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대한정형외과학회지 : 제 43 권제 4 호 2008 J Korean Orthop Assoc 2008; 43: 501-505 세라믹골두골절에서금속대폴리에틸렌관절면재치환술후발생한 Metallosis - 증례보고 - 이경재ㆍ정수원ㆍ조철현ㆍ민병우 계명대학교의과대학정형외과학교실 Metallosis after Revision of a Fractured Ceramic Head onto a Metal-on-Polyethylene Articulation - A Case Report - Kyung-Jae Lee, M.D., Su-Won Jung, M.D., Chul-Hyun Cho, M.D., and Byung-Woo Min, M.D. Department of Orthopedic Surgery, College of Medicine, Keimyung University, Daegu, Korea A ceramic articulation thought to be superior to metal-on-polyethylene due to its extremely low coefficient of friction and its potential for resistance to wear. But ceramic is brittle, which makes it theoretically susceptible to fracture. Although many authors have reported that metal-on-polyethylene articular pairing had good results after a ceramic head fracture, there have been few reports about complication due to the remaining ceramic particles after revision surgery. We report here on a case of severe metallosis that was thought to be due to third body wear by the remaining fractured ceramic particles after revision total hip arthroplasty. Key Words: Total hip arthroplasty, Ceramic head fracture, Third body wear, Metallosis 1970년대초 Boutine 3) 이인공고관절전치환술에서알루미나세라믹을도입한이래세라믹-세라믹관절면은높은마모에대한저항성및낮은마찰계수등의특징으로인해젊고활동적인환자들에게매우희망적인선택으로생각되어지고있다. 알루미나세라믹골두의파손빈도는 0.004% 정도로매우미미한정도로감소하였지만낮은파손인성 (fracture toughness) 으로인한세라믹골두의골절은여전히문제점으로지적되고있다. 세라믹골두골절후대퇴스템의 Morse taper 의소성변형으로인해여러저자들이안정고정된대퇴스템을재치환하거나금속- 폴리에틸렌관절면을이용하여재치환술을시행할것을제안하였지만 1,7,10), 재치환술후남 아있는세라믹입자에의한관절면의마모에대한보고는매우드물다 5,6). 이에저자들은양측성대퇴골두무혈성괴사로세라믹-세라믹관절면을이용한인공고관절전치환술후세라믹골두골절이발생한환자에서금속 -폴리에틸렌관절면을이용하여재치환술을시행하고추시관찰중남아있던세라믹입자에의한제 3개체마모 (third body wear) 로발생한과도한 metallosis 1예를경험하였기에문헌고찰과함께보고하는바이다. 증례보고양측고관절대퇴골두무혈성괴사로진단받고본원에서순차적으로양측의무시멘트성인공고관절전치환술 통신저자 : 민병우대구시중구동산동 194 번지계명대학교의과대학정형외과학교실 TEL: 053-250-7729 ㆍ FAX: 053-250-7205 E-mail: min@dsmc.or.kr Address reprint requests to Byung-Woo Min, M.D. Department of Ortopedic Surgery, College of Medicine, Keimyung University, 194, Dongsan-dong, Jung-gu, Daegu 700-712, Korea Tel: +82.53-250-7729, Fax: +82.53-250-7205 E-mail: min@dsmc.or.kr 501

502 이경재ㆍ정수원ㆍ조철현외 1 인 을시행받은 35세남자환자로수술당시키는 167 cm, 몸무게는 61 kg이었다. 2003년 1월좌측고관절에대해최소침습적전측방도달법을이용하여세라믹 -세라믹무시멘트성치환물 (BiCONTEACT system, Aesculap, Tuttlingen, Germany) 및 Biolox Forte (CeramTec AG, Plochingen, Germany) 로제조된비구컵내삽입물과짧은경부 ( 3.5 mm) 의 28-mm 대퇴골두를삽입하였고, 2004년 6월우측고관절에대해 PLUS Orthopedics 사의무시멘트성치환물 (SL-PLUS system, EP-FIT PLUS system, PLUS Endoprothetik AG, Rotkreuz, Switzerland) 및 Biolox Forte로제조된비구컵내삽입물과중간경부 (0 mm) 의 32-mm 대퇴골두를삽입하였다 (Fig. 1). 