Kawai A, Muschler G F, Lane J M, Otis J C, Healey J H
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
J Bone Joint Surg Am. 1998 May;80(5):636-47. doi: 10.2106/00004623-199805000-00004.
We evaluated the medium to long-term results of treatment with a custom prosthetic knee replacement after wide resection of a primary malignant tumor of the distal part of the femur in forty consecutive patients. The duration of follow-up ranged from five to seventeen years (median, eight years). At the time of the latest follow-up, thirty-five (88 per cent) of the forty patients were free of disease and five (13 per cent) were alive with metastatic disease. No local recurrence was observed. Twenty early complications occurred in eighteen patients (45 per cent). Aseptic loosening of the femoral component, which necessitated a revision in eleven patients at an average of fifty-one months, was the most frequent mode of failure. The rate of prosthetic survival, as estimated with use of the Kaplan-Meier method, was 85, 67, and 48 per cent at three, five, and ten years. Univariate analysis demonstrated that the rate of prosthetic survival was significantly worse for male patients, for those in whom at least 40 per cent of the femur had been resected, for those who had had total resection of the quadriceps muscles or subtotal resection (preservation of only the rectus femoris muscle), and for those in whom a straight femoral stem had been used (p < 0.05 for all comparisons). Multivariate analysis showed that the independent adverse prognostic factors for prosthetic survival were male gender, resection of at least 40 per cent of the femur, and fixation of the femoral stem with cement. The rate of limb salvage was calculated, with use of the Kaplan-Meier method, to be 93 per cent at three years and 90 per cent at five and ten years. At the latest follow-up examination, the functional scores according to the classification system of the Musculoskeletal Tumor Society ranged from 14 to 29 points; the mean was 24 points, which represents function that is 80 per cent that of normal. The mean scores in the categories of walking supports and gait were better for the patients in whom the quadriceps muscles had been preserved than for those who had had total or subtotal resection of those muscles. Although advances in imaging and local therapy narrow the indications for an extra-articular resection of a tumor, the implant that was used in the present study continues to be used in approximately 15 per cent of patients who have a fracture or an intra-articular extension of the tumor that necessitates extensive extra-articular resection.
我们评估了连续40例股骨远端原发性恶性肿瘤广泛切除术后定制人工膝关节置换治疗的中长期结果。随访时间为5至17年（中位数为8年）。在最近一次随访时，40例患者中有35例（88%）无疾病生存，5例（13%）有转移性疾病存活。未观察到局部复发。18例患者（45%）发生了20例早期并发症。股骨组件无菌性松动是最常见的失败模式，11例患者平均在51个月时需要进行翻修。使用Kaplan-Meier方法估计，人工关节在3年、5年和10年时的生存率分别为85%、67%和48%。单因素分析表明，男性患者、股骨切除至少40%的患者、股四头肌完全切除或次全切除（仅保留股直肌）的患者以及使用直柄股骨假体的患者，人工关节生存率明显较差（所有比较p<0.05）。多因素分析显示，人工关节生存的独立不良预后因素为男性、股骨切除至少40%以及股骨柄骨水泥固定。使用Kaplan-Meier方法计算，保肢率在3年时为93%，在5年和10年时为90%。在最近一次随访检查时，根据肌肉骨骼肿瘤学会分类系统的功能评分范围为14至29分；平均分为24分，代表功能为正常功能的80%。保留股四头肌的患者在行走辅助和步态类别中的平均评分优于股四头肌完全或次全切除的患者。尽管影像学和局部治疗的进展缩小了肿瘤关节外切除的适应证，但本研究中使用的植入物仍在约15%因骨折或肿瘤关节内扩展而需要广泛关节外切除的患者中使用。
