全肘关节置换术在严重类肿瘤病变治疗中的初步临床应用

Total elbow arthroplasty in patients with tumor-like lesions of elbow, preliminary results of a single-center experience

目的 探讨人工全肘关节置换术治疗肘关节类肿瘤疾患者的初期应用及临床疗效。 方法 回顾性分析2009年9月至2017年6月共11例严重肘关节类肿瘤病变患者资料,均采用保留肱三头肌止点的腱膜"舌形瓣"技术,肘关节后路或前后路联合,分块切除肘关节类肿瘤病变及关节囊,全肘关节假体恢复肱骨和尺骨连接。其中男6例,女5例;年龄25-78岁,平均(56.7±14.7)岁。滑膜软骨瘤病6例,非特异性滑膜炎症异常增生5例;病变切除采用单纯后路7例,前后路联合4例,病变切除后所有患者均从后路进行全肘关节置换。假体类型Coonrad-Morrey半限制型铰链假体(比较符合肘关节生物力学设计,允许7°内外翻和内外旋)7例,国产完全限制型铰链假体(只允许屈伸单平面活动)4例。术前患侧肘关节屈伸活动范围20°-70°,平均(50.5°±14.0°),2例术前存在尺神经压迫,其中1例伴爪形手畸形,术中行尺神经松解前移术。根据Mayo肘关节功能评分(MEPS评分),术前MEPS评分15-60分,平均(42.1±12.7)分。 结果 无围手术期并发症发生。所有患者存活,均获得随访,关节无疼痛,无肱三头肌断裂及肌力减弱,病变无一例复发。随访至假体失败或至2017年6月,随访时间7-63个月,平均(36.3±19.5)个月,平均屈伸活动范围由术前50.5°改善至105.9°,差异有统计学意义(t=-8.697,P=0.000),旋前旋后范围由105°改善至123.2°(t=-6.901,P=0.000)。术后MEPS评分平均为60-98分,平均(89±7.2)分,与术前比较差异具有统计学意义(t=-11.993,P=0.000)。两例术前存在尺神经损伤的患者中,1例术后2年尺神经功能未恢复,另外1例患者尺神经半年后恢复。7例Coonrad-Morrey假体中1例术后63个月发生深部感染,保守治疗无效,将假体取出,伤口愈合。完全限制型铰链假体4例中有2例术后12个月假体松动,另1例术后39个月肱骨假体周围骨折再次手术。半限制型铰链假体并发症的发生率(14%)低于完全铰链假体(75%),但差异无统计学意义。 结论 严重影响功能的肘关节类肿瘤疾患行保留肱三头肌止点的腱膜"舌形瓣"技术,对肱三头肌功能影响小,手术暴露充分,彻底切除病变后行全肘关节假体置换可有效地恢复肘关节的稳定性及改善活动范围,初期应用效果肯定,但随着时间的延长,完全限制型铰链假体的并发症逐渐增加。

Objective The purpose of this study was to investigate the preliminary clinical outcomes of total elbow arthroplasty (TEA) in the treatment of elbow deformity caused by tumor-like lesions. Methods Between September 2009 and June 2017, the technique of triceps facial tongue exposure was adopted for all 11 patients who underwent total elbow arthroplasty. There were 5 females and 6 males with the mean age of 56.7±14.7 years. There were 6patients with synovial chondromatosis and 5 with pathologic hypertrophy of synovium. Seven of 11 patients were performed by posterior approach only, while the other 4by combined posterior-anterior approach. A semi-constrained Coonrad-Morrey prosthesis which provides 7° varus/valgus laxity was used in 7 patients, and custom-made total constrained prosthesis which only allow flexion and extension on a single plane was used in 4 cases. Preoperative average flexion range of elbow was 50.5°±14.0° (range, 20°-70°). The ulnar nerve compression and claw hand deformity was identified in 2patients preoperatively and the nerve was transposed during operation. According to Mayo elbow function score (MEPS score), the average preoperative MEPS score was 42.1±12.7 points (range, 15-60). Results Perioperative complications were not found. None of patients lost in thefollow-up and all the patients were alive. There was no pain in the joints, no triceps fracture or weakening of muscle strength, and no recurrence of the lesions. All 11 patients were followed up for 7 to 63 months with an average of 36.3±19.5 months. The mean MEPS score was improved to 89±7.2 point after surgery (t=-11.993, P= 0.000). The average flextion-extension arc improved from preoperative 50.5° to 105.9° postoperatively (t=-8.697, P=0.000). The average pronation-supination arc improvement from preoperative 105°-123.2° postoperatively (t=-6.901, P=0.000). For the two patients with ulnar nerve deficit before surgery, one patient recovered 6 months after operation, however, the other patient did not 2 years later. One Coonrad-Morrey prosthesis with deep infection was treated by removing the implant. Three of 4 custom-made total constrained prostheses experienced implant failure due to loosening or periprosthetic fracture. The incidence of complications of semi-constrained prosthesis was lower than that of total constrained prosthesis (14% vs. 75%), however, it did not reach a significant difference. Conclusion This study reveals an acceptable outcome with triceps facial tongue exposure for TEA in the treatment of tumor-like lesions of elbow. TEA is a viable good alternative treatment for selected patients with large mass around the elbow or with severe deformation. However, the failure rate of fully constrained prosthesis tends to be higher than semi-constrained one, possible due to its design flaw.