节段性肿瘤假体治疗肱骨干转移癌合并病理性骨折的临床疗效及方法改进

Intercalary prosthetic reconstruction for pathological humeral diaphyseal fractures due to metastatic tumors:outcomes and improvements

目的评价节段性肿瘤假体治疗肱骨干转移癌并病理性骨折的近期临床疗效及并发症,报道附加钢板的节段肿瘤假体防止术后早期假体松动的应用。方法回顾性分析2011年3月至2017年9月,济南军区总医院、天津医院应用节段性肿瘤假体治疗的9例肱骨干转移癌并病理性骨折患者,男4例,女5例;平均初诊年龄(62.9±11.1)岁。肱骨干病理骨折部位:中段6例,近段1例,远段2例。原发肿瘤:肝癌1例,甲状腺癌2例,乳腺癌2例,肾癌2例,肺癌2例。按照无瘤原则广泛切除瘤段骨后,4例行节段性肿瘤假体置换术(A组),5例行附加钢板的节段性肿瘤假体置换术(B组)。9例术后均获得随访,并记录手术时间、出血量、上肢MSTS评分、ASES评分、并发症。采用t检验对两组进行统计学分析。结果 9例均顺利完成手术,A组平均切除长度(7.75±0.96)cm,B组平均切除长度(7.80±1.30)cm;A组平均用时(80±14)min,B组平均用时(94±5)min;A组平均术中出血量(115±26)ml,B组平均术中出血量(120±31)ml。术后随访1~25个月,平均8.6个月。截止末次随访,存活2例,其中1例随访1个月,1例随访2个月;死亡7例,其中6例死于肺转移,1例为原发肺癌恶化,术后平均生存(10.6±6.6)个月。末次随访,所有患者平均术后MSTS评分25.4分。A组(24.50±2.38)分,B组(26.20±0.84)分;所有患者平均术后ASES评分86.3分。A组(85.50±4.20)分,B组(87.00±2.55)分。所有患者术后上肢活动及肩肘关节功能均恢复到正常范围。2例(22.2%)出现并发症,均在A组,1例桡神经损伤,1例假体松动。结论节段肿瘤假体治疗肱骨干转移癌合并病理性骨折的近期疗效满意,附加钢板的节段肿瘤假体可以防止术后早期假体松动。

Objective To evaluate recent clinical outcomes of intercalary prosthetic reconstruction for pathological humeral diaphyseal fractures due to metastatic tumors. And to report the application of additional plates, which can prevent the early aseptic loosening of the prosthesis. Methods We retrospectively analyzed 9 patients [ 4 males and 5 females; average(62.9 ± 11.1） years old at diagnosis ], who received medical care at our institutions from March 2011 to September 2017. All underwent intercalary prosthetic reconstruction for pathological humeral diaphyseal fractures secondary to metastatic diseases. Pathological fracture locations： 6 cases in the middle segment, 1 case in the proximal segment, and 2 cases in the distal segment. Primary tumors： 1 case of liver tumors, 2 cases of thyroid tumors, 2 cases of breast tumors, 2 cases of renal tumors, and 2 cases of lung tumors. After a wide resection according to the tumor-free principle, 4 patients had intercalary prosthetic reconstruction(Group A）, and 5 patients had intercalary prosthesis implantation with an additional extracortical plate(Group B）. All 9 patients were followed up for 1-25 months(average： 8.6 months）. Operation time, blood loss volume, postoperative MSTS score, postoperative ASES score and complications were noted. Two-sample t-test was used to compare the results of the 2 groups. ResultsAll surgeries were successful. Group A： the mean bone removal length(7.75 ± 0.96） cm; the mean operation time(80 ± 14） minutes; the mean blood loss(115 ± 26） ml; the mean postoperative MSTS score for the upper extremity(24.50 ± 2.38）; the mean postoperative ASES score(85.50 ± 4.20）. Group B： the mean bone removal length(7.80 ± 1.30） cm; the mean operation time(94 ± 5） minutes; the mean blood loss(120 ± 31） ml, the mean postoperative MSTS score for the upper extremity(26.20 ± 0.84）; the mean postoperative ASES score(87.00 ± 2.55）. At the final follow-up, 2 patients(1 was followed-up for 1 month, 1 was followed-up for 2 months） were alive; 7 patients(6 with lung metastases, 1 with aggravated lung cancer） died; yielding a mean survival of(10.6 ± 6.6） months; The mean MSTS score and ASES score were 25.4 and 86.3 respectively in 2 groups. The range of motion and functions of the shoulder and elbow joints returned to the normal. Two patients(22.2%） developed complications(both were from Group A; 1 aseptic loosening, 1 radial nerve injury）. Conclusions Intercalary prosthetic reconstruction achieves satisfactory outcomes in patients with pathological humeral diaphyseal fractures due to metastatic tumors, and addition of an additional plate to the prosthesis stem can prevent early aseptic loosening.