骨肿瘤保肢术后异体骨骨折的影响因素与治疗

自１９４２年Ｉｎｃｌａｉｎ报道建立骨库经验以来,随着异体骨免疫学研究的进展及现代冷藏技术的提高,大段同种异体骨移植逐渐应用于修复各种原因引起的大段骨缺损。尤其近２０年来较成熟地应用于骨肿瘤保肢手术中,术后五年生存率达４０％～７０％,不仅与传统截肢手术相比无差异,而且保存了肢体的完整性和功能［１,２］。但临床长期随访结果发现其常发生异体骨骨折、感染、骨不连、肿瘤复发等并发症,影响保肢手术效果。尤其是异体骨骨折发生率高达１６－６％～１９％［３－５］。为此,本文着重阐述骨肿瘤保肢术后易发生异体骨骨折的…     

儿童恶性骨肿瘤保肢术研究进展

新辅助化疗的临床应用和保肢技术的不断发展 ,使传统的恶性骨肿瘤截肢术已逐渐被各种保肢手术所代替。由于儿童患者的病变多位于干骺端 ,为彻底切除肿瘤 ,术中需将骨骺和骺板一并切除 ,势必造成术后肢体不等长及功能恢复不理想[1～ 3 ] 。有研究报道股骨下端骨肉瘤切除骨骺及骺板后 ,将影响下肢纵向长度的 70 % [4] ,切除肱骨近端骨骺将影响肱骨长度的 80 %～ 82 % [5] 。为此 ,国外近年来报道了多种避免术后肢体不等长的手术方法 ,国内报道较少。现就儿童恶性骨肿瘤保肢术的临床应用进展作以下综述。1　可延长假体的临床应用八十年代末 ,可…     

应用假体翻修大段异体骨保肢失败后的功能重建

目的探讨应用组合式假体翻修大段异体骨感染或骨折的疗效。方法回顾性研究了美国迈阿密大学医学院和中山大学附属第一医院骨肿瘤科共22例肩关节或膝关节周围肿瘤的患者,大段异体骨保肢失败后,应用肿瘤型假体重建肢体功能。最初诊断包括骨肉瘤11例、软骨肉瘤4例、恶性纤维组织细胞瘤3例、骨巨细胞瘤2例、恶性血管内皮瘤1例和鼻咽癌转移瘤1例。发病部位包括股骨远端15例、肱骨近端3例和胫骨近端4例。结果异体骨失败原因包括:骨折14例、感染6例、持久不愈合1例、合并骨折和感染1例。异体骨移植后平均随访154.2(63～293)个月,假体翻修后平均随访73.4(24～234)个月。90.9%(20/22)的患者最终肢体功能良好,MSTS功能评分为76.5%(60%～93.3%)。81.8%(18/22)的患者假体翻修手术成功,在翻修失败的患者中,1例肱骨近端肿瘤患者为了改善功能经历了多次翻修手术,另1例股骨远端的患者,异体骨移植失败假体翻修后,由于假体近端松动而进行二次翻修——全股骨置换术,另外2例股骨远端的患者翻修后合并感染和骨折而截肢。结论异体骨重建因骨折或感染失败后,再次行假体翻修重建肢体功能是可靠的,并发症较低。翻修技术会影响重建肢体的功能。对于异体骨感染的患者,建议分期翻修重建肢体功能。     

恶性骨肿瘤保肢手术后的骨关节返修术

目的 分析四肢恶性骨肿瘤保肢手术后进行返修术的原因及手术治疗经验。方法 1994年1月－1997年12月进行保肢手术后骨关节返修术8例,平均无瘤生存时间8年。主要返修原因是严重的创伤性骨关节炎、骨折、骨吸收。影响返修手术的主要困难是软组织挛缩和肢体短缩。结果 行全髋返修1例,股骨下端长段同种异体骨移植再建3例,在原移植物基础上行全膝关节置换3例,更换髓内钉1例。术前骨扫描结果提示原移植的4例长段同种异体骨已有较活跃的骨代谢,术后病理学检查显示移植骨段存活。术后疼痛症状明显改善,功能满意。结论 保肢手术后的返修术主要原因是植入的异体骨或灭活瘤段发生骨折、关节功能较差。在有良好的软组织覆盖下,应用绞链式可旋转全膝关节假体或长段异体骨复合半限制球轴式表面置换人工膝关节假体可获得较理想的术后功能。     

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。     

恶性骨肿瘤保肢术应用的可行性

目的为了探讨保肢手术在治疗恶性骨肿瘤中的可行性。方法我们回顾了自1994年6月以来在我科诊治的12个恶性骨肿瘤病例。手术方法有瘤段切除人工关节置换2例，瘤段骨切除灭活再植4例，瘤段切除带血管蒂髂骨移植1例，瘤段切除关节融合2例，瘤段切除同种异体半关节移植1例，瘤段切除2例。并阐述常见术后并发症及处理原则。关节肢体功能评价参照Enneking标准。结果平均随访3年4个月(10个月至5年)。9例无复发。肢体功能优良率达66．7％。结论结果提示保肢手术在治疗恶性骨肿瘤中是切实可行的，并可达到较高的成功率。     

