骨盆骨肉瘤的外科治疗策略探讨

Objectives To investigate the clinical outcome of consecutive pelvic osteosarcoma treated with surgery and chemotherapy in a single institution, and to discuss the surgical strategy, resection and reconstruction. Methods Twenty-one consecutive cases with pelvic osteosarcoma underwent surgical procedures between June 2000 and June 2009. There were 12 male and 9 female with a mean age of 32 years. According to Enneking and Dunham pelvic classification system, type I was 3 cases, type I + IV 3 cases,type I + Ⅱ 4 cases,type Ⅱ + Ⅲ 4 cases,type I + Ⅱ + Ⅲ 1 case,type Ⅲ 1 case,and type I + Ⅱ + Ⅳ 5 cases. Among the 21 cases, 19 were diagnosed as classical osteosarcoma and 2 were diagnosed as low-grade pathologically. All the tumors were stage Ⅱ B. All the patients received en-bloc resection with 13 wide resection and 8 marginal resection. Thirteen patients underwent modular hemipelvic endoprosthesis reconstruction, and 5 patients underwent rod-screw system reconstruction combined with autograft. Two patients received hemipelvectomy and one type Ⅲ patients had resection without reconstruction. The mean follow-up period was 30. 3 months (range,6. 0-87. 0). Results Thirteen patients out of 21 survived after treatment The overall survival rate was 61. 9% , and 23. 8% patients were alive without disease. The estimated 5-year survival rate was 44. 2% based on Kaplan-Meier curve. The local recurrence rate was 28.6% , among which 4 cases were type Ⅱ resection, 1 was type I resection, 1 was type I + Ⅳ resection. No local relapse was found on the hemipelvectomy and type Ⅲ resection cases. The local recurrence rate after wide resection was 23. 1% ,and 37. 5% for marginal resection. Nine patients had lung metastases and one patient was found bone and lymph node metastases. The MSTS 93 function score was 20. 6±5. 4 for 13 patients,and 22. 5±2. 1 for rod-screw reconstruction cases. The function score was 17. 7±5. 5 for hemipelvic prosthetic reconstruction. Conclusion Limb salvage procedures could be performed on most pelvic osteosarcoma cases, and satisfying function outcome could be achieved with proper reconstruction,however,the overall survival is still lower compared with those in extremities.     

骨盆骨肉瘤的外科治疗策略探讨

Objectives To investigate the clinical outcome of consecutive pelvic osteosarcoma treated with surgery and chemotherapy in a single institution, and to discuss the surgical strategy, resection and reconstruction. Methods Twenty-one consecutive cases with pelvic osteosarcoma underwent surgical procedures between June 2000 and June 2009. There were 12 male and 9 female with a mean age of 32 years. According to Enneking and Dunham pelvic classification system, type I was 3 cases, type I + IV 3 cases,type I + Ⅱ 4 cases,type Ⅱ + Ⅲ 4 cases,type I + Ⅱ + Ⅲ 1 case,type Ⅲ 1 case,and type I + Ⅱ + Ⅳ 5 cases. Among the 21 cases, 19 were diagnosed as classical osteosarcoma and 2 were diagnosed as low-grade pathologically. All the tumors were stage Ⅱ B. All the patients received en-bloc resection with 13 wide resection and 8 marginal resection. Thirteen patients underwent modular hemipelvic endoprosthesis reconstruction, and 5 patients underwent rod-screw system reconstruction combined with autograft. Two patients received hemipelvectomy and one type Ⅲ patients had resection without reconstruction. The mean follow-up period was 30. 3 months (range,6. 0-87. 0). Results Thirteen patients out of 21 survived after treatment The overall survival rate was 61. 9% , and 23. 8% patients were alive without disease. The estimated 5-year survival rate was 44. 2% based on Kaplan-Meier curve. The local recurrence rate was 28.6% , among which 4 cases were type Ⅱ resection, 1 was type I resection, 1 was type I + Ⅳ resection. No local relapse was found on the hemipelvectomy and type Ⅲ resection cases. The local recurrence rate after wide resection was 23. 1% ,and 37. 5% for marginal resection. Nine patients had lung metastases and one patient was found bone and lymph node metastases. The MSTS 93 function score was 20. 6±5. 4 for 13 patients,and 22. 5±2. 1 for rod-screw reconstruction cases. The function score was 17. 7±5. 5 for hemipelvic prosthetic reconstruction. Conclusion Limb salvage procedures could be performed on most pelvic osteosarcoma cases, and satisfying function outcome could be achieved with proper reconstruction,however,the overall survival is still lower compared with those in extremities.     