2006 년 10월일상생활중발생한좌측고관절부의갑작스러운동통및덜거덕거리는소리가있어본원내원하여시행한방사선소견상세라믹대퇴골두의골절소견이관찰되었다 (Fig. 2). 수술소견상세라믹골두는여러조각으로깨어져있었으며세라믹라이너, 주위관절낭및활액막의일부가검게착색되어있었다. 고관절을탈구시킨후깨어진세라믹골두와세라믹라이너및검게착색된연부조직을포함한주위조직을광범위제거하였다. 금속비구컵및대퇴스템의움직임은관찰되지않아제거된것과같은회사에서생산된금속골두 (28-mm) 와폴리에틸렌라이너를결합한후고관절을정복하였다. 술후 2개월부터는전체중부하보행을시작 하였고이후정기적외래추적관찰을하며지냈다. 재치환술후 8개월째좌측고관절의동통을주소로내원하여시행한방사선소견상좌측고관절주위의연부조직에뭉게구름처럼보이는음영이증가된거품소견 (bubble sign) 이관찰되었으며수술소견상인공관절주위연부조직이검게착색되어있었고연부조직내에서깨진세라믹조각이발견되었다 (Fig. 3). 금속골두및폴리에틸렌라이너표면에긁힌상처 (scratch) 와마모소견이관찰되었으나, 대퇴스템및금속비구컵은안정고정되어있었고육안적으로 taper 의특이한소견이관찰되지 Fig. 2. A radiograph shows the fracture of the ceramic femoral head. Fig. 1. Radiographs of both femurs taken 4 weeks after each surgery show a well-fixed cup and stem. Fig. 3. (A) A radiograph immediately before the left hip re-revision surgery shows the bubble sign around the left hip that indicates severe metallosis. (B) A photograph during the re-revision THA reveals fragmented ceramic particles in the black tissue, indicating metallosis.

세라믹골두골절에서금속대폴리에틸렌관절면재치환술후발생한 Metallosis 503 Fig. 4. (A) Many scratches were observed on the abraded surface of the metal head on SEM. (B) Many large particles were embedded in the worn surface of the polyethylene as documented by SEM. (C) Those particles contained aluminum and oxygen on EDS examination. 않아같은회사의세라믹-세라믹관절면을이용하여재재치환술을시행하였다. 수술중제거된금속골두와폴리에틸렌라이너에대해 scanning electron microscope (SEM, JSM 5410, JEOL, Tokyo, Japan) 및 energy dispersive X-ray spectroscopy (EDS, 6587- SP, Oxford, England) 를이용한분석을시행하여금속골두및폴리에틸렌라이너관절면에수많은긁힌상처를확인할수있었으며라이너관절면에박혀있는세라믹입자를확인할수있었다 (Fig. 4). 재재치환술후 6개월째환자는장거리보행후수술부위의경미한동통이외에는일상생활을하는데특별한증상없이잘지낼수있었다. 고찰세라믹은기계적으로강성 (stiffness) 및경도 (hardness) 가높고마찰계수가낮아마모에대한저항성이우 수할뿐만아니라 1990년대이후고온균등압박 (hot isostatic pressurization) 과정을통해제작된제 3세대세라믹및 taper 디자인의개발등으로골두파손의빈도도크게줄어들어대체관절면의하나로주목받고있다 2). 그러나낮은파손인성 (fracture toughness) 으로인해응력- 변형률곡선에서소성변형구간이거의없어깨지기쉽다는문제가여전히존재하며임상적으로드물게보고되고있다 1,5,10). 세라믹골두골절의원인으로는직접적인외상, 육체적활동, 과체중등을들수있으며그외부품간의불일치, 직경이작은골두, 설계및제조상의오류도관여할수있다 4). 본증례에서는구형의 28 mm 골두를사용하였고직접적외상의병력은없었으나젊고활동적인연령의남자환자였다. 세라믹골두골절에대한재치환술시테이퍼에약간의미란성변화라도골두에스트레스집중을증가시켜재치

504 이경재ㆍ정수원ㆍ조철현외 1 인 금속-폴리에틸렌관절면을사용할경우금속골두마모에의한 metallosis 의발생에대한세심한관찰이필요할것으로사료된다. Fig. 5. A photograph shows an example of a metal adapter that, like an extension piece, is fitted onto the deformed cone. 환된세라믹골두의골절을일으킬수있기때문에 9) 여러저자들이안정고정된스템을재치환하거나스템을교체하지않을경우코발트 -크롬골두로교체하는것이좋다고보고하였다 4,5,8,9). 하지만세라믹골두골절후남아있던세라믹입자에의한 metallosis 등과같은심각한합병증이드물지만보고되고있으며 1,5,6), Allain 등 1) 은 multicenter survivorship study 에서세라믹골두골절에서재치환술후관절주위연부조직및관절면내에세라믹입자가남아제 3개체마모를유발할수있다고하였고, Matziolis 등 6) 은현실적으로수술중육안으로모든파손된세라믹입자의제거가불가능함으로수술후파손된세라믹입자가남아있을수있고이입자가금속- 폴리에틸렌관절면사이로들어가폴리에틸렌삽입물이금속골두에대해단단하고불규칙한마모면으로작용할수있으므로마모를줄이기위해대퇴스템을치환하지않을경우금속 adapter (Fig. 5) 를이용한세라믹- 세라믹관절면을사용할것을주장하였다. 