股骨远端肿瘤型假体无菌性松动分型与翻修手术策略

Classification and revision strategy of distal femoral megaprosthesis aseptic loosening:a retrospective review of three institutions

目的创建股骨远端肿瘤型假体无菌性松动分型,提出不同分型患者翻修手术策略。方法回顾性分析解放军第九六〇医院、天津医院、河北医科大学第三医院自2008年1月至2018年12月股骨远端肿瘤型假体无菌型松动翻修手术患者资料,基于患者影像资料,提出股骨远端肿瘤型假体无菌型松动分型,对于不同分型分析其翻修手术策略。结果 29例纳入本研究,男20例,女9例。年龄15~64岁,平均43.2岁。25例接受初次翻修手术,4例接受第二次翻修手术。依据影像表现,股骨远端肿瘤型假体无菌性松动可分为3种类型4种亚型:I型,假体无移位;Ia假体周围骨质结构正常,Ib假体周围骨质变薄,但包壳完整。II型,假体移位,股骨近端正常骨质长度不小于5 cm;IIa假体未穿破骨皮质,IIb假体尖端穿破骨皮质。III型,股骨近端正常骨质长度<5 cm。本组Ia型5例,翻修手术相对较为简单,可近似于初次假体置换。Ib型7例,可使用加长柄肿瘤假体进行翻修。IIa型9例,可使用加长柄肿瘤假体进行翻修,但翻修手术难以纠正的肢体短缩。IIb型7例,翻修术时建议采用异体骨板植骨及加长柄假体翻修,且需要注意假体力线。III型1例,可选择使用特殊类型假体翻修。结论股骨远端肿瘤型假体无菌性松动可分为3种类型4种亚型,可针对不同分型患者采取更加明确的翻修手术策略。

Objective To establish the classification,and propose individualized revision surgery strategy for distal femoral megaprosthesis aseptic loosening.Methods Clinical data of patients after revision surgery in 960th hospital,Tianjin Hospital and the Third Hospital of Hebei Medical University were retrospectively analyzed from January 2008 to December 2018.Aseptic loosening classifications of distal femoral magaprostheses were proposed,and the corresponding revision surgery strategy was recommended based on the imaging data.Results A total of29 patients aged 15-64 years(average:43.2 years),20 males and 9 females,were included in this study.Twenty-five patients underwent primary revision and four patients underwent secondary revision.Three types and four sub-types of aseptic loosening of the distal femoral megaprostheses were noted according to the imaging findings.Type I(n=12):no prosthesis displacement.Type Ia(n=5):normal surrounding bone structures;relatively simple revision similar to primary surgery.Type Ib(n=7):thin surrounding bone with intact envelope;long-stem prosthesis.Type II(n=16):prosthesis displacement;the length of the normal proximal femur bone was not less than 5 cm.Type IIa(n=9):prosthesis did not penetrate the cortical bone;long-stem prosthesis;the limb shortening was difficult to be corrected.Type IIb(n=7):prosthesis tip penetrated the cortical bone;long-stem prosthesis and bone grafting with allogeneic plates;the force line of the prosthesis need to be observed.Type III(n=1):the normal bone length of the proximal femur was less than 5 cm;special prosthesis for the revision.Conclusions Individualized revision will be performed based on different classifications in aseptic loosening of the distal femoral megaprostheses.