ORIGINAL ARTICLE http://dx.doi.org/10.5371/hp.2012.24.3.206 Periprosthetic Mass after Total Hip Replacement Yoo-Sun Jeon, MD, Deuk-Soo Hwang, MD, Chan Kang, MD, Eui-Chang Kim, MD*, Gi-Soo Lee, MD, Jae-Whang Song, MD Department of Orthopedic Surgery, Research Institute for Medical Science, Chungnam National University School of Medicine, Daejeon, Korea, On Orthopedic Clinic, Suwon, Korea* Purpose: To analyze the characteristics and causes of periprosthetic huge mass which occur after treatment by total hip arthroplasty. Materials and Methods: Of the patients who had undergone total hip arthroplasty from January 2000 to October 2007, we retrospectively evaluated the 10 patients who suffered huge soft tissue mass. Five of these patients had received metal-on-metal bearing (group 1) prostheses, and the other 5 had received metal-onpolyethylene bearings (group 2). We evaluated the size and location of the mass, the extent of osteolysis, and the hematologic and pathologic examination results. Results: Roentgenographically, the location of the masses varied from the acetabular area to the distal femoral stem. The mean mass diameter of all 10 patients was 14.6 cm(7-21 cm) 6.2 cm(3-9 cm) 7.2 cm(4-12 cm). Osteolytic lesions were found in 3 group 1 patients and 3 patients in group 2. High counts of lymphocytes and eosinophils were present in group 1. High counts of macrophages were present in group 2. Conclusion: The occurrence of osteolysis and huge soft mass after total hip arthroplasty is thought to be related to foreign body reaction by polyethylene wear particles and metal hypersensitivity. Outside-in patterned cortical thinning was considered to be indicative of a long standing periprosthetic soft tissue mass effect. Key Words: Metal hypersensitivity, Polyethylene wear particles, Huge soft tissue mass, Total hip arthroplasty 서 론 고령화사회가되고고령인구의활동이증가하면서최 Submitted: April 21, 2012 1st revision: June 1, 2012 2nd revision: July 4, 2012 3rd revision: July 25, 2012 4th revision: August 6, 2012 Final acceptance: August 6, 2012 Address reprint request to Deuk-Soo Hwang, MD Department of Orthopedic Surgery, Research Institute for Medical Science, Chungnam National University School of Medicine, 33 Munwha-ro, Jung-gu, Daejeon 301-721, Korea TEL: +82-42-280-7350 FAX: +82-42-252-7098 E-mail: dshwang@cnu.ac.kr 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. 근인공고관절치환술이많이시행되고있고, 그에따른합병증의발생에대해서도점점관심이높아지고있다. 