肩胛带区骨肿瘤的保肢治疗

目的探讨肩胛带区骨肿瘤的保肢手术方法及相关的临床效果。方法35例肩胛带骨肿瘤患者,男24例,女11例,平均年龄34岁(12～74岁)。肿瘤部位:肱骨上段21例,肩胛骨12例,锁骨2例;肿瘤类型:骨肉瘤10例,软骨肉瘤7例,恶性纤维组织细胞瘤3例,尤文肉瘤3例,纤维肉瘤1例,骨髓瘤1例,骨巨细胞瘤7例,转移瘤3例。按照Malawer等提出的手术分类方法进行分类。保肢手术方法:肿瘤假体置换8例,瘤段骨灭活回植4例,异体骨关节移植3例,自体腓骨移植2例,髓针骨水泥假体置换1例,Tikhoff-Linberg手术3例,瘤段肢体切除、上肢短缩再植2例,全肩胛骨或关节盂切除、肱骨头悬吊4例,部分肩胛骨切除6例,锁骨瘤段切除2例,其中16例作了化疗。结果本组患者平均随访71个月(6～186个月),局部复发4例,远处转移6例,死亡9例,无瘤存活22例。按MSTS上肢功能评分标准,35例患者上肢功能评分平均为77%(40%～100%),上肢功能与手术切除范围密切相关。并发症:切口感染裂开4例,移植骨骨折2例,暂时性桡神经麻痹2例,肩关节半脱位3例。结论肩胛带区骨肿瘤的治疗应根据患者情况、肿瘤类型及侵袭范围等因素决定切除范围并选择应用肿瘤假体置换、自体或异体骨关节移植、瘤段骨骨灭活回植及Tikhoff-Linberg手术等重建方法,可以达到控制肿瘤、稳定无痛的肩关节重建和保留良好的肘部与手部功能的目的。

Limb sparing surgery for bone tumors of the shoulder girdle

Objective To investigate the clinical and functional outcome of limb sparing surgery for bone tumors of the shoulder girdle. Methods 35 patients with bone tumors of the shoulder girdle, 24 males and 11 females, 34 years in average （range： 12 -74 years）, were treated with limb sparing surgery. The tumors, including 10 osteosarcomas, 7 chondrosarcomas, 3 malignant fibrous histiocytomas, 3 Ewing＇s sarcomas, 1 fibrosarcoma, 1 myeloma, 7 bone giant cell tumors and 3 metastases tumors, involved proximal humerus in 21 patients, scapula in 12, clavicle in 2. There were 5 patients accompanied with pathological fracture. The tumors were staged according to Enneking surgical staging system. Resections were classified according to the classification system of Malawer et al. as 19 type- I , 6 type- II , 4 type- ~I, 1 type-VI, 1 type-V and 1 type-IV. There were lateral clavicle resections in 2 patients and glenoid resection in 1. Two patients underwent marginal resections. The reconstruction procedures included 8 prosthetic replacements, and 4 tumorous bone devitalization and replantation, 3 osteoarticular allografts, 2 autogenous fibular grafts, 1 centromedullar cemented nailing, 3 Tikhoff-Linberg procedures, 2 replantation of shortening arms, and 4 humeral head suspension. 6 partial seapulectomy and 2 lateral clavicectomy needed no bone reconstruction. 16 cases received neo-adjuvant chemotherapy. Results The patients were followed up for mean 71 months （ range： 6 - 186 months）, including 4 local recurrences, 6 systemic metastases, 9 death and 22 patients with event free survival. According to functional rating system of the Musculoskeletal Tumor Society for the upper extremity, the mean functional score was 77% （40% -100% ） in all patients, 88% （ 77% - 100% ） in 8 cases without gleiohumeral joint involvement, 78% （ 57% - 90% ） in 18 cases with resection and reconstruction of proximal humerus, 63% （40% - 77% ） in 9 patients with shortening humeruses and humeral head suspension. The complications included wound infection or dehiscence in 4 patients, allograft bone fracture in 2, temporary radial nerve palsy in 2 and subluxation in 3. Conclusions Bone tumors of the shoulder girdle are treated mainly with limb sparing surgeries including prosthetic replacement, osteoarticular auto-or allo-graft, tumorous bone devitalization and replantation and Tikhoff-Linberg procedure et al. which are applied after tumor resection according to the patient＇s conditions and tumorous type and extension. Local tumor control, stable and painless shoulder reconstruction and good function of elbow and hand can be achieved in the majority of patients.