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1 ISSN (Print) ISSN (Online) 대한골절학회지제 28 권, 제 1 호, 2015 년 1 월 J Korean Fract Soc 2015;28(1): Original Article 대퇴전자간골절의금속정을이용한내고정술후실혈량 : 위험인자분석 박재형 정화재 신헌규 김유진 박세진 고택수 박종현 성균관대학교의과대학강북삼성병원정형외과학교실 Perioperative Blood Loss in Intramedullary Hip Screw for Intertrochanteric Fracture: Analysis of Risk Factors Jai Hyung Park, M.D., Ph.D., Hwa Jae Jung, M.D., Ph.D., Hun Kyu Shin, M.D., Ph.D., Eugene Kim, M.D., Ph.D., Se-Jin Park, M.D., Ph.D., Taeg Su Ko, M.D., Jong-Hyon Park, M.D. Department of Orthopaedic Surgery, Kangbuk Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Purpose: We compared visible blood loss and calculated blood loss after intramedullary fixation in intertrochanteric fracture, and evaluated correlation between blood loss and its risk factors. Materials and Methods: A total of 256 patients who underwent closed reduction and intramedullary fixation in femoral intertrochanteric fracture between 2004 and 2013 were enrolled in this study. The total blood loss was calculated using the formula reported by Mercuiali and Brecher. We analyzed several factors, including fracture pattern (according to Evans classification), gender, age, body mass index (BMI), anesthesia method, cardiovascular and cerebrovascular disease, preoperative anemia, American Society of Anesthesiologists (ASA) score and use of antithrombotic agents. Results: Total calculated blood loss (2,100±1,632 ml) differed significantly from visible blood loss (564±319 ml). In addition, the blood loss of unstable fracture patient was 2,496±1,395 ml and multivariate analysis showed a significant relationship between blood loss and fracture pattern (p<0.01). However, other factors showed no statistically significant difference. Conclusion: Total calculated blood loss was much greater than visible blood loss. Patients with unstable intertrochanteric fracture should be treated with care in order to reduce blood loss. Key Words: Femur, Intertrochanteric fractures, Intramedullary nailing, Surgical blood loss, Risk factors 서 론 Received October 26, 2014 Revised November 26, 2014 Accepted December 24, 2014 Address reprint requests to: Jai Hyung Park, M.D., Ph.D. Department of Orthopaedic Surgery, Kangbuk Samsung Medical Center, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul , Korea Tel: ㆍFax: jaihyung.park@samsung.com Financial support: None. Conflict of interest: None. 고관절의대퇴전자간골절에대해근위골수정을이용하여고정술을시행한경우수술중에는출혈이심하지않으나수술후경과관찰시혈색소 (hemoglobin, Hb) 감소로인해수혈을하는경우가흔하다. 이는대퇴경부골절시시행하는양극성반인공관절치환술이나전치환술에비해비교적짧은시간에끝나며절개부위가적은수술임에도불구하고실혈이종종발생한다. 인공관절수술후 Copyright c 2015 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. 53

