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.     

原位微波灭活术治疗骨盆恶性骨肿瘤的临床研究

目的 探讨原位微波灭活术治疗骨盆原发恶性肿瘤及转移瘤的疗效.方法 2000年2月至2009年4月对18例骨盆原发恶性肿瘤及转移瘤患者采用原位微波灭活及肿瘤全部或部分切除,男11例,女7例;年龄16～72岁,平均45岁.原发恶性骨肿瘤12例,转移瘤6例.肿瘤累及Ⅰ区6例、Ⅱ区10例、Ⅲ区2例.根据肿瘤所在区域采用传统髂腹股沟切口或髂腹股沟"T"形切口进行显露,以铜网保护周围软组织,用2450 MHz微波将肿瘤局部加热至50℃,持续20 min,全部或部分剥离坏死肿瘤组织,保留骨盆环的解剖连续性.结果 手术时间60～180min,平均110min;术中失血量400～800ml,平均480 ml.无严重的术中及术后并发症.随访0.5～7年,平均3.5年.1例软骨肉瘤患者术后8个月复发,随访6个月带瘤生存.1例恶性纤维组织细胞瘤患者术后24个月出现肺、脑和全身多发转移死亡.1例骨肉瘤患者术后18个月出现肺转移死亡.6例骨盆转移瘤患者中5例分别于术后6～19个月出现其他部位转移而死亡.术后3个月18例患者患侧髋关节屈曲80°～130°,后伸0°～10°,外展25°～35°,内收18°～23°.结论 原位微波灭活术具有操作简便、疗效可靠、创伤小的特点,可用于或辅助用于骨盆恶性骨肿瘤的治疗,能保持骨盆环的完整性.

Abstract：

Objective To investigate the clinical outcomes of microwave heliotherapy in situ on the primary or metastatic malignant tumors of the pelvis.Methods From February 2000 to April 2009,18 patients with primary or metastatic malignant tumors of the pelvis were treated with microwave heliotherapy in situ,and followed a total or partial tumor resection.There were 11 males and 7 females with an average age of 45 years(range,16-72).Twelve cases were diagnosed as primary malignant tumor and 6 as metastases.Locations of tumors involved:the Ⅰ region 6 cases.the Ⅱ region 10 cases.and the Ⅲ region 2 cases.The exposures of all tumors were via a"T"type or ilioinguinal approach.The lesions were heated at 50℃ for 20 min by 2450 MHz microwave,with surrounding soft tissue protected by copper.mesh.The necrotic tumor tissues were total or partial excised after treatment,with preservation of the anatomical continuity of the pelvic ring.Results The duration of surgery was 60-180 min (110 min on average).The blood loss was 400-800ml(480 ml on average).All patients were followed-up for 0.5-7 years(3.5 years on average).Tumor local recurred in 1 case with chondrosarcoma,and was survival in tumor-bearing after 6 months follow up.One case with malignant fibrous histiocytoma died due to brain,pulmonary,and all body metastases.One case with osteosarcoma died due to pulmonary metastases.Five cases with the metastases died due to non-pelvis metastases.Functions of hip joint in 18 patients were as follows:flexion 80°-130°,extension 0°-10°,abduction 25°-35°,and adduction 18°-23°.Conclusion The clinical result demonstrated that the advantages of microwave heliotherapy in situ were quick increase of temperature,sensitive responses,easy control of temperature,and effective inactivation of tumor cells in the malignant bone tumors of pelvis.     

血管重建在骨与软组织肉瘤保肢术中的应用

目的 探讨血管重建在骨与软组织肉瘤保肢术中的作用.方法 2004年8月至2009年6月累及肢体重要血管的骨与软组织肉瘤患者13例接受保肢手术,男8例,女5例;年龄14～63岁,平均38岁.恶性骨肿瘤4例,软组织肉瘤9例.1例位于肱骨上端,12例位于下肢.7例同时重建动脉和静脉,6例仅重建动脉.5例采用同侧或对侧大隐静脉移植,8例采用人工血管置换.结果 无一例出现重建血管感染.1例肱骨骨肉瘤行肱动脉人工血管置换的患者于术后第1天出现急性动脉栓塞,急诊取栓后保留了肢体.人工血管置换8例中出现肢体肿胀和伤口不愈合5例,大隐静脉移植5例伤口均一期愈合.全部患者随访7～45个月,平均19.4个月.1例肱骨骨肉瘤患者术后12个月出现局部复发,保肢成功率92.3%(12/13).1例术前肺转移患者于术后7.5个月死于肺转移,另4例患者于术后半年至1年出现肺转移.Kaplan-Meier生存曲线分析患者2年总生存率和无瘤生存率分别为90.9%和63.6%,重建动、静脉2年通畅率分别为100%和28.6%.12例下肢肿瘤患者末次随访时的1993年美国骨肿瘤学会评分系统评分平均为72%,肱骨骨肉瘤患者为33%.结论 肿瘤累及血管不是截肢的绝对适应证,肿瘤连同重要血管整块切除后进行血管重建的保肢手术可行,可获得良好的局部肿瘤控制和肢体功能.

