中国骨盆恶性肿瘤保肢治疗30年的发展与进步北大核心CSCD

本文回顾了中国近30年来在骨盆恶性肿瘤保肢治疗领域,外科技术和功能重建方面所取得的发展与进步。以不同部位骨盆肿瘤切除的手术分型为基础,详述了手术技术及骨缺损修复重建方法的发展历程。近年来,针对骨盆肿瘤切除后生物重建这一世界性难题,我国研究人员在国际上首次系统性地提出了不同部位肿瘤切除后骨缺损修复重建方法和假体设计。此外,还针对骨盆肿瘤累及骶骨这一棘手情况率先提出了系统的外科分型(Beijing分型),及相应的外科手术方案及修复重建方法。经过不懈努力,目前中国骨盆恶性肿瘤保肢率已达到80%以上,使广大患者保留肢体并恢复了行走功能,大幅降低了手术并发症,取得了国际瞩目的成绩。     

肩胛带恶性肿瘤的保肢治疗（附10例报告）

肩胛带恶性肿瘤,包括锁骨、肩胛骨、肱骨上端及其附丽的软组织恶性肿瘤。该部位肿瘤如作上肢的1/4截肢术,则牺牲正常的肘关节、前臂和手部。现今,对于肩胛带恶性肿瘤的保肢手术已越来越受重视,有逐步取代截肢的趋势。1 资料与方法1.1 一般资料 本组10例。男性6例、女性4例。年龄在15～58岁。肱骨上端7例、肩胛骨1例、三角肌2例。骨肉瘤3例、软骨肉瘤3例、纤维肉瘤2例、三角肌的横纹肌肉瘤及腺泡状肉瘤各1例。骨肿瘤按Enneking的外科分期本组8例均为ⅡB期,2例软组织肿瘤按Lawrenee的TNMG分期为ⅢB期。     

四肢恶性骨肿瘤保肢手术失败的原因分析

目的 探讨四肢恶性骨肿瘤保肢手术存在的诊疗失误,分析保肢手术失败的原因.方法 回顾性分析2005 年4 月至2010 年6 月新疆医科大学附属肿瘤医院收治的16 例四肢恶性骨肿瘤患者保肢手术时存在的诊断和治疗缺陷.结果 16 例患者保肢手术失败的原因包括：（1）对四肢恶性骨肿瘤疾病缺乏认识;（2）病理诊断困难;（3）对新辅助化疗及术后化疗认识不足;（4）对四肢恶性骨肿瘤保肢手术适应证把握不恰当;（5）肿瘤切除的手术边界不足;（6）肿瘤切除后重建方式选择不当;（7）活检通道选择错误.结论 对四肢恶性骨肿瘤患者实施保肢手术应尽量避免上述诊疗缺陷,提高保肢手术的成功率.     

超时限腘动脉损伤保肢的后遗症状及功能重建

目的 总结超时限膪动脉损伤的功能重建方法 .方法 47例超时限闭合性胭动脉损伤患者,损伤至血管再通时间13-173 h,平均33.4 h,一期修复腘动脉,对其远期后遗症状及功能重建的方法 和疗效进行随访.结果 本组获随访14个月～5年,平均3年7个月.疗效优:25例,占53.2%;良:17例,占36.2%;优良率89.4%;差:5例,占10.6%.结论 二期功能重建可以更好地恢复腘动脉损伤后的足踝部功能.     

超时限胭动脉损伤保肢的后遗症状及功能重建

目的总结超时限胭动脉损伤的功能重建方法。方法47例超时限闭合性胴动脉损伤患者，损伤至血管再通时间13～173h。平均33．4h，一期修复胭动脉，对其远期后遗症状及功能重建的方法和疗效进行随访。结果本组获随访14个月～5年，平均3年7个月。疗效优：25例，占53．2％；良：17例，占36．2％；优良率89．4％；差：5例，占10．6％。结论二期功能重建可以更好地恢复胭动脉损伤后的足踝部功能。     

