418 pissn : 1226-2102, eissn : 2005-8918 Case Report J Korean Orthop Assoc 2015; 50: 418-423 http://dx.doi.org/10.4055/jkoa.2015.50.5.418 www.jkoa.org 개방형경골근위부절골술후지연발생한슬와동맥가성동맥류 임해성 김상민 김종관 성균관대학교의과대학삼성창원병원정형외과학교실 Delayed Onset of the Popliteal Artery Pseudoaneurysm Following Medial Opening Wedge High Tibial Osteotomy Hae-Seong Lim, M.D., Sang-Min Kim, M.D., and Chong-Kwan Kim, M.D. Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea High tibial osteotomy is an established method in treatment of medial knee osteoarthritis with varus deformity in younger patients. The popliteal artery is vulnerable to injury during surgeries performed around the knee joint. Pseudoaneurysm of the popliteal artery following medial opening wedge high tibial osteotomy is rare. A femoral angiogram revealed a pseudoaneurysm arising from the popliteal artery near the osteotomy site. Careful placement of retractors around the osteotomy site during sawing and flexing the knee to displace the popliteal artery away are recommended to prevent this complication. We report on the case of a pseudoaneurysm of the popliteal artery complicating medial opening wedge high tibial osteotomy that was treated clinically and radio-graphically with literature reviews. Key words: popliteal artery, pseudoaneurysm, genu varum, angiography, osteotomy 비교적젊은나이에내반슬변형을동반한내측골관절염환자의 치료방법인근위경골절골술은 1958 년 Jackson 과 Waugh 1) 에의 해처음시행되었고 Conventry 2) 에의해보편화되었다. 1970 년대 이후절골부를고정할수있는금속판이발달하면서내측개방형 경골근위부절골술이가능해졌고이는폐쇄성절골술에비해수 술이쉬우면서도더정확하고빠르게비골신경손상의위험없이 시행할수있는술기로비골절골이나하지길이의단축등을피 할수있는이점이있지만지연골유합, 슬와신경및혈관의손상 등의합병증또한드물게발생할수있다. 3) 저자들은내측개방형 경골근위부절골술을시행하고슬와동맥가성동맥류발생시지 연적으로발생할수있는증상을경험하였기에문헌고찰과함께 Received November 24, 2014 Revised February 23, 2015 Accepted February 24, 2015 Correspondence to: Sang-Min Kim, M.D. Department of Orthopedic Surgery, Samsung Changwon Hospital, 158 Paryong-ro, Masanhoewon-gu, Changwon 51353, Korea TEL: +82-55-290-6030 FAX: +82-55-290-6888 E-mail: heavystone75@gmail.com 증례보고를하고자한다. 증례보고 56세여자환자로내원 6개월전부터시작된우측무릎통증을주소로내원하였다. 과거병력상갑상선기능저하증과당뇨병을앓고있었으나슬관절의변형을초래할만한수술병력이나외상병력등은없었다. 타병원에서우측내측반월판의열상및뿌리파열로수술적치료권유를받았으나보존적치료를시행하였으며이후우측무릎의통증이악화와완화를반복하였다 (Fig. 1). 이학적검사상우측무릎의후외측과내측의압통이있었으며반대쪽무릎에도내측에압통이동반되어있었으나굴곡구축이나운동범위의제한은없었다. 수술전장하지체중부하전후방사진에서측정한역학적대퇴-경골간각은우측이 8 o, 좌측이 5.8 o 로내반되어있으며 (Fig. 2A), 양측슬관절전후면단순방사선검사 (Rosenberg view) 상경도의퇴행성관절염소견을보였다 (Fig. 3). 본증례의환자의경우 65세이하의활동적인생활습관을가지고 The Journal of the Korean Orthopaedic Association Volume 50 Number 5 2015 Copyright 2015 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.