Abstract：

Objective To determine the feasibility of limb salvage with major vascular reconstruction for sarcomas of extremities, focusing on the early complications, oncological and functional outcomes.Methods Between August 2004 and June 2009, 13 patients (mean age 38 years, range 14-63 years) underwent wide resection of upper and lower extremity sarcomas to include the involved arterial and venous segments. 4 patients had bone sarcomas and 9 soft tissue sarcomas, 6 patients only had underwent artery replacement and the other 7 had underwent both artery and vein. 8 resected vessels were reconstructed with vascular graft and 5 with ipsilateral or contralateral saphenous vein. Results No patient suffered from reperfusion injury and infection. The patient with osteosarcoma in proximal humerus had suffered acute arterial graft thrombosis at first day postoperatively; however, the limb was salvaged after successful thrombectomy. 5 of 8 patients with synthetic graft developed minor delayed wound healing and hematoma, but the other 5 patients with autologous saphenous vein replacement did not. The mean follow-up was 19.4 months (7-45months). One patient died of pulmonary metastasis; the patient with osteosarcoma in proximal humerus had developed local recurrence, but refused amputation and was alive with metastasis. No arterial occlusion was observed at final follow-up or at the time of death, but the patency of artery and vein was 100% and 28.6%respectively. One patient who has pulmonary metastases before operation died of metastases 7.5 months after operation. Four patients developed pulmonary metastases, therefore, Kaplan-Meier survival analysis showed that 2-year overall and metastasis-free survival rate was 90.9% and 63.6% respectively. Functional status were judged as good or excellent (mean MSTS score 72%) in 12 of 13 patients. Conclusion The study indicate that malignant involvement of major vessels is not a contraindication for limb-salvage. Vascular reconstruction is a feasible option in limb salvage surgery. Wide resection with vascular reconstruction provide acceptable oncological and functional outcome of limb salvage.     

Role of shoulder gradient in the pathogenesis of rotator cuff tears

BACKGROUND Shoulder gradient has been associated with shoulder pathologies such as shoulder impingement syndrome.AIM To investigate if there is an association between shoulder gradient and incidence of rotator cuff tear(RCT).METHODS A total of 61 patients with a confirmed diagnosis of RCT were included in this retrospective study. The anteroposterior radiograph of the shoulder was used to measure shoulder gradient in adduction and neutral rotation positions. The pain level was assessed with the visual analog scale for pain.RESULTS The mean age of the patients was 55.7 ± 12.3 years. The mean visual analog scale of the patients was 4.1 ± 1.2. The mean shoulder gradient was 14.11°± 2.65° for the affected shoulder and 15.8°± 2.2° for the unaffected shoulders. This difference was not statistically significant(P = 0.41). A difference of 1.15°± 1.82° was found between the injured and non-injured shoulder. No significant association was found between the gradient difference of the shoulder and demographic and clinical characteristics of the patients.CONCLUSION Shoulder gradient is not associated with the pathology of RCT. Yet, future studies with more standardization and a larger sample size are needed to investigate the role of shoulder gradient in RCT pathogenesis further.     

