定制节段人工假体复合结构骨移植重建骨干肿瘤术后大段骨缺损的临床研究

目的 评价应用定制节段型人工假体复合大段结构骨移植重建骨干恶性肿瘤切除术后骨缺损的临床疗效。方法 回顾性分析我院骨肿瘤科2014年1月至2019年3月期间,采用定制节段型人工假体复合大段结构骨移植重建骨干恶性肿瘤切除术后骨缺损的病人共6例（股骨3例,胫骨2例,肱骨1例）,其中2例采用大段冻干异体骨,4例采用自体游离腓骨结构植骨。采用美国骨肿瘤学会评分系统（Musculoskeletal Tumor Society 93, MSTS 93）评价术后功能。结果 所有病人均未发生围手术期并发症,且均获得随访,平均随访时间为23.8个月（1~61个月）。术后根据肿瘤性质继续辅助化疗等治疗,随访期内无复发,5例无瘤生存,1例死于原发乳腺癌肺转移（术后25个月）,假体生存率为100%,4例术后6个月植骨愈合,术后MSTS 93评分平均为27分。结论 规范治疗和切除骨干恶性肿瘤后,采用定制节段型人工假体复合大段骨移植重建骨干骨缺损,实现即刻稳定重建,保留关节功能,中期植骨愈合后实现远期生物重建,并发症少,临床疗效满意。     

肱骨上段恶性肿瘤切除人工假体置换术

目的探讨应用人工假体置换治疗肱骨上段恶性肿瘤的手术疗效及并发症。方法1998年10月~2003年8月,收治肱骨上段恶性肿瘤4例。其中骨肉瘤2例,Enneking分期A期;骨巨细胞瘤2例,Enneking分期分别为A期和B期。根据国际保肢学会评分标准,术前综合评分骨肉瘤2例分别为4分和5分,骨巨细胞瘤2例分别是9分和11分。手术均采用距肿瘤边界以远5~8cm连同周围肌肉切除,行人工假体置换,骨水泥固定。结果4例均获随访24~58个月,平均44个月。术后无肿瘤复发及感染,1例于术后1年5个月出现假体松动,未作特殊处理。假体置换后肩关节伸22~41°(平均25°),屈29~80°(平均35°),外展5~28°,旋转15~22°。4例患者均有不同程度的肩关节不稳,力量减弱。根据国际保肢学会评分标准,术后综合评分骨肉瘤2例分别是19分和22分,较术前平均提高16分;骨巨细胞瘤2例分别是21分和28分,较术前平均提高9.5分。结论人工假体置换治疗肱骨上段恶性肿瘤,效果良好,但并发症较多,临床应用需慎重。     

定制型节段假体重建长骨骨干转移瘤骨缺损

目的探讨定制型节段假体重建治疗长骨骨干转移瘤骨缺损的临床效果。方法应用定制型节段假体重建治疗15例长骨骨干转移瘤骨缺损患者。采用Kaplan-Meier法计算患者生存率,NRS评分评估术后疼痛,MSTS 93评分系统评估术后肢体功能。结果8例存活,随访时间16~56(29.75±13.20)个月;7例死亡,随访时间12~44(23.86±12.24)个月。术后1年患者总生存率93.3%,术后2年患者总生存率73.3%。假体在体时间12~56(27.00±13.10)个月,假体长度6~13(9.73±2.15)cm。术后3个月MSTS评分24~29(26.87±1.55)分。NRS评分术前4~8(6.20±1.15)分,术后1个月0~1(0.20±0.40)分,差异有统计学意义(P<0.05)。1例肱骨转移瘤患者术后6个月复查出现影像学无菌性松动,未明显影响上肢功能。结论定制型节段假体重建长骨骨干转移瘤骨缺损具有缓解疼痛明显、允许早期负重及功能锻炼、保留较好肢体功能、术后并发症发生率较低等优势。     

肿瘤段切除,人工假体重建合并症的分析

作者对１６８例肿瘤扩大切除、人工假体重建术后的病例进行观察，随访１～９年，平均４．２年。发生术后合并症者３０例，其中术后感染２例，迟发感染６例，总感染率为４．８％；术后假体脱位３例（１．８％）；松动３例（１．８％）；肿瘤局部复发７例（４．２％）；肺转移１１例（６．６％），其中７例兼有肿瘤局部复发；假体排异反应１例。最后作者根据临床资料对上述主要合并症作了较为详细的分析讨论。     

人工补片肩关节囊重建防治肿瘤型人工肱骨头假体脱位

目的 探讨肿瘤型肱骨头假体置换采用人工补片行肩关节囊重建的方法和临床应用价值.方法 6例肱骨近端肿瘤患者中,初次置换4例,假体脱位翻修2例,置换时将Prolene网状补片一端固定在肩胛盂边缘关节囊上,包绕肱骨头后,另一端固定在肿瘤假体为重建肩袖预制的槽孔内,重建肩关节囊,稳定肩关节.结果 6例均获随访,时间12～28(21 2±64)个月,假体无脱位.肩关节疼痛VAS评分从术前平均7分±0 8分降至术后平均3 1分±1 1分.术后肩关节活动度前屈平均68 9°±14 7°,后伸平均27 5°±8°,外展平均72 7°±16 6°,肱骨旋转活动度平均22 5°±94°.结论 人工补片肩关节囊重建能帮助稳定肩关节,其网状结构还便于术中肩袖及肱骨驱动肌肉的重建,并使肿瘤型肱骨头假体保留良好活动度.     

