骨盆环软骨肉瘤的手术治疗

Surgical treatment of pelvic chondrosarcoma

目的探讨骨盆环软骨肉瘤适当的切除及重建方式。方法1998年7月至2006年7月，56例骨盆环软骨肉瘤患者接受肿瘤切除重建手术。Enneking骨盆肿瘤分区Ⅰ区7例，Ⅰ、Ⅱ区9例，Ⅱ、Ⅲ区21例，Ⅰ、Ⅱ、Ⅲ区9例，Ⅲ区2例，Ⅳ区3例；骶骨软骨肉瘤5例。高分化软骨肉瘤7例，去分化软骨肉瘤5例，间叶型软骨肉瘤5例，39例为中等分化。髂骨翼局部切除＋钉棒系统重建7例；髂骨翼局部切除＋自体骨移植3例；耻、坐骨局部切除2例；半骨盆截肢8例；髋臼切除重建31例；5例骶骨软骨肉瘤中2例采用广泛切除术，3例采用分块切除术。结果行Ⅰ区肿瘤切除的7例患者，2例局部复发；行Ⅲ区肿瘤切除的2例患者未见局部复发；31例行Ⅱ区肿瘤切除、髋臼重建患者，4例局部复发；8例行半骨盆截肢术患者，2例局部复发；3例采用病灶内手术的骶骨软骨肉瘤患者均局部复发。9例行Ⅰ或Ⅲ区肿瘤切除的患者，术后行走功能基本正常。21例行髋臼周围肿瘤切除、组合式人工半骨盆重建的患者，术后8周开始扶拐行走，半年后可弃拐行走，ISOLS评分平均20分；5例行马鞍式关节重建的患者术后均须扶双拐行走；5例行肿瘤骨灭活再植＋人工髋关节置换的患者，术后3个月可扶双拐下地行走，1例术后伤口出现深部感染，经清创伤口仍不愈合，取出灭活骨、下肢旷置，术后2年复查仍有1例髂骨处接点不愈。结论髋臼周围软骨肉瘤切除后，以马鞍式假体重建的患者术后功能最差，肿瘤骨灭活再植重建患者次之，组合式人工半骨盆重建患者术后功能最佳。

Objective To identify the proper surgical procedure of resection and reconstruction of pelvic chondrosarcoma. Methods Fifty-six patients had undergone resection and reconstruction of pelvic chondrosarcoma between July 1998 and July 2006. According to Enneking and Dunham pelvic classification system, 7 patients had been classified as type Ⅰ, 9 had type Ⅰ and Ⅱ, 21 had type Ⅱ and Ⅲ, 2 had type Ⅲ and 9 had type Ⅰ, Ⅱ and Ⅲ. There were 5 cases involving sacral area and 3 cases involving Ⅳ （type I /S） area. The pathological details were： low-grade chondrosarcoma in 7 cases, dedifferentiated chondrosarcoma in 5 cases, mesenehymal chondrosarcoma in 5 cases and intermediate-grade chondrosarcoma in 39 cases. Seven patients underwent skeletal reconstruction of rod-screw system and 3 autograft were used for pelvic repair after iliac local resection. Two patients had all or portion of the ischium and pubis resected. Acetabular reconstructions were performed in 31 cases and 8 patients underwent hemipelvectomy. Wide margin was achieved in 2 of the 5 patients involving sacral area and piecemeal removal was done in other 3 patients. Results Local recurrence occurred in 2 out of 7 patients undergone type Ⅰ resection. No recurrence was observed in 2 patients undergone type Ⅲ resections. Four patients happened local recurrences in the 31 cases treated with acetabular resection and reconstruction. There were 2 local recurrences in the 8 cases treated with amputation. All 3 patients who had piecemeal sacral resection had local recurrence. The 9 patients undergone type Ⅰ resection ambulated independently. Twenty-one patients reconstructed with hemipelvic endoprostheses began to walk with assistive device eight weeks postoperatively and ambulate without crutch six months after surgery. The average ISOLS function score for the 21 patients was 20. Five patients with saddle prosthesis could walk with crutch. Five patients with devitalized bone and hip arthoplasty could ambulate with crutch three months postoperatively. Nonunion occurred in ilium remained during the two years follow- up. Conclusion The functional result of saddle prosthesis is poor. Meanwhile the outcome of reconstruction with devitalized bone combined with internal fixation is much better. The hemipelvic endoprosthesis reconstruction achieved excellent outcome.