大段异体骨移植后骨端不愈合的外科治疗

目的 探讨应用自体骨植骨再固定的方法治疗大段同种异体骨移植后骨端不愈合的手术方法和疗效.方法 1994年1月至2006年12月北京积水潭医院所行大段同种异体骨移植患者176例中41例不愈合,22例进行了骨接触端的重新植骨治疗,其中15例临床资料完整.再植骨治疗时年龄15～34岁,平均为24岁.初始疾病为:骨肉瘤5例、骨巨细胞瘤4例、皮质旁骨肉瘤2例、血管内皮瘤2例、骨原始神经外胚瘤(PNET)2例.发病部位:股骨下端7例、肱骨中段3例、股骨中段2例、胫骨上端2例、肱骨上端1例.15例患者中,8例单纯不愈合行植骨术,另7例不愈合并发原内固定断裂行植骨和再固定手术.结果 随访时间18～148个月,平均47个月.15例中13例骨愈合,占86.7%.愈合时间5～20个月,平均13个月.其中8例无原内固定失败者均重新愈合,愈合时间平均为14个月.另7例原内固定失败者5例重新愈合,愈合时间平均为12个月,与上述8例比较愈合时间相似.无感染等并发症发生.2例仍不愈合,最终行人工假体置换术.13例骨愈合的患者MSTS评分平均25.1分,8例无原内固定失败者25.4分,5例原内固定失败者24.6分,评分基本相同.结论 应用自体骨植骨再固定的方法治疗大段异体骨移植后骨端不愈合手术简单,并发症少,愈合率高,再手术后功能影响小,较人工假体置换相比有明显优势,对于大段异体骨移植后骨端不愈合患者,应为首选治疗方法.

Surgical treatmeat for bone nonunion after massive allograft transplantation

Objective To evaluate the surgical treatment and outcome of autogenous bone grafting and internal fixation in management of bone nonunion after massive allografi transplantation. Methods From January 1994 to December 2006, 41 of 176 patients underwent bone nonunion after massive allograft transplantation. Twenty-two of 41 patients received autogenous bone grafting. Complete clinical and follow-up data was available for 15 cases. The average age at secondary autogenous bone grafting was 24 years old (ranging from 15 to 34). The primary diseases included esteosarcoma (5 cases), giant cell tumor (4cases), parosteal osteosareoma (2 cases), hemangioendothelioma (2 cases) and primitive neuroectodermal tumor (2 cases). Tumor was located at distal femur in 7 patients, middle of humerus in 3, middle of femur in 2, proximal tibia in 2 and proximal humerus in 1. Eight of 15 patients with simple bone nonunion received autogenous bone grafting. Another 7 patients with bone nonunion and fracture of primary internal fixation underwent autogenous bone grafting and re-internal fixation. Resets At a mean follow-up of 46.8 months (ranging from 18 to 148 months) , bone union was observed in 13 of 15 patients (86.7% ) with the mean healing time 13.3 months ( ranging from 5 to 20). Bone union could be observed in all 8 patients with simple bone nonunion and 5 of 7 patients with bone nonunion and internal fixation fracture, similar healing time 14 and 12 months respectively. There was no infection or any other complications. Two patients underwent re-nonunion received prosthesis replacement at last. The mean MSTS score of 13 patients was 25.1, with 8 simple bone nonunion patients and 5 combined with internal fixation fracture patients 25.4 and 24. 6 respectively, also basically no difference. Conclusions Autogenous bone grafting and internal fixation in management of nonunion after massive allograft transplantation have the advantage of easy operation, less complications, high rate of bone healing and good function result with obvious superiority to prosthesis replacement. For management of nonunion after massive allograft transplantation, autogenous bone grafting and internal fixation is mostly recommended.