自体肺动脉补片主动脉弓成形治疗婴儿主动脉缩窄合并弓发育不良

Objective To discuss the operative techniques and results of coarctation resection plus aortoplasty with pulmonary autograft patch for coarctation of the aorta combined with hypoplastic aortic arch in infant.Methods Between May 2007 and Dec 2009,14 cases including 9 males and 5 females with caorctation of the aorta and hypoplastic aortic arch underwent coarctation resection plus aortoplasty with pulmonary autograft patch in our hospital.The age ranged from 23 days to 17 months,with a median of 4.33 months.The mean body weight was (6.14 ±2.36) kg.All patients were diagnosed as aortic coarctation combined with VSD and hypoplastic aortic arch.The surgery was performed under deep hypothermia cardiopulmonary bypass with selective cerebral perfusion in 8 cases and circulation arrest in 6 cases.Fresh pulmonary autograft patch harvested from the main pulmonary artery was used for aortoplasty.The associated VSD was repaired in the same stage.Results All patients survived except one died from circulatory failure during the perioperative period.Low cardiac output syndrome occurred in another case who was cured afterwards by correspondent treatments.No residual obstruction was detected by echocar-diography after the operation.Follow-up was carried out in 13 cases from 4 months to 3 years.Echocardiographic examination showed that the pressure gradient across the aortic arch was less than 16 mm Hg in all cases.The blood velocity at the descending aortic arch was not significantly changed during the follow-up period as compared with that of the immediate after operation.Computed tomography showed that the morphology of aortic arch was normal.The left bronchus compression was relieved obviously or totally disappeared in patients who suffered from left bronchus stenosis before operation,and no aortic aneurysm were detected in these patients.Conclusion Conclusion Coarctation resection plus aortoplasty with pulmonary autograft patch is the optimal surgical method for treating coarctation of the aorta combined with hypoplastic aortic arch in infant.     

自体肺动脉补片主动脉弓成形治疗婴儿主动脉缩窄合并弓发育不良

Objective To discuss the operative techniques and results of coarctation resection plus aortoplasty with pulmonary autograft patch for coarctation of the aorta combined with hypoplastic aortic arch in infant.Methods Between May 2007 and Dec 2009,14 cases including 9 males and 5 females with caorctation of the aorta and hypoplastic aortic arch underwent coarctation resection plus aortoplasty with pulmonary autograft patch in our hospital.The age ranged from 23 days to 17 months,with a median of 4.33 months.The mean body weight was (6.14 ±2.36) kg.All patients were diagnosed as aortic coarctation combined with VSD and hypoplastic aortic arch.The surgery was performed under deep hypothermia cardiopulmonary bypass with selective cerebral perfusion in 8 cases and circulation arrest in 6 cases.Fresh pulmonary autograft patch harvested from the main pulmonary artery was used for aortoplasty.The associated VSD was repaired in the same stage.Results All patients survived except one died from circulatory failure during the perioperative period.Low cardiac output syndrome occurred in another case who was cured afterwards by correspondent treatments.No residual obstruction was detected by echocar-diography after the operation.Follow-up was carried out in 13 cases from 4 months to 3 years.Echocardiographic examination showed that the pressure gradient across the aortic arch was less than 16 mm Hg in all cases.The blood velocity at the descending aortic arch was not significantly changed during the follow-up period as compared with that of the immediate after operation.Computed tomography showed that the morphology of aortic arch was normal.The left bronchus compression was relieved obviously or totally disappeared in patients who suffered from left bronchus stenosis before operation,and no aortic aneurysm were detected in these patients.Conclusion Conclusion Coarctation resection plus aortoplasty with pulmonary autograft patch is the optimal surgical method for treating coarctation of the aorta combined with hypoplastic aortic arch in infant.     

复杂下腔静脉恶性肿瘤的外科处理

目的 探讨手术治疗复杂重症下腔静脉恶性肿瘤的方法及其效果.方法 2004年12月至2008年7月对8例下腔静脉肿瘤行手术治疗,其中7例患者8次在体外循环或右心房插管灌注下手术切除下腔静脉肿瘤或(和)延及右心房/室内肿瘤;1例下腔静脉平滑肌肉瘤局部复发行下腔静脉置换术.术前CT或MRI检查均已除外远处转移.结果 1例患者于术后2个月死于肝衰竭,其他7例术后症状均缓解并顺利出院.7例患者随访5～45个月,平均(15±4)个月.其中3例术后随访14～24个月,效果良好,无复发;3例术后4、5及32个月后原位复发并全身多处转移,其中1例是罕见的下腔静脉多形性恶性纤维组织细胞瘤,5个月后复发并右肾上腺转移癌,9个月后再次切除下腔静脉及右心房/室内肿瘤,术后11个月第3次复发死于心衰;另2例复发者未再次手术,其中1例术后7个月行化疗后症状缓解.1例45个月后失访.结论对于复杂腔静脉恶性肿瘤如未发现其他部位转移可采取积极手术治疗,如此可明显改善患者近期生存质量.

