412 pissn : 1226-2102, eissn : 2005-8918 Case Report J Korean Orthop Assoc 2015; 50: 412-417 http://dx.doi.org/10.4055/jkoa.2015.50.5.412 www.jkoa.org 건내결절종에의해발생한자발적전경골건완전파열 권석현 강홍제 이성인 원광대학교의과대학정형외과학교실 Complete Rupture of the Tibialis Anterior Tendon Due to Intratendinous Ganglion Cyst Seok Hyun Kweon, M.D., Ph.D., Hong Je Kang, M.D., Ph.D., and Seoung In Lee, M.D. Department of Orthopaedic Surgery, Wonkwang University School of Medicine, Iksan, Korea Spontaneous rupture of the tibialis anterior tendon is rare among ordinary people. The tendon rupture usually occurs in patients iatrogenically after local steroid injection to the tendon or with pre-existing systemic disease such as diabetes mellitus, gout, and rheumatic disease. However, no case of complete rupture of the tibialis anterior tendon due to an intratendinous ganglion cyst has been reported. We report on a case of a 39-year-old female with spontaneous rupture of the tibialis anterior tendon due to intratendinous ganglion cyst and her clinical results. Key words: anterior tibial tendon, ganglion cyst, spontaneous rupture 전경골건의파열은드물며대부분강한외력에의해발생한다. 1) 그러나당뇨, 류마티스질환등의기저질환이있는경우나국소스테로이드주사의기왕력이있는경우매우드물게자발적전경골건파열이발생할수있다. 1-6) 결절종은상하지에흔하게발생하는낭포성종양으로주로관절막이나건초에발생하며드물게건내결절종 (intratendinous ganglion) 이발생하기도한다. 7) 건내결절종은매우드물게보고되었고건내결절종에의한건의완전파열은현재까지보고된바없으며건내결절종에대한치료방법역시정립되지않았다. 이에저자들은외상력및특이기왕력이없는 39세여자환자의건내결절종에의해발생한전경골건의완전파열 1예를경험하였기에이를문헌고찰과함께보고하고자한다. 증례보고 39 세여자환자로, 3 개월전부터발생한서서히발생한좌측족하 Received March 28, 2014 Revised April 24, 2014 Accepted May 16, 2015 Correspondence to: Hong Je Kang, M.D., Ph.D. Department of Orthopaedic Surgery, Wonkwang University School of Medicine, 460 Iksan-daero, Iksan 54538, Korea TEL: +82-63-859-1360 FAX: +82-63-852-9329 E-mail: kanghongje@hanmail.net Figure 1. Photograph showing mild erythematous skin color change and swelling just anterior of the tibialis anterior tendon. The Journal of the Korean Orthopaedic Association Volume 50 Number 5 2015 Copyright 2015 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
413 TAT Rupture by Intratendinous Ganglion Cyst A CB C D Figure 2. Magnetic resonance imaging showing the cystic lesion located along the tibialis anterior tendon. Low signaled in T1-weighted image (A, B) and high signaled in T2-weighted image. (C, D) Continuity of tibialis anterior tendon near the cystic lesion was not seen, suggesting complete rupture. Figure 3. Intraoperative photograph illustrating the deep purple, well demarcated 8 5-cm-sized soft tissue mass. Figure 4. After incision of the cystic wall, we observed a completely ruptured tibialis anterior tendon. And severe delaminated and degenerative changes were observed on the proximal and distal end of the ruptured tendon. Figure 5. The distal portion of the ruptured tibialis anterior tendon was sutured to the side of the intact extensor hallucis longus tendon. 