366 pissn : 1226-2102, eissn : 2005-8918 Case Report J Korean Orthop Assoc 2019; 54: 366-371 https://doi.org/10.4055/jkoa.2019.54.4.366 www.jkoa.org 동측의동정맥루를가진만성신부전증환자의회전근개파열에대한관절경적수술이후발생한혈관절증 허순호 김세진 박진영 강경록 성가롤로병원정형외과 Hemarthrosis Occurred after Arthroscopic Rotator Cuff Repair in a Chronic Renal Failure Patient with a Stenosis in an Ipsilateral Arteriovenous Fistula Soon Ho Huh, M.D., Se Jin Kim, M.D., Jin Yeong Park, M.D., and Kyung Rok Kang, M.D. Department of Orthopaedic Surgery, St. Carollo Hospital, Suncheon, Korea Hemarthrosis occurring after arthroscopic surgery for lesions of the shoulder joint is a very rare complication that can develop due to an injury to the blood vessels when an anterior portal is formed. This is a complication that rarely develops in patients who are taking antithrombotic drugs or who do not have associated diseases, such as thrombocytopenia. We report a case of hemarthrosis that occurred after performing arthroscopic surgery to repair a rotator cuff tear in a patient with a stenosis in an arteriovenous fistula for hemodialysis in the ipsilateral upper arm. Key words: shoulder, arthroscopy, rotator cuff, hemarthrosis, arteriovenous fistula 견관절회전근개파열은관절경술기와기구의발전으로인하 여대부분의수술들이관절경적수술로이루어지고있으며, 이 와함께재파열, 관절강직, 내고정물관련합병증, 신경혈관손상 등많은술후합병증들이문헌상으로보고되고있다. 1,2) 그중혈 관손상에관한합병증은전방삽입구형성도중발생한액와동 맥 (axillary artery), 요측피정맥 (cephalic vein) 의손상으로인해발 생할수있으며, 1) 혈관손상으로인하여관절경적수술이후발생 한가성낭종 (pseudoaneurysm) 이보고된바있다. 3,4) 저자들은혈액 투석 (hemodialysis) 을위한동정맥루 (arteriovenous fistula) 를동측 에갖고있는만성신부전환자에서특별한혈관의손상없이회 Received July 14, 2018 Revised August 15, 2018 Accepted September 13, 2018 Correspondence to: Se Jin Kim, M.D. Department of Orthopaedic Surgery, St. Carollo Hospital, 221 Sungwang-ro, Suncheon 57931, Korea TEL: +82-61-720-2404 FAX: +82-61-720-6000 E-mail: abeli@naver.com ORCID: https://orcid.org/0000-0001-9311-862x 전근개파열을관절경적수술로치료한후정맥성고혈압 (venous hypertension) 으로인하여 2일이내에반복적으로재발하는혈관절증을경험하였다. 국내외에서문헌검색상이와관련된증례가보고된바가없어문헌고찰과함께보고하는바이다. 증례보고 55세남자환자가약 1년전부터발생한좌측견관절통증을주소로내원하였다. 환자는견관절의통증과함께능동적관절운동범위는전방거상은 120도, 외회전은 45도, 내회전은요추 3번확인되었으며, 수동적관절운동범위는제한되지않았다. 과거력상환자는만성신부전으로인하여동측상완부에동정맥루를이용하여주 3회투석중이었고, 동정맥루의기능저하로인하여 3차례재수술을경험한적이있었으며, 혈액학적검사상혈소판과응고인자들은모두정상범위로확인되었다. 단순방사선검사상견봉-상완골간격이감소되어있었으며 The Journal of the Korean Orthopaedic Association Volume 54 Number 4 2019 Copyright 2019 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
