대한견 주관절학회지제 11 권제 1 호 J. of Korean Shoulder and Elbow Society Volume 11, Number 1, June, 2008 흉쇄관절에발생된결핵성관절염의수술적치료 - 2 예보고 - 원광대학교의과대학정형외과학교실 박진영 김정우 전철홍 권석현 최윤홍 이석중 Operative Treatment of the Tuberculous Arthritis on the Sternoclavicular Joint - A Report of Two Cases- Jin Young Park, M.D., Jeong Woo Kim, M.D., Churl Hong Chun, M.D., Seok Hyun Kwon, M.D., Yun Hong Choi, M.D., Seok Jung Lee, M.D. Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, Korea Tuberculous arthritis on the sternoclavicular joint is an uncommon disease and a delayed diagnosis can be due to the obscure clinical symptoms. We should suspect tuberculous arthritis in patients with slowly progressive pain, swelling, mild fever and a previous history of tuberculosis. Early diagnosis is important through conducting a thorough physical examination and performing laboratory tests and radiologic study. Tuberculous arthritis on the sternoclavicular joint should be treated with a combination of systemic antituberculous agents and thorough surgical debridement in marked damaged joints. When performing this operation, it is important not only to minimized the injury of the costoclavicular ligament, but also to avoid injury to the surrounding the vital structures such as the mediastinum and pleura after aggressive resection or radical debridement. We describe here 2 cases of the tuberculous arthritis on the sternoclavicular joint: one case had a good result after surgical debridement with using an anti-tuberculous agent, and the other had fatal complications such as mediastinal abscess and pleural effusion after the operation. Key Words: Sternoclavicular joint, Tuberculous arthritis 통신저자 : 김정우전라북도익산시신용동 344-2 원광대학교의과대학정형외과학교실 Tel: 063) 859-1366, Fax: 063) 852-9329, E-Mail: serina@wonkwang.ac.kr * 본논문의요지는 2008 년도대한정형외과학회추계학술대회에서발표되었음. * 본논문은 2008 년도원광대학병원의임상연구비의지원을받아이루어졌음. 57
대한견 주관절학회지제 11 권제 1 호 A B Fig. 1. (A) Multifocal ill defined and irregular nodular and patchy increased density in both upper lobes on chest X-ray. (B) MRI scan at the level of the left sternoclavicular joint showing cortical destruction and bone edema on clavicle. 결핵성관절염 2예를경험하고수술결과와합병증에대해증례보고하고자한다. 증례보고 증례 1 Fig. 2. Histologic finding. The study demonstrates focal caseous necrosis and Langerhans giant cell. 흉쇄관절에발생되는결핵성관절염은전체결핵관절염의 1~2% 정도로매우드물어그에대한증례보고도드물며 1,4) 아직까지국내에보고된논문은없다. 흉쇄관절의관절염의진단은임상적소견과조직학적소견을종합하여진단하게되는데임상적증상이저명하지않는경우가많아늦게진단되는경우가많고진단후에는관절염과함께골수염까지진행되는경우가있어대개진단이되면먼저항결핵제투여를하고증상이호전이없는경우수술적치료를시행하도록보고되어왔다 2,4,8,9). 