Scope and limitations of limb-sparing surgery in childhood sarcomas

The authors reviewed 43 children with high-grade sarcomas of bone and soft tissue who underwent surgery during the past 9 years. Twenty-six patients had osteosarcoma, 7 had Ewing sarcoma, and 10 had soft tissue sarcomas. Patients ranged in age from 4 months to 13 years. Mean follow-up period was 6 years. The feasibility of resection, results of local resection, and failure of local disease control were reviewed. Limb salvage was feasible in 81% of patients. Of the 35 patients undergoing limb salvage, margins were considered adequate in 88% and inadequate in 12%. Limb-sparing resection was not feasible in 19% of patients. Five patients (four with metastatic disease at presentation) did not undergo surgery and were given palliative care; three other patients underwent amputation. The decision of whether to proceed with limb salvage surgery must depend on the aggressiveness of the underlying tumor, its stage, the feasibility of obtaining tumor-free resection margins, and the response to neoadjuvant therapy.     

Early experience with cryopreserved arterial allografts in below-knee revascularization for limb salvage

BACKGROUND: Below-knee revascularization for limb salvage in the absence of a suitable autogenous saphenous vein is a frequent challenge associated with a high amputation rate. The aim of this prospective study was to evaluate the usefulness of cryopreserved arterial allografts in such cases. METHODS: Arterial allografts were harvested from multiple organ donors and cryopreserved at -80 degrees C. From March 1993 to December 1997, 35 cryopreserved arterial allografts were used as below-knee bypasses for repeated limb salvage in 32 patients. There were 15 men and 17 women with a mean age of 75 years (+/-10.7). Seven patients had rest pain and 25 patients (78%) had gangrene or nonhealing ulceration. Runoff was through a single tibial vessel in 25 cases (71%) and two vessels in 10 cases. Previous ipsilateral bypasses had been done in 26 of 35 limbs (74%). Patients were followed up prospectively for an average period of 18 months (range 2 to 56). RESULTS: Aneurysmal dilatation occurred in two patent grafts, requiring segmental replacement at 13 and 18 months, respectively. The overall primary patency rate was 75% at 6 months, 57% at 12 months, and 39% at 18 months. The overall secondary patency rate was 75% at 6 months, 75% at 12 months, and 59% at 18 months. Overall limb salvage rate was 80% at 12 months, 73% at 18 months. CONCLUSIONS: These early data indicate that below-knee bypass with arterial allografts results in acceptable patency and limb salvage. Arterial allografts may be a useful alternative to other arterial substitutes in a difficult group of patients with critical ischemia and no suitable saphenous vein.     

Concomitant arterial and venous reconstruction with resection of lower extremity sarcomas

INTRODUCTION: Limb salvage can now be achieved in many cases of lower extremity sarcoma. Obtaining disease-free margins may require resection of adjacent vascular structures. We present our experience with a consecutive series of patients undergoing resection of lower extremity sarcomas en block with the artery and vein, focusing on the mid- and long-term outcomes of their vascular reconstruction. METHODS: Records were reviewed retrospectively for patient age, tumor location and type, procedure, and early and late outcomes. Between 1991 and 2004, 10 children (mean age 12 years, range 6-18 years) and 9 adults (mean age 48 years, range 24-73 years) underwent wide resection of lower extremity sarcomas to include the involved arterial and venous segments. All children had bone sarcomas, and because of their skeletal immaturity, they were treated with rotationplasty--a type of intercalary amputation that removes the distal thigh, knee, and proximal tibia while preserving the distal leg and foot. In rotationplasty, the distal residual limb is preserved, rotated 180 degrees, and attached to the thigh, positioning the ankle at the level of the former knee joint. In these cases, the residual vessels were reconstructed by primary anastomosis. All of the adults except one had soft tissue sarcomas; the resected vessels were reconstructed with contralateral saphenous vein. In all cases, the operative approach included shunting of artery and vein during tumor removal and orthopedic reconstruction. RESULTS: The mean follow-up was 5.7 years. Three patients died of metastatic disease, and one died from a postoperative pulmonary embolism. No patient had local recurrence. Two patients ultimately required above-knee amputation: one child for tissue loss secondary to reperfusion injury, and one adult because of graft thrombosis secondary to progression of peripheral arterial disease. Two patients required early re-exploration for perioperative graft thrombosis. Both required replacement of saphenous vein conduits with polytetrafluoroethylene (PTFE) prosthetic graft; one of the PTFE grafts became infected. CONCLUSIONS: Limb salvage can be achieved in the majority of patients who have lower extremity sarcomas even when en bloc resection includes the artery and vein. Intraoperative shunting can limit ischemia and is especially useful when immediate vascular repair is delayed by orthopedic reconstruction. The long-term patency rate of the reconstructed vessels is high. Saphenous vein is the preferred conduit when it is of adequate caliber.     

