采用3D打印多孔结构金属支...胞瘤瘤性骨缺损的有限元分析_杜贵锋.pdf

骨科临床与研究杂志 2023 年 3 月第 8 卷第 2 期J Clin Orthop es，March 2023，Vol8，No2DOI:1019548/j2096-269x 202302006作者单位:610041 成都，四川大学华西医院骨科 骨科研究所通信作者:闵理，E-mail:jacky-min163 com骨肿瘤诊治采用 3D 打印多孔结构金属支撑假体治疗股骨远端骨巨细胞瘤瘤性骨缺损的有限元分析杜贵锋虎鑫文阳谭淋云卢敏勋张瑀琦周勇罗翼闵理屠重棋【摘要】目的探讨 3D 打印多孔结构金属支撑假体运用于重建股骨远端骨巨细胞瘤瘤性骨缺损的早期疗效。方法2019 年 8 月至 2020 年 12 月四川大学华西医院骨科接受病灶内刮除灭活联合关节面下自体骨植骨及 3D 打印多孔结构金属支撑假体重建术的股骨远端骨巨细胞瘤患者 6 例。男 4 例，女2 例;年龄 29 44(35 6 6 8)岁;5 例 Campanacci 级，1 例 Campanacci 级。软骨下骨受损范围比例为27 0%8 0%。术前影像学评估病变范围、软骨下骨受损范围比例。手术前后评估膝关节疼痛、下肢功能状况及膝关节活动度。术后评估假体 骨界面愈合情况、肿瘤学预后及并发症。同时建立 3 组三维有限元模型，分别为正常股骨、股骨远端瘤性骨缺损模型和 3D 打印多孔结构金属支撑假体联合关节面自体骨植骨重建瘤性骨缺损模型。采用髋关节 股骨肌肉多力负荷进行有限元分析各模型的力学差异。结果患者随访 12 27(25 6 1 2)个月，无失访。末次随访时，膝关节疼痛视觉模拟评分(VAS)低于术前(2 6 1 5)分比(5 1 1 7)分。国际骨肿瘤协会功能评分系统(MSTS)高于术前(28 1 1 7)分比(25 6 1 2)分。膝关节屈曲范围与较术前改善(142 3 6 4)比(130 8 4 9)。所有患者骨整合良好，无局部复发或远处转移。3D 打印多孔结构金属支撑假体重建瘤性骨缺损不但为关节面和软骨下骨提供有效的的保护，且在位移和应力分布方面表现同正常股骨相似。结论3D打印多孔结构金属支撑假体联合关节面下自体骨植骨是骨巨细胞瘤瘤性骨缺损的精准重建方式，能够提供良好的骨整合以及软骨下骨和关节面保护。【关键词】骨巨细胞瘤;股骨;假体安装;有限元分析基金项目:成都市科技局技术创新项目(2017-CY02-00032-GX);四川大学青岛研究院“8122 计划”(20GZ30301)Finite element analysis of three-dimensional printed strut-type prosthesis in the treatment of bone defectfor giant cell tumor of bone in distal femurDu Guifeng，Hu Xin，Wen Yang，Tan Linyun，Lu Minxun，Zhang Yuqi，Zhou Yong，Luo Yi，Min Li，Tu Chongqi Institute of Orthopaedic，Department of Orthopaedics，West China Hospital，Sichuan University，Chengdu 610041，ChinaCorresponding author:Min Li，E-mail:Jacky-min163 com【Abstract】ObjectiveTo investigate the design details and related surgical techniques of 3D printedporous metal strut-type prosthesis and the early curative effect of the prosthesis applied to the bone defect ofgiant cell tumor of the distal femur MethodsFrom August 2019 to December 2020，the data of 6 patientswith giant cell tumor of distal femur who underwent intrafocal curettage by subarticular autogenous bone graftwith 3D printing porous structure strut-type prosthesis were collected in Department of Orthopaedics，WestChina Hospital，Sichuan University There were 4 males and 2 females with an age of(35 6 6 8)years，including 5 cases of Campanacci grade and 1 case of Campanacci grade The proportion of subchondralbone damage was 27 0%8 0%The extent of lesion and the proportion of subchondral bone damage wereevaluated by preoperative imaging Knee pain，lower limb function and range of motion of knee joint were recor-ded before and after operation The healing of prosthesis-bone interface，oncology prognosis and complicationswere