관절순으로발생한다. 3,4) 슬관절내에서의 석회침착은대퇴사두건, 외측측부인대, 내측측부인대, 슬와건에 서발생한증례가보고된적은있으나후방십자인대내에서발생 한증례는보고된적이없다. 슬관절주변에서발생한석회침착은발생한부위의국소적인 동통및압통을특징으로하지만발생한인대위치에따라다른 질환과의감별이필요하다. Holt 와 Keats 3) 는대퇴사두건, 슬개건, 대퇴이두건에서발생한석회화건염의임상증상이슬관절에발 생한통풍또는화농성관절염과비슷하다고하였으며, 특히대 퇴이두건에서발생할경우좌골신경의외측으로주행하는대퇴 Figure 5. In H&E staining ( 200), laminated or amorphous calcific deposition can be seen between the degenerated tendon fibers. 이두건의특성상좌골신경통과비슷한임상양상을가질수있으 므로주의를요한다고하였다. 슬와건에서발생한석회화건염은 슬관절후외측부의급성동통및경련을동반하면서잠김현상을 일으켜외측반월연골판손상과감별이필요하다. 5,6) Chan 등 7) 은 대퇴이두건의비골부착부에서발생한석회화건염을보고하면 서슬관절외측구획관절염또는골연골손상, 외측측부인대손 상과비슷한임상양상을가지므로자기공명영상검사를통해감 별진단이필요하다고하였다. Song 등 8) 은내측측부인대에서발 생한석회화건염을관절경적절제술을통해치료결과를보고하 면서 Pellegrini-Stieda 질환과감별진단이필요하다고하였다. 본증례에서와같이외상력없이발생한슬관절통증을호소하 는환자에서시행한방사선검사상슬관절내석회성병변이관 찰되면먼저유리체를고려해볼수있다. 관절내에유리체가고 정된위치에있는경우에는특별한증상이없을수도있으나가 동성이있는경우간헐적으로관절운동의기계적인방해를일 으켜통증, 잠김현상, 운동제한, 관절손상등을일으킬수있다. Molloy 와 McCarthy 9) 는석회의관절강내유출이급성통증의원 인이될수있다고하였고, 본환자에서의비특이적통증은석회 물질의관절강내노출에따른염증반응의결과가아닐까추측된 다. 석회화건염의치료방법은다양하다. 급성통증기에는약물 치료, 물리치료, 흡인및주사요법, 체외충격파요법등비수술적 방법을우선적으로사용하지만이러한치료에증상이호전되지 않거나악화되는경우, 반복되는통증으로일상생활에지장을초 래하는경우에는수술적방법을고려할수있다. 이러한치료의 결과에대해다양한이견이보고되고있는데, 일부저자들은보 존적요법만으로증세를완화시키거나완전히소실시킬수있다 고보고하였으나일부에서는수술적치료를통해석회침착을제 거함으로써조기에우수한결과를얻을수있다고보고하기도하

4 175 Symptomatic Calcific Deposition in Posterior Cruciate Ligament of the Knee 였다. 최근에는짧은재활기간및기능회복기간을이유로석회화건염의진단및치료에관절경적수술을이용하는빈도가증가하고있는추세이다. 10) 특히슬관절내에발생하는경우에는병변위치로의주사침도달이용이하지않으며, 체외충격파요법또한병변까지도달이쉽지않아치료방법선택에제한이있다. 본환자의경우에약물치료및관절강내스테로이드주입치료를시행하였으나반응이없었고일상으로의조기복귀를원하여수술적치료를결정하였다. 슬관절후방십자인대에서발생한석회화건염은슬관절내통증을유발하는질환들과임상양상이유사할수있어정확한진단을위해서는외상력등의세심한병력청취, 단순방사선검사, 자기공명영상, 조직검사등이필요하다. 관절경적수술은다른질환과의감별진단을위해유용할수있으며, 통증의이환기간을줄이고, 빠른시간내에정상생활로의복귀가가능하므로우선적으로고려할수있다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Chan R, Kim DH, Millett PJ, Weissman N. Calcifying tendinitis of the rotator cuff with cortical bone erosion. Skeletal Radiol. 2004;33: Uhthoff HK, Loehr JW. Calcific tendinopathy of the rotator cuff: pathogenesis, diagnosis, and management. J m cad Orthop Surg. 1997;5: Holt PD, Keats TE. Calcific tendinitis: a review of the usual and unusual. Skeletal Radiol. 1993;22: McKendry RJ, Uhthoff HK, Sarkar K, Hyslop PS. Calcifying tendinitis of the shoulder: prognostic value of clinical, histologic, and radiologic features in 57 surgically treated cases. J Rheumatol. 1982;9: Shenoy PM, Kim DH, Wang KH, et al. Calcific tendinitis of popliteus tendon: arthroscopic excision and biopsy. Orthopedics. 2009;32: Tibrewal S. cute calcific tendinitis of the popliteus tendon: an unusual site and clinical syndrome. nn R Coll Surg Engl. 2002;84: Chan W, Chase HE, Cahir JG, Walton NP. Calcific tendinitis of biceps femoris: an unusual site and cause for lateral knee pain. MJ Case Rep. 2016;2016. pii: bcr Song K, Dong J, Zhang Y, et al. rthroscopic management of calcific tendonitis of the medial collateral ligament. Knee. 2013;20: Molloy ES, McCarthy GM. Hydroxyapatite deposition disease of the joint. Curr Rheumatol Rep. 2003;5: Kim MK, ae JH, Jeon YS. Conservative and early arthroscopic treatment of calcific tendinitis. J Korean rthroscop Soc. 2009;13:

5 176 pissn : , eissn : Case Report J Korean Orthop ssoc 2019; 54: 슬관절후방십자인대에발생한동통성석회침착 정환용 박상준 성승용 가톨릭관동대학교의과대학정형외과학교실 석회화건염을포함한석회침착성질환은슬관절내에는드물게발생하는병변으로이를보고하는문헌도제한되어있으며특히후 방십자인대에발생한동통성석회침착의국내보고는없었다. 저자들은슬관절후방십자인대에발생한동통성석회침착을관절경하 에서절제후병리학적으로확진하였으며임상적으로좋은결과를보였기에문헌고찰과함께보고하고자한다. 색인단어 : 석회침착증, 후방십자인대 접수일 2017 년 11 월 10 일수정일 2018 년 2 월 20 일게재확정일 2018 년 3 월 19 일책임저자성승용 22711, 인천시서구심곡로 100 번길 25, 가톨릭관동대학교국제성모병원정형외과 TEL , FX , sysung@ish.ac.kr, ORCID 대한정형외과학회지 : 제 54 권제 2 호 2019 Copyright 2019 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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