骨肿瘤初次保肢手术后生物性重建失败的肿瘤假体翻修术

目的评估骨肿瘤初次保肢手术后生物性重建失败的肿瘤假体翻修的疗效。方法2004至2006年，13例骨肉瘤和3例骨巨细胞瘤患者在香港威尔斯亲王医院接受手术治疗。15例患者应用同种异体骨重建，另1例患者应用带血管腓骨移植重建骨缺损。应用肿瘤型假体进行翻修手术的重建。翻修术后患者膝关节活动范围良好时，订制的可延长假体接受延长手术。结果患者平均年龄23．2岁（13～43岁），平均随诊26．4个月（6～47个月）。翻修手术的原因包括：7例患者出现同种异体骨骨折或软骨下骨塌陷，5例患者骨不愈合，3例患者异体骨感染，1例患者膝关节僵硬。翻修手术的假体包括10例患者应用订制型假体，其他患者应用组合式假体。翻修手术的部位包括9例股骨远端假体，6例胫骨近端假体和1例股骨中段假体。订制假体中6例是可延长假体，假体的延长方式中5例是微创延长、1例无创延长。翻修手术后，膝关节活动改善，平均从18．1°（0°-90°）至91．9°（50°-120°）。下肢缩短不等长畸形从平均5cm（2-11．5cm）纠正至平均1．5cm（0-4cm）。翻修术后患肢功能MSTS评分从34．6％改善到89．2％。翻修术后2例患者出现部分皮肤坏死，1例患者出现腓总神经麻痹，以后部分恢复，1例患者出现胫骨裂纹骨折；没有感染和植入物失败。结论保肢手术后生物学重建失败所引起下肢缩短和僵硬，应用人工假体翻修是可行的，早期效果令人鼓舞。膝关节僵硬患者可获得良好的关节活动度。严重的下肢缩短畸形通过可伸长假体逐渐获得纠正。     

Paget's sarcoma: limb salvage by custom mega prosthesis: four case reports

Of 4 Paget's sarcoma patients (age range, 55-68 years) underwent limb salvage surgery by custom mega prosthesis, 3 had lesions in the upper extremity and one in the proximal femur. Three of the patients were at stage IIB of the disease, according to Enneking's system of staging musculoskeletal tumours. All 4 patients underwent wide resection with a mean length of 152.5 mm. The defects were reconstructed with custom-made prostheses: proximal humeral prostheses in 2 of the patients, total elbow prosthesis in one, and total hip prosthesis in one. During a mean postoperative follow-up period of 40 months, one died of disseminated disease 14 months after surgery; one remained disease-free; 2 had local recurrence and required amputation, of whom one died of disseminated disease one year after amputation, the other had no further evidence of the disease. We report the functional outcomes of the 2 patients who were alive at the latest follow-up. The 2-year patient survival rate was 50%.     

Single stage osteotomy and total knee arthroplasty for tibio-femoral malunion with osteoarthritis of the knee

Extraarticular tibiofemoral malunion causing malalignment and osteoarthritis of the knee can be managed by an extraarticular osteotomy, or by compensatory distal femoral or proximal tibial wedge resection along with total knee replacement, to achieve limb alignment and improve knee function. We operated on 6 knees with tibiofemoral malunion with osteoarthritis of the knee. All knees had an extraarticular osteotomy either at the site of malunion (3 knees) or away from the malunion site (3 knees). There were 4 femoral deformities and 2 tibial malunions. In one patient a femoral osteotomy was done as a part of revision knee replacement for loosening with supracondylar malunion. 5 of these patients had a press fit stemmed superstabiliser total knee replacement. In the remaining patient with tibial malunion, a conventional total condylar total knee replacement was done along with a high tibial osteotomy. At a mean follow-up of 45 months (range 24 to 84), one osteotomy had not healed inspite of bone grafting and one patient had an above knee amputation for infection. The HSS (Hospital for Special Surgery) scores revealed a good result in 4 knees, fair in 1 and poor in 1 patient. None of the surviving knee replacement has required a revision to date for clinical or radiological loosening. All patients had a good mechanical alignment of the lower limb, with no ligamentous imbalance following surgery. Single stage osteotomy and total knee arthroplasty is a technically demanding surgery associated with complications and should be reserved for large deformities. Minor deformities should be corrected by intraarticular distal femoral or proximal tibial wedge resection taking due care that ligament balance is not compromised and a satisfactory alignment is restored.      

