19例股骨颈原发溶骨性损害的手术治疗

目的：总结股骨颈原发溶骨性损害的手术治疗结果。方法：自1973－1999年共收治股骨颈原发溶骨性病损19例,其中瘤样样病变11例,良性肿瘤4例,恶性骨肿瘤2例,骨梗死2例,采用瘤段切除,人工股骨头置换1例,肿瘤刮除,骨水泥和髓内钉填塞,接骨板固定2例,肿瘤刮除植骨16例。结果：随访6个月－20年,平均5．8年,骨肉瘤患者术后2年死于肿瘤肺转移,软骨肉瘤患者术后1．5年肿瘤局部复发,行股骨近端置换,1例骨水泥和三翼钉植入者8年后患侧股骨粗隆部骨折,再次手术安装接骨板,3个月后骨折愈合,余患者4－8个月植骨融合,无股骨头坏死或塌陷,肿瘤无复发征象,结论：原发股骨颈溶骨性损害以瘤样病变居多,良性病变无论病变范围的大小,采用病灶清除,腔内植骨骨或骨水泥填塞均取得良好效果。     

股骨头软骨母细胞瘤的诊断与治疗

目的 探讨股骨头软骨母细胞瘤的诊断及治疗方法.方法 对1999年2月至2008年3月收治的13例股骨头软骨母细胞瘤病例的诊断和治疗进行回顾性分析,男8例,女5例;年龄9～29岁,平均17.9岁.术前Hartis评分平均为67分(38～78分).所有患者术前经详细的影像学评估后行手术治疗.术前活检3例,术中冰冻病理检查2例.所有最终诊断以术后病理为准.所有患者行前侧Smith-Peterson入路经股骨头圆韧带止点开窗行肿瘤刮除植骨术,自体骨植骨7例,异体骨植骨5例,自体骨加异体骨混合植骨1例.结果 13例均获得随访,中位随访时间26个月(6～84个月).所有患者随访期间无肿瘤复发.1例自体骨植骨患者术后2个月部分负重后出现股骨头塌陷坏死,6个月后改行股骨头切除人工全髋关节置换.其余患者功能良好,术后Harris评分平均88分(69～98分),较术前提高21分.自体骨植骨患者平均骨愈合时间5.3个月(3～11个月),异体骨植骨患者6.8个月(3～13个月),混合植骨患者4个月.结论 股骨头软骨母细胞瘤是一种少见肿瘤,有独特的临床及影像学特征.髋关节前侧Smith-Peterson入路经股骨头圆韧带止点开窗肿瘤刮除植骨术是一种有效的治疗方案.术后植骨愈合前避免负重,并进行免负重髋关节功能锻炼,可以提高治疗效果.     

带血供腓骨移植重建股骨近端溶骨性病变致骨缺损

[目的]评价带血供游离腓骨移植重建股骨近端侵袭性良性溶骨性病变所致骨缺损的临床疗效。[方法]总结自2008年4月~2013年3月收治股骨近端良性侵袭性肿瘤或肿瘤样病变共14例,采用病灶内扩大刮除、氯化锌烧灼瘤壁,吻合血管腓骨移植,支持钢板内固定等方法手术治疗,影像学随访评价病变转归、植骨愈合;采用改良肌肉骨髂系统肿瘤学会(Musculoskeletal Tumor Society,MSTS)肢体功能评价表随访肿瘤切除术后患者肢体功能。[结果]随访18~67个月,平均(35.71±15.80)个月。其中1例骨巨细胞瘤患者于术后12个月复发。其余13例患者随访期间均未见病变复发表现,钢板固定无松动、断裂,无术后病理性骨折,未见股骨头缺血性坏死等其他并发症。移植腓骨无缺血坏死表现、与受区2~7个月骨性愈合,平均愈合时间(4.54±1.27)个月。术后3、6个月MSTS功能评分依次为(25.57±4.27),(27.07±6.53)分。[结论]病灶刮除,氯化锌烧灼瘤壁,吻合血管腓骨移植填充重建,结合支持钢板内固定是股骨近端侵袭性良性肿瘤及瘤样病变的有效外科治疗方法。中期随访表现为病变复发率低,破坏骨结构得以重建,髋关节功能良好。     

