Survival of Modern Knee Tumor Megaprostheses: Failures, Functional Results, and a Comparative Statistical Analysis
Survival of Modern Knee Tumor Megaprostheses: Failures, Functional Results, and a Comparative Statistical Analysis
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DOI：
10.1007/s11999-014-3699-2
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发表时间：
2015-03-01
影响因子：
4.2
通讯作者：
Ruggieri, Pietro
中科院分区：
文献类型：
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作者：
Pala, Elisa;Trovarelli, Giulia;Ruggieri, Pietro
模块化巨型假体现在是下肢长骨节段切除后最常见的重建方法。先前的研究报告了膝关节巨型假体重建后的不同结果和失败率。本研究的目的是分析膝关节周围骨肿瘤切除后模块化肿瘤假体在以下方面的结果：（1）生存率； (2)故障率； (3) 不同重建部位以及初次和翻修种植体的比较存活率； (4)肌肉骨骼肿瘤协会(MSTS)评分系统的功能结果。2003年至2010年，我院恶性和侵袭性良性肿瘤研究所植入了247个旋转铰链全球模块化重建系统(GMRS)膝关节假体。在此期间，该组占原发性或转移性骨肿瘤切除后进行膝关节肿瘤巨型假体重建的患者的 23%（1086 名患者中的 247 名）。在另外 77% 的病例中，我们使用其他类型的肿瘤假体。 2003 年之前，我们使用较旧的 Howmedica 模块化切除系统和 Kotz 模块化股骨/胫骨置换系统，从 2003 年开始，我们主要使用 GMRS，但在某些情况下，例如预后不良的患者、老年患者或转移患者，我们继续使用 HMRS。部位包括 187 个股骨远端和 60 个胫骨近端。根据 Henderson 等人对巨型假体失败的原因进行了分类。分为五种类型：1 型（软组织衰竭）、2 型（无菌性松动）、3 型（结构性衰竭）、4 型（感染）和 5 型（肿瘤进展）。随访时间至少为 2 年（平均 4 年；范围 2-8 年）。绘制了种植体存活率至重大故障的 Kaplan-Meier 精算曲线。根据MSTS II系统分析功能结果； 247 例患者中，有 223 例可进行功能评分（81%）。 截至最新随访，在 175 例接受初次重建治疗的患者中，117 例持续无病，26 例治疗后复发后无疾病证据，8 例带病存活，24 例因病死亡。我们系列中巨型假肢的总体失败率为 29.1%（247 个中的 72 个）。 1 型故障发生率为 8.5%（247 例中的 21 例），2 型故障发生率为 5.6%（247 例中的 14 例），3 型故障发生率为 0%，4 型故障发生率为 9.3%（247 例中的 23 例），5 型故障发生率为 5.6%（247 例中的 14 例）。 Kaplan-Meier 曲线显示，所有类型失败的种植体总体存活率在 4 年时为 70%，在 8 年时为 58%。 5 年修复修复体存活率为 80%，5 年初次重建修复体存活率为 60% (p = 0.013)。翻修患者的 5 年感染存活率为 95%，原发患者的 5 年感染存活率为 84% (p = 0.475)。平均 MSTS 评分为 84 分（25.2；范围为 8-30），定位部位之间没有差异（胫骨近端重建为 24.7，股骨远端重建为 25.4；p = 0.306）。使用这种模块化假体至少 2 年的结果在生存率（肿瘤学和重建性）以及失败原因和失败率方面令人满意。尽管这些结果看起来与其他类似植入物相当，但我们将继续跟踪这一队列，并且我们认为需要对可用的巨型假体设计进行比较试验。IV 级治疗研究。有关证据级别的完整描述，请参阅作者指南。
Modular megaprostheses are now the most common method of reconstruction after segmental resection of the long bones in the lower extremities. Previous studies reported variable outcome and failure rates after knee megaprosthetic reconstructions.The objectives of this study were to analyze the results of a modular tumor prosthesis after resection of bone tumor around the knee with respect to (1) survivorship; (2) failure rate; (3) comparative survivorship against different sites of reconstructions and of primary and revision implants; and (4) functional results on the Musculoskeletal Tumor Society (MSTS) scoring system.Between 2003 and 2010, 247 rotating-hinge Global Modular Reconstruction System (GMRS) knee prostheses were implanted in our institute for malignant and aggressive benign tumors. During this time, that group represented 23% of the patients who had oncologic megaprosthesis reconstruction about the knee after resection of primary or metastatic bone tumors (247 of 1086 patients). In the other 77% of cases we used other types of oncologic prostheses. Before 2003 we used the older Howmedica Modular Resection System and Kotz Modular Femur/Tibia Replacement from 2003 we used mostly the GMRS but we continued to use the HMRS in some cases such as patients with poor prognoses, elderly patients, or metastatic patients. Sites included 187 distal femurs and 60 proximal tibias. Causes of megaprosthesis failure were classified according to Henderson et al. in five types: Type 1 (soft tissue failure), Type 2 (aseptic loosening), Type 3 (structural failure), Type 4 (infection), and Type 5 (tumor progression). Followup was at a minimum oncologic followup of 2 years (mean, 4 years; range, 2-8 years). Kaplan-Meier actuarial curves of implant survival to major failures were done. Functional results were analyzed according to the MSTS II system; 223 of the 247 were available for functional scoring (81%).At latest followup, among 175 treated patients for primary reconstruction, 117 are continuously disease-free, 26 have no evidence of disease after treatment of relapse, eight are alive with disease, and 24 died from disease. The overall failure rate of the megaprostheses in our series was 29.1% (72 of 247). Type 1 failure occurred in 8.5% (21 of 247) cases, Type 2 in 5.6% (14 of 247), Type 3 in 0%, Type 4 in 9.3% (23 of 247), and Type 5 in 5.6% (14 of 247). Kaplan-Meier curve showed an overall implant survival rate for all types of failures of 70% at 4 years and 58% at 8 years. Prosthetic survivorship for revisions was 80% at 5 years and for primary reconstructions was 60% at 5 years (p = 0.013). Survivorship to infection was 95% at 5 years for revision patients and 84% at 5 years for primary patients (p = 0.475). The mean MSTS score was 84 (25.2; range, 8-30) with no difference between sites of localization (24.7 in proximal tibia versus 25.4 in distal femur reconstruction; p = 0.306).Results at a minimum of 2 years with this modular prosthesis are satisfactory in terms of survivorship (both oncologic and reconstructive) and causes and rates of failure. Although these results seem comparable with other like implants, we will continue to follow this cohort, and we believe that comparative trials among the available megaprosthesis designs are called for.Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.