CASE REPORT Hip Pelvis 24(3): 250-255, 2012 http://dx.doi.org/10.5371/hp.2012.24.3.250 Traumatic Recurrent Dislocation of the Hip with Bankart Type Lesion - A Case Report - Dong-Soo Kim, MD, Hyun-Chul Shon, MD, Yong-Min Kim, MD, Eui-Sung Choi, MD, Byung-Ki Cho, MD, Ji-Kang Park, MD, Dong-Hwan Kim, MD Department of Orthopaedic Surgery, College of Medicine, Chungbuk National University, Cheongju, Korea The recurrent dislocation of hip in adult can be uncommonly induced by neuromuscular disease or dysplasia of hip. But in the case of traumatic dislocation of hip with acetabular fracture, the possibility of recurrent dislocation can be decreased if treated with accurate fixation or traction. We have experienced a case of hip dislocation with comminuted acetabular fracture, which was treated only with soft tissue suture and without fixation because of severity of the acetabular fracture. An inappropriate conservative management was done during the post operation period, eventually result in recurrent dislocation and degeneration of posterior wall and head of femur which resembled bony Bankart lesion of the shoulder. The reduction was not able to be maintained, as a result THRA was done. A year after the operation, good prognosis was found in replaced hip without any recurrent dislocation. Key Words: Hip joint, Posterior wall of acetabulum, Recurrent dislocation 일반적으로외상성고관절탈구에서후벽골절이동반된경우관혈적정복술및내고정술이필요하다. 대부분의비구후벽골절은골편이크고하나의골편으로분리되어비구연에정복이용이하기때문에금속판이나나사를이용하 Submitted: April 3, 2012 1st revision: July 4, 2012 2nd revision: July 25, 2012 3rd revision: August 14, 2012 4th revision: September 6, 2012 5th revision: September 19, 2012 Final acceptance: September 21, 2012 Address reprint request to Hyun-Chul Shon, MD Department of Orthopaedic Surgery, Chungbuk National University Hospital, 62, Gaesin-dong, Heungdeok-gu, Cheongju 360-711, Korea TEL: +82-43-269-6077 FAX: +82-43-274-8719 E-mail: hcshon@hanmail.net 이논문은 2010 년도충북대학교학술연구지원사업의연구비지원에의하여연구되었음. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons. org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 여고정해주는것이일반적이다 1). 그러나때때로비구후벽골절의골편이작거나분쇄되어있을때에는정복및고정이어렵다. 이와같은경우엔적절한침상안정이나고관절불안정성을해결할수있는다른형태의안정화수술이필요하다. 저자들은비구후벽골절이동반된외상성고관절탈구가있는환자에서고관절의후벽이견관절의골성 Bankart 병변처럼변화하여재발성탈구로발전하였던증례를경험하였다. 이에비구후벽의형태와보존적치료의중요성, 후벽재건술또는인공관절치환술과같은수술적치료의필요성과비구후벽의정복및고정술의중요성에대해국내에는보고된바없어증례와문헌고찰을통해보고하고자한다. 증례보고 44 세남자환자로내원하루전자동차사고로우측고관절탈구및골절이발생하였다. 타병원에서고관절탈구는사고후 3 시간만에도수정복하였으나, 비구후벽골절이심하고, 골편이관절내에있어수술적치료가필요하다는소견하에본원으로전원되었다. 응급실에서시행한이학적 250 Copyright c 2012 by Korean Hip Society