419 Pseudoaneurysm Follwing HTO A B Figure 1. Preoperative magnetic resonance imaging. (A) A longitudinal horizontal tear is present from body to posterior horn. (B) A radial tear is present at the posterior horn of the lateral meniscus. Figure 3. Preoperative radiographs of both knees. The Rosenberg view of both knees shows mild gonarthrosis of both knees. PA, posterioranterior. 있고내반 (10 o ) 및외반 (10 o ) 변형이심하지않으며퇴행성병변이 내측에만국한되고골손실이거의없는등경골근위부절골술 의적응증에해당되어수술적치료를시행하였다. A Figure 2. Pre- and postoperative scenography. (A) The femorotibial angle measured 8 o on the right and 5.8 o on the left of anatomical varus. (B) Postoperative standing radiographs showing satisfactory correction of the varus deformity. 수술적인접근은먼저변형된슬관절에관절경을삽입하여슬 관절내의병변을확인하고손상된관절면이나연골판등에대 하여변연절제술등을시행하였다. 그후경골상부의전내측을 따라피부절개후봉곤근, 박근, 반건양근을골막에서분리또 는이완시키고표재성내측측부인대를절골부위까지박리하였 B 다. 경골내측관절면의 3 cm 아래에서부터비골두의정점을향해외측근위부로유도핀을비스듬하게삽입한후톱을사용하여외측피질골및골막에손상이가해지지않도록하면서절골을시행하였다. C-arm을사용하여고관절-슬관절-족관절 (hipknee-ankle) 축이슬관절외측경골극을지나도록하였으며쐐기형골결손부위에는골대체재를이용하여골이식을시행하였고, 해부학적금속판을이용하여내고정하였다 (Fig. 4). 수술당일 P-visual analogue scale score가 10점만점중 7점으로높았으나경과관찰하였으며, 수술다음날부터사두근수축운동과하지직거상운동을시행하였다. 수술후하지동맥의맥박은정상적으로촉지되었고, 정맥폐쇄 (venous obstruction) 의소견은관찰되지않았다. 수술 7일후좌측다리오금부위에서부기가관찰되었으나호전양상이며적혈구침강속도와 C-반응성단백 (C-reactive protein) 은모두정상수치를보여경과관찰하였다. 수술 10일후부기가악화되는소견을보여촬영한하지전산화단층촬영 (computed tomography, CT) 상좌측족저근아래근위경
420 Sang-Min Kim, et al. 골의높이에서 6 5 cm 정도의균일한음영의병변이관찰되었으나증상및부기가호전양상을보여경과관찰하기로하였다 (Fig. 5). 수술 4주후장하지체중부하전후방사진을이용한역학적하지축을측정하였는데, 우측 4.6 o 좌측 2.7 o 로외반되어있었으며방사선학적으로나기능적으로적절한교정각을보이고있었고좌측동통및부기역시호전되어퇴원하였다 (Fig. 2B). 수술 6 주이후에좌측하지의동통및부기가악화되었으며촉지시박동감발생하여재입원한후시행한하지혈관조영 CT상좌측슬와동맥쪽의가성동맥류의심병변이관찰되었다. 이후영상의학과전문의와협진후혈관조영술을시행하였고좌측슬와동맥에슬와정맥과교통하는 11.5 8.5 cm 크기낭상 (saccular) 의가성동맥류를관찰할수있었다. Artery의 total rupture인경우에는 open saphenous vein graft가예후가좋지만 pseudoaneurysm과같은합병증에는 stent와 open saphenous vein graft 둘다좋은예후를가지는것으로알려져있어 4) 본원에서는덜침습적인방법인경피 적혈관내스텐트이식설치술을하였다 (Fig. 6). 추시 1 개월째환 자는증상의재발또는골수염, 불유합, 관절강직등의합병증은 없었고수술부위의동통이나압통, 보행장애등을호소하지않 았으며추시관찰을위한혈관조영 CT 상가성동맥류의호전소 견을보였다 (Fig. 7). 56.50 mm Figure 5. Lower extremity nonenhanced computed tomography. Approximately 6-cm-sized, ill-defined round isodense mass like lesion at the soleus muscle area of the proximal tibia level. Figure 4. Postoperative radiographs of both knees. Preoperative varus gonarthrosis is well corrected by open wedge high tibial osteotomy fixed with an anatomical plate. Figure 7. Lower extremity angio-computed tomography (CT). One month after stent implantation. Follow-up CT image demonstrates improvement of pseudoaneurysm. Balloon 6-4 cm A B C Figure 6. (A) Femoral angiography study showing a pseudoaneurysm (11.5 8.5- cm-sized) from the popliteal artery with the neck just near the lateral end of the osteotomy site. (B, C) Femoral angiography shows complete obliteration of the pseudoaneurysm after placing a stent in the popliteal artery.