THE FUNCTIONAL EVALUATION OF PATIENTS WITH PRIMARY MALIGNANT TUMOURS ABOUT THE KNEE TREATED BY MODULAR ENDOPROSTHETIC REPLACEMENT

Between 1985 and 1992, 39 patients with primary malignant neoplasms about the knee presented to the musculoskeletal oncology service at the Royal Prince Alfred Hospital, Sydney. Twenty-eight patients met the criteria for limb salvage surgery and underwent reconstruction using a modular endoprosthetic replacement. Twenty surviving patients and the modular prosthesis were evaluated using the rating system adopted by the Musculoskeletal Tumour Society. Eighteen patients had resection of the distal femur and two had resection of the proximal tibia. The average follow up was 36.5 months (range 6–93). Overall the results were excellent in two patients, good in 16 and fair in two. The prosthesis was rated as excellent in 13, good in four, fair in two and poor in one. The complications encountered are discussed. The authors conclude that this prosthesis provides a satisfactory form of reconstruction following limb salvage surgery for tumours about the knee.     

定制型人工关节置换治疗成人股骨远端肿瘤

目的评价定制型人工关节在股骨远端肿瘤保肢术中的作用。方法回顾分析我院接受定制型人工关节置换进行保肢治疗的股骨远端肿瘤患者38例，其中良性肿瘤9例，分别是骨巨细胞瘤7例（复发性骨巨细胞瘤5例，骨折2例），骨巨细胞瘤合并动脉瘤样骨囊肿1例，骨母细胞瘤1例；恶性肿瘤29例，分别是成骨性骨肉瘤16例，转移性肿瘤6例（骨折2例），软骨肉瘤2例，恶性纤维组织细胞瘤3例（骨折1例），纤维肉瘤1例，局灶性骨髓瘤1例。所有患者均使用国产定制型人工膝关节，铰链式17例，后稳定型21例。结果9例良性肿瘤患者1例失访，1例死于其他不相关疾病，其余7例病人随访时膝关节功能按Enneking制定的标准进行评定，优5例，良1例，差1例，保肢成功率为100％；29例恶性骨肿瘤患者，骨肉瘤患者失访7例，2例患者术后局部复发，行截肢术；其余20例患者生存期间膝关节功能优10例，良4例，差6例。7例效果评价差的病人为有6例为铰链式膝关节假体。结论定制型人工膝关节置换是一种较好的股骨远端肿瘤保肢方法。     

The Stanmore knee arthrodesis prosthesis

Knee arthrodesis is most commonly performed for failed total knee arthroplasty. Conventional arthrodesis techniques are associated with a high incidence of complications and are unsuitable in cases with extensive bone loss. We report our medium-term results using a custom-made cemented knee arthrodesis prosthesis in 10 patients with a mean follow-up of 56.4 months (range, 15-199 months). The prosthesis was implanted as a 1- or 2-stage procedure for infected revision knee arthroplasty or tumor endoprosthesis in 9 patients and as a primary procedure in 1 patient with angiosarcoma involving the knee extensor mechanism. The average combined femoral and tibial bone deficit was 170 mm (range, 56-220 mm). Implant survivorship was 90%. All patients with retained prosthesis had no evidence of residual infection or loosening and were able to mobilize independently. One prosthesis was revised though retained following a prosthetic fracture, and 1 patient underwent above-knee amputation for uncontrolled infection. We conclude that the Stanmore knee arthrodesis prosthesis provides reliable fusion in an otherwise difficult-to-treat group of patients.     

