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股骨遠(yuǎn)端腫瘤患者假體置換后遠(yuǎn)期翻修三例報(bào)告

2014-02-14 06:34:44閻洪亮董揚(yáng)張智長馬煥之張春林楊慶誠
中國骨與關(guān)節(jié)雜志 2014年5期
關(guān)鍵詞:假膜假體遠(yuǎn)端

閻洪亮 董揚(yáng) 張智長 馬煥之 張春林 楊慶誠

股骨遠(yuǎn)端腫瘤患者假體置換后遠(yuǎn)期翻修三例報(bào)告

閻洪亮 董揚(yáng) 張智長 馬煥之 張春林 楊慶誠

目的報(bào)告 3 例股骨遠(yuǎn)端腫瘤患者假體置換 25 年后的翻修病例,總結(jié)股骨遠(yuǎn)端腫瘤型假體因遠(yuǎn)期松動(dòng)而再次行假體翻修手術(shù)的結(jié)果與體會(huì)。方法回顧性分析 2008 年 1 月至 2012 年 12 月,3 例因股骨遠(yuǎn)端腫瘤型假體置換術(shù) 25 年后松動(dòng),在本院行假體翻修術(shù)患者的臨床資料,包括臨床癥狀( 膝關(guān)節(jié)周圍疼痛、行走困難等 )、影像學(xué)表現(xiàn)( X 線示假體松動(dòng)移位及翻修后假體位置 )、手術(shù)方法及技巧、術(shù)后功能恢復(fù)等,3 例翻修術(shù)后隨訪至少 5 年。結(jié)果3 例翻修術(shù)后臨床癥狀改善,膝關(guān)節(jié)周圍疼痛緩解,術(shù)后 X 線示關(guān)節(jié)位置可,隨訪過程中均未出現(xiàn)假體松動(dòng)、移位、斷裂等并發(fā)癥,根據(jù) 1993 年美國骨腫瘤學(xué)會(huì)評(píng)分系統(tǒng)( MSTS93 ),3 例術(shù)后功能評(píng)分分別為 70%、80% 及 73.3%,術(shù)后患者功能恢復(fù)良好,同時(shí)也未出現(xiàn)腫瘤局部復(fù)發(fā)及轉(zhuǎn)移。結(jié)論腫瘤型假體長期使用,可出現(xiàn)松動(dòng)、感染及排異等并發(fā)癥。腫瘤假體遠(yuǎn)期松動(dòng)行翻修時(shí),取出松動(dòng)的假體及骨水泥較容易;初次假體置換術(shù)后,假體周圍會(huì)形成大量瘢痕組織甚至生物假膜,生物假膜切除應(yīng)盡量徹底;翻修時(shí)患者多有軟組織缺損,應(yīng)準(zhǔn)備肌瓣轉(zhuǎn)移術(shù)。

股骨腫瘤;關(guān)節(jié)成形術(shù),置換,髖;人工關(guān)節(jié);再手術(shù);骨腫瘤;髖關(guān)節(jié)

隨著骨腫瘤保肢手術(shù)的開展,腫瘤假體置換是保肢手術(shù)中重要的方法之一。然而在腫瘤假體置換的同時(shí),也會(huì)出現(xiàn)一系列的并發(fā)癥,如腫瘤假體的松動(dòng)[1]、感染及排異等[2-3]。置換后假體的 5 年使用率為 57%~93%[4]。因此,由于假體遠(yuǎn)期松動(dòng)所導(dǎo)致的翻修手術(shù)也日益增多。我院為股骨遠(yuǎn)端腫瘤假體置換后 25 年以上的 3 例,進(jìn)行了翻修手術(shù),現(xiàn)報(bào)告如下。

資料與方法

一、一般資料

本組 3 例中,女 2 例,男 1 例,平均年齡63 歲,左側(cè) 1 例,右側(cè) 2 例。3 例均因數(shù)年前患侵襲性股骨遠(yuǎn)端骨巨細(xì)胞瘤,在外院行股骨遠(yuǎn)端瘤段切除及全膝關(guān)節(jié)置換術(shù)[5-6],病理診斷均為骨巨細(xì)胞瘤。術(shù)后患者功能恢復(fù)尚可,沒有出現(xiàn)腫瘤局部復(fù)發(fā)、轉(zhuǎn)移等情況。但分別于數(shù)年后出現(xiàn)膝關(guān)節(jié)周圍疼痛,行走后加重或無法行走等癥狀。

二、翻修原因

在行股骨瘤段切除腫瘤假體置換術(shù)數(shù)年后,3 例均出現(xiàn)了不同程度的膝關(guān)節(jié)周圍疼痛,2 例行走后加重,1 例無法行走,3 例均有不同程度的假體松動(dòng)移位,1 例松動(dòng)移位穿破骨皮質(zhì)。

