How Much Clinical and Functional Impairment do Children Treated With Knee Rotationplasty Experience in Adulthood?
How Much Clinical and Functional Impairment do Children Treated With Knee Rotationplasty Experience in Adulthood?
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DOI：
10.1007/s11999-016-4691-9
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发表时间：
2016-04-01
影响因子：
4.2
通讯作者：
Manfrini, Marco
中科院分区：
文献类型：
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作者：
Benedetti, Maria Grazia;Okita, Yusuke;Manfrini, Marco
一些儿童股骨远端或胫骨近端骨肉瘤可能需要旋转成形术；在适当选择的患者中，它可能比经股截肢具有功能优势，并且比假体具有更持久的效果。该手术的临床和功能结果报道通常仅限于平均随访约8年的研究，包括肌肉骨骼肿瘤学会评分（MSTS）、体格检查和步态分析。然而，据我们所知，残腿长度对步态的影响还没有被研究过。我们的问题是：(1)相对于对侧大腿，手术治疗的残余股骨胫的长度是否会导致步态模式的改变？(2)行旋转成形术并存活至成年的患者的临床和功能损伤及影像学表现如何？(3)成人的步态分析结果是否与先前报道的儿童步态参数（如最大地面反作用力和膝关节矢状角）不同？从1986年1月到2009年12月，254名儿童（年龄范围3-14岁）因股骨远端高级别骨肉瘤在我院接受手术治疗。其中42例（16.5%）行旋转成形术。在此期间，三名年龄超过15岁的青少年因肿瘤体积大和室外受累性而接受旋转成形术治疗。总共有45名患者接受了旋转成形术。从1986年1月到2000年12月，旋转成形术通常是9岁以下高级别骨肉瘤患者的首选治疗方法，只要能保留坐骨神经，就需要在股骨远端进行关节内或关节外切除。从2001年1月起，这一程序就不再经常使用了。在45名接受旋转成形术的患者中，14名患者在平均37个月时死于疾病（31%）；31名患者（69%）在研究完成时是幸存者，其中29名患者持续无疾病（64%），2名患者在肺转移瘤切除术后无疾病证据（5%）。这31名患者被邀请参加研究，其中25人同意参加。男性15例，女性10例，平均年龄23.8岁（SD， 7.5岁），平均随访15年（SD， 5.8岁）。临床评估包括通过临床评估和患者访谈获得的MSTS评分（总分在0 - 30分之间，0分表示结果差，30分表示结果好）、对侧大腿和股骨残余长度的测量、手术治疗和对侧脚的长度以及旋转和对侧脚踝的活动ROM。在25例患者中，22例（88%）同意进行下肢x线片检查，16例（64%）同意进行步态分析。剩余股骨胫平均比对侧大腿长5.8%。相对于对侧大腿，残余股骨柄长度的差异导致步态模式的改变。残腿长度较长的患者在站立和摆动时假膝屈曲较大。剩余股骨-小腿长度较短的患者走路时的步态与对照组相似。MSTS平均评分为25分（SD, 2）。相对于对侧足，手术治疗后的足短10%，距骨长轴短11%，短7.6%，跟骨长轴短2.7%，短8.6%。放射性关节炎出现在大多数患者的胫距关节、距下关节和距舟关节。作为成年人，我们的患者与先前报道的儿童旋转成形术的结果相比，步态参数有所改善。站立时垂直地面反作用力降低6%，步态周期内膝关节ROM增加24.6A度。残腿骨长度影响步态表现，手术治疗与对侧差异较小的患者步行表现最佳。膝关节旋转成形术后平均15年的MSTS评分证实了短期内功能和疼痛的报告结果。手术治疗侧的脚比对侧的脚小，并且存在退行性改变，这可能导致功能受损。尽管在手术治疗的成年患者和对侧肢体之间仍然存在负荷差异，但在地面反作用力和膝关节ROM方面，我们的成年患者的步态表现有所改善。基于这些发现，外科医生应努力使对侧膝关节和假膝关节在骨骼成熟时具有旋转的中轴线。成年患者的残余股骨-小腿长度过大可能需要对侧延长以改善功能结果。四级，治疗性研究。
Rotationplasty may be indicated for some children with osteosarcoma in the distal femur or proximal tibia; in properly selected patients, it may offer functional advantages over transfemoral amputation and more durable results than a prosthesis. The clinical and functional outcomes reported for this procedure generally have been limited to studies with a mean followup of approximately 8 years in terms of Musculoskeletal Tumor Society Score (MSTS), physical examination, and gait analysis. However, the effects of residual thigh-shank length on gait have not been explored to our knowledge.We asked: (1) Do differences in the length of the surgically treated residual thigh-shank relative to the contralateral thigh result in altered gait patterns? (2) What were the clinical and functional impairments and radiographic findings of patients who underwent rotationplasty and who survived to adulthood? (3) Do gait analysis findings in adults differ from previously reported findings in children in terms of relevant gait parameters such as maximal ground reaction forces and sagittal knee angles?From January 1986 to December 2009, 254 children (age range, 3-14 years) affected by high-grade bone sarcomas located in the distal half of the femur were surgically treated at our institute. Forty-two of these patients (16.5%) underwent rotationplasty. During this period, three adolescents older than 15 years were treated by rotationplasty owing to the tumor volume and extracompartmental involvement. In total, 45 patients underwent rotationplasty. From