定制人工假体置换治疗骨肿瘤的临床分析

目的：对应用定制肿瘤型人工假体置换治疗恶性骨肿瘤的临床疗效进行分析。方法回顾性分析我科2009年5月-2013年2月收治的恶性骨肿瘤患者29例,男18例,女11例;年龄17-65岁,平均38.5岁,股骨上端5例,股骨远端14例,胫骨上端7例,股骨下端3例。所有患者均接受对肿瘤进行广泛切除或根治性切除,包括综合性治疗及定制型人工假体置换治疗,术后对患者进行定期随访,对治疗效果进行评价。结果置换后1年采用MSTS保肢评分系统对随访患者进行功能评价,显示股骨远端患者（15.5-28.0）分,平均23.5分;股骨上端0.5-29.0分,平均23.5分;胫骨近端10.5-29.0分,平均22.4分。其中优9例,良15例,中4例,差1例,优良率为82.7%。术后并发症发生率为10.0%。1例患者于术后7个月死亡,1例患者于术后18个月后肺转移死亡,1例在术后13个月时出现局部复发现象而截肢,1例在术后8个月时出现局部复发单纯行瘤体切除。在随访时,所有患者均未出现人工假体断裂、松动现象。结论在骨肿瘤患者采用人工假体置换术前、术后给予综合性治疗,在对肢体功能加以保留,与其他重建方法相比,具有肢体早期负重、功能恢复快、使用期长的优点,患者生活质量大幅提高,是骨肿瘤保肢治疗的较理想选择,值得在临床中推广。     

定制型肱骨近端假体结合人工补片重建肩关节的疗效分析

目的 探讨肱骨近端骨肿瘤保肢术中使用人工补片重建盂肱关节囊的手术方法及其对稳定肩关节、预防术后肱骨头脱位的效果.方法 2006年2月至2009年1月,回顾性分析接受定制型肱骨近端假体结合聚丙烯非降解性人工补片重建肩关节的患者12例,男7例,女5例;年龄21～55岁,平均38岁.肿瘤类型:骨巨细胞瘤9例,骨肉瘤1例,软骨肉瘤2例.9例骨巨细胞瘤患者中3例为Campanacci Ⅱ期,6例为Campanacci Ⅲ期;1例骨肉瘤患者为Enneking ⅡB期;2例软骨肉瘤患者均为Enneking Ⅱ A期.采用国际骨与软组织肿瘤协会(MSTS)功能评估标准评价术后肩关节功能.结果 患者均获得随访,随访时间24～52个月,平均35个月.手术出血量150～500 ml,平均254 ml;手术时间150～200 min,平均172 min.术后患者肩关节前屈20°～60°,平均41°;外展20°～70°,平均42°.MSTS评分为53%～77%,平均66%.术后无一例患者出现臂丛损伤、切口感染及假体脱位;随访期间无一例患者出现局部复发、远处转移或死亡.结论 使用聚丙烯非降解性人工补片重建盂肱关节囊可显著减少肱骨近端骨肿瘤保肢术后肱骨头假体脱位的发生,便于周围软组织的附着和长入.

Abstract：

Objective To investigate the surgical technique,postoperative function and dislocation incidence of proximal humerus reconstruction with metallic endoprostheses and polypropylene knitted nonabsorbable mesh after proximal humeral tumor resection.Methods Twenty patients with proximal humeral tumor were retrospectively reviewed.They were performed proximal humerus reconstruction with proximal humeral prosthesis and polypropylene knitted non-absorbable mesh from February 2006 to January 2009.There were 5 women and 7 men with a mean age of 38 years(range,21-55 years)at the time of surgery,and giant cell tumor in 9 patients(including Campanacci Ⅱ for 3,Campanacci Ⅲ for 6),osteosarcoma in 1(Enneking ⅡB).and chondrosarcoma in 2 (Enneking ⅡA).The operative time,blood loss,and shoulder movement postoperation were analysed.According to the assessment system by MSTS,the function of limb after surgery was assessed.Results Patients were followed clinically and radiographically for a minimum of 24 months (mean,35 months;range,24-52 months).The mean operative time was 172 min(range,150-200min).The mean blood loss was 254 ml (range,150-500 ml).There were no shoulder dislocations at final follow-up.The mean shoulder flexion was 41°(range,20°-60°)and mean shoulder abduction was 42°(range,20°-70°).The mean postoperative functional assessment score of the limb was 66%(range,53%-77%).None of the Datients had a wound infection,traction neuropraxia or died after the surgical procedure.Conclnsion The data suggests that the use of a polypropylene knitted non-absorbable mesh for proximal humerus reconstruction may reduce dislocations and facilitate soft tissue attachment after tumor resection.     