Abstract：

Objective To explore the surgical strategy and effects for treating complex malignant tumors of the inferior vena cava (IVC) or/and the tumors extending into right atrium/ventricle.Methods Between Dec 2004 and Jul 2008, eight patients underwent surgical resections, among those seven patients with tumors of IVC or the tumors extending into right atrium/ventricle were operated on under deep hypothermia with cardiopulmonary bypass( CPB), and one patient with recurrence of leiomyosarcoma of the IVC successfully underwent en bloc resection and caval reconstruction. The prosthetic graft was used for IVC reconstruction in two patients and vascular patch in the other two patients. Preoperative chest roentgenography, computed tomography, ultrasonography, or magnetic resonance imaging was used to exclude the presence of metastatic disease, to assess local resectability of the tumour and the extent of involvement and obstruction of the IVC. Results One patient died of liver failure postoperatively. The postoperative course was uneventful in other 7 patients. On follow-up two patients died 2 and 5 months later due to functional disorder of the liver. Three patients have been followed up for 14 - 24 months and were     

Combined anterior and posterior surgery for treatment of cervical fracture-dislocation in patients with ankylosing spondylitis

To discuss the pathological characteristics of cervical spinal fracture complicating ankylosing spondyli-tis-(AS) and the effect of combined anterior and posterior operation. Methods: Eighteen AS patients with traumatic cervical fracture-dislocation were treated operatively from January 2000 to January 2006. The symptom duration of AS was 14.5 years on average. Three cases had undergone osteotomy in lumbar spine. There were 4 cases of Grade A, 3 cases of Grade B, 9 cases of Grade C and 2 cases of Grade D accord-ing to Frankel's score. There were 15 cases of Grade Ⅲ dislocation and 3 cases of Grade Ⅱ. All patients underwent surgical procedures by combined anterior and posterior approach.Results: There were 4 anterior-posterior procedures, 8 anterior-posterior-anterior procedures and 6 posterior-an-terior procedures. Seven patients had one stage operation and 11 cases underwent two stage surgeries. There was certain extent of neorological improvement in 14 incomplete paraplegic patients, but no improvement in 4 complete paraplegic patients. The follow-up period was 21.2 months on average and the time for bone fusion was 3.6 months. There were 4 complications during operation and a long-term complication in follow-up. Conclusions: The study suggests that anterior com-bined with posterior approach makes the spine stable and relieves the pressure immediately. It is a reasonable surgical strategy for treatment of cervical spinal fracture-dislocation with AS.     

Combined anterior and posterior surgery for treatment of cervical fracture-dislocation in patients with ankylosing spondylitis

To discuss the pathological characteristics of cervical spinal fracture complicating ankylosing spondyli-tis-(AS) and the effect of combined anterior and posterior operation. Methods: Eighteen AS patients with traumatic cervical fracture-dislocation were treated operatively from January 2000 to January 2006. The symptom duration of AS was 14.5 years on average. Three cases had undergone osteotomy in lumbar spine. There were 4 cases of Grade A, 3 cases of Grade B, 9 cases of Grade C and 2 cases of Grade D accord-ing to Frankel's score. There were 15 cases of Grade Ⅲ dislocation and 3 cases of Grade Ⅱ. All patients underwent surgical procedures by combined anterior and posterior approach.Results: There were 4 anterior-posterior procedures, 8 anterior-posterior-anterior procedures and 6 posterior-an-terior procedures. Seven patients had one stage operation and 11 cases underwent two stage surgeries. There was certain extent of neorological improvement in 14 incomplete paraplegic patients, but no improvement in 4 complete paraplegic patients. The follow-up period was 21.2 months on average and the time for bone fusion was 3.6 months. There were 4 complications during operation and a long-term complication in follow-up. Conclusions: The study suggests that anterior com-bined with posterior approach makes the spine stable and relieves the pressure immediately. It is a reasonable surgical strategy for treatment of cervical spinal fracture-dislocation with AS.     