经Watson-Jones入路股骨近端防旋髓内钉联合病灶刮除植骨治疗股骨近端良性病变

目的探讨经Watson-Jones入路股骨近端防旋髓内钉(proximal femoral nail anti-rotation,PFNA)联合病灶刮除植骨治疗股骨近端良性肿瘤和瘤样病变的可行性,评估治疗效果。方法回顾分析2008年1月—2015年1月采用经Watson-Jones入路PFNA联合病灶刮除植骨治疗的38例股骨近端良性病变患者临床资料。其中男24例,女14例;年龄15～57岁,平均28岁。病理类型:纤维结构不良20例,骨囊肿7例,动脉瘤样骨囊肿5例,骨巨细胞瘤3例,内生软骨瘤2例,非骨化性纤维瘤1例。临床表现:髋关节疼痛19例,病理性骨折12例,肢体短缩、髋关节内翻畸形4例,出现原有病灶复发3例。记录手术时间、术中出血量以及术后完全负重时间。随访摄X线片及三维CT,了解植骨融合情况及内固定物位置,采用疼痛视觉模拟评分(VAS)评价疼痛程度,国际骨与软组织肿瘤协会(MSTS93)评分标准评估下肢功能,Harris评分评估髋关节功能。结果手术时间为130～280 min,平均182 min;术中出血量为300～1 500 mL,平均764 mL。术后3例出现切口脂肪液化,均经正规换药顺利愈合,未造成深部感染;其余患者切口均Ⅰ期愈合。所有患者均于术后2～4周开始部分负重,完全负重时间为3～6个月,平均4.2个月。38例均获随访,随访时间24～108个月,中位随访时间60个月。影像学检查提示植骨均融合,融合时间为8～18个月,平均11.4个月。随访期间无病理性骨折、股骨头缺血性坏死、关节脱位、内固定物松动断裂等并发症发生,无肿瘤复发和远处转移。末次随访时,VAS评分、MSTS93评分和Harris评分均较术前显著改善,差异有统计学意义(P0.05)。结论经Watson-Jones入路刮除植骨后联合PFNA内固定治疗股骨近端良性病变,能够在彻底清除病灶的同时获良好力学稳定性,且术后并发症少,是一种安全有效的治疗方法。     

四肢长骨骨巨细胞瘤手术治疗

目的比较不同手术方法治疗四肢长骨骨巨细胞瘤的临床效果。方法回顾分析1998年11月至2006年4月手术治疗的37例四肢长骨骨巨细胞瘤。结果37例患者均获得随访，随访时间8个月至7年2个月，平均2年11个月。病灶刮除＋酒精灭活＋骨水泥填充术21例，肿瘤复发3例；病灶刮除＋酒精灭活＋骨水泥填充植骨术12例，肿瘤复发3例；瘤段切除人工假体置换术4例，肿瘤复发0例。病灶刮除组总复发率18．2％，瘤段切除组织复发率为0。结论病灶刮除＋酒精灭活＋骨水泥填充术和肿瘤瘤段切除术均是治疗骨巨细胞瘤的可靠方法。     

弹性髓内钉在治疗儿童长骨部分瘤样病变并病理性骨折中的应用

目的 探讨病灶刮除植骨结合弹性髓内钉内固定术治疗儿童长骨部分瘤样病变合并病理性骨折的疗效及特点。 方法 2010年 1 月至2013年 12月我院共收治儿童长骨部分瘤样病变并病理性骨折 16 例,均实施病灶刮除植骨并弹性髓内钉内固定术,通过术后影像学X线片结果和临床随访两方面评价治疗效果。影像学X线结果评估包括病变骨骨折复位有无丢失及病灶愈合情况。临床评估采用肩、肘、髋、膝、踝等关节功能综合评价标准及随访术后患者的满意度。结果 16 例患儿平均随访25.6个月。影像学X线片显示病理性骨折均达骨性愈合,愈合时间4～6个月,平均 5 个月。在随访过程中,病灶未出现复发或者再次骨折。术后平均 12.5 个月取钉。至末次随访时病灶完全消失（14 例）或部分消失（2例）;患肢无疼痛,关节活动均不受限。结论 病灶刮除植骨结合弹性髓内钉内固定术可作为治疗儿童长骨部分瘤样病变并病理性骨折的有效方法。     