감염, 탈구, 삽입물의해리등과같은합병증은인공고관절치환술에대한수술적, 기술적발전으로감소하고있지만인공고관절치환술시사용되는인공삽입물에대한인체의금속과민증혹은인공삽입물로부터생성되는마모입자에의한이물반응은고관절주위연부조직에거대종괴의형성이나인공관절주위골용해를일으킬수있는합병증으로관심의대상이되고있다 1). 저자들은금속대금속치환술과금속대폴리에틸렌치환술모두에서수술후장기경과후인공관절주위연부조직에거대종괴의형성을경험하였고, 이는삽입관절면의종류에따라종괴형성의원인과양상에차이가있을것으로추정하였으며, 이에인공고관절치환술의장기추시합병증으로서치환물주변의다양한부위에발생한연부조직의거대종괴에대해후향적으로분석해보고자하였다 206 Copyright c 2012 by Korean Hip Society
Yoo-Sun Jeon et al.: Periprosthetic Mass after Total Hip Replacement 대상및방법 2000 년 1 월에서 2007 년 10 월까지본원에서인공고관절치환술을시행받은환자중수술후추시상거대종괴및골용해가발생하여수술적치료가필요했던 10 예를대상으로후향적분석을시행하였다. 10 예중 6 예는압통을동반한통증과종창을주소로내원하였고 4 예의경우에는종창만을주소로내원하였다. 대상환자총 10 예중남자는 4 예, 여자는 6 예였고, 평균연령은 53.1 세 (36-68 세 ) 였으며, 좌측은 4 예, 우측은 6 예이었다. 이중금속대금속치환술을시행한 5 예를 1 군 (MetaSUL, Sulzer Orthopedics, Baar, Switzerland), 금속대폴리에틸렌치환술을시행한 5 예를 2 군 (Modular head & Insert, Sulzer Orthopedics, Barr, Switzerland) 으로분류하였다. 인공고관절치환술시행후연부조직의거대종괴가발생했을때까지의평균추시기간은 1 군은 76 개월 (47-94 개월 ), 2 군은 92.4 개월 (59-144 개월 ) 이었고, 종괴의수술적제거후환자들의평균추시기간은각각 24.4 개월 (6-30 개월 ), 24.6 개월 (17-35 개월 ) 이었다. 1 군의평균연령은 55.8 세 (43-68 세 ) 였으며남자 2 예, 여자 3 예였고, 종괴가발견되었을당시에 4 예는일차인공고관절전치환술상태였으며 1 예는인공고관절재치환술상태였다. 2 군의평균연령은 50.4 세 (36-59 세 ) 였으며남자가 2 예, 여자가 3 예였다. 종괴가발견되었을때 3 예는일차고관절전치환술상태였고, 2 예는인공고관절재치환술상태였다. 각각의증례에서단순방사선촬영및자기공명영상촬영등을통해종괴의크기및위치, 골용해의정도와삽입물의해리정도등에대해분석하였고, 종괴의크기는자기공명영상을이용하여상하, 좌우및전후직경을각각측정하였다. 적혈구침강속도와 C- 반응단백질을포함한혈액학적검사와배양검사를통해감염의가능성도조사하였다. 종괴가발견되었던시점에서의 cobalt 와 chromium 혈중금속이온농도를측정하였고 cobalt 와 chromium 에대한금속과민증의동반여부에대해서피부단자검사를시행하였다. 대상환자들의종괴위치를자기공명영상에서확인한후이전수술의절개부위에절개를가한후종괴주위의유착조직을유리하고가능한전절제술을시행하였으며수술시에주대와비구컵의안정성에대해검사하였다. 수술중제거된종괴의내부의성분에대해세포학적검사 ( 적혈구, 백혈구및분화도, 산도 ) 를시행하였고배양검사를시행하였다. 수술후종괴의조직에대해병리학적생검을시행하였으며과민반응에대한표지자로림프구, 호산구및대식세포를관찰하다. 편광현미경하복굴절률을이용하여금속대폴리에틸렌치환술에대한폴리에틸렌마모입자에대해검사하였다. Table 1. Data of Mass Formation or Osteolysis Patients after Total Hip Arthroplasty in This Study. Case No. System Erosion Cyst Size Skin Prick Lymphocyte Macrophage Eosinophil IgE Polyethylene Serum Metal Ion (cm) Test Wear Debris (Co/Cr, μg/l) 1 M-on-M* O 7 5 7 (-) O X O X X 01.4 / 1.52 2 M-on-M0 O 10 4 5 (-) O X X X X 1.65 / 1.43 3 M-on-M0 X 19 8 6 (-) O O O X X 1.24 / 1.89 4 M-on-M0 O 8 3 9 (-) O X X X X 01.7 / 1.63 5 M-on-M0 X 18.5 9 10 (-) O X O X X 1.15 / 1.39 6 M-on-P. O 20.5 11 12 (-) O O X X O 0.82 / 0.85 7 M-on-P0 O 21 5 7 (-) X O X X O 0.64 / 0.98 8 M-on-P0 X 12 6 6 (-) O O O X O 0.45 / 0.56 9 M-on-P0 O 20 7 4 (-) O O X X O 1.08 / 0.56 10 M-on-P0 X 10 4 6 (-) X O X X O 0.64 / 0.68 Average 14.6 6.2 7.2 1.077 / 1.205 * M-on-M: metal-on-metal total hip arthroplasty, M-on-P: metal-on-polyethylene total hip arthroplasty. www.hipandpelvis.or.kr 207