367 Hemarthrosis after Arthroscopic Rotator Cuff Repair 견봉하골극을확인할수있었고 (Fig. 1), 회전근개의파열을의심하여시행한자기공명영상검사상극상건, 극하건의파열과심한퇴축과함께견갑하건의부분파열관찰되는광범위회전근개파열이관찰되었다 (Fig. 2). 이에관절경적수술을계획하였으며출혈경향을최소화하기위해수술전일과수술다음날에혈액투석을시행하기로하고광범위회전근개파열에대하여회전근개봉합술을시행하였다. 수술은사각근간차단 (interscalene block) 후해변의자자세 (beach chair position) 로시행되었으며견봉의후외측에서하방 2 cm, 내측 1 cm 부위에후방삽입구를형성하였다. 전방삽입구는 outside-in 기법으로회전근개간격사이에형성하였고, 그외에외측삽입구와후외측삽입구를형성하였다. 수술소견상회전근개의광범위파열이관찰되어이에대해견갑하건은일열봉합술 (single row technique) 으로봉합하고, 극상건과극하건은교량형봉합술 (suture bridge technique) 으로봉합하였으며, 수술중혈종발생가능성을최소화하고자지혈을철저히시행하였다 (Fig. 3). 수술도중압력식주입펌프의수압은상황에따라 30-100 mmhg 로유지하며진행하였고관절내부에급성출혈소견은관찰되지않았으며수술전시행한혈액검사에서도출혈성소인이관찰되지않아관절내로배액관은삽입하지않았다. 술후재활은 6주까지외전보조기를착용시키면서수동적관절운동은시행하지않기로하였다. 환자는술후투석일정에따라수술다음날부터투석을시행하였으며, 투석시사용하는항혈전제는술후출혈성경향을최소화하기위해헤파린 (heparin) 은사용하지않고반감기가짧은메실산나파모스탓트 (nafamostat mesylate) 를사용하였다. 술후 3일째에수술부위를소독하던중전방삽입구주변으로불거져나온종창이관찰되어이에대해관절천자를시행하자 65 ml가량정맥혈양상의검붉은액체가배액되었으며관절천자액에대한검사상적혈구수치가 220,000/ml 관찰되었다 (Fig. 4A, 4B). 이후압박붕대를이용하여견관절주변을압박하였으나 2일후투석후소독을시행하기위해압박붕대를풀자마찬가지로전방삽입구주변의종창이재차관찰되었으며마찬가지로 50 ml 가량검붉은액체가배액되었다. Figure 1. Plain radiographs showing the subacromial spur, proximal humeral migration and reduced acromiohumeral interval. A B C Figure 2. T2-weighted fat suppression magnetic resonance imaging. Axial (A), sagittal (B), and coronal (C) images showing a massive cuff tear with retraction.
368 Soon Ho Huh, et al. Figure 3. Arthroscopic images. A partial subscapularis tear was observed and repaired using a single row technique (A), and full thickness tears of the supraspinatus and infraspinatus tendons were repaired using a suture bridge tec hnique (B). There was no evidence of intra-articular bleeding during the procedure. Figure 4. (A, B) On postoperative day 3, swelling was observed around the anterior portal, so joint aspiration was performed, and approximately 65 ml of dark-bloody fluid was drained. (C, D) Computed tomography angiography images. No dye leakage was observed, which implies vascular injury or a pseudoaneurysm, but a large collection of fluid around the joint was noted. Total occlusion of the cephalic vein (arrowhead) was observed, and subtotal stenosis of the axillary vein (empty arrow) and the outflow of the arteriovenous fistula (white arrow) was observed. 종창주변으로맥동 (pulsation) 은관찰되지않았으나짧은시일내에반복적인종창이반복되어관절경적수술이후발생할수있는가성낭종이나관절주변혈관의손상의심하에혈관조영컴퓨터단층촬영 (computed tomography angiography) 을시행하였다. 혈관조영컴퓨터단층촬영소견상관절내부로다량의액체저류가관찰되었으나가성낭종이나조영제가새어나오는소견은관 찰되지않았으며, 다른특이소견으로는동정맥루의유출로 (outflow tract) 인액와정맥 (axillary vein) 의아전협착 (subtotal stenosis) 소견이관찰되고있었고, 이전에유출로로사용하였던요측피정맥 (cephalic vein) 의완전협착 (total stenosis) 이관찰되었다 (Fig. 4C, 4D). 특별히관절주변의조영제유출이관찰되지않아충분한압박을시행하면지혈될것으로생각되어압박붕대를다시적용하
