Albergo Jose I, Gaston Czar L, Aponte-Tinao Luis A, Ayerza Miguel A, Muscolo D Luis, Farfalli Germán L, Jeys Lee M, Carter Simon R, Tillman Roger M, Abudu Adesegun T, Grimer Robert J
Carlos E. Ottolenghi Institute of Orthopedics, Italian Hospital of Buenos Aires, Potosí 4247 (1199), Buenos Aires, Argentina.
Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK.
Clin Orthop Relat Res. 2017 Mar;475(3):676-682. doi: 10.1007/s11999-016-4843-y.
The proximal tibia is one of the most challenging anatomic sites for extremity reconstructions after bone tumor resection. Because bone tumors are rare and large case series of reconstructions of the proximal tibia are lacking, we undertook this study to compare two major reconstructive approaches at two large sarcoma centers.
QUESTIONS/PURPOSES: The purpose of this study was to compare groups of patients treated with endoprosthetic replacement or osteoarticular allograft reconstruction for proximal tibia bone tumors in terms of (1) limb salvage reconstruction failures and risk of amputation of the limb; (2) causes of failure; and (3) functional results.
Between 1990 and 2012, two oncologic centers treated 385 patients with proximal tibial resections and reconstruction. During that time, the general indications for those types of reconstruction were proximal tibia malignant tumors or bone destruction with articular surface damage or collapse. Patients who matched the inclusion criteria (age between 15 and 60 years old, diagnosis of a primary bone tumor of the proximal tibia treated with limb salvage surgery and reconstructed with endoprosthetic replacement or osteoarticular allograft) were included for analysis (n = 149). In those groups (endoprosthetic or allograft), of the patients not known to have reached an endpoint (death, reconstructive failure, or limb loss) before 2 years, 85% (88 of 104) and 100% (45 of 45) were available for followup at a minimum of 2 years. A total of 88 patients were included in the endoprosthetic group and 45 patients in the osteoarticular allograft group. Followup was at a mean of 9.5 (SD 6.72) years (range, 2-24 years) for patients with endoprosthetic reconstructions, and 7.4 (SD 5.94) years for patients treated with allografts (range, 2-21 years). The following variables were compared: limb salvage reconstruction failure rates, risk of limb amputation, type of failures according to the Henderson et al. classification, and functional results assessed by the Musculoskeletal Tumor Society system.
With the numbers available, after competitive risk analysis, the probability of failure for endoprosthetic replacement of the proximal tibia was 18% (95% confidence interval [CI], 10.75-27.46) at 5 years and 44% (95% CI, 31.67-55.62) at 10 years and for osteoarticular allograft reconstruction was 27% (95% CI, 14.73-40.16) at 5 years and 32% (95% CI, 18.65-46.18) at 10 years. There were no differences in terms of risk of failures at 5 years (p = 0.26) or 10 years (p = 0.20) between the two groups. Fifty-one of 88 patients (58%) with proximal tibia endoprostheses developed a reconstruction failure with mechanical causes being the most prevalent (32 of 51 patients [63%]). A total of 19 of 45 osteoarticular allograft reconstructions failed (42%) and nine of 19 (47%) of them were caused by early infection. Ten-year risk of amputation after failure for endoprosthetic reconstruction was 10% (95% CI, 5.13-18.12) and 11% (95% CI, 4.01-22.28) for osteoarticular allograft with no difference between the groups (p = 0.91). With the numbers available, there were no differences between the groups in terms of the mean Musculoskeletal Tumor Society score (26.58, SD 2.99, range, 19-30 versus 27.52, SD 1.91, range, 22-30; p = 0.13; 95% CI, -2,3 to 0.32). Mean extension lag was more severe in the endoprosthetic group than the osteoarticular allograft group: 13.56° (SD 18.73; range, 0°-80°) versus 2.41° (SD 5.76; range, 0°-30°; p < 0.001; 95% CI, 5.8-16.4).
