应用假体翻修大段异体骨保肢失败后的功能重建

目的探讨应用组合式假体翻修大段异体骨感染或骨折的疗效。方法回顾性研究了美国迈阿密大学医学院和中山大学附属第一医院骨肿瘤科共22例肩关节或膝关节周围肿瘤的患者,大段异体骨保肢失败后,应用肿瘤型假体重建肢体功能。最初诊断包括骨肉瘤11例、软骨肉瘤4例、恶性纤维组织细胞瘤3例、骨巨细胞瘤2例、恶性血管内皮瘤1例和鼻咽癌转移瘤1例。发病部位包括股骨远端15例、肱骨近端3例和胫骨近端4例。结果异体骨失败原因包括:骨折14例、感染6例、持久不愈合1例、合并骨折和感染1例。异体骨移植后平均随访154.2(63～293)个月,假体翻修后平均随访73.4(24～234)个月。90.9%(20/22)的患者最终肢体功能良好,MSTS功能评分为76.5%(60%～93.3%)。81.8%(18/22)的患者假体翻修手术成功,在翻修失败的患者中,1例肱骨近端肿瘤患者为了改善功能经历了多次翻修手术,另1例股骨远端的患者,异体骨移植失败假体翻修后,由于假体近端松动而进行二次翻修——全股骨置换术,另外2例股骨远端的患者翻修后合并感染和骨折而截肢。结论异体骨重建因骨折或感染失败后,再次行假体翻修重建肢体功能是可靠的,并发症较低。翻修技术会影响重建肢体的功能。对于异体骨感染的患者,建议分期翻修重建肢体功能。

Salvage of failed massive allograft reconstruction with endoprosthesis

Objective To evaluate the functional result of reconstruction with endoprostheses for the failure of massive allograft. Methods twenty-two patients with failed massive allograft following tumor resection of the shoulder and knee were revised with modular oncology endoprostheses. Original diagnosis were osteosarcoma （ 11 ）, chondrosarcoma （4）, malignant fibrous histocytoma （3）, giant cell tumor （2）, malignant hemangioendothelima （ 1 ） and metastasis of nasopharyngeal carcinoma cell. The sites involved distal femur （14）, proximal humerus （3） and proximal tibia （3）. Results Reasons for failure of the original allograft included fracture （ 14 ）, infection （5）, both fracture and infection （ 2 ） and nonunion （ 1 ）. Patients were followed up for averaged 154.2 months （ 63 - 293 ） after allograft reconstruction and 73.4 months （24 -234） after endoprosthetic revision. In 81.8% （18/22） of the cases, a successful revision procedure was obtained. 90.9% （20/22） patients retained functional limbs at recent follow-up. MSTS scores of these patients were averaged 76.5% （ range 60% - 93.3% ）. However, one patient （proximal humerus ） required multiple revision procedures to improve his function; another patient underwent a second revision from distal femoral endoprosthesis to total femoral replacement due to proximal femoral loosening, two others （ distal femur endoprostheses） underwent amputation because of infection and fracture. Conclusions Endoprosthetic revision for failed massive allograft is a successful salvage strategy. Reconstruction outcome was affected by operative technique. A limb with function can be reserved by two stages revision after allograft infection. With regard to the treatment of allograft failure-infection and fracture, endoprosthetic salvage affords the opportunity to preserve limb function with limited complications.