国产肿瘤型膝关节假体翻修术的临床疗效与相关诊治策略

目的 分析肿瘤型膝关节假体置换术后翻修手术的原因与围手术期的相关注意事项,提高翻修术的临床疗效.方法 回顾分析2001年1月-2009年1月间完成13例肿瘤型膝关节假体翻修手术.男9例,女4例.平均年龄45.3岁.股骨远端11例,胫骨近端2例.骨巨细胞瘤9例,骨肉瘤3例,骨韧带样纤维瘤1例.原肿瘤假体均为国产,铰链膝关节10例,旋转铰链膝关节3例.翻修手术时间为首次手术后1-29年.翻修手术原因11例为假体无菌性松动,3例为假体松动伴窦道形成,2例伴有假体断裂.翻修手术前肢体功能平均评分16.7.翻修手术时6例应用原假体,4例将原铰链膝关节更新为旋转铰链膝关节;3例单纯更换假体的松动部分.3例合并窦道的患者均行一期翻修手术.结果 所有患者的切口均一期愈合并获得随访,最长为8年,最短为1年,平均为3年4个月.1例骨肉瘤患者于翻修术后1年因肺转移死亡,12例无瘤生存.10例无窦道的患者中1例于术后5年发生假体再松动,余未发生与假体有关的并发症.3例合并窦道一期翻修的患者中,1例术后7年无异常,2例因感染复发而行截肢手术.11例保留住肢体的功能评分平均为23.6分.肢体长度较翻修术前无明显变化.结论 肿瘤型膝关节假体翻修术的主要原因为假体无菌性松动、感染和假体断裂.翻修术前应依据患者病情决定手术的具体方式;合并窦道的患者应行二期翻修术;肿瘤假体松动诊断一旦确立,应及时行翻修手术,可获得令患者满意的肢体功能,但肢体的长度无法改变.

Clinical efficacy and treatment strategies of the revision surgery for homemade tumor prosthesis of the knee

Objective To analyse the causes of revision surgery for homemade tumor prosthesis of the knee and the perioperative management, and to improve the clinical efficacy of the revision surgery. Methods 13 patients （9 males and 4 females） underwent the revision surgery for homemade tumor prosthesis of the knee between January, 2001 and January, 2009. Their average age was 45.3. The tumor located at the distal femur （n=11） and the proximal tibia （n=2）. The tumor was giant cell bone tumor （n=9）, osteosarcoma （n=3）, and skeletal desmoplastic fibroma （n=1）. All patients underwent en bloc resection of the tumor and reconstruction with homemade tumor prosthesis which were hinge prosthesis （n=10） and rotatable hinge prosthesis （n=3）. The revision surgery was perfomed 1 to 29 years after the first surgery. 11 patients underwent revision due to aseptic prosthetic loosening, 3 due to prosthetic loosening associated with sinus tract formation, and 2 due to prosthetic fracture. The pre-operative mean MSTS score was 16.7. 4 patients underwent replacement of hinge prosthesis with rotatable hinge prosthesis while 6 patients underwent revision with the previous prosthesis. 3 patients underwent replacement of the loose component. 3 patients with sinus tract underwent stage 1 revision. Results The incisions of all patients healed by first intention.All patients were followed up for 1 to 8 years, 40 months on average. 1 patient with osteosarcoma died of pulmonary metastases 1 year after revision, and 12 patients survived tumor-free. 1 of the 10 patients without sinus tract developed prosthestic loosening 5 years after revision, and no complication with prosthesis occurred in others. 1 of the 3 patients with sinus tract showed no abnormalities 7 years after surgery, and the other 2 underwent amputation due to recurrence of infection. The mean MSTS score in 11 patients with limb salvage was 23.6. There was no obvious change in the length of the affected extremities. Conclusions The main cause of the revision surgery for homemade tumor prosthesis of the knee was aseptic prosthetic loosening, infection and prosthesis fracture. The surgical method should be determined on the basis of the patient’s condition. Stage 2 revision should be chosen for patients with sinus tract. Once the diagnosis of prosthetic loosening is confirmed, revision should be performed immediately so that satisfactory function of the joint can be achieved. The limb length will not be changed.