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目的通过对膝关节定制型肿瘤假体的翻修进行回顾性分析,总结手术技术和翻修原因,明确翻修术后并发症的发生,以及假体生存和功能情况。方法回顾性分析2002年6月-2007年6月收治的33例膝关节定制型肿瘤假体置换术后再次翻修患者的临床资料。其中男17例,女16例;年龄16～67岁,平均33.1岁。骨肉瘤17例,骨巨细胞瘤11例,骨恶性纤维组织细胞瘤2例,软骨肉瘤、滑膜肉瘤、脂肪肉瘤各1例。肿瘤部位:股骨远端22例,胫骨近端11例。翻修术与置换术间隔时间为6～180个月,平均45.3个月。翻修原因:肿瘤局部复发2例,假体周围感染8例,假体无菌性松动7例,创伤后假体周围骨折伴松动1例,假体柄折断6例,假体铰链机构失败9例。6例假体周围感染者,将原假体取出后行二期假体翻修;其余患者均行一期翻修。翻修假体均采用骨水泥固定假体,其中2例残留髓腔长度短于翻修假体柄,用异体骨段移植复合假体植入。结果17例两次手术均于同一医院进行的患者,首次置换手术时间为(149.8±40.5)min,翻修术为(189.9±43.8)min;置换术出血量为(605.2±308.0)mL,翻修术为(834.1±429.9)mL;以上指标比较差异均有统计学意义(P<0.05)。患者术后均获随访,随访时间12～76个月,平均45.1个月。2例行异体骨移植者分别于术后1年半和2年达骨性愈合。3例于翻修术后12～24个月死于肺转移;3例发生肺转移,随访期间带瘤生存。术后30例存活患者9例出现并发症,发生率为30%;其中浅表感染2例,深部感染5例,机械性并发症2例。7例发生假体失败,失败率为23.3%。Kaplan-Meier生存曲线分析翻修假体5年生存率为68.6%。翻修术前患者肢体功能根据1993年美国骨肿瘤学会评分系统(MSTS93)评分为57.1%±10.6%,术后6个月为73.6%±14.4%,差异有统计学意义(P<0.01)。结论膝关节定制型肿瘤假体的翻修主要原因是机械性问题和感染,翻修手术虽较复杂,具有一定并发症,但可保留大部分患者的肢体并恢复其功能。
OBJECTIVE: To retrospectively analyze the revision of the custom-made tumor prosthesis in the knee joint, summarize the surgical technique and the reason of the revision, and to clarify the postoperative complications and the survival and function of the prosthesis. Methods Retrospective analysis of the clinical data of 33 patients who had undergone revision of prosthetic knee prosthesis replacement surgery between June 2002 and June 2007 was retrospectively analyzed. Including 17 males and 16 females; aged 16 to 67 years old, with an average of 33.1 years old. 17 cases of osteosarcoma, 11 cases of giant cell tumor of bone, 2 cases of malignant fibrous histiocytoma, 1 case of chondrosarcoma, synovial sarcoma and 1 case of liposarcoma. Tumor site: 22 cases of distal femur, 11 cases of proximal tibia. Renal repair and replacement interval of 6 to 180 months, an average of 45.3 months. Renovation reasons: local tumor recurrence in 2 cases, 8 cases of periprosthetic infection, prosthesis aseptic loosening in 7 cases, traumatic periprosthetic fracture with loosening in 1 case, prosthesis handle fracture in 6 cases, prosthesis hinge failure in 9 cases . 6 cases of infection around the prosthesis, the original prosthesis removed after the second prosthesis revision; the rest of the patients were undergoing a revision. The revision prostheses were all fixed cemented prosthesis, of which 2 cases of residual medullary cavity length shorter than the revision prosthesis handle, with allogeneic bone graft composite implants implantation. Results In the 17 patients who underwent both operations in the same hospital, the time of the first replacement was (149.8 ± 40.5) min and the revision was (189.9 ± 43.8) min. The amount of bleeding during the replacement was (605.2 ± 308.0) mL, (834.1 ± 429.9) mL; the above indexes were statistically significant (P <0.05). Patients were followed up after surgery, followed up for 12 to 76 months, an average of 45.1 months. 2 cases of allogeneic bone graft in one and a half years and 2 years after surgery respectively up to bone healing. Three patients died of lung metastases 12 to 24 months after revision. Three patients developed lung metastases and survived during follow-up. Complications occurred in 9 of 30 survivors after surgery, the incidence was 30%. Among them, 2 were superficial infections, 5 were deep infections and 2 were mechanical complications. Seven patients had a failed prosthesis with a failure rate of 23.3%. The Kaplan-Meier survival curve analysis of revision prosthesis 5-year survival rate was 68.6%. According to the 1993 American Society of Bone Tumor Score (MSTS93) score of 57.1% ± 10.6% and 6 months postoperatively, the limb function of the patients before revision was 73.6% ± 14.4%, the difference was statistically significant (P <0.01). Conclusions The main reason of custom knee prosthesis renovation is mechanical problems and infection. The revision surgery is complicated and has some complications. However, most patients’ limbs can be preserved and their function restored.