保留关节的瘤段切除酒精灭活再植术治疗股骨远端骨肉瘤的临床疗效

Clinical outcomes of alcohol-inactivated autograft replantation with articulation preservation for osteosarcoma in the distal femur

目的：探讨保留关节的瘤段切除酒精灭活骨再植术治疗股骨远端骨肉瘤的临床疗效，分析常见并发症的发生原因并提出治疗策略。方法2004年1月至2011年5月，采用保留关节的瘤段切除酒精灭活再植术治疗股骨远端骨肉瘤10例。男7例，女3例；年龄15～24岁，平均20.1岁，中位年龄21岁；左股骨下段6例，右股骨下段4例；Enneking分期II B期9例，III期1例；术后疗效评价采用MSTS功能评分和ISOLS复合移植物影像评分。结果10例术后切口均I期愈合。随访12～110个月，平均随访34个月，1例13个月局部复发并全身多发转移而死亡。3例分别于术后9、12、24个月因全身多处转移而死亡。3例患者（30％）于术后2～9个月因灭活骨骨折而行切开复位、植骨、环抱器内固定术，1例于术后半年死亡；1例术后4个月骨折处愈合，再次术后48个月无异常。另1例再次术后13个月再次出现骨折而行切开复位、植骨、钢板内固定术，术后半年骨愈合良好，随访12个月出现关节不稳及膝关节屈曲受限。ISOLS影像评分28～34分，平均31分（87%）；MSTS肢体功能评分19～28分，平均23分（77%）。结论在严格掌握适应证的前提下，应用保留关节的酒精灭活再植术治疗股骨远端干骺端骨肉瘤是一种可行的手术方式，具有保留关节的重要结构、瘤段骨与宿主骨匹配良好、无排异反应等优点。灭活骨骨折是该手术最常见的并发症，灭活骨自身骨质改变和内固定方式选择不当是导致骨折发生的主要原因。应用钢板内固定及延长外固定时间是降低灭活骨骨折的有效措施。

Objective To investigate the clinical outcomes of alcohol-inactivated autograft replantation with articulation preservation in the treatment of osteosarcoma in the distal femur, to analyze the occurrence of common complications and to propose the treatment strategies. Methods From January 2004 to May 2011, 10 patients with osteosarcoma in the distal femur were treated with alcohol-inactivated autograft replantation with articulation preservation. There were 7 males and 3 females, with an average age of 20.1 years old and a median age of 21 years old （ range;15-24 years ）. Neoplasms were located in the left distal femur in 6 cases, and in the right distal femur in 4 cases. According to the Enneking staging system, 9 patients were identiifed as stage II B and 1 patient as stage III. The postoperative outcomes were evaluated according to the Musculoskeletal Tumor Society （ MSTS ） rating scale, and the International Society of Limb Salvage （ ISOLS ） composite graft scores were calculated. Results All the 10 cases were healed by primary intention. The mean follow-up period was 34 months （ range;12-110 months ）. One patient died of local recurrence and systemic multiple metastases 13 months after the operation, and 3 patients died of systemic multiple metastases at 9, 12 and 24 months after the operation respectively. Three patients （ 30%） experienced the second operation of open reduction, bone implantation and internal ifxation with the embracing ifxator at 2-9 months after the operation because of inactivated bone fractures. One of them died at 6 months after the operation. One got bone healing at 4 months after the operation with no abnormal signs during the 48-month follow-up. One of the above 3 patients experienced the third operation of open reduction and bone implantation with plate internal ifxation because of the fractures 13 months after the second operation, who got bone healing at 6 months after the operation but had joint instability and limited knee lfexion during the 12-month follow-up. The mean ISOLS score was 31 points （87%） （ range;28-34 points ）. The mean MSTS functional score was 23 points （ 77%） （ range;19-28 points ）. Conclusions Based on the premise that the indications are strictly mastered, alcohol-inactivated autograft replantation with articulation preservation is a feasible operation method in the treatment of osteosarcoma in the distal femoral metaphysis, with the advantages of preserving important joint structures, good matching between the tumor-bearing bone and the host bone and no immunologic rejection. The inactivated bone fracture is the most common complication. The main causes of fractures are the change of inactivated bone quality and the inappropriate choice of internal ifxation. The fracture rate will be signiifcantly decreased if plate ifxation is chosen and the time of external ifxation is prolonged.