결 과 단순방사선소견에서대상환자 10 예중 7 예에서단순방사선촬영에서종괴로의심되는연부조직음영이관찰되었고이중 1 군의 3 예, 2 군의 3 예에서종괴와접촉하는부위의대퇴골피질바깥에서안쪽으로눌리는양상의골침식소견이관찰되었다 (Fig. 2A). 자기공명촬영에서측정한종괴의평균상하직경은 14.6 cm(7-21 cm), 평균좌우직경은 6.2 cm(3-9 cm), 평균전후직경은 7.2 cm(4-12 cm) 으로측정되었다. 종괴는비구주위에서부터대퇴주대원위부까지존재하였는데대부분이대퇴주대근위부주위에발생하였고, 이중가장큰용적을보인예는비구근위부까지종괴가확장되었다. 자기공명촬영에서의종괴는모든예에서 T1 강조영상에서저신호강도를보이고, T2 강조영상에서고신호강도를보이는낭종의양상을보였으며 T2 조영증강장기공명촬영에서낭종의벽은조영증강되었으며실질부는다발성격막을가지고있었다. 수술전시행한혈액학적검사에서적혈구침강속도는평균 67 mm/h(47-79 mm/h), 평균 C- 반응단백질은평균 1.1(0.3-1.7) 였고, 배양검사에서특이소견이없어감염을 배제하였다. 수술전시행한 cobalt 와 chromium 의평균혈액농도는 1 군에서는각각 1.43 μg/l(1.15-1.7 μg/l), 1.57 μg/l(1.39-1.89 μg/l) 이었으며, 2 군은각각 0.73 μg/l (0.45-1.08 μg/l), 0.73 μg/l(0.56-0.98 μg/l) 이었다. 대상환자들의 cobalt 와 chromium 에대한피부단자검사에서양성을보인예는없었다 (Table 1). 1 군에서는 4 예에서수술시주대및비구컵은안정되게고정되어있었으며방사선사진에서해리의증거가없어종괴제거술만을시행하였으나 1 예에서는종괴의제거와함께해리소견을보여비구컵재치환술을시행하였다 (Fig. 1). 2 군에서도 1 예에서는종괴제거술만을시행하였고, 해리소견을보이는 3 예에서는종괴제거와비구컵재치환술을, 1 예에서는종괴제거와인공고관절재치환술을시행하였다 (Fig. 2). 수술시관절과의연결을육안으로확인한예는 5 예이었으나모든예에서관절과연결되어있을것으로사료되고, 낭종에서흡입한액체는옅은노란색의장액성삼출액으로세포학적결과는평균백혈구수는 15,000 개 (8,000-34,000 개 ) 이었으며배양검사에서는특이소견이없었다. 제거한낭종의외막및고관절의활액막은비후되어있고, 육아종성병변을보였으며, 낭종과접촉하여있던대퇴골의피질골 A B C D Fig. 1. 61 years old male patient underwent metal on metal bearing total hip arthroplasty. (A) Gross photographs of right inguinal mass and simple radiography of right hip. (B) Ultrasonography & MRI shows multiple septation of cystic mass. (C) We performed incision of mass. (D) Microscopy demonstrates lymphocytes. 208 www.hipandpelvis.or.kr
Yoo-Sun Jeon et al.: Periprosthetic Mass after Total Hip Replacement 은얇아진소견을보였다. 조직학적생검에서전예가급, 만성의염증반응과육아종성조직의증식이관찰되었고 1 군은모든예에서림프구가관찰되었다. 2 군은대식세포가관찰되었으며, 편광현미경검사상복굴절률을보이는폴리에틸렌마모입자가확인되었고, 이러한폴리에틸렌마모입자를포함한거대세포의모습도확인할수있었다. 술후추시에서낭종의재발은없었으며골병변의변화도관찰되지않았다. 고 찰 인공고관절전치환술은심각한고관절질환의해결책으로오랫동안사용되고있는수술법이고, 수술후발생할수있는여러합병증에대해서도다양한연구가이루어지고있다. 감염, 탈구, 골용해및삽입물의해리와같은이미잘알려진합병증외에도수술후고관절주변에종괴의형성은드문합병증으로최근두드러지고있는문제이다. 이미여러증례보고에서다양한크기의종괴가보고되고있는데 2-7), 저자들의연구에서보인종괴의크기는 10 4 5 B A C D E Fig. 2. 