그러나흉쇄관절수술시주위의중요한구조물손상가능성이있어주의를요하는데저자들은항결핵제투여와수술적치료를시행한흉쇄관절 약 1년전부터점진적으로진행되는좌측흉쇄관절부위의압통과종창을주소로내원한 61 세남자환자로 6개월전개인병원에서폐결핵진단받고항결핵제 (Isoniazid, Rifampin, Ethambutol, Pyrazinamide) 투여하며경과관찰중이었으며항결핵제투여이후에도동통과종창이더심해지는양상보여본원에내원하신분으로시행한이학적검사상압통과종창소견보이고있었으며검사실소견상 ESR 77 mm/hr, CRP 18.21 mg/l로증가되어있었으며흉부방사선상양측상부폐에음영이증가된결핵소견보이고있었고 MRI 상좌측흉쇄관절부위의골파괴와함께테두리가조영증가된연부조직농양소견보이고있어수술시행하였다 (Fig. 1). 흉쇄관절을중심으로피부절개를가한다음늑쇄골인대손상에주의하면서관절낭을절개한후에괴사조직과함께농을제거하고침범된골조직에대해서변연절제술시행하고관절에대해철저한세척실시한후에봉합하고제거된조직에대해서는조직학적검사를실시하였다. 조직학적소견상 Langerhans 거대세포와건락괴사가보이는결핵조직소견보이고있었다 (Fig. 2). 술후 58
박진영 : 흉쇄관절에발생된결핵성관절염의수술적치료 - 2 예보고 - 지속적인항결핵제 (Isoniazid, Rifampin, Ethambutol, Pyrazinamide) 투여실시하였으며 3개월추시결과상우측견관절관절운동시약간의동통을호소하는것외에흉쇄관절의압통이나종창은소실되었으며방사선상골파괴진행소견등은없었다. 증례 2 한달전부터점진적으로진행된우측견갑부흉쇄관 절부위의경도의동통과종창을주소로내원한 61 세남자환자로이학적검사상흉쇄관절부위의압통과종창소견보이고있었으며야간의미열이있었던환자로시행한검사실소견상 ESR, CRP 증가, lymphocyte 증가소견보이고있었고방사선소견상흉부사진상폐결핵의소견은없었으나골주사검사상흉쇄관절부위와우측흉골부위에흡수증가소견보이고있었고흉부 CT상흉쇄관절부위의골파괴소견보이고있었다 (Fig. 3). 항결핵제 (Isoniazid, Rifampin, Ethambutol, Pyrazinamide) 를 3개월동안투여하였으나증상의악화소견보여우측흉쇄골관절부위에대해변연절제술시행하고제거된조직은조직검사를시행하였고조직검사상 Langerhans 거대세포와건락괴사가보이는결핵조직소견보이고있었다. 경과관찰중지속적인동통과미열지속되는소견보여재시행한 CT 소견상우측흉쇄관절부위와흉골부위에골파괴가술전에비해진행된소견보이고있었고종격동부위의농양소견보이고있어다시변연절제술시행하였으나증상의호전없었으며흉부방사선소견상삼출성늑막염소견보여늑막박피술시행하고현재경과관찰상흉쇄관절부위의동통과종창은소실되었으나보행시약간의호흡곤란을호소하고있다 (Fig. 4). 고 찰 Fig. 3. CT scan of the chest shows a soft tissue mass in the right sternoclavicular region with associated bony destruction of the clavicular head. 흉쇄관절의결핵관절염은다른관절의결핵성관절염처럼폐결핵의발생이나재활성화로혈행성전파를통해이루어지지만 Yasuda 등 9) 은비정형폐결핵이흉쇄관절로직접전파되는경우도있다고하였다. A B Fig. 4. (A) Pleural effusion on right chest X-ray. (B) Last follow up X-ray shows chronic loculated hydropneumothorax in right chest. 59
대한견 주관절학회지제 11 권제 1 호 Dhillon 등 2) 은흉쇄관절의관절염은동통, 종창, 누공등을주소로내원하게되며결핵의과거력이있으면서흉쇄관절의동통성종창이있는경우결핵에의한관절염을의심해보아야한다고하였다. 대개 X-ray로는진단이어렵고 CT에서흉쇄관절의파괴소견이나 MRI 상농양의소견이보이는경우진단할수있으나진단이쉽지않다고하였으며흉쇄관절결핵관절염은병원균의감염성이나숙주저항력에따라골과관절의파괴가심하며동통이심한경우와골과관절의파괴가적고동통이심하지않은 2가지경우로나뉘어지고조직학적진단시철저한변연절제술이조기회복에도움이될수있다고보고하고있다. Shah 등 6) 은흉쇄관절을침범한결핵관절염 15 예의보고에서심하지않은동통, 종창, 미열등을주소로내원하게되며 ESR, CRP 의상승, 임파구의증가, 혈청 IgM, IgG의증가. Tuberculin 검사양성등의소견을보였으며조직학적으로 Langerhans 거대세포, 건락성괴사등의소견으로확진하였다고하였다. 2예에서 HIV 감염자였으며 HIV 감염같은면역억제상태에있는환자에서위험성이높다고하였다. CT상으로골연골파괴, 테두리가조영된연부조직농양, 석회화등이보이며 MRI 상 T2 영상에서신호증가소견을보이는관절삼출, 흉골에서의신호강도의변화등의소견이보이며이러한방사선적진단을통해결핵의조기진단이수술적치료계획에도움이될것이라고하였다. Song 등 7) 은일반적인흉쇄관절의관절염의치료원칙은그발생빈도가낮아아직까지정립되지않았으나흉쇄관절의구조상피부바로아래에존재하고있으며주위에중요한혈관, 신경구조물들이있어수술시합병증발생가능성이있으며단순절개와배농만으로치료가효과적이지않아관절에대한철저한변연절제술흉골과내측쇄골일부의골절제가함께이루어져야재발을방지할수있다고소개하였다. 