背景:在过去的几十年里,植入物的许多结构变化,医疗,并且已经为膝盖周围的恶性骨肿瘤(MBT)制定了外科手术技术。然而,整体护理改善仍不清楚.该方法在分析涉及肿瘤的调查结果时至关重要,对死亡率进行全面评估是强制性的,因为死亡是竞争事件。这项研究的目的是1)对修订进行全面和纵向的评估,并进行广泛的随访和适当的方法2)全面的死亡率审查以考虑竞争风险。
目的:假设是一些假体的结构改进,而手术费用增加,死亡率也有望提高。
方法:对248例MBT患者进行了分析(平均随访8.7年,1972年至2017年之间的手术)。随着时间的推移,相继使用了三种假体模型:120Guepar(较旧的模型),42Tornier,和86Stanmore(较新的模型)。主要结果是根据Henderson分类的修订评估:1型软组织失败或不稳定,2型无菌性松动,3型结构故障,4型假体周围感染,5型肿瘤进展。死亡和截肢被认为是相互竞争的事件。通过将数据集与法国死亡登记册(INSEE)合并,对死亡率进行了广泛的评估。计算2年、5年、10年和15年的累积概率,并与Gray检验进行比较。
结果:5年总生存率为,Guepar的80%(95%CI:73-87),托尔尼尔为69%(95%CI:56-84),斯坦莫尔为71%(95%CI:62-82)(p=0.4)。1型的5年累积风险为5%(95%CI:1-9),9%(95%CI:0-18),Guepar为17%(95%CI:9-25),Tornier,还有Stanmore,分别(p=0.01)。2型的15年累积风险为22%(95%CI:15-39),Guepar的8%(95%CI:0-17)和8%(95%CI:2-14),Tornier,还有Stanmore,分别(p=0.10)。十个病人植入失败,九个Guepar,还有一个Tornier.类型4的5年累积风险为7%(95%CI:2-12),19%(95%CI:7-31),Guepar为12%(95%CI:5-18),Tornier,还有Stanmore,分别(p=0.08)。有29例肿瘤进展;15年风险为16%(95%CI:2-22),2%(95%CI:0-7%),Guepar为12%(95%CI:4-19%),Tornier,还有Stanmore,分别(p=0.08)。胫骨近端和股骨远端之间没有任何差异。
结论:假体设计(锻钢代替铸钢)有一些改进,可能在骨水泥柄固定方面也有一些改进,但在人工关节感染和局部复发超过四十年。在过去40年中,受益于铰链重建假体的特定患者队列中,总死亡率没有显着变化。
方法:III;具有敏感性分析的比较病例系列。
Over the past decades, numerous structural changes in implants, medical treatments, and surgical techniques have been made for Malignant Bone Tumors (MBT) around the knee. However, the overall care improvement is still unclear. The method is crucial when analyzing outcomes in surveys involving tumors, and a thorough assessment of the mortality is mandatory because death acts as competing event. The aims of this study were: 1) a comprehensive and longitudinal assessment of the revisions with an extensive follow-up and adequate methods; 2) a complete mortality review to consider competing risks.
The hypothesis was that some prosthesis\'s structural improvements were made while the surgical toll increased as well as an improvement of mortality was also expected.
Analyses were performed on 248 patients with MBT (mean follow-up was 8.7 years, surgeries between 1972 and 2017). Three prosthesis models were successively used over time: 120 Guepar (older model), 42 Tornier, and 86 Stanmore (more recent model). The primary outcome was the assessment of revisions sorted out according to Henderson: type-1 soft-tissue failures or instability, type-2 aseptic loosening, type-3 structural failures, type-4 periprosthetic infections, type-5 tumoral progression. Death and amputations were considered as competing events. An extensive assessment of mortality was performed by merging the dataset with the French register of Deaths (INSEE). Cumulative probabilities were computed at 2, 5, 10, and 15 years and compared with Gray\'s tests.
The overall 5-year survival was, 80% (95% CI: 73-87) for Guepar, 69% (95% CI: 56-84) for Tornier, and 71% (95% CI: 62-82) for Stanmore (p=0.4). The 5-year cumulative risks for type-1 were 5% (95% CI: 1-9), 9% (95% CI: 0-18), and 17% (95% CI: 9-25) for Guepar, Tornier, and Stanmore, respectively (p=0.01). The 15-year cumulative risks for type-2 were 22% (95% CI: 15-39), 8% (95% CI: 0-17) and 8% (95% CI: 2-14) for Guepar, Tornier, and Stanmore, respectively (p=0.10). Ten patients had an implant failure, nine Guepar, and one Tornier. The 5-year cumulative risks for type-4 were 7% (95% CI: 2-12), 19% (95% CI: 7-31), and 12% (95% CI: 5-18) for Guepar, Tornier, and Stanmore, respectively (p=0.08). There were 29 tumoral progressions; the 15-year risks were 16% (95% CI: 2-22), 2% (95% CI: 0-7%), and 12% (95% CI: 4-19%) for Guepar, Tornier, and Stanmore, respectively (p=0.08). No difference whatsoever was found between the proximal tibial and distal femur.
There were some improvements in prosthesis design (forged steel instead of cast steel) and probably also in cemented stem fixation, but not in prosthetic joint infection and local recurrence over forty years. The overall mortality did not change significantly over the last 40 years amongst this specific cohort of patients who benefited from a hinge reconstruction prosthesis.
III; comparative case series with sensibility analysis.