본증례에서도 SEM 사진상수많은마모입자가폴리에틸렌표면에존재함을확인하였고이들로인해금속골두표면에마모가발생하였고, EDS 분석결과대부분이세라믹입자임을확인할수있었다. 세라믹골두골절은드물게발생하지만 metallosis 등으로인해여러차례의재치환술을필요로할수있는심각한합병증이다. 본증례에서처럼재치환술후에도파손된세라믹입자가남아제 3개체마모를유발할수있으므로술중파손된세라믹입자에대한세심한제거가선행되어야하겠고대퇴스템을치환하지않을경우금속 adapter 를이용한세라믹-세라믹관절면을사용하는것이하나의선택사항이될수있을것으로사료되며, 참고문헌 1. Allain J, Roudot-Thoraval F, Delecrin J, Anract P, Migaud H, Goutallier D: Revision total hip arthroplasty performed after fracture of a ceramic femoral head. A multicenter survivorship study. J Bone Joint Surg Am, 85: 825-830, 2003. 2. Archibeck MJ, Jacobs JJ, Black J: Alternate bearing surfaces in total joint arthroplasty: biologic considerations. Clin Orthop Relat Res, 379: 12-21, 2000. 3. Boutin P: Total arthroplasty of the hip by fritted aluminum prosthesis. Experimental study and 1st clinical applications. Rev Chir Orthop Reparatrice Appar Mot, 58: 229-246, 1972. 4. Callaway GH, Flynn W, Ranawat CS, Sculco TP: Fracture of the femoral head after ceramic-on-polyethylene total hip arthroplasty. J Arthroplasty, 10: 855-859, 1995. 5. Kempf I, Semlitsch M: Massive wear of a steel ball head by ceramic fragments in the polyethylene acetabular cup after revision of a total hip prosthesis with fractured ceramic ball. Arch Orthop Trauma Surg, 109: 284-287, 1990. 6. Matziolis G, Perka C, Disch A: Massive metallosis after revision of a fractured ceramic head onto a metal head. Arch Orthop Trauma Surg, 123: 48-50, 2003. 7. Miki H, Sugano N, Yamamura M, Nakamura N, Nishii T, Yoshikawa H: Serious metallosis of a metal head due to fragmented ceramic screws in a cemented THA. Arch Orthop Trauma Surg, 126: 192-196, 2006. 8. Otsuka NY, Schatzker J: A case of fracture of a ceramic head in total hip arthroplasty. Arch Orthop Trauma Surg, 113: 81-82, 1994. 9. Pulliam IT, Trousdale RT: Fracture of a ceramic femoral head after a revision operation. A case report. J Bone Joint Surg Am, 79: 118-121, 1997. 10. Torán MM, Cuenca J, Martinez AA, Herrera A, Thomas JV: Fracture of a ceramic femoral head after ceramic-onceramic total hip arthroplasty. J Arthroplasty, 21: 1072-1073, 2006.

세라믹골두골절에서금속대폴리에틸렌관절면재치환술후발생한 Metallosis 505 = 국문초록 = 세라믹은마찰계수및마모에대한저항성에있어금속 - 폴리에틸렌관절보다우수하지만소성변형범위가매우적어 (brittle) 깨지기쉬운특성을가지고있다. 알루미나세라믹골두의파손은드물게보고되고있으며골두파손시대퇴스템의 Morse taper 의소성변형으로인해금속 - 폴리에틸렌관절면을이용한재치환술을시행하는것이좋은결과를보인다고보고되고있지만재치환술후남아있는세라믹입자에의한관절면의마모에대한보고는매우드물다. 저자들은양측성대퇴골두무혈성괴사로세라믹 - 세라믹관절면을이용한인공고관절전치환술후세라믹골두골절이발생한환자에서금속 - 폴리에틸렌관절면을이용하여재치환술을시행하고추시관찰중남아있던세라믹입자에의한제 3 개체마모 (third body wear) 로발생한과도한 metallosis 1 예를경험하였기에이를보고하고자한다. 색인단어 : 인공고관절전치환술, 세라믹골두파손, 제 3 개체마모, Metallosis