evaluated after operation At the same time，three groups of three-dimensional finite element models were99骨科临床与研究杂志 2023 年 3 月第 8 卷第 2 期J Clin Orthop es，March 2023，Vol 8，No2established(normal femur，tumor bone defect model of distal femur and 3D printed porous metal strut-typeprosthesis combined with autogenous bone graft on articular surface to reconstruct tumor bone defect model)The multi-force load of hip joint and femur muscle was used for finite element analysis The mechanical differ-ences of each model were analyzed esultsThe patients were followed up for 12-27(25 6 1 2)months Atthe last follow-up，the mean knee VAS score was lower than that before surgery (2 6 1 5)vs(5 1 1 7)The MSTS score after operation was higher than that before operation (28 1 1 7)vs(25 6 1 2)Kneeflexion range was improved compared with preoperative data (142 3 6 4)vs(130 8 4 9)All thepatients had good bone integration without local recurrence or distant metastasis The 3D printed porous metalstrut-type prosthesis not only provides effective protection for the articular surface and subchondral bone，butalso shows similar displacement and stress distribution to normal femur Conclusion3D printed porous metalstrut-type prosthesis combined with subarticular autogenous bone graft is an accurate way to reconstruct tumorbone defects of giant cell tumor of bone，providing good bone integration and protection of subchondral bone andarticular surface【Key words】Giant cell tumor of bone;Femur;Prosthesis fitting;Finite element analysisFund program:Innovation Projects of Chengdu Science Technology Bureau(2017-CY02-00032-GX);8122 Project，Qingdai esearch Institute of Sichuan University(20GZ30301)骨巨细胞瘤(giant cell tumor of bone，GCTB)是一种好发于膝关节周围长骨骨端的交界性原发性骨肿瘤;其中股骨远端约占全身 GCTB 发生部位的33%1-2。依据 X 线片肿瘤对骨破坏程度将骨巨细胞瘤分为 3 级3。针对股骨远端 Campanacci、级的 GCTB，扩大刮除病灶是行之有效的治疗手段2，4。GCTB 病灶刮除术后瘤性骨缺损的重建直接关系到患者的预后，是外科治疗的重点。骨水泥具有可塑形性强、机械强度高及聚合释放热量杀伤肿瘤细胞等优势。骨水泥填充逐渐成为目前 GCTB刮除后骨缺损重建的主流方式5-6。但仅使用骨水泥填充骨缺损，其硬化过程中释放的高热可造成膝关节的关节软骨及软骨下骨区医源性损伤，进而影响患者的长期预后，故目前外科医生使用骨水泥填充瘤腔的同时常联合关节面下自体骨移植来减少热损伤效应。此外，当肿瘤侵犯程度较大时，通常辅以接骨板螺钉内固定以降低术后病理性骨折的发生风险。然而，该方式仍然存在一定的弊端6。其主要缺陷包括骨水泥的骨诱导性和传导性较差，填充瘤腔后表面无法实现周围自体骨或宿主骨的骨长入，以至于重建界面无法达到理想的骨整合7。其次，尽管骨水泥可以任意塑形以填充瘤腔，但考虑到关节面软骨下植骨的要求，使用不规则的自体骨重建难以适应膝关节的弧面形态，无法达到适形匹配的需求。再有，联合使用接骨板螺钉内固定缺乏平面支撑、螺钉影响所穿透的植骨区以及增加周围软组织并发症等相关问题8-11。随着对 3D 打印(three-dimensional printing)技术的认识逐步加深及其在医疗领域的应用与发展，定制的钛合金多孔结构假体具有骨整合能力良好、形状契合瘤腔以及对骨移植量要求较低等优势，越来越受到骨科领域的重视。胫骨近端 GCTB 的患者使用 3D 打印多孔结构假体重建瘤性骨缺损，取得了满意的骨整合效果以及良好的预后12-13。为此，本研究设计 3D 打印多孔结构金属支撑假体，采用有限元分析(finite e