前外侧和外侧联合入路的股骨颈肿瘤刮除植骨及内固定术

目的 探讨前外侧和外侧联合入路肿瘤刮除植骨重建治疗股骨颈骨肿瘤的疗效.方法 2005年7月至2009年8月采用前外侧和外侧联合入路手术治疗股骨颈肿瘤12例,男7例,女5例;年龄1768岁,平均34岁.软骨母细胞瘤4例,原发性骨巨细胞瘤2例,纤维结构不良3例,骨囊肿3例.7例有病理性骨折,5例骨皮质变薄.按国际保肢协会股骨颈肿瘤分区H1区1例、H2区4例、H1,2区7例.前外侧Smith-Peterson入路行肿瘤刮除植骨,外侧Watson-Jones入路行内固定.内固定采用解剖钢板10例,经皮空心螺钉2例.结果 全部患者随访12～68个月,平均35个月.患者疼痛均消失,随访期间无复发,无病理性骨折、股骨头坏死、关节退变.1例出现股骨外侧皮肤麻木,术后6个月自行缓解;1例出现外展无力.11例恢复正常活动范围,前屈120°～135°,后伸9°～15°,外展30°～45°.国际骨与软组织肿瘤协会功能评分27～30分,平均29.2分.结论 前外侧"SP"入路可以充分暴露肿瘤部位,手术视野清晰,刮除彻底,复发率低;外侧"WJ"入路易于植入内固定,防止术后病理性骨折的发生.股骨颈骨折采用前外侧"SP"与外侧"WJ"联合入路肿瘤刮除植骨重建的近期疗效较好.

Abstract：

Objective To explore surgical procedure of combined anterior-lateral and lateral approach for the treatment of bone tumors of femoral neck. Methods Forty patients with bone tumors of femoral neck treated in Tianjin Hospital were included from July 2005 to August 2009. Of the patients, 12 who were treated with curettage and bone graft through combined anterior-lateral and lateral incision were analyzed in this study. There were 7 males and 5 females with an average age of 34 years ranging from 17 to 68 years. 4 patients were diagnosed as chondroblastoma, 2 giant cell tumor, 3 fibrous dysplasia, and 3 single bone cysts. 7 patients suffered from pathologic fractures, and 5 had presented thin cortical bone because of tumor involvement. There were 1 tumor located in H1 zone, 4 in H2 zone and 7 in H1,2 zone according to ISOLS femoral neck classification. All patients were treated by curettage and bone graft via anterior-lateral approach, 10 cases underwent internal fixation with anatomical plate, and 2 cases with canulated screws with lateral approach. Results The follow-up time ranged from 10 to 68 months with an average of 35 months.Pain disappeared in all patients, and there were not recurrence of tumor, pathologic fractures and avascular necrosis. One case had complained of lateral femoral skin numbness which may be caused by injures of femoral lateral nerves. One case had difficulties in the valgus of hip joint. The mean MSTS score was 29.2 points ranging from 27 to 30 points. Conclusion Anterior approaches of "SP" incision is helpful to thorough curettage which decrease the risk of recurrence due to good visualization and intemal fixation is easy to perform via lateral approaches. The result suggested that combined anterior-lateral "SP" and lateral incision is liable option in treatment of bone tumors of femoral neck.     

可体内、外示踪的BMP2真核表达载体的构建和表达

目的 拟构建双顺反子增强型绿色荧光蛋白标记的人骨形态发生蛋白2(bone morphogenetic protein-2,BMP2)真核表达载体,为其在真核细胞体内外示踪定位打下基础.方法 以重组质粒pcDNA3.1/CT-hBMP2为模板,结合已设计好的特异性引物,采用PCR方法获得BMP2片段,将其分别与克隆载体pTA2-T-easy和真核表达载体pSELECT-GFPzeo-MCS连接,转化入感受态DH5α细胞中,通过筛选得到含有绿色荧光蛋白的重组表达载体pSELECT-GFPzeo-hBMP2,并进行测序鉴定.将质粒转染CHO细胞后Western Blot检测BMP2蛋白表达,用RT-PCR检测BMP2mRNA表达.结果 琼脂糖电泳显示PCR产物为一条长约1216 bp的带,重组表达载体pSELECT-GFP zeo-hBMP2经双酶切可得到约1216 bp的片段,测序证实与Genebank中hBMP2序列完全相符,重组表达载体脂质体法转染CHO细胞48～72 h后荧光显微镜下证实转染成功,经RT-PCR证实CHO细胞中存在BMP2基因表达,采用免疫荧光化学方法证实载体中CHO细胞表达BMP2蛋白.经Western Blotting鉴定重组蛋白为分泌蛋白,相对分子质量在17×103左右.结论 成功构建可体内外示踪增强含双顺反子绿色荧光蛋白人BMP2真核表达载体.     