腹腔镜下扩大性膀胱部分切除联合盆腔淋巴结清扫术治疗脐尿管癌

Objective To discuss the techniques and clinical efficacy of laparoscopic partial cystectomy with bilateral pelvic lymphadenectomy for urachal adenocarcinoma. Methods From July 2006 to April 2008, 4 patients with urachal adenocarcinoma were managed by the laparoscopic procedure. Three patients were male, the other one was female, with a median age of 51 (range 42 to 66)years. The mean size of tumors was 3.4(rang 1.9 to 5.4)cm in diameter. Three of them were diagnosed as mucinous adenocarcinoma, the other one was adenocarcinoma. There was 1 patient at stage Ⅱ , and the other three as stage Ⅲ according to Sheldon Stage. Four patients were performed by transperitoneal approach. The boundaries of resection were similar to the open surgery, including resection of the tumor with normal margins, the peritoneum lateral to the two medial unbilical ligaments,the posterior sheath of the rectus muscle and the muscle fibers of the rectus muscle below it, and bilateral pelvic lymphanodes. Results The procedure was successfully in all 4 patients, with a mean operative time of 220(range 150 to 350)min, a mean estimated blood loss of 180 (range 120 to 290)ml.No significant intraoperative or postoperative complications occurred, except for an inferior epigastric artery injury in 1 case. The mean postoperative in-dwelling urinary catheter time was 6 (range 5 to 7)d, and the mean postoperative hospital stay was 6 (range 5 to 8)d. All 36 resected lymph nodes (range 8 to 11) were negative. At a median follow-up of 25(range 15 to 36) months, there was no evidence of recurrent disease by radiologic or cystoscopic evaluation. Conclusion Laparoscopic partial cystectomy and bilateral extended pelvic lymphadenectomy in selected patients with urachal tumors could be a safe, feasible, minimally invasive procedure.     

腹腔镜下扩大性膀胱部分切除联合盆腔淋巴结清扫术治疗脐尿管癌

Objective To discuss the techniques and clinical efficacy of laparoscopic partial cystectomy with bilateral pelvic lymphadenectomy for urachal adenocarcinoma. Methods From July 2006 to April 2008, 4 patients with urachal adenocarcinoma were managed by the laparoscopic procedure. Three patients were male, the other one was female, with a median age of 51 (range 42 to 66)years. The mean size of tumors was 3.4(rang 1.9 to 5.4)cm in diameter. Three of them were diagnosed as mucinous adenocarcinoma, the other one was adenocarcinoma. There was 1 patient at stage Ⅱ , and the other three as stage Ⅲ according to Sheldon Stage. Four patients were performed by transperitoneal approach. The boundaries of resection were similar to the open surgery, including resection of the tumor with normal margins, the peritoneum lateral to the two medial unbilical ligaments,the posterior sheath of the rectus muscle and the muscle fibers of the rectus muscle below it, and bilateral pelvic lymphanodes. Results The procedure was successfully in all 4 patients, with a mean operative time of 220(range 150 to 350)min, a mean estimated blood loss of 180 (range 120 to 290)ml.No significant intraoperative or postoperative complications occurred, except for an inferior epigastric artery injury in 1 case. The mean postoperative in-dwelling urinary catheter time was 6 (range 5 to 7)d, and the mean postoperative hospital stay was 6 (range 5 to 8)d. All 36 resected lymph nodes (range 8 to 11) were negative. At a median follow-up of 25(range 15 to 36) months, there was no evidence of recurrent disease by radiologic or cystoscopic evaluation. Conclusion Laparoscopic partial cystectomy and bilateral extended pelvic lymphadenectomy in selected patients with urachal tumors could be a safe, feasible, minimally invasive procedure.     

后路经椎弓根儿童半椎体全切除术的近期疗效评估

Objective To evaluate the early outcomes of children with congenital scoliosis treated by one-stage transpedicular hemivertebra resection. Methods From July 2005 to June 2006, 27 consecutive cases of congenital scoliosis managed by one-stage transpedicular hemivertebra resection with instrumentation were investigated retrospectively. There were 11 girls and 16 boys, with a mean age of 5. 5 years at surgery (range 1.3-10.0 years). Location of the hemivertebra was in the thoracic spine in 12 cases and in the lumbar spine in 15 cases. Radiographic evaluations were performed on the preoperative, postoperative, and latest follow-up standing posteroanterior and lateral radiographs. Results The average operation time was 4 hours (range 3-6 hours), and the mean blood loss during operation was 750 ml (range 300-2200 ml). The mean fusion level was 2 to 7 segments, average 4. 4 segments. The average follow-up period was 16 months (range 12-34 months). Mean Cobb angle of the total main curve was 40.0° before surgery, 12. 6° after surgery, and 15. 2° at latest follow-up. Mean Cobb angle of the segmental main curve was 35. 6° before surgery, 11.6° after surgery, and 12. 1° at latest follow-up. The trunk shift was improved from 16. 5 mm before operation to that of 7. 5 mm after the operation and 7. 6 mm at the latest follow-up. Compensatory cranial curve improved from 19.4° before surgery to 8.9° after surgery, and compensatory caudal curve improved from 26. 3° to 12. 8°. The angle of segmental kyphosis was 26.4° before surgery and 14. 6° after surgery in cases with thorcic hemivertebrae, and averaged 11. 2° before surgery and 3. 9° after surgery in cases with lumbar hemivertebrae. Peri-operative complications included two pedicle screws malpositioning and one case with pelvic tilt. There was no neurological complication. Conclusion One-stage transpedicular hemivertebra resection with instrumentation has a good capability of correcting deformity on the frontal and sagittal planes, which is available in children with middle or lower thoracic or lumbar hemivertebrae.     