59 years old female patient underwent metal on polyethylene bearing total hip arthroplasty. (A) Gross photographs of left asymmetric proximal thigh mass and simple radiography of left hip shows contour of soft tissue mass and cortical erosion (arrow) of the proximal femur due to mass effect. We performed revision of total hip replacement due to osteolysis around cup. (B) Ultrasonography shows large amount of joint effusion and synovial thickening with multiple septation and MRI shows a cystic mass extending from pelvic cavity to mid thigh along the iliopsoas muscle. (C) The mass contained large amount of serosanguineous fluid in pseudocapsule and the cortex of proximal femur was thinning by mass effect. (D) Microscopy demonstrates macrophage. (E) Polarized microscopy demonstrates birefringent material indicating polyethylene wear debris. www.hipandpelvis.or.kr 209
cm 에서부터 21 11 12 cm 까지이르는다양한크기를보였고, 이중최대크기를보인종괴는 Hananouchi 등 4) 이거대종괴 (20 16 12 cm) 로보고했던정도로큰것이었다. 이런종괴의형성은금속대금속치환술과금속대폴리에틸렌치환술모두에서발생하였다. Sieber 등 8) 에의하면금속마모가폴리에틸렌마모입자보다마모율이작다고하더라도, nm 단위의작은입자의생성은약 500 배가량많은것으로보고하였다. 수술후발생한금속마모입자는혈중금속이온농도의상승, 금속과민증, 과민증으로인한종괴의형성, 발암성유발및유전자독성등의생물학적문제를야기할수있다 9). 금속대금속치환술후종괴의형성은금속과민증에인한이물반응으로발생할수있는데 2,10,11), Svensson 등 12) 에따르면 cobalt-chromium-molybdenum 고관절치환물에대한과민반응이연부조직의가성낭성종양을유발한다고보고한바있고, Pandit 등 13) 도금속대금속치환술을시행한 1,300 명의환자중에서 20 예에서가성종양의발생을보고하였다. Park 등 7) 과 Jacobs 등 14) 의보고에서이러한종괴의형성은혈중의금속이온이단백질과혼합되어숙주의면역체계에항원으로작용하여과민반응을유발하고, 제 4 형과민반응에의해형성된종괴의병리학적소견상, Ig-E 의출현및호산구, 림프구의출현을관찰할수있다고하였다. 또한 Mikhael 등 15) 은병리학적소견에서혈관주변의림프구의침윤과비감염성림프구성혈관염병변 (aseptic lymphocytic vasculitis associated lesions, ALVAL) 으로이루어진만성염증소견을관찰할수있다고하였다. 인공관절치환후발생한종괴를가진환자에대한평가에상기물질에대한과민반응검사를포함시키는것이진단에도움이된다는보고들이있다 9,14,16,17). 또한 Brodner 등 18-20) 은금속대금속치환술의장기추시상에서혈액내금속이온의농도의상승을언급하였고, Savarino 등 21) 의보고에서혈중 cobalt 농도는 0.69 ug/l 이하, 혈중 chromium 농도는 0.86 ug/l 이하를정상수치로보고하였다. 장기추시상에서금속이온농도를측정하여이러한과민증에의한이물반응의발생에대해예측해볼수있을것이다 22). 최근금속대금속치환술의시행이많아지면서, 영국정형외과협회 23) 에서는금속대금속치환술을시행한경우에, 추시상에서혈중금속이온농도및방사선촬영을반드시확인할것을권고하기도하였다. 저자들의연구에서는금속대금속치환술을시행한 1 군에서, 전예에서림프구의출현과동반된혈관염을확인할수있었고, 3 예에서는호산구도발견되었다. 후향적으로시행한금속과민증에대한피부단자검사상특이소견을보이지는않았지만, 낭종발생시에측정하였던혈중금속이온농도는모두높게측정되어금속대금속치환술후장기추시상에서혈중금속이온농도의측정이필요할것으로판단된다. 금속대폴리에틸렌치환술은골용해, 비감염성해리, 폴리에틸렌마모입자에의한이물반응, 이로인한종괴의형성등이문제점으로대두되어왔다 24-26). 금속대폴리에틸렌치환술후삽입물의표면에서생성되는폴리에틸렌마모입자는마이크로단위이하의작은입자로서 27) 이러한미세한마모입자들은대식세포들의대식작용으로인해심각한이물반응을일으킬수있으며, 육아종성병변의원인이된다. 이러한육아종성병변은림프구와대식세포들로주로이루어져있고, 폴리에틸렌마모입자를포함하고있는다핵성거대세포들을발견할수있다 28,29). 이러한폴리에틸렌마모입자에의한이물반응으로인하여면역체계에의해숙주의세포파괴를일으킬수있고, 이것은삽입물주변의골용해로이어질수있다 1,30,31). 마모입자에대한이물반응으로인하여관절액의생산및관절내압력이증가되며, 관절내마모입자는저항이적은골또는연부조직을통해이동하게되며고관절낭또는장요점액낭등을통해고관절주위에종괴를형성할수있다 5,6). 이러한고관절주변부의종괴로인해방광및요관압박, 심부정맥혈전증, 혈관압박에의한하지부종등이발생할수있다 2,4). 