胸腔镜辅助下侧前路减压融合术治疗腰椎间盘突出症伴椎体后缘骨软骨病

目的探讨胸腔镜辅助下侧前路减压融合术治疗胸腰段或高位腰椎间盘突出症(lumbar disc herniation,LDH)伴椎体后缘骨软骨病(vertebral osteochondrosis,VO)的可行性及其临床效果。方法回顾性分析2017年12月至2019年12月采用胸腔镜辅助下侧前路减压融合术治疗胸腰段或高位LDH伴VO 10例患者的病历资料,男6例,女4例;年龄37~65岁,平均49.2岁。手术节段均为单节段,累及T₁₂L₁节段5例、L_1,2节段2例、L_2,3节段3例。4例患者为单纯胸腰段或高位LDH伴VO;6例患者合并黄韧带增生、骨化致椎管狭窄或后凸畸形,联合后路减压内固定术或矫形手术。主要观察指标为疼痛视觉模拟评分(visual analogue scale,VAS)、Oswestry功能障碍指数(Oswestry disability index,ODI)及椎间隙前、后缘高度,根据改良MacNab标准评估临床疗效。结果10例患者均顺利完成手术,术中在胸腔镜辅助下能清晰显露并彻底去除突出的椎间盘和骨化物,脊髓、神经根和硬膜囊得到充分减压。手术时间(115.4±23.8)min(范围70~180 min);术中失血量(122.6±21.3)ml(范围40~310 ml)。术后随访时间为12~36个月,平均21.6个月。末次随访时10例患者VAS评分由术前(7.2±1.9)分降至(1.8±1.1)分,ODI由术前64.3%±13.9%降至16.3%±5.1%,椎间隙前缘高度由术前(7.8±1.5)mm改善至(11.9±2.3)mm,椎间隙后缘高度由术前(4.5±1.1)mm改善至(7.4±1.6)mm,差异均有统计学意义(P<0.05)。末次随访时改良MacNab疗效评定为优9例、良1例。结论胸腔镜辅助下侧前路减压融合术治疗胸腰段或高位LDH伴VO,可提供清晰的手术视野,能够充分显露、彻底去除突出的椎间盘及骨化物,术后近期疗效满意。     

继发于甲状旁腺功能亢进的骨病损的临床特点（附8例报告）

目的探讨继发于甲状旁腺功能亢进症（PHPT）的骨病损的临床特点。方法回顾总结8例PHPT患者的临床资料,男3例,女5例,平均年龄38岁（21-54岁）。所有患者均有骨痛和骨质疏松,病理性骨折6例（75％）,纤维囊性骨炎7例（87.5％）,大部分患者多骨受累。实验室检查显示高钙血症、高尿钙、低磷血症、甲状旁腺素增高,血碱性磷酸酶升高。骨关节X线主要表现为骨质稀疏、骨膜下骨质吸收、纤维囊样骨炎、颅盖骨磨砂玻璃样变等。1例患者接受左肱骨近端骨巨细胞瘤肿瘤切除＋人工肩关节置换之后接受甲状旁腺瘤切除术,其余患者均转入外科接受甲状旁腺腺瘤摘除术。结果术后1例患者死于呼吸衰竭,余患者骨痛症状完全缓解,术后血钙均恢复正常,8例患者病理回报均为甲状旁腺瘤。随访6-30个月,平均15.8个月,6例骨科病损大部分好转。结论PHPT早期诊断最有效的方法是血钙常规筛查,对于高血钙者进一步检测PTH并结合骨关节x线特征以明确诊断,早期手术治疗效果良好,能明显减轻患者症状,并发症较少。     