January 1986 to December 2000, rotationplasty generally was the preferred treatment for patients younger than 9 years with a high-grade bone sarcoma calling for an intra- or extraarticular resection of the distal femur, as long as the sciatic nerve could be spared. From January 2001, the procedure was not used as often. Of the 45 patients who underwent a rotationplasty, 14 died of disease at a mean of 37 months (31%); 31 patients (69%) were survivors at the time the study was done, 29 of whom were continuously disease free (64%) and two had no evidence of disease after a pulmonary metastasectomy (5%). These 31 patients were invited to participate in the study, and 25 of the 31 agreed to participate. There were 15 males and 10 females with a mean age of 23.8 years (SD, 7.5 years) and mean followup of 15 years (SD, 5.8 years). Clinical assessment included the MSTS score (total score ranges between 0 and 30 with 0 indicating poor results and 30 indicating good results), obtained by clinical assessment and patient interview, measurements of the residual thigh-shank length and of the contralateral thigh, of the lengths of the surgically treated and contralateral feet, and of active ROM of the rotated and contralateral ankles. Of the 25 patients, 22 (88%) agreed to have lower limb radiographs and 16 (64%) agreed to perform gait analysis.The residual thigh-shank was, on average, 5.8% longer than the contralateral thigh. Differences in the length of the residual thigh-shank relative to the contralateral thigh resulted in altered gait patterns. Patients with longer residual thigh-shank length had greater pseudoknee flexion during stance and swing. Patients with shorter residual thigh-shank length walked with a gait similar to that of controls. The mean MSTS score was 25 (SD, 2). With respect to the contralateral foot, the surgically treated foot was 10% shorter, the talus 11% shorter in the long axis and 7.6% in the short axis and the calcaneus was 2.7% shorter in the long axis and 8.6% in the short axis. Radiologic arthritis was present in most patients at the tibiotalar, subtalar, and talonavicular joints. As adults, our patients showed improved gait parameters compared with previously reported findings for children undergoing rotationplasty. Vertical ground reaction force during midstance was reduced by 6% and knee ROM during the gait cycle was increased by 24.6A degrees.The residual thigh-shank length influences the gait performance, such that patients with smaller discrepancies between the surgically treated and contralateral sides had the best walking performance. The MSTS score at a mean of 15 years after knee rotationplasty confirmed the results reported in the shorter-term for function and pain. The foot on the surgically treated side was smaller than the contralateral foot, and degenerative changes were present, which could contribute to impaired function. Gait performance, in terms of ground reaction forces and knee ROM, was improved in our adult patients although a difference in loading was still present between the surgically treated and contralateral limbs. Based on these findings, surgeons should endeavor to have the center axis of rotation of the contralateral knee and pseudoknee at skeletal maturity. An excessive residual thigh-shank length in adult patients could require contralateral lengthening to improve functional results.Level IV, therapeutic study.