Combined anterior and posterior surgery for treatment of cervical fracture-dislocation in patients with ankylosing spondylitis

To discuss the pathological characteristics of cervical spinal fracture complicating ankylosing spondyli-tis-(AS) and the effect of combined anterior and posterior operation. Methods: Eighteen AS patients with traumatic cervical fracture-dislocation were treated operatively from January 2000 to January 2006. The symptom duration of AS was 14.5 years on average. Three cases had undergone osteotomy in lumbar spine. There were 4 cases of Grade A, 3 cases of Grade B, 9 cases of Grade C and 2 cases of Grade D accord-ing to Frankel's score. There were 15 cases of Grade Ⅲ dislocation and 3 cases of Grade Ⅱ. All patients underwent surgical procedures by combined anterior and posterior approach.Results: There were 4 anterior-posterior procedures, 8 anterior-posterior-anterior procedures and 6 posterior-an-terior procedures. Seven patients had one stage operation and 11 cases underwent two stage surgeries. There was certain extent of neorological improvement in 14 incomplete paraplegic patients, but no improvement in 4 complete paraplegic patients. The follow-up period was 21.2 months on average and the time for bone fusion was 3.6 months. There were 4 complications during operation and a long-term complication in follow-up. Conclusions: The study suggests that anterior com-bined with posterior approach makes the spine stable and relieves the pressure immediately. It is a reasonable surgical strategy for treatment of cervical spinal fracture-dislocation with AS.     

肩胛带区骨肿瘤的保肢治疗

目的探讨肩胛带区骨肿瘤的保肢手术方法及相关的临床效果。方法35例肩胛带骨肿瘤患者,男24例,女11例,平均年龄34岁(12～74岁)。肿瘤部位:肱骨上段21例,肩胛骨12例,锁骨2例;肿瘤类型:骨肉瘤10例,软骨肉瘤7例,恶性纤维组织细胞瘤3例,尤文肉瘤3例,纤维肉瘤1例,骨髓瘤1例,骨巨细胞瘤7例,转移瘤3例。按照Malawer等提出的手术分类方法进行分类。保肢手术方法:肿瘤假体置换8例,瘤段骨灭活回植4例,异体骨关节移植3例,自体腓骨移植2例,髓针骨水泥假体置换1例,Tikhoff-Linberg手术3例,瘤段肢体切除、上肢短缩再植2例,全肩胛骨或关节盂切除、肱骨头悬吊4例,部分肩胛骨切除6例,锁骨瘤段切除2例,其中16例作了化疗。结果本组患者平均随访71个月(6～186个月),局部复发4例,远处转移6例,死亡9例,无瘤存活22例。按MSTS上肢功能评分标准,35例患者上肢功能评分平均为77%(40%～100%),上肢功能与手术切除范围密切相关。并发症:切口感染裂开4例,移植骨骨折2例,暂时性桡神经麻痹2例,肩关节半脱位3例。结论肩胛带区骨肿瘤的治疗应根据患者情况、肿瘤类型及侵袭范围等因素决定切除范围并选择应用肿瘤假体置换、自体或异体骨关节移植、瘤段骨骨灭活回植及Tikhoff-Linberg手术等重建方法,可以达到控制肿瘤、稳定无痛的肩关节重建和保留良好的肘部与手部功能的目的。     

Limb sparing surgery for bone tumours of the shoulder girdle: the oncological and functional results

It is a great challenge to spare the upper limb with a malignant or invasive benign bone tumour of the shoulder girdle. We retrospectively analysed 35 patients with bone tumours of the shoulder girdle treated with various limb salvage procedures. The tumours included 25 primary malignancies, three metastases and seven giant cell tumours which involved the proximal humerus in 21 patients, scapula in 12 and clavicle in two. The reconstruction procedures included eight prosthetic replacements, four devitalised tumorous bone grafts, three osteoarticular allografts, two autogenous fibular grafts, one intramedullary cemented nail, three Tikhoff-Linberg procedures, two replantation of shortened arms, and four humeral head suspensions. Six partial scapulectomies and two lateral clavicectomies needed no bone reconstruction. With an average follow-up of 71 months, local recurrences occurred in four cases and systemic metastases in six. Nine patients died and 23 remained disease free. The five year Kaplan-Meier survival rate of 28 patients with malignancies was 69.5%. The average Musculoskeletal Tumour Society (MSTS) functional score was 77% (range 40–100%) in all patients.     

