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1 대한골절학회지제 23 권, 제 2 호, 21 년 4 월 Journal of the Korean Fracture Society Vol. 23, No. 2, April, 21 상완골병적골절의수술적치료 강호정ㆍ황병윤ㆍ이재정ㆍ신규호ㆍ한수봉ㆍ김성재 연세대학교의과대학정형외과학교실 목적 : 상완골병적골절의수술적치료에대한방사선학적, 임상적결과에대해평가해보고자하였다. 대상및방법 : 1993 년 1 월부터 27 년 9 월까지상완골의병적골절로치료받은 13 예를대상으로방사선학적, 임상적인분석을하였다. 원발성종양은 4 예였으며, 전이암에의한골절은 9 예였다. 수술방법으로는관혈적정복술및내고정술은 4 예, 도수정복술및골수강내고정술은 8 예시행하였으며, 1 예는광범위절제술및반관절치환술을시행하였다. 결과 : 전이암에의한골절인경우총 9 예중 3 예는골절후원발암이발견되었다. 6 예에서암진단후평균 36.7 개월 (2 144 개월 ) 에병적골절이발견되었으며, 9 예의평균생존기간은수술후 22.8 주 (12 35 주 ) 였다. 원발암 4 예에서모두골유합소견이관찰되었고전이암에의한경우는모든예에서골유합이관찰되지않았으나, 11 예의환자에있어서양호한통증완화와기능회복이관찰되었다. 결론 : 상완골병적골절에대한수술적치료로통증의완화와기능의회복에대해비교적만족스런결과를얻을수있었다. 원발양성종양의경우는상지의기능회복및골유합을얻기위해적극적인치료가필요하며, 전이암에의한경우는골유합보다는통증의감소와기능의회복에그비중을두어야할것으로생각된다. 색인단어 : 상완골, 병적골절, 수술적치료 Surgical Treatment of Pathologic Humeral Fracture Ho Jung Kang, M.D., Byoung Yoon Hwang, M.D., Jae Jeong Lee, M.D., Kyoo Ho Shin, M.D., Soo Bong Hahn, M.D., Sung Jae Kim, M.D. Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea Purpose: To evaluate and analyze the radiographic and clinical outcomes after the surgical treatments of pathologic humeral fractures. Materials and Methods: From October 1993 to September 27, a retrospective investigation was conducted with a total of 13 patients who underwent operations for pathologic humeral fractures. The methods of surgical treatment were as follows-four cases of open reduction and internal fixation; eight cases of closed reduction and internal fixation with intramedullary nailing; and one of radical excision and hemiarthroplasty. Results: Of nine patients with metastatic bone lesions, three were diagnosed with primary cancer after the incidence of pathologic humeral fracture. The mean period between the diagnosis of primary cancer and pathologic fracture in the latter six cases was 36.7 (2 144) months and the mean survival period after the surgical treatments was 22.8 (12 35) weeks in all patients with bone metastasis. Fracture unions were noted in all four cases of primary humeral bone lesion but none in metastatic cases. Pain relief and functional recovery were noted in eleven patients of this study. Conclusion: Satisfactory clinical outcomes with sustained pain relief and functional recovery were observed after the surgical treatments of pathologic humeral fracture. Benign bone lesions require more active and early treatments in order to facilitate the functional recovery of upper extremities and fracture union. With pathologic humeral fractures originated from metastasis, palliative treatments were preferred to fracture union method for planning long-term pain relief and functional recovery. Key Words: Humerus, Pathologic fracture, Surgical treatment 통신저자 : 황병윤서울시서대문구성산로 25 ( 신촌동 134) 연세대학교의과대학정형외과교실 Tel: ㆍ Fax: sogood95@yuhs.ac 접수 : 심사 ( 수정 ): 게재확정 : Address reprint requests to:byoung Yoon Hwang, M.D. Department of Orthopaedic Surgery, Yonsei University College of Medicine, 25, Seongsan-ro, Seodaemun-gu, Seoul , Korea Tel: ㆍ Fax: sogood95@yuhs.ac 187

