生物型同种异体骨-假体复合物重建股骨近端肿瘤性骨缺损的远期疗效

Long-term effectiveness of uncemented allograft-prosthesis composite for reconstruction of bone defects after proximal femur tumor resection

目的 探讨生物型同种异体骨-假体复合物(allograft-prosthesis composite,APC)重建股骨近端肿瘤性骨缺损的远期疗效。方法 回顾分析2007年6月—2014年3月21例行股骨近端骨肿瘤切除并生物型APC重建的患者临床资料。男9例,女12例;年龄19~54岁,平均33.2岁。肿瘤类型:骨巨细胞瘤9例,骨肉瘤5例,骨母细胞瘤4例,软骨肉瘤2例,多形性未分化肉瘤1例。13例良性骨肿瘤Enneking分期均为3期;8例恶性骨肿瘤根据美国癌症联合委员会(AJCC)分级系统,ⅡB级7例、ⅡA级1例。其中7例为复发后再次手术,其余患者均为初次手术。8例合并病理性骨折。术前Harris髋关节评分(HHS)为43(30,49)分,美国骨与软组织肿瘤协会(MSTS)评分为(9.1±3.5)分。术中截骨长度为80~154 mm,平均110 mm。术后1年和末次随访时,采用HHS评分以及MSTS评分评估患者关节功能状态,以臀中肌力量评分评估外展肌功能。术后1、3、6、9、12个月以及之后每年影像学复查,观察骨-骨界面愈合以及骨质吸收情况。记录术中及术后随访并发症发生情况。结果 患者均获随访,随访时间84~163个月,平均123.5个月。术后1年及末次随访时MSTS评分、HHS评分均较术前提高(P<0.05);术后两时间点间上述评分及臀中肌力量评分差异均无统计学意义(P>0.05)。影像学复查示患者骨-骨界面均愈合,愈合时间5~10个月,平均7.6个月;末次随访时患者均存在骨吸收,其中重度11例、中度4例、轻度6例;骨吸收部位涉及Gruen 1、2和7区。并发症包括10例骨折以及1例假体断裂。随访期间3例局部复发,3例发生肺转移。结论 生物型APC是重建股骨近端肿瘤性骨缺损可靠方法,具有较好远期疗效,在骨-骨界面愈合上具有明显优势。

Objective To investigate the long-term effectiveness of uncemented allograft-prosthesis composite(APC)for reconstruction of bone defects after proximal femur tumor resection.Methods Between June 2007 and March 2014,21 patients who underwent uncemented APC reconstruction of proximal femur after tumor resection were retrospectively evaluated.There were 9 males and 12 females with an average age of 33.2 years(range,19-54 years).There were 9 cases of giant cell tumor of bone,5 cases of osteosarcoma,4 cases of osteoblastic osteosarcoma,2 cases of chondrosarcoma,and 1 case of undifferentiated pleomorphic sarcoma.Thirteen cases of benign bone tumors were all classified as stage 3 by Enneking staging;and 8 cases of malignant bone tumors were classified as gradeⅡB in 7 cases and gradeⅡA in 1 case according to the American Joint Committee on Cancer(AJCC)staging system.Among them,7 patients underwent reoperation after recurrence,and the rest were primary operations;8 patients presented with pathological fractures.The preoperative Harris hip score(HHS)and American Musculoskeletal Tumor Society(MSTS)score was 40(30,49)and 9.1±3.5,respectively.The length of osteotomy was 80-154 mm,with an average of 110 mm.At 1 year after operation and last follow-up,HHS and MSTS scores were utilized to evaluate the function of hip joint;the gluteus medius strength score was used to evaluation of the hip abduction function.Image examinations were taken at 1,3,6,9,and 12 months after operation and every year thereafter to assess the union of allograft-host bone interfaces.Intra-and post-operative complications were also recorded.Results All patients were followed up 84-163 months(mean,123.5 months).At 1 year after operation and last follow-up,the HHS and MSTS scores significantly improved when compared with the preoperative scores(P<0.05).However,there was no significant difference in the HHS score,MSTS score,and gluteus medius strength score between the two time points after operation(P>0.05).Image examination showed that all allograft-host bone interfaces achieved union after 5-10 months(mean,7.6 months).At last follow-up,all patients had bone resorption,including 11 severe cases,4 moderate cases,and 6 mild cases;the bone resorption sites included Gruen 1,2,and 7 regions.Complications included 10 fractures and 1 prosthetic fracture.Local recurrence occurred in 3 patients and pulmonary metastasis in 3 patients.Conclusion Uncemented APC is a reliable method for the reconstruction of bone defects after proximal femur tumor resection.It has the good long-term effectiveness and possesses obvious advantages in the union at the bone-bone surface.