保留骨骺的保肢手术临床研究

Limb salvage surgery for malignant bone tumor of the extremities

目的介绍儿童及青少年保留骨骺的保肢手术方法,并讨论肿瘤复发率、转移情况及术后并发症与关节功能。方法1995年12月至2003年1月,对33例儿童及青少年肢体原发性恶性或侵袭性骨肿瘤进行保留骨骺的保肢手术,年龄8～16岁,平均12.2岁。股骨下端24例,胫骨上端9例;骨肉瘤23例,尤文肉瘤6例,软骨肉瘤2例,侵袭性骨母细胞瘤2例。Enneking外科分期:ⅠA期2例,ⅠB期2例,ⅡA期17例,ⅡB期12例。恶性肿瘤患者接受术前2～4个周期、术后6个周期的化疗。采用大段同种异体骨移植重建骨缺损,并用松质骨拉力螺钉将其与骨骺进行固定。结果29例患者随访资料完整。随访时间12～72个月,平均37.6个月。3例复发,分别于术后1年在骨骺处复发、术后15个月和30个月在原肿瘤位置的股动、静脉周围复发,复发率为10.3%。对复发病例行截肢术。共9例死亡,5年生存率为57.9%。4例患者发生5例并发症,发生率为17.2%。依据Enneking术后功能评价标准,优11例,良13例,可3例,差2例,总优良率为82.8%。结论四肢恶性骨肿瘤保留骨骺的保肢手术可以使患者获得较好的肢体功能,在严格掌握手术适应证和有效化疗的前提下,实施该手术是安全的。

Objective To analyze the clinical features of limb salvage surgery with epiphyseal preservation in children and adolescents, and to evaluate the recurrence rate, metastasis, complications, and the joint functional results after tumor resection. Methods From December 1995 to January 2003, we operated on 33 patients aging from 8 to 16 years （average 12.2 years） with diagnosis of primary malignant bone tumor of the extremities with preserving the epiphysis in the limb salvage surgery. In this group, the tumor located in distal femur in 24 cases and in proximal tibia in 9 cases. There were 23 osteosarcomas, 6 Ewing sarcomas, 2 chondrosarcomas, and 2 invasive osteoblastomas. The tumors were staged clinically, 2 cases in Ⅰ A, 2 cases in ⅠB, 17 cases in Ⅱ A, and 12 cases in ⅡB. According to the relationship between the tumor and epiphyseal plate, the metaphyseal tumors in children were classified into 3 types： 18 cases were categorized as type Ⅰ, 13 as type Ⅱ, and 2 as type Ⅲ. The patients received 2-4 cycles of preoperative adjuvant chemotherapy, and another 6 cycles after surgery. Serious bone defects after tumor resections were repaired with massive allograft bone transplantation, followed by internal fixation by intramedullary nails and cancellous screws. Results Among the 33 cases, 3 cases were lost to follow up. 29 cases had complete clinical data. Postoperative follow-up was 12-72 months （average 37.6 months）. Recurrences were seen in 3 cases, with one local recurrence in type Ⅲ case one year after tumor resection, other 2 recurrences around the femoral vessels in type Ⅱ cases 15 and 30 months after the tumor resection respectively. The recurrence rate accounted for 10.3%. Amputation was performed for the cases with recurrences. But pulmonary metastasis developed and the patients died. In this cohort, 9 cases died. Five-year survival rate was 57.9%. 4 cases reported 5 complications （17.2%）. No patient reported skin necrosis, hematoma, infection, rejection to the allograft, and nonunion at the end of the follow-up. According to the functional evaluation criteria of Enneking, excellent were 11 cases, good 13 cases, fair 3 cases, and poor 2 cases. The excellent or good rate was 82.8%. Conclusion The limb salvage surgery with preservation of epiphysis for malignant bone tumors in children and adolescents guarantees the patient＇s satisfactory postoperative limb functional results. Preoperative effective adjuvant chemotherapy and prevention of postoperative complications deserve great attention.