四肢恶性骨肿瘤保肢术病人的护理

对19例四肢骨肿瘤病人采用骨水泥、自体骨粒、骨形态发生蛋白(BMP)、庆大霉素加内固定重建骨肿瘤切除骨段及人工关节治疗。术前给予心里支持，预防或减轻化疗并发症；术后加强生命体征监测及患肢护理，早期实施患肢功能锻炼。结果随访8个月至3年，除1例术后1年因发生肺部转移而死亡，其余病人重建肢体功能恢复良好。该手术方法具有操作简便，肿瘤切除彻底．重建肢体功能恢复快而好等优点。     

恶性肿瘤保肢术并发症的原因及治疗

目的：分析恶性骨肿瘤保肢技术并发症发生的原因及其治疗。方法：我院7年半间对86例恶性骨肿瘤行保肢术,其中22例出现了不同的并发症,同期收治外院资料完整的保肢术并发症患者8例。男22例,女8例。年龄平均23．5岁。部位：胫骨上端12例,腓骨上端4例,股骨下端9例,尺骨远端、肱骨近端、桡骨远端、胫骨远端、髂骨各1例。骨肉瘤18例,骨巨细胞瘤7例,软骨肉瘤2例,皮质旁骨肉瘤、骨纤维肉瘤和恶性纤维组织细胞瘤各1例。复发18例,切口感染和延迟愈合7例,神经损伤5例,异体骨或灭活骨骨折5例。结果：除4例拒绝治疗外,13例行截肢或关节离断术,4例行扩大切除术,肌皮瓣转位术和人工关节置换术各2例,清创缝合术,石膏外固定及切开复位内固定术各1例。另2例神经损伤患者未予处理。21例获得平均20．2月的随访（3月－6年）,4例死亡,3例带瘤生存,余14例无异常。结论：术后复发与术中切除不彻底,种植和治疗不当有关;切口感染和延迟愈合多发生于胫骨上端;神经损伤除与手术有关外,还与放疗不当有关;异体骨或灭活骨骨折多发生术术后2－12个月。对于出现并发症的患者应该根据不同的情况采取不同的治疗方法。     

人工关节在四肢恶性骨肿瘤保肢重建功能中的应用

目的探讨人工关节置换在恶性骨肿瘤保肢术中的应用价值。方法2000年3月～2005年8月收治48例恶性骨肿瘤,男23例,女25例;年龄15～47岁,平均21岁。其中骨肉瘤位于股骨远端15例,近端7例,肱骨近端9例,胫骨近端5例;软骨肉瘤位于股骨近端3例,肱骨近端2例,胫骨近端1例;尤文瘤5例,位于股骨近、远端各2例,股骨近端1例;股骨远端恶性纤维组织细胞瘤1例。病程3个月～2年。参照Enneking分期标准,B期2例,A期22例,B期24例。均进行人工关节置换术。结果术后48例获12～65个月随访。术后3例皮下积液,2例局部皮肤坏死换药后治愈,迟发感染1例,经引流抗感染治愈;3例疼痛,1例服止痛药,2例能忍受;1例外伤后股骨上段假体折断,行翻修术后可行走。2例术后分别于8、17个月局部复发行截肢术。术后1～2年肺转移7例,2～3年肺转移4例,恶性肿瘤最终保肢率93.8%。参照Enneking骨骼肌肉肿瘤术后肢体功能评定标准,获优18例,良21例,可5例,差4例。结论辅以综合治疗,人工假体置换术是四肢恶性骨肿瘤保肢、重建功能的一种有效方法。     

肩胛部恶性肿瘤保肢治疗

目的探讨肩部骨肿瘤保肢治疗的手术方法。方法对2例肩部恶性肿瘤实施保肢术，肱骨近端成骨肉瘤1例，行肱骨瘤段切除，锁骨翻转重建骨缺损，肩胛骨恶性纤维组织细胞瘤1例，行肿瘤切除、肱骨肩峰悬吊术。结果术后短期随访，肩关节被动活动有一定的功能。结论肩部恶性肿瘤应根据肿瘤发生的不同部位，患者的经济实力，选择不同保肢手术，目的是使肩部保留一定的功能和外形，提高患者生活的质量。     