2 188 강호정, 황병윤, 이재정, 신규호, 한수봉, 김성재 서 장골에생기는종양은단순낭종, 거대세포종등과같은양성종양및다발성골수종, 골육종등의악성종양이며, 가장많은것은전이에의한골종양이다 2,13). 전이성골종양은척추, 골반골, 대퇴골, 늑골순으로호발하는양상을보이며, 장골중에서는상완골이대퇴골에이어흔하게침범되고, 특히유방암, 폐암, 신장암에의한골전이가많다 7,1). 상완골의병적골절은하지의병적골절과는달리체중부하가없기때문에비교적생활에제약이적지만, 통증이심하고상지의기능소실로인해서많은고통을겪게된다. 최근에는평균수명이늘어나고각종치료법의발달로인한생존율의증가에의해원발암에의한골전이가증가되는양상을보이고있다 25). 따라서골전이에대한적극적인치료가필요하게되었고, 치료의발달로인해골전이의합병증을줄이고삶의질향상및생존기간의연장까지도기대해볼수있다 15,16,18). 상완골의전이는비교적늦게침범되고 9), 침범시이미다른부위에도전이된경우가많아서치료에있어서제한점이있지만, 수술적치료를통해동통을줄여주고사지의기능을보존하여삶의질을높일수있는것으로보고되고있다 11). 본연구에서는상완골의병적골절환자에대해수술적치료후방사선학적및임상적인결과에대해알아보고자하였다. 론 대상및방법 1993 년 1 월부터 27 년 9 월사이본원에서외상에의한골절이나병적골절을포함한상완골골절로 497 예에서수술적치료를받았다. 그중추시관찰이가능하였던병적골절환자 13 예를대상으로입원기록및수술후정기적인외래방문과의무기록을통해추시관찰하였다. 수술적방법으로는관혈적정복술및내고정술, 도수정복술및골수강내고정술, 광범위절제술및인공관절술을시행하였으며, 결손부위가크거나견고한고정을위해서골시멘트도사용하였다. 남자는 5 명, 여자는 8 명이었으며, 평균연령은 57.1 세 (28 79 세 ) 였다. 원발성종양은 4 예였으며, 전이암에의한골절은 9 예였다. 원발성종양으로는 거대세포종 2 예, 섬유이영양증 1 예, 단순낭종 1 예였으며, 전이암은간암 2 예, 폐암 3 예, 신장암 1 예, 자궁경부암 1 예, 유방암 1 예, 원발부위를모르는선암이 1 예였다. 병변부위로는근위부가 1 예, 원위부가 2 예, 간부가 1 예였다. 7 예에서경미한외상이있었으며, 나머지 6 예에서는일상생활중외상력없이골절이일어났다. 수술방법은골절부위및골절양상에따라달라졌으며, 관혈적정복술및내고정술은 4 예, 도수정복술및골수강내고정술은 8 예였으며, 나머지 1 예는광범위절제술및반관절치환술을시행하였다. 전이암 5 예에대하여골절부위를포함하여그외골전이부위에술후방사선치료를시행하였다. 골유합은방사선학적으로전후면및측면사진상골절선을가로지르는골소주가있으면서세부위의피질골에연속성이관찰되고, 임상적으로압통및가성운동이없을때를기준으로하였다. 통증완화와기능회복에대한임상적평가는 Modified Perez 등의방법 (Table 1) 을사용하여우수, 양호, 보통, 불량으로하였다. 결 원발성종양 4 예에서모두골유합소견이관찰되었으며, 전이암에의한경우는전례에서골유합이관찰되지않았다. 전이암에의한골절인경우총 9 예중 3 예는골절후원발암이발견되었으며, 나머지 6 예에서는원발암진단후병적골절이일어났다. 골절후원발암이발견된경우는간암과유방암의경우가각각 1 예씩있었으며, 나머지 1 예는원발부위를모르는선암이었다. 간암인경우 23 주생존하였으며유방암의경우 14 주, 선암의경우수술후 2 주생존하였다. 6 예에서원발암진단후평균 36.7 개월 (2 144 개월 ) 에병적골절이발생하였으며, 총 9 예의평균생존기간은수술후 22.8 주 (12 35 주 ) 였다. 원발암진단후병적골절까지기간은유방암에의한상완골병적골절이 144 개월로가장길었으며, 이경우를제외하면평균 18 개월 (2 6 개월 ) 에원발암진단후병적골절이발견되었다. 전이암에의한골절진단시타부위전이는총 9 예중 3 예에서있었으며, 1 예는유방암에의한골전이로부위는 과 Table 1. Modification of the rating system of Perez et al. Rating Pain relief Function Poor Essentially complete relief of pain Mild discomfort; occasional use of mild analgesics Moderate pain Unchanged from pretreatment pain level Essentially normal function Slight impairment of use of upper extremity, but able to perform well the activities of daily living Limited use of upper extremity Inability to use extremity