Osteoarticular and Total Elbow Allograft Reconstruction With Severe Bone Loss

Osteoarticular allograft reconstruction is an option in patients with massive periarticular elbow bone loss secondary to tumor surgery or trauma. Our consecutive series consisted of 18 patients with tumors and one patient with trauma. Reconstruction consisted of 16 hemiarticular allografts and three total elbow osteoarticular allografts; patients had a minimum followup of 2 years (mean, 9.9 years; range, 2-12 years). For patients who had hemiarticular allografts, 14 of 16 were able to return to their preoperative level of occupational function, with one patient experiencing failure of the allograft from infection. For the three patients who had total elbow allograft reconstructions, all had degenerative changes develop after surgery and two of the allografts failed. Complications occurred in six of 19 patients. Hemiarticular elbow allograft reconstruction is useful for limb salvage with massive bone loss. Total elbow allograft reconstructions have a high failure rate in the mid-term. LEVEL OF EVIDENCE: Level IV, therapeutic study.     

Cadaveric elbow allografts. A six-year experience

Transplantation of total elbow allografts has been employed as a salvage procedure in an attempt to provide patients with a useful, painless range of motion of the elbow. Patients who are candidates for this procedure include those with disabling elbow joint symptoms who refuse an arthrodesis or are not candidates for conventional total elbow replacement because of excessive bone loss or young age. Allografts must be subjected to rigid internal fixation. Rush rod fixation used early in this series was associated with a high incidence of nonunion. In this series, ten patients followed for one to six years were provided with a functional elbow. However, long-term results are still unknown. Although not recommended for routine use, this operation is viewed as a salvage procedure. The use of allografts in elbow reconstruction does not preclude subsequent reconstruction with another allograft or fusion. In patients with deficient bone stock, the allografts reestablish bone mass to permit an arthrodesis or reconstructive arthroplasty.     

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.     

Revision hip arthroplasty using strut allografts and fully porous-coated stems

At a minimum of 10 years after surgery, we prospectively evaluated the clinical and radiographic outcomes of revision total hip arthroplasties using cortical strut allografts and fully porous-coated cementless revision femoral components in patients with massive femoral bone deficiency. There were 21 men and 33 women (54 hips) in the series, with patients' mean age at the time of index revision being 54.6 years (range, 36 to 65 years). All femurs had 2 or 3 fresh-frozen femoral strut allografts. The Harris hip score improved from a mean of 21 points before revision surgery to a mean of 83 points at the latest case review. Two femoral stems (4%) had aseptic loosening and were revised. All allografts were predictably united to the host femur. On the basis of favorable results at a mean follow-up of 10.5 years, we recommend, as a salvage procedure, the use of fully porous-coated cementless femoral stems and strut allografts in revision surgery of the hip for massive femoral bone loss.     

人工关节假体复合大段同种异体骨移植重建肢体功能

目的 探讨采用复合人工关节假体大段同种异体骨移植的方法治疗肢体恶性骨肿瘤的手术原理及效果。方法 骨肿瘤患者１６例,年龄１９岁－６０岁,其中骨肉瘤４例,软骨肉瘤２例,恶性骨巨细胞瘤３例,纤维肉瘤３例,其它恶性骨肿瘤４例,肢体功能重建方法包括：复合股骨近端的全髋关节置换术３例,复合股骨近端的双极人工股骨头置换术７例,复合股骨下端或胫骨上端的全膝关节置换６例,结果 本组１６例经１．５－５．０年随访,１例     