髋臼周围恶性肿瘤切除后股骨头旷置术的临床应用

目的 探讨髋臼周围恶性肿瘤切除后股骨头旷置术的临床应用.方法 1997年5月至2005年6月共有25例切除后采用股骨头旷置术的髋臼周围恶性肿瘤患者得到随访,其中男性15例,女性10例;年龄16～75岁,平均42岁;骨肉瘤4例,软骨肉瘤12例,尤文肉瘤1例,原始神经外胚层瘤1例,骨髓瘤1例,恶性纤维组织细胞瘤1例,滑膜肉瘤2例,转移性肿瘤3例.根据Enneking骨盆肿瘤分区:肿瘤累及Ⅰ、Ⅱ区12例;Ⅰ、Ⅱ、Ⅲ区5例;Ⅱ、Ⅲ区4例;Ⅱ区2例;Ⅰ、Ⅱ、Ⅳ区2例.共有7例行新辅助化疗,5例行单纯术后辅助化疗,4例行术后放疗.髋臼周围切除后,采用股骨头旷置术,术后皮牵引6～8周,牵引质量2～3 kg.以后扶拐逐渐步行活动.结果 25例股骨头旷置术中6例出现手术后并发症(24.0%).随访时间3～10年,11例由于肺转移或远处转移并发肺转移死亡;2例带瘤生存;12例无瘤生存.术后5年及10年生存率分别为60%和54%.股骨头旷置术后肢体短缩在2.5～7.5 cm,平均5 cm.本组病例术后功能评价根据Enneking1993MSTS评分系统进行,平均术后功能评分是17分(12～19分).术后3个月后,患者基本能够正常坐,扶单拐跛行,能自主上下楼梯,去拐后也能跛行行走.结论 累及髋臼周围的恶性肿瘤,切除后股骨头旷置术是一种可选择的重建方式,能取得相对满意的临床效果.髋臼周围高度恶性肿瘤、软组织重建条件不佳、具有感染高危倾向者、经济条件不佳的患者,是股骨头旷置术的适应证.

Abstract：

Objective To discuss the resection pseudoarthrosis for pelvic malignant tumors around acetabular. Methods From May 1997 to June 2005, 25 patients with malignant tumors around acetabular were treated surgically with resection pseudoarthrosis. The series comprised 15 males and 10 females with an average age of 42 years old (range from 16 to 75 years old ) . There were 4 osteosareomas, 12chondrosarcomas, 1 Ewing's sarcoma, 1 neuroectodermal tumor, 1 myeloma, 1 malignant fibrohistiocytoma,2 synovial sarcomas, and 3 metastases. Pseudoarthrosis was performed after resection of pelvic malignant tumors around acetabular. The affected side was protected postoperatively by skin traction with 2-3 kg weight for 6 to 8 weeks. After then, the patients walked gradually with a cane. Results Among 25 patients, 6 had complications(24% ). At a follow-up ranging from 3 to 10 years, 11 patients died of lung metastases, 2relapsed, 12 remained alive free of disease. There was an average crispation of 5 cm( range from 2. 5 to 7.5cm). The patients were functionally evaluated according to Enneking's MSTS criteria in 1993. The average MSTS functional score was 17 points ( 12 to 19 points). After 3 months postoperative, the patients could sit normally, walk with a cane, and even walk limpingly without cane. Conclusions Resection pseudoarthrosis for pelvic malignant tumors around acetabular results in good clinical results at the time of mid-term and long-term follow-up. And pseudoarthrosis is advisable especially for patients with malignant highly tumors around acetabular, poor soft tissue reconstruction condition, high risk for infection, poor economy.     

