膝关节肿瘤型假体非感染性失败骨水泥固定翻修术的疗效

Evaluation of utilizing cement-in-cement technique for endoprosthetic revision surgeries around the knee

目的探讨非感染因素导致的膝关节肿瘤型假体失败病例进行骨水泥固定翻修的临床效果。方法回顾性分析2002年2月至2020年8月北京大学人民医院骨与软组织肿瘤治疗中心128例膝关节肿瘤型假体失败接受骨水泥固定翻修手术患者的临床资料,男71例、女57例,年龄(33.5±15.4)岁(范围8~77岁)。128例患者中骨肉瘤73例、骨巨细胞瘤38例、未分化肉瘤8例、软骨肉瘤4例、Ewing肉瘤2例、纤维肉瘤2例、滑膜肉瘤1例。假体翻修部位:股骨远端假体105例、胫骨近端假体23例。翻修原因:无菌性松动64例、假体部件损坏47例、肿瘤复发17例。经初次骨水泥固定翻修术后失败19例,其中16例接受了二次骨水泥固定翻修术。主要观察指标为假体生存情况、手术时间、术中出血量、流行病学数据、手术相关并发症及美国肌肉骨骼肿瘤协会(Musculoskeletal Tumor Society,MSTS)93膝关节功能评分等。结果128例初次骨水泥固定翻修患者的随访时间为(127±33)个月(范围6~326个月)。初次翻修手术后发生并发症25例(19.5%),其中导致假体寿命终结19例(14.8%),包括5例(3.9%)结构性失败、6例(4.7%)无菌性松动、2例(1.6%)肿瘤复发和6例(4.7%)感染;5例切口浅表愈合不良,经局麻清创后痊愈;1例髌韧带止点断裂,经切开修补后痊愈。初次翻修手术后假体5年、10年和15年的累积生存率分别为85.0%、76.6%和70.7%,保肢率为97.7%。16例接受了二次骨水泥固定翻修术,初次骨水泥固定翻修手术时间为(206±51)min,术中出血量为(596±217.99)ml,术后MSTS 93功能评分为(26.38±2.47)分;二次翻修手术时间为(258±41)min,术中出血量为(621±245.84)ml,术后MSTS93功能评分为(25.06±2.11)分,初次与二次翻修手术的手术时间、术中出血量及术后MSTS 93功能评分的差异均无统计学意义(t=3.18,P=0.399;t=0.30,P=0.926;t=1.61,P=0.376)。结论骨水泥固定翻修术治疗非感染因素导致的膝关节肿瘤型假体失败病例具有假体生存率高、并发症发生率低,肢体功能恢复良好,且可重复性高,是治疗膝关节肿瘤型假体失败的一个有效方法。

Objective To investigate the clinical efficacy of cement-in-cement(CiC)technique for endoprosthetic revision surgeries of noninfectious causes around the knee.Methods All of 128 patients who had received cement-in-cement technique for endoprosthetic revision from February 2002 to August 2020 including 71 males and 57 females,whose mean age was 33.5±15.4 years(range,8-77 years).128 patients included 73 cases of osteosarcoma,38 cases of giant cell tumors,8 cases of undifferentiated sarcoma,4 cases of chondrosarcoma,2 cases of Ewing sarcoma,2 cases of fibrosarcoma and 1 case of synovial sarcoma,with 105 cases in distal femur and 23 cases in proximal tibia.The failure mode classification included 64 cases of aseptic loosening,47 cases of structure failure and 17 cases of tumor progression.16 out of the 19 endoprosthese failure after the first cement-in-cement procedure received a second cement-in-cement procedure.The survival of revised prostheses,duration of the operation,the amount of blood loss,epidemiological data,complications and limb function were enrolled and statistical analyzed.Results The mean follow-up from CiC revision was 127±33 months(range,6-326 months).There were 25(19.5%)complications for the first CiC procedure and 19(14.8%)of the 25 complications lead to the protheses failure including 5(3.9%)structure failure,6(4.7%)aseptic loosening,2(1.6%)tumor recurrence and 6(4.7%)infection.The other 6 cases included 5 poor superficial wound healing and 1 patellar ligament rupture.All were recovered after debridement and tendon repair.The cumulative survival rates of first CiC procedure were 85.0%,76.6%and 70.7%at 5,10 and 15 years,respectively.Limb salvage rate was 97.7%.Sixteen of the 19 cases received a second CiC revision.The mean operative time(206±51 min vs.258±41 min,t=3.18,P=0.399),blood loss(596±217.99 ml vs.621±245.84 ml,t=0.30,P=0.926)and the median MSTS 93 score(26.38±2.47 vs.25.06±2.11,t=1.61,P=0.376)of the first and second CiC procedure for the 16 cases were similar.Conclusion CiC technique is a repeatable,conservative and viable option for endoprosthetic revision surgeries of noninfectious causes around the knee,with acceptable prosthetic survival rate,complication rate and limb function.