髋部骨肿瘤患者行定制人工髋关节置换的体会

目的探讨定制人工髋关节假体在髋部骨肿瘤保肢术中的应用疗效。方法收集我院自1999年3月~2010年10月因髋部骨肿瘤行定制人工假体置换术病例,按照Enneking标准评价术后肢体功能,并分析术后并发症。结果本组病例中,38例获得良好随访,随访时间为14个月~8年﹙平均55个月﹚,其中髋臼9例,股骨近端29例;肿瘤类型:骨巨细胞瘤12例,软骨肉瘤4例,良性纤维组织瘤10例,骨肉瘤8例,复发性软骨瘤2例,动脉瘤性骨囊肿2例,本组病例;术后肢体功能:优﹙≥23分﹚11例,良﹙15~22分﹚19例,差﹙<15分﹚8例,平均19.8分,优良率为78.95%;1例术后出现假体脱位,成功手法复位。结论定制人工髋关节假体置换术后患者肢体功能恢复较快,是髋部骨肿瘤较为满意的一种保肢治疗方法。     

旋转铰链式膝关节假体置换治疗恶性骨肿瘤

背景：在新的辅助化疗和人工假体设计的协助下,肢体恶性骨肿瘤的治疗效果得到大幅度提高,关节置换成为恶性骨肿瘤治疗的主要保肢方法 目的：观察旋转铰链式膝关节假体在恶性骨肿瘤保肢治疗中的疗效。 方法：选择2005-01/2009-10盐城市第一人民医院骨科收治的膝关节恶性骨肿瘤患者15例,均行旋转铰链式膝关节假体置换。置换后采用Enneking肢体肌肉骨骼肿瘤外科治疗重建置换后膝关节功能评估标准进行评估。 结果与结论：15例患者置换后获随访7~51个月。1例置换后出现感染并发症,血沉检查结果升高,经清创、关节松解和抗炎治疗后好转,关节功能得到恢复。置换后患者均未出现肿瘤复发和肺转移病例,无假体松动和体断裂出现。Enneking功能评估,肢体功能优7例(47%),良5例(33%),差3例(20%),优良率达80%。提示应用旋转铰链式膝关节假体置换治疗膝关节恶性肿瘤效果良好,可以保留良好的肢体功能,是一种较为满意的保肢方法。     

计算机导航系统辅助下髋臼区肿瘤的保肢治疗

背景:下肢的不等长影响肢体保肢治疗的效果。即便通过透视监测,在手术中确保肢体等长,仍是一个难以把握的问题,尤其是对于髋臼区域恶性肿瘤的保肢治疗。在骨科的其他方面,如脊柱和关节,导航技术已经较多应用于内固定器械安置和假体放置。目的:回顾分析在计算机导航系统指导下髋臼区恶性肿瘤保肢治疗的效果。方法:选择2001-01/2009-06上海瑞金医院骨科收治的11例骨盆恶性骨肿瘤患者,术前经病理确诊,肿瘤切除后应用定制型假体重建。其中8例患者进行常规保肢手术,另外3例患者行计算机导航技术辅助保肢治疗。所有患者骨盆恶性肿瘤的切除范围位于髋臼周围区(骨盆Ⅱ区)。患者保肢治疗后予以临床、影像学检查,并行下肢保肢功能MSTS评分。结果与结论:随访12～60个月。经常规保肢治疗的8例患者,平均手术时间7.6h,平均失血量2400mL,1例患者因肺部转移而在术后3年死亡,1例患者因局部复发行截肢术。除去这2例患者,保肢治疗后有3例患者髋臼假体的移位超过2cm而形成下肢不等长。MSTS评分平均20.3分。在计算机导航技术辅助下保肢治疗的3例患者,平均手术时间8.3h,平均失血量2100mL,保肢治疗后未见下肢不等长现象。MSTS评分平均21.7分。提示在计算机导航系统指导下进行髋臼区恶性肿瘤保肢手术,可以精确截骨,准确安放假体,减少髋臼区恶性肿瘤保肢治疗后下肢不等长发生率,提高患肢功能。     