3 상완골병적골절의수술적치료 189 척추, 골반, 대퇴골이었고, 1 예는간암에의한척추전이였으며, 1 예는선암에의한골반전이가있었다. Modified Perez 등의방법에의한통증과기능적평가에의하면, 통증완화는수술전불량에서수술후우수가 2 예, 양호가 5 예, 보통이 2 예였으며, 기능회복은우수가 1 예, 양호 2 예, 보통 4 예, 불량이 2 예였다. 원발성종양은모든예에서통증과기능적평가가우수하였으며, 간암에의한병적골절의경우 1 예에서수술후에도빠른골파괴가진행되어서견고한고정이불가능하여보조기착용하면서방사선치료를시행한경우가있었고, 기능적인면에서는불량하였으나, 통증완화는보통의호전을보였다 (Table 2, 3). 1. 증례보고 1) 증례 1 51 세여자로발이걸려넘어지며발생한우측상완부통증으로타병원에서전원된환자로자기공명영상검사상상완골근위부에단순골낭종, 내연골종, 거대세포종, 동맥류뼈낭종 (aneurysmal bone cyst) 이의심되는소견으로 1 차수술로골수강내고정술및상완골두의골수강입구 (entry) 를통한생검소파술시행하였다. 조직검사상거대세포종으로확진되어일주일후 2 차수술을통해내고정골수정을유지하면서원형적 (circumferential) 으로일괄절제술 (en bloc excision) 후자가장골이식을시행하였으며 6 개월만에골유합을얻었다. 현재 1 년 6 개월외래추시경과상종양의재발소견은관찰되지않았다 (Fig. 1). 2) 증례 2 55 세남자로 3 년전교통사고후좌측상완골간부골절로타병원에서관혈적정복술후금속판고정술시행후불유합소견지속되어서 1 차례자가골이식술시행하였다. 1 차이식술후골유합이되지않아서일차수술 3 년만에본원전원된환자로 3 차수술전흉부단순촬영및전산화단층촬영검사에서좌측폐암진단되었으며, 3 차수술로관혈적정복술, 골수강내고정술및골이식술을시행하였다 (Fig. 2). 수술중불유합부에서보낸조직생검에서폐 Table 2. Data of 4 cases with benign humeral lesion Case Age (yrs)/ Sex Diagnosis Fx site Op method Time period to Fx from Dx Another lesion Pain relief Function improvement F/73 M/28 M/52 F/52 Simple bone cyst Fibrodysplasia Giant cell tumor Giant cell tumor Distal Head & neck Hemiarthroplasty 12 months Skull, spine, pelvis, femur Fx: Fracture, Dx: Diagnosis, IM: Intramedullary, Op: Operation. Table 3. Data of 9 cases with metastatic humeral lesion Case Age (yrs)/ Sex Diagnosis Fx site Op method Survival period after Op Time period to Fx from Dx Other metastatic lesion Pain relief Function improvement F/54 F/72 M/51 F/55 M/79 F/72 F/44 F/56 M/55 Breast cancer Hepatocellular carcinoma Hepatocellular carcinoma Lung cancer Lung cancer Unclear Renal cell carcinoma Cervix cancer Lung cancer Distal Middle 14 weeks 35 weeks 23 weeks 12 weeks 32 weeks 2 weeks 18 weeks 25 weeks 26 weeks 144 months 7 months 6 months 2 months 8 months 13 months Pelvis, sacrum, spine Spine Pelvis Poor Poor Fx: Fracture, Dx: Diagnosis, IM: Intramedullary, Op: Operation.

