3D打印定制半骨盆假体在组配式半骨盆假体无菌性松动或螺钉断裂患者翻修中的应用

Three-dimensional-printed hemi-pelvic prosthesis for revision of aseptic loosening or screw fracture of modular hemi-pelvic prosthesis

目的 探讨组配式半骨盆假体无菌性松动或螺钉断裂患者采用3D打印定制半骨盆假体进行翻修的有效性。方法 2017年2月—2020年1月,对11例组配式半骨盆假体无菌性松动或螺钉断裂患者,采用3D打印定制半骨盆假体进行翻修术。男7例,女4例;年龄25~60岁,平均44岁。初次手术均为肿瘤整块切除并采用组配式半骨盆假体重建、自体股骨头移植。根据Enneking骨盆分区系统,Ⅰ+Ⅱ区切除8例,Ⅰ+Ⅱ+Ⅲ区切除3例。初次手术至该次翻修手术间隔14.3~66.2个月,平均35.8个月。记录手术时间、术中出血量以及并发症发生情况;初次术后6个月、翻修术前以及末次随访时,采用美国骨与软组织肿瘤协会(MSTS)评分及Harris评分评价下肢功能恢复情况;末次随访时记录患者无支具辅助下无痛步行距离。初次术后1个月、翻修术前和翻修术后1个月摄X线片,测算健患侧体质量力臂差值和髋臼杯高度差值,以评估髋臼位置;末次随访时,以数字化X线体层摄影评估假体-骨整合情况及有无无菌性松动发生。结果 手术时间182.6~238.4 min,平均197.4 min;术中出血量400~860 mL,平均550.0 mL。术后切口均Ⅰ期愈合,无深部感染、髋关节脱位、神经损伤及血管相关不良事件等并发症发生。末次随访时,MSTS评分及Harris评分较初次术后6个月及翻修术前均提高,而翻修术前较初次术后6个月降低,差异均有统计学意义(P<0.05);患者均能在无支具辅助下无痛步行1 000 m以上。影像学复查示,翻修术后1个月髋臼杯高度差值低于初次术后1个月及翻修术前,初次术后1个月低于翻修术前,差异有统计学意义(P<0.05)。初次术后1个月及翻修手术前后体质量力臂差值差异均无统计学意义(P>0.05)。所有假体与骨整合良好,无假体无菌性松动或螺钉断裂发生。结论 组配式半骨盆假体置换术后发生假体无菌性松动或螺钉断裂患者,采用3D打印定制半骨盆假体翻修能重建骨盆环完整性,恢复正常力学传导。术后早期行恰当康复训练能够最大限度恢复患者肢体功能、减轻行走时疼痛、降低并发症发生率。

Objective To investigate the effectiveness of three-dimensional(3D)-printed hemi-pelvic prosthesis for revision of aseptic loosening or screw fracture of modular hemi-pelvic prosthesis.Methods Between February 2017 and January 2020,11 patients with aseptic loosening or screw fracture of modular hemi-pelvic prosthesis were revised using 3D-printed hemi-pelvic prostheses.There were 7 males and 4 females with an average age of 44 years(range,25-60 years).In the first operation,all patients underwent total tumor resection,modular hemi-pelvic prosthesis reconstruction,and autologous femoral head transplantation.According to the Enneking pelvic partition system,8 cases were resected in zonesⅠ+Ⅱand 3 cases in zonesⅠ+Ⅱ+Ⅲ.The interval from the initial operation to this revision ranged from 14.3-66.2 months,with an average of 35.8 months.The operation time,the amount of intraoperative bleeding,and the occurrence of complications were recorded.At 6 months after the first operation,before revision,and at last follow-up,the American Musculoskeletal Tumor Society(MSTS)score and Harris score were used to evaluate the recovery of lower limb function.The pain-free walking distance of patients without brace assistance was recorded at last follow-up.X-ray films were taken at 1 month after the first operation,before revision,and at 1 month after revision,the acetabulum position was assessed by the differences in weight arm and cup height between bilateral hip joints.At last follow-up,the digital X-ray tomography was taken to evaluate the prosthesis-bone integration and the occurrence of aseptic loosening.Results The operation time was 182.6-238.0 minutes(mean,197.4 minutes).The amount of intraoperative bleeding was 400-860 mL(mean,550.0 mL).All incisions healed by first intention with no infection,hip dislocation,nerve damage,or vascular-related adverse events.The MSTS score and Harris score at last follow-up were significantly higher than those at 6 months after the first operation and before revision(P<0.05),while the score before revision was significantly lower than that at 6 months after the first operation(P<0.05).At last follow-up,the patients were able to walk more than 1000 meters painlessly without brace assistance.Imaging review showed that the difference of cup height at 1 month after revision was significantly lower than that at 1 month after the first operation and before revision,and at 1 month after the first operation than before revision operation,and the differences were significant(P<0.05).There was no significant difference in the difference of weight arm among three time points(P>0.05).All prostheses were well integrated,and no aseptic loosening of the prosthesis or screw fracture occurred.Conclusion Revision with 3D-printed hemi-pelvic prostheses benefited in reconstructing stable pelvic ring and natural bodyweight transmission for patients encountering the aseptic loosening or screw fracture of modular hemi-pelvic prosthesis.Early postoperative rehabilitation training can maximize the recovery of patient limb function,reduce pain during walking,and reduce the incidence of complications.