폴리에틸렌마모입자에의해발생한낭성종괴의경우수술전혹은수술중채취한관절낭및종괴내의천자액의편광현미경검사를통해조기진단에도움을줄수있는데, 편광현미경검사상의복굴절률을보이는이물질을확인함으로써수술전조기진단및수술후확진에도움이될수있다 26). 본연구에서는금속대폴리에틸렌치환술을시행한 2군에서발생한종괴의위치는고관절부에서부터대퇴근위부까지확장되는양상을보였고, 골침식을동반되었던예중종괴와접촉하여있던피질골이얇아진소견을보였는데이것이종괴에의하여발생한것인지는알수없었다. 인공고관절전치환술후감염, 양성또는악성신생물등에의해종괴가발생할수있다 6,24). 이의감별을위해단순방사선사진, 초음파, CT, MRI 등의검사및적혈구침강속도와 C-반응단백질검사등이필요하며, 금속대폴리에틸렌치환술의경우에는종괴내혹은관절내천자를시행하여편광현미경검사를시행해보는것이도움이될수있고, 금속대금속치환술의경우에는추시상에서혈액내금속이온농도를측정함으로써금속마모입자에의한과민반응의발생을예측해볼수있을것이다 18). 본연구의제한점으로는연구가후향적으로이루어져혈중금속이온농도의측정이나방사선촬영등의검사가불규칙하게이루어졌고, 증례수가적어결론을이끌어내는데무리가있을것으로보인다. 하지만저자들의연구에서는금속대금속뿐만아니라금속대폴리에틸렌치환술을시행한환자에서도거대종괴의형성을확인하였고, 이물반응에의한골용해뿐만아니라종괴와접촉하는부위의피질골이얇아지는소견도관찰되었다. 또한, 조직검사상 210 www.hipandpelvis.or.kr
Yoo-Sun Jeon et al.: Periprosthetic Mass after Total Hip Replacement 1 군에서는림프구와호산구, 2 군에서는대식세포들을확인할수있었고, 육아종성병변을발견할수있었다. 이렇듯인공고관절치환술을시행한환자들의추시상, 치환물주위의종괴가발생한경우에는초음파및자기공명영상촬영, 혈액검사등을통한선별검사를시행하여야하고, 폴리에틸렌마모입자에의한이물반응이의심되는경우에는관절천자를시행하여편광현미경을통해폴리에틸렌마모입자를확인해볼수있으며, 추시상에서혈중금속이온농도측정및정기적인방사선촬영을시행해보는것이좋을것으로사료된다. 결 론 인공고관절치환술후추시중에발생한치환물주위의종괴는치환물의관절면과관련된금속입자나폴리에틸렌마모입자에의한것임을반드시고려해야할것이며, 수술후주기적인혈중금속이온농도의측정및방사선적검사, 관절천자를통해이를확인해야할것이다. 삽입물의해리와불안정성을유발하는골용해가관찰되면서통증이동반되는종괴는종괴제거술및인공관절재치환술이필요할것으로사료된다. REFERENCES 01.Archibeck MJ, Jacobs JJ, Roebuck KA, Glant TT. The basic science of periprosthetic osteolysis. Instr Course Lect. 2001;50:185-95. 02. Butler RA, Barrack RL. Total hip wear debris presenting as lower extremity swelling. A report of two cases. J Bone Joint Surg Am. 2004;86-A:142-5. 03.Gruber FW, Böck A, Trattnig S, Lintner F, Ritschl P. Cystic lesion of the groin due to metallosis: a rare longterm complication of metal-on-metal total hip arthroplasty. J Arthroplasty. 2007;22:923-7. 04.Hananouchi T, Saito M, Nakamura N, Yamamoto T, Yonenobu K. Huge pelvic mass secondary to wear debris causing ureteral obstruction. J Arthroplasty. 2005;20: 946-9. 05.Korkala O, Syrjänen KJ. Intrapelvic cyst formation after hip arthroplasty with a carbon fibre-reinforced polyethylene socket. Arch Orthop Trauma Surg. 1998;118: 113-5. 06.Mak KH, Wong TK, Poddar NC. Wear debris from total hip arthroplasty presenting as an intrapelvic mass. J Arthroplasty. 2001;16:674-6. 07.Park YS, Moon YW, Lim SJ, Yang JM, Ahn G, Choi YL. Early osteolysis following second-generation metal-onmetal hip replacement. J Bone Joint Surg Am. 2005;87: 1515-21. 08.Sieber HP, Rieker CB, Köttig P. Analysis of 118 secondgeneration metal-on-metal retrieved hip implants. J Bone Joint Surg Br. 1999;81:46-50. 