股骨中段原发恶性肿瘤切除后生物学重建的临床疗效分析

Evaluation of clinical effects on biological reconstruction for large femoral diaphyseal defect after primary bone sarco- ma en-bloc resection

目的探讨股骨中段原发恶性骨肿瘤切除术后采用瘤段骨灭活再植或异体骨重建的临床疗效。方法回顾性分析2005年2月至2013年12月收治19例股骨中段原发恶性骨肿瘤患者的病例资料，男11例，女8例；年龄2～38岁，平均18岁。骨肉瘤13例，Ewing肉瘤5例，恶性纤维组织细胞瘤1例。所有患者均获得广泛性切除边界，19例患者瘤段骨截除长度平均为16．9cm（9-24cm），骨重建采用异体骨9例，瘤段骨灭活再植10例；内固定采用髓内钉固定4例，钢板固定15例（其中10例结合自体腓骨髓内支撑）。38处骨断端中骨干-骨干断端28处，骨干-干骺端断端10处。结果灭活再植手术时间平均为5．1h，异体骨移植手术平均为4．22h，差异无统计学意义。患者术后随访3-107个月，平均33．5个月。灭活骨再植骨干-骨干断端愈合时间平均为10．3个月，骨干-干骺端为7．25个月；异体骨重建骨干-骨干断端愈合时间平均为13．8个月，骨干-干骺端为11．5个月；灭活骨和异体骨的骨干-骨干断端、骨干-干骺端断端愈合时间的差异均有统计学意义。术后MSTS评分平均为83．7％（70％-95％）。8例患者（42．1％）术后出现并发症，包括灭活骨深部感染1例、异体骨骨折并局部复发1例，灭活骨吸收1例，异体骨骨折3例和局部复发2例（其中1例为软组织复发）。随访期间因肺转移死亡5例。Kaplan—Meier曲线预测2年生存率为76．5％，5年生存率为61．2％。结论股骨中段原发恶性骨肿瘤切除术后灭活骨再植较异体骨重建操作复杂，但其与宿主骨愈合速度快于异体骨。重建方法推荐采取灭活骨结合自体腓骨髓内支撑。

Objective To evaluate the clinical and functional outcome of biological reconstruction by using pasteurized autograft and massive allograft after en-bloc resection of primary femoral diaphyseal sarcomas. Methods Retrospectively reviewed 19 consecutive patients with primary femoral diaphyseal sarcomas between Feb. 2005 and Dec. 2013. There were 11 males and 8 females with the mean age of 18 （2-38） years old. Thirteen patients were diagnosed as osteogenie sarcoma （OS）, while five Ewing＇ s sarcoma （EWS） and one malignant fibrous histoeytoma （MFH）. All patients were treated with wide local excision, and 9 patients were reconstructed by intercalary femur segmental allograft and 10 by pasteurized autograft. The median length of the re- sected bone was 16.9 （9-24） cm. 15 segmental grafts were fixed by using plates including 10 intramedullary free vascularised fibular graft constructs, the other 4 segmental gratis were fixed by intramedullary nails. The average operation time for pasteurized autograft construct was 5.1 hours, while the time for intercalary allograft construct was 4.22 hours. Of 38 host-donor junctions, there are 28 diaphyseal junctions and 10 metaphysea] junctions. Results The average operation time for pausterized autograft con- struet tended to be longer than intercalary allograft （5.1h Vs 4.22h）, although the difference did not reach the significance. Bone union occurred at a median of 10.3 months and 7.25 months at diaphyseal and metaphyseal junction for pasteurized autograft-host construct; 13.8 months at the diapyhseal junction and 11.5 months at the metaphyseal junction for allografi-host construct. Bone healing time of diaphyseal junction and metaphyseal junction between these two constructs were significant difference. Eight of 19 patients （42.1%） developed complications： 5 bone unnunion/fracture （including 1 subsequently developed local recurrence）, ldeep infection and 2 local recurrence （including 1 soft tissue recurrence）. The mean overall follow-up was 33.5 months （3-107）, five patients died of lung metastases, the cumulative patient survival was 76.5% at 2 years and 61.2% at 5 years determined by Kaplan- Meier method. All living patients except the MFH patients who received amputation, had a mean MSTS score of 83.7% （70%- 95%）. Conclusion Although the reconstructive procedure with pasteurized autograft is more complicated and needs longer operation time than allograft reconstruction, the bone healing time with autograft is significant shorter than allograft. Our observations suggest the pausterized autograft shell with intramedullary free fibular graft is strongly recommeded.