膝关节周围骨肉瘤保留关节保肢术后关节功能及生活质量的评价

目的 探讨膝关节周围骨肉瘤患者行保留关节的保肢术(JPLS)治疗后关节功能及生活质量情况。方法 回顾性分析。纳入2000年11月-2019年12月解放军联勤保障部队第九六〇医院骨科膝关节周围骨肉瘤患者34例,其中男19例、女15例,年龄16~49(28.47±9.57)岁 。按照手术方式分为两组,行JPLS的17例患者为保留关节组,行假体关节置换术(JPRS)的17例患者为假体置换组。另外选取2019年12月-2020年2月我科患者陪护人员中17名健康成人作为正常对照组,其中男8名、女9名,年龄18~50(29.83±10.25)岁 。于术后12个月,分别采用骨骼肌系统肿瘤协会(MSTS)评分系统、国际膝关节委员会(IKDC)膝关节主观评分量表、生活质量简明健康问卷(SF-36)评价并对比较正常对照组、保留关节组、假体置换组下肢功能、膝关节功能及生活质量情况,比较保留关节组、假体置换组患者在MSTS、IKDC评分标准中各条目的分布情况。结果 (1)正常对照组、保留关节组、假体置换组基线资料比较,差异均无统计学意义(P值均>0.05)。保留关节组、假体置换组34例患者均顺利完成手术,术后切口均一期愈合。(2)术后12个月,假体置换组MSTS评分为(22.82±5.47)分,低于保留关节组的(27.12±1.69)分和正常对照组的(28.18±1.78)分,差异有统计学意义(H=15.152, P＜0.05);而保留关节组和正常对照组间MSTS评分差异无统计学意义(P＞0.05)。假体置换组、保留关节组、正常对照组IKDC评分分别为(59.71±11.73)、(76.18±9.73)、(90.41±7.61)分,评分依次增高,差异均有统计学意义(H=33.283, P＜0.05)。(3)术后12个月SF-36评分结果显示,假体置换组生理机能、生理职能、躯体疼痛、社会功能评分均低于正常对照组,健康变化评分高于正常对照组;而保留关节组健康变化评分高于正常对照组,生理机能、社会功能评分高于假体置换组:差异均有统计学意义(P值均＜0.05)。SF-36量表中其他指标各组间比较,差异均无统计学意义(P值均＞0.05)。(4)保留关节组、假体置换组MSTS、IKDC评分标准中各条目分布情况比较:保留关节组患者与假体置换组肢体功能情况上差异无统计学意义(P＞0.05);保留关节组的疼痛、满意度、支具辅助、行走、步态情况优于假体置换组,差异均有统计学意义(P值均＜0.05)。保留关节组与假体置换组在直跪、下蹲、膝关节弯曲方面比较,差异均无统计学意义(P值均＞0.05);而在无疼痛、肿胀、绞锁、打软腿及一般情况下可进行的运动和上下楼、坐下从椅子上站起、向前直跑、用伤腿跳起并落地、迅速停止或开始等方面,保留关节组均优于假体置换组,差异均有统计学意义(P值均＜0.05)。结论 JPLS相比JPRS能给骨肉瘤患者带来更好的关节功能及生活质量,值得临床推广。对骨肉瘤患者术后肢体功能的评价,建议联合应用IKDC和SF-36等评价指标,以弥补MSTS功能评分的不足,从而更加准确科学地反映患者的肢体功能。

Evaluation of knee joint function and quality of life of patients with peripheral osteosarcoma of the knee treated by limb salvage with joint preservation

Objective To investigate the joint function and quality of life of patients with osteosarcoma around the knee joint after joint salvage operation (JPLS).Methods Thirty-four patients with knee periarticular osteosarcoma admitted to the Department of Orthopaedics of the 960th Hospital of PLA Joint Logistics Support Force from November 2000 to December 2019 were analyzed retrospectively. Among them, 17 patients who underwent JPLS were in the joint reservation group, 17 patients who underwent joint prosthesis replacement (JPRS) were in the prosthesis replacement group. In addition, 17 healthy patients from December 2019 to February 2020 were selected as the normal control group. The skeletal Muscle System Tumor Association Scoring System (MSTS), international knee committee (IKDC) knee master rating scale, and short form health (SF-36) questionnaire were used to evaluate the knee function, knee function, and quality of life in the normal control group, joint reservation group and prosthesis replacement groups. The distribution of items in the MSTS and IKDC scoring criteria was compared between the joint reservation group and prosthesis replacement group.Results (1) Baseline data among normal control group, joint reservation group and prosthesis replacement group were compared. No significant differencewas found among groups (all P values>0.05). All 34 patients in the joint reservation group and prosthesis replacement group successfully completed the operation, and all the incisions healed in one stage. (2) At 12 months after the operation, the MSTS scores in the prosthesis replacement group (22.82±5.47) were significantly lower than those in the joint reservation group (27.12±1.69) and the normal control group (28.18±1.78). Statistical differences were found among groups(F=15.152, P<0.05). No significant difference was found for MSTS scores between the joint reservation group and normal control group (P>0.05). The IKDC scores of the prosthesis replacement group, joint reservation group, and normal control groups were 59.71±11.73, 76.18±9.73, and 90.41±7.61, respectively. The scores increased successively with statistically significant differences (H=33.283, P<0.05). (3) The scores of SF-36, physiological function, physical pain, and social function in the prosthesis replacement group were lower than those in the normal control group at 12 months after the operation. The scores of health changes in the prosthesis replacement group were higher than those in the normal control group. The scores of health changes in the joint reservation group were higher than those in the normal control group. The scores of physiological function and social functions in the joint reservation group higher than those in the prosthesis replacement group. The differences were statistically significant (all P values<0.05). No significant difference was found for the other indexes (all P values>0.05). (4) Considering the scores of MSTS and IKDC in the joint reservation group and prosthesis replacement group: no significant difference was found in limb function between these groups (P>0.05). The pain, satisfaction, support, walking, and gait of the joint reservation group were significantly better than those of the prosthesis replacement group (all P values<0.05). No significant differences in terms of kneeling, squatting and knee joint bending were observed between the joint reservation group and prosthesis replacement group(all P values>0.05). For the indexes of no pain, swelling, strangulation, flexing of the soft legs, general movement up and down stairs, sitting down from a chair, running straight ahead, jumping up and down with the injured leg, and stopping or starting rapidly, significant differences were found between the joint reservation group and prosthesis replacement group (all P values<0.05).Conclusions Compared with JPRS, JPLS can bring better joint function and quality of life to patients with osteosarcoma, which is worthy of clinical promotion. For the evaluation of postoperative limb function in patients with osteosarcoma, it is recommended to combine application of IKDC, SF-36 and other evaluation indicators. In order to make up for the deficiency of MSTS function score, so as to reflect the patient's limb function more accurately and scientifically.