$(A) A 51-year-old female had proximal humeral fracture from a$ slip down injury.

$(C) After the surgical treatment, biopsy of fracture site was$ confirmed as giant cell tumor.

bone graft were performed (Black arrow is an autologous iliac

$2. (A) A 55-year-old male, with humerus shaft fracture from car$ accident 3 years ago, initially had an internal fixation, but a

$lung mass, biopsy of fracture site was confirmed as pathologic$

4 19 강호정, 황병윤, 이재정, 신규호, 한수봉, 김성재 Fig. 1. (A) A 51-year-old female had proximal humeral fracture from a slip down injury. Possible diagnosis was simple bone cyst, enchondroma, giant cell tumor or aneurismal bone cyst. (B) She was treated with closed reduction and intramedullary nailing. (C) After the surgical treatment, biopsy of fracture site was confirmed as giant cell tumor. One week after the primary operation, curettage and autoiliac bone graft were performed (Black arrow is an autologous iliac bone block). (D) The bone union was gained at 13 months after operation. Fig. 2. (A) A 55-year-old male, with humerus shaft fracture from car accident 3 years ago, initially had an internal fixation, but a follow-up bone graft was carried out due to the continuous mal-union. (B) After his third operation with preoperative evaluation of lung mass, biopsy of fracture site was confirmed as pathologic fracture originated from lung cancer (White arrow is a lung mass). (C) At 5 months after closed reduction and with bone graft, we found persistent non-union of humeral shaft. He died at 26 weeks after operation. 암 전이에 의한 병적 골절, 불유합으로 확진되었다. 수술 후 감염, 신경마비, acrometastasis 등 수술과 관계되는 합 병증은 없었으나, 골유합은 얻지 못하였으며 술 후 26주에 사망하였다. 고 찰 악성 종양에 대한 치료법의 발달로 인한 생존율의 증가 에 따라 골전이 및 병적 골절이 증가하고 있다. 이러한 병