421 Pseudoaneurysm Follwing HTO 고찰 슬와동맥은슬관절주위의수술을하는데취약한부위이다. 가 성동맥류는슬관절주위수술에서발생확률은낮지만내측개 방형절골술, 5) 원위대퇴골의비개방골절, 6) 슬관절인공관절전 치환술, 4) 전방십자인대재건술, 7) 인공슬관절단관절치환술 8) 등 의수술에있어발생할수있다는보고가있다. Shenoy 등 5) 은술후 2 주째슬와의박동성종창으로가성동맥류를발견하였고, Shin 등 6) 은술후발등굽힘의쇠약으로, van Dorp 등 4) 은술후 1 일째통증 을동반한종아리의종창에의해, Lee 등 7) 은술후 3 일째슬와의 통증으로, Tejero-Garcia 등 8) 은술후 29 일째하지의종창으로인 해가성동맥류를발견하였다. 대부분말단혈액순환은정상이었 고조기진단이 3 예, 지연진단이 2 예보고되었으며모든사례에서 임상적인결과는만족할만하였다. 슬와동맥의손상을의심할수 있는단서로는슬와부위또는하지전체의종창, 슬와의난치성 통증, 가청잡음을동반한박동성혈종, 설명이안되는마비등이 있다. 이럴때는뒤정강동맥및발등동맥이촉지된다하여도슬 와동맥의손상을의심하여야한다. 흔한오진으로는술후의혈 종, 심부정맥혈전증, 온종아리신경의마비등이있으며심한합병 증으로발전하는것을막기위하여조기진단이매우중요하다. 하지만손상된슬와동맥의혈액순환이유지되는경우진단이지 연될때에도치료결과에는영향을주지는않는다. 저자들의경우술후반대편에비해다소특이적인동통이있 었으나혈액순환이좋으며오금의부기소견이없어절골에의한 통증의가능성이높아경과관찰을하였으며술후 1 주일째오금 의종창이발생하여 CT 를시행하였고, CT 상에서종괴와같은병 변이있었으나판독상혈종의심소견을보였고오금부위의통 Figure 8. Intraoperative C-arm fluoroscopy. Radiolucent hohmann retractor protects the popliteal artery. 증감소소견을보이며부기가감소하여다시한번경과관찰을하게되었다. 이후외래추시관찰시오금부위의떨림느껴지며부기가다시발생하여이때에서야동맥류가능성을확인할수있었고추가적인처치를시행하였다. Kim 등 9) 은시체혈관연구를통하여슬와동맥과후방경골사이의거리를연구하였으며굽힘각이증가할수록경골의후방과슬와동맥과의거리가멀어진다는것을확인하였다. 또한관상면에서의톱의각도가커질수록슬와동맥을손상시킬확률이커질수있다는것을확인하였다. 본원에서발생한가성동맥류의경우슬건을박리후에공간을확보하고 long tongue retractor를뼈에붙이고동맥을절골술위치에서벗어나게한후절골술을시행하였지만그럼에도불구하고충분히보호되지않아 electrical saw에의하여손상된것으로추정된다 (Fig. 8). 내측개방형절골술을안전하게시행하기위해서는이상동맥을확인하기위하여자기공명영상을주위깊게보아야하고, 무릎을굽힌자세를유지하여야하며, 톱의각도를관상면에서 30 o 이하로절골을시행해야한다. 또한오금의깊은부위로보호구를삽입해야하며, 수술부위를닫기전에압박띠를풀어출혈부위를다시한번확인하여야한다. 9) CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Jackson JP, Waugh W. Tibial osteotomy for osteoarthritis of the knee. J Bone Joint Surg Br. 1961;43:746-51. 2. Coventry MB. Osteotomy about the knee for degenerative and rheumatoid arthritis. J Bone Joint Surg Am. 1973;55:23-48. 3. Shin YS, Lee DH, Lee SH, Kim MJ, Han SB. Basic principles and current trends of medial opening-wedge high tibial osteotomy. J Korean Orthop Assoc. 2014;49:85-94. 4. van Dorp KB, Breugem SJ, Driessen MJ. Popliteal pseudoaneurysm after arthroscopic posterior cruciate ligament reconstruction. Knee Surg Relat Res. 2014;26:187-9. 5. Shenoy PM, Oh HK, Choi JY, et al. Pseudoaneurysm of the popliteal artery complicating medial opening wedge high tibial osteotomy. Orthopedics. 2009;32:442. 6. Shin YS, Hwang YG, Savale AP, Han SB. Popliteal artery pseudoaneurysm following primary total knee arthroplasty. Knee Surg Relat Res. 2014;26:117-20. 7. Lee GC, Kim DH, Park SH. Popliteal artery pseudoaneurysm after anterior cruciate ligament re-revision using a rigidfix
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423 pissn : 1226-2102, eissn : 2005-8918 Case Report J Korean Orthop Assoc 2015; 50: 418-423 http://dx.doi.org/10.4055/jkoa.2015.50.5.418 www.jkoa.org Pseudoaneurysm Follwing HTO 개방형경골근위부절골술후지연발생한슬와동맥가성동맥류 임해성 김상민 김종관 성균관대학교의과대학삼성창원병원정형외과학교실 근위경골절골술은비교적젊은나이에내반슬변형을동반한내측골관절염환자의정립된치료방법중하나이다. 슬와동맥은슬관절주위의수술중손상을받기쉽다. 근위경골절골술후슬와동맥의가성동맥류가발생하는것은드문일이다. 대퇴혈관조영술로절골부위근처의슬와동맥으로부터발생한가성동맥류를발견하였다. 이러한합병증을예방하기위하여절골부위절골시주위를견인기로조심하게당기고슬와동맥을보호하기위하여무릎을굽히는것을추천한다. 저자들은개방형경골근위부절골술후발생한슬와동맥의가성동맥류사례에대한임상적및방사선적치료를보고하는바이다. 색인단어 : 슬와동맥, 가성동맥류, 내반슬, 혈관조영술, 절골술 접수일 2014 년 11 월 24 일수정일 2015 년 2 월 23 일게재확정일 2015 년 2 월 24 일책임저자김상민 51353, 창원시마산회원구팔용로 158, 삼성창원병원정형외과 TEL 055-290-6030, FAX 055-290-6888, E-mail heavystone75@gmail.com 대한정형외과학회지 : 제 50 권제 5 호 2015 Copyright 2015 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.