胸腰椎椎体骨样骨瘤的临床表现和切除重建策略

目的探讨胸腰椎椎体骨样骨瘤患者的临床表现特点和后路经椎弓根肿瘤切除植骨内固定手术的疗效。方法 2001年1月-2010年6月,收治8例胸腰椎椎体骨样骨瘤患者。男5例,女3例;年龄6～27岁,中位年龄15.5岁。出现症状至就诊时间为2～19个月,平均11.8个月。病灶节段:L2、L5各2例,L3、L4、T8和T10各1例。主要临床表现为腰背部疼痛,1例存在下肢放射痛,4例合并脊柱侧凸。病灶直径0.9～2.0 cm,平均1.6 cm。患者均行后路经椎弓根椎体内病灶刮除、打压植骨、一期内固定手术。结果手术时间70～170 min,平均110 min。术中出血量300～1 400 mL,平均720 mL。术后病理检查均证实为骨样骨瘤。患者切口均Ⅰ期愈合,腰背疼痛和下肢放射痛均完全消退,无并发症发生。术后随访时间12～58个月,平均39个月。随访期间无肿瘤复发及脊柱畸形发生。结论 CT能显示椎体骨样骨瘤低密度瘤巢和周围的骨硬化带,是胸腰椎椎体骨样骨瘤重要影像学检查方法;采用后路经椎弓根椎体内病灶刮除、打压植骨、一期内固定手术可获得较好疗效。     

四肢长骨良性肿瘤并发骨折的手术时机

目的:探讨四肢长骨良性肿瘤并发骨折的手术时机。方法:回顾性分析25例四肢长骨良性肿瘤并发骨折患者,其中骨囊肿11例,骨纤维异常增殖症5例,嗜酸性肉芽肿3例,动脉瘤样骨囊肿2例,内生软骨瘤2例,非骨化性纤维瘤1例,骨化性纤维瘤1例。采用Ⅰ期外固定、Ⅱ期肿瘤刮除植骨术13例,Ⅰ期肿瘤清除植骨内固定术12例。结果:随访时间12~88个月,术后感染1例,复发3例,再骨折2例。结论:对于良性肿瘤或类肿瘤疾病发生病理性骨折应优先选择Ⅰ期外固定、Ⅱ期行肿瘤病灶清除植骨术;骨质破坏较轻者可选择Ⅰ期肿瘤病灶清除植骨内固定术。     

经Watson-Jones入路动力髋螺钉内固定联合病灶刮除治疗股骨近端良性病变

目的探讨经Watson-Jones入路采用动力髋螺钉(dynamic hip screw,DHS)内固定联合病灶扩大刮除治疗股骨近端良性肿瘤及肿瘤样病变的疗效。方法 2012年3月—2016年12月,采用经Watson-Jones入路DHS内固定联合病灶扩大刮除治疗股骨近端良性肿瘤及肿瘤样病变患者20例(21处)。其中男13例,女7例;年龄11~51岁,平均27.8岁。病变累及单侧股骨19例,双侧1例。病理类型:纤维结构不良11例,骨囊肿2例,动脉瘤样骨囊肿2例,良性纤维组织细胞瘤2例,骨巨细胞瘤2例,软骨母细胞瘤1例。Enneking外科分期:除3例病理性骨折为S2期外,其余均为S1期。术前均无股骨近端内、外翻畸形。记录手术时间、术中出血量以及患者术后完全负重时间。随访摄X线片及CT,了解植骨及DHS情况;采用疼痛视觉模拟评分(VAS)评价疼痛缓解情况,国际骨与软组织肿瘤协会(MSTS)评分标准评估下肢功能。结果手术时间110~265 min,平均177.1 min;术中出血量200~2 300 mL,平均828.6 mL。术后发生切口浅表感染1例,深部感染1例,存在患髋不适感1例。患者均获随访,随访时间为6~63个月,平均27.4个月。2例骨巨细胞瘤患者术后2 d达完全负重;其余患者术后2~13周完全负重,平均7.2周。末次随访时,VAS评分为(0.19±0.51)分,与术前的(3.52±2.62)分比较,差异有统计学意义(t=5.565,P=0.000)。患者髋关节功能均恢复良好,末次随访时MSTS评分为(29.62±0.97)分,与术前的(23.71±8.77)分比较,差异有统计学意义(t=–3.020,P=0.007)。影像学检查示植骨均融合,融合时间为5~12个月,平均8.2个月。术后无病理性骨折、内固定物松动和断裂、股骨头缺血坏死以及关节脱位发生。随访期间无肿瘤复发、转移。结论经Watson-Jones入路充分暴露后行病灶刮除修复病损、DHS内固定治疗股骨近端良性肿瘤及肿瘤样病变安全、有效。     