三、翻修時(shí)間

3 例從前次手術(shù)到此次翻修術(shù)時(shí)間間隔分別為30、29、26 年,平均 28.3 年( 表1 )。

四、手術(shù)方法

由于 3 例均未出現(xiàn)假體周圍感染,因此均一期行假體翻修。患者假體時(shí)間久遠(yuǎn),術(shù)前應(yīng)準(zhǔn)備全套翻修假體。

患者全麻后,取仰臥位,手術(shù)區(qū)域常規(guī)消毒,鋪巾并上消毒止血帶。在原手術(shù)入路進(jìn)入,逐層切開皮膚、皮下及筋膜。值得一提的是二次手術(shù)后膝關(guān)節(jié)周圍的組織通常較厚,因此切口應(yīng)比原來稍加延長,以便充分暴露。將膝關(guān)節(jié)脫位,由于 3 例假體均不同程度松動(dòng),因此可直接將松動(dòng)假體部件取出,但其中 1 例較為牢固,須用專用打拔器將其取出。如果假體部件牢固,上述方法難以取出時(shí),可先在骨干鉆孔、開槽,去除部分骨水泥后,再去除假體。待假體部件全部去除后,再用球形髓腔鉆磨去除大部分腔內(nèi)殘留的骨水泥,后改用薄鼓搗鑿除剩余少量骨水泥,注意不要造成骨折及皮質(zhì)穿透。相對(duì)于假體和骨水泥的去除,生物假膜的去除就困難很多,3 例術(shù)中均見不同程度的生物假膜及周圍組織瘢痕形成,可以用電刀、腦膜剪、咬骨鉗等去除生物假膜及瘢痕組織,徹底清創(chuàng),直至正常組織。最后安裝翻修假體。2 例可直接安放假體,1 例因殘端皮質(zhì)極薄,因此將殘端適當(dāng)截除,然后放置新的骨水泥假體。由于 1 例軟組織缺損較為嚴(yán)重,因此對(duì)其行腓腸肌內(nèi)側(cè)頭肌皮瓣轉(zhuǎn)移修復(fù)術(shù)[7]。確切止血,大量生理鹽水沖洗,C 型臂機(jī)下透視腫瘤假體在位,位置滿意,放置引流,逐層縫合切口。

五、術(shù)后處理及功能鍛煉

術(shù)后對(duì) 3 例行常規(guī)抗炎補(bǔ)液支持治療,患肢抬高,膝關(guān)節(jié)屈曲 30°,引流管放置 3~5 天( 當(dāng)引流量<50 ml 時(shí)拔出 )。術(shù)后患者疼痛緩解后( 一般在術(shù)后 2 天 )可行股四頭肌收縮鍛煉,在傷口良好情況下,5~7 天可用 CPM 機(jī)進(jìn)行屈曲鍛煉。術(shù)后 2 周患者可部分負(fù)重與關(guān)節(jié)活動(dòng)練習(xí),術(shù)后 3~4 周逐漸負(fù)重行走。

3 例腫瘤假體翻修均為骨水泥固定,術(shù)后隨訪時(shí)間 68~82 個(gè)月,均在 5 年以上。

結(jié) 果

二次翻修術(shù)后,3 例均無腫瘤復(fù)發(fā),亦未出現(xiàn)假體松動(dòng)、假體感染、假體移位、假體斷裂等并發(fā)癥?;颊咝g(shù)后功能恢復(fù)良好( 表2~4 )( 圖1 )。

表1 本組 3 例一般資料Tab.1 The general data of the 3 patients

表2 例 1 術(shù)前及術(shù)后 MSTS( 93 )評(píng)分( % )Tab.2 The preoperative and postoperative MSTS 93 scores of the 1st patient

表3 例 2 術(shù)前及術(shù)后 MSTS( 93 )評(píng)分( % )Tab.3 The preoperative and postoperative MSTS 93 scores of the 2nd patient

圖1 患者,女,54 歲。左膝關(guān)節(jié)腫瘤假體翻修術(shù)后 a:翻修前 X 線片,見假體松動(dòng)移位并穿破近端骨皮質(zhì);b:術(shù)中見大量生物假膜形成,將假體取出;c:取出的假體及盡可能清除掉的生物假膜;d:再次置入的腫瘤型膝關(guān)節(jié)假體;e:清楚假膜及瘢痕后缺損大,行腓腸肌瓣轉(zhuǎn)移;f:術(shù)后 X 線片,見翻修后假體位置可;g:患者超過 5 年的隨訪,膝關(guān)節(jié)伸直、屈曲等功能可Fig.1 Prosthetic revision was performed on a 54-year-old female patient with tumors in the left knee joint a: The preoperative X-ray showed prosthetic loosening and migration, and the prosthesis had broken through the proximal cortex; b: A lot of biological pseudomembranes were formed during the operation, and the prosthesis was pulled out; c: The removed prosthesis and the resected biological pseudomembranes; d: The tumor prosthesis of the knee joint was implanted again; e: Muscle fap transplantation was performed due to serious defects after the pseudomembranes and scars were removed; f: The postoperative X-ray showed the prosthetic position was good; g: The extension and fexion of the knee joint were satisfactory during the over-5-year follow up