旋转铰链式人工假体置换:治疗股骨远端恶性骨肿瘤后肢体功能和生存率评价

背景:股骨远端是原发性骨肿瘤的好发部位,目前大部分都选用保肢治疗。国内外有很多关于股骨远端肿瘤型人工膝关节假体早期和中期功能及预后的报道,但对其长期功能及预后的报道尚少。目的:探讨行国产型股骨远端肿瘤型旋转铰链式膝关节假体置换后患者的假体长期预后情况及肢体功能。方法:回顾性分析2000年1月至2008年6月安徽医科大学第一附属医院骨科收治的股骨远端恶性骨肿瘤患者34例,均采用旋转铰链式人工假体置换。结果与结论:34例患者平均随访时间62.4个月(11-126个月),末次随访23例患者生存,11例患者死亡;23例生存患者中7例发生与假体相关并发症:4例行翻修,3例行截肢。肿瘤型膝关节假体的患者5年生存率为67.6%;29例患者在置换后2年时行膝关节Enneking评分,总体平均分为19.3分(7-27分):优6例,良16例,中5例,差2例,患者假体功能总的优良率为75.9%。结果提示,旋转铰链式人工假体置换在治疗股骨远端恶性骨肿瘤中能获得满意的肢体功能和患者长期生存率。     

定制旋转铰链型人工膝关节置换治疗膝部骨肿瘤19例

背景:早期的固定铰链式关节由于存在较高的假体翻修率,已逐渐被旋转铰链式人工关节所替代。定制型人工膝关节还可以更好的匹配患者的解剖形态,实现机械和解剖的多样性个体化。目的:评估定制旋转铰链型人工膝关节置换治疗膝部良恶性骨肿瘤的临床效果。方法:应用旋转铰链型人工膝关节置换治疗膝部骨肿瘤患者19例,男13例,女6例,年龄19~51岁;其中良性骨肿瘤6例,恶性骨肿瘤13例,股骨下端肿瘤15例,胫骨上端肿瘤4例。采用Enneking功能评定标准评估术后功能,复查X射线片评估假体情况与肿瘤复发。结果与结论:手术时间2.5~5.3(3.64±0.89)h,术中出血量300~800(452.63±135.88)mL。19例均获随访,随访时间3~64(30.45±21.44)个月,仅1例局部复发,无肺部转移。膝关节活动范围伸0°,屈曲95°~140°(124.47±12.89)°,Enneking功能评分为(20.95±3.69)分,优良率为89%。结果说明定制旋转铰链型人工膝关节置换是一种有效的治疗膝部良恶性骨肿瘤的保肢方法。     

制型肿瘤膝关节假体在膝关节周定围肿瘤中的应用体会

目的探讨采用国产定制型肿瘤膝关节假体治疗膝关节周围肿瘤的临床疗效.方法对2004年6月~2011年10月应用定制肿瘤型铰链膝关节假体置换膝关节周围肿瘤的15例病人进行回顾性分析,男6例,女9例;年龄27~76岁,平均51.4岁.骨肉瘤4例,骨巨细胞瘤6例,非典型性纤维组织细胞瘤2例,软骨肉瘤3例,均为股骨远端肿瘤.均行瘤段广泛切除国产骨水泥定制肿瘤型铰链膝关节假体重建.结果全部15例随访14~96个月,平均32个月.术后切口均一期愈合,未出现感染、免疫排斥、皮肤会死等近期并发症.1骨肉瘤患者术后10个月出现局部复发,拒绝手术,术后16个月死亡,1例骨肉瘤患者18个月肺转移死亡,1例骨肉瘤患者术后3年局部复发截肢.所有患者无关节脱位、假体松动、断裂、肢体短缩.术后膝关节主动屈曲活动度70~120°,平均89.4°,末次随访ISLOS影像评分24~31分,平均28.6分;骨肿瘤术后MSTS功能评分21~25分,平均22.8分.结论对膝关节周围恶性与侵袭性骨肿瘤切除后骨缺损采用国产定制肿瘤型人工假体重建是有效的保肢方法.     