后路经椎弓根儿童半椎体全切除术的近期疗效评估

Objective To evaluate the early outcomes of children with congenital scoliosis treated by one-stage transpedicular hemivertebra resection. Methods From July 2005 to June 2006, 27 consecutive cases of congenital scoliosis managed by one-stage transpedicular hemivertebra resection with instrumentation were investigated retrospectively. There were 11 girls and 16 boys, with a mean age of 5. 5 years at surgery (range 1.3-10.0 years). Location of the hemivertebra was in the thoracic spine in 12 cases and in the lumbar spine in 15 cases. Radiographic evaluations were performed on the preoperative, postoperative, and latest follow-up standing posteroanterior and lateral radiographs. Results The average operation time was 4 hours (range 3-6 hours), and the mean blood loss during operation was 750 ml (range 300-2200 ml). The mean fusion level was 2 to 7 segments, average 4. 4 segments. The average follow-up period was 16 months (range 12-34 months). Mean Cobb angle of the total main curve was 40.0° before surgery, 12. 6° after surgery, and 15. 2° at latest follow-up. Mean Cobb angle of the segmental main curve was 35. 6° before surgery, 11.6° after surgery, and 12. 1° at latest follow-up. The trunk shift was improved from 16. 5 mm before operation to that of 7. 5 mm after the operation and 7. 6 mm at the latest follow-up. Compensatory cranial curve improved from 19.4° before surgery to 8.9° after surgery, and compensatory caudal curve improved from 26. 3° to 12. 8°. The angle of segmental kyphosis was 26.4° before surgery and 14. 6° after surgery in cases with thorcic hemivertebrae, and averaged 11. 2° before surgery and 3. 9° after surgery in cases with lumbar hemivertebrae. Peri-operative complications included two pedicle screws malpositioning and one case with pelvic tilt. There was no neurological complication. Conclusion One-stage transpedicular hemivertebra resection with instrumentation has a good capability of correcting deformity on the frontal and sagittal planes, which is available in children with middle or lower thoracic or lumbar hemivertebrae.     

经皮肾镜技术治疗上尿路肿瘤的初步经验

目的 评价经皮肾镜技术在上尿路肿瘤中的应用效果.方法 2006年6月至2010年6月经皮肾镜治疗上尿路肿瘤患者8例(10侧).男6例(7侧),女2例(3侧).年龄52～72岁,平均61岁.孤立肾4例,慢性肾功能不全2例,双侧肾盂肿瘤2例.高级别肿瘤4侧,低级别肿瘤6侧.肿瘤直径0.5～3.5 cm,平均2.6 cm.患者均接受经皮肾镜激光或电刀肿瘤切除术,术中留置输尿管支架管,术后经肾造瘘管灌注化疗药物.结果 8例手术均获成功,手术时间45～95 min,平均73 min;术中出血量20～300 ml,平均50 ml,术后SCr水平较术前下降或无明显变化.随访10～36个月,采用CT、MRI及输尿管镜检观察肿瘤复发情况.1例死于肿瘤转移,2例肿瘤局部复发.余5例未见肿瘤复发.结论 经皮肾镜技术治疗上尿路肿瘤安全可行,手术效果良好,对不宜行肾输尿管切除术的上尿路肿瘤患者来说是一种良好的选择.

Abstract：

Objective To evaluate the application of percutaneous nephroscopy in the treatment of upper urinary tract transitional cell carcinoma, particularly renal pelvic carcinoma. Methods From June 2006 to June 2010, eight cases (with 10 sides) of renal pelvic carcinoma received percutaneous nephroscopy tumor resection. There were six males (with 7 sides) and two females (with 3 sides) in the study group. There were six cases with solitary kidney and two cases with bilateral renal pelvic tumors. There were four cases with high-grade tumors and six cases with low-grade tumors. The age of patients ranged from 52 to 72 yrs (average 61.2 yrs). Tumor sizes ranged from 0.5 to 3.5 cm (average 2.6 cm). Patients were treated with laser or electrocautery through percutaneous nephroscopy. A ureteral stent was placed in the patients after the procedure. Chemotherapy was administered postoperatively through the nephrostomy tube. Results All the operations were successfully completed uneventfully. The operative time was 45-95 min (average 73 min), estimated blood loss was 20-300 ml (average 50 ml). No remarkable differences were found in serum creatinine levels before and after operation. After 10 to 36 mon. follow-up by CT, MRI, and ureteroscopy, one patient died of tumor metastasis and two patients had local tumor recurrence. The remaining patients had no local recurrence. Conclusions Percutaneous nephroscopy in treating renal pelvic tumor is safe and feasible. This is a better choice for the renal pelvic carcinoma patients who are unsuitable for ureteronephrectomy.     