Dong-Soo Kim et al.: Traumatic Recurrent Dislocation of the Hip with Bankart Type Lesion - A Case Report - 검사상우측고관절의동통및관절운동제한이있었다. 단순방사선촬영과컴퓨터단층촬영결과우측고관절은정복된상태였으나, 관절내에여러조각의골편및비구후벽에분쇄골절이있었다 (Fig. 1). 비구후벽의끝부분은분쇄가심하였으나전체비구후벽면적의 50% 이상은보존되어있었다 (Fig. 2). 우측고관절외상성탈구및비구후벽골절진단하에관절내유리체및분쇄골편제거수술을결정하였다. 수술장에서우측고관절부위를접근해보니이상근 (piriformis) 을제외한다른단외전근이파열되어있었고, 관절낭의손상이심하였다. 관절내에여러조각의골편을제거해주었으며, 비구후벽골절은고정해주려하였으나분쇄가심하고골과연골이분리되어고정하지못하고골편만제거하였다 (Fig. 3). 수술당시관절막과외회전근을봉합한후고관절 을 90 굴곡, 30 내회전에서도탈구가되지않아안정성이있는것으로판단되어수술을마쳤다. 수술직후연부조직의손상을감안하여골견인을유지하였고, 입원 5 일만에환자가원하여개인병원으로전원되었다. 개인병원에서환자의협조가되지않아골견인은수술후 1 주일만에제거하였고자의퇴원하였다. 그후목발보행하였으나주기적으로술을마시고 4-5 차례고관절탈구가지속되었고, 그때마다근처병원에서도수정복하였다. 수술후 10 주째우측고관절탈구가다시재발하였고, 개인병원에서정복하지못하고본원으로전원되었다. 내원당시환자의우측고관절은굴곡, 내전, 내회전되어있었으며단순방사선검사상우측고관절의후방탈구및골절이확인되었다 (Fig. 4). 응급실에서근육이완제투여후도수정복하였으며, 도수정복후촬영한컴퓨터단층촬영결과첫손상과비교하여 A B Fig. 1. (A) Anteroposterior radiograph of the both hip and (B) CT scans show intraarticular osteochondral fragment and posterior wall fracture of acetabulum. Fig. 2. Preoperative axial CT scans show 30-40% bony defect of posterior wall of acetabulum and intraarticular osteochondral fragment. www.hipandpelvis.or.kr 251
Hip Pelvis 24(3): 250-255, 2012 A Fig. 3. (A) This photography shows bone and soft tissue fragments after operation. Fixation could not be done due to severe comminuted fracture. (B) Immediate postoperative anteroposterior radiograph shows satisfactory reduction. B 고 찰 Fig. 4. Anteroposterior radiograph of the right hip shows fracture-dislocation and defect of posterior wall of the acetabulum. 비구의후벽이 50% 이상결손되어있었으며, 대퇴골두는전내측이마모되어골결손이있었고골두의골편이관절내에끼어있었다 (Fig. 5). 환자는다음날우측고관절전치환술을시행받았다 (Fig. 6). 수술소견상고관절은불안정하였고견관절의골성 Bankart 병변처럼관절낭이후벽골편과함께분리되어있었으며비구후벽의마모도많이진행되어있었다. 인공관절치환술과함께비구의후벽골결손에대해서는대퇴골두를이용해서보강해주었다. 수술후 1 년째환자는일상생활에큰불편감이없이만족스러워했으며, 고관절탈구의재발없이양호한결과를보였다. 외상에의한급성탈구에서관혈적정복에의한치료는드물며, 대부분의탈구는전신, 국부또는국소마취하에서도수정복을시행한다. 그후관절주위의인대, 혹은관절낭등의연부조직이치유될때까지석고붕대, 석고부목, 견인등으로고정하는비수술적방법으로치료하게된다 2). 일반적으로급성탈구의도수정복은응급을요하며, 가능한한빨리시행하는것이좋고, 특히고관절탈구는복부손상보다도빨리응급으로정복을해주어야한다. 고관절탈구는수상후 12 시간지나서정복한경우대퇴골두무혈성괴사의발생률이현저하게증가된다 3). 