肱骨近端肿瘤关节内切除重建的结果及并发症分析

Functional outcomes and complications of construction with three methods after intra-articular tumor resection of the proximal aspect of humerus

目的对肱骨近端具有侵袭性的良性肿瘤及恶性肿瘤行瘤段切除后不同重建方法的结果和并发症进行评估。方法共25例肱骨近端肿瘤行Malaver Ⅰ型切除后重建的患者，重建方式为肿瘤型假体置换（6例）、大段同种异体骨关节（12例）与异体骨段复合人工关节假体（allograft-prosthetic composite，APC，7例）移植。对患者进行肿瘤学结果评定、影像学评估及切除重建后功能评价（改良MSTS评分）。结果25例患者中良性肿瘤5例，恶性肿瘤20例。平均随访48个月（16-80个月），局部复发2例，转移2例，死亡2例。MSTS评分：肿瘤型假体组（22．5±1．6）分，异体半关节组（24．6±1．4）分，APC移植组（27．0±1．5）分，三组间差异有统计学意义（F=15．03，P=-0．000）。肱盂关节的外展度数：肿瘤型假体组42．2°±4．5°，异体半关节组48．3°±5．3°，APC移植组58．0°±5．7°，三组间差异有统计学意义（F=15．40，P=-0．000）。间室内肿瘤的外展范围显著大于间室外肿瘤（t=5．40，P=-0．000）。关节不稳是影响术后功能的主要晚期并发症，共10例。结论肱骨近端肿瘤瘤段切除后APC和异体骨移植术效果优于单纯肿瘤型假体置换。术后功能结果主要取决于肿瘤侵犯及切除范围，尤其是外展装置保留及重建程度。重建后肩关节不稳是重要的远期并发症，多发生于间室外肿瘤。

Objective To evaluate the functional results and complications for three different reconstructive procedures after intra-articular resection of malignant tumor or invasive benign tumor of the proximal humerus. Methods Twenty-five patients who had Malaver Ⅰ type resection and reconstruction of proximal aspect of humerus for the treatment of the malignant or invasive benign tumors were evaluated. A variety of reconstructive procedures, including modular tumor prosthesis （6 cases）, an osteoarticular allograft （12 cases）, and an allograft-prosthetic composite （APC, 7 cases）, were performed after tumor resection. The oncological parameters that were evaluated included survival of the patient, local recurrence, and metastasis. The radiographic parameters included time to union, stability of the joint, fracture of the allograft, and the fragmentation of the epiphysis of the allograft （subchondral collapse）. The modified Musculoskeletal Tumor Society （MSTS） evaluation system was used to assess functional outcome. Results Twenty patients had a malignant bone tumor and 5 had benign tumor. At a mean of 48 months （range, 16 to 80 months） follow-up after the operation, 2 patients died of disease. Two patients had local recurrence and 2 had metastatic disease. The mean MSTS score were 22.5±1.6 in modular prosthesis group, 24.6±1.4 in osteoarticular allograft group, 27.0±1.5 in APC group respectively. There was significant difference among 3 groups. Joint instability and subluxation affecting shoulder functions were noted in 10 patients. Conclusion Reconstruction of proximal aspect of the humerus with different method is an option that provides good relief of pain and preserves manual dexterity. Functional outcome in APC and osteoarticular allograft is superior to modular prosthesis, which is due to the preservation of rotation cuff. Complications in APC group is less than that in allograft one. The functional outcome after reconstruction depends on the extent of tumor resection, but also preservation and reconstruction of abduction mechanisms of the shoulder. Glenohumeral instability was the most frequent late complication due to the sacrifice of the rotator cuff and other soft tissue.