수를주소로내원하였다. 환자의직업은주부로특별한내과적 질환과외상력은없었으며국소스테로이드주사를맞은적도없 었다. 10 개월전부터족관절전방부에종괴가만져졌으며점점커 지는양상이었다. 이학적검사상좌측족관절상방전내측에 8 5 cm 의경계가비교적뚜렷한타원형의종괴가관찰되었으며, 전 경골건의주행을따라위치하고있었다 (Fig. 1). 압통은경미하였 고좌측족관절의수동적관절운동시동통이있었으며좌측족 관절의능동적신전및내번은도수근력검사상 3 등급으로저하 되었고족관절배측굴곡운동은 -20 도로감소되어있었다. 근전 도검사상신경학적이상소견은보이지않았으며방사선검사에 서골극형성등의특이이상소견은보이지않았다. 자기공명영상 (magnetic resonance imaging) 에서족관절전내 측에 T1 강조영상에서는저신호, T2 강조영상에서는고신호 강도의경계가명확한낭종이전경골건주행경로를따라족관절
414 Seok Hyun Kweon, et al. A B Figure 6. Photomicrograph demonstrates hyalinized collagenous fibrous wall and a characteristic myxoid degeneration (H&E; A: 40, B: 100). These are specific findings of ganglion. Figure 7. Active dorsal ankle flexion at 30 months. 전면부에관찰되었으나족관절과연결되어있지않았다 (Fig. 2). 낭종근위부및원위부에서전경골건은확인되었으나낭종위치에서관찰되지않아전경골건완전파열로진단되었다. 수술적치료시종괴를따라배측으로종적절개를시행하였으며수술소견에서피막으로둘러싸인낭성종괴가관찰되었고종괴근위부와원위부에는전경골건이연결되어있었다. 종괴를절제하는과정에서낭종내부의젤리같은물질이배출되었다 (Fig. 3). 종괴를제거한후노출된전경골건은퇴행성변화에의해완전파열을보이고있었다 (Fig. 4). 이에전경골건의퇴행성변성부분과종괴를제거한후족관절과족무지를최대족배굴곡상태에서파열된전경골건원위부의단단을장무지신전건 (extensor hallucis longus tendon) 에종측봉합술 (end to side suture) 을시행하여족지신전시족배굴곡이가능하도록하였다 (Fig. 5). 낭종벽과파열된건과만나는이행부부위의조직을채취하였으며병리검사상치밀한섬유조직으로구성된낭종벽을둘러싼다른밀도의섬유조직양상으로전경골건초 (sheath) 가관찰되고있어건내결절종을진단할수있었다 (Fig. 6). 환자는술후 6주간의족저굴곡제한부목고정후능동적관절운동을시작하였다. 술후 30개월추시상족관절의족배굴곡은건측과유사하였으며족배굴곡근력은건측에비해약간감소하였으나도수검사상 5- 등급으로양호한소견을보였으며대부분일상생활에는지장이없었다 (Fig. 7). 고찰 전경골건의파열은드물며 45 세이상의남성환자, 특히 60-70 대
415 TAT Rupture by Intratendinous Ganglion Cyst 이상의고령환자에게서보고되고있다. 8) 손상기전은대개족관절의능동적족배굴곡상태에서갑작스런족저굴곡력이가해질때발생한다. 8) 전경골건파열의가장흔한증상은족배굴곡력의약화이지만장무지신전건과장족지신전건 (extensor digitorum longus) 에의한보상 (compensation) 으로진단이어려운경우가많아초음파혹은자기공명영상검사가필요하다. 5) 또한족하수를유발하는비골신경마비, 요추 5번신경근성병증 (L5 radiculopathy) 등의신경병증과감별을위해근전도검사가필요하다. 자발적전경골건파열은매우드물어당뇨환자에서는당뇨병성혈관병증 (diabetic angiopathy) 에의해전경골건에혈액공급이감소되어자발적파열이발생할수있고, 2,4) 통풍환자에서통풍결절의침착에의해발생할수있으며 1) 건선, 류마티스질환이있는경우건초염에의해건에병적변화가발생하여자발적파열이발생할수있다. 5) 특히국소스테로이드주사를한경우미세외상에의해서도자발적파열이발생한다. 8) Petersen 등 8) 은신근지대 (extensor retinaculum) 하방에서전경골건전방부에 56.6 mm 가량의무혈성구역 (avascular zone) 이존재하기때문에고령의환자에서퇴행성변화가많이발생하여자발적전경골건파열이잘발생하는부위라고하였다. 본증례는나이도비교적젊고기저질환도없었으며국소스테로이드를주사한기왕력도없었으나건내결절종을동반하고있었다. 건내결절종의발생원인은정확히알수없으나지속적인물리적자극을받는곳에잘생기고건막염에의하여약해진건내부로활액막이침투하여건내결절종이발생한다고하였으며 Waldecker 7) 는족관절외상후발생한건내결절종과동반된단비골건 (peroneus brevis tendon) 의부분파열을보고하였다. 본증례에서는특별한외상력은없었다는것이특이적이며건내결절종이발생한부위가신근지대하방의무혈성구역인것으로미루어보아무혈성구역에서발생한건내결절종으로인한압박에의해전경골건의혈행장애가더심화되어전경골건의미세손상이회복되지않아건의파열이발생한것으로추측된다. 건내결절종은발생빈도가적어현재까지치료방법이정립되지않았다. 대부분의결절종은증상이없는경우보존적인치료를권한다. 그러나건내결절종은건의실질내에위치하기때문에건의손상을야기하여파열을유발할수있으며본증례와같이완전파열을유발할수있다. 따라서건내결절종은진단후증상이없더라도가능한조기수술적치료를시행하는것이건손상을최소화하며술후예후에도움을줄수있을것으로생각된다. 자발적전경골건파열에대한치료는이견이있으나 2,5) 활동이적고나이가많은경우보조기등의보존적인치료를할수있다. 하지만대부분의경우기능적인장해가남게되어 1,5) 젊고활동량이많은경우수술적인치료가선호된다. 1,2,4,5) 자발적전경골건파열이빨리진단된경우에는봉합술로좋은결과를보일수있으나대부분의경우진단이늦어져일차적인봉합술을시행하기어 렵다. 1,2) 지연된파열의수술적치료에서는유리활강전경골건이식술 (free sliding tibialis anterior tendon graft), 건이식술 (tendon graft), 건이전술 (tendon transfer) 이이용될수있으며장력을줄이기위한비복근퇴행술 (gastrocnemius recession) 을같이시행할수있다. 