고관절탈구후에는무혈성괴사이외에관절연골, 관절낭, 인대등의손상으로외상성관절염이나, 이소성화골형성등의합병증이생길수있다. 급성탈구에서관혈적정복술의적응증은, 연부조직혹은골연골골절편이관절내로삽입되어도수정복이불가능한경우, 도수정복후탈구를자주일으키고안정된정복을유지할수없는경우, 탈구의정복전에는신경손상이없었으나정복후신경손상이나타난경우, 정복후에도손상된원위부사지의혈액순환장애가호전되지않을경우등이다. 본예에서는고관절이탈구되면서연부조직, 골연골골편이관절내에끼어있어서골편제거술을시행하였다. 외상성고관절탈구에서비구의후벽골절은흔히동반된다. 고관절탈구와동반되어비구골절이있을때비구골절의전위가 2-3 mm 이상이거나, 비구후벽골절이 40-50% 이상, 골견인이나피부견인으로고관절관절면유지가어려운경우, 연골하호각도 (roof arc) 가 45 이하, 관절내에골편이있는경우는수술의적응증이된다 3). 반대로 Olson 4) 은관절면이일치되고안정적이며후벽이 50% 이상 252 www.hipandpelvis.or.kr
Dong-Soo Kim et al.: Traumatic Recurrent Dislocation of the Hip with Bankart Type Lesion - A Case Report - 남아있을경우는보존적인치료를할수있다고하였다. Marchetti 등 5) 은고관절탈구에서비구의후벽골절이있을때정복후수술적으로고정하지않고보존적치료시에는피부견인또는골견인을최소 3-6 주간유지해야하고, 6 주간체중부하를금지해야한다고보고하였다. 본예의경우는비구의후벽골절이 40-50% 정도였고관절내에골편이있어수술적처치가필요하여골편은제거하였으나, 비구후벽에대한고정술은분쇄가심하여시행하지못하였다. 당시장골을이용한비구후벽의재건술또는인공관절치환술을고려하였으나고관절이안정성이있다고판단하여시행하지않았다. 또한최소한 3 주이상골견인, 또는피부견인이이루어졌어야하나, 환자의협조가이루어지지않아 1 주일동안만견인치료하여견인치료에대한기간도충분치않았다. 비구후벽골절시골편이하나의단일골편이고크기가크면수술적으로고정하기쉬우나, 골편이작을경우나분쇄골절의경우는금속판이나나사로고정하기어렵다. 이 러한경우장골을이용한비구후벽재건술을시도할수있다. 1993 년 Daum 6) 은외상성고관절탈구와동반된심한비구후벽의분쇄골절이있을때장골을이용하여비구후벽재건술을시행한두예를보고하였다. 그중한예에서는수술후단기적으로는좋은결과를보였으나시간이지나면서외상후관절염의진행, 무혈성괴사, 이소성골화등이나타나인공관절치환술을시행하였고, 다른예에서는장기적추시결과만족할만한결과를얻었다. 두예모두에서고관절탈구의재발은일어나지않았다고보고하였다. 또한 Mears 등 7) 에의하면비구후벽의골절에서관절면의감입의정도가 20% 이상이면관혈적정복을하여도결과가좋지않으므로일차적으로인공관절치환술을고려해야한다고하였다. 따라서본증례에서도고관절의안정성이있다고판단되었더라도비구후벽에대해일부라도고정을하거나일차적으로인공관절치환술을시행하는것이재발성탈구를방지하는데도움이되었을것이라는아쉬움이있다. Fig. 5. Second preoperative axial CT scans show bony defect of posterior wall of acetabulum and anterior aspect of femoral head. A B Fig. 6. Postoperative anteroposterior (A) and translateral (B) radiographs of the right hip show THRA state. www.hipandpelvis.or.kr 253
Hip Pelvis 24(3): 250-255, 2012 고관절의지속적인탈구가고관절이형성증, 감염, 또는다운증후군, 소아마비등의병적이상없이발생하는경우는전체탈구의 0-2% 로굉장히드물다. Weber 와 Ganz 8) 는지속적고관절탈구가있는환자에서관절낭봉합과 4 주간체중부하금지를통하여치료한예를보고하였고, Marti 등 9) 은대퇴골전자간부를내회전하여절골술로교정하고비구후벽을재건함으로서좋은결과를얻어보고하였다. Lieberman 등 10) 은고관절의지속적탈구가있을때비구관절와순이견관절의 Bankart 병변처럼손상이있는것에주목하였다. 비구의후벽골절은 10% 정도로미미하였으나비구관절와순의파열로탈구가재발되는환자에서관절와순과관절낭을봉합하여고관절의안정성을얻어고관절의재탈구를방지한증례를보고하였다. 본예의경우에는첫번째손상당시에는비구후벽이 50% 이상보존되었으나충분한침상안정이이루어지지않아재발성탈구가발생하였다. 그로인하여비구와대퇴골두에견관절의골성 Bankart 병변처럼골손상이발생하였고고관절은더욱불안정하여정복을유지할수없었다. 저자들은외상성고관절탈구에비구의후벽골절이동반되었을때적절한치료가시행되지않을경우재발성탈구로인한합병증이발생한다는점을통하여, 비구후벽의중요성을강조하고자한다. 