骨盆Ⅰ区及Ⅰ+Ⅳ区肿瘤切除和重建术后内固定失败的预后因素分析

Prognostic factors of mechanical failures after resection and reconstruction for pelvic tumors in region Ⅰ/Ⅰ and Ⅳ

背景:钉棒系统内固定已成为重建骨盆Ⅰ区及Ⅰ+Ⅳ区肿瘤切除术后骨盆环缺损的主要方式之一,但固定方式尚无统一的认识。不同固定方式的内固定失败率有所不同,其临床疗效比较仍需进一步探讨。目的:对比不同钉棒系统重建骨盆Ⅰ区及Ⅰ+Ⅳ区肿瘤切除后骨缺损的临床效果,并评估患者发生内固定失败的危险因素。方法:回顾性分析2003年5月至2017年2月我院收治的42例累及骨盆Ⅰ区及Ⅰ+Ⅳ区的肿瘤患者,其中男23例,女19例;年龄15~69岁,平均(41.0±17.7)岁。所有病例均接受了骨盆肿瘤切除以及钉棒系统固定,部分患者同时进行了植骨或骨水泥强化。钉棒系统固定时,12例使用单棒双钉,30例使用双棒四钉。对患者的一般情况、手术及其他治疗情况、临床效果以及内固定失败率进行统计分析。结果:术后随访13~168个月,平均(36.1±32.3)个月。6例患者出现了内固定失败,其中单棒双钉组4例,双棒四钉组2例。2例内固定失败患者进行了翻修手术,其中1例进行了内固定拆除,另一例接受了内固定翻修以及自体腓骨植骨重建。双棒四钉组的内固定生存率明显高于单棒双钉组(P=0.003)。内固定生存率与年龄有一定的相关性(P=0.009),年龄≤21岁的患者内固定失败率较年龄>21岁高。骨盆Ⅰ+Ⅳ区肿瘤切除组内固定失败率高于骨盆Ⅰ区切除组(P=0.007)。结论:骨盆Ⅰ区及Ⅰ+Ⅳ区肿瘤切除术后双棒四钉固定可以提供良好的短期及长期稳定性,而单棒双钉固定的强度相对不足,内固定容易失败。对于年轻患者以及良性肿瘤患者,肿瘤切除后建议采用钉棒系统固定联合自体骨移植的生物学重建;对于老年患者、恶性肿瘤患者以及需要放化疗的患者,建议采用钉棒系统固定联合骨水泥强化的机械性重建。

Background：Internal fixation with screw-rod system has become one of the main means to reconstruct the pelvic ring defect after Enneking type Ⅰ/Ⅰ＋Ⅳ resection.However,there is no unified standard of the fixation methods.The rates of mechanical failure of different fixation methods are varied,and the clinical efficacy still needs to be further explored.Objective：To compare the outcomes of different rod-screw systems in reconstruction after Enneking typeⅠ or Ⅰ＋Ⅳ resection,and to investigate the risk factors of postoperative mechanical failures.Methods：A retrospective analysis of 42 patients with pelvic tumors in region Ⅰ/Ⅰ＋Ⅳ from May 2003 to February 2017 in our hospital were performed.There were 23 males and19 females aged from 15 to 69 years with an average of（41.0±17.7） years old.All patients underwent pelvic tumor resection and fixation with the rod-screw systems.Some patients additionally received bone graft or cement.One-rod and two-screw（ORTS） was used in 12 cases and two-rod and four-screw（TRFS） used in 30 cases.The demographics,surgical and other treatments,clinical effects and the rate of mechanical failures were investigated.Results：The patients were followed up for13-168 months with an average of（36.1±32.3） months.Six patients suffered from mechanical failures,including 4 ORTS and 2 TRFS.Two patients with mechanical failure received revision surgery,one of whom underwent removal of internal fixation and the other had internal fixation and autologous fibular bone transplantation.The survival rate of internal fixation of TRFS group was significantly higher than that of ORTS group（P=0.003）.The implant survival rate was correlated with age（P=0.009）,and younger patients aged ≤21 years were more likely to fail than those aged more than 21 years.Zone Ⅳinvolvement may be a potential risk factor of fixation failure（P=0.007）.Conclusions：TRFS fixation for pelvic reconstruction after Enneking type Ⅰ/Ⅰ＋Ⅳ resection can provide better short to long-term mechanical stability compared with ORTS fixation.Biological reconstruction such as autologous bone graft is recommended for the patients who are younger or suffer from benign tumor.As for the patients who are older,with malignant tumors,underwent adjuvant radiotherapy or chemotherapy,mechanical reconstruction with bone cement is a good choice.