保留假体的序贯疗法治疗骨肿瘤保肢术后假体周围感染

目的:探索应用保留假体的"多米诺"序贯疗法治疗骨肿瘤保肢术后假体周围感染的注意事项和临床疗效。方法:收集并回顾性分析2016年1月至2020年1月共11例采用保留假体的序贯疗法治疗骨肿瘤保肢术后假体周围感染患者资料,其中男8例,女3例;年龄（51.82±15.57）岁（范围21~74岁）。股骨远端肿瘤膝假体6例,胫骨近...     

Functional outcome of limb salvage surgery with mega-endoprosthetic reconstruction for bone tumors

Background

The use of a mega-endoprosthesis has become the method of choice for reconstruction after bone tumors. In this study, we sought to determine the functional outcome and complications associated with mega-endoprosthesis.

Methods

A retrospective review of the charts of 16 patients who had undergone resection of bone tumors followed by reconstruction with mega-endoprosthesis between 2006 and 2011 was performed. Functional evaluation was based on the Musculoskeletal Tumor Society (MSTS) scoring system. Complications of the procedures were also analyzed.

Results

Eight men and eight women at an average age of 36.7?years were included in the study. The tumor involved lower limb in 14 patients and upper limb in 2 patients. The average MSTS functional score was 72.3?±?15. Excellent results were achieved in six patients, good in five, moderate and fair in two each and poor in one. Complications occurred in eight patients. Two patients had aseptic loosening of the femoral component of total knee replacement. Flap necrosis occurred in two patients, both of whom required latissimus dorsi free flap for coverage of total knee prosthesis. One patient underwent revision of femoral component subsequent to knee dissociation. Local recurrence of tumor, patellar tendon rupture and foot drop occurred in one patient each.

Conclusion

Mega-endoprosthetic reconstruction in limb salvage provides good functional outcome in patients with bone tumors.     

Rotational osteotomy for proximal femoral focal deficiency

Thirteen patients who had a proximal femoral focal deficiency and were treated with a rotational osteotomy of the tibia (Van Nes procedure) were evaluated at an average of five years after operation. Five patients needed a repeat osteotomy of the tibia: four because the limb had spontaneously derotated toward the original position and one because the limb had had insufficient rotation at the time of operation. One patient had a disarticulation at the ankle after the first stage of a planned two-stage procedure because the mother was not happy with the child's appearance. In ten limbs, the distal femoral growth plate and epiphysis were removed and in two, the femoral epiphysis and growth plate and the tibial growth plate were removed so that the joint of the prosthetic knee would be positioned at the proper height at the completion of the child's growth. Neither growth plate was removed from one limb, the shorter one in the child who had bilateral involvement. A ten-point grading scale based on use and fit of the prosthesis, gait, range of motion of the ankle, use of external support, and final height of the ankle compared with that of the contralateral knee was used to evaluate the result, which was excellent in six patients, good in four, fair in one, and poor in one. One patient, who had a disarticulation at the ankle, was excluded from the final evaluation. Rotational osteotomy provided good function and acceptable cosmetic appearance in the patients who had unilateral involvement.     

Free microvascular rotationplasty with nerve repair for rhabdomyosarcoma in a 18‐month‐old patient

Rotationplasty is a limb‐sparing surgical option in lower limb malignancies. Sciatic or tibial nerve encasement has been considered an absolute contraindication to this procedure. We report a case of an 18‐month‐old girl with a rhabdomyosarcoma that affected the leg and popliteal fossa, with neurovascular involvement. Knee and proximal leg intercalary resection was performed followed by reconstruction with free microvascular rotationplasty and neurorraphy from tibial division of sciatic nerve to sural and tibial nerves, and from saphenous nerve to superficial peroneal nerve. Postoperative course was uneventful and ambulation with a provisional prosthesis was restarted during the sixth week after surgery. Bone consolidation was observed after two months. Eighteen months later, the patient had a good gait pattern with a below‐knee prosthesis and had recovered sensation in the whole foot and ankle area. This case shows that rotationplasty with nerve repair may provide a sensate stump, which is vital for successful prosthetic adaptation. We believe it may be considered as an alternative to above‐knee amputation in tumors with sciatic involvement.     