비구후벽의골절이동반된고관절후방탈구의경우에는가능한비구후벽을고정하여고관절의안정성을얻는것이좋을것으로생각되며, 비구후벽의고정이힘들경우에는비구후벽의재건술도고려해야할것이다. REFERENCES 01.Heeg M, Klasen HJ, Visser JD. Operative treatment for acetabular fractures. J Bone Joint Surg Br. 1990;72:383-6. 02.Schlickewei W, Elsasser B, Mullaji AB, Kuner EH. Hip dislocation without fracture: traction or mobilization after reduction? Injury. 1993;24:27-31. 03.Keith JE Jr, Brashear HR Jr, Guilford WB. Stability of posterior fracture-dislocations of the hip. Quantitative assessment using computed tomography. J Bone Joint Surg Am. 1988;70:711-4. 04.Olson SA. The computerized tomography subchondral arc: a new method of assessing acetabular articular continuity after fracture (a preliminary report). J Orthop Trauma. 1993;7:402-413. 05.Marchetti ME, Steinberg GG, Coumas JM. Intermediateterm experience of Pipkin fracture-dislocations of the hip. J Orthop Trauma. 1996;10:455-61. 06.Daum WJ. Traumatic posterior acetabular defects reconstructed with iliac crest autograft. A report of two cases. Clin Orthop Relat Res. 1993;(291):188-92. 07.Mears DC, Velyvis JH, Chang CP. Displaced acetabular fractures managed operatively: indicators of outcome. Clin Orthop Relat Res. 2003;(407):173-86. 08. Weber M, Ganz R. Recurrent traumatic dislocation of the hip: report of a case and review of the literature. J Orthop Trauma. 1997;11:382-5. 09.Marti RK, Kloen P. Chronic recurrent posterior dislocation of the hip after a Pipkin fracture treated with intertrochanteric osteotomy and acetabuloplasty. A case report. J Bone Joint Surg Am. 2000;82:867-72. 10.Lieberman JR, Altchek DW, Salvati EA. Recurrent dislocation of a hip with a labral lesion: treatment with a modified Bankart-type repair. Case report. J Bone Joint Surg Am. 1993;75:1524-7. 254 www.hipandpelvis.or.kr
Dong-Soo Kim et al.: Traumatic Recurrent Dislocation of the Hip with Bankart Type Lesion - A Case Report - 국문초록 반복적인외상성고관절탈구로인해발생한 Bankart 유형의병변 김동수 손현철 김용민 최의성 조병기 박지강 김동환충북대학교의과대학정형외과학교실 성인고관절의재발성탈구는신경근육성질환이있거나고관절이형성증이있는경우에드물게발생할수있다. 저자들은비구의후벽골절이동반된고관절탈구환자에서비구후벽의분쇄가심해고정이힘들어연부조직만봉합한후, 적절한보존적치료를하지못한환자에서지속적인재발성탈구로진행하였고, 고관절의후벽이견관절의골성 Bankart 병변처럼변화하고대퇴골두의전내측은골결손을보여정복이유지되지않아고관절인공관절전치환술을시행한예를경험하였다. 수술후 1 년째에고관절은탈구없이양호한결과를보이고있었으며, 본증례를통해고관절후벽고정의중요성에대해강조하고자한다. 색인단어 : 고관절, 비구후벽, 재발성탈구 www.hipandpelvis.or.kr 255