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무혈성 골괴사에 관한 임상 및 병리조직학적 고찰

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 Clinical and histopathological studies on avascular osteonecrosis 
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[한글] 무혈성 골괴사는 외상후 또는 전신질환과 동반하거나 뚜렷한 원인 없이 체중이 부하되는 골단부 특히 대퇴골두에 무균적으로 괴사를 일으키고 종국에는 관절의 기능장애 및 변형을 초래하는 중요한 질환으로서 아직도 그 원인 및 발병기전이 구명되지 않고 있다. 20세기 이후 무혈성 골괴사의 유발요인, 발생기전 및 진행과정에 관한 광범위한 임상적 및 실험적 연구에 의하여 괴사의 예방, 조기진단, 치료에 있어서 괄목할만한 진전이 있었으나 우리나라에서는 무혈성 골괴사에 대한 산발적인 증례 보고만 있을 뿐 총괄적인 연구가 거의 이루어지지 못하고 있는 실정이다. 이에 저자는 1970년 1월부터 1978년 12월까지 만 9년간 연세의료원 병리학교실 및 고려병원 병리과에서 진단한 무혈성 골괴사 총 57예를 대상으로 육안적 및 현미경적 검사에 의한 조직학적 검색과 방사선검사를 통하여 병변의 진행과정을 고찰하였으며, 임상기록 조사가 가능했던 예에서는 환자의 연령, 성별, 발생부위, 주소, 병력기간 등의 임상소견을 문헌들과 비교검토 하였다. 결과를 요약하면 다음과 같다. 1. 무혈성 골괴사 총 57예를 원인별로 검토한 바, 특발성이 21예로 36.9%, 외상성이 24예로 42.1%를 차지하였다. 2. 특발성 괴사의 약 절반은 각종 전신질환과 동반되었고, 외상성 괴사는 대부분 대퇴골경부 골절에 합병되었다. 3. 무혈성 골괴사의 대다수가 30세 이후의 성인층에 분포하였다. 4. 특발성 괴사는 남자에, 외상성 괴사는 여자에 많았다. 5. 환자의 대다수가 동통을 동반한 운동장애를 호소하였다. 6. 특발성 괴사는 대체로 증세발생 1년 이후에, 외상성 괴사는 1년 이내에 관찰되었다. 7. 무혈성 골괴사는 대다수가 대퇴골에 발생하였으며 특발성 대퇴골두 괴사의 약 50%가 양측성이었다. 8. 골괴사는 골수로부터 시작되었고, 골자체의 괴사는 다소 시일이 경과된 후에 진행되었으며 치유는 약 2주부터 시작되었으나 골형성은 1개월 이후에 관찰되었다. 활액막 및 연골의 변화도 상당시일이 경과된 후에 진행되었다. 위와 같은 소견은 괴사의 원인에 관계없이 대동소이하였다. 9. 대체로 병력 1년 이상인 환자에서 방사선 검사상 무혈성 골괴사의 진단이 가능하였는데 이는 병소의 혈관재생에 기인된 것이었다. 이상과 같은 결과를 토대로 저자는 무혈성 골괴사의 발병기전을 이해하고 현병력, 방사선 및 병리조직학적 검사에 의하여 병변을 조기에 발견함으로써 관절의 기능장애를 예방하고 적절한 치료양식의 채택에 큰 도움을 줄 수 있을 것으로 생각하였다.
[영문] Avascular(aseptic) necrosis of the bone is an infarctive process of debated etiology that most commonly involves the femoral head of adult(Teitelbaum, 1977). It can be classified into the idiopathic(nontraumatic) type in which the interruption of the blood supply is not conditioned by the trauma or pre-existing disease process and posttraumatic type appearing in the wake of a fracture or dislocation(Jaffe, 1972). The precise etiology of both traumatic and nontraumatic osteonecrosis is uncertain. However, that of the traumatic osteonecrosis is believed to be the mechanical interference with arterial blood supply. So-called nontraumatic osteonecrosis has long been termed "Idiopathic" signifying that the condition is of uncertain origin. However it is often associated with several systemic disorders or conditions such as alcoholism, hypercortisonism, Gaucher's disease, connective tissue disease, gout, hemoglobinopathies, Caisson's disease, pancreatitis, pregnancy, occlusive vascular disease and etc. Currently ischemia due to blood vessel wall disease perse or blokage of blood flow by thrombosis or emboli have been postulated to be the underlying cause of idiopathic osteonecrosis(Glimcher & Kenzora, 1978). Fisher(1978) emphasized the important relationship of hyperlipemia, fatty liver and systemic(intraosseous) fat embolism in corticoid-induced osteonecrosis. These finding have also been recorded both clinically and experimentally by Cruess(1978) who suggests that avascular osteonecrosis should properly be classified as either traumatic(macrovascular injury) or embolic(microvascular injury) in nature. The pathological changes are quite characteristic and regardless of what causes the osteonecrosis, the biological events constituting repair are the same(Kenzora et al, 1978; Catto, 1965). The X-ray shows a remarkably similar picture of wedgeshaped anterolateral sclerosis with subchondral lucency. The orthopedic surgeon should classify each lesion according to the histologic biology and X-ray manifestations and stage each lesion in order to determine the optimum treatment modalities. Comprehensive experimental and clinical studies regarding the epidemiology, etiology, and pathophysiology were presented by foreign reseachers. However there is no comprehensive report on avascular osteonecrosis among Koreans bases on clinical and histopathological aspects. The present study is an attempt to clarify the pathogenesis, to investigate clinico-histopathological characteristics and to contribute to the early idagnosis, proper treatment and prevention of avascular osteonecrosis. Materials and Method A total 57 cases of avascular osteonecrosis observed during 9 years from Jan., 1970 to Dec., 1978 were reviewed clinically, roentgenographically, and histopathologically. For all cases of avascular osteronecrosis whose clinical records were available, age, sex, location, chief complaints, duration, and associated disease were investigated. The histopathological study was attempted by microscopic examination following gross inspection. Correlation of the rediologic appearances and microscopic features has been possible in 22 cases in which X-ray films were available. Results and Summary Based on the clinical, histopathological and radiologic studies of 57 cases of avascular necrosis of bone, which were submitted to the department of pathology, Yonsei University, College of Medicine and Korea General Hospital during the period of 9 years from Jan., 1970 to Dec., 1978, following results were obtained. 1. Among 57 cases, 21 cases(36.9%) were idiopathic(nontraumatic) and 24 cases(42.1%) were posttraumatic type. 2. The half of the idiopathic osteonecrosis were associated with systemic disorders such as alcoholism, hypercortisonism, Caisson's disease and diabetes mellitus. The majority of posttraumatic osteonecrosis were caused by femoral neck fracture. 3. The majority of avascular osteonecrosis developed in adult age gorup with peak age incidence of 30-60 years old. 4. The sex distribution of idiopathic type was about 2 times more common in males than in females, but that of the posttraumatic type showed slight female preponderance. 5. Clinical symptoms were pain, limitation of motion, limping and local swelling in order of frequency. 6. The most cases of posttraumatic necrosis were evident within 1 year of trauma, but that of idiopathic necrosis after 1 year. 7. The histopathiological findings were quite similar regardless of what causes the osteonecrosis. The nature and sequence of tissue responses according to the duration were well accordant to the foreign reports. 8. The pathognomonic radiologic findings were resulted from revascularisation and repair after 1 year.
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