Artroplastia total de old la pacienii tineri cu afectare articular post-terapie imunosupresiv

Mr. Dr. Marius Stnescu*; Dr. Adrian-Bogdan Popescu*

(* Spitalul Universitar de Urgen Militar Central Carol Davila, Bucureti, Clinica de Ortopedie Traumatologie Gheorghe Niculescu)

Rezumat: n practica zilnic, ntre prezentrile pacienilor pentru acuze ortopedicotraumatologice, numrul pacienilor oncologici este n continu cretere. De remarcat este vrsta tot mai scazut a acestor pacieni, a cror boal non-osoas are ecouri sistemice printre care i osteoarticulare, fie ca o determinare secundar, fie ca efect secundar al terapiei imunosupresive. Tratamentul chirurgical, n mod expres cel artroplastic, este metoda larg controversat la momentul actual, dar tot mai des aplicat, innd cont de benificiile funcionale i integrarea social aproape garantate, deziderate de neconceput n eventualitatea tergiversrii ndrumrii pacienilor oncologici ctre tratamentele moderne chirurgicale, de endoprotezare. Metod: ntr-o perioad de 5 ani (2008 2012) printre cei 6747 pacieni personali, ce s-au prezentat n clinica de ortopedie, s-a marcat existena a 51 de pacieni oncologici cu implicare osteoarticular din care 24 au fost cazuri descoperite incidental ( primitive sau relevate de fracturi) iar restul de 27 au fost cazuri cu neoplazii complicate cu determinari secundare osoase. Pe lng aceti 51 de pacieni au mai fost remarcai trei pacieni cu afectiuni oncologice non scheletale, cu vrste pn n 20 de ani, dintre care - 2 paciente cu leucemie acut limfoblastic (LAL), una fiind cel mai tanar pacient cu endoproteza de resurfatare din Romania (14 ani si 6 luni) i un pacient cu neoplasm testicular. Ca urmare a tratamentelor medicamentoase antineoplazice ei au suferit afectarea articulaiei coxofemurale (unisau bilateral) dezvoltnd necroz aseptic de cap femural (NACF) post-medicamentoas imunosupresiv. Tratamentul chirurgical de care au beneficiat a fost de endoprotezare total de old necimentat de tip metal-metal (M-on-M), cu rezultate functionale excelente. Rezultate: Cazurile de NACF post-terapie imunosupresiv pentru afeciuni oncologice au fost rezolvate chirurgical prin implantarea de proteze totale necimentate de old de resurfaare tip BHR (2 cazuri) i cu stem femural scurt (un caz) toate avnd acelai cuplu metalmetal. Endoprotezele folosite sunt produse de aceeai firm,de top in domeniul implanturilor articulare, cu anvergur internaional iar raportrile din cadrul Registrelor Naionale de Endoprotezare releva fr echivoc cele mai bune si durabile rezultate la 10 ani. Concluzii: Adresabilitatea pacienilor oncologici tineri cu efecte secundare ale oncoterapiei implicnd sistemul osteoarticular este nc minimal din pricina ndrumrii reduse de ctre oncolog i medicul de familie a patologiei osteoarticulare postimunosupresive ctre chirurgul ortoped, din pricina complianei sczute a pacientului tnr (pn 25 i 30 de ani) la implantarea unei endoproteze ntr-o articulaie mare i important ca cea coxofemural i din perspectiva unei bariere economico-financiare, atta timp ct implantul este scump i de cele mai multe ori, costul este suportat de ctre pacieni. Cuvinte cheie: artroplastie, tineri, necroz aseptic de cap femural, postimunosupresie, endoproteza de sold, metal-metal.

Total hip replacement at young pacients with postimmunosuppressive therapy articular involvement
Maj. PhD. MD. Marius Stnescu*; MD. Adrian-Bogdan Popescu*
(* Carol Davila Central Universitary Emergency Military Hospital, Bucharest, Gheorghe Niculescu Orthopaedics and Traumatology Clinic)

Abstract: In daily practice, among pacients with ortopedics-traumatology cases, the number of oncologic patients is constantly growing. A very important aspect of this matter is their early age and the sistemic effects of their extra-bone disease, some of which are osteoarticular, are either a secundary determination, or a side effect of the immunosupressive therapy. Surgical treatment, particulary the artoplastic one, is the most controversed method at this moment, but it is also applied more frequently, considering the almost guaranted functional benefits and the social integration that are practically impossible in the case of the late guidens of the oncologic pacients towards modern surgical treatments such as endoprostetis. Methods: In a 5 year period (2008-1012) among the 6747 personal pacients that presented at the Orthopaedic Clinic there were noticed 51 oncologic pacients with osteoarticular involvement, out of which 24 were accidently discovered cases (primitive or shown by fracture), and the rest of 27 were cases of complicated neoplasia with secondary bone determination. Besides the 51 pacients, there were noticed other three cases of oncologic extrabone disease, at pacients in their 20s, among which 2 female pacients had limfoblastic acute leukemia (LAL), one of them being the youngest pacient with resurfacing endoprostetis in Romania and one had testiculary neoplasia. As a result of antineoplasia medical treatment their hip joint was affected (uni or bilateral) and they developed post immunosupressive medical treatment aseptic necrosis of the femural head (NACF). Their surgical treatment was uncemented total hip replacement metal-metal type (M-on-M), with excellent functional results. Results: The NACF post immuno supressive therapy cases for oncologic diseases were solved through surgery by using resurfacing uncemented total hip replacements BHR type (in 2 of the cases) and with short femoral stem (in one case), all of them having the same metal-onmetal type. The endoprostetis used are produced by the same company, top of the articular implant field, with international prestige and the records of the National Endoprostetis Register show with no doubt the best and long lasting results in 10 years. Conclusion: The presence of young oncologic patients with side effects of the oncotherapy that affects osteoarticular system is still minimal because of the reduced guidence of the oncotherapist and the general practitioner of the post immunosupressive osteoarticular pathology towards the orthopaedic surgeon, because of the poor compliance of the young patient (under 25 and 30 years old) on using an endoprostetis in a major joint such as the hip joint and also because of the economic-financial barrier, as long as the implant is expensive and, in most cases, the cost is supported by the patient. Key words: artroplastia, youngsters, aseptic necrosis of the femural head, post immuno supressive, hip endoprostetis, metal-on-metal.