摘要
目的 探讨异体骨复合假体重建股骨远端恶性肿瘤切除后大段骨缺损的中长期疗效.方法 回顾性收集2013年6月至2018年12月于上海市第一人民医院骨肿瘤科就诊的股骨远端恶性肿瘤并接受同种异体骨复合假体重建的患者19例,男10例、女9例,年龄(22.3±11)岁(范围11～42岁),体质指数(19.3±3.4)kg/m2(范围14～27 kg/m2).病理类型:骨肉瘤18例,Ewing肉瘤1例.骨肿瘤Ennecking分期:Ⅱ B期17例,Ⅲ期2例.记录术中出血量、手术时间,观察假体和患者生存情况和术后并发症.采用美国肌肉骨骼肿瘤协会(Musculoskeletal Tumor Society,MSTS)93功能评分评价肢体功能.结果 所有患者均顺利完成手术,手术时间为(187.3±39.8)min(范围110～260 min),术中出血量为(284.9±87.0)ml(范围200～500 ml),输血量为(327±213)ml(范围100～800 ml).股骨近端剩余长度为(153.7±26.6)mm(范围93～190 mm),异体骨长度为(84.1±24.6)mm(范围39～134 mm).19例患者中9例(47％)达到骨性愈合,愈合时间为(16.7±4.8)个月(范围10～25个月),其中7例延迟愈合,愈合时间为(18.4±4.0)个月(范围15～25个月);剩余10例为异体骨与宿主骨不愈合.所有患者均获得随访,随访时间为(80.7±20.2)个月(范围56～121个月).随访过程中3例因骨肿瘤肺部转移而死亡,死亡时间分别为术后57个月、63个月和59个月.末次随访时患者生存率为84％(16/19),16例患者MSTS 93功能评分为(24.3±2.4)分(范围21～28分),优良率为100％(16/16).7例患者接受翻修手术,3例为无菌性松动、3例为异体骨与宿主骨交界处假体柄断裂、1例为假体周围感染,其中假体周围感染的患者因术前放疗导致局部软组织条件较差,经两次翻修手术感染得到控制.5例采用同种异体骨复合假体翻修,2例采用带皮质钢板或锁定钉的短柄巨型假体翻修.翻修术后股骨近端剩余长度为(143.4±31)mm(范围91～175 mm),异体骨长度为(92.6±26.6)mm(范围61～123 mm),7例翻修患者仍在持续随访中.术后无一例出现肺感染、神经损伤、深静脉血栓形成等并发症.结论 采用异体骨复合假体重建股骨远端恶性肿瘤切除后大段骨缺损术后患者生存期满意,肢体功能良好,但假体并发症发生率较高,可通过翻修进行二次重建.
Abstract
Objective To investigate the mid-to-long term therapeutic effects of allogeneic bone composite prosthesis re-construction in patients with large bone defects after the resection of distal femoral tumors.Methods From June 2013 to Decem-ber 2018,a total of 19 patients with malignant tumors of the distal femur who underwent reconstruction with allogeneic bone com-posite prosthesis in the Department of Bone Tumor,Shanghai General Hospital were retrospectively collected.There were 10 males and 9 females,aged 22.3±11 years(range,11-42 years).The mean body mass index was 19.3±3.4 kg/m2(range,14-27 kg/m2).There were 18 cases of osteosarcoma and 1 case of Ewing's sarcoma.According to Ennecking staging,there were 17 cases of stage ⅡB and 2 cases of stage Ⅲ.The intraoperative blood loss and operation time were recorded,and the prosthesis and patient survival conditions and postoperative complications were observed.The limb function was evaluated by the Musculoskeletal Tu-mor Society(MSTS)93 function score.Results All patients successfully completed the operation.The operation time was 187.3± 39.8 min(range,110-260 min),the intraoperative blood loss was 284.9±87.0 ml(range,200-500 ml),and the blood transfusion volume was 327±213 ml(range,100-800 ml).The remaining length of the proximal femur was 153.7±26.6 mm(range,93-190 mm),and the length of allogeneic bone was 84.1±24.6 mm(range,39-134 mm).Among the 19 patients,9 patients(47％)achieved bony union with an average healing time of 16.7±4.8 months(range,10-25 months),and 7 patients had delayed healing with an av-erage healing time of 18.4±4.0 months(range,15-25 months).The remaining 10 cases were nonunion between allogeneic bone and host bone.All patients were followed up for 80.7±20.2 months(range,56-121 months).During the follow-up,3 cases died due to pulmonary metastasis of bone tumors,and the time of death was 57 months,63 months,and 59 months after surgery,respective-ly.At the last follow-up,the patient survival rate was 84％(16/19),and the MSTS 93 function score of the 16 patients was(24.3± 2.4)points(range,21-28 points),with an excellent rate of 100％(16/16).Seven patients underwent revision surgery,3 cases were aseptic loosening,3 cases were prosthesis stem fracture at the junction of the allograft bone and the host bone,and 1 case was peri-prosthetic infection,among which the patient with periprosthetic infection had poor local soft tissue conditions due to preoperative radiotherapy,and the infection was controlled after two revision surgeries.Five cases were revised with allogeneic bone composite prosthesis,and 2 cases were revised with short-stem giant prosthesis with cortical steel plate or locking nail.After revision,the re-maining length of the proximal femur was 143.4±31 mm(range,91-175 mm),and the length of the allograft bone was 92.6±26.6 mm(range,61-123 mm).The 7 revised patients were still in follow-up.There were no cases of pulmonary infection,nerve injury,deep vein thrombosis or other complications after surgery.Conclusion The survival period of patients after the surgery to recon-struct large bone defects following the resection of malignant tumors at the distal end of the femur using allogeneic bone composite prosthesis is satisfactory,and the limb function is good.However,the incidence of prosthesis complications is high,which can be reconstructed through revision.
维普
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