经肛门内镜微创手术在治疗局限性直肠肿瘤中的应用

Objective To investigate the therapeutic effect of transanal endoscopic microsurgery (TEM) for localized rectal neoplasms. Methods Seventy-five patients with localized rectal neoplasms were treated by using TEM between April 2006 and December 2008. The clinical data was summarized and analyzed retrospectively to report the therapeutic effect of TEM in these cases. Results The mean diameter of the rectal lesions was (1.6 ± 0.8) cm (range, 0.5-5.0 cm). The average distance of lesions from the anal verge was (7.6 ± 2.8) cm (range, 5-20 cm). Locations of the lesions at the rectal wall : 25 located at the anterior wall, 24 at the posterior wall, 14 at the left wall and 12 at the right walL Surgical procedures included the transmural excision (64 cases) and the submucosal excision with partial muscular layer excision (11 cases) was performed. The average operating time was (73.7±32.1) win (range, 30-180 min). The mean operative blood loss was (9. 8 ± 7.7) ml (range, 3-50 ml). The postoperative pathological examination identified 28 cases of rectal adenoma, 25 rectal adenocarcinoma or carcinomatous changes of adenoma (14 cases with phase Tis tumor, 5 cases T1 and 6 cases T2), 7 rectal carcinoid and 15 cases of inflammatory polyps or others. Surgical margins of all specimens were negative. Postoperative complications occurred in 4 cases (5.3%), included 2 cases of anal hemorrhage, 1 case of pulmonary infection and 1 urinary infection. The average postoperative hospital stay was (3.4 ± 1.2) d (range, 2-7 d). All the patients were followed-up for a mean period of 8.4 months (range, 3-26 months), no tumor recurrence or metastasis was observed. Conclusion Being a kind of minimally invasive surgery, TEM shows advantages of decreased blood loss, better therapeutic effect and faster recovery, and it is a better choice of procedure for local excision for rectal neoplasms.     

经肛门内镜微创手术在治疗局限性直肠肿瘤中的应用

Objective To investigate the therapeutic effect of transanal endoscopic microsurgery (TEM) for localized rectal neoplasms. Methods Seventy-five patients with localized rectal neoplasms were treated by using TEM between April 2006 and December 2008. The clinical data was summarized and analyzed retrospectively to report the therapeutic effect of TEM in these cases. Results The mean diameter of the rectal lesions was (1.6 ± 0.8) cm (range, 0.5-5.0 cm). The average distance of lesions from the anal verge was (7.6 ± 2.8) cm (range, 5-20 cm). Locations of the lesions at the rectal wall : 25 located at the anterior wall, 24 at the posterior wall, 14 at the left wall and 12 at the right walL Surgical procedures included the transmural excision (64 cases) and the submucosal excision with partial muscular layer excision (11 cases) was performed. The average operating time was (73.7±32.1) win (range, 30-180 min). The mean operative blood loss was (9. 8 ± 7.7) ml (range, 3-50 ml). The postoperative pathological examination identified 28 cases of rectal adenoma, 25 rectal adenocarcinoma or carcinomatous changes of adenoma (14 cases with phase Tis tumor, 5 cases T1 and 6 cases T2), 7 rectal carcinoid and 15 cases of inflammatory polyps or others. Surgical margins of all specimens were negative. Postoperative complications occurred in 4 cases (5.3%), included 2 cases of anal hemorrhage, 1 case of pulmonary infection and 1 urinary infection. The average postoperative hospital stay was (3.4 ± 1.2) d (range, 2-7 d). All the patients were followed-up for a mean period of 8.4 months (range, 3-26 months), no tumor recurrence or metastasis was observed. Conclusion Being a kind of minimally invasive surgery, TEM shows advantages of decreased blood loss, better therapeutic effect and faster recovery, and it is a better choice of procedure for local excision for rectal neoplasms.     

累及骶骨的骨盆恶性肿瘤切除及重建

目的 探讨累及骶骨的骨盆恶性肿瘤合理的手术切除及重建方式.方法 1999年7月至2007年7月,共有19例累及骶骨的骨盆恶性肿瘤患者在北京大学人民医院骨肿瘤科接受肿瘤切除重建手术.平均年龄37岁(12～78岁);男性12例,女性7例. 其中,软骨肉瘤5例、尤文肉瘤4例、骨肉瘤4例、恶性纤维组织细胞瘤(MFH)1例、骨巨细胞瘤1例、转移癌4例.切除髂骨翼及部分骶骨、保留髋臼手术10例,采用了钉棒系统内固定,其中5例患者同时进行了自体腓骨或髂骨植骨;切除部分骶骨、髂骨翼及髋臼手术9例,应用组配式人工半骨盆重建骨盆环完整性.结果 肿瘤学结果:7例出现局部复发(7/19,36.9%),其中骨肉瘤2例、软骨肉瘤2例、尤文肉瘤2例及转移癌1例.19例患者随访时间为1至7年,平均4.5年.功能结果:9例保留髋臼、钉棒重建的患者术后正常行走,无步态异常.9例行Ⅱ区肿瘤切除、人工半骨盆重建的患者中,8例术后2个月能够扶拐行走.ISOLS评分平均20分以上,其中,良好3例,一般5例,较差1例.人工半骨盆重建的患者中,术后脱位1例,行切开复位;因深部感染取出假体1例.结论 对于保留髋臼的髂骨肿瘤切除,采用钉棒内固定结合自体骨植骨是一种理想的重建骨盆环稳定性的方法,可使患者早期恢复行走功能.将股骨头颈植于骶骨侧方,将组配式人工半骨盆卡于质骨块的下方,重建累及骶骨及髋臼的骨盆切除,是一种可取的重建方式.     