Is Amputation Necessary for Sarcomas? A Seven-Year Experience with Limb Salvage

The rationale for amputation for local tumor control of skeletal and soft tissue sarcomas was based on results obtained from surgical therapy alone. However, our previous results from a pilot trial of multimodality therapy of preoperative chemotherapy and radiation therapy followed by surgical resection indicated that limb salvage (without amputation) could be accomplished in most patients with little morbidity and low recurrence rate. This report summarizes our experience in a prospective trial from January 1972 to December 1979. A total of 105 consecutive patients with soft tissue sarcomas (65 patients) or bone sarcomas (40 patients) were treated with preoperative intraarterial adriamycin, 3500 rads of rapid-fraction radiation and radical en bloc resection of primary tumor. Diseased bones were replaced with cadaver allografts (22 patients), metallic endoprostheses (10 patients) autologous bone (2 patients), or no replacement (ilium or fibula—4 patients). Salvage of a viable, neurologically intact, functional extremity was achieved in 98/105 patients (98%); 97% of limb salvage patients were free of local recurrence after a median follow-up period of 28 months. Major complication rate that required amputation was 3/105 patients (2%). Postoperative adjuvant chemotherapy with cyclical adriamycin and high-dose methotrexate was employed for all patients with osteosarcoma and 35 patients with grade III soft tissue sarcomas. The overall disease-free rate is 50% (18/35) for osteosarcomas and 65% (42/65) for soft tissue sarcomas. These results indicate that local tumor control can be achieved in 91% of patients without amputation. Their functional capabilities are excellent with a low complication rate. Since the advent of adriamycin and methotrexate has significantly improved the overall survival for patients with skeletal and soft tissue sarcomas, the quality of this survival has become even more important. Preoperative multimodality therapy is a major advance in this direction and since results of limb salvage procedures appear to be equal or superior to those achieved by amputation we believe these alternatives should be offered to all patients.     

髋臼周围恶性肿瘤的外科治疗

目的 探讨髋臼周围恶性肿瘤保肢手术的方法和疗效.方法 回顾性分析1999年1月至2006年12月行保肢手术的31例髋臼周围恶性肿瘤患者的临床资料.其中男性17例,女性14例;年龄42～75岁,平均53岁.软骨肉瘤24例、尤文肉瘤4例、骨肉瘤1例、转移性肿瘤2例.Ⅱ区切除16例,Ⅰ+Ⅱ区切除5例,Ⅱ+Ⅲ区切除5例,Ⅰ+Ⅱ+Ⅲ区切除5例.肿瘤切除后重建17例,未重建14例.结果 31例患者随访时间12～84个月,平均52个月.14例患者无瘤生存,4例带瘤生存,13例死亡.软骨肉瘤的复发率为20.8%,死亡率33.3%.2例转移性肿瘤患者广泛转移,死于术后11和34个月.1例骨肉瘤和2例尤文肉瘤患者死于肺转移.采用Enneking骨肿瘤术后患者的功能评估方法,18例存活的患者参加功能评价.13例切除后重建的患者中优6例、良好6例、差1例.6例未重建患者优3例、良好2例、差1例.6例患者术后出现可控性并发症.结论 广泛切除肿瘤降低局部复发率是围髋臼肿瘤保肢手术的基本要求,重建髋关节的功能应综合考虑肿瘤破坏的范围和手术切除的范围,遵循个体化原则.     

Combination regional therapy for extremity sarcoma. A tricenter study

Patients with extremity sarcomas were treated with a neoadjuvant therapy protocol that had originated within the Southeastern Cancer Study Group. Major objectives were to determine tolerance of therapy and its effects on tumor control and survival. After undergoing biopsy, patients received intra-arterial infusion with doxorubicin hydrochloride (Adriamycin) (30 mg every 24 hours) for 3 days and were allocated by institution to receive irradiation of 30 or 35 Gy in 10 fractions or 46 Gy in 23 to 25 fractions. Surgery was done within 7 to 10 days or 30 days pending irradiation dose. Postoperative chemotherapy was given to 31 patients. There were 60 patients, 29 women and 31 men with a median age of 48 years, with 53 soft-tissue tumors and 7 malignant bone tumors. Stages (American Joint Committee on Cancer) included stage IB, 2 patients; stages IIA and IIB, 9 patients; stage IIIA, IIIB, or IIIC, 39 patients; and stages IVA or IVB, 10 patients. Limb salvage surgery was done in 57 patients, including radical resection in 23 with large extensive tumors, wide local excision in 30, excision with narrow margins in 7, primary amputation in 3, and delayed amputation in 2 because of wound complications. There was one local recurrence in the 57 patients who had limb salvage surgery. Disease-free and overall survival at 48 months were 47% and 56%, respectively. We conclude that combined therapy for extremity sarcomas in a multicenter setting resulted in excellent local control, good function, and reasonable long-term survival in patients having limb salvage surgery.     