369 Hemarthrosis after Arthroscopic Rotator Cuff Repair Figure 5. (A) Gross photograph of the arteriovenous fistula on the upper arm before ligation of the arteriovenous (AV) fistula. (B) After ligation of the AV fistula, a permanent catheter for dialysis was inserted through the contralateral internal jugular vein. 였다. 그러나 2일후투석전에확인한결과마찬가지로전방삽입구주변의종창이관찰되었으며다시 50 ml가량검붉은액체가배액되었다. 반복되는혈관절증에대한적극적인치료가필요할것으로보여지혈을위한재수술을고려하던중동정맥루의유출로의협착의영향이있는지문의하고자흉부외과협진을시행하였고, 유출로로사용되던액와정맥의아전협착으로인해관절주변의정맥압이동맥압수준으로상승하게되는상완부의정맥성고혈압이발생한것으로보이며, 이로인해관절내부의작은혈관들이지혈되지않아출혈이있는것으로보인다는답변과함께현재사용중인동정맥루의협착이심하여재수술을고려하고있었던상황이었기때문에반대측내경정맥 (internal jugular vein) 에투석을위한영구도관 (permanent catheter) 을삽입하고동정맥루를결찰 (ligation) 하여상완부의정맥성고혈압을감소시키는것이좋겠다는답변을얻어당일응급수술을시행하였다 (Fig. 5). 동정맥루의결찰이후다음날부터혈관절증은재발하지않았으며, 술후 6개월간의추시기간동안견관절의관절가동범위는정상에가까운회복상태를보였으며, 다른합병증들은관찰되지않았다. 고찰 정맥성고혈압은신부전환자에게혈액투석을위한도관을생성하였을경우 10%-15% 의환자에서발생가능하며, 중심정맥계 (central venous system) 의협착으로인하여발생하는것으로알려져있다. 5) 정맥성고혈압이발생한경우주증상은환측상지의부종 (edema), 통증, 운동불가등으로나타날수있으며심한경우괴사가발생할수있고, 그외에도동정맥루의맥동 (pulsation) 의증가및투석바늘을제거한뒤지혈이잘되지않을경우의심해 볼수있다. 5) 정맥성고혈압은대부분무증상이나증상이발현된경우혈류초음파나혈관조영술에서동정맥루유출로의협착이확인되었을때진단이가능한것으로알려져있다. 6) 견관절의병변에대한관절경적수술은관절경적술기와기구의발전으로인해보편화되어가고있으며점진적으로증례의수와적용범위가늘어가면서다양한종류의합병증이보고되고있는상태이다. 관절경수술후발생하는혈관절증의비율은슬관절관절경수술에서는전체합병증중 60.1% 로보고되었으나, 7) 견관절과타관절에서는매우드물게발생하며, 혈관절증의경우응고인자결핍이없을경우에는자연흡수되는경우가대부분이다. 8) Lo 등 1) 은해변의자자세에서 outside-in 기법으로전방삽입구의형성시손상가능한신경혈관구조물 (neurovascular structure) 에대한사체연구 (cadevaric study) 에서전방삽입구로부터요측피정맥까지의거리는평균 18.8 mm (0-31 mm), 액와동맥까지의거리는 46.3 mm (40-52 mm) 였으며, 1예에서요측피정맥이관통되었다고보고하였으며, Curtis 등 2) 도 660예의관절경환자중 1예에서요측피정맥의손상을보고한바있다. 또한 Cameron 3) 은동측동정맥루를가진환자에서전방삽입구를형성한후발생한정맥성가성낭종 (venous pseudoaneurysm) 을보고하였으며, Godin 등 4) 은흉견봉동맥 (thoracoacromial artery) 의견봉분지 (acromial branch) 에서발생한가성낭종을보고한바있다. 하지만본증례에서는술후시행한혈관조영컴퓨터단층촬영에서특별한혈관손상이나가성낭종은관찰되지않았으나급속도로재발하는혈관절증이관찰되었다. 이에다른원인을감별하던중동정맥루의유출로인액와정맥의협착으로인하여동정맥루보다근위부의정맥압이증가되어있는정맥성고혈압이있었