Tikhoff-Linberg procedure for bone and soft tissue tumors of the shoulder girdle

OBJECTIVE: To evaluate complications and the oncological and intermediate-term functional results in patients with bone and soft tissue tumors of the shoulder girdle who were managed with interscapulothoracic resection (Tikhoff-Linberg procedure). DESIGN: Case series of 19 consecutive patients during a 10-year period at a mean follow-up of 6.3 years (range, 1-11 years). SETTING: University hospital; referral center for musculoskeletal tumor surgery. PATIENTS: The initial diagnosis in this consecutive series of patients with shoulder girdle tumors requiring the Tikhoff-Linberg procedure was chondrosarcoma in 7 patients, Ewing sarcoma in 3 patients, malignant fibrous histiocytoma in 3 patients, solitary metastasis of thyroid carcinoma in 2 patients, osteosarcoma, synovial sarcoma, angiosarcoma, ancd neurofibrosarcoma in 1 patient each. According to the Musculoskeletal Tumor Society staging system, there were 6 in surgical stage IB, 10 in stage IIB, and 3 in stage III. Nine tumors involved the proximal humerus, 8 were located in the scapula or surrounding soft tissues, 1 in the lateral clavicle, and 1 in the acromioclavicular joint. INTERVENTIONS: For reconstruction of the proximal humerus after en bloc tumor resection an isoelastic cemented shoulder tumor prosthesis was inserted in every patient to restore arm length. MAIN OUTCOME MEASURES: Complications, and oncological and intermediate-term functional results. RESULTS: Twelve patients were alive with no evidence of disease. One of these patients died of nontumorous disease 2 years after surgery. One patient is alive with pulmonary metastases after 12 months. Six patients died of metastases at a mean (SD) interval of 18 months (range, 3-35 months) postoperatively. Two of these patients had additional local recurrence. A deep infection necessitated the explantation of the prosthesis in 1 patient. The mean functional score and SD according to the rating system of the Musculoskeletal Tumor Society was 72%+/-14% (range, 33%-87%) for the 12 surviving patients evaluated. Major complications (1 infection and 2 local recurrences) that may be attributed to the procedure occurred in 3 of the 19 patients. CONCLUSION: Despite an overall complication rate of 74% the Tikhoff-Linberg procedure proved to be a valuable surgical procedure for extended tumors of the shoulder girdle for functional and oncological outcome and is superior to forequarter amputation.     

Constrained total scapula reconstruction after resection of a high-grade sarcoma

Patients with high-grade sarcomas arising from the scapula or periscapular soft tissues traditionally have been treated with either a total scapulectomy or a wide, en bloc, extraarticular scapular resection, termed the Tikhoff-Linberg resection. The major challenge after such resections is to restore shoulder girdle stability while preserving a functional hand and elbow. The current authors describe three patients who had an extraarticular, total scapula resection (modified Tikhoff-Linberg) for a high-grade sarcoma. Each patient had reconstruction with a constrained (rotator cuff-substituting) total scapula prosthesis in an effort to optimally restore the normal muscle force couples of both glenohumeral and scapulothoracic mechanisms. At latest followup, the Musculoskeletal Tumor Society functional score was 24 to 27 of 30 (80%-90%). All patients had a stable, painless shoulder and functional hand and elbow. Forward flexion and abduction ranged from 25 degrees to 40 degrees. Glenohumeral rotation (internal rotation, T6; external rotation -10 degrees) below shoulder level, shoulder extension, and adduction were preserved. Protraction, retraction, elevation, and abduction of the scapula were restored and contributed to shoulder motion and upper extremity stabilization. There were no complications. Total scapula reconstruction with a constrained total scapula prosthesis is a safe and reliable method for reconstructing the shoulder girdle after resection of select high-grade sarcomas. The authors emphasize the clinical indications, prosthetic design, surgical technique, and early functional results.     

