LUMiC(®) Endoprosthetic Reconstruction After Periacetabular Tumor Resection: Short-term Results.
LUMiC(®) Endoprosthetic Reconstruction After Periacetabular Tumor Resection: Short-term Results.
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DOI：
10.1007/s11999-016-4805-4
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发表时间：
2017-03
影响因子：
4.2
通讯作者：
Dijkstra PD
中科院分区：
文献类型：
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作者：
Bus MP;Szafranski A;Sellevold S;Goryn T;Jutte PC;Bramer JA;Fiocco M;Streitbürger A;Kotrych D;van de Sande MA;Dijkstra PD
骨盆肿瘤切除后髋臼周围缺损的重建是骨科肿瘤学中最具挑战性的手术之一，而重建技术通常与令人不满意的机械和非机械并发症发生率有关。为了减少脱位、无菌性松动和感染的风险，我们于2008年推出了Lumic®假体(Implantcast，Buxtehude，德国)。Lumic®假体是一种模块化装置，由单独的假体(羟基磷灰石涂层的未粘结或粘结)和髋臼假体组成。阀杆和杯体有不同的尺寸(后者还提供银涂层以防止感染)，并在连接处配备锯齿，以便在阀杆植入后旋转调整杯体位置。这种植入物在短期内是否确实耐用还没有得到评估。(1)骨盆肿瘤切除后使用Lumic®进行髋臼周围重建的患者中有多大比例出现机械性并发症，相关危险因素是什么？(2)骨盆肿瘤切除后发生非机械性并发症的患者比例是多少，使用Lumic®进行髋臼周围重建的相关危险因素是什么？(3)2年和5年内植体失败的累积发生率是多少，重建失败的机制是什么？(4)根据肌肉骨骼肿瘤学会(MSTS)的评分，最终随访时的功能结果如何？我们对2008年7月至2014年6月在8个骨科肿瘤学中心使用Lumic®假体重建骨盆肿瘤内侧半盆切除术后髋臼周围缺陷的患者进行了回顾性图表回顾，随访时间至少为24个月。纳入47名患者(26名男性，占55%)，平均年龄50岁(范围12-78岁)。在回顾时，32名患者(68%)还活着。采用反向Kaplan-Meier法计算中位随访期为3.9年(95%可信区间为3.4~4.3)。在研究期间，我们使用该植入物的一般适应症是骨盆肿瘤切除后重建髋臼周围缺陷，其中保留了毗邻骶髂关节的内侧髂骨；替代治疗包括髋关节转位和鞍部或在一些促成中心的定制假体；这些通常在肿瘤过程中涉及内侧髂骨或当时特定国家尚未推出Lumic®的情况下使用。主要诊断为传统软骨肉瘤(n=22[47%])；5例(11%)有远处癌的骨转移，3例(6%)有多发性骨髓瘤。非骨水泥型固定43例(91%)。在我们研究的早期阶段，双活动杯(n=24[51%])主要用于假想脱位风险较高的情况；后来，双活动杯成为大多数重建的标准。在29例髋臼重建中使用镀银髋臼杯，占62%；因为只有最大尺寸的镀银髋臼杯可用，所以它的使用取决于所选择的杯的大小。我们使用竞争风险模型来估计种植失败的累积发生率。6名患者(13%)仅有一次脱位；4名患者(9%)有反复脱位。使用双活动杯重建的脱位风险(1/24[4%])低于未使用双活动杯组(9/23[39%])(危险比，0.11；95%可信区间，0.01-0.89；p=0.038)。3名患者(6%；1名曾接受同种异体骨结构重建，1名因术中骨折初次固定不良，1名假体骨柄粘连)松动并进行翻修。13例(28%)发生感染。中位手术时间：感染组6.5h(4.0~13.6h)，非感染组5.3h(2.8~9.9h)(P=0.060)；出血量2.3 L(0.8~8.2h L)，非感染组1.5 L(0.4~3.8 L)(p=0.039)。2年和5年种植失败的累积发生率，机械原因分别为2.1%(95%CI，0~6.3)和17.3%(95%CI，0.7~33.9)，感染分别为6.4%(95%CI，0~13.4)和9.2%(95%CI，0.5~17.9)。重建失败的原因有：不稳定1例(2%)，松动3例(6%)，感染4例(9%)。随访时平均MSTS功能结果评分为70%(范围为33%-93%)。在短期的随访中，Lumic®假体在用于大型骨盆肿瘤切除患者的髋臼重建时，机械并发症和失败的发生率很低，我们相信这是一种有用的重建方法，用于髋臼周围肿瘤切除或先前重建失败。尽管如此，在这些复杂的重建后，感染和脱位相对常见。在我们的经验中，双活动关节与较低的脱位风险相关。未来，更大规模的研究将需要对双活动关节和镀银等因素进行进一步控制。我们将继续对我们的患者进行长期跟踪，以确定这种植入物在这种情况下的作用。第四级，治疗性研究。
Reconstruction of periacetabular defects after pelvic tumor resection ranks among the most challenging procedures in orthopaedic oncology, and reconstructive techniques are generally associated with dissatisfying mechanical and nonmechanical complication rates. In an attempt to reduce the risk of dislocation, aseptic loosening, and infection, we introduced the LUMiC® prosthesis (implantcast, Buxtehude, Germany) in 2008. The LUMiC® prosthesis is a modular device, built of a separate stem (hydroxyapatite-coated uncemented or cemented) and acetabular cup. The stem and cup are available in different sizes (the latter of which is also available with silver coating for infection prevention) and are equipped with sawteeth at the junction to allow for rotational adjustment of cup position after implantation of the stem. Whether this implant indeed is durable at short-term followup has not been evaluated. (1) What proportion of patients experience mechanical complications and what are the associated risk factors of periacetabular reconstruction with the LUMiC® after pelvic tumor resection? (2) What proportion of patients experience nonmechanical complications and what are the associated risk factors of periacetabular reconstruction with the LUMiC® after pelvic tumor resection? (3) What is the cumulative incidence of implant failure at 2 and 5 years and what are the mechanisms of reconstruction failure? (4) What is the functional outcome as assessed by Musculoskeletal Tumor Society (MSTS) score at final followup? We performed a retrospective chart review of every patient in