定制型节段性肿瘤假体置换治疗胫骨干转移癌一例报道

骨的转移癌多为血行转移而来,肿瘤细胞容易侵蚀血运循环丰富而缓慢的骨骼部位,发生于脊柱与骨盆部位的转移癌占70%以上。由于长骨的滋养血管,包括动脉和静脉,位于骨干中部,肿瘤细胞也可以在该处滞留而形成转移病灶。在临床中长骨干转移性肿瘤也不少见。发生于长骨干的转移癌,多有明显疼痛、功能障碍甚至病理性骨折。按照转移癌治疗原则,对于适合手术的病例,多采用骨水泥填充髓内针或钢板固定的     

假体置换治疗肱骨上端恶性肿瘤

报道１２例肱骨上端恶性肿瘤的非截肢手术治疗的结果，介绍了手术适应证及手术方法。经平均８．３年随访，功能属一般以上者８例，差１例，３例在５年内死于肿瘤局部复发和远处转移。讨论了人工肱骨头假体的制作方法，手术适应证，并发症，以及补救方法等。     

节段性肿瘤假体置换治疗股骨干转移癌合并病理性骨折1例

笔者于2013—11—03应用国产定制型节段性肿瘤假体置换治疗股骨干转移癌合并病理性骨折1例,近期疗效满意。     

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。     

Custom endoprosthetic reconstruction for malignant bone disease in the humeral diaphysis

The optimal reconstructive method following segmental resection of malignant tumours in the humeral diaphysis is unknown as there are no prospective long-term studies comparing biologic with endoprosthetic reconstruction. This is a retrospective review of 13 patients who, between 1995 and 2010, had undergone limb salvage at our institution using a custom-made humeral diaphyseal endoprosthetic replacement following excision of malignant bone disease. There were 9 males and 4 females with a mean age of 35 years at the time of surgery (range: 10 to 78). Mean follow-up was 56.8 months (range: 5 to 148). Cumulative patient survival was 75% at 10 years. Implant survival, with removal of the endoprosthesis or part of it for any reason as an end point, was 47% at 10 years. Seven patients required revision (54%). Complications included metastases in four, aseptic loosening in four, peri-prosthetic fracture in two and local recurrence in two. Mean MSTS and TESS scores were 23 (18 to 27) and 67% (52-80) respectively. Custom-made humeral diaphyseal replacement following resection of malignant bone tumours provided functional results superior to amputation, without an obvious compromise in patient survival. There was a relatively high revision rate for aseptic loosening and peri-prosthetic fracture and patients should be counselled about this preoperatively.     

Intercalary endoprosthetic reconstruction for diaphyseal bone tumours

Custom-made intercalary endoprostheses may be used for the reconstruction of diaphyseal defects following the resection of bone tumours. The aim of this study was to determine the survival of intercalary endoprostheses with a lap joint design, and to evaluate the clinical results, complications and functional outcome. We retrospectively reviewed six consecutive patients, three of whom underwent limb salvage with intercalary endoprostheses of the tibia, two of the femur, and one of the humerus. Their mean age was 42 years (28 to 64). The mean follow-up was 21.6 months (9 to 58). The humeral prosthesis required revision at 14 months owing to aseptic loosening. There were no implant-related failures. Musculoskeletal Tumour Society functional outcome scores indicated that patients achieved 90% of premorbid function. Custom intercalary endoprostheses result in reconstructions comparable with, if not better than, those of allografts. Using this design of implant reduces the incidence of early complications and difficulties experienced with previous versions.     

Intercalary endoprosthetic reconstruction for impending pathological fractures in patients with femoral diaphyseal bone metastases

Improvement of the life expectancy in patients with metastatic bone tumors has increased the emphasis on preserving the function of affected limb. Between 2006 and 2008, we used custom-made endoprostheses in four patients to reconstruct femoral diaphyseal defects after excision of metastatic bone tumors. The mean age at operation was 65 years (55–78) and the median follow-up 10 months (4–17). Using the Musculoskeletal tumor society (MSTS) functional scoring system, the mean MSTS functional score was 67%. Local recurrence and mechanical loosening were not occurred. We conclude that diaphyseal endoprostheses in femoral bone offer a good clinical and functional outcome.     

