肱骨近端恶性肿瘤的保肢治疗

目的 探讨肱骨近端恶性肿瘤切除术后的重建方法。方法 36例肱骨近端恶性肿瘤,其中骨肉瘤 11例、软骨肉瘤 6例、皮质旁骨肉瘤及纤维肉瘤各 3例、原始神经外胚层瘤及恶性纤维组织细胞瘤各 2例、转移性骨肿瘤 5例、恶性骨巨细胞瘤 4例。骨肉瘤、原始神经外胚层瘤与恶性纤维组织细胞瘤患者均接受了新辅助化疗。肿瘤关节内切除 33例,关节外切除 3例。 21例采用异体半关节移植, 4例采用人工假体置换, 6例行游离锁骨移植, 5例行带骨膜血管蒂锁骨移植。结果 随访 6～ 118个月,平均 62.7个月。死亡 11例,局部复发 3例。按 Enneking功能评价标准, 21例采用异体半关节移植的患者,平均得分 24分; 4例人工假体置换的患者,平均得分 26分; 11例采用同侧锁骨重建肱骨近端的患者,平均得分 23分。结论 肱骨近端恶性肿瘤保肢手术的重建以人工假体置换和异体半关节移植为首选,儿童的保肢可选用同侧锁骨移植。保肢术后的功能与肩袖和肩外展肌的修复密切相关。     

Clavicula pro humero--a new surgical method for malignant tumors of the proximal humerus]

In the majority of cases with malignant tumors in the proximal part of the humerus a limb saving tumor resection is possible. Reconstruction of the defect is necessary to maintain the length of the arm and to create a fulcrum for elbow flexion and extension. Several methods of reconstruction have been described in the literature including the fixation of distal humerus to the second rib or to the clavicle by means of Küntscher-nails, the implantation of a proximal humerus prosthesis without or with accompanying bone transplantation, a bridging of the defect using an allograft or an arthrodesis of the shoulder joint using free or vascularized bone transplants. The following paper describes a new surgical procedure whereby the vascularization of the clavicle is preserved and the clavicle used to bridge the defect. Although the follow-up period of the patients operated on so far in this way is relatively short, the functional advantages of this operation over the other forms of reconstruction can already be observed.     

复合骨移植修复骨肿瘤切除后大段骨关节缺损

目的 报道复合骨移植修复骨肿瘤切除后大段骨关节缺损的临床疗效。方法 2001年1月-2002年12月应用带监测皮岛的自体腓骨与大段同种异体深低温冷冻骨关节复合移植修复骨肿瘤切除后大段骨关节缺损10例。结果 10例均得到随访，随访时间5～24个月。移植的自体腓骨长度最长28cm，最短15cm。8例在术后3个月即有影像学骨性愈合，10例均于术后半年完全负重和邻近关节自由活动，术后超过1年的5例均已拆除内固定，术后1年均完全愈合。结论 带监测皮岛的自体腓骨与大段同种异体深低温冷冻骨关节复合移植是修复骨肿瘤切除后大段骨关节缺损的有效且可靠的方法，可用于骨肿瘤保肢术中。     

Treatment of malignant tumors of the proximal humerus with allograft-prosthesis composite reconstruction

Malignant tumors of the proximal humerus are challenging to treat. Reconstruction with a metallic implant or allograft is the most common method, but each has known risks and frequent complications. Allograft-prosthesis composite reconstruction has not been widely used and may avoid problems posed by metal prostheses or allografts used alone. Six patients with malignant tumors of the proximal humerus were treated with allograft-prosthesis composite reconstruction after excision of the intra-articular tumor. Outcomes were assessed by use of the Disabilities of the Arm, Shoulder and Hand questionnaire; the Short Form 36 (SF-36) Health Survey; and the American Shoulder and Elbow Surgeons Shoulder Assessment Form. Preoperative and postoperative scores at a mean of 55 months were compared. Disability increased after surgery based on the Disabilities of the Arm, Shoulder and Hand questionnaire and SF-36, although disability appeared to decrease with time. The mean mental component score on the SF-36 showed continued improvement with time after surgery. One asymptomatic nonunion was repaired, and painful loosening developed in one patient, requiring revision at 45 months. Allograft-prosthesis composite reconstruction is a safe method for treating some malignant tumors of the proximal humerus, providing stable reconstruction and preserving function of the shoulder joint.     