膝关节骨巨细胞瘤复发的危险因素分析

 目的 探讨膝关节骨巨细胞瘤术后复发的临床及影像学相关危险性因素。方法回顾性分析来自国内6 家骨肿瘤治疗单位的105例膝关节骨巨细胞瘤,包括36例术后局部复发病例和69例术后未复发病例的临床和影像学资料。通过单因素法分析临床因素（包括发病性别、年龄、部位、临床评分、分级、手术方式）和影像学因素与肿瘤术后复发的相关性,将有统计学意义的指标放入多因素Logistic回归方程中确定影响肿瘤复发的相关危险因素。结果105例患者中,男49例,女56例;随访时间为（45.6±32.1）个月。其中复发组36例,平均年龄（35.64±10.87）岁,复发时间为术后平均（18.9±6.5）个月;未复发组69例,平均年龄（36.32±13.82）岁。单因素χ²检验显示病灶边缘清晰或硬化、骨皮质中断、软组织肿块、Hu评分和手术方式与术后复发有关,其他临床因素（发病性别、年龄、部位、Campanacci影像学分级）以及部分影像学因素（膨胀性、多房性或骨性分隔、骨皮质破坏、病理性骨折、病灶是否达到关节面、骨髓水肿、病灶囊性变）与术后复发无关。多因素Logistic回归分析显示边缘清晰或硬化（P=0.048）、软组织肿块（P=0.041）、Hu评分（P=0.040）和手术方式（P=0.001）与肿瘤术后复发密切相关。结论膝关节骨巨细胞瘤术后复发受多种因素影响,其中病灶边缘模糊、软组织肿块两项影像学征象为独立危险因素,而术前Hu评分和手术方式是影响肿瘤术后复发的重要因素。     

髋臼周围肿瘤切除股骨头旷置术

目的 探讨股骨头旷置术治疗髋臼周围肿瘤的可行性.方法 1999年10月至2009年8月采用髋臼肿瘤切除股骨头旷置术治疗累及髋臼的Enneking Ⅱ区肿瘤患者18例,男16例,女2例;年龄18～72岁,平均54岁.软骨肉瘤4例,骨肉瘤2例,骨巨细胞瘤4例,滑膜肉瘤1例,恶性纤维组织细胞瘤1例,Ewing肉瘤1例,转移瘤5例.3例行术前选择性动脉栓塞,4例行麻醉后腹主动脉或髂总动脉球囊临时阻断.术后门诊随访观察关节功能及影像学变化.结果 全部病例随访3～118个月,平均55个月.手术时间120～350min,平均170min.出血量600～2200ml,平均1200ml.切口均愈合,无一例发生伤口感染.1例骨肉瘤、3例转移癌患者于术后6个月至2年死于多脏器转移,其余病例无肿瘤局部复发.肢体不等长2.0～7.5 cm,平均5.0 cm,所有患者均需足跟垫高2～3 cm的矫形鞋进行矫正.术后3个月Enneking评分20～27分,平均23分.影像学资料提示,至随访期末无股骨头坏死发生,8例假臼磨造较好,1例发生轻度腰椎侧凸.结论 对于累及髋臼的Enneking Ⅱ区肿瘤采用肿瘤切除股骨头矿置术术后并发症发生率低,近期功能良好,肿瘤复发率低.