肩胛带巨大软组织肉瘤的外科治疗

目的 探讨肩胛带巨大软组织肉瘤的外科治疗特点和影响治疗效果的各种因素.方法 2005-2009年我科治疗7例肩胛带巨大软组织肉瘤患者,男性4例,女性3例.7例均为术后复发患者.年龄14 ～75岁,平均43.8岁.肿瘤最大径10～ 16 cm.所有患者均行手术治疗,其中广泛切除4例,边缘切除3例.5例患者行肿物局部切除背阔肌肌瓣转移取皮植皮术,1例患者行局部推进皮瓣术,另1例患者行肿物局切取皮植皮术.术后病理:3例恶性纤维组织细胞瘤、1例低度恶性黏液性纤维肉瘤、1例原始神经外胚层瘤、1例腺泡状横纹肌肉瘤、1例皮肤隆突性纤维肉瘤.术后采用国际肌肉骨骼系统肿瘤协会(MSTS)标准进行肩关节功能评分.结果 7例患者得到长期随访,平均随访时间29个月(10 ～46个月).2例患者有局部复发,其中1例再次术后6个月肺转移死亡;1例患者有肺转移;其余4例患者无复发及肺转移.术后患者肩关节功能满意,MSTS评分28分.结论 肩胛带软组织肉瘤在早期常被误诊误治,广泛的外科边界是控制局部复发的主要因素.外科边界和病变的侵袭性是肩胛带软组织肉瘤预后的主要影响因素.手术造成的巨大软组织缺损常需局部肌瓣或皮瓣转移来修补,常用背阔肌肌瓣转移.     

Function following limb salvage for primary tumors of the shoulder girdle: 10 patients followed 4 (1-11) years

10 patients with primary neoplasms of the shoulder girdle underwent limb salvage procedures involving resection of the proximal humerus and parts of the scapula and clavicle. The function of the ipsilateral limb was assessed in all patients, in 9 at least one and a half years after surgery. Function was good in 3 of the 6 patients in whom an interposition bone graft was used and a successful shoulder arthrodesis was achieved. In the remaining 3, proximal arthrodesis was unsuccessful and the result was fair in 2 and a failure in 1. All 3 patients in whom the extended Tikhoff Linberg type of reconstruction was undertaken had good function although unsatisfactory cosmetic results. The 10th patient, who had a temporary cement and wire interposition, died of distant metastases 8 months after surgery and was considered a failure.     

Functional results and quality of life after shoulder girdle resections in musculoskeletal tumors

From 1981 to 2001, 91 shoulder resections were performed to treat shoulder girdle tumors (64 primary and 27 metastatic) in 90 patients (53 male and 37 female patients). The mean age was 34 years in patients with a primary tumor and 61 years in those with metastases. There were 7 partial scapulectomies, 13 total scapulectomies, 56 proximal humeral resections, 5 diaphyseal resections, 5 total shoulder girdle resections (Tikhoff-Linberg procedure), and 5 other procedures performed. Prosthesis implantation was carried out in 41 cases, autologous fibular transposition was done in 19, and massive homologous bone grafting was done in 4. Of the patients, 37 were clinically reviewed with a mean follow-up of 4.7 years (range, 1-20 years) by use of the recommendations of the Musculoskeletal Tumor Society for pain, function, position of hand, lifting ability, manual dexterity, and satisfaction. Nine patients were reviewed via a questionnaire and telephone interview. Twenty-six had died, and eighteen were lost to follow-up. The best results were achieved after partial scapulectomy and after humeral resection reconstructed with fibular transposition, when the function of the rotator cuff was preserved. After total scapulectomy and after humeral resection with the implantation of a tumor endoprosthesis, the function of the shoulder remained moderate because the rotator cuff was damaged. The overall satisfaction was generally good after all types of shoulder resections as a result of pain relief, preserved hand function, and improvement of psychological status. Patients can compensate extremely well by using the preserved joints and the contralateral upper limb; therefore, patient satisfaction does not rely on shoulder function alone.     

Radikale Skapulektomie mit Musculus-trapezius-Transfer bei Weichteilsarkom des Schultergürtels

In soft-tissue sarcoma, wide tumour excision (R0) has become the most important factor in local tumour control. Nowadays, radical scapulectomy with limb salvage is the treatment of choice for soft-tissue sarcomas of the shoulder girdle. We present the case of a 78-year-old man with extended low-grade fibrosarcoma of the left shoulder girdle. Despite his age, radical scapulectomy with intraoperative radiation and functional reconstruction of the shoulder girdle with a myocutaneous trapezius flap was performed. Good functional and aesthetic results could be obtained.     

Tikhoff-Linberg scapulo-humeral resection]

There is a trend away from amputation to salvage procedures for limb cancer. An effective adjuvant chemotherapy and the development of diagnostic imaging allow the surgeon to be more confident and conservative with a limb-salvage procedure. The Tikhoff-Linberg resection is a limb-sparing option to be considered for tumors of the proximal humerus and shoulder girdle. There are three different variants of the procedure published in the literature. An exact classification of the local extent of disease is necessary to indicate the variant of Tikhoff-Linberg resection which will promise the best functional result without loss of oncological adequacy.