肩胛带骨肿瘤的外科治疗结果及评价

目的 探讨肩胛带骨肿瘤的手术切除方式、重建方法,观察术后功能恢复情况及临床结果.方法 回顾性分析1998年7月至2006年7月收治的71例肩胛骨周围骨肿瘤患者的病例资料,其中恶性肿瘤61例,骨巨细胞瘤10例.15例恶性肿瘤起源于肩胛骨,56例起源于肱骨近端.男42例,女29例;年龄11～62岁,平均36.5岁.手术方法:肩胛带离断术10例,单纯肩胛骨切除3例,肩胛骨切除、人工肩胛骨置换3例,部分肩胛骨及肱骨近端切除、假体置换8例,肱骨近端切除、假体置换47例.结果 10例骨巨细胞瘤患者肩周肌肉保留较好,术后MSTS功能评分平均28分.起源于肱骨近端的原发恶性骨肿瘤患者三角肌止点处均予以切除,术后肩外展30°～60°,MSTS功能评分平均23分.37例肱骨骨肉瘤患者中4例(10.8%)局部复发,2例骨转移,5例肺转移.7例转移患者均死亡.1例恶性骨巨细胞瘤患者出现肺转移死亡.3例尤文肉瘤患者出现肺转移死亡.5例肱骨及5例肩胛骨软骨肉瘤患者术后未见局部复发及转移.结论 肩胛带骨肿瘤切除、人工肱骨近端假体重建能保留完整肘部及手部功能、并发症少,是肩部恶性肿瘤的首选术式;肱骨近端骨肉瘤和下肢骨肉瘤比较预后较好;肱骨近端恶性肿瘤行关节内肿瘤切除和关节外肿瘤切除肿瘤的局部复发率接近,提示对多数肱骨近端恶性肿瘤可以采用关节内切除.     

Alumina ceramic prostheses for bone tumor surgery

Summary Between 1979 and 1990 reconstruction using a ceramic prosthesis with a polycrystal alumina segment and a monocrystal alumina stem was carried out in 65 patients after the resection of malignant or benign aggressive bone tumors. Resection of 18 osteosarcomas, 5 chondrosarcomas, 9 other sarcomas, 10 giant cell tumors, 20 metastatic bone tumors, and 3 other bone tumors was followed by replacement of 17 proximal femurs, 12 distal femurs, 12 proximal tibia, 11 proximal humeri, 3 distal radii, 5 midshafts of the long bone, 2 pelvises, and 3 other parts. Results were rated excellent in 4 cases, good in 43, fair in 13, and poor in 4. In the cases with benignly aggressive or low-grade malignant tumors and those with tumors of the proximal femur, proximal tibia, or midshaft, satisfactory results can be obtained. Four skin ulcers, three dislocations, three loosenings, two infections, and two breaks were noted. Close interfacing between the ceramic prosthesis and the bone was observed radiologically in all cases with cementless fixation except in cases with high-grade malignancies in the knee joint. These results demonstrate that the ceramic prosthesis can be beneficial for the management of patients with benignly aggressive or low-grade malignant bone tumors who have retained adequate muscle strength around the joint even after tumor resection.     

Resection followed by vascularized bone autograft in patients with possible recurrence of malignant bone tumors after conservative treatment

In conservative treatment of malignant bone tumors, assessment of the local condition is difficult. The radiological changes seen in the irradiated tumor and the frequent occurrence of pathological fractures at this site may give rise to the fear that the tumor has relapsed. Resection of the whole of the involved bone is the best way to assure adequate local control but the extent of the bone defect and the bad local conditions secondary to irradiation make reconstruction hazardous. In two patients (one with Ewing's sarcoma of the femur and one with osteogenic sarcoma of the humerus) the authors used a free, vascularized fibular graft for the reconstruction having obtained consolidation of the limb after resection of the irradiated tumor, with preservation of its function. The encouraging results obtained have suggested a conservative attitude as primary treatment of specific malignant bone tumors.     

Implant cement spacer-a cost-effective solution for reconstruction of proximal humerus defects after tumor resection

The proximal humerus is a common location for both primary benign and malignant bone tumors and may require sacrificing deltoid muscles, axillary nerve and/or rotator cuff along with proximal humerus resection. Thus, post operatively shoulder movements are restricted. The main goals of reconstruction are to maintain a stable shoulder so that the function of elbow and hand can be optimized. Various reconstruction options are available after proximal humerus resection. We present our experience in using implant-cement spacers as a primary reconstruction option for limb salvage in the primary tumors of proximal humerus. All cases were retrieved from our prospectively maintained surgical database. 142 patients (96 males and 46 females) with a median age of 17.5 years (3–70 years) were operated with implant cement spacer between January 2006 and April 2019. Median follow up was 34 months (1–174 months). Functional outcome of the surgery was assessed in survivors by Musculoskeletal Tumor Society score (MSTS). Implant survival was assessed by Kaplan Meier analysis and competing risk analysis. On last follow up, out of 142 cases, 81 patients had died, 54 are alive and seven were lost to follow up. 18(13%) patients underwent revision surgery for symptomatic proximal migration, implant failure or infection. Four (2.8%) patients underwent forequarter amputation for local recurrence. The five years implant survival (IS) by Kaplan Meier analysis was 79.6% and as per competing risk analysis, the chances of implant revision are 12% and 18% at five and ten years respectively. Mean MSTS score in survivors was 71% (60–80%). Implant cement spacer is a cost-effective alternative for reconstruction of proximal humerus with revision rates and function comparable to other reconstructions in cases where deltoid, axillary nerve and/or rotator cuff are excised.     

Resection replantation of the arm for sarcoma: an alternative to amputation

Resection-replantation for primary malignant tumors of the arm as an alternative to forequarter amputation first was reported in 1995. Segmental resection of the upper arm and replantation of the distal segment to the proximal humerus as an alternative to shoulder disarticulation for a large tumor of the humerus is reported. This procedure provides the patient with an aesthetically acceptable single-segment arm, which is useful for activities of daily living and recreation. There has been no local recurrence or metastasis at 5 years followup.     

Endoprosthetic replacement following resections of malignant tumors of the extremities (author's transl)]

Due to advances in chemotherapy and endoprothetics, amputation is increasingly being replaced by local resectioning in malignant tumors. While suitable implantations for bridging defects in the proximal humerus and proximal femur are available, prostheses for resectioned tumors in the knee area have not yet been fully developed. From 1966 to 1978, 77 endoprostheses were implanted in 29 primary bone tumors, 3 malignant soft-tissue tumors and 45 bone metastases. There were 43 endoprostheses of the proximal femur, 31 endoprostheses of the proximal humerus and 3 special endoprostheses of the knee region. In most cases, eliminating the tumor radically was successful and a functional extremity was retained.     

Multicentric giant cell tumor of the upper extremities: 16 years of ongoing disease

Multicentric giant cell tumor is rare and accounts for less than 1% of all giant cell tumors of bone. We describe a case in which all the lesions occurred in the upper extremities. The 13-year-old boy's first tumor was in the left index metacarpal. Over 16 years, giant cell tumors occurred in 8 sites: right distal radius, left lunate, left middle metacarpal, left distal radius, right ring finger proximal phalanx, right radial head, left distal humerus, and left proximal humerus. Intralesional curettage of the lesions located in the hand and carpals was associated with a high incidence of local recurrence, whereas lesions in the proximal radius and in the humerus have not recurred.     

Upper limb salvage with microvascular bone transfer for major long-bone segmental tumor resections

A series of 14 young, active patients who underwent vascularized bone graft reconstructions of large (9-15 cm) segmental skeletal defects of the upper extremity resulting from resection of a variety of bony tumors is presented. Eight defects involved the proximal humerus and required shoulder joint reconstruction, two were mid humeral and four involved the distal radius. Surgical techniques for both distal radius reconstruction with vascularized iliac crest and vascularized fibular head and glenohumeral reconstruction using the vascularized fibula are described. Several cases are discussed in detail, including achievement of bony union, postoperative range of motion and pain, and each patient's ability to resume activities. The literature is reviewed, and other reconstructive options for large bony defects of the upper extremity after tumor resection are discussed: nonvascularized bone grafts, allograft transfer, and custom prosthetic devices. The authors think that vascularized bone grafting offers the most favorable method of upper extremity salvage with preservation of joint function, especially at the shoulder.     

Adult proximal humerus locking plate for the treatment of a pediatric subtrochanteric femoral nonunion: a case report

Nonunions of pediatric subtrochanteric femur fractures are exceedingly rare and have to date not been reported in the literature. We present the case of an 11-year-old boy who developed such a nonunion after open reduction internal fixation using a pediatric locked proximal femur plate. Using an adult proximal humerus locking plate, adequate proximal fixation of the nonunion was obtained. Furthermore, previously placed distal screw holes were safely bridged and the biomechanical environment around the nonunion site improved. Uneventful healing was possible with the use of adjuvant bone grafting. No short- or midterm complications occurred. Although other implants can certainly be adapted to a use different than that of its original design, the present case suggests that adult proximal humerus locking plates may be a safe option for revision surgery of the proximal pediatric femur.     

吻合血管的近段腓骨移植重建肩腕关节

目的 探讨带血管蒂的近段腓骨移植重建肩、腕关节炎的疗效。方法 对近端肱骨和桡骨远端骨巨细胞瘤病例彻底切除瘤段骨及周围反应组织,采用带血管蒂的游离近段腓骨移植重建肩关节和腕关节。结果 经术后6个月－2年随访,2例重建肩、腕关节外观和功能恢复良好,肿瘤无复发。结论 带血管蒂近段腓骨移植是治疗肱骨近端和桡骨远端肿瘤切除后骨缺损和重建肩、腕关节的理想方法。     

Use of osteocutaneous "double-barrel fibular flaps" in limb reconstruction: four clinical cases.

The use of a vascularized fibular transfer is a technique used for the reconstruction of large defects in long bones. A technical variation that consists of osteotomizing the transplant, giving two distinct segments, is adapted in the reconstruction of long bones with a large diameter, in particular, the femur or the proximal tibia. The results obtained using this technique in four clinical cases are presented here. The length of the bone defects was between 7.5 and 11 cm. There were two cases involving the tibia, one case the distal humerus, and one case the pelvis.     

吻合血管带腓骨头腓骨移植重建肩腔关节

目的：扩展活腓骨移植在骨肿瘤保肢手术中的应用,特别涉及关节端骨肿瘤保肢治疗的应用。方法：采用吻合血管带腓骨头的腓骨移植重建10例肱骨头周,5例桡骨远端骨肿瘤瘤段切除术后的肩、腕关节。结果：术后6个月所有腓骨移植段与受区骨端愈合良好,骨形态替代理想,重建后的肩、腕关节无论从外观或功能方面均获得较好的重建效果。结论：吻合血管带腓骨头的腓骨移植对肩关节肱骨端、腕关节桡骨端骨肿瘤保肢手术的关节重建中起到较好的替代作用。     

Primary parosteal osteosarcoma of the rib

Osteosarcoma is a common primary malignant tumour of bones that produces an osteoid matrix. Parosteal osteosarcoma is an uncommon neoplasm and principally affects the long bones, especially in the distal femur, proximal tibia and proximal humerus. Rarely, the tumour may arise in a flat bone, and rib involvement is very infrequent. An unusual case of primary parosteal osteosarcoma of the rib in an asymptomatic 28-year old female is presented here. A chest X-ray film suggested an intrapulmonary homogeneous mass, while a computed tomography scan revealed a broad-based calcified mass attached to the inner cortex of the right fourth anterior rib. The patient underwent a wide excision of the tumour together with adjacent intercostal muscles and chest wall reconstruction. Postoperative histopathological outcome was consistent with primary parosteal osteosarcoma.     

上肢骨肿瘤切除后的自体骨移植重建

目的探讨应用自体骨移植对上肢骨肿瘤切除后的骨缺损修复重建的效果。方法1998年8月～2004年3月，收治上肢骨肿瘤切除后的骨缺损16例。男8例，女8例。年龄7～45岁。经病理确诊，肱骨近端尤文肉瘤和骨肉瘤各1例；肱骨远端尤文肉瘤2例；桡骨远端骨巨细胞瘤8例，高分化软骨肉瘤2例，恶性纤维组织细胞瘤和骨肉瘤各1例。2例肱骨近端肿瘤行自体锁骨代肱骨；2例肱骨远端肿瘤行自体腓骨代肱骨；12例桡骨远端肿瘤中，1例行自体髂骨移植，11例行自体腓骨代桡骨进行重建。采用MSTS系统进行术后功能评价。结果2例肱骨近端自体锁骨移植患者分别随访36个月和12个月，术后保持部分肩关节前屈和后伸功能，但外展功能丧失；MSTS评分分别为23分和22分。2例肱骨远端自体腓骨移植患者分别随访4个月和6个月，肘关节功能良好，移植骨连接处已经出现骨愈合；MSTS功能评分分别为24分和19分。12例桡骨远端自体骨移植患者中11例随访6～75个月，功能良好，无明显并发症；1例髂骨植骨的桡骨远端骨巨细胞瘤术后3个月移植骨完全愈合，至今随访75个月，肿瘤无复发。MSTS功能评分18~27分，平均22．6分。结论自体骨移植在上肢骨肿瘤切除后骨缺损的重建，尤其是儿童的骨缺损重建中，是一种较好的方法。     

骨干人工假体在股骨近端恶性肿瘤切除后骨缺损重建中的初步应用

 目的 探讨采用骨干人工假体对股骨近端骨干恶性肿瘤切除后结构性骨缺损进行重建的可行性。方法 2011年6月至2014年7月对7例股骨近端恶性骨肿瘤患者采用骨干人工假体置换,男3例,女4例;年龄28~76岁,平均61.8岁。原发恶性骨肿瘤4例,转移癌3例。术前常规行X线、CT及MR检查,通过MRI测量瘤段骨长度及软组织侵犯范围,再根据截骨长度选择骨干人工假体配件。取股骨近端外侧直切口,逐层切开皮肤、皮下组织,按肿瘤切除原则充分显露术前MRI测量的瘤段骨及软组织肿瘤并截骨,扩髓后安装骨干人工假体,依次缝合各层组织。术后切除组织送病理学检查。结果 手术时间45~120 min,平均90 min;术中出血量200~800 ml,平均400 ml。随访6~24个月,平均14个月。1例骨肉瘤患者术后1年因出现肺转移而死亡,3例原发恶性骨肿瘤患者术后未出现术区复发及远处转移。1例乳腺转移癌患者术前多发转移,术后行综合治疗,带瘤生存;2例乳腺转移癌患者随访期间未出现原位复发或转移。7例患者术后患肢髋关节功能均无受限。结论 使用骨干人工假体对股骨近端骨干恶性肿瘤切除后结构性骨缺损进行重建,保留了邻近的髋关节及肌腱附着点,操作简单,住院时间较短,可早期负重,是一种理想的治疗股骨近端骨肿瘤的保肢手术方法。     

Segmental limb reconstruction after tumor resection

Limb salvage of large segmental and osteoarticular defects after tumor resection has become the standard of care for most patients with musculoskeletal tumors because overall survival is the same when compared with that seen in amputation patients. This study examines limb salvage for the surgical management of large segmental defects in terms of local recurrence, complications, and functional outcome in both primary and metastatic lesions. We retrospectively identified 32 patients with benign or malignant tumors of bone who underwent resection and limb salvage reconstruction by means of a custom or modular metal implant between 1985 and 1995. The most common tumor sites were the proximal femur (41%), distal femur (37.5%), and proximal humerus (12.5%). Primary bone lesions accounted for 18 patients (56%); metastatic disease accounted for 14 patients (44%). Osteosarcoma (n = 11) and chondrosarcoma (n = 3) were the most frequent primary tumors. The overall limb salvage rate (91%) was high, yet complications (28%) were common. Except for 3 patients who underwent amputation after prosthetic failure, all surviving patients were independent with or without assistive devices at latest follow-up. In patients with advanced metastatic disease, average survival was 7.6 months. No cases of aseptic loosening or implant breakage were observed in patients followed up for 2 years or more. Treatment after tumor resection with a limb salvage prosthetic reconstruction has shown good functional outcomes with an acceptable complication rate. This modality, therefore, offers patients a more favorable functional outcome with a more energy-efficient gait when compared with limb amputation.