摘要
目的 探讨3D打印金属垫块或胫骨假体重建全膝关节置换(total knee arthroplasty,TKA)和膝关节翻修术中巨大骨缺损的临床疗效.方法 回顾性分析2018年7月至2023年12月就诊于浙江大学医学院附属第二医院骨科的存在巨大骨缺损的TKA或膝关节翻修患者7例(7膝),其中TKA4例、膝关节翻修术3例.男3例、女4例,年龄(58.7±7.6)岁(范围54～68岁),左膝3例、右膝4例.患者膝关节均存在骨缺损,均为AORIⅢ型,2例仅股骨存在骨缺损,4例仅胫骨存在骨缺损,1例胫骨和股骨均存在缺损,采用3D打印个性化重建治疗.比较手术前后的髋膝踝角、美国膝关节协会评分(Keen Society score,KSS),观察术后并发症情况.结果 所有患者均顺利完成手术,手术时间为(189.3±35.5)min(范围125～240 min).复杂TKA 4例,手术时间分别175、195、210、240 min,翻修术3例,手术时间分别125、180、200 min.术中出血量为(114±24.4)ml(范围100～150 ml).5例使用3D打印金属垫块,2例使用3D打印一体式胫骨部件.所有患者均获得随访,随访时间分别为2、2、5、6、7、20、57个月.术后3个月5例患者的KSS膝评分分别为56、61、66、56、56分,大于术前的35、44、36、27、41分.术后3个月5例患者的KSS功能评分分别为45、45、45、30、45分,大于术前的30、30、15、20、20分.末次随访时髋膝踝角为181.8°±3.4°(范围177.9°～188.0°),术前为175.8°±12.4°(范围153.3°～192.1°),差异无统计学意义(t=-1.230,P=0.242).末次随访时3D打印部件与骨面结合良好,假体位置稳固,下肢力线均正常.两组术后无一例出现切口愈合不良、感染、脂肪液化、神经损伤、下肢深静脉血栓形成、膝关节僵硬、假体周围感染及松动等并发症.结论 采用3D打印金属垫块或胫骨假体重建全膝关节置换和翻修术中巨大骨缺损早期临床疗效满意,可获得比较满意的关节功能,手术安全性较好.
Abstract
Objective To investigate the clinical efficacy of 3D printed metal augment or tibial prosthesis for reconstruc-tion of large bone defects in total knee arthroplasty(TKA)and knee revision surgery.Methods A total of 7 patients(7 knees)with TKA or knee revision who were admitted to the Department of Orthopaedics of the Second Affiliated Hospital of Zhejiang Uni-versity School of Medicine with large bone defects from July 2018 to December 2023 were retrospectively analyzed,including 4 pa-tients with TKA and 3 patients with knee revision.There were 3 males and 4 females,aged 58.7±7.6 years(range,54-68 years),3 patients with left knee and 4 patients with right knee.All the patients had bone defects in the knee joint(AORI type Ⅲ),2 cases had bone defects only in the femur,4 cases had bone defects only in the tibia,and 1 case had bone defects in both the tibia and fe-mur,which were treated with personalized reconstruction using 3D printing.Hip-knee-ankle angles,American Knee Society score(KSS)before and after surgery were compared,and postoperative complications were observed.Results All patients successfully completed the operation,and the operation time was 189.3±35.5 min(range,125-240 min).Complex TKA was performed in 4 cas-es with surgical times of 175,195,210,and 240 min,and revision surgery was performed in 3 cases with surgical times of 125,180,and 200 min,respectively.Intraoperative blood loss was 114±24.4 ml(range,100-150 ml).Five cases used 3D printed metal augment,and two used 3D printed one-piece tibial components.All patients were followed up for 2,2,5,6,7,20,57 months,re-spectively.The KSS of the five patients at 3 months postoperatively were 56,61,66,56,and 56 points,respectively,greater than the preoperative scores of 35,44,36,27,and 41 points.The KSS functional scores of the five patients at 3 months postoperatively were 45,45,45,30,and 45 points,respectively,which were greater than the preoperative scores of 30,30,15,20,and 20 points.The hip-knee-ankle angle was 181.8°±3.4°(range,177.9° to 188.0°)at the final follow-up and 175.8°±12.4°(range,153.3° to 192.1°)before surgery,with no significant difference(t=-1.230,P=0.242).At the final follow-up,the 3D printed component was well integrated with the bone surface,the prosthesis was securely positioned,and the force lines of the lower limbs were normal.There were no postoperative complications such as poor wound healing,infection,fat liquefaction,nerve injury,deep vein thrombo-sis of lower limbs,knee joint stiffness,periprosthesis infection and loosening.Conclusion Using 3D printed metal augment or tibial prosthesis to reconstruct the huge bone defect in TKA and revision has a satisfactory early clinical effect,satisfactory joint function and good surgical safety.
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