The external fixation in the treatment of humeral diaphyseal fractures: outcomes of 84 cases

We retrospectively review 84 cases of diaphyseal humeral fractures (24 type A, 38 type B, 22 type C of the AO/OTA classification) treated with external fixation (Hoffmann II frame) between 1995 and 2007. Six of these fractures were complicated with radial nerve palsy. Four cases were open fractures. All reductions were achieved closely or through minimal open approaches. All fractures achieved consolidation with an average of 95 days (range 58-140). The six radial nerve palsies had complete spontaneous recovery. According to the Constant score excellent shoulder function was recorded in 54.6% of the cases, good results in 25%, fair in 13.6% and poor in 6.8%. The elbow function according to the Mayo elbow performance index was excellent in 81.8% of cases, good in 13.6%, fair in 2.3%, and poor in 2.3%. We observed superficial pin tract infections in 12% of the patients. There was no cases of deep infection.External fixation of humeral diaphyseal fractures as recorded in this case series, represents a management option, which allows straightforward fracture reduction and adequate stability, with a short operative time, excellent consolidation rate and good functional results with no major complications secondary to this type of surgery.     

Functional long-term outcome of the shoulder after antegrade intramedullary nailing in humeral diaphyseal fractures

Intramedullary nailing is one of the most commonly used surgical treatments for humeral diaphyseal fractures. Once an intramedullary fixation technique has been selected, the choice between antegrade or retrograde approach remains controversial. Forty patients with humeral diaphyseal fracture treated with Seidel antegrade intramedullary nailing through an "danterior deltoid incision" (ADI) were evaluated after an average period of 62 months. Clinical and functional evaluation of the shoulder was performed using the Constant Score. Results were excellent in 33 patients, good in 5 and acceptable in 2. Radiological assessment was performed using antero-posterior (AP) and latero-lateral (LL) radiographs of the humerus and AP and Neer radiographs of the shoulder. Radiographic findings demonstrated good consolidation of all fractures; nail and locking proximal screw malpositioning were detected in 2 cases (2 patients with acceptable results). The positive results obtained for shoulder function correlate with patient age and demonstrate that antegrade intramedullary nailing is a valid option for the treatment of humeral diaphyseal fractures, as long as it is performed through ADI access and with the appropriate surgical technique. Surgical technical errors will lead to functional problems of the shoulder, which in some cases will not be completely eliminated even after nail removal.     

节段性脾切除术是治疗脾良性肿瘤的优先选择

目的 探讨节段性脾切除治疗脾良性肿瘤的可行性.方法 总结近两年笔者对6例脾良性肿瘤实施的保脾手术.结果 全部手术过程顺利,术后恢复平稳,未发生急性凶险感染.经彩超检查残脾血供好,周围血象手术前后无明显变化.结论 只要熟悉了脾脏的血管解剖,实施保脾手术是安全、可靠和可行的.     

The efficacy of cylindrical titanium mesh cage for the reconstruction of a critical-size canine segmental femoral diaphyseal defect.

The authors developed a novel technique for the reconstruction of large segmental long bone defects using a cylindrical titanium mesh cage (CTMC). Although the initial clinical reports have been favorable, the CTMC technique has yet to be validated in a clinically relevant large animal model, which is the purpose of this study. Under general anesthesia, a unilateral, 3-cm mid-diaphyseal segmental defect was created in the femur of an adult canine. The defect reconstruction technique consisted of a CTMC that was packed and surrounded with a standard volume of morselized canine cancellous allograft and canine demineralized bone matrix. The limb was stabilized with a reamed titanium intramedullary nail. Animals were distributed into four experimental groups: in Groups A, B, and C (six dogs each), defects were CTMC reconstructed, and the animals euthanized at 6, 12, and 18 weeks, respectively; in Group D (three dogs), the same defect reconstruction was performed but without a CTMC, and the animals were euthanized at 18 weeks. The femurs were harvested and analyzed by gross inspection, plain radiography, computed tomography (CT), and single photon emission computed tomography (SPECT). The femurs were mechanically tested in axial torsion to failure; two randomly selected defect femurs from each group were analyzed histologically. Groups A, B, and C specimens gross inspection, plain radiography, and CT, demonstrated bony restoration of the defect, and SPECT confirmed sustained biological activity throughout the CTMC. Compared to the contralateral femur, the 6-, 12-, and 18-week mean defect torsional stiffness was 44.4, 45.7, and 72.5%, respectively; the mean torsional strength was 51.0, 73.6, and 83.4%, respectively. Histology documented new bone formation spanning the defect. Conversely, Group D specimens (without CTMC) demonstrated no meaningful bone formation, biologic activity, or mechanical integrity at 18 weeks. The CTMC technique facilitated healing of a canine femur segmental defect model, while the same technique without a cage did not. The CTMC technique may be a viable alternative for the treatment of segmental long bone defects.