四肢长骨骨巨细胞瘤伴病理性骨折的外科治疗

Surgical treatment for long bone giant cell tumor of extremity with pathologic fracture

目的：回顾性分析肢体长骨骨巨细胞瘤伴发病理性骨折病例的临床特点和外科治疗策略.方法：1999年1月至2011年12月间在北京大学人民医院骨与软组织肿瘤治疗中心接受手术治疗的四肢长骨骨巨细胞瘤伴发病理性骨折病例,收集性别、年龄、骨折部位、外科治疗方式、术后并发症、肢体功能、肿瘤学随访（复发、转移）等临床资料并进行统计学分析,连续变量和二分类变量分别应用t检验和卡方检验.结果：201例肢体长骨骨巨细胞瘤患者中发生病理性骨折33例（16.42%）,男/女性别比为1.06,初诊中位年龄33岁（15~62岁）.病理性骨折发生部位以股骨远端最为常见（17例/81例,20.99%）,以下依次为股骨近端（5例/13例,38.46%）、胫骨近端（5例/54例,9.26%）、肱骨近端（4例/13例,30.77%）和桡骨远端（2例/16例,12.50%）.9例病理性骨折累及关节面.11例患者接受扩大的囊内刮除手术,22例接受大块切除术.重建方式包括：人工假体重建20例,自体髂骨和人工骨混合植骨7例,骨水泥填充3例,自体腓骨移植2例,异体半关节移植1例.9例患者行二次手术（27.3%）,主要原因包括局部复发和假体相关并发症.假体置换组患者术后平均骨与软组织肿瘤协会（Musculoskeletal Tumor Society,MSTS）评分为81%,其他重建方式平均评分为82%.结论：扩大的囊内刮除和整块切除是骨巨细胞瘤伴发病理性骨折的两种常用手术方式.囊内刮除术后局部复发率较高,但瘤段截除术后的植入物相关并发症同样可能给患者造成不良影响,因此手术方式的选择需格外谨慎.

Objective ：To identify the clinical features of patients with giant cell tumors （GCT） of long bones in extremities presented with pathological fracture （ PF）, and discuss the surgical strategy with ret- rospective analysis and literature review. Methods： We searched medical electronic records from January 1999 to December 2011 in our hospital to identify patients with definite diagnosis of extremity GCT presented with PF. Clinical data including gender, tumor site, age, surgical treatment option, postopera- tive complication, limb function, local recurrence and pulmonary metastasis were collected and analyzed statistically. The t-test and Chi-square test were used for continuous and dichotomous variables, respec- tively. Results： Between 1999 and 2011 we treated 201 patients with GCT in extremities （long bone on- ly ： femur, tibia, fibula, humerus, ulna, and radius）, 33 of whom presented with a PF. The gender ratio was 1.06 for a male predominance. The median age was 33 （15 -62） , and the most common site of pathologic fractures was distal femur （ n = 17 ） , followed by proximal tibia （ n = 5 ）, proximal femur （ n = 5 ） , proximal humerus （ n = 4） , and distal radius （ n = 2 ）. Nine fractures were intra-articular. The tumors were treated by extended curettage （ n = 11 ） or en bloc excision （ n = 22）, and the fractures were reconstructed by endoprosthesis （n = 20）, autologous iliums graft combined with synthetic bone substi- tutes （ n = 7）, acrylic cementing （ n = 3 ）, autologous fibula graft （ n = 2 ）, or allograft （ n = 1 ）. Ten operations were followed by complications of any kind, where implant failure and recurrence were the commonest, and re-operation rate was 27.3 %. The mean functional score according to the scoring system of the Musculoskeletal Tumor Society （MSTS） was 81% in patients who received endoprosthesis replace- ment and 82% in other reconstruction options. were all considered to be the effective treatment Conclusion： Extended curettage and en bloc resection options for patients with extremity GCT presented with PF. However, local recurrence and implant related complication were the major concern for joint reserva- tion and prosthetic replacement, respectively.