2 54 Jai Hyung Park, et al. 에는실혈량 (visible blood loss) 이많으므로이에대해서는이전에많은연구가이루어졌으나 1,2) 상대적으로출혈량이적은대퇴전자간골절수술의경우의실혈량에대한연구는부족하다. 수혈을시행할경우여러가지합병증을가져올수있기때문에가장효과적인방법은수술전, 후로실혈이예상되는환자를사전에예측하여대비하는것이다. 3-5) 술후수혈이필요한경우를예측하기위해많은연구가시행되었지만대부분 Hb 수치를이용한연구이거나 6) 실혈에영향을주는위험인자에대해명확한결과를나타내지못했다. 7,8) 이에대해본연구는대퇴전자간골절에서시행한금속정을이용한내고정술시계산된총실혈량을이용하여측정된실혈량과의차이와실혈량을증가시키는위험인자에대해알아보고자하였다. 대상및방법 2004 년부터 2013 년까지본원에서시행한대퇴전자간골절후비관혈적정복술및근위골수정을이용한내고정술을시행한환자중암과관련된병적골절환자와정보가불명확한환자를제외한 256 예를대상으로하였다. 남자환자가 86 예, 여자환자가 170 예였으며평균연령은 75.12±12.2 세였다. 환자의평균체질량지수 (body mass index, BMI) 는 21.96±3.53 kg/m 2 였으며골절분류는 Evans 분류를기본으로안정골절과불안정골절로구분하였으며안정골절이 165 예, 불안정골절이 91 예였다. 측정된실혈량은수술시발생된실혈량과수술후흡입배액량으로측정하였다. 수술시발생된실혈량은흡입기에채워진양에서세척량을제외한양과혈액이충분히적셔진 4 4 cm 크기의거즈를 10 ml 또는개복술용패드를 ml 의실혈로간주하고그양을합한값으로, 마취과의사의기록을근거로측정하였다. 계산된총실혈량 (total calculated blood loss) 은 Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study group 에의해제안된 Mercuriali 와 Brecher 에의한공식을사용하였으며 9) 다음과같은계산을통하여얻었다. Total red blood cell (RBC) loss (ml)=uncompensated RBC loss (ml)+compensated RBC loss (ml) Uncompensated RBC loss (ml)=initial RBC (ml) final RBC (ml) Compensated RBC loss=sum of RBCs received from the various sources of transfusion Initial RBC=estimated blood volume (ml) initial hematocrit level (%) at day 1 Final RBC (ml)=estimated bloodvolume (ml) final hematocrit level (%) at day+3 측정된혈액량 (estimated blood volume) (ml) 은남자와여자를구분하여다음과같은방법을사용하였다. Women: body surface area (m 2 ) 2,430 Men: body surface area (m 2 ) 2,530 체표면적 (body surface area) 은다음과같은방법을사용하였다 height (cm) weight (kg) 마지막으로 total blood loss (TBL) (ml) 은다음과같은방법을사용하였다. TBL (ml)=total RBC loss (ml)/0.35 실혈량을증가시킬수있는위험인자로성별, 나이, BMI, 마취방법, 심혈관질환이나뇌혈관질환유무, 술전빈혈여부, American Society of Anesthesiologists (ASA) 점수, 골절의안정성여부, aspirin 등의항혈전제사용여부를비교분석하였다. 각환자의 PASW Statistics for Windows version 18.0 (IBM Co., Armonk, NY, USA) 를이용하여통계처리하였고, 각인자는 mean±standard deviation 으로표시하였으며이에대한 TBL 의평균차이검정은 Student t-test 를이용하여분석하였다. 또한각인자가 TBL 에미치는영향을살펴보기위해 multivariate linear regression analysis 를사용하였다. 각결과는유의수준이 0.05 보다작을경우통계적으로유의하다고판정하였다. 결 Mercuriali 와 Brecher 에의한공식에의한계산된총실혈량은 2,100±1,632 ml, 측정된실혈량은 564±319 ml 로계산된총실혈량이측정된실혈량과큰차이를보였다 (p<0.001). 실혈량을증가시킬수있는위험인자중성별은남자 86 예, 여자 170 예로총실혈량에서통계적으로성별간유의한차이가없었고나이는 65 세이상의환자에서도유의한차이를보이지않았다. 수술전빈혈은 Hb 수치 8.0 이하를기준으로총 22 예로총실혈량에서는빈혈이아닌경우에비해유의한차이를보이지않았으며 ASA score 가 3 이상인경우는 74 예로 2 이하인경우와비교하여차이를보이지않았다. 전신마취는 35 예로척추마취에비교하여통계적으로유의한차이를보이지않았으며, 심혈관질환을가지고있는경우는 145 예로심혈관질환이없는경우에비해통계적으로유의한차이를보이지않았다. 뇌혈관질환을가지고있는경우는 45 예로통계적으로유의한차이를보이지않았으며, 수술전 aspirin 을포함한항혈전제를사용한경우는 49 명으로사용하지않는경우에비해통계적으로유의한차이를보이지않았으며, BMI 가 30 이상 과