Aseptic osteonecrosis of acetabulum following prosthetic replacement of the femoral head

Summary Acetabular osteonecrosis is a rare condition. Only five cases with histological analysis have been reported in the literature, and these patients had previously received radiotherapy. The 67-year-old woman reported on here, who had had no major systemic disorder or local radiotherapy, and who had never consumed alcohol, developed aseptic osteonecrosis of the acetabulum after femoral head replacement with a cemented Austin-Moore prosthesis for aseptic osteonecrosis of the femoral head following femoral neck fracture. The necrosis was found during surgery to go so deeply into each bone composing the acetabulum that the hip joint could not be revised, and we had to perform a Girdlestone resection arthroplasty. The radiographic and histological findings resembled those reported in cases of aseptic osteonecrosis of the acetabulum after radiotherapy.     

骨盆Ⅰ-Ⅱ-Ⅳ区肉瘤整块切除后腰盆钉棒重建系统

目的探讨骨盆Ⅰ-Ⅱ-Ⅳ区肉瘤整块切除后新设计的腰盆钉棒重建系统的临床应用。方法回顾性研究中山大学附属第一医院骨肿瘤科,2009年6月到2010年12月期间,行骨盆Ⅰ区、Ⅱ区和Ⅳ区肉瘤整块切除和腰盆钉棒系统重建术的病例资料,评价该术式的治疗效果及术后并发症。入选条件:穿刺活检证实骨盆原发性肉瘤;肺部CT未见转移灶,Eneking分期为ⅡB期;患者能完成规范的新辅助化疗;术前MRI评估证实肉瘤未侵犯髂外动静脉、坐骨神经和盆腔脏器,确认肉瘤累及骨盆Ⅰ-Ⅱ-Ⅳ三个区域。结果 4例累及骨盆Ⅰ区、Ⅱ区和Ⅳ区的原发性肉瘤患者接受肿瘤整块切除后腰盆钉棒系统重建。患者男3例,女1例;平均年龄29.75岁(18～45岁)。病理类型包括:尤文肉瘤2例,软骨肉瘤1例和骨肉瘤1例,尤文肉瘤和骨肉瘤完成新辅助化疗。肉瘤整块切除范围包括骨盆Ⅰ区、Ⅱ区和Ⅳ区肿瘤、肿瘤累及的髂肌、臀中小肌和部分臀大肌,同时采用骨盆髋臼和腰椎椎弓根钉棒系统重建髋臼、骨盆环和腰骶连接。术后3周患者开始进行康复治疗,术后3个月可扶拐行走。术后平均随访14个月(9～19个月),目前尚未发现复发和转移。MSTS功能评分平均为66.67%(63%～73%);Harris髋关节评分良2例,差2例。结论骨盆原发性肉瘤治疗的主要目标是通过广泛切除而获得治愈,通过骨盆环重建挽救下肢的主要功能。骨盆Ⅰ区、Ⅱ区和Ⅳ区肉瘤整块切除和腰盆钉棒系统既能完整的切除肿瘤,又能有效重建骨盆和腰骶连接功能。这种重建方式近期疗效观察能够达到患者及骨肿瘤专科医生的功能期望。     

股骨转子下叠加缩短截骨在CroweⅣ型成人髋脱位全髋置换术的应用

目的总结CroweⅣ型成人髋脱位采用股骨转子下叠加缩短截骨行全髋置换术的方法与疗效。方法2000年1月至2003年12月，收治8例（11髋）CroweⅣ型成人髋脱位患者，男3例，女5例；年龄40-57岁，平均48岁；单髋5例，双髋3例；先天性发育不良7例，陈旧性髋关节结核1例。假体臼杯为金属杯＋聚乙烯内衬设计，其中Duraloc（Depuy，Warsaw，USA）8髋，Pressfit SⅡ（LINK，Ger-many）3髋。股骨柄假体采用AML（Depuy，Warsaw，USA）4髋，Summit（Depuy，Warsaw，USA）4髋，Ribbed（LINK，Germany）3髋。假体均采用生物学固定。手术均采用股骨转子下叠加缩短截骨，并附加断端“V”形截骨，其中6髋因最小号股骨柄假体置 入困难，而附加股骨劈开成形术。结果无一例发生感染、脱位等并发症，无一例行臀大肌或臀中、小肌等短肌松解。转子下平均缩短截骨长度为4．5cm（4～6cm），无一例因截骨过短，导致股骨头假体复位困难或坐骨神经牵伸伤；也无一例因截骨过长，导致股骨头假体松弛性脱位。术后X线片示臼杯均位于真臼区，股骨柄假体的初始固定均优良，截骨断端在3～6个月后均骨性愈合。测量显示患肢平均延长3cm（2．5～3．5cm）。随访3～7年，髋关节Harris评分从术前的25～32分改善至1年后的90～98分。无一髋假体显示有X线松动和邻近骨溶解。结论股骨转子下叠加缩短截骨术可用于CroweⅣ型成人髋脱位的全髋置换术治疗。     