四肢恶性骨肿瘤保肢术后并发症的分析及对策

目的通过对四肢恶性骨肿瘤保肢术后并发症的分析,探讨并发症的原因及预防。方法本文总结了45例四肢恶性骨肿瘤的保肢治疗,其中男28例,女17例;年龄9～40岁。肿瘤切除人工假体置换29例,其中绞链式关节22例,肿瘤髋关节4例,肱骨近端假体3例;肿瘤切除离体灭活再植13例,桡骨远端切除,取同侧腓骨近端移植3例。结果观察及随访7个月～10年。45例有18例发生并发症,其中发生感染2例,发生肿瘤关节脱位2例,局部复发6例,假体或内固定折断3例,应力骨折4例,不愈合1例。结论四肢恶性骨肿瘤保肢术后并发症的发生与手术方式及术后辅助治疗、功能锻炼密切相关。     

骨肿瘤的保肢手术

2 0世纪 80年代由于肿瘤化疗的不断发展 ,特别是新辅助化疗的应用使保肢成为可能 ;先进的影像学诊断和外科技术的进步为保肢提供了客观条件 ;Ｅｎｎｅｋｉｎｇ外科分期在临床上的应用 ,为保肢选择手术方法提供了科学依据 ;国际恶性骨肿瘤保肢学会于 1981年成立并召开第一次会议 ,以后每两年一次的国际会议统一肿瘤的分期系统、手术方法和治疗结果的评定标准 ,大大推动了保肢技术在世界范围内的推广应用。在化疗、放疗和免疫治疗的基础上 ,根据患者的年龄、肿瘤性质、部位、外科分期、预后和要求手术达到的程度 ,选择既能彻底切除肿瘤、又…     

Results of free vascularized fibula grafting for allograft nonunion after limb salvage surgery for malignant bone tumors

The purpose of this study was to assess the results of free vascularized fibula grafting (FVFG) in the treatment of allograft fracture nonunion after limb salvage surgery for malignant bone tumors.A retrospective study was performed on 8 patients who underwent FVFG for allograft fracture nonunions. All had prior tumor resection and allograft reconstruction for osteosarcoma (n = 6) or Ewing sarcoma (n = 2) of the femur (n = 3), tibia (n = 2), humerus (n = 2), or ulna (n = 1). All patients failed an initial course of immobilization; 4 patients failed prior open reduction and internal fixation with autogenous nonvascularized bone grafting. Average age at the time of FVFG was 14 years. Average follow-up was 44 months.The FVFG resulted in successful bony healing in 7 of 8 patients, providing pain relief, limb preservation, and restoration of function. One patient developed an infection requiring fibula removal and staged prosthetic reconstruction. Additional complications requiring further treatment included limb-length discrepancy, additional allograft fracture, and wound infection.The FVFG is an effective treatment option for allograft nonunion after limb salvage surgery because it provides both the mechanical stability and biological stimulus for bony healing. Attention to internal fixation, limb alignment, and microvascular principles is essential to prevent complications and allow for the best functional outcomes.     

肿瘤型假体翻修手术的相关策略

[目的]分析肿瘤型假体置换术后翻修手术的原因，探讨手术的策略。[方法]10a间完成5例患者的肿瘤性假体翻修手术。男4例，女1例；平均年龄41．2岁。股骨远端4例，胫骨近端1例。再手术时间3．29a。翻修手术的原因均为假体松动，其中2例患者伴有窦道，1例假体远端断裂。翻修手术时2例应用原假体，3例应用新制作的假体，改为旋转铰链膝关节。[结果]本组5例均获得随访，最长为5a，最短为1a，平均为2a 4个月。5例均无瘤生存，假体无松动，切口愈合良好，关节功能的评分为21．5分。[结论]对于出现假体松动的患者，应及时行翻修手术，可获得较理想的肢体功能。     

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.     

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).     

Walking ability and activities of daily living after limb salvage operations for malignant bone and soft-tissue tumors of the lower limbs

We evaluated the number of steps, activities of daily life (ADL) score, Enneking score, active range of motion and muscle strength by muscle manual testing for function in lower limbs after reconstructive procedures in surgical treatment of tumors. The 56 patients with 20 malignant bone tumors and 36 malignant soft-tissue tumors averaged 7119 ± 3563 steps per day, or 69.8% of the control group. The average ADL score of patients was 14.0 ± 4.1 points (70.0%), and the average Enneking score 20.4 ± 6.0 points (68.0%). The scores of the bone tumor group were lower than those of the soft-tissue tumor group. These scores were not correlated with the range of motion. The number of steps and ADL score were correlated with Enneking score (coefficient 0.52 and 0.84, respectively). The number of steps and the ADL score appear to be useful, as is Enneking score. Received: 24 February 2000     

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.     

骨盆恶性肿瘤保肢术并发症防治

随着骨盆恶性肿瘤保肢术的不断发展及病例数的增加,各种并发症随之出现,严重影响骨盆肿瘤患者的功能恢复及生存质量,严重者可导致保肢手术失败.球囊导管腹主动脉暂时性阻断可有效减少保肢术中出血,提高手术安全性;软组织保护及腹壁重建对减少切口感染及腹部疝具有重要意义;带血管蒂自体游离骨移植融合重建术并发症率低,远期效果良好;假体置入重建术并发症的预防关键在于提後高手术技巧,优化假体设计.该文就骨盆恶性肿瘤保肢术并发症的发生原因、预防及处理等作一综述.     

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。