5 상완골병적골절의수술적치료 191 적골절및임박골절에서수술적치료는완화적치료 (palliative treatment) 방법이주류를이루고있다. 수술적치료의목적은병변부위의기능유지와통증의조절을목적으로하고있으며, 이러한목적은견고한골절의고정을통해얻을수있다 27). 상지의병적골절은체중부하를하지않으므로하지의병적골절에비해서비교적관심이많지않았으나 19), 최근골절후생존기간이증가함에따라심한통증과상지의기능소실로인한삶의질의저하를초래함으로상지의병적골절에대해보다적극적치료가필요하게되었다. 방사선치료만으로는약간의통증완화를얻을수는있으나상지기능의회복을기대할수없고 14), 또한방사선치료가무혈성괴사, 유합방해등의합병증을유발시킬수있어서많은저자들이수술적치료를권하고있다. 병적골절에서의수술적치료는다발성병적골절이나임박골절 (impending fracture) 의위험성이높은경우, 통증이너무심한경우, 병적골절의병명이확실치않은경우, 불유합을주소로내원한상완골골절의경우, 사소한외상에의한병적골절이의심되는경우를적응증으로하였다 22). 수술적치료는수술후수일내에통증의완화가있으며, 조기상지관절운동을시킬수있는장점이있고, 골유합이없더라도견고한내고정을통한기능회복을얻을수있는장점이있다 12). 여러논문에서수술적치료로 9% 이상의환자에서통증의감소와상지의기능회복을얻을수있다고하였으며 5 7,23,24), 또한수술후방사선치료를병행함으로통증의완화및국소적골전이를늦출수있다고보고되고있다. Townsend 등은수술후방사선치료를병용하는경우그렇지않은경우에비해서 15 2% 의골파괴감소를보인다고하였다 26). 본연구에서도 5 예의전이성병적상완골골절환자에서방사선치료를병용하여통증의일시적완화를얻을수있었다. 상완골병적골절의내고정방법으로는도수정복술후골수강내금속적고정술, 관혈적정복술및내고정술, 광범위절제술및인공관절치환술등이있으며, 각각의방법에대해서여러가지논의가있다. 금속정고정술은골절부위의노출없이수술합병증을최소화하면서골절부위의내고정을할수있는장점이있어서 21), 술후방사선치료를시행할경우도상처에의한문제를줄일수있고수술자체에의한통증을감소시키는장점을가지고있다. 금속판을이용한관혈적정복술및내고정술은또다른수술적방법의하나로금속정고정술후생길수있는합병증의하나인회전근개의손상을줄일수있는장점을가지고있으며, 골결손이큰경우골시멘트를사용하여견고한고정에도움을줄수있다. 그러나골절근위부와원위부에충분한나사못고정을위한부위가보존되어야한다. 또한관절부위를침범한경우와상완골근위부의큰 골결손이있는경우인공관절치환물이도움이될수있다. Bae 등은골수강내금속정고정술및금속판고정술사이에술후운동범위의차이는없으나견관절기능평가상전자에서유의하게낮은점수를보고하였다 1). 본연구에서는골수강내고정술을 8 예에서가장많이사용하였으며, 관혈적정복술및내고정술로치료한 4 예와비교하여임상적결과및합병증에서별차이는없었다. 골전이환자에있어서생존기간은전이부위의치료보다는원발암의종류에따라서경과가결정되는양상을보이고, 폐암이나간암같은경우는원발암진단후비교적짧은기간에골전이가되는양상이관찰되며원발암환자에서의생존기간이긴것은골전이후의생존기간보다는골전이가일어나기까지의기간이긴것에기인하는것으로알려져있다. 많은연구에서전이암에의한상완골의병적골절후평균 8 1 개월의생존기간을보고하고있으며 8,19), 과거 4 6 개월가량의생존기간보다더오래생존하는것으로보고되고있다 17). 악성병변의경우본연구에서는평균 22.8 주간생존하였으나, 통증의감소와상기기능의회복은양호한결과를보였다. 유방암에의한골전이의경우진단후골전이까지의기간이가장길었으며, 폐암에의한골전이의경우 12 주로가장짧은생존기간을보였다. 수술후경과를예측하는인자로는원발암의종류, 내장기로의전이유무, 다발성전이유무, 술전항암치료유무가관여하는것으로알려져있다 17). 또한골전이시골절위험도를평가하여예방적치료를시행하는것이수술적위험도를낮추고, 수술을쉽게하고예후향상에도움이되며 15), 골절위험도가높은경우는장골의골파괴가피질골의 5% 이상인경우, 순수한골용해병변 (osteolytic lesion) 이있는경우, 장골간부의병변이있는경우, 움직임과동반된통증이증가하는경우등이있으며 15), Chao 등은병변이 3 cm 이상이거나직경의 5% 이상침범시골절위험도가 5% 나타난다고하였다 4). 또한 Mirels 는골절위험도를수치화하여예측하였다 2). 본연구에서도상완부의골전이로골절위험도가높은환자에있어서수술적치료를권유하였으나거절한 1 예에있어서 2 달후병적골절이발생하여수술적치료를시행한경우가있었다. 상완골의양성골병변일경우모든예에서골유합을얻었으며, 통증의감소및상지기능의회복이만족할만한결과를보였으나, 1 예에있어서단순방사선및자기공명영상소견상단순골낭종, 내연골종, 거대세포종, 동맥류뼈낭종의심하에수술을진행한후조직검사상거대세포종으로확진되어 2 차수술로일괄절제술및동종골이식술을시행한경우가있었다. 이처럼상완골의양성골병변이의심되는경우에도반드시세침조직검사 (needle biopsy) 나개방조직검사 (open biopsy) 를통한일차수술적

