肿瘤型全膝关节假体置换术治疗胫骨近端骨巨细胞瘤15例分析

Total knee prosthesis replacement of tumorous type in the treatment of giant cell tumors in the proximal tibia:15 cases report

目的探讨肿瘤型全膝关节假体置换术治疗胫骨近端骨巨细胞瘤的临床效果。方法15例胫骨近端骨巨细胞瘤患者行胫骨近端瘤段骨广泛切除和肿瘤型全膝关节假体置换手术。其中男9例，女6例。平均年龄39．8（26—62）岁，均为单侧胫骨，左膝8例，右膝7例。按照放射影像学Campanacci’s分级：原发III级9例，原发II级6例，另3例原发II级患者先行肿瘤边缘切除后植入同种异体骨后局部复发。手术采用膝关节前正中纵行切口，或纵“S”形切口切开，所有病例切除活检通道。根据肿瘤的范围，在肿瘤边界外3cnl进行切除。分别于胫骨近端和股骨远端植入大小合适的肿瘤型全膝关节假体，并用骨水泥固定。髌骨不进行置换，把髌韧带止点与假体固定装置以及翻转的腓肠肌内侧头部分肌瓣缝合，并用打断筋膜后网状纵横延展的肌瓣覆盖，把两侧与切口两边的深筋膜缝合，重建伸膝装置。结果所有患者均能较好地耐受手术。手术时间平均（177±24）min，术中出血量平均（593±115）ml，输血量平均（613±160）ml。15例都获32～53个月的随访，没有发生神经血管损伤、感染、深静脉栓塞、假体周围骨折、假体松动和断裂。术后1年患者MSTS功能评价：优5例，良6例，中4例，差1例，优良率73％。伸膝肌力平均4．2（3—5）级，膝关节屈曲平均（98．1±12．4）°，伸膝平均3．3°（0—15）°。结论瘤段骨广泛切除和肿瘤型全膝关节假体置换术治疗胫骨近端骨巨细胞瘤，能较好地恢复膝关节功能，提高患者生活质量。

Objective To investigate the clinical outcomes of total knee prosthesis replacement of tumorous type in the treatment of giant cell tumors in the proximal tibia. Methods A total of 15 patients with giant cell tumors in the proximal tibia underwent the surgical treatment of wide excision of tumor segments in the proximal tibia and total knee prosthesis replacement of tumorous type. There were 9 males and 6 females, with a mean age of 39.8 years old （ range; 26-62 years ）. Only unilateral tibia was involved, with 8 cases in the left side and 7 cases in the right side. According to the radiology Campanacci＇s classification, 9 cases were classified at primary level III and 6 cases at primary level II. Local recurrence occurred to 3 patients at primary level II who were treated with marginal resection after the implantation of the allogeneic bone. An anterior median longitudinal incision or a longitudinal ＂S＂ shape incision was applied in the knees. In all cases the biopsy channel was excised. According to the size, tumors were resected 3cm away from the tumor boundary. The sizable total knee prostheses of tumorous type were implanted into the proximal tibia and distal femur respectively, and were fixed with bone cements. The patella was not replaced. The medial head of gastrocnemius muscle was flipped, and then was sutured with the patellar ligament terminal and the prosthesis fixation device. The reticular muscle flap of vertical and horizontal extension was used to cover the patellar ligament terminal after the fascia was interrupted. Both sides of the patellar ligament terminal were sutured with the deep fascias on both directions of the incision to reconstruct the extension knee apparatus. Results All patients tolerated the operation well. The average operation duration was （ 177±24 ） min, The average intraoperative blood loss was （ 593±115 ） ml and the average blood transfusion was （ 613±160 ） ml. After the operation, all of 15 patients werefollowed up for 32-53 months. No injuries of nerves and blood vessels, infection, deep vein thrombosis, periprosthetic fractures, loosening or breakage of prostheses occurred in patients. The function of patients was evaluated according to the criteria of Musculoskeletal Tumor Society （ MSTS ） 1 year after the operation. There were 5 excellent cases, 6 good cases, 4 fair cases and 1 bad case, and the excellent and good rate was 73%. The mean muscle strength of knee extension was grade 4.2 （ range; grade 3-5 ）. The mean degree of knee flexion was （ 98.1±12.4 ）° and the mean degree of knee extension was 3.3° （ range; 0°-15°）. Conclusions It is an effective method to treat giant cell tumors in the proximal tibia with the wide excision ＇of tumor segments and total knee prosthesis replacement of tumorous type, which can help restore the knee joint function and improve the patients＇ quality of life.