3 Perioperative Blood Loss in Intramedullary Hip Screw for Intertrochanteric Fracture 55 인비만의경우는 6 예로정상군에비해통계적으로유의한차이를보이지않았다. 반면불안정성골절의경우는 91 예로총실혈량이 2,496±1,395 ml 로 1,882±1,715 ml 인안정성골절에비해통계적으로유의한차이를보였다 (p<0.05) (Table 1-3). 결론적으로불안정성골절의경우에총실혈량이증가하였다. Table 1. Characteristics of Studied Patients Clinical factor 고 대퇴전자간골절환자의경우대개고령이므로빈혈및순환혈액량감소등에더취약할수있어실혈량을미리예상하고그에대한적절한대처를시행하는것이환자에게발생할수있는수술후합병증을최소화할수있다. 또한수술후시행한혈액검사에서수혈적응증의경계치 찰 Value 에해당한다고하여도환자의추가실혈량을예상하여불필요한수혈을막는데도움을줄수있을것이다. 5) 인공관절치환술의경우이전많은연구들에서다양한원인들에의해실혈이증가될수있다고보고된바있다. 4,8,10-13) 본연구에서는척추마취 14,15) 나비만, 16,17) 항혈전제사용 18) 등이전에규명되었던출혈을증가시킬수있는요인들이통계적으로유의한차이를보이지않았다. 이는전자간골절의경우수술시의출혈보다는골절에의한골출혈및고관절주위혈관손상에의한출혈의대부분을차지하기때문이라고생각된다. 계산된총실혈량과측정된실혈량의차이가큰것도이를뒷받침한다고볼수있다. 이는측정된실혈외에다른잠재된실혈이있는것을 Table 2. Predictor of Total Blood Loss in Patients Who Underwent Intramedullary Fixation for Intertrochanteric Fracture in Student T-test Clinical factor Mean volume (ml) p-value Stable : Unstable fracture Male : Female Age ( 65 yr) GA : SA Cardiovascular disease Neurovascular disease Preoperative anemia (Hb<8.0) Use of antithrombotic agents ASA score 3 BMI : 91 (64.5 : 35.5) 86 : 170 (33.6 : 66.4) 220 (86.0) 35 : 221 (13.7 : 86.3) 145 (58.0) 45 (17.6) 22 (8.6) 49 (19.1) 74 (28.9) 6 (2.3) Stable : unstable fracture Sex (male : female) Age ( 65 yr) GA : SA Cardiovascular disease Neurovascular disease Preoperative anemia (Hb < 8.0) Use of antithrombotic agents ASA score>3 BMI>30 1,882±1,715/2,496±1,395 1,939±1,528/2,182±1,681 2,119±1,667/1,983±1,414 2,488±2056/2,039±1,551 2,102±1,707/2,097±1,528 1,891±1,192/2,145±1,710 2,124±1,618/1,849±1,802 2,108±1,734/2,068±1,120 2,418±2,122/1,971±1,371 2,630±525/2,087±1, Values are presented as number (%). GA: General anesthesia, SA: Spinal anesthesia, Hb: Hemoglobin, ASA: American Society of Anesthesiologists, BMI: Body mass index. Values are presented as mean±standard deviation. GA: General anesthesia, SA: Spinal anesthesia, Hb: Hemoglobin, ASA: American Society of Anesthesiologists, BMI: Body mass index. Table 3. Predictor of Total Blood Loss in Patients Underwent Intramedullary Fixation for Intertrochanteric Fracture in Multivariate Analysis Variable Coefficient SE p-value 95% CI Stable : unstable fracture Sex (male : female) Age ( 65 yr) GA : SA Cardiovascular disease Neurovascular disease Preoperative anemia (Hb<8.0) Use of antithrombotic agents ASA score>3 BMI>30 Stable : unstable fracture , , SE: Standard error, CI: Confidence interval, GA: General anesthesia, SA: Spinal anesthesia, Hb: Hemoglobin, ASA: American Society of Anesthesiologists, BMI: Body mass index.