Cortical strut allografts in salvage revision arthroplasty: Surgical technique and clinical outcomes

BackgroundThe aim of this study was to present our clinical outcomes and surgical technique in strut allografts preparation using staggered holes to enhance osteointegration and demineralised bone matrix (DBM) as an adjunct to cortical strut allografts in salvage revision arthroplasty patients.MethodsRetrospective consecutive series of patients who required strut allograft femoral reconstructions with minimum 2 years follow up between 2012 and 2018. Frozen washed irradiated, cortical struts were used and prepared adding 2 mm staggered drill holes along the length of the strut and applying DBM paste on the graft-host interface. Outcome measures included radiographic strut union, graft resorption, infection and complications.Results15 patients included; 3 males and 12 females with median age 72 years (range 60–93). All had significant bony defects (Paprosky III/IV in 12 cases including 3 cases of periprosthetic hip fractures and further 3 cases of periprosthetic knee fractures around revision hinged implants). At final follow up, median 3.8 years (range 2.7–7.2), 14/15 (93.3%) struts had united at a median 6 months (range 5–8), complete incorporation with cortical round-off was seen at median 12 months (range 8–48) in 12/15 (80%) struts, 2/15 (13.3%) show radiographic evidence of proximal minimal graft resorptions although the remainder of the strut had integrated and were asymptomatic. There were no cases of infection.ConclusionsUse of strut allografts helps to reconstruct bone defects, restore bone stock, and provide stable fixation for complex patterns of periprosthetic fractures around hip/knee implants and salvage revision cases with 93.3% union rate at median 6 months.     

Isolated limb perfusion with tumor necrosis factor and melphalan for limb salvage in 186 patients with locally advanced soft tissue extremity sarcomas. The cumulative multicenter European experience.

OBJECTIVE: The objective of the study was to achieve limb salvage in patients with locally advanced soft tissue sarcomas that can only be treated by amputation or functionally mutilating surgery by performing an isolated limb perfusion (ILP) with tumor necrosis factor (TNF) + melphalan (M) as induction biochemotherapy to obtain local control and make limb-sparing surgery possible. SUMMARY BACKGROUND DATA: To increase the number of limb-sparing resections in the treatment of locally advanced extremity soft tissue sarcoma, preoperative radiation therapy or chemotherapy or a combination of the two often are applied. The ILP with cytostatic agents alone is another option but rarely is used because of rather poor results. The efficacy of the application of TNF in ILP markedly has changed this situation. METHODS: In 8 cancer centers, 186 patients were treated over a period of almost 4.5 years. There were 107 (57%) primary and 79 (43%) recurrent sarcomas, mostly high grade (110 grade III; 51 grade II; and 25 very large, recurrent, or multiple grade I sarcomas). The composition of this series of patients is unusual: 42 patients (23%) had multifocal primary or multiple recurrent tumors; median tumor size was very large (16 cm); 25 patients (13%) had known systemic metastases at the time of the ILP. Patients underwent a 90-minute ILP at 39 to 40 C with TNF + melphalan. The first 55 patients also received interferon-tau. A delayed marginal resection of the tumor remnant was done 2 to 4 months after ILP. RESULTS: A major tumor response was seen in 82% of the patients rendering these large sarcomas resectable in most cases. Clinical response rates were: 33 complete response (CR) (18%), 106 partial response (PR) (57%), 42 no change (NC) (22%), and 5 progressive disease (PD) (3%). Final outcome was defined by clinical and pathologic response: 54 CR (29%), 99 PR (53%), 29 NC (16%), and 4 PD (2%). At a median follow-up of almost 2 years (22 months; range, 6-58 months), limb salvage was achieved in 82%. Regional toxicity was limited and systemic toxicity minimal to moderate, easily managed, with no toxic deaths. CONCLUSIONS: In the setting of isolated limb perfusion, TNF is an active anticancer drug in patients. The ILP with TNF + melphalan can be performed safely in many centers and is an effective induction treatment with a high response rate that can achieve limb salvage in patients with locally advanced extremity soft tissue sarcoma.     