결핵성흉쇄관절염의몇몇보고에의하면 Yasuda 등 9) 은결핵성농양은종양으로오인될수있기때문에조심해야하고결핵성흉쇄관절염은흉쇄관절의종창의원인일수있음을고려해야한다고하였으며결핵성관절염초기에는항결핵제투여만으로도치료가충분하지만진행된관절염이나골수염이있는경우에는항결핵제투여와함께철저한수술적변연절제술을실시해야한다고보고하였다. Fukasawa 등 3) 은흉쇄관절의결핵관절염이진단되게되면최소한 1년이상항결핵제투여가원칙이며증상의호전이없거나증상이심한경우에는수술적변연절제술을시행하여야한다고보고하였다. Dhilon 등 2) 은결핵성흉쇄관절염으로진단받은 10 예를대상으로 4가지항결핵제병합요법으로 14~18개월간치료하였으며 2~3 개월화학요법으로증상이호전되지않은 2예는 수술적치료시행하여모두치유되었다고보고하면서항결핵제투여후임상적반응이나타난후부터 1년간은항결핵제를투여해야하며심하게손상된관절염인경우에는조기에수술적치료를권장하였다. Lemos 등 5) 은흉쇄관절주위에는위험한구조물이많아수술적치료시에주의를요한다고하였다. 흉쇄관절주위에는경정맥, 식도, 기관, 미주신경, 흉격신경등의손상위험이있으며감염, 종양, 관절염등으로과도한변연절제술이나변연절제관절성형술을시행할경우종격동의손상을줄수있으로주의를요한다고하였다. 또한, 변연절제술시늑쇄골인대손상시흉쇄관절의불안정성이생겨동통이잔재할수있음을보고하였다. 저자들은흉쇄관절의결핵성관절염발생시 1년이상의항결핵제투여가필요하며화학요법으로증상의호전이없는경우나증상이진행되어관절의파괴소견이보이는경우수술적치료가필요한데수술적치료시늑쇄골인대의손상을최소화하고또한종격동, 늑막등흉쇄관절의주위의중요구조물의손상을주지않으면서관절의철저한변연절제술로증상의호전을가져올수있으리라사료된다. REFERENCES 01) Dhillon MS, Gupta R, Rao KS, Nagi ON: Bilateral sternoclavicular joint tuberculosis. Arch Orthop Trauma Surg, 120: 363-365, 2000. 02) Dhillon MS, Gupta RK, Bahadur R, Nagi ON: Tuberculosis of the sternoclavicular joints. Acta Orthop Scand, 72: 514-517, 2001. 03) Fukasawa H, Suzuki H, Kato A, et al: Tuberculous arthritis mimicking neoplasm in a hemodialysis patient. Am J Med Sci, 322: 373-375, 2001. 04) Kawasaki T, Sasaki Y, Shinozaki A, et al: [Tuberculosis of the sternoclavicular joint]. Kekkaku, 82: 475-479, 2007. 05) Lemos MJ, Tolo ET: Complications of the treatment of the acromioclavicular and sternoclavicular joint injuries, including instability. Clin Sports Med, 22: 371-385, 2003. 06) Shah J, Patkar D, Parikh B, et al: Tuberculosis of the sternum and clavicle: imaging findings in 15 patients. Skeletal Radiol, 29: 447-453, 2000. 07) Song HK, Guy TS, Kaiser LR, Shrager JB: Current presentation and optimal surgical management of sternoclavicular joint infections. Ann Thorac Surg, 73: 427-431, 2002. 08) Sy MH, Konate I, Gassama A, Kane A, Seye SI: Monoarticular sterno-clavicular arthritic tuberculosis: a proposal and an observation. Int J Tuberc Lung Dis, 4: 486-487, 2000. 09) Yasuda T, Tamura K, Fujiwara M: Tuberculous 60
박진영 : 흉쇄관절에발생된결핵성관절염의수술적치료 - 2 예보고 - arthritis of the sternoclavicular joint. A report of three cases. J Bone Joint Surg Am, 77: 136-139, 1995. 초록 흉쇄관절의결핵성관절염은매우드문질환으로임상증상이뚜렷하지않기때문에진단이늦어지는경우가많다. 흉쇄관절부위의점진적으로진행하는동통이나종창, 미열이있으면서결핵의과거력이있는경우에결핵성관절염을의심해야하고혈액검사, 방사선검사, 조직검사를통한조기진단이중요하다. 흉쇄관절결핵관절염의경우 1년이상의항결핵제투여가필요하며증상의호전이없거나증상이진행되어흉쇄관절의관절파괴소견이보이는경우수술적치료가필요하게되는데수술적치료시흉쇄관절의늑쇄골인대의손상을최소화하면서과도한변연절제술로인해흉쇄관절의주위의종격동, 늑막등의중요구조물이손상되는것을피해야한다. 저자들은경험한 2예의흉쇄관절결핵관절염에서변연절제술로증상의호전을가져온 1예와변연절제술후종격동농양, 삼출성늑막염등의합병증이발생된 1예를함께보고하고자한다. 색인단어 : 흉쇄관절, 결핵성관절염 61