人工关节假体复合大段同种异体骨移植重建肢体功能

目的 探讨采用复合人工关节假体大段同种异体骨移植的方法治疗肢体恶性骨肿瘤的手术原理及效果。方法 骨肿瘤患者１６例,年龄１９岁－６０岁,其中骨肉瘤４例,软骨肉瘤２例,恶性骨巨细胞瘤３例,纤维肉瘤３例,其它恶性骨肿瘤４例,肢体功能重建方法包括：复合股骨近端的全髋关节置换术３例,复合股骨近端的双极人工股骨头置换术７例,复合股骨下端或胫骨上端的全膝关节置换６例,结果 本组１６例经１．５－５．０年随访,１例     

Results of total knee arthroplasty after failed proximal tibial osteotomy for osteoarthritis

The cases of twenty-one consecutive patients who had a minimally constrained total knee arthroplasty (six of whom had a cemented and fifteen, an uncemented prosthesis) after a failed proximal tibial osteotomy for osteoarthritis were compared with those of a non-consecutive group of twenty-one patients who had had a primary total knee arthroplasty for osteoarthritis. The groups were matched according to age and sex of the patient, type of prosthesis and fixation, and length of follow-up. At an average length of follow-up of 2.9 years, a good or excellent result was obtained in 81 per cent of the patients who had had a previous osteotomy. At an average length of follow-up of 2.8 years, a good or excellent result was obtained in 100 per cent of the patients who had had a primary arthroplasty. Two patients in the osteotomy group and none in the primary arthroplasty group required additional surgery. At the time of arthroplasty, technical difficulties in exposing the proximal part of the tibia were noted in three patients in the group that had undergone an osteotomy. The results of total knee arthroplasty after failed proximal tibial osteotomy approached but did not equal the results after primary total knee arthroplasty.     

A modular femur-tibia reconstruction system

A 26 piece modular system for the reconstruction of the bones of the lower extremity from the femoral head to the distal third of the tibia is described. This modular system can be implanted without cement and allows for the intraoperative determination of the amount of resection necessary. The implant material is the well-known cast, Co-Cr-Mo alloy Vitallium. From 1982 to the end of 1985, 52 patients were treated with this cementless tumor endoprosthesis of the Kotz Modular Femur-Tibia Reconstruction System (KMFTR) at the University of Vienna, Department of Orthopedics. The locations of the tumors were: proximal femur (28), distal femur (17), and proximal tibia (7). In two cases a total femur was implanted and in another patient a total knee. Indications for the resection of the bone segments and joints concerned included primary bone tumors, metastases, and loosening of conventional endoprostheses and tumor resection endoprostheses. Twenty-one patients with an average follow up of 20.4 months and a minimum follow up of 1 year were evaluated according to Enneking's criteria. Eight patients had proximal femoral replacement. The results were excellent in two, good in five, and fair in one. Eleven patients had undergone replacement surgery in the knee joint area. The overall rating showed five excellent results, four good and two fair. One patient with a total femoral replacement had multiple bone metastases with polytopic pain and was no longer available for regular assessment. Another patient with a total knee replacement suffered a rupture of the patellar ligament after 10 months and had to be revised. Radiologically we have observed excellent bone incorporation of the prosthesis in 15 of 25 evaluated patients. Ten cases showed no changes in radiologic features as compared to the initial findings. These were patients with short follow up periods. Although complications did occur in these major surgical interventions, the final results were very satisfactory and the patients were subjectively content with the operation.     