恶性骨肿瘤保肢治疗的原则及问题

保肢手术已成为治疗肢体恶性骨肿瘤的经典方法。保肢治疗的目的是不但要提高患者的生存率，而且要保存良好的肢体功能。保肢手术的第一个目的是避免局部复发，第二个目的是尽可能多地保留功能。治疗格言为：“肿瘤第一，功能第二”。国内近20年来骨肿瘤的治疗已经取得了很大的进步，     

骨关节假体在四肢恶性骨肿瘤保肢手术中的应用

随着有效的新辅助化疗在临床治疗中的广泛应用，大大减少了恶性骨肿瘤的转移，提高了患者的5年生存率，从而为保肢手术提供了强有力的保证，保肢手术已经成为四肢恶性骨肿瘤的规范治疗方式。保肢手术应确保局部复发率不比截肢手术高，并且可以产生良好的功能结果。因此，术中必须对肿瘤进行广泛切除，但这样往往会造成严重的骨关节缺损。人工骨关节假体置换术是目前保肢术中重建骨关节的完整性，保留肢体功能的最有效的方法之一。     

Functional outcome of limb salvage surgery with mega-endoprosthetic reconstruction for bone tumors

Background

The use of a mega-endoprosthesis has become the method of choice for reconstruction after bone tumors. In this study, we sought to determine the functional outcome and complications associated with mega-endoprosthesis.

Methods

A retrospective review of the charts of 16 patients who had undergone resection of bone tumors followed by reconstruction with mega-endoprosthesis between 2006 and 2011 was performed. Functional evaluation was based on the Musculoskeletal Tumor Society (MSTS) scoring system. Complications of the procedures were also analyzed.

Results

Eight men and eight women at an average age of 36.7?years were included in the study. The tumor involved lower limb in 14 patients and upper limb in 2 patients. The average MSTS functional score was 72.3?±?15. Excellent results were achieved in six patients, good in five, moderate and fair in two each and poor in one. Complications occurred in eight patients. Two patients had aseptic loosening of the femoral component of total knee replacement. Flap necrosis occurred in two patients, both of whom required latissimus dorsi free flap for coverage of total knee prosthesis. One patient underwent revision of femoral component subsequent to knee dissociation. Local recurrence of tumor, patellar tendon rupture and foot drop occurred in one patient each.

Conclusion

Mega-endoprosthetic reconstruction in limb salvage provides good functional outcome in patients with bone tumors.     

Periacetabular limb salvage for malignant bone tumours

PURPOSE: To evaluate treatment outcomes in primary malignant periacetabular bone tumour removal and limb salvage with or without bone-graft reconstruction. METHODS: A total of 13 patients were treated for malignant periacetabular bone tumours at Siriraj Hospital, Bangkok, Thailand. The diagnoses were chondrosarcoma (n=8), Ewing's sarcoma (n=2), osteosarcoma (n=1), well-differentiated osteosarcoma (n=1), and malignant giant cell tumour (n=1). 11 patients did not undergo reconstruction following tumour resection; 2 patients received fibular bone grafts bridging the periacetabulum to the remaining sacrum. Adjuvant chemotherapy was administered for high-grade malignant tumours, and postoperative radiation therapy was performed on patients with a closed surgical margin. RESULTS: At a mean follow-up of 24.3 months (range, 8.9-43.9 months), 9 patients remained disease-free, 3 had died of the disease, and one was alive with disease. According to the Musculoskeletal Tumor Society classification system, the mean functional analysis at final follow-up was 68.7%. Patients who underwent internal hemipelvectomy experienced a subsequent leg-length discrepancy ranging from 3 to 10 cm. Four patients had complications (one each for deep wound infection, skin necrosis, seroma, and vascular spasms) and were successfully treated with multiple debridements and appropriate antibiotics. Three patients had local recurrences; one required a classic hemipelvectomy. CONCLUSION: Malignant periacetabular tumours are difficult to manage. Functional results of our patients with no reconstruction or with bone-graft bridging were fair. Patients undergoing internal hemipelvectomy may experience leg-length discrepancies, which can be balanced with shoe lifts.     