Abstract：

Objective To study clinical application of femoral head exclusion after resection of pelvic tumors around acetabulum with less limb damage and complications.Methods From October 1999 to August 2009,18 patients with pelvic tumors around acetabalum (zone Ⅱ of Ennekingl were treated with tumor resection and femoral head exclusion,including 16 males and 2 females with an average age of 54 years(range,18-72).The diagnosis were chondrosarcoma(4 cases),osteosarcoma(2),giant cell tumor of bone(4),synoviosareoma(1),malignant fibrous histiocytoma(1),Ewing sarcoma(1),and metastatic carcinoma(5).Throe cases were treated by selective arterial embolization before operation and 4 cases by temporary block of lower abdominal aorta or common iliac arte.Regular follow-up in clinic was done to observe function of joint and radiographic imaging.Results All patients were followed up for 55 months(range,3-118).The mean surgical time was 170 min(range,120-350 min).The mean blood loss was 1200 ml(range,600-2200 ml).All wounds were healed without infection.One patient with osteosarcoma and 3 with metastatic carcinoma died of multiple organ metastases during 6 months to 2 years after operation.The others had no local relapse.The mean limb discrepancy was 5.0 cm (range,2.0-7.5 cm).The mean Enneking score was 23 (range,20-27).All patients needed custom-made shoes with heightened heel of 2-3 cm.Osteonecrosis of the femoral head was not found in radiographic images.Eight cases had formed artificial acetabulum.One case had gentle lumbar scoliosis.Conclusion The clinical application of femoral head exclusion after resection of pelvic tumors around acetabulum had low complications,less pain,low relapse,better function in the recent period.     

肩胛体爆裂骨折合并同侧髋臼高位横形骨折及股骨头后脱位一例报告

肩胛体爆裂骨折处"假性肩胛胸壁分离(false scapulothoracic dissociation)"合并同侧髋臼高位横形骨折及股骨头后脱位非常少见.检索近20年的国内外相关文献,这种同时发生在上下肢带两个解剖部位的"联合损伤"及"骨折脱位",目前尚未见报道.我院于2007年3月收治1例,术后取得满意疗效.     

胫骨骨内表皮样囊肿一例报告

女,18岁,因左膝隐痛间断发作3年、加重1个月入院.患者无明确外伤史.患者入院前3年无明确诱因出现左胫骨近端隐痛,间断发作,活动或受凉后均可加重,可自行缓解.入院前1个月,左膝疼痛次数及持续时问增加,左膝无法单独支撑全身重量,但活动自如.外院X线检查发现左胫骨近端有溶骨性、膨胀性骨破坏,边界清晰,骨皮质变薄但完整(图1).左膝关节及左胫骨近端CT(图2)示:左胫骨近端关节面下方囊状膨胀性溶骨破坏,边界清晰,骨皮质尚完整.考虑左胫骨近端良性骨肿瘤、骨巨细胞瘤、非骨性纤维瘤,不除外软骨母细胞瘤.     

无骨盆前环放射影像学异常的孤立性骶骨"U"型骨折合并马尾综合征一例报告

无骨盆前环放射影像学异常表现的孤立性骶骨"U"型骨折(isolated U-shaped sacral fractures without roentgenographic abnormalities),合并马尾综合征(cauda equina syndrome)十分罕见,目前尚未检索到国内外相关文献报道.我们于2007年9月收治1例,术后取得较满意的疗效.     

MRI在测量恶性骨肿瘤髓内浸润范围及确定合理截骨平面中的作用

目的研究MRI在测量恶性骨肿瘤髓内浸润范围及确定合理截骨平面方面的作用。方法选取各类恶性骨肿瘤患者共12例，术前对所有患者行MRI、X线检查。骨肉瘤患者于术前行规范新辅助化疗。术后将肿瘤标本沿纵轴剖开，肉眼观察并测量肿瘤的髓内范围。术中截断病变骨后分别于截骨端、截骨端近肿瘤处1cm、截骨端近正常组织处1cm、2cm共四点进行骨髓组织取材取材，与肿瘤标本一同送病理组织学检查，确定微观肿瘤范围以及各取材点有无肿瘤细胞浸润。术后对所有患者进行随访，按Enneking肌肉骨骼肿瘤术后上下肢功能评分标准对患者肢体功能进行评估。对所得数据进行统计学分析。结果按Enneking肌肉骨骼肿瘤术后上下肢功能评分标准。平均功能恢复率为75％。经统计学分析得出X线测量所得肿瘤范围均明显小于病理测量的肿瘤范围，与镜下结果有明显统计学差异；而MRI测量的恶性骨肿瘤髓内的浸润范围与病理测量的肿瘤范围无明显统计学差异。结论对于恶性骨肿瘤来说，MRI在测量恶性骨肿瘤髓内侵润范围方面精确性较高，并能有效指导保肢手术截骨平面的确定，减少术后复发，保留患肢功能。