二期翻修治疗膝关节肿瘤型人工关节感染

目的探讨二期翻修术治疗膝关节肿瘤型人工关节感染的疗效。方法 2003年8月-2010年8月,收治22例保肢术后膝关节肿瘤型人工关节感染患者。男11例,女11例;年龄15～55岁,平均29.6岁。其中20例为初次关节置换术后感染,2例为翻修术后;术后15 d～89个月发生感染。感染按照Coventry和Fitzgerald等人工关节感染分型标准:Ⅰ型3例,Ⅱ型15例,Ⅲ型4例。发生感染至该次入院时间为5～47个月,平均10.2个月。细菌培养提示阳性9例,阴性13例。2例出现发热,白细胞计数升高。一期清创术取出假体,临时骨水泥填充旷置;待感染控制后行二期翻修。结果一期清创术前C反应蛋白及红细胞沉降率均明显高于二期翻修术前,差异有统计学意义(P<0.05)。术后患者均获随访,随访时间5～63个月,平均23.6个月。一期清创术后18例(81.8%)感染控制,其中1例拒绝二期翻修,17例行二期翻修术;17例中1例因术后5个月感染复发,行截肢术。4例(18.2%)感染未控制,行截肢术。保肢率为77.3%(17/22)。1例肾癌骨转移患者因原发病于术后1年6个月死亡。末次随访时16例关节功能采用美国骨与软组织肿瘤学会功能评分(MSTS 93)为(69.4±12.7)分。结论肿瘤型人工关节重建后感染,应根据情况及时行二期翻修手术,可获得较好疗效。     

Trabecular metal endoprosthetic limb salvage reconstruction of the lower limb

Currently, porous tantalum (trabecular metal) implants are widely accepted and frequently used for primary and revision hip and knee replacement surgery. This study examines the results of porous tantalum endoprostheses used to reconstruct large skeletal defects following resection of bone tumors. Seven custom tantalum implants were used to reconstruct 7 patients following resection for skeletal sarcomas in the femur and proximal tibia. Patient ages ranged from 13 to 71, with a mean of 34 years. Minimum patient follow-up was 6 years. The average Musculoskeletal Tumor Society functional evaluation score was 95 % of normal. There were no infections, hardware failures, or adverse events. One implant was revised 98 months post insertion because of fibrosis, loss of motion and loosening. In this small clinical series, the use of porous tantalum for limb salvage reconstruction is shown to be safe, to successfully provide osteointegration and soft tissue ingrowth, and to facilitate return of limb girdle muscle function.     

Modular megaprosthesis for distal femoral tumors

We treated 48 patients with distal femoral tumors by resection and limb salvage with an uncemented megaprosthesis (Howmedica Modular Replacement System). Diagnoses included: 32 osteosarcomas, five chondrosarcomas, six giant cell tumors of the bone, three fibrosarcomas, and two Ewing's sarcomas. The mean follow-up was 5.6 years (2-10 years). The overall complication rate was 39%. Seven patients died of their disease, but none from complications related to the surgery. Five patients were revised to arthrodesis, and one required amputation because of complications. The mean postoperative Musculoskeletal Tumor Society score (MSTS) score was 21 (6-28) for the remaining 35 patients. The most frequent complications were infection (14.6%) and aseptic loosening (4.8%). Ten-year survival of the prosthesis was 65%.     

Expandable endoprosthesis for limb-sparing surgery in children: long-term results

Purpose

Most children today with bone sarcomas undergo limb-sparing surgery. When treating children younger than 12 years of age, the result is significant limb length discrepancy (LLD). One of the solutions is the use of an expandable endoprosthesis.

Methods

A retrospective analysis of 38 skeletally immature patients with bone sarcoma of the lower limb in whom different types of expandable endoprostheses were used from January 1988 to December 2005 were included. All patients were under the age of 14 years. There were 26 osteosarcoma and 12 Ewing’s sarcomas. The data collected included the tumor characteristics, the surgical and other treatment modalities, complications and their treatment, and the final LLD and functional results.