6 192 강호정, 황병윤, 이재정, 신규호, 한수봉, 김성재 확진후에최종치료방법을결정하여야한다. 전이암에의한병적골절에서는모든예에서골유합을얻을수없었으나, 통증의감소와기능의회복이관찰되었다. 전이암 9 예에대해서모두골유합을얻지는못한이유로는수술후평균생존기간이 22.8 주여서골유합을확인할수있는충분한기간이없었던점, 3 예에있어서는상완골이외의타부위에도전이가있는경우로이런환자들의경우수술당시 bone quality 가더좋지않았던점또한 1 예의환자에있어서처음수술적치료를거부했다가통증의악화로수술적치료가시행되어그동안골병변이진행되었던점들을생각할수있다. 전이암의경우수술후방사선치료가통증의감소에도움이되었다. 전이성병적골절이나임박골절의경우수술적치료와수술후방사선치료는생존기간에영향을미치지못하지만통증완화및상지기능회복면에서환자의삶의질향상에도움이되는것으로알려져있다. 따라서전이성병적골절의치료는완치의목적이아니더라도, 기능의보존과통증의감소를목적으로골유합보다는견고한고정의유지가더고려되어야할것이며, 원발양성종양의경우는상지의기능회복및골유합을얻기위해적극적인치료가필요할것으로생각된다. 본연구의단점은첫째, 원발양성종양은 4 예, 전이암의경우는 9 예로그수가적은점, 둘째, 수술후방사선치료가어느정도임상적경과에영향을미쳤는지평가를따로시행하지못한점을들수있겠다. 결 상완골병적골절에대한수술적치료로통증의완화와기능의회복으로비교적만족스런결과를얻을수있었으며전이암의경우수술후방사선치료가통증의감소에도움이되었다. 원발양성종양의경우는상지의기능회복및골유합에목적을둔치료가필요하며, 전이암에의한경우는골유합보다는통증의감소와기능의회복에그비중을두어야할것으로생각된다. 론 참고문헌 1) Bae SW, Kim WJ, Song BY, Choi NH, Lee JH: Postoperative functional assessments in adult humerus shaft fractures comparison among plates and screws, intramedullary nail and external fixatior. J Korean Fracture Soc, 14: , 21. 2) Brage ME, Simon MA: Evaluation, prognosis, and medical treatment considerations of metastatic bone tumors. Orthopedics, 15: , ) Carlin BI, Andriole GL: The natural history, skeletal complications, and management of bone metastases in patients with prostate carcinoma. Cancer, 88(Suppl 12): , 2. 4) Chao EYS, Sim FH, Shives TC, Pritchard DJ: Management of pathological fracture. In: Kim AH ed. Diagnosis and management of metastatic bone disease. A multidisciplinary approach. New York, Raven Press: , ) Chin HC, Frassica FJ, Hein TJ, et al: Metastatic diaphyseal fractures of the shaft of the humerus. The structural strength evaluation of a new method of treatment with a segmental defect prosthesis. Clin Orthop Relat Res, 248: , ) Damron TA, Sim FH, Shives TC, An KN, Rock MG, Pritchard DJ: Intercalary spacers in the treatment of segmentally destructive diaphyseal humeral lesions in disseminated malignancies. Clin Orthop Relat Res, 324: , ) Dijstra S, Stapert J, Boxma H, Wiggers T: Treatment of pathological fractures of the humeral shaft due to bone metastases: a comparison of intramedullary locking nail and plate osteosynthesis with adjunctive bone cement. Eur J Surg Oncol, 22: , ) Dijstra S, Wiggers T, van Geel BN, Boxma H: Impending and actual pathological fractures in patients with bone metastases of the long bones. A retrospective study of 233 surgically treated fractures. Eur J Surg, 16: , ) Flemming JE, Beals RK: Pathologic fracture of the humerus. Clin Orthop Relat Res, 23: , ) Frassica FJ, Frassica DA: Evaluation and treatment of metastases to the humerus. Clin Orthop Relat Res, 415(Suppl): S , ) Friedl W: Indication, management and results of surgical therapy for pathological fractures in patients with bone metastases. Eur J Surg Oncol, 18: , ) Galasko CSB: Skeletal metastases. Butterworth, London, ) Habermann ET, Lopez RA: Metastatic disease of bone and treatment of pathological fractures. Orthop Clin North Am, 2: , ) Harrington KD, Sim FH, Enis JE, Johnston JO, Dick HM, Gristina AG: Methylmethacrylate as an adjunct in internal fixation of pathologic fractures. Experience with