Structural allografting in revision total knee arthroplasty

Between 1985 and 1991, 15 patients underwent structural allografting as part of revision total knee arthroplasty. All patients had large segmental, cavitary, or combination defects of the femur and/or tibia. Seven distal femurs and 12 proximal tibias required allografting. Patients were evaluated with physical examination, radiographs, and The Hospital for Special Surgery knee rating scale. Three patients died, leaving 15 allografts for follow-up study. The average age at surgery was 63 years. The follow-up period averaged 47 months (range, 30–101 months). Average range of motion before surgery was 4° to 93°, and after surgery, 2° to 104°. Average knee score was 47 before and 86 after surgery. Preoperative alignment averaged 5° varus, ranging from 25° valgus to 20° varus, and postoperative alignment averaged 4° valgus, ranging from neutral to 6° valgus. All patients, except one, had improvement of pain and stability. All of the 15 allografts healed to host—bone and 13 showed evidence of incorporation. There were no infections or fractures of the allografts. One complication directly related to the allograft occurred; that patient had a tibial component fracture over a proximal tibial allograft 3 years after surgery. Three other complications occurred. One was tibial loosening in a patient who received a distal femoral allograft, the second was a proximal tibial fracture in a patient who received a distal femoral allograft, and the third was an intraoperative patellar tendon avulsion. These results suggest that structural allografting can provide a satisfactory method of managing large bone defects in the failed total knee arthroplasty.     

儿童及青少年膝关节周围骨肉瘤的保肢治疗

目的探讨儿童和青少年患者膝关节周围骨肉瘤切除后的重建方法及治疗效果。方法1996年10月至2005年12月,共治疗儿童和青少年膝关节周围骨肉瘤患者89例,平均年龄13岁;部位：股骨下端52例,胫骨上端36例,病变同时累及股骨下端及胫骨上端1例。根据患者年龄及骺板闭合情况分别选择灭活再植（灭活组,n=20）、半关节假体置换（半关节组,n=19）及全关节假体置换（全关节组,n=50,包括可延长假体及儿童特制假体）进行肿瘤切除后的重建。结果85例患者获得随访,平均随访时间42个月,灭活组中4例局部复发,11例死于肺转移,5年生存率47,1％;半关节组中1例局部复发,4例死于肿瘤转移,5年生存率71．7％;全关节组中4例复发,9例死于转移,5年生存率68,2％。1例灭活病例、1例半关节病例及3例全关节病例出现了深部感染;2例半关节病例出现了假体半脱位;1例半关节置换病例因术后肢体缺血,接受了截肢。功能情况,灭活组MSTS93评分平均21．43分,半关节组23,40分,全关节组25．32分。平均肢体不等长范围,灭活组5．48cm,半关节组4．50cm,全关节组3．12cm。结论儿童及青少年膝关节周围骨肉瘤的保肢治疗较为困难,对于骨骺生长活跃的病例应尽量采用半关节假体等保留对侧骨骺的方法,以减少肢体不等长的情况,以便于今后的翻修;对于骺板接近闭合的病例可直接采用全关节假体,以取得良好的功能。     

The total condylar III knee prosthesis in elderly patients

Sixteen knee arthroplasties using a total condylar III prosthesis were performed in 14 patients with an average follow-up period of 4.5 years and a minimum follow-up period of 3 years. Eleven of the sixteen knee arthroplasties were revision prostheses. The average age was 71 year, with all but three patients being 69 years of age or older. In this age group, fifteen of sixteen implants had a good to excellent Hospital for Special Surgery (HSS) knee score at the most recent follow-up evaluation. One patient had a fair score, the result of a remote postoperative proximal tibial fracture, and requires a long leg brace for ambulation.     

The clinical outcomes of extracorporeal irradiated and re-implanted cemented autologous bone graft of femoral diaphysis after tumour resection

Purpose

We report the outcome of intercalary resection of the femoral diaphysis and extracorporeal irradiated autologous bone graft reconstruction, without the use of vascularized fibular graft.

Methods

Six patients with Ewing sarcoma of the mid-shaft femur who were treated by limb sparing tumour resection and reconstruction with extracorporeal irradiated autologous bone graft with intramedullary cement between 2002 and 2010 were studied.

