节段型假体在骨干肿瘤重建中的临床应用研究

Clinical application of segmental prosthesis in reconstruction of diaphyseal tumors

目的探讨节段型假体在骨干缺损修复中的临床使用价值。方法回顾性分析2010年6月至2017年6月国内2家骨肿瘤治疗中心采用节段型假体重建四肢长骨骨缺损患者40例，男18例，女22例；年龄13-83岁，平均（63．6±13．9）岁。手术部位包括：股骨28例，肱骨8例，胫骨3例，尺骨1例。原发肿瘤5例，多发性骨髓瘤3例，骨转移瘤32例。32例患者（80％，32／40）发生了手术部位病理性骨折。分析性别、年龄、手术部位、病理类型、手术重建方式、术后肢体功能、术后并发症、患者生存情况及假体生存情况，手术部位差异组间比较分析不同部位假体重建的差异性，是否发生并发症组间统计分析导致并发症发生的危险因素，采用多因素线性回归分析影响术后肢体功能的因素。结果手术时间（104．6±20．0）min，出血量200-2800ml，中位出血量600ml。术中截骨长度（93．5±27．4）mm。患者的中位生存时间为8．5个月（3-79个月），假体中位生存时间8个月（3-79个月）。根据Henderson肿瘤假体并发症分型，Ⅰ型并发症3例，包括2例切口愈合延迟和1例桡神经麻痹；Ⅱ型并发症1例，为肱骨节段型假体无菌性松动；Ⅲ型并发症1例，股骨假体力线与生物力线成角；Ⅴ型并发症2例，均为肿瘤局部复发，均行截肢治疗。肌肉骨骼肿瘤协会（Musculoskeletal Tumor Society，MSTS）肢体功能评分为（20．4±4．1）分。2例患者因肿瘤复发截肢导致假体未能继续使用，38例患者假体均使用至患者死亡或随访时间截点，40例患者生存曲线与假体生存曲线高度拟合，提示患者生存情况是影响术后假体生存的主要因素。肱骨与股骨不同部位假体重建组间比较发现，肱骨接骨板使用率（4／8，50．0％）高于股骨接骨板使用率（5，28，17．9％），但差异并无统计学意义（F=3．426，P=0．064）。是否发生并发症组间统计分析结果显示肿瘤类型是导致并发症发生的独立危险因素（χ^2=7．446，P=0．024），原发肿瘤术后并发症发生率明显高于骨转移瘤和多发性骨髓瘤，无并发症发生的患者术后肢体功能更优（F=9．709，P=0．003）。多因素线性回归分析提示患者年龄、肿瘤类型、术前是否发生病理性骨折、手术部位、截骨长度均不是影响术后肢体功能的危险因素，患者生存时间与术后肢体功能正相关（t=4．228，P=0．000）。结论节段型假体是骨转移瘤骨干缺损修复的可靠方法，联合使用接骨板固定，能够有效减少假体并发症的发生。

Objective To investigate the clinical value of segmental prosthesis in the repair of diaphyseal defect. Meth- ods The clinical data and follow-up information of 40 patients who accepted segmental prosthesis reconstruction of long bone defects in limbs were collected from June 2010 to June 2017 in General Hospital of Jinan Military Commanding and Tianjin Hospital. The parameters for outcome evaluation including general information, surgical complications, Musculoskeletal Tumor Society （MSTS） functional score, survival and prostheses status were analyzed. Results Forty patients were underwent segmental prosthesis surgery, including 18 males and 22 females, with a median age of 64 years and the age range of 13-83 years. The surgery was performed on 28 cases of femur, 8 cases of humerus, 3 cases of tibia, and 1 cases of ulna. There were 5 cases of primary tumor, 3 cases of multiple myeloma and 32 cases of metastatic tumor of bone, in which lung cancer, breast cancer, kidney cancer, liver cancer and colorectal cancer are common. Pathological fracture of surgical site occurred in 32 cases. The average osteotomy length was 93.5 mm. The shortest osteotomy was 60 mm and the longest osteotomy was 190 mm. The average operation time was 104.6 minutes. The median bleeding volume was 600 ml. The least bleeding was 200 ml and the most bleeding was 2 800 ml. The pa- tients median survival time was 8.5 months from 3 to 79 months. The prosthesis median survival time was 8 months from 3 to 79 months. According to the Henderson tumor prosthesis Complications classification, there were 3 cases of type I including 2 cases of incision delayed healing and 1 case of radial nerve paralysis. There was 1 case of type II with humeral prosthesis aseptic loosening. There was 1 case of type III with angulation deformity between femoral prosthesis force line and biological force line. There were 2 cases of type V with tumor recurrence followed by amputation. The limb function score of MSTS was 20.4±4.1 points. Except for two patients with tumor recurrence and amputation, 38 patients got stable prosthesis function until the death or follow-up cut-off. The similar tendency of patients survival curve and prosthesis survival curve indicated that survival was the main factor affecting postoperative prosthesis survivorship. Although the use rate of humeral plate （4/8, 50.0%） was higher than that of femoral plate （5/28, 17.9%）, the difference was not statistically significant （F=3.426, P=0.064）. The results of statistical analysis of compli- cations showed that the type of tumor was an independent risk factor for complications （χ^2=7.446, P=0.024）. The postoperative complications rate of primary tumor was significantly higher than that of multiple myeloma and bone metastasis. Patients with no complications have better limb function after surgery （F=9.709, P=0.003）. Multivariate linear regression analysis showed that age, tumor type, preoperative pathologic fracture, surgery, osteotomy length did not affect limb functions after operation. The longer sur- vival time mean better limb function （t=4.228, P=0.000）. Conclusion Segmental prosthesis is a reliable method for the repair of bone metastases with defects. Combined with bone plate fixation, it can effectively reduce the occurrence of prosthetic complications.