370 Soon Ho Huh, et al. 음을알수있었고, 이에대해동정맥루를결찰하자견관절의혈관절증은자연소실되었다. 정형외과영역에서환측상지에동정맥루가존재할경우지혈대를사용하는것뿐만아니라혈관손상을줄수있는압박이나혈종과동정맥루의발생가능성으로인해침습적술기등은사용하기어려우므로많은경우수술적응증에해당하나보존적인처치를사용하는경우가많다. 9) 하지만견관절관절경의경우수술부위가대부분동정맥루보다근위부에존재하여접근이불가능한것이아니며지혈대의착용을하지않아동정맥루의손상을방지할수있다. 본증례의경우에는회전근개의광범위파열이관찰되어보존적처치를하더라도증상의호전이어려워수술적처치를시행하였고, 수술전후로투석시에헤파린을사용하지않고수술중지혈기구를이용하여혈종의발생가능성을최소화하였다. 그러나본증례처럼혈액투석환자에게중심정맥계의협착이있거나혈전이발생한경우정맥고혈압이발생할수있으며, 5) 높은정맥압으로인하여수술후혈관절증이발생할수있다. 동측동정맥루를가진환자의견관절관절경수술시에는반드시수술전동정맥루의기능과주변혈관의협착에대한감별을위해혈류초음파나혈관조영컴퓨터단층촬영을이용하는것이필요하며, 수술중에혈관손상에주의하여전방삽입구를형성하고면밀한지혈을시행하는등주의깊은술기가필요하다. 아울러수술후에도환자를면밀히관찰하여만약합병증이발생하더라도조기에진단하고치료를하는것이필요하다고생각된다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Lo IK, Lind CC, Burkhart SS. Glenohumeral arthroscopy portals established using an outside-in technique: neurovascular anatomy at risk. Arthroscopy. 2004;20:596-602. 2. Curtis AS, Snyder SJ, Del Pizzo W, Friedman MJ, Ferkel RD, Karzel RP. Complications of shoulder arthroscopy. Arthroscopy. 1992;8:395. 3. Cameron SE. Venous pseudoaneurysm as a complication of shoulder arthroscopy. J Shoulder Elbow Surg. 1996;5:404-6. 4. Godin JA, Mayer SW, Garrigues GE, Mather RC 3rd. Pseudoaneurysm after shoulder arthroscopy. J Shoulder Elbow Surg. 2013;22:e12-7. 5. Hall HC, Moudgill N, Kahn M, et al. An unusual cause of venous hypertension after dialysis access creation. Ann Vasc Surg. 2011;25:983.e1-4. 6. Neville RF, Abularrage CJ, White PW, Sidawy AN. Venous hypertension associated with arteriovenous hemodialysis access. Semin Vasc Surg. 2004;17:50-6. 7. Small NC. Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy. 1988;4:215-21. 8. Tsujii A, Tanaka Y, Yonetani Y, Shiozaki Y, Tomiyama Y, Horibe S. Knee hemarthrosis after arthroscopic surgery in an athlete with low factor XIII activity. Sports Med Arthrosc Rehabil Ther Technol. 2012;4:35. 9. Im JH, Huh SW, Park MK, Lee JY. Volar loking plate fixation for distal radius fractures in hemodialysis patients. J Korean Soc Surg Hand. 2015;20:96-103.
371 pissn : 1226-2102, eissn : 2005-8918 Case Report J Korean Orthop Assoc 2019; 54: 366-371 https://doi.org/10.4055/jkoa.2019.54.4.366 www.jkoa.org 동측의동정맥루를가진만성신부전증환자의회전근개파열에대한관절경적수술이후발생한혈관절증 허순호 김세진 박진영 강경록 성가롤로병원정형외과 견관절의병변에대해관절경적수술을시행한후발생한혈관절증은매우드문합병증으로전방삽입구의형성도중혈관의손상으로인해발생할수있으며항혈전제를복용중이거나혈소판감소증등동반질환이없을경우발생하기어려운합병증이다. 저자들은동측상완부에혈액투석을위한동정맥루의협착이있는환자에게회전근개파열에대한관절경적수술을시행한후발생한혈관절증의사례를보고하는바이다. 색인단어 : 견관절, 관절경, 회전근개, 혈관절증, 동정맥루 접수일 2018 년 7 월 14 일수정일 2018 년 8 월 15 일게재확정일 2018 년 9 월 13 일책임저자김세진 57931, 순천시순광로 221, 성가롤로병원정형외과 TEL 061-720-2404, FAX 061-720-6000, E-mail abeli@naver.com, ORCID https://orcid.org/0000-0001-9311-862x 대한정형외과학회지 : 제 54 권제 4 호 2019 Copyright 2019 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.