[膝关节定制肿瘤假体翻修手术]

Tang Xiaodong, Guo Wei, Yang Rongli, Yan Taiqiang, Qu Huayi

Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, 100044, PR China.

Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2010 Jan;24(1):5-10.

OBJECTIVE

To evaluate the surgical skill, cause of revision, complications, prosthetic survival and postoperative function in revision of custom-made tumor prosthesis replacement of knee joint.

METHODS

The clinical data of 33 patients who received prosthetic revision surgery between June 2002 and June 2007 were reviewed. There were 17 males and 16 females with an average age of 33.1 years (range, 16-67 years). The pathological diagnosis included 17 osteosarcomas, 11 giant cell tumors, 2 malignant fibrous histiocytomas, 1 chondrosarcoma, 1 synovial sarcoma, and 1 liposarcoma. The involved locations were distal femur in 22 cases and proximal tibia in 11 cases. The average interval between first prosthetic replacement and revision surgery was 45.3 months (range, 6-180 months). The reason for revision included local recurrence in 2 cases, deep infection in 8 cases, aseptic loosening in 7 cases, periprosthetic fracture in 1 case, prosthetic stem fracture in 6 cases, and prosthetic hinge failure in 9 cases. Six patients with deep infection received two-stage revision surgery, while the other 27 patients received one-stage revision. Cemented prostheses were used in all patients. Allograft prosthetic composite and revisions were used in 2 patients who had deficit of diaphysis for stem fixation.

RESULTS

In 17 patients who received both primary prosthetic replacement and revision, the operative time was (149.8 +/- 40.5) minutes and (189.9 +/- 43.8) minutes, and the blood loss was (605.2 +/- 308.0) mL and (834.1 +/- 429.9) mL for primary prosthetic replacement and revision, respectively; all showing statistically significant differences (P < 0.05). The mean time of follow-up was 45.1 months (range, 12-76 months). Healing between allograft and host bone was obtained in 2 patients with allograft prosthetic composite and revision after 1.5 years and 2 years, respectively. After revision surgery, 3 patients died of lung metastasis after 12-24 months, and other 3 patients having lung metastasis were alive with disease. Nine (30%) complications occurred in 30 patients who were alive at last follow-up. The complications included wound infection in 2 patients, deep infection in 5 patients, mechanical problems in 2 patients. Prosthetic failure occurred in 7 patients (23.3%). The 5-year survival rate of revised prosthesis was 68.6%. The Musculoskeletal Tumor Society (MSTS) score at 6 months after revision (73.6% +/- 14.4%) was significantly improved (P < 0.01) when compared with before revision (57.1% +/- 10.6%).

CONCLUSION

The main reasons for revision of custom-made tumor prosthesis of knee joint were mechanical problems and deep infection. Although revision surgery of knee is relatively complicated and has some complications, a functional limb could be maintained in most tumor patients.

目的

评估定制肿瘤人工膝关节置换翻修手术的手术技巧、翻修原因、并发症、假体生存率及术后功能。

方法

回顾性分析2002年6月至2007年6月间接受假体翻修手术的33例患者的临床资料。其中男性17例，女性16例，平均年龄33.1岁（16 - 67岁）。病理诊断包括骨肉瘤17例、骨巨细胞瘤11例、恶性纤维组织细胞瘤2例、软骨肉瘤1例、滑膜肉瘤1例、脂肪肉瘤1例。累及部位为股骨远端22例，胫骨近端11例。首次假体置换至翻修手术的平均间隔时间为45.3个月（6 - 180个月）。翻修原因包括局部复发2例、深部感染8例、无菌性松动7例、假体周围骨折1例、假体柄骨折6例、假体铰链故障9例。6例深部感染患者接受二期翻修手术，其余27例患者接受一期翻修。所有患者均使用骨水泥型假体。2例骨干缺损需行柄固定的患者使用了同种异体骨假体复合物及翻修假体。

结果

17例接受初次假体置换及翻修的患者，初次假体置换手术时间为（149.8±40.5）分钟，翻修手术时间为（189.9±43.8）分钟；初次假体置换失血量为（605.2±308.0）ml，翻修失血量为（834.1±429.9）ml；差异均有统计学意义（P < 0.05）。平均随访时间为45.1个月（12 - 76个月）。2例使用同种异体骨假体复合物及翻修的患者，同种异体骨与宿主骨分别在1.5年和2年后愈合。翻修手术后，3例患者于12 - 24个月后死于肺转移，另外3例有肺转移的患者带瘤生存。末次随访时存活的30例患者中发生9例（30%）并发症。并发症包括伤口感染2例、深部感染5例、机械问题2例。7例（23.3%）患者出现假体失败。翻修后假体的5年生存率为68.6%。翻修后6个月的肌肉骨骼肿瘤学会（MSTS）评分（73.6%±14.4%）较翻修前（57.1%±10.6%）显著提高（P < 0.01）。