Benedetti Maria Grazia, Okita Yusuke, Recubini Elena, Mariani Elisabetta, Leardini Alberto, Manfrini Marco
Physical Medicine and Rehabilitation Unit, Rizzoli Orthopedic Institute, Via Pupilli 1, 40136, Bologna, Italy.
Movement Analysis Laboratory, Rizzoli Orthopedic Institute, Bologna, Italy.
Clin Orthop Relat Res. 2016 Apr;474(4):995-1004. doi: 10.1007/s11999-016-4691-9. Epub 2016 Jan 11.
Rotationplasty may be indicated for some children with osteosarcoma in the distal femur or proximal tibia; in properly selected patients, it may offer functional advantages over transfemoral amputation and more durable results than a prosthesis. The clinical and functional outcomes reported for this procedure generally have been limited to studies with a mean followup of approximately 8 years in terms of Musculoskeletal Tumor Society Score (MSTS), physical examination, and gait analysis. However, the effects of residual thigh-shank length on gait have not been explored to our knowledge.
QUESTIONS/PURPOSES: We asked: (1) Do differences in the length of the surgically treated residual thigh-shank relative to the contralateral thigh result in altered gait patterns? (2) What were the clinical and functional impairments and radiographic findings of patients who underwent rotationplasty and who survived to adulthood? (3) Do gait analysis findings in adults differ from previously reported findings in children in terms of relevant gait parameters such as maximal ground reaction forces and sagittal knee angles?
From January 1986 to December 2009, 254 children (age range, 3-14 years) affected by high-grade bone sarcomas located in the distal half of the femur were surgically treated at our institute. Forty-two of these patients (16.5%) underwent rotationplasty. During this period, three adolescents older than 15 years were treated by rotationplasty owing to the tumor volume and extracompartmental involvement. In total, 45 patients underwent rotationplasty. From January 1986 to December 2000, rotationplasty generally was the preferred treatment for patients younger than 9 years with a high-grade bone sarcoma calling for an intra- or extraarticular resection of the distal femur, as long as the sciatic nerve could be spared. From January 2001, the procedure was not used as often. Of the 45 patients who underwent a rotationplasty, 14 died of disease at a mean of 37 months (31%); 31 patients (69%) were survivors at the time the study was done, 29 of whom were continuously disease free (64%) and two had no evidence of disease after a pulmonary metastasectomy (5%). These 31 patients were invited to participate in the study, and 25 of the 31 agreed to participate. There were 15 males and 10 females with a mean age of 23.8 years (SD, 7.5 years) and mean followup of 15 years (SD, 5.8 years). Clinical assessment included the MSTS score (total score ranges between 0 and 30 with 0 indicating poor results and 30 indicating good results), obtained by clinical assessment and patient interview, measurements of the residual thigh-shank length and of the contralateral thigh, of the lengths of the surgically treated and contralateral feet, and of active ROM of the rotated and contralateral ankles. Of the 25 patients, 22 (88%) agreed to have lower limb radiographs and 16 (64%) agreed to perform gait analysis.
The residual thigh-shank was, on average, 5.8% longer than the contralateral thigh. Differences in the length of the residual thigh-shank relative to the contralateral thigh resulted in altered gait patterns. Patients with longer residual thigh-shank length had greater pseudoknee flexion during stance and swing. Patients with shorter residual thigh-shank length walked with a gait similar to that of controls. The mean MSTS score was 25 (SD, 2). With respect to the contralateral foot, the surgically treated foot was 10% shorter, the talus 11% shorter in the long axis and 7.6% in the short axis and the calcaneus was 2.7% shorter in the long axis and 8.6% in the short axis. Radiologic arthritis was present in most patients at the tibiotalar, subtalar, and talonavicular joints. As adults, our patients showed improved gait parameters compared with previously reported findings for children undergoing rotationplasty. Vertical ground reaction force during midstance was reduced by 6% and knee ROM during the gait cycle was increased by 24.6°.
The residual thigh-shank length influences the gait performance, such that patients with smaller discrepancies between the surgically treated and contralateral sides had the best walking performance. The MSTS score at a mean of 15 years after knee rotationplasty confirmed the results reported in the shorter-term for function and pain. The foot on the surgically treated side was smaller than the contralateral foot, and degenerative changes were present, which could contribute to impaired function. Gait performance, in terms of ground reaction forces and knee ROM, was improved in our adult patients although a difference in loading was still present between the surgically treated and contralateral limbs. Based on these findings, surgeons should endeavor to have the center axis of rotation of the contralateral knee and pseudoknee at skeletal maturity. An excessive residual thigh-shank length in adult patients could require contralateral lengthening to improve functional results.
Level IV, therapeutic study.
对于一些股骨远端或胫骨近端骨肉瘤患儿，可考虑行旋转成形术；在恰当选择的患者中，与经股骨截肢相比，旋转成形术可能具有功能优势，且比假体更持久。关于该手术的临床和功能结果报道，通常局限于以肌肉骨骼肿瘤学会评分（MSTS）、体格检查和步态分析为指标、平均随访约8年的研究。然而，据我们所知，尚未探讨残留大腿-小腿长度对步态的影响。
问题/目的：我们提出以下问题：（1）手术治疗后的残留大腿-小腿长度与对侧大腿长度的差异是否会导致步态模式改变？（2）接受旋转成形术并存活至成年的患者的临床和功能损害以及影像学表现如何？（3）在最大地面反作用力和矢状面膝关节角度等相关步态参数方面，成人的步态分析结果与先前报道的儿童结果是否不同？
1986年1月至2009年12月，我院对254例患有位于股骨远端下半部的高级别骨肉瘤的儿童（年龄范围3 - 14岁）进行了手术治疗。其中42例患者（16.5%）接受了旋转成形术。在此期间，3例年龄超过15岁的青少年因肿瘤体积大及肿瘤侵犯关节外组织而接受了旋转成形术。总计45例患者接受了旋转成形术。1986年1月至2000年12月，对于需要进行股骨远端关节内或关节外切除的9岁以下高级别骨肉瘤患者，只要能保留坐骨神经，旋转成形术通常是首选治疗方法。从2001年1月起，该手术的使用频率降低。在接受旋转成形术的45例患者中，14例（31%）平均在37个月时死于疾病；在研究进行时，31例患者（69%）存活，其中29例（64%）持续无病，2例在肺转移瘤切除术后无疾病证据（5%）。这31例患者被邀请参加本研究，31例中有25例同意参加。其中男性15例，女性10例，平均年龄23.8岁（标准差7.5岁），平均随访15年（标准差5.8年）。临床评估包括通过临床评估和患者访谈获得的MSTS评分（总分范围为0至30分，0分表示结果差，30分表示结果好），测量残留大腿-小腿长度、对侧大腿长度、手术治疗侧和对侧足部长度以及旋转侧和对侧踝关节的主动活动度。25例患者中，22例（88%）同意拍摄下肢X线片，16例（64%）同意进行步态分析。
残留大腿-小腿平均比对侧大腿长5.8%。残留大腿-小腿长度与对侧大腿长度的差异导致步态模式改变。残留大腿-小腿长度较长的患者在站立期和摆动期有更大的假膝关节屈曲。残留大腿-小腿长度较短的患者行走步态与对照组相似。MSTS评分平均为25分（标准差2分）。与对侧足部相比（手术治疗侧），手术治疗侧足部短10%，距骨长轴短11%、短轴短7.6%，跟骨长轴短2.7%、短轴短8.6%。大多数患者在胫距关节、距下关节和距舟关节出现放射性关节炎。作为成年人，我们的患者与先前报道的接受旋转成形术的儿童相比，步态参数有所改善。站立中期的垂直地面反作用力降低了6%，步态周期中的膝关节活动度增加了24.6°。
残留大腿-小腿长度影响步态表现，手术治疗侧与对侧差异较小的患者步行表现最佳。膝关节旋转成形术后平均15年的MSTS评分证实了短期研究中关于功能和疼痛的结果。手术治疗侧的足部比对侧足部小，且存在退行性改变，这可能导致功能受损。尽管手术治疗侧和对侧肢体之间仍存在负荷差异，但我们的成年患者在地面反作用力和膝关节活动度方面的步态表现有所改善。基于这些发现，外科医生应努力使对侧膝关节和假膝关节的旋转中心轴在骨骼成熟时对齐。成年患者残留大腿-小腿长度过长可能需要对侧肢体延长以改善功能结果。
IV级，治疗性研究。