特制人工膝关节假体在骨肉瘤合并病理骨折保肢治疗中的应用

背景:骨肉瘤合并病理性骨折以往采用截肢治疗。随着新辅助化疗的临床应用,人工假体制作工艺和材料的改进,部分骨肉瘤合并病理性骨折的患者获得了保肢治疗的可能。目的:探讨特制人工膝关节假体置换在骨肉瘤合并病理性骨折保肢治疗中的效果。方法:2002年6月至2012年9月共收治11例临近膝关节骨肉瘤合并病理性骨折患者,根据患者的个体情况定制肿瘤膝关节假体行保肢治疗,对其随访结果进行回顾性分析。其中男6例(54.5%),女5例(45.5%);年龄11-50岁,平均25.4岁;发病部位:股骨远端7例,胫骨近端4例。所有患者均接受新辅助化疗并应用特制膝关节假体行保肢治疗,随访时间9-105个月。结果与结论:11例患者假体置换后局部复发率为18%,肺转移率为36%,5年生存率为58%。4例患者发生肺转移,死亡时间为假体置换后9-24个月。末次随访患肢Enneking评分11-30分,平均23.3分,优良率为82%。提示应用特制膝关节假体置换联合新辅助化疗方案,对膝关节周围骨肉瘤合并病理骨折患者行保肢治疗近期效果理想,远期疗效尚需评价。     

股骨近端骨肿瘤及瘤样病变骨缺损的修复重建

目的 探讨股骨近端骨肿瘤及瘤样病变骨缺损的修复重建方式.方法 对自1998～2003年共49例股骨近端骨肿瘤或瘤样病变的手术治疗及术后疗效进行回顾性分析,本组中17例采取病变刮除,瘤壁烧灼,自体、异种骨、人工骨或复合移植术;12例采取病变刮除,瘤壁烧灼或酒精浸泡,自体骨、异种骨、人工骨或复合骨移植,并辅予内固定固定术;20例采取瘤段切除,定制人工关节假体重建关节术;术后均获随访.结果 术后随访17～51个月,平均31个月,X线片可见缺损修复区内有骨降解和骨替代现象发生,2例复发,其中1例伴内固定物旁骨折,其余术后患肢功能恢复良好,4～12个月撤拐行走,无跛行;假体重建者1例假体断裂,1例死亡,根据Enneking术后功能评估系统,20例术后10～14月的评分73%～87%.结论 根据肿瘤生物学行为及股骨近端生物力学选择个体化的修复重建方式,对股骨近端骨肿瘤及瘤样病变的疗效满意.     

定制旋转铰链式膝关节假体置换治疗膝关节周围侵袭性骨肿瘤的临床观察

目的 观察定制旋转铰链式膝关节假体置换治疗膝关节周围侵袭性骨肿瘤患者的临床疗效.方法 回顾性分析2000年1月至2005年1月收治的27例膝关节周围侵袭性骨肿瘤患者的临床资料,其中股骨远端肿瘤13例,胫骨近端肿瘤14例;包括骨巨细胞瘤16例、骨肉瘤9例、滑膜肉瘤1例、恶性纤维组织细胞瘤1例.所有患者进行肿瘤切除、定制旋转铰链式膝关节假体置换治疗,术后进行康复治疗,恶性肿瘤患者进行常规化疗.术后随访,参照国际骨与软组织肿瘤协会(MSTS)评分标准进行膝关节功能评分.结果 所有患者随访11～122个月,中位时间64.5个月.术后6个月随访所有患者生存,MSTS评分为(22.2±3.5)分,膝关节功能优良率为81.5%(22/27).近期随访23例患者生存,4例患者死亡,4例发生与假体相关的并发症;其中22例生存患者MSTS评分为(21.0±2.3)分,膝关节功能优良率为72.7%(16/22).本组患者治疗后5年生存率为85.2%(23/27).结论 应用定制旋转铰链式膝关节假体置换治疗膝关节周围侵袭性骨肿瘤能获得良好的治疗效果.     