表4 例 3 術(shù)前及術(shù)后 MSTS( 93 )評(píng)分( % )Tab.4 The preoperative and postoperative MSTS 93 scores of the 3rd patient

討 論

保肢治療是膝關(guān)節(jié)周圍惡性腫瘤手術(shù)的主要方式,保肢治療的方法有很多,如自體骨移植、滅活再植、異體骨移植、腫瘤型人工關(guān)節(jié)置換及復(fù)合重建等[8],其中人工關(guān)節(jié)假體置換應(yīng)用最為廣泛。即使人工關(guān)節(jié)置換有較好的早期效果,并可以長期使用,但卻存在諸多并發(fā)癥。其中股骨遠(yuǎn)端腫瘤假體翻修可能性 5 年為 17%,10 年為 33%,20 年為58%。同首次人工關(guān)節(jié)置換一樣,腫瘤假體翻修術(shù)后存在一系列并發(fā)癥[9],如神經(jīng)血管損傷、假體感染、機(jī)械性松動(dòng)、斷裂等,但是仍能保留患者的肢體并恢復(fù)其部分功能。由于大部分腫瘤假體翻修患者的骨皮質(zhì)較薄、骨缺損范圍的不確定性以及軟組織缺乏彈性并且缺損廣泛[10],因此術(shù)前應(yīng)有詳細(xì)的手術(shù)計(jì)劃,并告知患者有肢體不等長及關(guān)節(jié)功能受限的可能。同第一次的腫瘤假體置換相比,腫瘤假體翻修術(shù)有其獨(dú)特的特點(diǎn):( 1 )由于遠(yuǎn)期松動(dòng)所導(dǎo)致的假體翻修,假體的取出相對(duì)容易,有的部件可以直接取出,有的則需要先在骨干鉆孔、開槽,去除部分骨水泥再去除假體。( 2 )水泥型膝關(guān)節(jié)腫瘤假體置換的患者,股骨和脛骨的髓腔內(nèi)都有大量骨水泥填充,為了安裝新的腫瘤假體,必須將其盡可能地取出。一般骨水泥的取出也相對(duì)容易,可先用球形髓腔鉆磨去除大部分腔內(nèi)殘留的骨水泥,后改用薄鼓搗鑿除剩余少量骨水泥,此時(shí)要當(dāng)心不要造成骨折及皮質(zhì)穿透。( 3 )初次假體置換術(shù)后,假體周圍會(huì)形成大量瘢痕組織甚至生物假膜[11-12],為改善術(shù)后功能和控制術(shù)后感染,需要盡可能地清楚這些生物假膜及瘢痕組織。生物假膜的清除較假體和骨水泥的取出更為復(fù)雜和繁瑣,可以用電刀、腦膜剪、咬骨鉗等去除。由于翻修時(shí)患者解剖結(jié)構(gòu)不清楚,也很容易造成血管神經(jīng)的損傷,因此術(shù)中應(yīng)格外小心。( 4 )翻修手術(shù)難度較大,由于患者軟組織缺損較為嚴(yán)重,因此可以進(jìn)行腓腸肌內(nèi)側(cè)頭等肌皮瓣的轉(zhuǎn)移,以更好地覆蓋。另外,較首次假體置換,翻修術(shù)所用手術(shù)時(shí)間及術(shù)中出血量也較多。

同普通關(guān)節(jié)置換假體一樣,惡性腫瘤患者或部分侵襲性骨巨細(xì)胞瘤患者的腫瘤假體可以長期使用,甚至可達(dá)數(shù)十年。腫瘤假體遠(yuǎn)期松動(dòng)在行翻修術(shù)時(shí)應(yīng)注意:術(shù)前要有完善的計(jì)劃,且告知患者有肢體不等長及關(guān)節(jié)功能受限的可能。手術(shù)過程中取出松動(dòng)的假體以及骨水泥較容易;初次假體置換術(shù)后,假體周圍會(huì)形成大量瘢痕組織甚至生物假膜,生物假膜盡量切除徹底,以改善患者功能及減少術(shù)后感染可能,但相對(duì)較為繁瑣;翻修時(shí)患者多有軟組織缺損,應(yīng)準(zhǔn)備肌瓣轉(zhuǎn)移術(shù)。

[1] Unwin PS, Cannon SR, Grimer RJ, et al. Aseptic loosening in cemented custom-made prosthetic replacements for bone tumours of the lower limb. J Bone Joint Surg Br, 1996, 78(1): 5-13.