自体骨泥混入骨膜碎片修复肿瘤及瘤样病变骨缺损

目的探讨自体骨泥混入骨膜碎片修复肿瘤及瘤样病变骨缺损的疗效方法对18例骨肿瘤及瘤样病变患者行病灶刮除,自体骨泥混入骨膜碎片修复骨缺损。结果经8～38个月随访,X线片显示成骨良好,骨缺损完全修复,肢体无畸形,功能基本恢复正常。结论自体骨泥混入骨膜碎片修复肿瘤及瘤样病变骨缺损效果满意,是一种值得研究的新方法     

股骨近端良性骨肿瘤和瘤样病变的手术治疗

股骨近端的良性骨肿瘤和瘤样病变并不少见，其病变亦多种多样，术前术后均易发生各种并发症。本文统计分析了我所１９８３年７月～１９９３年１０月收治的４９例股骨近端良性骨肿瘤和瘤样病变的病人，所有病人均经手术治疗，术后病理诊断。本组病人采用病变刮除，５０％氯化锌烧灼，皮质骨和／或松质骨植骨的方法治疗。不同的植骨方法对病变的预后有不同的影响，皮质骨植骨有助于防止术后髋内翻和病理骨折的发生。对于病变累及股骨头的病人，其病变较大可能发生股骨头无菌坏死，用单纯病变刮除，５０％氯化锌烧灼加植骨的方法难以奏效，需用更彻底的方法去除病变和功能重建，如人工股骨头置换。     

股骨颈骨折延迟及不连接的股骨头病理改变与手术疗效观察

１９８２～１９９５年间收治２５９例陈旧性股骨颈骨折，手术前采用Ｘ线片、病理组织学、电镜、四环素荧光标记和ＥＣＴ观察股骨头病理改变，发现股骨头坏死在不负重状态下有其自然的修复规律，股骨头塌陷在其修复过程中与所受的应力大小有关。２５９例中１９８例采用吻合血管腓骨移植治疗，２４例采用缝匠肌肌瓣骨移植，２２例采用带旋髂深血管蒂髂骨移植，１５例行人工关节置换处理。其中１６６例吻合血管腓骨移植病例得到了３～１２年的系统Ｘ线片和功能随访观察，优良率为８４．３％。作者认为；陈旧性股骨颈骨折在良好的复位情况下采用吻合血管的腓骨与加压螺纹钉有协同固定和支撑作用。     

青壮年移位性股骨颈骨折的治疗——附55例病例长期随访

目的 评价股方肌肌骨瓣移植治疗青壮年移位性股骨颈骨折的长期疗效.方法 55例26～57岁股骨颈移位性骨折(GardenⅢ-Ⅳ型)患者,采用带股方肌肌蒂骨瓣移植和螺纹钉内固定术治疗.结果 本组55例均获随访,随访时间为4年6个月～10年8个月.所有患者的股骨颈骨折均在6～9个月内愈合,5例发生股骨头坏死.结论 带股方肌肌蒂骨瓣移植治疗青壮年移位性股骨颈骨折是一种疗效确切、创伤较小、操作方便的有效方法.     

Combined anterior and lateral approaches for bone tumors of the femoral neck and head