4 56 Jai Hyung Park, et al. 의미하며그원인은조직내로의혈액유출이나주위근육내잔류혈, 용혈로인한혈액소실, 원위대퇴부로의혈종으로인해발생될수있다. 19) 또한불안정성골절의경우정복이어려운경우골절부위에최소절개를넣은후골절부위를일부노출한후정복술을시행하는경우가있어안정형골절보다절개부위가크고수술시간이길어지는것도출혈이증가하는원인으로생각해볼수있다. 항혈전제사용에따른출혈의차이는이론적으로는가능하나본연구결과에서는차이가없었던것은 aspirin, clopidogrel, cilostazol, salpogrelate, warfarin 등을기전및작용등으로나누어분석하지않았기때문으로생각된다. 항혈소판제의경우 aspirin 23예, clopidogrel 6예, aspirin+clopidogrel 6예, cilostazol이나 salpogrelate 등기타항혈소판제 8예로나타났으며항혈소판제와달리항응고제로분류되는 warfarin 의경우는 6예로관찰되었다. 항응고제의경우대부분 antidote를사용하거나 prothrombin time을확인후수술하였기때문에오히려출혈경향에는의미가적었을것으로생각된다. 각각에대해통계적분석을시행하기에는그숫자가적었으며이는후향적분석의한계점이라고하겠다. 통상고관절골절의경우외래보다는응급실을통해내원하는경우가많으며응급실에서채혈시대부분의경우 Hb 수치에실혈이반영되지않는다. 이는수술시까지일정시간경과후수술직전의빈혈수치를반영하지못해과소평가할가능성이있다. 또한대부분의골절환자들은수술전경구섭취량감소등으로인하여탈수가발생하고이로인하여혈구용적치가높게변화되어증가되어보일수있다. Hb 수치나적혈구용적치 (hematocrit) 는탈수나수분공급등의여러인자에의해변화될수있어순간적인변화에예민하지못하고, 짧은시간에다량의출혈이일어나는경우에는실혈량을정확히대변해주지는못하는것으로알려져있다. 12) 실혈량에대한계산은과거여러가지방법을이용하지만본논문에서는 Mercuriali 와 Brecher 에의한공식으로 OSTHEO 에의해추천되는공식을사용하였다. 이는이전연구에서발표된단순한 Hb 수치의비교가아닌성별, 신장, 몸무게, 수술과관련된수혈등과같은실혈량측정에있어영향을줄수있는요인을대부분반영하였기때문이다. 9) 대퇴전자간골절의분류는여러학자및기관들에의해이루어져왔다. 본연구에서는 Evans의분류체계를통해안정골절과불안정골절로구분하였다. 20) 대퇴골의후내측피질골의분쇄정도가심하거나및역경사골절인경우를불안정골절로정의하였다. 전자하골절의경우일반적전자간골절에비하여더많은출혈량이발생한다고보고 한바있다. 21) 본연구에서도불안정골절의경우안정골절의경우보다출혈량이더많은것으로유의한결과를얻었다 (p<0.05). 본연구에서시행한계산된총실혈량은간단한계산으로전체실혈량을측정할수있는장점이있지만수술전고령환자들의탈수와같은전신상태를반영할수없었으며수상당시시행한혈액검사시점이다양하여 multivariate analysis 에도불구하고실혈량을증가시킬수있는위험인자분석시각인자간의상호작용을고려하지못한단점이있다. 결 발생된총실혈량은측정된실혈량에비해많은양이측정되므로항상숨겨진실혈이있을수있음을염두해두어야한다. 고관절대퇴전자간골절후금속정을이용한내고정술시총실혈량은특별한유발인자에의해증가하지않고수술전골절의양상에의해결정된다. 불안정골절의경우수상으로인한골출혈과혈관손상, 경우에따른추가적인절개로인해출혈이많을수있다는것에대해인지하고수술후환자의활력징후에대한보다긴밀한추적관찰을시행하여야하겠다. 론 References 1) Sehat KR, Evans RL, Newman JH: Hidden blood loss following hip and knee arthroplasty. Correct management of blood loss should take hidden loss into account. J Bone Joint Surg Br, 86: , ) Good L, Peterson E, Lisander B: Tranexamic acid decreases external blood loss but not hidden blood loss in total knee replacement. Br J Anaesth, 90: , ) Lemos MJ, Healy WL: Current concepts review: blood transfusion in orthopaedic operations. J Bone Joint Surg Am, 78: , ) Keating EM, Meding JB: Perioperative blood management practices in elective orthopaedic surgery. J Am Acad Orthop Surg, 10: , ) Lemaire R: Strategies for blood management in orthopaedic and trauma surgery. J Bone Joint Surg Br, 90: , ) Salido JA, Marín LA, Gómez LA, Zorrilla P, Martínez C: Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: analysis of predictive factors. J Bone Joint Surg Am, 84: ,