等离子喷涂陶瓷钛合金人工半骨盆置换术(附5例报告)

目的：介绍等离子喷涂陶瓷钛合金人工半骨盆在半骨盆切除术后行保肢手术中的应用方法，并评估其优缺点。方法：5例恶性骨肿瘤患者在行半骨盆根治性切除术后，用定制的钛合金人工半骨盆连同其全髋关节作假体置换术。结果：本组中，2例分别于术后3～6个月因肿瘤转移而死亡，1例术后8a因哮喘性肺炎而死亡，1例术后15a因肺心病而死亡，另1例术后17a至今仍存活，外出时需扶手持行走。结论：将半侧骨盆完全切除后采用人工半骨盆置换术而保全该侧肢体存活，使其具有神经支配状态良好的下肢，并保留该肢的满意功能，是一种值得推荐的手术方法之一。     

高屈曲后稳定型旋转平台人工膝关节假体全膝关节置换

背景：传统的人工膝关节假体已成功在临床应用。有报道高屈曲后稳定型固定平台人工膝关节假体置换后有较高的高分子聚乙烯垫磨损,而高屈曲后稳定型旋转平台人工膝关节假体的设计能更好地解决这一问题。 目的：回顾性分析高屈曲后稳定型旋转平台PFC sigma RPF人工膝关节假体全膝关节置换后的近期效果。 方法：78例(113膝)行高屈曲后稳定型旋转平台PFC sigma RPF人工膝关节假体置换,采用骨水泥固定假体,髌骨不进行置换。随访3年,分别比较置换前、置换后膝关节活动度及特种外科医院膝关节功能评分。 结果与结论：随访3年,膝关节活动度从置换前平均110.7°改善到置换后平均124°,特种外科医院膝关节功能评分从置换前平均54.2分改善到置换后平均95.4分,优良率达93.58%,各种并发症发生率低。提示高屈曲后稳定型旋转平台PFC sigma RPF人工膝关节假体的近期置换效果满意,置换后的持续疼痛是患者不满意的主要因素,长期效果还需进一步观察。     

Changing pattern of AIDS: a bone marrow study

We compared bone marrow findings in 2 groups of patients with AIDS during 2 different periods: group 1, n = 20; male/female ratio, 19/1; and group 2, n = 120; male/female ratio, 6/1. Bone marrow iron stores were decreased significantly in group 2 (P < .01), and the incidence of AIDS-related lymphomas was higher, with frequent bone marrow involvement. Two group 1 patients had Kaposi sarcoma, and a 21-month-old girl with transfusion-transmitted AIDS had Burkitt-like lymphoma. In group 2, 44 patients had a history of malignant neoplasms, including Kaposi sarcoma (10 cases), hematologic neoplasms (33 cases), and metastatic leiomyosarcoma (1 case). Of the 120 patients, 15 (12.5%) had bone marrow involvement by malignant neoplasms. The majority of the non-Hodgkin lymphomas were high-grade lymphomas. Patients with AIDS-related malignant neoplasms had higher CD4+ cell counts and viral loads than patients without malignant neoplasms (P < .01, P < .05, respectively). The finding of decreased iron stores in patients with AIDS might aid clinical management of their anemia. The increased incidence of malignant neoplasms, especially lymphomas, in recent years might be related to prolonged survival but with incomplete reconstitution of immune function after antiretroviral therapy.     