2,3,4,6,9) Sammarco 등 9) 은만성전경골건파열에서늦게발견되어수술적인치료를시행한 11예중에서 8예에서는근력등급 5, 2 예에서는근력등급 4, 1예에서근력등급 3으로수술적인치료를시행한경우보존적인치료를시행한경우보다그결과가좋다고보고하였다. DiDomenico 등 4) 은자발적전경골건파열에서유리활강전경골건이식술을시행하였으며근력등급 4-5를얻었다고보고하였다. Khoury 등 3) 은장무지신전건을원위전경골건으로건이전술을시행하여좋은결과를보고하였으며 Markarian 등 6) 은장무지신전건건이전술후원위장무지신전건을단무지신전건에건고정술을시행하였다. 본증례에서는파열된건의근위부및원위부의심한퇴행성변화소견과함께결손부가너무길어직접단단봉합이불가능하여장무지신전건에종측봉합술을시행하였으며근력등급 5-로비교적양호한결과를얻었다. 전경골건의자발적파열은드물게보고되고있으며, 건내결절종에의해발생한파열은보고된바없다. 이에저자들은외상력및특이기왕력없는 39세여자환자의건내결절종을동반한자발적전경골건의파열 1예를경험하였기에자기공명영상과수술소견을함께보고하는바이다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Jerome JT, Varghese M, Sankaran B, Thomas S, Thirumagal SK. Tibialis anterior tendon rupture in gout--case report and literature review. Foot Ankle Surg. 2008;14:166-9. 2. Sapkas GS, Tzoutzopoulos A, Tsoukas FC, Triantafillopoulos IK. Spontaneous tibialis anterior tendon rupture: delayed repair with free-sliding tibialis anterior tendon graft. Am J Orthop (Belle Mead NJ). 2008;37:E213-6. 3. Khoury NJ, el-khoury GY, Saltzman CL, Brandser EA. Rupture of the anterior tibial tendon: diagnosis by MR imaging. AJR Am J Roentgenol. 1996;167:351-4. 4. DiDomenico LA, Williams K, Petrolla AF. Spontaneous rupture of the anterior tibial tendon in a diabetic patient: results of operative treatment. J Foot Ankle Surg. 2008;47:463-7. 5. Aydingöz U, Aydingöz O. Spontaneous rupture of the tibi-
416 Seok Hyun Kweon, et al. alis anterior tendon in a patient with psoriasis. Clin Imaging. 2002;26:209-11. 6. Markarian GG, Kelikian AS, Brage M, Trainor T, Dias L. Anterior tibialis tendon ruptures: an outcome analysis of operative versus nonoperative treatment. Foot Ankle Int. 1998;19:792-802. 7. Waldecker U. Unusual location of a posttraumatic ganglion and rupture of the peroneus brevis tendon: a case report. J Foot Ankle Surg. 2005;44:163-5. 8. Petersen W, Stein V, Tillmann B. Blood supply of the tibialis anterior tendon. Arch Orthop Trauma Surg. 1999;119:371-5. 9. Sammarco VJ, Sammarco GJ, Henning C, Chaim S. Surgical repair of acute and chronic tibialis anterior tendon ruptures. J Bone Joint Surg Am. 2009;91:325-32.
417 pissn : 1226-2102, eissn : 2005-8918 Case Report J Korean Orthop Assoc 2015; 50: 412-417 http://dx.doi.org/10.4055/jkoa.2015.50.5.412 www.jkoa.org TAT Rupture by Intratendinous Ganglion Cyst 건내결절종에의해발생한자발적전경골건완전파열 권석현 강홍제 이성인 원광대학교의과대학정형외과학교실 자발적전경골건파열은매우드물어당뇨, 류마티스질환등의기저질환이있는경우나국소스테로이드주사의기왕력이있는경 우발생할수있으나건내결절종에의해발생한완전파열은보고된바없다. 이에저자들은외상력및특이기왕력없는 39 세여자 환자의건내결절종에의한자발적전경골건의파열 1 예를경험하였기에이를문헌고찰과함께보고하고자한다. 색인단어 : 전경골건, 결절종, 자발적파열 접수일 2014 년 3 월 28 일수정일 2014 년 4 월 24 일게재확정일 2015 년 5 월 16 일책임저자강홍제 54538, 익산시익산대로 460, 원광대학교의과대학정형외과학교실 TEL 063-859-1360, FAX 063-852-9329, E-mail kanghongje@hanmail.net 대한정형외과학회지 : 제 50 권제 5 호 2015 Copyright 2015 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.