[2] Orlic D, Smerdelj M, Kolundzic R, et al. Lower limb salvage surgery: Modular endoprosthesis in bone tumour treatment. Int Orthop, 2006, 30(6):458-464.

[3] Morii T, Morioka H, Ueda T, et al. Deep infection in tumor endoprosthesis around the knee: a multi-institutional study by the Japanese musculoskeletal oncology group. BMC Musculoskelet Disord, 2013, 14:51.

[4] Biau D, Faure F, Katsahian S, et al. Survival of total knee replacement with a megaprosthesis after bone tumor resection. J Bone Joint Surg Am, 2006, 88(6):1285-1293.

[5] Karpik M, Resze? J, Skowroński J. Custom made tumorprosthesis as a primary treatment for giant cell tumor of femur--case report. Ortop Traumatol Rehabil, 2011, 13(1):73-81.

[6] Khan SA, Kumar A, Inna P, et al. Endoprosthetic replacement for giant cell tumour of the proximal femur. J Orthop Surg (Hong Kong), 2009, 17(3):280-283.

[7] Trieb K, G?ggel M, Dürr HR. et al. [Proximal tibial reconstruction with gastrocnemius flap]. Oper Orthop Traumatol, 2012, 24(3):263-269.

[9] Foo LS, Hardes J, Henrichs M, et al. Surgical difficulties encountered with use of modular endoprosthesis for limb preserving salvage of failedallograft reconstruction after malignant tumor resection. J Arthroplasty, 2011, 26(5):744-750.

[10] 湯小東, 郭衛(wèi), 楊榮利, 等. 膝關(guān)節(jié)定制型腫瘤假體的翻修. 中國修復(fù)重建外科雜志, 2010, 24(1):5-10.

[11] Mavrogenis AF, Papagelopoulos PJ, Coll-Mesa L, et al. Infected tumor prostheses. Orthopedics, 2011, 34(12):991-998.

[12] Dunne N, Hill J, McAfee P, et al. In vitro study of the effcacy of acrylic bone cement loaded with supplementary amounts of gentamicin: effect onmechanical properties, antibiotic release, and biofilm formation. Acta Orthop, 2007, 78(6): 774-785.

( 本文編輯:李貴存 )

Long-term revision after prosthetic replacement for the patients with tumors in the distal femur: three cases report


YAN Hong-liang, DONG Yang, ZHANG Zhi-chang, MA Huan-zhi, ZHANG Chun-lin, YANG Qing-cheng. Department of Orthopaedics, the sixth People’s Hospital Affliated to Shanghai Jiaotong University, 200233, PRC

ObjectiveTo report revision surgery in 3 patients with tumors in the distal femur who underwent prosthetic replacement 25 years ago and to summarize the experience of revision surgery because of long-time loosening of the tumor prosthesis in the distal femur.MethodsA total of 3 patients underwent prosthetic revision from January 2008 to December 2012, due to loosening in the distal femur after prosthetic replacement 25 years ago. Their clinical data were retrospectively analyzed, including the clinical symptoms( pain around the knee and walking difficulties ), imaging manifestations( prosthetic loosening and migration and prosthetic position after revision surgery based on the X-ray ), operation methods and techniques, postoperative functional recovery and so on. All the 3 patients were followed up for at least 5 years.ResultsThe clinical symptoms of the 3 patients were improved after revision surgery, with pain relief around the knee. The postoperative X-ray showed the joint position was good. No complications such as prosthetic loosening, migration or breakage were noticed during the follow-up. According to the Musculoskeletal Tumor Society( MSTS 1993 )staging system, their postoperative functional scores were 70%, 80% and 73.3%. The postoperative functional recovery of all the patients was satisfactory and no local tumor recurrence or metastasis was noticed.ConclusionsThe tumor prosthesis is durable. However, the complications such as loosening, infection or rejection may occur. It is relatively easy to pull out the prosthesis and the bone cement in revision surgery due to long-term loosening of the tumor prosthesis. After primary prosthetic replacement, a lot of scar tissues and even biological pseudomembranes will be formed around the prosthesis. Biological pseudomembranes should be resected as completely as possible. Muscle fap transplantation should be prepared for the patients with soft tissue defects during the revision.

Femoral neoplasms; Arthroplasty, replacement, hip; Joint prosthesis; Reoperation; Bone neoplasms; Hip joint

10.3969/j.issn.2095-252X.2014.05.016

R738.1, R687.3

200233 上海交通大學(xué)附屬第六人民醫(yī)院骨科

董揚(yáng),Email: dongyang6405@163.com

2013-10-13 )

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