5 Perioperative Blood Loss in Intramedullary Hip Screw for Intertrochanteric Fracture ) Bell TH, Berta D, Ralley F, et al: Factors affecting perioperative blood loss and transfusion rates in primary total joint arthroplasty: a prospective analysis of 1642 patients. Can J Surg, 52: , ) Walker RW, Rosson JR, Bland JM: Blood loss during primary total hip arthroplasty: use of preoperative measurements to predict the need for transfusion. Ann R Coll Surg Engl, 79: , ) Rosencher N, Kerkkamp HE, Macheras G; OSTHEO Investigation, et al: Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe. Transfusion, 43: , ) Slappendel R, Dirksen R, Weber EW, van der Schaaf DB: An algorithm to reduce allogenic red blood cell transfusions for major orthopedic surgery. Acta Orthop Scand, 74: , ) Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB: An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am, 81: 2-10, ) Nam WD, Kim IY, Rhyu KH: Blood loss and transfusion in primary total hip arthroplasty. J Korean Hip Soc, 18: 1-5, ) Mylod AG Jr, France MP, Muser DE, Parsons JR: Perioperative blood loss associated with total knee arthroplasty. A comparison of procedures performed with and without cementing. J Bone Joint Surg Am, 72: , ) Sharrock NE, Salvati EA: Hypotensive epidural anesthesia for total hip arthroplasty: a review. Acta Orthop Scand, 67: , ) Juelsgaard P, Larsen UT, Sørensen JV, Madsen F, Søballe K: Hypotensive epidural anesthesia in total knee replacement without tourniquet: reduced blood loss and transfusion. Reg Anesth Pain Med, 26: , ) 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: , ) Stickles B, Phillips L, Brox WT, Owens B, Lanzer WL: Defining the relationship between obesity and total joint arthroplasty. Obes Res, 9: , ) Chechik O, Thein R, Fichman G, Haim A, Tov TB, Steinberg EL: The effect of clopidogrel and aspirin on blood loss in hip fracture surgery. Injury, 42: , ) Foss NB, Kehlet H: Hidden blood loss after surgery for hip fracture. J Bone Joint Surg Br, 88: , ) Jensen JS: Classification of trochanteric fractures. Acta Orthop Scand, 51: , ) Dimon JH, Hughston JC: Unstable intertrochanteric fractures of the hip. J Bone Joint Surg Am, 49: , 1967.

6 ISSN (Print) ISSN (Online) 대한골절학회지제 28 권, 제 1 호, 2015 년 1 월 J Korean Fract Soc 2015;28(1): Original Article 대퇴전자간골절의금속정을이용한내고정술후실혈량 : 위험인자분석 박재형 정화재 신헌규 김유진 박세진 고택수 박종현 성균관대학교의과대학강북삼성병원정형외과학교실 목적 : 고관절대퇴전자간골절의금속정을이용한내고정술후보이지않는실혈을포함한실질적인총실혈량을계산하여측정된실혈량과의차이를알아보고위험인자가수술전, 후실혈량에미치는영향을알아보고자한다. 대상및방법 : 2004년부터 2013년까지본원에서내고정술을시행한환자 256예를대상으로하였고총실혈량의계산은 Mercuriali와 Brecher에의한공식을사용하였으며실혈량에미치는위험인자로골절유형 (Evans 분류기준 ), 성별, 나이, 체질량지수, 마취방법, 심혈관질환이나뇌혈관질환유무, 술전빈혈여부, American Society of Anesthesiologists 점수, 골절의안정성여부, aspirin 등의항혈전제사용여부를비교분석하였다. 결과 : 계산된총실혈량은 2,100±1,632 ml이고측정된실혈량은 564±319 ml로유의한차이를보였고실혈량과관련된위험인자중불안정골절의경우 2,496±1,395 ml로안정형골절에비해증가된결과를보였다. 다른위험인자들은통계적으로유의한차이를보이지않았다. 결론 : 고관절대퇴전자간골절후수술시발생된총실혈량은측정된실혈량에비해많은양이측정되었으며특히불안정골절환자의수술시에는관찰되는양보다많은실혈량이예측되므로수술후관리에신경써야한다. 색인단어 : 대퇴, 전자간골절, 골수정고정술, 실혈, 위험인자 접수일 수정일 게재확정 교신저자박재형서울시종로구새문안로 29, 성균관대학교의과대학강북삼성병원정형외과학교실 Tel , Fax , jaihyung.park@samsung.com Copyright c 2015 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. 58

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar