대흉외지 2009;42:220-225 임상연구 흉늑쇄패혈성관절염의수술적치료의임상결과 김신 * ㆍ이희성 ** ㆍ김건일 * ㆍ조성우 *** ㆍ김형수 **** 신호승 ***** ㆍ이재웅 ****** ㆍ홍기우 ****** The Clinical Results of Surgical Treatment for Sternoclavicualr Septic Arthritis Shin Kim, M.D.*, Hee-Sung Lee, M.D.**, Kun-Il Kim, M.D.*, Sung-Woo Cho, M.D.***, Hyoung-Soo Kim, M.D.****, Ho-Seung Shin, M.D.*****, Jae-Woong Lee, M.D.******, Ki Woo Hong, M.D.****** Background: Sternoclavicular septic arthritis manifests serious complications such as abscess, osteomyelitis, mediastinitis and empyema; therefore, a prompt diagnosis and appropriate treatment are necessary. Material and Method: The treatment results of eight patients with sternoclavicular septic arthritis and who had been surgically treated at our institutions between September 2005 and July 2008 were retrospectively reviewed. The surgical treatment they underwent was en bloc resection, including partial resection of the sternum, the clavicular head and the 1st rib. Result: The patients ranged in age from 40 to 74 years with an average of 55.1±10.3 years. Five were men and three were women. There were 6 patients with spontaneous sternoclavicular septic arthritis and 2 patients had their condition induced by central venous catheters. The pathogens isolated from the patients blood and wounds were MRSA (3), Streptococcus intermedius (1), Streptococcus agalactiae (1) and Pseudomonas luteola (1). One patient expired from aggravation of preoperative sepsis on POD 31. Conclusion: The life-threatening complications from sternoclavicular septic arthritis can progress and lead to death unless appropriate treatment is administered. A prompt diagnosis, appropriate antibiotics therapy and effective surgical treatment such as radical en bloc resection can reduce the morbidity and mortality of this malady. Key words: 1. Infection 2. Treatment outcome 3. Sternoclavicular joint 4. Septocemia (Korean J Thorac Cardiovasc Surg 2009;42:220-225) * 한림대학교의과대학성심병원흉부외과학교실 Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine ** 한림대학교의과대학강남성심병원흉부외과학교실 Department of Thoracic and Cardiovascular Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine *** 한림대학교의과대학강동성심병원흉부외과학교실 Department of Thoracic and Cardiovascular Surgery, Kangdong Saced Heart Hospital, Hallym University College of Medicine **** 한림대학교의과대학춘천성심병원흉부외과학교실 Department of Thoracic and Cardiovascular Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine ***** 한림대학교의과대학한강성심병원흉부외과학교실 Department of Thoracic and Cardiovascular Surgery, Hangang Sacred Heart Hospital, Hallym University College of Medicine ****** 한림대학교의과대학흉부외과학교실 Department of Thoracic and Cardiovascular Surgery, Hallym University College of Medicine 논문접수일 :2008 년 8 월 31 일, 심사통과일 :2008 년 10 월 27 일책임저자 : 이희성 (150-950) 서울시영등포구대림 1 동 948-1, 한림대학교강남성심병원흉부외과 (Tel) 02-829-5138, (Fax) 02-849-4469, E-mail: lheecs@naver.com 본논문의저작권및전자매체의지적소유권은대한흉부외과학회에있다. 220
김신외 Clinical Results of Sternoclavicualr Septic Arthritis Table 1. Summary table of 8 cases of sternoclavicular septic arthritis Other Age Isolated Positive Predisposing Surgical Antibiotics, Patient Sex site of (yr) bacteria culture factor treatment outcome infection 1 64 F Pseudomonas Wound DM, CRF No. En block resection of Cepha. I st generation x 1 day, luteola Perm. Catheter Rt. SC jt., tazocin x 13 days: cure 2 60 M MRSA Blood DM, CRF No. En block resection of Cepha. Ist. generation x 11 days, Rt. SC jt., I&D gatifloxacin x 31 days: cure 3 52 M None None None, No. En block resection of Cepha. Ist. generation x 11 days, acupuncture Rt. SC jt. netilmycin x 9 days: cure 4 52 M MRSA Wound None No. En block resection of Cepha. Ist. generation x 17 days; Rt. SC jt., I&D cure 5 74 F None None DM, Tbc No. En block resection of Anti-TBc medications Rt. SC jt. moxifloxacin x 10 days: cure 6 45 M Streptococcus Wound DM, No. En block resection of Cepha. 1st. generation x 13 days, intermedius acupuncture Rt. SC jt. netilmucin x 3 days, tazocin x 11 days: cure 7 43 M MRSA Blood Rt. Jugular No. En block resection of Vancomycin x 22 day: death Wound vein catheter Rt. SC jt.&neck insertion dissection 8 51 M Streptococcus Wound DM No. En block resection of Cepha. 3rd. generation x 5 days, agalactiae Rt. SC jt. ciprofloxacin x 8 days, Abscess drainage penicilin x 7 days: cure yr=years; M=Male; F=Female; MRSA=Methicillin-resistant Staphylococcus aureus; DM=Diabetes mellitus; CRF=Chronic renal failure; TBc=Tuberculosis; SC=Sternoclavicular; I&D=Incision&drainage; Cepha=Cephalosporin. 서 론 대상및방법 흉늑쇄패혈성관절염은매우드문질환이다 [1]. 흉늑쇄패혈성관절염은임상증상이모호하며다른질병과혼돈되는경우가적지않아진단이늦어지고치료가지연되는경우가많다 [2]. 이러한흉늑쇄패혈성관절염이진행하여경부나앞쪽흉곽의농양 [3,4], 골수염 [5], 종격동염 [6], 농흉 [7] 등의합병증이동반될수있고, 패혈증으로진행시사망의가능성이높다. 뿐만아니라이에대한치료도보존적항생제치료및단순한배농술에서보다더적극적인흉늑쇄관절의광범위절제술까지다양하게시행되고있어논쟁이많다. 이에저자들은흉늑쇄패혈성관절염으로근치절제술을받은환자들의의무기록을후향적으로조사하고수술적치료의임상결과를보고한다. 연구대상은 2005년 9월부터 2008년 7월까지흉늑쇄패혈성관절염으로진단되어근치적절제술을시행한 8명의환자를대상으로하였다. 본연구에서는자연성패혈성관절염환자 ( 자연성환자 ) 6명과중심정맥관거치후에발생한흉늑쇄패혈성관절염환자 ( 의인성환자 ) 2명이었다. 자연성환자들중에 2명은본의료원내원전한방병원에서침술을시행받았던기왕력이있으나흉늑쇄관절염에준하는증상으로한방병원을내원하였고, 침술이흉늑쇄패혈성관절염의유발인자나악화인자라고단정짓기어려운이유로자연성환자로구분하였다. 진단은병력청취, 이학적검사소견, 혈역학적검사, 단순흉부촬영및견갑부단순촬영, 흉부컴퓨터전산화단층촬영, 골주사검사, 흉부자기공명영상을통해이루어졌다. 흉늑쇄패혈성관절염으로진단되면혈액배양검사및염증부위천자를통한배양검사를시행하여균을동정하였다. 균동정전에는세팔로스포린 (1세대또는 2세 221
대흉외지 2009;42:220-225 Fig. 1. Preoperative chest CT. Computed tomographic image (bone windows) of a patient with right sternoclavicular joint infection. The study demonstrates involvement of the joint space (thick arrow) as well as surrounding soft tissue involvement (thin arrow). Fig. 2. Preoperative bone scan. Focal hot uptake was seen on Rt. Sternal and clavicle area. 대 ) 과아미노글루코사이드를병용투여하였고, 균동정후적절한항생제치료와가능한신속하게근치적절제술을시행하였다. 근치적절제술은쇄골골두의내측 1/3정도와흉골의자루부일부및첫번째늑골의연골부를포함하여농양의주머니를제거한후, 다량의생리식염수와 2% 타우로린주를이용하여세척술을시행하였다. 결손된공간의최소화를위해 JP 배액관을거치시키고수술후수술부위를거즈공을만들어압박하였다. 대상환자의의무기록을후향적으로조사하였고성별, 연령, 위험인자, 병변부위와양상, 동반질환, 임상증상, 동반합병증, 수술적치료방법, 술후합병증및사망률등을분석하였다. 통계처리는 SPSS (window version10.1) 을이용하였고모든변수는평균 ± 표준편차로표시하였다. 222
김신외 Clinical Results of Sternoclavicualr Septic Arthritis 결과흉늑쇄패혈성관절염으로수술받은 8명의환자중남자가 5명여자가 3명이었다. 평균연령은 55.1±10.3세였고, 연령분포는 40세에서 74세까지였다. 자연성흉늑쇄패혈성관절염이생긴경우기저질환으로당뇨병을가진 2예, 당뇨병에결핵의기왕력이있는 1예, 당뇨와만성신부전 1예, 그리고 2예는기저질환이없었다. 중심정맥관거치후흉늑쇄패혈성관절염이생긴경우는기저질환으로당뇨와만성신부전을가진환자 1예와기저질환이없는환자가 1예이었다 (Table 1). 환자의혈액및염증부위에서동정된균종은 MRSA 3예, Streptococcus intermedius 1예, Streptococcus agalactiae 1예, Pseudomonas luteola 1예였고, 뚜렷한원인균을찾지못한환자가 2예였다 (Table 1). 흉늑쇄패혈성관절염의진단은임상양상과단순방사선사진만으로는부족한점이많아모든환자에서전산화단층촬영을시행하였으며 (Fig. 1) 뼈주변의염증반응, 부골형성, 반응성경화, 누공, 공기액체증등의소견이명확하지않아흉늑쇄패혈성관절염을진단하기에애매모호한경우에골주사검사를실시하여흉늑쇄관절을포함하는주변의골조직의음영증가여부를검사하였다 (Fig. 2). 본연구에서는 4예에서추가로골주사검사를시행하였으며 8명의환자모두에게서골수염소견이관찰되어수술적조치를취하였다. 본연구에포함된 7예의흉늑쇄패혈성관절염환자에서수술후합병증은없었다. 한명의환자가타의료기관에서시행한우측내경정맥을통한중심정맥관거치후흉늑쇄패혈성관절염이발생하였고, 경부의흉쇄유돌근내농양배농및세척과함께흉늑쇄관절부근치절제술을시행하였으나이후수술전패혈증이진행되어반복된폐렴, 급성신부전등의합병증으로사망하였다. 고찰흉늑쇄관절은쇄골의내측골두의아랫부분과, 복장자루뼈의상부위바깥쪽부분의패임, 그리고첫번째늑골의연골을포함하는활액막으로둘러싸인공간을이른다 [1]. 흉늑쇄패혈성관절염은성인의경우약물남용이나면역저하자 ( 스테로이드로전신질환치료를받는환자, 당뇨환자, 또는만성신부전환자 ) 및중심정맥도관삽입환자들에서주로발병한다 [8]. 