Reconstruction of the proximal tibia with either endoprosthetic replacement or osteoarticular allograft appears to offer similar reconstruction failures rates. The primary cause of failure for allograft was infection and for endoprosthesis was mechanical complications. We believe that the treating surgeon should have both options available for treatment of patients with malignant or aggressive tumors of the proximal tibia. (S)he might consider an allograft in a younger patient to achieve better extensor mechanism function, whereas in an older patient or one with a poorer prognosis where return to function and ambulation quickly is desired, an endoprosthesis may be advantageous.
Level III, therapeutic study.
胫骨近端是骨肿瘤切除术后肢体重建最具挑战性的解剖部位之一。由于骨肿瘤罕见且缺乏大量胫骨近端重建的病例系列，我们开展了这项研究，以比较两个大型肉瘤中心的两种主要重建方法。
问题/目的：本研究的目的是比较接受胫骨近端骨肿瘤人工关节置换或骨关节异体移植重建治疗的患者组在以下方面的情况：（1）保肢重建失败和肢体截肢风险；（2）失败原因；（3）功能结果。
1990年至2012年期间，两个肿瘤中心对385例胫骨近端切除并重建的患者进行了治疗。在此期间，这些类型重建的一般适应症为胫骨近端恶性肿瘤或伴有关节面损伤或塌陷的骨破坏。符合纳入标准（年龄在15至60岁之间，诊断为胫骨近端原发性骨肿瘤并接受保肢手术，采用人工关节置换或骨关节异体移植重建）的患者纳入分析（n = 149）。在这些组（人工关节置换或异体移植）中，在2年之前未知已达到终点（死亡、重建失败或肢体丢失）的患者中，85%（104例中的88例）和100%（45例中的45例）至少有2年的随访资料。人工关节置换组共纳入88例患者，骨关节异体移植组纳入45例患者。人工关节置换重建患者的随访平均时间为9.5（标准差6.72）年（范围，2至24年），异体移植治疗患者的随访平均时间为7.4（标准差5.94）年（范围，2至21年）。比较了以下变量：保肢重建失败率、肢体截肢风险、根据亨德森等人分类的失败类型以及通过肌肉骨骼肿瘤学会系统评估的功能结果。
根据现有数据，经过竞争风险分析，胫骨近端人工关节置换在5年时失败的概率为18%（95%置信区间[CI]，10.75 - 27.46），在10年时为44%（95%CI，31.67 - 55.62）；骨关节异体移植重建在5年时失败的概率为27%（95%CI，14.73 - 40.16），在10年时为32%（95%CI，18.65 - 46.18）。两组在5年（p = 0.26）或10年（p = 0.20）时的失败风险无差异。88例胫骨近端人工关节置换患者中有51例（58%）发生重建失败，其中机械原因最为常见（51例患者中的32例[63%]）。45例骨关节异体移植重建中有19例（42%）失败，其中19例中的9例（47%）是由早期感染引起的。人工关节置换重建失败后10年的截肢风险为10%（95%CI，5.13 - 18.12），骨关节异体移植为11%（95%CI，4.01 - 22.28），两组之间无差异（p = 0.91）。根据现有数据，两组在肌肉骨骼肿瘤学会平均评分方面无差异（26.58，标准差2.99，范围，19 - 30对27.52，标准差1.91，范围，22 - 30；p = 0.13；95%CI， - 2.3至0.32）。人工关节置换组的平均伸展滞后比骨关节异体移植组更严重：13.56°（标准差18.73；范围，0° - 80°）对2.41°（标准差5.76；范围，0° - 30°；p < 0.001；95%CI，5.8 - 16.4）。
胫骨近端采用人工关节置换或骨关节异体移植重建似乎具有相似的重建失败率。异体移植失败的主要原因是感染，人工关节置换失败的主要原因是机械并发症。我们认为，治疗外科医生在治疗胫骨近端恶性或侵袭性肿瘤患者时应具备这两种选择。对于年轻患者，可能考虑采用异体移植以获得更好的伸肌机制功能，而对于老年患者或预后较差且希望快速恢复功能和行走能力的患者，人工关节置换可能更具优势。
III级，治疗性研究。