High complication rates with pelvic allografts: Experience of 22 sarcoma resections

We performed 22 reconstructions by allografts in patients with pelvic sarcoma: 14 Ewing's sarcomas, 7 chondrosarcomas, and 1 osteosarcoma. All patients with Ewing's sarcoma and osteosarcoma received chemotherapy. No patients with chondrosarcoma had adjuvant treatment. 12 reconstructions were iliosacral arthrodesis after resection of an ilium tumor, 1 was iliofemoral arthrodesis and 9 were pelvic reconstructions with total hip prosthesis after re section of an acetabulum tumor. in the surviving patients, the mean length of follow-up was 4 (2-6) years.

2 allografts fractured and 8 allografts developed an infection. the infection was commoner in patients who had chondrosarcomas, large tumors, and a long operation time. Neither chemotherapy nor radiotherapy increased the infection rate. All infected allografts had to be removed.     

Femoral neck fracture complicating orthopedic reposition of a dislocated hip: four cases

Posterior dislocation of the femoral head with fracture is an exceptional hip injury. Emergency reduction is required. Reposition into the acetabular cavity of the dislocated femoral head may not be feasible. Irreducibility, instability, and more rarely accidental fracture of the femoral neck may also occur. We encountered this latter complication in four patients and report here its frequency and mechanism and propose preventive therapeutic measures. Seventy dislocations and fracture-dislocations of the hip were treated in our unit from March 1997 to February 2003. Among these cases, fourteen hip dislocations were complicated by femoral head fractures. Fracture of the femoral neck occurred during reduction in four. All four cases occurred in men, mean age 49.7 years, who were traffic accident victims (drivers or passengers). There were two Pipkin IV fracture-dislocations and two Pipkin II. The first reduction, achieved under general anesthesia in an emergency setting, was performed by an orthopedic surgeon in one patient and a general surgeon in three patients. Arthroplasty was used to treat the femoral neck fracture in three patients and pinning in one. We reviewed retrospectively the clinical and imaging data before and after reduction. Sub-capital fracture situated 4.0 cm (mean, range 3.5-4.5 cm) from the lesser trochanter occurred in all four cases. The head remained attached above and posteriorly to the acetabulum and was rotated less than 90 degrees . The fragment remaining in the acetabulum was displaced in two cases. In one patient, the fracture-dislocation of the head was associated with a fracture of the posterior rim of the acetabulum. This complication appears to result from an abrupt inappropriate reduction movement. The neck fracture would occur when capsulomuscular retention of the femoral head is associated with a head defect which catches on the rim of the acetabulum during the reduction movement. Neck fracture during reduction of traumatic hip dislocation is a serious complication. Prevention of this iatrogenic event requires a slow, progressive reduction limiting the trauma to a minimum; first intention open surgery may be required in selected cases.     

恶性骨肿瘤活检安全性评估

目的 研究恶性骨肿瘤穿刺及切开活检道后被肿瘤污染的发生率及活检的安全性.方法 选取2005年7月至2007年10月恶性骨肿瘤行穿刺活检后的病理标本48例,男37例,女11例;年龄10～64岁,平均23.3岁;骨肉瘤37例,恶性纤维组织细胞瘤5例,皮质旁骨肉瘤1例,髓内高分化骨肉瘤1例,骨膜骨肉瘤1例,骨原发恶性黑色素瘤1例,软骨肉瘤2例.活检至再次手术间隔0～2个月,平均1.3个月;均行保肢治疗.选取同期行切开活检病理标本26例,男21例,女5例;年龄8～59岁,平均21.9岁;骨肉瘤20例,Ewing肉瘤1例,软骨肉瘤2例,间叶性软骨肉瘤1例,恶性纤维组织细胞瘤1例,淋巴瘤1例.活检至再次手术间隔1～4个月,平均2.3个月.活检道的手术切除范围均为其内外各2cm,连同瘤段整块切除.对活检道途经的组织取材,以病理为标准判断活检道途经的组织有无恶性肿瘤污染,并确定被肿瘤污染的发生率及范围.结果 48例穿刺活检患者中44例获得随访,随访时间4～39个月,平均17.6个月.4例(4/48,8.3%)活检道存在恶性肿瘤种植污染.末次随访时,4例发生非活检道肿瘤复发.26例切开活检患者均获得随访,随访时间2～29个月,平均12.9个月.2例活检道病理可见肿瘤,阳性率为7.7%(2/26).末次随访时,3例发生非活检道肿瘤复发.结论 恶性骨肿瘤进行穿刺活检和切开活检虽存在活检道被肿瘤污染的危险,但在最终手术时活检道连同肿瘤一同切除后不会发生因活检而造成的肿瘤复发.