腭裂修复术前后听力阈值比较

目的：比较腭裂患儿修复术前后听力阈值变化以了解腭裂术后听力恢复情况。方法：检测24例腭裂患儿修复术前后48耳听力阈值,自身对照,x^2检验。结果：腭裂患儿行腭裂修补术前听力异常发生率93．8％,术后复查听力异常发生率为43．8％,差异极显著,P〈0．005。术前异常45耳。结论：早期行腭裂修补术对患儿听力的恢复和改善有明显效果。     

人工半肩关节置换在肱骨近端骨折治疗中的应用

目的：探讨人工肱骨头治疗肱骨近端复杂骨折的临床疗效和并发症的预防。方法：12例肱骨近端复杂骨折患者施行人工肱骨头置换术，患者平均年龄64．8岁，1例为三部分骨折，1例为肱骨头劈裂性骨折，10例为四部分骨折，其中3例伴肩关节脱位，手术全部采用可调节式骨水泥型人工肱骨头假体。结果：术后平均随访18．1月，Constant评分平均为78．6分（46～92分）。随访发现肱骨大结节上移、肩关节下方不稳定和异位骨化各1例。结论：人工肱骨头置换是治疗肱骨近端复杂骨折的有效方法，精细的手术操作是减少并发症、取得满意疗效的关键。     

Treatment of high-risk neuroblastoma with intensive chemotherapy, radiotherapy, autologous bone marrow transplantation, and 13-cis-retinoic acid. Children's Cancer Group.

BACKGROUND: Children with high-risk neuroblastoma have a poor outcome. In this study, we assessed whether myeloablative therapy in conjunction with transplantation of autologous bone marrow improved event-free survival as compared with chemotherapy alone, and whether subsequent treatment with 13-cis-retinoic acid (isotretinoin) further improves event-free survival. METHODS: All patients were treated with the same initial regimen of chemotherapy, and those without disease progression were then randomly assigned to receive continued treatment with myeloablative chemotherapy, total-body irradiation, and transplantation of autologous bone marrow purged of neuroblastoma cells or to receive three cycles of intensive chemotherapy alone. All patients who completed cytotoxic therapy without disease progression were then randomly assigned to receive no further therapy or treatment with 13-cis-retinoic acid for six months. RESULTS: The mean (+/-SE) event-free survival rate three years after the first randomization was significantly better among the 189 patients who were assigned to undergo transplantation than among the 190 patients assigned to receive continuation chemotherapy (34+/-4 percent vs. 22+/-4 percent, P=0.034). The event-free survival rate three years after the second randomization was significantly better among the 130 patients who were assigned to receive 13-cis-retinoic acid than among the 128 patients assigned to receive no further therapy (46+/-6 percent vs. 29+/-5 percent, P=0.027). CONCLUSIONS: Treatment with myeloablative therapy and autologous bone marrow transplantation improved event-free survival among children with high-risk neuroblastoma. In addition, treatment with 13-cis-retinoic acid was beneficial for patients without progressive disease when it was administered after chemotherapy or transplantation.     

Neoplasms arising in Paget's disease of bone: a study of 82 cases

Eighty-two cases of neoplasms arising in Paget's disease of bone from the Mid-America Bone Tumor Registry, accessioned between 1958 and 1983, were reviewed. There were 77 osteosarcomas, 3 fibrosarcomas, 1 chondrosarcoma, and 1 giant cell tumor. The male/female ratio was 2:1. The age distribution was 18%, 29%, 36%, and 17% for the groups less than 51 years, 51-60 years, 61-70 years, and greater than 70 years, respectively. The femur was involved by tumor in 22%; the humerus in 21%; the pelvis in 21%; the calvarium in 12%; the tibia in 10%; and other bones in 15% of the cases. There were 48% survivors after 1 year; 17% after two; and 5% after three and five years; two additional patients with tumor lived for more than seven and 11 years. Radiographs available for simultaneous study in 43 cases revealed predominant tumor patterns that were mixed in 69%, osteoblastic in 21%, and osteolytic in 10%. Other radiographic data and the clinical and histopathologic data are in agreement with five earlier major studies. While the prognosis of neoplasms arising in Paget's disease generally is not good, a small fraction of long-term survivors after aggressive therapy makes this complication a challenge for timely radiographic diagnosis and histopathologic confirmation.     

肾移植后重症肝炎19例分析

背景：研究认为肾移植后感染肝炎病毒,比术前感染有更为严重的肝损害表现,且有观点认为术前肝炎病毒感染对肾移植术后5年内肾功能影响不大。 目的：分析肾移植后的重症肝炎发病情况和治疗方法。 方法：对19例肾移植后重症肝炎病例进行回顾性分析。治疗包括一般治疗、抗病毒治疗、免疫抑制剂方案调整和人工肝治疗。主要观察患者综合治疗后一般情况、肝功能、血常规及死亡率。 结果与结论：19例重症肝炎患者经过常规治疗和抗病毒治疗,部分应用胆红素吸附治疗,12例应用人工肝治疗患者,精神和神智均有不同程度的好转,胆红素和转氨酶均有一定程度的下降。死亡13例,其中术后感染肝炎病毒的4例全部死亡,3例单纯药物性肝损害患者全部痊愈。结果提示肾移植后重症肝炎死亡率高,对于诊断为重症肝炎患者常规治疗基础上,进行一定的抗病毒治疗和/或人工肝治疗,可使部分患者病情逆转,可能降低死亡率。     

含抗生素可活动关节骨水泥对全膝关节置换过程中血沉、C-反应蛋白及关节功能的影响

BACKGROUND: Antibiotic-loaded bone cement for artificial joint fixation can locally play the anti-inflammatory effects of antibiotics, thereby preventing the occurrence of infection. OBJECTIVE: To investigate the effect of antibiotic-loaded bone cement on erythrocyte sedimentation rate, C-reactive protein and joint function of patients treated by total knee arthroplasty. METHODS: Totally 86 patients, including 43 males and 43 females, aged 45-75 years, were enrolled and divided into observation and control groups (n=43/group). The artificial knee joints of patients in the observation group were fixed with antibiotic-loaded bone cement, while the artificial knee joints of patients in the in the control group were fixed with conventional bone cement. The surgical condition, blood indexes, knee function and therapeutic efficacy were compared between these two groups. RESULTS ADN CONCLUSION: The bed time and incidence of infection after operation in the observation group were significantly lower than those in the control group (P < 0.05); the knee bending angle and total efficiency of treatment after 2 weeks of treatment were significantly higher than those in the control group (P < 0.05). The C-reactive protein level and erythrocyte sedimentation rate at 3 and 7 days after treatment in these two groups were significantly decreased compared with those before treatment (P < 0.05), especially in the observation group (P < 0.05). The knee joint function scores after 6 months of treatment in these two groups were significantly increased compared with those before treatment (P < 0.05), especially in the observation group (P < 0.05). These results demonstrate that antibiotic-loaded bone cement is conductive to prevent the occurrence of infections, improve blood indexes and promote the knee joint function recovery.      

Metaplastic carcinomas of the breast. I. Matrix-producing carcinoma

The clinical and pathologic features of 26 examples of a histopathologically distinct form of metaplastic carcinoma of the breast are reported. All neoplasms had overt carcinoma with direct transition to a cartilaginous and/or osseous stromal matrix without an intervening spindle cell zone or osteoclastic giant cells. Therefore, we designate this distinctive form of metaplastic carcinoma as "matrix-producing carcinoma" (MPC). All patients were women, the average age was 58 years, and all patients were eligible for a minimum of 5 years follow-up (mean follow-up period, 8.6 years). Twenty-three patients were treated by a form of mastectomy and three were treated by local excision. The 5-year survival rate for patients following mastectomy or partial mastectomy was 70%, contrasted with 50% for patients treated by local excision. The cumulative 5-year survival rate for MPC was 68%. All of the nine lesions that recurred did so within 2.5 years of initial therapy. Eight of these patients (89%) died from tumor within 4 years of initial therapy. The ninth was alive at last contract. Radiation and chemotherapy were of limited effectiveness. Significant features of the neoplasm associated with progression were large size, diffuse cellularity of the stromal matrix, and atypical cartilaginous metaplasia. Ultrastructural examination of one case and immunohistochemical evaluation of 12 cases revealed MPC to have myoepithelial characteristics.