본연구에서는 2예의환자를제외하고모두유발인자 (Table 1) 가존재하였고그중 2예의 Table 2. Clinical features of sternoclavicular septic arthritis Characteristic No. of patients Chest pain 2 Shoulder pain 5 Dyspnea 2 SCJ swelling without pain 6 Rt. SCJ involve 8 Lt. SCJ involve 0 Tender SCJ 8 Decreased ROM shoulder 4 Fever >38 o C 3 WBC >11 10 3 6 Bacteremia 2 Clavicular and/or sternal osteomyelitis 8 Chest wall abscess 8 Abscess on SCM muscle 1 Mortality 1 SCJ=Sternoclavicular joint; WBC=White blood cell; ROM= Range of motion; SCM=Sternocleidomastoid. 환자에서중심정맥도관으로인하여흉늑쇄패혈성관절염이발병하였다. 흉늑쇄패혈성관절염환자들의임상증상은경미하거나다양하며 (Table 2) 환자가치료를위해병원을방문하게되기까지시간이늦어지게되는경우가많아골수염을포함한다른합병증으로이행하는빈도가높다 [1,9-12]. Linscheid 등 [13] 은흉늑쇄관절부위의부기가천천히진행하여비전형적흉통만으로흉늑쇄패혈성관절염을폐질환으로오진한 2예를보고한바있으며, Wohlgethan JR 등 [4] 의 1988년보고에선흉늑쇄패혈성관절염환자들의조기진단이늦어져고름집형성과종격동및흉벽으로직접파급이동반된임상예가 21% 였다. 흉늑쇄패혈성관절염의빠른진단은치료에성공여부에있어서가장중요한부분이며비전형적전흉부통증시흉늑쇄패혈성관절염의가능성을고려해야만한다. 본연구에서타의료기관에서시행한우측내경정맥을통한중심정맥관거치후흉쇄유돌근내농양및흉늑쇄패혈성관절염이동반된 1예에서증상발현 10일후본원으로전원되어진단이늦어져수술전발병한패혈증이진행하여수술후합병증으로사망하였다. 만약감염의증후와증상이빠르게소실되지않으면전산화단층촬영을시행하여수술을위한감염의범위를정확히알아내야한다. 흉늑쇄패혈성관절염의전산화단층촬영상소견은뼈주 223
대흉외지 2009;42:220-225 변의염증반응, 부골형성, 반응성경화, 누공, 공기액체증등이있으며 [4,14,15], 전산화단층촬영소견이애매모호한경우에골주사검사를시행하였고본연구와과거발표된논문에서골수염진단에있어매우효과적이었다 [16]. 흉늑쇄패혈성관절염의치료법에대해서는아직논란이있다. 보존적항생제치료및단순한배농술을조기에치료하는경우도있으나이경우실패율이높은것으로보고되고있다 [17]. 뿐만아니라조기치료실패로주변골조직에골수염이발생하면치료가어렵고, 적절한치료가늦어지면관절낭이터져감염이흉벽과후종격, 심하면상위의종격동까지파급되어생명을위협할수있다 [7,12]. 흉늑쇄폐혈성관절염의치료로조기에전신마취하에흉늑쇄관절의근치적절제술과적절한항생제의투여가심각한합병증으로의진행을막을수있다. 결 결론적으로흉늑쇄패혈성관절염은적절한치료가이루어지지않으면합병증으로사망까지이를수있는질환으로신속한진단과적절한항생제의사용및광범위근치절제술등의효과적인치료를통하여이환율과사망률을낮출수있을것이다. 론 참고문헌 1. Yood YA, Goldenberg DL. Sternoclavicular joint arthritis. Arthritis Rheum 1980;23:232-9. 2. Western VC, Jones AC, Bradbury N, Fawthrop F, Doherty M. Clinical features and outcomes of septic arthritis in a single UK health district 1982-1991. Ann Rheum Dis 1999;58:214-9. 3. Linthoudt DV, Velan F, Ott H. Abscess formation in sternoclavicular joint septic arthritis. J Rheumatol 1989;16:413-4. 4. Wohlgethan JR, Newberg AH, Reed JI. The risk of abscess from sternoclavicular arthritis. J Rheumatol 1988;15:1302-6. 5. Tecce PM, Fishman EK. Spiral CT with multiplanar reconstruction in the diagnosis of sternoclavicular osteomyelitis. Skeletal Radiol 1995;24:275-81. 6. Pollack MS. Staphylococcal mediastinitis due to sternoclavicular pyarthrosis: CT appearance. J Comput Assist Tomogr 1990;14:924-7. 