7 상완골병적골절의수술적치료 193 three hundred and seventyfive cases. J Bone Joint Surg Am, 58: , ) Jacobson AF, Shapiro CL, Van den Abbeele AD, Kaplan WD: Prognostic significance of the number of bone scan abnormalities at the time of initial bone metastatic recurrence in breast carcinoma. Cancer, 91: 17-24, ) Janjan N: Bone metastases: approaches to management. Semin Oncol, 28(suppl 11): 28-34, ) Kim JI, Yoo CI, Suh JT, Suh KT, Kim HT, Moon NH: Surgical treatment and prognostic factor for metastatic bone tumor. J Korean Orthop Assoc, 43: , ) Kollender Y, Bickels J, Price WM: Metastatic renal cell carcinoma of bone: indications and technique of surgical intervention. J Urol, 164: ) Lancaster JM, Koman LA, Gristina AG, et al: Pathologic fractures of the humerus. Southern Med J, 81: 52-55, ) Mirels H: Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res, 249: , ) Park SR, Lee TJ, Kim RS, Moon KH, You DS: Result of interlocking intramedullary nailing for humeral shaft fracture evaluation of post-operative shoulder function. J Korean Fracture Soc, 2: , ) Patel B, DeGroot H 3rd: Evaluation of the risk of pathologic fractures secondary to metastatic bone disease. Orthopedics, 24: , ) Redmond BJ, Biermann JS, Blasier RB: Interlocking intramedullary nailing of pathological fractures of the shaft of the humerus. J Bone Joint Surg Am, 78: , ) Sim FH, Frassica FJ, Chao EY: Orthopaedic management using new devices and prostheses. Clin Orthop Relat Res, 312: , ) Sim FH, Prichard DJ: Metastatic disease in the upper extremity. Clin Orthop Relat Res, 169: 83-94, ) Townsend PW, Rosenthal HG, Smalley SR, Cozad SC, Hassanein RE: Impact of postoperative radiation therapy and other perioperative factors on outcome after orthopedic stabilization of impending or pathologic fractures due to metastatic disease. J Clin Oncol, 12: , ) Vail TP, Harrelson JM: Treatment of pathologic fractures of the humerus. Clin Orthop Relat Res, 268: , ) van der Hulst RR, van den Wildenberg FA, Vroemen JP, Greve JW: Intramedullary nailing of (impending) pathologic fractures. J Trauma, 36: , 1994.

김범수

김범수 Analysis of Outcomes after Resection of Sarcomatous Hepatocellular Carcinoma Purpose: Sarcomatous hepatocellular carcinoma (HCC) is rare. Therefore, the clinicopathologic characteristics and prognosis