Results

Mean age at the time of surgery was ten years (range, four–23). The length of resected femoral bone averaged 23 cm (15–32 cm). The ratio of bone resection length to total femoral length averaged 60 % (56–66 %). The patients had been followed up for between 16 and 79 months (mean, 41 months) at the time of the study. There was no infection nor fracture in this series. Primary union of the distal and proximal osteotomy sites was achieved in three patients. Delayed union of the proximal osteotomy site occurred in one patient that was successfully treated with iliac crest bone grafting. One patient developed non-union at the distal osteotomy site which failed to heal with bone grafting and was therefore converted to endoprosthetic replacement, and another patient was converted to rotationplasty at five months post-surgery because of contaminated margins. Function was excellent in all patients with surviving re-implanted bone. Local recurrence arose in one patient.

Conclusion

Our experience suggests that cement augmentation of extracorporeal irradiated and re-implanted bone autografts offer a useful method of reconstructing large femoral diaphyseal bone defects after excision of primary malignant bone tumours.     

Reconstruction of musculoskeletal defects about the knee for tumor

One of the most challenging problems of limb salvage is a large tumor involving the knee joint. Since 1970, 79 patients, ranging in age from 14 to 74 years (mean, 27 years), have had reconstruction of the knee after en bloc resection of a primary bone tumor. Sixty-one patients had lesions involving the distal femur, with a mean resection length of 13.5 cm, and 18 patients had lesions involving the proximal tibia, with a mean resection length of 10.5 cm. Thirty-nine patients had malignant lesions, of which osteosarcomas predominated, and 40 patients had benign tumors, of which giant cell tumors were the most prevalent. Reconstruction was done with a custom total knee arthroplasty in 41 patients, a resection arthrodesis in 27, and an allograft in 11. The functional results were graded according to the rating system devised by the Musculoskeletal Tumor Society. of the patients with resection arthroplasty, 70% had a good or excellent rating, although ten required revision. Of the patients with resection arthrodesis, 74% had a good or excellent rating, as did 55% of the patients with osteochondral allografts. When a limb salvage procedure is done, careful consideration must be given to the type of procedure chosen to reconstruct the knee. This decision is based on a number of factors related to the tumor and the patient. Although these various procedures promise functional restoration, the reconstructive procedure should be individualized and designed to meet the needs of the patient.     

Long‐term outcome of giant cell tumors of bone around the knee treated by en bloc resection of tumor and reconstruction with prosthesis

Objective: To study the long‐term outcomes and complications of giant cell tumors around the knee treated with en bloc resection and reconstruction with prosthesis. Methods: From January 1991 to March 2005, 19 patients (11 men, 8 women, average age 35.4 years) were treated in our hospital with en bloc resection and reconstruction with domestic prosthesis (15 hinge knee and 4 rotating‐hinge knee). The distal femur was involved in 12 and the proximal tibia in 7 cases. Nine tumors were primary and 10 recurrent. All cases were Campanacci grade III. The affected limb functions were evaluated by the Musculoskeletal Tumor Society scoring system. Results: All patients underwent operation successfully with no complications. The mean follow‐up time was 128.9 months (60 to 216 months). Apart from one patient who underwent amputation because of wound infection two years after reoperation, the range of knee motion of 18 patients was 30°–110°. The mean functional score of the affected limb was 22.7 (15 to 27 points). The length of the lower extremities was equal in nine cases; the affected limb was 2–9 cm shorter in the other ten cases. Prosthesis fracture and loosening developed in one, prosthesis aseptic loosening in three, and delayed deep infection and prosthesis loosening in two cases. The prosthesis loosening rate was 31.6%. One patient developed a proximal femur fracture. Conclusion: En bloc resection and reconstruction with prosthesis is a feasible method for treating giant cell tumor of bone around the knee. Complications related to the prosthesis, mainly prosthesis loosening and limb shortening, increase gradually with longer survival time.