7. Chen WS, Wan YL, Lui CC, Lee TU, Wang KC. Extrapleural abscess secondary to infection of the sternoclavicular joint. J Bone Joint Surg 1993;75:1835-9. 8. Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine 2004;83:139-48. 9. Muir SK, Kinsella PL, Trebilcock RG, Blackstone IW. Infectious arthritis of the sternoclavicular joint. Can Med Assoc J 1985;132:1289-90. 10. Lindsey RW, Leach JA. Sternoclavicular osteomyelitis and pyarthrosis as a complication of subclavian vein catheterization: a case report and review of the literature. Orthopedics 1984;7:1017-21. 11. Hunter D, Moran JF, Venezio FR. Osteomyelitis of the clavicle after Swan-Ganz catheterization. Arch Intern Med 1983;143:153-4. 12. Sonobe M, Miyazaki M, Nakagawa M, et al. Descending necrotizing mediastinitis with sternocostoclavicular osteomyelitis and partial thoracic empyema: report of a case. Surg Today 1999;29:1287-9. 13. Linscheid RL, Kelly PJ, Martin WJ, Rontana RS. Monarticular bacterial arthritis of the sternoclavicular joint. JAMA 1961;178:421-2. 14. Gerscovich EO, Greenspan A. Osteomyelitis of the clavicle: clinical, radiologic, and bacteriologic findings in ten patients. Skeletal Radiol 1974;23:205-10. 15. Alexander PW, Shin MS. CT manifestation of sternoclavicular pyarthrosis in patients with intravenous drug abuse. J Comput Assist Tomogr 1990;14:104-6. 16. Gerscovich EO, Greenspan A. Osteomyelitis of the clavicle: clinical, radiologic, and bacteriologic findings in ten patients. Skeletal Radiol 1974;23:205-10. 17. Song HK, Guy TS, Kaiser LR, Shrager JB. Current presentation and optimal surgical management of sternoclavicular joint infections. Ann Thorac Surg 2002;73:427-31. 224
김신외 Clinical Results of Sternoclavicualr Septic Arthritis = 국문초록 = 배경 : 흉늑쇄패혈성관절염은농양, 골수염, 종격동염, 농흉등의심각한합병증이동반되는흉늑쇄관절부감염으로신속한진단및적절한치료가이루어져야한다. 대상및방법 : 2005 년 9 월부터 2008 년 7 월까지본의료원에서흉늑쇄패혈성관절염으로수술적치료를받은 8 명의환자를대상으로수술적치료결과를후향적으로조사하였다. 흉늑쇄패혈성관절염의수술적치료로는광범위흉골, 쇄골두및첫번째늑골의부분절제를포함하는근치절제술을시행하였다. 결과 : 환자의연령분포는 40 세에서 74 세까지였고평균연령은 55.1±10.3 세였다. 남자가 5 명, 여자가 3 명이었다. 자연성흉늑쇄패혈성관절염이 6 예이었고, 중심정맥관거치후에발생한흉늑쇄관절염이 2 예였다. 흉늑쇄패혈성관절염의위치는모두우측이었다. 환자의혈액및염증부위, 객담배양에서동정된균종은 MRSA 3 예, Streptococcus intermedius 1 예, Streptococcus agalactiae 1 예, Pseudomonas luteola 1 예였다. 근치절제술환자중 1 명의환자가수술전패혈증이진행하여수술후 31 일째사망하였다. 결론 : 흉늑쇄패혈성관절염은적절한치료가이루어지지않으면합병증으로사망까지이를수있는질환으로신속한진단과적절한항생제의사용및광범위근치절제술등의효과적인치료를통하여이환율과사망률을낮출수있을것이다. 중심단어 :1. 감염 2. 치료결과 3. 흉늑쇄관절 4. 패혈증 225