儿童及青少年膝关节周围骨肉瘤的保肢治疗

Limb salvage surgery for osteosarcoma around the knee in children and adolescent patients

目的探讨儿童和青少年患者膝关节周围骨肉瘤切除后的重建方法及治疗效果。方法 1996年10月至2005年12月,共治疗儿童和青少年膝关节周围骨肉瘤患者89例,平均年龄13岁;部位:股骨下端52例,胫骨上端36例,病变同时累及股骨下端及胫骨上端1例。根据患者年龄及骺板闭合情况分别选择灭活再植(灭活组,n=20)、半关节假体置换(半关节组,n=19)及全关节假体置换(全关节组,n=50,包括可延长假体及儿童特制假体)进行肿瘤切除后的重建。结果 85例患者获得随访,平均随访时间42个月,灭活组中4例局部复发,11例死于肺转移,5年生存率47.1%;半关节组中1例局部复发,4例死于肿瘤转移,5年生存率71.7%;全关节组中4例复发,9例死于转移,5年生存率68.2%。1例灭活病例、1例半关节病例及3例全关节病例出现了深部感染;2例半关节病例出现了假体半脱位;1例半关节置换病例因术后肢体缺血,接受了截肢。功能情况,灭活组 MSTS 93评分平均21.43分,半关节组23.40分,全关节组25.32分。平均肢体不等长范围,灭活组5.48 cm,半关节组4.50 cm,全关节组3.12 cm。结论儿童及青少年膝关节周围骨肉瘤的保肢治疗较为困难,对于骨骺生长活跃的病例应尽量采用半关节假体等保留对侧骨骺的方法,以减少肢体不等长的情况,以便于今后的翻修;对于骺板接近闭合的病例可直接采用全关节假体,以取得良好的功能。

Objective To discuss the reconstruction methods and treatment effects of osteosarcoma around the knee in skeletal immature children and adolescent patients. Methods Between October 1996 and December 2005, 89 children and adolescent patients with ostosarcoma around the knee received limb salvage surgery. The average age was 13 years old. Tumor involved distal femur in 52 cases, proximal tibia in 36 cases, and both parts in one patient. Different limb salvage methods, including tumor recycle bone reimplantation（ n = 20）, partial endoprosthesis （ n = 19 ） and total knee megaprosthesis replacement （ n = 50） were chosen according to both the age of the patient and the skeletal. Expandable and special designed pediatric prosthesis some times might also be considered. Results After average follow up of 42 months, 4 cases of local recurrence and 11 of metastasis occurred in tumor recycle bone group; 1 case of local recurrence and 4 of metastasis in partial endoprosthesis group; another 4 cases of local recurrence and 9 patients died of disease in total knee megaprosthesis group. The five-year survival rate was 47. 1%, 71.7% and 68.2% in 3 groups respectively. There were 3 deep infections in all the cases, 2 subluxations and 1 amputation after operation for limb ischemia in partial endoprosthesis group. The average functional score of MSTS 93 was 21.43 point,23.40 point and 25.32 point; and the average leg length discrepancy was 5.48, 4. 50 and 3. 12 cm in 3 groups respectively. Conclusions Partial-joint prosthesis or other methods which can avoid injury of the opposite epiphysis should be used to decrease the possibility of limb length discrepancy and ease the following revised arthroplasty. For patient with almost mature skeletal, total knee megaprosthesis may be a proper choice for better function result.