09.Lee JM, Salvati EA, Betts F, DiCarlo EF, Doty SB, Bullough PG. Size of metallic and polyethylene debris particles in failed cemented total hip replacements. J Bone Joint Surg Br. 1992;74:380-4. 10.Boardman DR, Middleton FR, Kavanagh TG. A benign psoas mass following metal-on-metal resurfacing of the hip. J Bone Joint Surg Br. 2006;88:402-4. 11.Brown GC, Lockshin MD, Salvati EA, Bullough PG. Sensitivity to metal as a possible cause of sterile loosening after cobalt-chromium total hip-replacement arthroplasty. J Bone Joint Surg Am. 1977;59:164-8. 12.Svensson O, Mathiesen EB, Reinholt FP, Blomgren G. Formation of a fulminant soft-tissue pseudotumor after uncemented hip arthroplasty. A case report. J Bone Joint Surg Am. 1988;70:1238-42. 13.Pandit H, Glyn-Jones S, McLardy-Smith P, et al. Pseudotumors associated with metal-on-metal hip resurfacings. J Bone Joint Surg Br. 2008;90:847-51. 14. Jacobs JJ, Hallab NJ. Loosening and osteolysis associated with metal-on-metal bearings: A local effect of metal hypersensitivity? J Bone Joint Surg Am. 2006;88:1171-2. 15.Mikhael MM, Hanssen AD, Sierra RJ. Failure of metal-onmetal total hip arthropalsty mimicking hip infection. A report of two cases. J Bone Joint Surg Am.2009;91:443-6. 16.Deutman R, Mulder TJ, Brian R, Nater JP. Metal sensitivity before and after total hip arthroplasty. J Bone Joint Surg Am. 1977;59:862-5. 17.Milavec-Puretić V, Orlić D, Marusić A. Sensitivity to metals in 40 patients with failed hip endoprosthesis. Arch Orthop Trauma Surg. 1998;117:383-6. 18. Brodner W, Bitzan P, Meisinger V, Kaider A, Gottsauner- Wolf F, Kotz R. Elevated serum cobalt with metal-onmetal articulating surfaces. J Bone Joint Surg Br. 1997; 79:316-21. 19. Brodner W, Bitzan P, Meisinger V, Kaider A, Gottsauner- Wolf F, Kotz R. Serum cobalt levels after metal-on-metal total hip arthropalsty. J Bone Joint Surg Am. 2003;85- A:2168-73. 20.Brodner W, Grübl A, Jankovsky R, Meisinger V, Lehr S, Gottsauner-Wolf F. Cup inclination and serum concentration of cobalt and chromium after metal-onmetal total hip arthroplasty. J Arthroplasty. 2004;19:66-70. 21.Savarino L, Granchi D, Ciapetti G, et al. Ion release in stable hip arthroplasties using metal-on-metal articulating surfaces: a comparison between short- and medium-term results. J Biomed Mater Res A. 2003;66:450-6. 