肢体大块骨缺损的大段同种异体骨关节移植

作者为３５例四肢恶性肿瘤切除后的骨缺损患者进行了大段同种异体骨移植重建，其中男性２３例，女性１２例。股骨下端和胫骨上端占６８．５％。骨肉瘤占４０％。所有病例均经术前、术后化疗。植骨材料来源于该院综合骨库。作者强调充分的术前准备，仔细选择匹配移植骨段，手术中注意设计骨膜袖套和软组织袖套以利于骨愈合。本组病例随访５个月～１０年，平均３年，其中无病存活者２５例，死亡６例，带病存活４例。部分患者于术后２年、４年进行移植骨段活检及９９ｍＴｅＳＰＥＣＴ骨扫描，显示骨段大部完成爬行替代。本组１０例出现１８个合并症，占２８．６％。骨接触端的紧密结合，坚强可靠的内固定或带锁髓内钉固定是有效减少骨不愈合的方法。作者认为，复合同种大段骨移植将成为今后发展的方向。     

骨肿瘤的保肢手术

2 0世纪 80年代由于肿瘤化疗的不断发展 ,特别是新辅助化疗的应用使保肢成为可能 ;先进的影像学诊断和外科技术的进步为保肢提供了客观条件 ;Ｅｎｎｅｋｉｎｇ外科分期在临床上的应用 ,为保肢选择手术方法提供了科学依据 ;国际恶性骨肿瘤保肢学会于 1981年成立并召开第一次会议 ,以后每两年一次的国际会议统一肿瘤的分期系统、手术方法和治疗结果的评定标准 ,大大推动了保肢技术在世界范围内的推广应用。在化疗、放疗和免疫治疗的基础上 ,根据患者的年龄、肿瘤性质、部位、外科分期、预后和要求手术达到的程度 ,选择既能彻底切除肿瘤、又…     

Limb salvage using distraction osteogenesis

Distraction osteogenesis is a novel technique for the biological restoration of segmental bone defects. Definitive treatment of musculoskeletal tumors often requires large bony resections that can leave patients with significant osseous defects. Limb salvage using distraction osteogenesis is an attractive reconstructive alternative that may, in fact, offer advantages over other conventional techniques. We present our initial experience with the use of distraction osteogenesis in limb salvage.     

肢体大块骨缺损的大段同种异种骨关节移植

作者为３５例四肢恶性肿瘤切除后的骨缺损患者进行了大段同种异体骨移植重建，其中男性２３例，女性１２例。股骨下端和胫骨上端占６８．５％。骨肉瘤占４０％。所有病例均经术前、术后化疗。植骨材料来源于该院综合骨库。作者强调充分的术前准备，仔细选择匹配移植骨段，手术中注意设计骨膜油套和软组织袖套以利于骨愈合。本组病例随访５个月￣１０年，平均３年，其中无病存活者２５例，死亡６例，带病存活４例。部分患者于术后２年     

Limb salvage in primary malignant bone tumors

Advances in adjuvant chemotherapy and improvements in techniques of oncologic reconstruction have stimulated renewed interest in limb saving operation for malignant bone tumors. Between 1970 and 1981, 160 patients underwent local resection for malignant osseous lesions at the Mayo Clinic. This included 102 patients with chondrosarcoma, 44 with osteosarcoma, and 14 with fibrosarcoma. Ninety-three of the lesions were stage I and 67 were stage II. The overall local recurrence rate was 11.8%. The reconstructive procedures were effective in providing adequate functional restoration. Limb sparing operation is a valid viable option in carefully selected patients with malignant bone tumors. A continued search for effective adjuvant treatment programs is necessary.     

肩胛部恶性肿瘤保肢治疗

目的探讨肩部骨肿瘤保肢治疗的手术方法。方法对2例肩部恶性肿瘤实施保肢术，肱骨近端成骨肉瘤1例，行肱骨瘤段切除，锁骨翻转重建骨缺损，肩胛骨恶性纤维组织细胞瘤1例，行肿瘤切除、肱骨肩峰悬吊术。结果术后短期随访，肩关节被动活动有一定的功能。结论肩部恶性肿瘤应根据肿瘤发生的不同部位，患者的经济实力，选择不同保肢手术，目的是使肩部保留一定的功能和外形，提高患者生活的质量。     

Limb salvage for bone sarcoma of the proximal tibia

Summary We have treated 12 cases of high grade malignant bone tumours of the proximal tibia by various methods of limb salvage. Nine osteosarcomata and 3 malignant fibrous histiocytomata were included. Muscle flaps were needed in all cases except in the one arthrodesis, and reconstruction of the extensor mechanism was carried out. In nine cases an endoprosthesis was inserted. There were poor results due to loss of movement or failure to regain extension power. A two-stage method of reconstruction of the knee joint is described.

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Résumé Nous avons traité 12 cas de tumeurs de l'extrémité supérieure du tibia, d'un haut degré de malignité, par des méthodes conservatrices. Cette série comprotait neuf ostéosarcomes et trois histiocytomes fibreux malins. Nous avons dû avoir recours à des lambeaux musculaires dans tous les cas, sauf dans celui qui a été arthrodésé, et nous avons cherché à reconstituer les moteurs de l'extension. Dans neuf cas une prothèse a été mise en place. Les résultats ont été médiocres, soit par perte de la mobilité, soit par défaut de force des extenseurs. Nous décrivons une méthode de reconstruction en deux temps de l'articulation du genou.

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Reprint requests to: Y. Ogihara     

Limb salvage surgery in bone tumour with modular endoprosthesis

 Thirty-three patients with bone tumours were treated by resection of the growth and reconstruction with a Kotz modular endoprosthesis. The average follow-up was for 50 months, ranging from 14 to 79 months. At the last review, 12 patients (36%) had died due to the tumour and 9 others (27%) had metastases. All 4 patients with proximal tibial reconstruction had poor functional results, due to an extension lag or to knee stiffness. Four of the six tumours of the proximal femur were complicated by local recurrence or dislocation of the hip, and had poor or fair functional results. Of the patients with distal femoral reconstruction, 17 out of 22 had excellent or good functional results. Reconstruction with a modular prosthesis after resection of a tumour gives excellent or good functional results in more than three-fourths of the cases of distal femur reconstruction, but it should be used with caution in the proximal tibia and proximal femur.

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Resumé  33 patients avec une tumeur(s) osseuse(s) ont ete traites par résection chirurgicale suivie d’une reconstruction avec endoprothese modulaire de Kotz. Les patients étaient suivis pour une periode allant de 14 a 79 mois (50 mois). Au dernier bilan 12 malades (36%) avaient une mort liee a la-tumeur. Le resultat fonctionnel a ete insatisfaisant chez tous les patients ayant subi une reconstruction tibiale proximale: soit un deficit de l’extension due genou ou la raideur. Dans les deux-tiers des cas (4 sur 6) avec reconstruction femorale proximale, des complications ont été observees: recidive locale, luxation de la tete femorale et mauvais voir mediocre resultat fonctionnel. Plus des trois quarts des patients avec reconstruction femorale distale (17/22) ont eu un bon voir excellent resultat fonctionnel. Le type de reconstruction avec prothèse modulaire apres résection tumorale parait bien indiquée chez des patients avec grosse tumeur osseuse et souhaitant preserver une mobilité adequate. Cette chirurgie peut donner un bon ou excellent resultat fonctionnel dans plus de 3/4 des cas de reconstruction distale du femur, mais elle doit être utilisée avec précaution dans la reconstruction tibiale et femorale proximales vu le risque de complications a type de luxation de la tête femorale et de déficit de l’extension.

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Accepted: 8 July 1998     

Limb salvage in poor-risk patients using transluminal angioplasty

We performed percutaneous transluminal angioplasty (PTA) in 97 limbs of 86 patients with end-stage occlusive disease in whom vascular reconstruction was not possible. Most patients required dilation of long-segment occlusions and/or multiple lesions. Angiographic appearance was improved in 87 limbs of 78 patients (90%). Ankle-brachial pressure index increased from 0.40 +/- 0.03 to 0.64 +/- 0.03, and increased more than 0.15 in 63% of the limbs. Major amputation was required in 19 of the 87 limbs (22%) following PTA. The incidence of restenosis was 19% at three months, 42% at six months, and 57% at one year. Repeated PTA successfully maintained vascular patency in ten limbs, and four patients have since had successful distal bypass. Two limbs that initially improved needed amputation four to 19 months after dilatation. Follow-up ranged from one to 45 months; overall limb salvage rate was 76%. Thus PTA can enhance limb salvage in poor-risk patients with end-stage disease.     

Limb salvage surgery

The threat of lower limb loss is seen commonly in severe crush injury, cancer ablation, diabetes, peripheral vascular disease and neuropathy. The primary goal of limb salvage is to restore and maintain stability and ambulation. Reconstructive strategies differ in each condition such as: Meticulous debridement and early coverage in trauma, replacing lost functional units in cancer ablation, improving vascularity in ischaemic leg and providing stable walking surface for trophic ulcer. The decision to salvage the critically injured limb is multifactorial and should be individualised along with laid down definitive indications. Early cover remains the standard of care, delayed wound coverage not necessarily affect the final outcome. Limb salvage is more cost-effective than amputations in a long run. Limb salvage is the choice of procedure over amputation in 95% of limb sarcoma without affecting the survival. Compound flaps with different tissue components, skeletal reconstruction; tendon transfer/reconstruction helps to restore function. Adjuvant radiation alters tissue characters and calls for modification in reconstructive plan. Neuropathic ulcers are wide and deep often complicated by osteomyelitis. Free flap reconstruction aids in faster healing and provides superior surface for offloading. Diabetic wounds are primarily due to neuropathy and leads to six-fold increase in ulcerations. Control of infections, aggressive debridement and vascular cover are the mainstay of management. Endovascular procedures are gaining importance and have reduced extent of surgery and increased amputation free survival period. Though the standard approach remains utilising best option in the reconstruction ladder, the recent trend shows running down the ladder of reconstruction with newer reliable local flaps and negative wound pressure therapy.KEY WORDS: Limb salvage, limb trauma, lower limb reconstruction, foot ulcers     

复合移植重建恶性骨肿瘤切除后骨缺损

目的将切除的肿瘤骨去除瘤组织、经灭活处理后植回原位．重建骨骼的缺损。方法1997年7月～2000年12月．对24例长骨恶性骨肿瘤患者施行了广泛切除加灭活骨移植物复合假体重建骨缺损的治疗．其中成骨肉瘤17例，骨转移癌7例。肿瘤广泛切除后．清除瘤骨上所有的肿瘤组织，开槽打通髓腔，再经200g／L高渗盐水浸泡30mm．体积分数95％的酒精浸泡20min．然后植回原位。13例采用灭活肿瘤骨结合人工关节复台重建骨缺损．11例采用灭活肿瘤骨结合交锁髓内钉重建骨干缺损。所有成骨肉瘤患者术前均行两个周期的规范化疗。结果所有患者均获随访，中位随访时问为2.5年。术后1例患者发生灭活骨与宿主骨接合处的连接失败。2例患者在术后6个月～2年内局部复发，1例接受了肿瘤再切除治疗、另1例接受了截肢手术。无一例发生灭活骨的疲劳性骨折。术后6个月时重建关节的功能评分均在25分以上。结论应用自体灭活骨代替同种异体移植物进行复合移植重建骨缺损的优点包括：(1)相对于同种异体骨，降低了骨连接部的不愈台率；(2)降低了局部感染率；（3)造价低；(4)经过平均2．5年的随访，来发现灭活骨有异体骨移植常见的骨吸收现象。体外实验证实200g/G高渗盐水对骨的渗透力较强．具有良好的灭活效果。与酒精联合应用进一步降低了局部复发率。全部病例中只有2例局部复发．占9％．达到国际上对保肢术规定的局部复发率的要求。     

膝关节周围恶性骨肿瘤的保肢治疗

目的 探讨对膝关节周同恶性骨肿瘤切除后，采用不同方法行保肢治疗的效果，比较其优缺点：方法 自1995年1月至2004年10月收治了膝关节周围恶性骨肿瘤39例。39例39肢均行肿瘤节段截除、肢体重建手术：其中人工假体置换16例、复合骨移植16例、旋转成形7例。肿瘤按照Enneking分期：IB期13例，ⅡA期3例，ⅡB期23例。比较三种保肢手术后局部复发率、并发症和膝关节功能MSTS评分：结果 局部复发率：人工假体置换12．5％，复合骨移植12．5％，旋转成形无局部复发；术后平均膝关节功能MSTS评分：人工假体置换88％，复合骨移植88．7％，旋转成形68％，差异有统计学意义：结论 人工假体置换术和复合骨移植术应用于相对局限、无转移的膝周围恶性肿瘤术后重建，具有并发症少、恢复快、功能好等优点，但仍有一定的转移率和局部复发率。旋转成形术局部复发率低，但功能较差.     

保留骨骺的保肢手术临床研究

目的 介绍儿童及青少年保留骨骺的保肢手术方法，并讨论肿瘤复发率、转移情况及术后并发症与关节功能。方法1995年12月至2003年1月，对33例儿童及青少年肢体原发性恶性或侵袭性骨肿瘤进行保留骨骺的保肢手术，年龄8-16岁，平均12．2岁。股骨下端24例，胫骨上端9例；骨肉瘤23例，尤文肉瘤6例，软骨肉瘤2例，侵袭性骨母细胞瘤2例。Enneking外科分期：ⅠA期2例，ⅠB期2例，ⅡA期17例，ⅡB期12例。恶性肿瘤患者接受术前2-4个周期、术后6个周期的化疗。采用大段同种异体骨移植重建骨缺损，并用松质骨拉力螺钉将其与骨骺进行固定。结果29例患者随访资料完整。随访时间12～72个月，平均37．6个月。3例复发，分别于术后1年在骨骺处复发、术后15个月和30个月在原肿瘤位置的股动、静脉周围复发，复发率为10．3％。对复发病例行截肢术。共9例死亡，5年生存率为57．9％。4例患者发生5例并发症，发生率为17．2％。依据Enneking术后功能评价标准，优11例，良13例，可3例，差2例，总优良率为82．8％。结论四肢恶性骨肿瘤保留骨骺的保肢手术可以使患者获得较好的肢体功能，在严格掌握手术适应证和有效化疗的前提下，实施该手术是安全的。     

肢体恶性骨肿瘤及骨转移癌保肢治疗

目的:探讨肢体恶性骨肿瘤及转移癌行瘤段切除假体重建的方法及意义。方法:本组共62例,男38例,女24例;年龄10~72岁,平均28.4岁。原发肢体恶性骨肿瘤41例,其中骨肉瘤19例,骨巨细胞瘤9例,恶性纤维组织细胞瘤8例,浆细胞瘤3例,尤文氏瘤1例,骨血管内皮瘤1例。骨转移癌21例,原发病灶分别为:肺癌9例,胃癌3例,肾癌2例,乳腺癌2例,甲状腺癌1例,颌下腺癌1例,原发灶不明者3例。对62例肢体恶性骨肿瘤及转移癌应用肿瘤段切除并修复重建治疗。方法有:①瘤段切除人工假体置换术;②瘤段切除自体腓骨移植术;③瘤段切除髓内针骨水泥重建术。结果:术后随访5~42个月,平均14.2个月,41例恶性骨肿瘤中,术后无瘤生存21例,死亡4例,7例发生肺转移,3例发生其他部位转移,6例局部复发后截肢。37例生存患者患肢功能按Enneking骨肿瘤外科治疗后功能评定标准,优良率81.1%。21例骨转移瘤患者中,术后存活3个月以上者19例(占90.4%);术后疼痛消失15例(占71.4%),其余均有疼痛减轻;日常生活工作恢复者11例(占52.3%)。结论:对可施行广泛切除的肢体恶性骨肿瘤患者采用不同方法修复重建,行保肢治疗,可在治疗肿瘤的前提下尽量保留肢体功能,对肢体骨转移癌行合适的保肢手术对提高骨转移癌患者的生存质量有积极意义。     

肢体恶性骨肿瘤及骨转移癌保肢治疗

目的:探讨肢体恶性骨肿瘤及转移癌行瘤段切除假体重建的方法及意义。方法:本组共62例,男38例,女24例;年龄10⁷2岁,平均28.4岁。原发肢体恶性骨肿瘤41例,其中骨肉瘤19例,骨巨细胞瘤9例,恶性纤维组织细胞瘤8例,浆细胞瘤3例,尤文氏瘤1例,骨血管内皮瘤1例。骨转移癌21例,原发病灶分别为:肺癌9例,胃癌3例,肾癌2例,乳腺癌2例,甲状腺癌1例,颌下腺癌1例,原发灶不明者3例。对62例肢体恶性骨肿瘤及转移癌应用肿瘤段切除并修复重建治疗。方法有:①瘤段切除人工假体置换术;②瘤段切除自体腓骨移植术;③瘤段切除髓内针骨水泥重建术。结果:术后随访5⁴2个月,平均14.2个月,41例恶性骨肿瘤中,术后无瘤生存21例,死亡4例,7例发生肺转移,3例发生其他部位转移,6例局部复发后截肢。37例生存患者患肢功能按Enneking骨肿瘤外科治疗后功能评定标准,优良率81.1%。21例骨转移瘤患者中,术后存活3个月以上者19例（占90.4%）;术后疼痛消失15例（占71.4%）,其余均有疼痛减轻;日常生活工作恢复者11例（占52.3%）。结论:对可施行广泛切除的肢体恶性骨肿瘤患者采用不同方法修复重建,行保肢治疗,可在治疗肿瘤的前提下尽量保留肢体功能,对肢体骨转移癌行合适的保肢手术对提高骨转移癌患者的生存质量有积极意义。     

Limb salvage using advanced technologies: a case report

Patients with severe acute and chronic lower extremity wounds often present a significant challenge in terms of limb salvage. In addition to control of infection, assuring adequate perfusion and providing standard wound care, advanced modalities are often required to facilitate final wound closure. We herein present a case study on a diabetic patient with gangrene and necrotising soft‐tissue infection who underwent a forefoot pedal amputation to control the sepsis. Despite his non invasive vascular studies demonstrating poor healing potential at this level, he was not deemed suitable for revascularisation by our vascular surgeons and ankle‐level amputation was recommended. Nonetheless, over a 5‐month period using multiple advanced wound care therapies, wound closure was ultimately achieved.     

Limb salvage for proximal tibial tumours using a modular prosthesis

We report early results after the resection of proximal tibial tumours followed by reconstruction using a modular prosthesis. The indication for wide resection was a malignant tumour in 13 patients, and a neglected giant cell tumour in 2. There were no mechanical failures during an average follow-up of 3.5 years. However, there were 5 peroneal nerve palsies, 1 complete sciatic nerve palsy, 1 vascular injury leading to an above knee amputation, and 2 deep prosthetic infections. There were 2 superficial skin necroses and 1 fracture proximal to the femoral prosthetic component. The mean post-operative Musculo-Skeletal Tumour Society (MSTS) score in 12 patients who still had their prosthesis in situ was 18.3 out of a possible total of 30 (range: 10–28). Limb salvage surgery in the proximal tibia has a high early complication rate even with the use of modern implants and improved techniques.

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Résumé  Nous rapportons les résultats préliminaires de la résection de tumeurs tibiales proximales suivies d’une reconstruction avec une prothèse modulaire. 13 patients étaient porteurs de tumeurs malignes et 2 de tumeur a cellules géantes. Nous n’avons observé aucune complication mécanique au cours d’une période de suivie de 3.5 années. Les complications suivantes ont été rencontrées: paralysie du nerf pèronéal (5); paralysie complète du nerf sciatique (1); accident vasculaire exigeant une amputation au dessus du genou (1); infections prothétiques profondes (2); nécroses cutanées superficielles (2); enfin, fracture au dessus de la prothèse fémorale (1). Le score moyen post-opératoire de la Musculo-Skeletal Tumor Society chez 12 patients avec prothèse in situ était de 18.3 (écart de 10–28). La chirurgie du tibia proximal s’accompagne d’un taux de complications précoces élevées, même en présence d’implants modernes et d’améliorations techniques.

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Accepted: 13 April 2000     

肩胛带S2区恶性肿瘤保肢术的疗效评价

目的 评估肩胛带S2区恶性肿瘤保肢术后的疗效.方法 2005年1月至2009年1月,17例肩胛带S2区恶性骨肿瘤患者行保肢术,男13例,女4例;年龄14～55岁,平均32.6岁;软骨肉瘤6例,骨肉瘤4例,纤维肉瘤、骨髓瘤、Ewing肉瘤、横纹肌肉瘤、非霍奇金淋巴瘤、恶性骨巨细胞瘤、复发的软骨肉瘤各1例.Enneking分期:Ⅰ B期4例,ⅡB期13例.按国际骨与软组织肿瘤协会(MSTS)肩胛带分区标准,11例累及S2区和外1/3 S1区,6例累及S2区和S1区.肩袖均不同程度受累,肩关节囊受累8例.14例行新辅助化疗.8例瘤体范围较广或肩关节囊受累者行人工全肩胛骨置换术,9例瘤体范围较小或肩关节囊可保留者行肩胛骨次全切除、异体肩胛骨重建、肩关节囊及肩袖修复术.结果 随访16～62个月,平均35.1个月.9例患者出现并发症,其中发生异体骨排斥反应和异体骨吸收1例,异体骨排斥反应1例,假体肩峰外露3例,异体骨吸收4例.局部复发1例,死亡3例,死亡原因均为术后肿瘤广泛转移.MSTS功能评分53.3%～93.3%,平均74.1%.结论 在肩胛带S2区保肢手术中,将肿瘤完整切除与功能重建行个体化平衡,可获得较满意的肿瘤学疗效及稳定、美观、功能良好的肩关节.

Abstract：

Objective To investigate and discuss the limb salvage strategies of malignant bone tumors in region S2 of shoulder girdle.Methods The data of 17 patients(13 males and 4 females)were retrospectivelv analyzed.All of them had malignant scapular tumor at least in region S2,and underwent limb salvage between January 2005 and January 2009.They aged from 14 to 55 years old(mean,32.6 years).The histologic types of them were chondrosarcoma in 6 patients,osteosarcoma in 4,fibrosareoma in 1,myeloma in 1,Ewing's sarcoma in 1,rhabdomyosarcoma in 1,non-Hodgkin lymphoma in 1,malignant giant cell tumor of bone in 1 and recurrent chondrosarcoma in 1.The tumors were staged according to Enneking surgical staging system:IB in 4 and IIB in 13.According to the MSTS classification system,the region S2 and lateral 1/3 of region S1 were effected in 11 cases,the region S2 and large part of region S1 were effected in 6 cases.The rotator cuff was involved to some extent in all patients,and the articular capsule were involved in 8 cases.Neo-adjuvant chemotherapy was given to 14 patients.The surgical strategies were depended on the range of tumor and preservation of articular capsule.The scapular prosthetic replacement was done in 8 cases with a relatively large range of tumor or resection of articular capsule,otherwise the scapular allograft replacement was done.Among the 11 cases with region S2 and lateral 1/3 of region S1 effected,the scapular allograft replacement was done in 9 cases with articular capsule preserved and the prosthetic replacement was done in 2 cases with articular capsule resected.And the prosthetic replacement was done in the other 6 cases.The articular capsule and partial rotator cuff were preserved and reconstructed preferentially.Results All patients were followed up 16-62 months (mean,35.1 months).Postoperative complications were noted in 9 patients, including mild allograft rejection and mild allograft resorption in 1 patient,allograft rejection in 1,prosthetic acromion exposure in 3,allograft resorption in 4.Local recurrence were noted in 1 patients.Three patients were dead because of extensive metastasis.The average function scores were 74.1%(range,53.3%-93.3%).Conclusion During the limb salvage surgery.it's very important to guarantee the en bloc resection of the tumor.In the meanwhile,the en bloc resection and functional reconstruction should be well balanced.