Results

Fifty-five percent of the patients survived and had a mean follow-up of 113 months. All survivors reached skeletal maturity at the time of last follow-up. Seventy-one percent of the survivors had satisfactory function and 29% had a poor result. There were three secondary amputations due to local recurrence. Complications were documented in 58% of patients; the most common was infection that was diagnosed 56 times (primary 16% and secondary 84%). A significant correlation was found between function and final LLD (greater than 5 cm = inferior function), the number of complications, and the number of surgical procedures performed other than prosthesis elongation. The younger the patient was at definitive surgery, the shorter the time it took for the prosthesis to fail.

Conclusion

In order to improve results, the number of operations must be reduced. This can be achieved by the use of novel non-invasive expandable endoprostheses or biological reconstruction.     

Free tissue transfer in children

We reviewed 11 cases of free tissue transfer used to salvage limbs in young patients (age range 4-16 years, mean 8.9 years). The defects were the result of acute trauma in eight cases, osteomyelitis in one, unstable scar over bony prominence in one, and correction of a previously infected talipes equinovarus repair in another patient. Donor tissues used were the latissimus dorsi muscle, scapular skin, lateral arm skin, and vascularized fibular graft. Defect sizes included 3 x 3 to 10 x 40 cm and 11 cm of humeral diaphysis. Microvascular success rate was 100%. In each case, the successful transfer provided the viable tissue required and resulted in salvage of the limb. Our results suggest that free tissue transfer is a viable solution to limb salvage in pediatric patients.     

下肢远端原发恶性骨肿瘤患者的生存和肢体功能分析

目的 分析下肢远端原发恶性骨肿瘤患者的生存情况,评估保肢后的肢体功能.方法 2003年11月至2010年1月,20例下肢肢体远端原发恶性骨肿瘤接受保肢或截肢手术.男性15例,女性5例,平均年龄20岁.肿瘤位置:胫骨远端14例,腓骨远端3例,跟骨3例.肿瘤分期:ⅠB期3例,ⅡB期16例,Ⅲ期1例.除3例胫骨下端肿瘤截肢外,其他11例胫骨远端肿瘤行自体骨(4例)或异体骨(7例)踝关节融合手术,6例腓骨远端和跟骨肿瘤行自体骨重建手术.平均随访36.4个月.结果 5例异体骨踝关节融合和1例跟骨自体骨重建患者伤口延迟愈合,自体骨和异体骨对伤口愈合的影响差异有统计学意义(P=0.036).2例异体骨出现吸收和不愈合(其中1例截肢,另1例更换为骨水泥临时假体),1例胫骨远端骨肉瘤术后11个月复发截肢,2例分别于确诊后22和48个月死于肺转移.患者2和5年的总生存率分别为92.9%和79.6%,12例高度恶性骨肉瘤的2和5年生存率分别为87.5%和70.0%.保肢患者功能MSTS评分为82%.结论 下肢肢体远端原发恶性骨肿瘤的整体生存情况相对较好,保肢可以获得良好的肿瘤控制和肢体功能.     

结构性植骨修复膝关节翻修术中严重骨缺损的临床效果及相关分析

目的探讨同种异体结构性植骨在膝关节翻修术中大块骨缺损中应用的临床效果和意义。方法1994～2001年芬兰坦佩雷大学医院应用单一翻修假体及同种异体骨结构性植骨治疗膝关节置换术大块骨缺损患者10例（膝）,男1例,女9例,平均年龄70岁（61—77岁）,平均随访5年（1～8年）,所有手术均由两名高年资专科医师执行,采取KSS评分评估术前术后膝关节功能。结果最后随访时,患者膝关节KSS评分由术前的平均39分（4～51分）提高至81分（28—102分;P〈0．05）;疼痛评分由术前的18分（0—30分）提高至42分（10—50分;P〈0．05）。2例出现假体周围透亮线（〈1mm）,但没有任何松动症状;所有结构性植骨均获得满意的愈合,最后随访时没有出现吸收征象,1例患者术后出现膝前疼痛,经髌骨表面置换后症状消失。结论同种异体骨结构性植骨应用在膝关节翻修术中大块骨缺损中可取得满意的临床效果,重建下肢力线、第三代骨水泥技术的应用及有由专科医师实施手术是获得良好临床效果的保证。