全膝关节置换术治疗膝关节恶性骨肿瘤

Total knee arthroplasty in the treatment of malignant bone tumors

背景：膝关节周围是恶性骨肿瘤的好发部位,手术选择对术后肢体功能的恢复至关重要。目的：探讨膝关节恶性骨肿瘤行全膝关节置换术（TKA）的术前设计、手术技术和临床疗效。方法：回顾分析2003年10月至2010年12月于我科行TKA治疗膝关节恶性骨肿瘤患者临床资料14例。其中男5例,女9例;年龄19-63岁,平均年龄（37.6±4.5）岁;骨肉瘤4例,纤维肉瘤1例,软骨肉瘤2例,骨巨细胞瘤7例;其中股骨端8例,胫骨端6例。本组病例术前均未发现转移。14例患者均采用定制型旋转铰链膝关节假体。术中截骨范围为肿瘤外界3-4 cm。6例胫骨近端骨肿瘤需重建髌韧带的止点,其中2例通过切断的髌韧带缝合固定在胫骨假体附丽装置上,重建伸膝装置,术中注意勿横断髌韧带止点,应连同胫骨表面的深筋膜和骨膜（如有肿瘤浸润则不宜包括骨膜）一并翻向外侧,即保持伸膝装置与胫骨前方软组织的连续性;另外4例利用半腱股薄肌腱重建伸膝装置,有效重建髌韧带止点。结果：14例患者全部获得随访,随访时间为10-84个月,平均（32.2±3.7）个月。术后6个月随访,按Enneking肢体肌肉骨骼肿瘤外科治疗重建术后功能评估标准进行评定,优7例,良7例,中0例,差0例,优良率为100%;末次随访时,优7例,良3例,中1例,差3例,优良率为78.6%。末次随访时,14例中2例于术后3年发生转移,其中1例因远处转移于术后52个月时死亡,生存率为92.9%。结论：TKA可以解决膝关节恶性骨肿瘤的治疗难题,既能彻底切除肿瘤组织,又能保留患肢及其功能,提高患者的生存质量。

Background： The knee is a predilection site of malignant tumors, and surgery is an essential treatment for the recovery of limb function. Objective： To investigate the surgical planning, operation technique and clinical outcomes of total knee arthroplasty （TKA） for malignant knee joint tumors. Methods： Fourteen patients with malignant knee joint tumors treated by TKA between October 2003 and December 2010 in our hospital were enrolled in this retrospective study. There were 5 males and 9 females with an average age of （37.6±4.5） years （range, 19-63 years）. There were 4 cases of osteosarcoma, 1 case of fibrosarcoma, 2 cases of osteochondroma and 7 cases of giant cell tumors of bone. The distal femur was affected in 8 cases and the proximal tibia was affected in 6 cases. No RLrnor metastasis was found before operation. Custom-made rotating hinge prosthesis was applied in all patients. The range of osteotomy was beneath 3-4 cm from tumors. The insertion of patellar ligament had to be reconstructed in the 6 pa- tients with proximal tibia tumors. In two of them, excised ligaments were sutured and fixed on the device through the tibial prosthesis to reconstruct the extensor mechanism. During the operation, the insertion of patella ligament cannot be transect- ed, but it should be linked with the deep fascia and periosteum from tibial surface （once invaded by the tumors, the periosteum should be excluded） and turned to the outside to maintain the continuity of the soft tissues in the front of tibial and the extensor mechanism. The extensor mechanism was reconstructed through semitendinous and gracilis tendon in another 4 patients, and the reconstruction of patella ligament insertion effectively achieved. Results： All 14 patients were followed-up for （32.2±3.7） months （range, 10-84 months） after the operations. According to the Enneking fimctional evaluation for limb musculoskeletal surgical oncology treatment reconstruction, postoperative function was excellent in 7 patients and good in another 7 patients at 6 months after surgery, and the function was excellent in 7 patients, good in 3 patients, fair in 1 patient and poor in 3 patients at the final follow-up （the excellent and good rate was 78.6%）. Metastasis occurred in 2 patients 3 years after operation. One of them died from distant metastasis 52 months postoperatively. The survival rate was 92.9%. Conclusions： Arthroplasty can completely remove the tumor, preserve limbs and their fimctions, and improve quality of life in patients with knee malignant bone tumor.