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膝关节周围骨巨细胞瘤合并病理性骨折的外科治疗

Surgical treatment of giant cell tumors with pathological fracture around the knee

摘要:

目的 比较不同手术方式治疗膝关节周围骨巨细胞瘤合并病理性骨折在局部复发、重建持久性及功能评价等方面的差异.方法 回顾性分析2001年1月至2014年7月在北京积水潭医院骨肿瘤科接受手术治疗的50例膝关节周围骨巨细胞瘤合并病理性骨折的患者资料.男性30例,女性20例,平均年龄为33.7岁(范围:17~71岁).骨折部位为股骨远端45例,胫骨近端5例.按照AO骨折分型,A型3例,B型36例,C型11例.Campanacci影像学分级,Ⅱ级5例,Ⅲ级45例.20例接受扩大刮除术,30例采用整块切除术.重建方式包括骨水泥填充内固定16例,单髁异体骨移植内固定5例,骨端1/2异体骨大段移植1例,人工关节置换28例.对手术情况和治疗效果进行分析,纳入性别、年龄、骨折部位、骨折分型、外科治疗方式、外科边界、重建方法、术后并发症、术后肿瘤学评价、功能评分等临床资料,用x2检验或Fisher确切概率法比较两组复发率、并发症发生率、手术方式的差异,用独立样本t检验比较组间均数差异,无复发生存分析采用Kaplan-Meier曲线,多组间均数比较采用方差分析.结果 术后平均随访时间为66.9个月(范围:24~149个月),共4例局部复发(扩大刮除组3例,整块切除组1例),扩大刮除组和整块切除组的复发率比较差异无统计学意义(P=0,289),且扩大刮除组(3/20,15.0%)与我科骨巨细胞瘤大宗无病理性骨折病例刮除复发率(10/116,8.6%)比较无差异(P=0.407).不同骨折类型复发率的差异无统计学意义(P=0.160),不同骨折类型的手术方式选择有明显差异(P=0.006).并发症情况:扩大刮除组出现并发症2例(2/20,10.0%),均为关节退变;整块切除组出现并发症15例(15/30,50.0%),其中单髁异体骨移植组异体骨吸收1例,关节置换组感染2例,无菌性松动12例(含1例合并假体周围骨折、1例合并假体断裂).两组术后并发症发生率的差异有统计学意义(P=0.005).扩大刮除组和整块切除组术后MSTS功能评分分别为(93.5±6.5)%和(82.6±12.9)%,差异有统计学意义(F=4.838,P=0.033).结论 扩大刮除术不增加膝关节周围骨巨细胞瘤合并病理性骨折的复发风险.不同骨折类型对复发率无影响,但骨折类型影响手术方式的选择.整块切除术后并发症发生率高于扩大刮除组,扩大刮除组术后功能优于整块切除组.

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abstracts:

Objective To compare the local recurrent rate,the persistence of reconstruction and functional recovery of Giant Cell Tumor (GCT) after the treatments of extensive curettage or resection.Methods A retrospective review was conducted on the clinical data of 50 patients who had giant cell tumor with pathological tracture around the knee treated in our hospital from January 2001 to July 2014.There were 30 males and 20 females.The average age was 33.7 years respectively (range,17 to 71 years).The fracture localizations of 45 cases were distal femur and of 5 cases were proximal tibia.According to AO fracture classification,3 cases were in type A,36 cases in type B and 11 cases in type C.In Campanicci system for image grading study,5 cases were in grade Ⅱ and 45 cases in grade Ⅲ.Surgical treatment included 20 cases of extensive curettage and 30 cases of resection.The surgical reconstructive methods included 16 cases of cement reconstruction with internal fixation,5 cases of unicompartmental arthroplasty with allograft,1 case of segment osteoarticular allograft transplantation and 28 cases of prosthesis replacement.Final statistical analysis of surgery and therapeutic effect were carried out by SPSS,version 16.0 for Windows.Enrolling parameters collected gender,age,location,fracture type,surgical treatment,surgical margin,reconstruction,complications,local recurrence (LR) and functional evaluation.Categorical data were described by result frequencies.The comparison of the rate was performed by chi-square or Fisher's exact test.Between the two groups compared using independent t-test.The recurrence-free survival was estimated by the method of Kaplan-Meier.Results The mean postoperative follow-up time was 66.9 months (range,24-149 months).Four patients developed local recurrence (4/50,8.0%) including 3 cases of curettage group (3/20,15.0%)and 1 case of resection group (1/30,3.3%),there was no significant difference between curettage and resection group (P =0.289).The comparison of local recurrence between this curettage group (3/20,15.0%) and the GCT group without fracture published before (10/116,8.6%) in our institution also had no significant difference (P =0.407).There was no significant difference among the three types of fracture regarding the rate of local recurrence (P=0.160),but there was significant difference in the choice of surgical procedures for different fracture types (P =0.006).The complications:2 patients (2/20,10.0%)had joint degeneration in curettage group.15 cases (15/30,50.0%) had complications in resection group,1 case of unicompartmental arthroplasty allograft absorption,2 cases of infection and 12 cases of aseptic loosening after prosthesis replacement (including 1 case with periprosthetic fracture and 1 case with prosthesis fracture).The postoperative complications in curettage group had a significant reduction (P =0.005) when compared with the resection group.The mean score of functional evaluation with Musculoskeletal Tumor Society (MSTS) for curettage and resection group were (93.5±6.5)% and (82.6± 12.9)% (F=4.838,P=0.033).Conclusions (1) Extensive curettage did not increase the risk of local recurrence of giant cell tumor with pathological fracture around the knee.(2)The different fracture type had no effect on the local recurrence rate,but affect the decision of surgical procedures options.(3)The reconstructive complications in resection group was significant higher than curettage group,and the postoperative function of curettage group was better than resection group.

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作者: 刘巍峰 [1] 杨发军 [1] 李远 [1] 李斌 [1] 郝林 [1] 牛晓辉 [1]
第一作者: 刘巍峰
期刊: 《中华外科杂志》2018年56卷9期 677-686页 MEDLINEISTICPKUCSCD
栏目名称: 论著
DOI: 10.3760/cma.j.issn.0529-5815.2018.09.008
发布时间: 2018-09-25
基金项目:
国家自然科学基金资助项目(61372179)National Natural Science Foundation of China
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