可延长半关节假体置换治疗儿童下肢骨肉瘤术后假体相关并发症分析

ANALYSIS OF PROSTHESIS-RELATED COMPLICATIONS AFTER EXTENSIBLE SEMI-JOINT PROSTHESIS REPLACEMENT FOR LOWER LIMBS OSTEOSARCOMA IN CHILDREN

目的 探讨可延长半关节假体置换治疗儿童下肢骨肉瘤术后假体相关并发症发生原因及防治策略。方法 2006年5月-2012年10月,共11例下肢骨肉瘤患儿行瘤段切除、可延长半关节假体置换术。男6例,女5例;年龄7-12岁,平均9.3岁。股骨远端6例,股骨近端2例,胫骨近端3例。病程2-8个月,平均3.6个月。根据Enneking分期：ⅡA期3例,ⅡB期8例。术前肺部CT和ECT检查示,肿瘤无转移及多发。术前全部患儿接受4次化疗。结果 术后10例切口Ⅰ期愈合,1例术后1周发生感染,经对症处理后愈合。术后9例接受12次化疗,另2例分别接受了2次和4次化疗。1例因局部复发后多处转移死亡;3例出现肺转移,其中2例死亡,另1例切除单发肺转移灶后存活。存活的8例患儿获随访25-89个月,平均42.5个月。1例股骨近端假体发生松动并脱位,3例股骨远端假体分别发生松动下沉、半脱位、延长后退缩;假体相关并发症发生率为50%。存活患儿中3例接受1次延长术,1例2次延长术;其余4例尚未行延长术。末次随访时,根据Enneking肢体恶性肿瘤保肢术后功能评价标准,获优1例,良3例,可3例,差1例,优良率为50%。结论 可延长半关节假体置换治疗儿童下肢骨肉瘤术后,存在假体松动下沉、脱位、关节不稳、延长后退缩等假体相关并发症,在提高假体设计、制造水平的同时术中骨水泥、人工补片及术后限制性支具的使用,可减少假体相关并发症发生。

Objective To investigate the causes of the complications and prevention strategy by analyzing occurrence of prosthesis-related complications after extensible semi-joint prosthesis replacement for lower limbs osteosarcoma in children. Methods Eleven children with lower limbs osteosarcoma underwent resection of tumor and replacement of the extensible semi-joint prosthesis between May 2006 and October 2012. There were 6 boys and 5 girls, with an average age of 9.3 years （range, 7-12 years）. The lesions located at the distal femur in 6 cases, at the proximal femur in 2 cases, and at the proximal tibia in 3 cases. The disease duration was 2-8 months （mean, 3.6 months）. According to the Enneking stage, 3 cases were rated as stage II A and 8 cases as stage II B. The pulmonary CT and ECT results showed no pulmonary metastasis or multi spots before operation. All patients received preoperative chemotherapy treatment for 4 times. Results Primary healing of incision was obtained in 10 cases. Infection occurred in 1 case at 1 week after operation, and was cured after symptomatic treatment. Nine patients received postoperative chemotherapy for 12 times, 2 patients for 2 times and 4 times respectively. One case died of multiple metastasis; in 3 cases of pulmonary metastasis, 2 cases died and 1 case survived after resection of metastatic lesion. Eight survival cases received a follow-up of 25-89 months （mean, 42.5 months）. Loosening and dislocation of the proximal femoral prosthesis occurred in 1 case, loosening and subsidence of the distal femoral prosthesis in 1 case, subluxation in 1 case, and retraction in 1 case. The incidence of prosthesis-related complications was 50%. Lengthening operation was performed on 3 cases for 1 time, and on 1 case for 2 times. And 4 cases did not undergo lengthening operation. According to Enneking function evaluation standard after malignant tumor limb-salvage surgery, the results were excellent in 1 case, good in 3, fair in 3, and poor in 1 at last follow-up with an excellent and good rate of 50%. Conclusion The prosthesis-related complications include loosening and subsidence, dislocation, knee instability, and retraction after extensible semi-joint prosthesis replacement for lower limbs osteosarcoma. The prosthesis-related complications can be reduced by the improvement of prosthesis design and manufacture, and the use of intraoperative bone cement, artificial mesh, and postoperative restrictive brace.