Abstract：

Objective To investigate the incidence and extent of biopsy tract contamination in malignant bone tumors by either core needle biopsy or open biopsy and detect the safe extent in resection of biopsy tract. Methods Forty-eight cases were performed core needle biopsy, including 37 osteosarcomas, 5 malignant fibrous histiocytomas, 1 juxtacortical osteosarcoma, 1 low grade central osteosarcoma, 1 periosteal osteosarcoma, 1 primary malignant melanoma of bone and 2 chondrosarcomas. There were 37 males and 11 females with a mean age of 23.3 years (range, 10-64 years). The mean time between core needle biopsy and definitive surgery was 1.3 months (range, 0-2 months). All the patients were performed limb salvage surgery.Twenty-six cases were performed open biopsy, including 20 osteosareomas, 1 Ewing's sarcoma, 2 chondrosarcomas, 1 mesenchymal chondrosarcoma, 1 malignant fibrous histiocytoma, 1 lymphoma. There were 21males and 5 females with a mean age of 21.9 years (range, 8-59 years). The mean time between open biopsy and definitive surgery was 2.3 months (range, 1-4 months). The tumor and tissue around the biopsy tract at least 2 cm were resected. The pathological examination was performed in specimens via the biopsy tract, including the normal soft tissue outside the tumor, deep fascia, subcutaneous tissue and skin. The incidence and extent of biopsy tract contamination were evaluated with pathological examination. Results Forty-four cases were followed up. The mean follow-up time was 17.6 months (range, 4-39 months). In core needle biopsy group, four of forty-eight cases were found malignant tumor cells seeding in biopsy tract, the positive rate was 8.3%. In open biopsy group, all the cases were followed up with the mean time of 12.9 months (range, 2-29 months), and two of twenty-six cases were found malignant tumor cells seeding in biopsy tract,the positive rate was 7.7%. Conclusion Biopsy of malignant bone tumors has the risk of biopsy tract contamination. The tumor cell seeding exists in both core needle biopsy and open biopsy. The biopsy tract should be performed en bloc resection with the tumor.     

髋臼周围肿瘤的切除与重建

目的 探讨髋臼周围肿瘤切除与重建的方式及合并症。方法 回顾分析1997年7月至2003年7月髋臼部位原发肿瘤患者行肿瘤切除重建手术的临床资料。3l例患者中,男性19例,女性12例,年龄12～78岁,平均年龄37岁。其中,软骨肉瘤12例、尤文瘤1例、骨肉瘤3例、淋巴瘤1例、癌肉瘤1例、恶性纤维组织细胞瘤1例、骨髓瘤2例、骨巨细胞瘤9例、动脉瘤样骨囊肿1例。2l例患者行髋臼切除、骨盆重建,其中人工半骨盆8例、马鞍式关节7例、灭活再植 人工髋关节置换6例。10例患者行肿瘤刮除 骨水泥填充 人工髋关节置换。结果 21例行Ⅱ区肿瘤切除、髋臼重建的患者中,5例出现局部复发,其中3例为行半骨盆灭活再植的患者。3例骨肉瘤中2例死亡;12例软骨肉瘤患者中,随访9人,6例无瘤生存。术后2个月后,21例患者能够正常坐、扶单拐行走。结论 髋臼区域的肿瘤切除后可行异体或人工半骨盆移植进行修复,或将瘤段骨壳灭活再植进行重建。髋臼周围肿瘤切除重建的过程中应注意：(1)广泛切除肿瘤;(2)熟悉各种髋臼重建方法的优缺点,防止合并症的发生;(3)髋臼重建后的稳定性较差,应注意站立时在健侧拄一手杖,保护再造髋关节;(4)预防皮缘坏死及伤口感染,骨盆肿瘤切除容易发生伤口问题。     

Traumatic dislocation of the hip with separation of the capital epiphysis: 5 adolescent patients with 3 9 years of follow-

We reviewed 5 cases of type I epiphyseal fracture with dislocation of the femoral head from the acetabulum in adolescent patients. All children had an open reduction and screw fixation. In all cases, the femoral head developed avascular necrosis. The clinical result after a mean of 3-9 years' follow-up was good according to the Merle d'Aubigné-Postel scale. Despite necrosis, 2 heads developed spherically after treatment: one which had a primary physeal resection and fixation, the other after an autogenous bone graft in the screw track following removal of the screw.     

Traumatic dislocation of the hip with separation of the capital epiphysis: 5 adolescent patients with 3-9 years of follow-up

We reviewed 5 cases of type I epiphyseal fracture with dislocation of the femoral head from the acetabulum in adolescent patients. All children had an open reduction and screw fixation. In all cases, the femoral head developed avascular necrosis. The clinical result after a mean of 3-9 years' follow-up was good according to the Merle d'Aubigné-Postel scale. Despite necrosis, 2 heads developed spherically after treatment: one which had a primary physeal resection and fixation, the other after an autogenous bone graft in the screw track following removal of the screw.