Few reports in the literature describe the treatment experience of benign lesions of the femoral head and neck. Between July 2005 and August 2009, twenty-four patients with bone tumor of the femoral neck and head were treated at the authors' institution. Fourteen patients had pathological fractures of the femoral neck; in the other 10 patients, the bone cortex was involved. Average tumor size was 78 cc (range, 45-130 cc). The patients were treated by curettage plus bone grafting via an anterior approach (Smith-Petersen incision) and internal fixation via a lateral approach (Hardinge approach). Average follow-up was 34 months (range, 10-68 months).Average blood loss and operative time were 450 mL and 87 minutes, respectively. Six patients experienced complications: 2 superficial wound infections, 2 immunological rejections, and 2 hollow screw loosenings and slight limps at 12 and 16 months postoperatively, respectively. No recurrence or other serious complications, such as pathological fracture, ischemic necrosis of the femoral head, or joint degeneration, occurred. Average Musculoskeletal Tumor Society score for lower extremity function was 29.2 (range, 27-30) at final follow-up, and all patients resumed their normal preoperative work and were pain free postoperatively, although 1 patient had a slight limp at final follow-up.A combination of anterior and lateral approaches may produce good clinical and functional results with minimal complications in bone tumors of the femoral neck.     

儿童股骨近端骨肿瘤的手术治疗

目的:总结儿童股骨近端骨肿瘤手术治疗的经验教训。方法:37例14岁以下的患者接受不同方式的手术治疗,平均随访37.2个月。结果:病变刮除、瘤壁残留肿瘤组织灭活、植骨术仍是目前治疗良性病变常用的手术方法,应避免损伤股骨头骨骺。对病灶范围较大伴有髋内翻畸形的良性病变,行病变部分刮除、外翻截骨及内固定后可维持正常的颈干角和髋关节功能。瘤段切除、长柄人工股骨头置换术,是修复股骨近端恶性骨肿瘤切除后大块骨缺损的一种较好的方法,具有早期恢复肢体功能、并发症少、材料来源充足等优势。结论:儿童股骨近端骨肿瘤的手术治疗应考虑到病变的性质、侵袭范围、股骨近端的应力分布及儿童骨骺未闭合等特点,采用适当的术式,多可获得良好的效果。     

Free vascularized fibular bone grafting in the management of femoral neck nonunion in patients younger than fifty years

PURPOSE: The incidence of nonunion and osteonecrosis after femoral neck fracture has been well documented. In older patients implant arthroplasty is well established as an acceptable treatment of these problems. However, in the younger population alternatives to implant arthroplasty are favored to preserve the femoral head. Surgical treatments for nonunion of the femoral neck include osteotomy, nonvascularized bone grafting, muscle-pedicle bone grafting, and vascularized bone grafting. The purpose of this study is to examine the results of free vascularized fibular grafting as a treatment of nonunion of the femoral neck in patients younger than fifty years. MATERIALS AND METHODS: Twenty-two consecutive patients underwent vascularized bone grafting for nonunion of the femoral neck after failed internal fixation between 1984 and 1998. The mean age of the patients was 28.7 years. There were thirteen male and nine female patients. The mean interval between internal fixation and free vascularized fibular grafting was 18.3 months. The average follow-up to date is 84.7 months (range 29 to 195 months). RESULTS: Twenty of twenty-two nonunions healed. Two patients required an additional procedure to facilitate union; one patient had iliac crest bone grafting at four months postoperatively and another underwent muscle-pedicle grafting at six months postoperatively. The average time to union for all patients was 9.9 months (range 3 to 23 months). Progression of osteonecrosis of the femoral head occurred in thirteen patients. However, successful long-term salvage of the femoral head was achieved in twenty of twenty-two patients, with an average Harris hip score of 78.9. Four patients required hardware removal or exchange for intraarticular migration with no long-term clinical sequelae. DISCUSSION: Rates of complications, such as nonunion and osteonecrosis, after femoral neck fractures in young patients have been reported to be as high as 86 percent. Treatments such as osteotomy, muscle-pedicle bone grafting, nonvascularized bone grafting, and vascularized bone grafting have reported variable results. Based on the results reported in this study, vascularized fibular bone grafting compares favorably with a high union rate (91 percent initially, 100 percent after secondary procedures) and successful long-term salvage of the femoral head in 91 percent of the patients. Free vascularized fibular bone grafting represents a promising solution for this difficult problem.     

带血管蒂髂骨瓣复合骨基质明胶移植治疗股骨颈骨折不愈合

目的探讨带血管蒂髂骨瓣复合骨基质明胶移植治疗青壮年股骨颈骨折不愈合的疗效。方法本组28例股骨颈骨折经手术或非手术治疗6～9个月，骨折仍不愈合者，采用带血管蒂髂骨瓣复合骨基质明胶移植，术后观察骨折愈合，股骨头坏死及关节功能恢复情况。结果28例骨折全部愈合，关节功能按Ja-cobs标准评定，优19例，良7例，差2例。结论青壮年股骨颈骨折不愈合的手术治疗，带血管蒂髂骨瓣复合骨基质明胶(BMG)移植是有效术式，治疗结果体现了该术式具有“活骨移植”及诱导成骨的双重作用，疗效明显。     

Augmented osteosynthesis with tensor fascia latae muscle pedicle bone grafting in neglected femoral neck fracture

Background:

Neglected intracapsular femoral neck fracture in young patients may fail to unite because of the excessive shearing strain at the fracture site and it is a surgical challenge to any orthopedic surgeon. The problem is compounded by resorption of the femoral neck and avascular necrosis (AVN) of femoral head. There is no satisfactory solution available in the management of femoral neck fracture as far as the union of the fracture and AVN of femoral head are concerned. Muscle pedicle bone grafting has been advocated to provide additional blood supply to the femoral head. We report a retrospective analysis of 48 cases of neglected femoral neck fracture treated by internal fixation and tensor fascia latae based muscle pedicle bone grafting.

Materials and Methods:

48 patients with femoral neck fractures with age varied from 20 to 53 years (average age 32.9 years) with male to female ratio of 2:1 were enrolled. All fractures were more than 3 weeks old with mean delay being 86 days (22–150 days). Open reduction and internal fixation along with tensor fascia latae muscle pedicle bone grafting was done in all cases. It was supplemented by multiple drilling and cortico-cancellous bone grafting. Fracture fixation was done with three parallel 6.5-mm AO cannulated cancellous lag screws and the graft fixed with a 4-mm cancellous screw to provide a secure fixation. During the followup period of 2-6.8 years (average 4.4 years) the results were assessed clinically by modified Harris hip scoring system and radiologically by the evidence of signs of fracture union.

Results:

Union was achieved in 41/48 (85.41%) cases which were followed for an average period of 4.4 years (2–6.8 years) with good functional results and ability to squat and sit cross-legged. Results were assessed according to modified Harris Hip Scoring system and found to be excellent in 19, good in 22, fair in 5, and poor in 2 patients. Complications were nonunion, (n=3) avascular necrosis (n=2), and coxa vara deformity (n=2).

Conclusion:

Internal fixation with muscle pedicle bone grafting is a suitable option to secure union in neglected femoral neck fractures in physiologically active patients with late presentation.     

Benign lytic lesions of the femoral neck: mid-term results of extended curettage and sartorius muscle pedicle bone grafting

Introduction

Benign lytic lesions of bone encompass a group of neoplastic or developmental disorders of human skeleton. They may involve different sites with varied clinical presentation and pattern of aggressiveness for which the treatment strategy needs to be tailored accordingly. Planning a treatment protocol for a lytic lesion in the femoral neck is a matter of concern for the operating surgeon with due consideration to the risks involved.

Patients and method

This prospective study comprised of 16 patients (9 females and 7 males) with an average age of 23.37 years (range 14 to 35) who presented with lytic lesion in the neck of femur. Only those lesions which were involving the anterior or the inferior aspect of the femoral neck in which the destruction was more than 50 % of the cortex in a single view or there was a pathological fracture were included in this study. There were six cases of giant cell tumour, five cases of fibrous dysplasia, four cases of aneurysmal bone cyst and one case of benign fibrous histiocytoma. All the lesions were operated using anterior approach, and after extended curettage, the cavity was packed with bone chips and sartorius-based muscle pedicle bone grafting (MPBG) was done. Four patients presented with pathological fracture in which the fibula strut grafting was done in addition to MPBG. The patients were assessed using Musculoskeletal Tumour Society (MSTS) score. The mean follow-up period was 32 months (range 26–74 months).

Results

The average time to clinical healing was 8 weeks (range 6–12 weeks) in patients without pathological fracture at the presentation. At final follow-up, the average MSTS score was 28.2 and full radiological consolidation had occurred in all but one patient who developed recurrence. There was no evidence of avascular necrosis or pathological fracture in any of the cases.

Conclusions

Sartorius muscle pedicle bone grafting using anterior approach is a good and reliable option in patients presenting with benign lytic lesion in the neck of femur.