whom a LUMiC® prosthesis was used to reconstruct a periacetabular defect after internal hemipelvectomy for a pelvic tumor from July 2008 to June 2014 in eight centers of orthopaedic oncology with a minimum followup of 24 months. Forty-seven patients (26 men [55%]) with a mean age of 50 years (range, 12–78 years) were included. At review, 32 patients (68%) were alive. The reverse Kaplan-Meier method was used to calculate median followup, which was equal to 3.9 years (95% confidence interval [CI], 3.4–4.3). During the period under study, our general indications for using this implant were reconstruction of periacetabular defects after pelvic tumor resections in which the medial ilium adjacent to the sacroiliac joint was preserved; alternative treatments included hip transposition and saddle or custom-made prostheses in some of the contributing centers; these were generally used when the medial ilium was involved in the tumorous process or if the LUMiC® was not yet available in the specific country at that time. Conventional chondrosarcoma was the predominant diagnosis (n = 22 [47%]); five patients (11%) had osseous metastases of a distant carcinoma and three (6%) had multiple myeloma. Uncemented fixation (n = 43 [91%]) was preferred. Dual-mobility cups (n = 24 [51%]) were mainly used in case of a higher presumed risk of dislocation in the early period of our study; later, dual-mobility cups became the standard for the majority of the reconstructions. Silver-coated acetabular cups were used in 29 reconstructions (62%); because only the largest cup size was available with silver coating, its use depended on the cup size that was chosen. We used a competing risk model to estimate the cumulative incidence of implant failure. Six patients (13%) had a single dislocation; four (9%) had recurrent dislocations. The risk of dislocation was lower in reconstructions with a dual-mobility cup (one of 24 [4%]) than in those without (nine of 23 [39%]) (hazard ratio, 0.11; 95% CI, 0.01–0.89; p = 0.038). Three patients (6%; one with a preceding structural allograft reconstruction, one with poor initial fixation as a result of an intraoperative fracture, and one with a cemented stem) had loosening and underwent revision. Infections occurred in 13 reconstructions (28%). Median duration of surgery was 6.5 hours (range, 4.0–13.6 hours) for patients with an infection and 5.3 hours (range, 2.8–9.9 hours) for those without (p = 0.060); blood loss was 2.3 L (range, 0.8–8.2 L) for patients with an infection and 1.5 L (range, 0.4–3.8 L) for those without (p = 0.039). The cumulative incidences of implant failure at 2 and 5 years were 2.1% (95% CI, 0–6.3) and 17.3% (95% CI, 0.7–33.9) for mechanical reasons and 6.4% (95% CI, 0–13.4) and 9.2% (95% CI, 0.5–17.9) for infection, respectively. Reasons for reconstruction failure were instability (n = 1 [2%]), loosening (n = 3 [6%]), and infection (n = 4 [9%]). Mean MSTS functional outcome score at followup was 70% (range, 33%–93%). At short-term followup, the LUMiC® prosthesis demonstrated a low frequency of mechanical complications and failure when used to reconstruct the acetabulum in patients who underwent major pelvic tumor resections, and we believe this is a useful reconstruction for periacetabular resections for tumor or failed prior reconstructions. Still, infection and dislocation are relatively common after these complex reconstructions. Dual-mobility articulation in our experience is associated with a lower risk of dislocation. Future, larger studies will need to further control for factors such as dual-mobility articulation and silver coating. We will continue to follow our patients over the longer term to ascertain the role of this implant in this setting. Level IV, therapeutic study.