22. Hallab N, Merritt K, Jacobs JJ. Metal sensitivity in patients with orthopaedic implants. J Bone Joint Surg Am. 2001;83-A:428-36. 23.Skinner J, Gie G, Kay P. Metal on metal hip replacement and hip resurfacing arthroplasty: What does the MHRA medical device alert mean?-letter from John Skinner, Graham Gie and Peter Kay. In: British Hip Society Newsletter. London: British Hip Society. July 2010.19-20. 24.Cho MR, Lee SW. A giant mass mimicking malignancy developed in the proximal thigh after hip arthroplasty: A case report. J Korean Hip Soc. 2006;18:132-7. 25. Lachiewicz PF. Case report: a thigh mass resulting from polyethylene wear of a revision total hip arthroplasty. Clin www.hipandpelvis.or.kr 211
Orthop Relat Res. 2007;455:274-6. 26.Suh KT, Lee CK, Lee JS. An inguinal mass associated with polyethylene wear debris after a total hip arthroplasty: A case report. J Korean Orthop Assoc. 2005;40:365-8. 27.Jacobs JJ, Shanbhag A, Glant TT, Black J, Galante JO. Wear debris in total joint replacements. J Am Acad Orthop Surg. 1994;2:212-20. 28.Santavirta S, Konttinen YT, Bergroth V, Eskola A, Tallroth K, Lindholm TS. Aggressive granulomatous lesions associated with hip arthroplasty. Immunopathological studies. J Bone Joint Surg Am. 1990;72:252-8. 29.Hallab NJ, Anderson S, Stafford T, Glant T, Jacobs JJ. Lymphocyte responses in patients with total hip arthroplasty. J Orthop Res. 2005;23:384-91. 30.Hanna MW, Thornhill TS. Thigh mass and lytic diaphyseal femoral lesion associated with polyethylene wear after hybrid total knee arthroplasty. A case report. J Bone Joint Surg Am. 2006;88:2473-8. 31.Zicat B, Engh CA, Gokcen E. Patterns of osteolysis around total hip components inserted with and without cement. J Bone Joint Surg Am. 1995;77:432-9. 국문초록 인공고관절전치환술후발생한치환물주위종괴 전유선 황득수 강 @ 찬 김의창 * 이기수 송재황충남대학교의학전문대학원정형외과학교실 의학연구소, 수원온정형외과의원 * 목적 : 인공고관절치환술후치환물주변에발생한거대종괴를보고하고종괴의원인과양상을분석하였다. 대상및방법 : 2000 년 1 월부터 2007 년 10 월까지인공고관절치환술을시행받은환자들에서연부조직에거대종괴가발생한 10 예를대상으로하였다. 금속대금속치환술을시행한 5 예를 1 군, 금속대폴리에틸렌치환술을시행한 5 예를 2 군으로분류하고각군의종괴크기및위치, 골용해의양상을관찰하고혈액학적검사및조직학적소견을후향적으로검토하였다. 결과 : 방사선학적소견상대퇴치환물주위종괴의위치는비구주위에서부터대퇴치환물원위부까지존재하였다. 종괴의크기는평균 14.6 cm(7-21 cm) 6.2 cm(3-9 cm) 7.2 cm(4-12 cm) 로측정되었다. 골용해는 1 군에서 3 예, 2 군에서 3 예가동반되었고, 1 군에서는림프구와호산구가관찰되었으며, 2 군은모든예에서대식세포가관찰되었다. 결론 : 인공고관절치환술후발생하는골용해와연부조직의거대종괴는폴리에틸렌마모입자에대한이물반응과금속이온에대한과민반응과관련이있을것으로생각되며, 오래지속된종괴의압박효과에의해서피질골이바깥에서안쪽으로눌리는양상으로얇아지는소견을보일수있음을고려해야하겠다. 색인단어 : 금속과민증, 폴리에틸렌마모입자, 거대연부조직종괴, 인공고관절치환술 212 www.hipandpelvis.or.kr