Limb salvage in primary malignant bone tumors

Advances in adjuvant chemotherapy and improvements in techniques of oncologic reconstruction have stimulated renewed interest in limb saving operation for malignant bone tumors. Between 1970 and 1981, 160 patients underwent local resection for malignant osseous lesions at the Mayo Clinic. This included 102 patients with chondrosarcoma, 44 with osteosarcoma, and 14 with fibrosarcoma. Ninety-three of the lesions were stage I and 67 were stage II. The overall local recurrence rate was 11.8%. The reconstructive procedures were effective in providing adequate functional restoration. Limb sparing operation is a valid viable option in carefully selected patients with malignant bone tumors. A continued search for effective adjuvant treatment programs is necessary.     

Infection in limb salvage surgery for bone tumors

The authors present a retrospective study of 66 infected cases in their series of limb salvage surgery performed from January 84 to August 92. Special emphasis was given to the alternative techniques of treatment in infection. In 85% of the cases healing was achieved, however removal of the implant and amputation are still frequent occurrences. Time to recovery is very demanding.     

The UCLA experience in limb salvage surgery for malignant tumors

Between December 1980 and January 1985, 95 patients with 98 malignant bone tumors were treated at UCLA by a multidisciplinary approach. Seventy-eight patients with 81 lesions underwent primary limb salvage procedures utilizing 66 custom endoprostheses and, in 15 instances, soft tissue reconstruction alone. Sixty-three of 78 (80.7%) underwent successful limb salvage without complication. The 22 local complications in 15 patients (19.2%) were all successfully managed either by surgical or nonoperative techniques salvaging all 15 extremities at risk. Seventeen patients underwent primary amputation for local control of their tumor. The local recurrence rate of 6.4% in the limb salvage group is comparable to the 5.8% found in the amputation group. The selection of patients for limb salvage did not adversely prejudice these patients in terms of rates of progression or ultimate survivorship. The cosmetic and functional results of limb sparing surgery is felt to be at least comparable with that obtained by primary amputation and the use of external prostheses.     

恶性骨肿瘤保肢手术并发症的原因及防治

目的探讨恶性骨肿瘤保肢手术并发症发生的原因及防治措施.方法采用微波原位灭活术和人工假体置换术对66例膝关节周围恶性肿瘤患者行保肢术,微波原位灭活38例,人工膝关节置换28例.在复习病历的基础上分析其手术并发症.结果微波原位灭活组随访11～67个月,平均29.6个月,其中12例死亡,3年生存率为65.8%;6例因感染、肿瘤局部复发等原因而截肢,保肢率为84.2%;出现了22例次不同种类的并发症,发生率为57.9%.人工膝关节置换组随访17～62个月,平均34.8个月,其中8例死亡,3年生存率为71.4%;2例因肿瘤局部复发而截肢,保肢率为92.9%;出现了9例次不同种类的并发症,发生率为32.1%.结论恶性骨肿瘤保肢术后局部复发率不高,但肺转移发生率较高并成为恶性骨肿瘤复发致死的主要原因.切口感染多发生在胫骨上端.微波原位灭活骨段骨折多发生于术后8～16个月.除局部复发和远处转移外,人工膝关节置换组的并发症发生率低于微波原位灭活组(P＜0.05).     

Low dose irradiation for limb salvage in malignant bone tumours

Summary We have assessed the value of adding low dose radiotherapy to preoperative chemotherapy in 20 patients with high grade malignant bone tumours. Histology of the resected specimens showed a considerable tumouricidal effect and a distinct capsule enclosing the extraosseous part of the tumour. There were no serious side effects.

---

Résumé Nous avons étudié sur le plan clinique et anatomo-pathologique, chez 20 malades atteints de tumeurs osseuses de haut degré de malignité, la valeur de la radiothérapie à la dose de 30 Gy en complément de la chimiothérapie pré-opératoire. L'histologie des pièces réséquées chirurgicalement a montré un effet tumoricide considérable et l'encapsulement de la partie extra-osseuse de la tumeur. La radiothérapie n'a pas déterminé d'effets secondaires fâcheux. Elle paraît donc indiquée pour la conservation des membres en cas de tumeurs osseuses de haut degré de malignité.