酒精灭活瘤段骨在重建恶性骨肿瘤骨缺损中的应用

Alcohol-inactivated autograft replantation in reconstruction of bone defects in management of malignant bone tumors

目的评价酒精灭活在重建恶性骨肿瘤骨缺损中的疗效,并分析影响疗效的相关因素。方法回顾性分析1995年1月至2013年6月,我科对53例恶性骨肿瘤患者进行酒精灭活再植治疗。平均年龄17.7（9～49）岁。其中股骨下段23例,股骨中段2例,胫骨上段20例,胫骨下段3例,肱骨上段3例,骶骨、髂骨各1例;Enneking分期II b期48例,III期5例;骨肉瘤44例,尤文肉瘤6例,横纹肌肉瘤、软骨肉瘤、非霍奇金淋巴瘤各1例。术后疗效评价采用（musculoskeletal tumor society system,MSTS）功能评分和（international society of limb salvage,ISOLS）影像评分。统计并分析各因素与术后功能、生存率的相关性。结果随访13～216（平均55）个月。广泛切除39例,边缘切除14例。灭活回植的瘤段平均长度为16.3（5～26）cm。II b期的48例中11例出现肿瘤复发,肺转移9例,转移率18.8%,6例死亡,5例带瘤生存;44例骨肉瘤中7例出现肿瘤复发,肺转移6例,转移率13.6%,术后3年生存35例。5年生存率为42.5%,其中骨肉瘤5年生存率为54.5%。30例灭活骨得以长期存在,其3年总生存率57%（30/53）,保肢率68%（36/53）。术后切口感染4例（7.6%）,骨折、内固定断裂5例（9.4%,5/53）,内固定断裂2例（3.8%,2/53）。灭活骨延迟愈合、不愈合共8例（15.1%,8/53）。MSTS功能评分19～33（平均27）分;ISOLS影像评分22～31（平均26）分。单因素分析提示：（1）灭活瘤段长度与骨痂出现率、骨痂出现时间、术后复发率、总生存率、MSTS评分、ISOLS评分均具有相关性（P〈0.05）;（2）肿瘤分期与术后复发率具有相关性（P〈0.05）;（3）是否保留关节与MSTS评分具有相关性（P〈0.05）;（4）病程、肿瘤分期（P=0.026）、发病部位与患者3年生存率具有相关性（P〈0.05）。多因素分析提示：灭活瘤段长度、病程长短、肿瘤分期是影响总生存率的独立因素（P〈0.05）。结论酒精灭活瘤段骨治疗恶性骨肿瘤骨缺损能提高患者的生存率、减少灭活瘤段长度、保留关节有利于提高患者功能。灭活瘤段长度、病程长短、肿瘤分期是影响总生存率的独立因素。

Objective To evaluate the clinical outcomes of alcohol-inactivated autograft replantation in reconstruction of bone defects in management of malignant bone tumors, and to analyze the related factors affecting the survival rate and functional results. Methods The clinical data of 53 patients with malignant bone tumors who were admitted and treated by alcohol-inactivated autograft replantation from January 1995 to June 2013 were retrospectively analyzed. The mean age was 17.7 years old （ range： 9-49 years ）. Twenty-three neoplasms were located in the distal femur, 2 neoplasms in the middle femur, 20 neoplasms in the proximal tibia, 3 neoplasms in the distal tibia, 3 neoplasms in the proximal humerus, 1 neoplasm in the sacrum and 1 neoplasm in the ilium respectively. According to the Enneking system, 48 patients were identified as stage IIb and 5 patients as stage III. Forty-four patients were diagnosed as osteosarcoma, 6 patients as Ewing＇s sarcoma, 1 patient as rhabdomyosarcoma, 1 patient as chondrosarcoma, and 1 patient as non-Hodgkin＇s lymphoma. The postoperative results were evaluated according to the Musculoskeletal Tumor Society （ MSTS ） system and the International Society of Limb Salvage （ ISOLS ） graft evaluation method. A statistical analysis of the correlation among all the related factors, survival and postoperative function was conducted.Results The mean follow-up period was 55 months （ range： 13-216 months ）. Thirty-nine patients were treated with wide resection and 14 patients with marginal resection. The average length of alcohol-inactivated autograft was 16.3 cm （ range： 5-26 cm ）. The recurrence rate was 22.9% （ 11 / 48 ） in stage IIb group, and there were 9 cases of pulmonary metastases with the metastasis rate of 18.8%, 6 death cases and 5 cases of survival with tumors. The recurrence rate was 15.9% （ 7 / 44 ） in osteosarcoma group, and there were 6 cases of pulmonary metastases with the metastasis rate of 13.6% and 35 cases of survival during the follow-up of 3 years. The overall 5-year survival rate was 42.5%, which was 54.5% in osteosarcoma group. Devitalized bone existed for a long time in 30 patients, among whom the overall 3-year survival rate was 57% （ 30 / 53 ） and limb-salvage rate was 68% （ 36 / 53 ）. The postoperative complications included incision infection （ 7.6%, 4 / 53 ）, fracture and internal fixation breakage （ 9.4%, 5 / 53 ）, internal fixation breakage （ 3.8%, 2 / 53 ） and delayed union and non-union of inactivated bone （ 15.1%, 8 / 53 ）. The mean MSTS score was 27 （ range： 19-33 ）, and the mean ISOLS score was 26 （ range： 22-31 ）. The following results were achieved with the single factor analysis. （ 1 ） The length of alcohol-inactivated autograft was correlated with the occurrence rate of callus, the occurrence time of callus, postoperative recurrence rate, overall survival rate, MSTS score and ISOLS score （ P〈0.05 ）. （ 2 ） There was a correlation between neoplasm staging and postoperative recurrence rate （P〈0.05 ）. （ 3 ） There was a correlation between joint preserving and MSTS score （ P〈0.05 ）. （ 4 ） The disease course, neoplasm staging （ P=0.026 ） and tumor location were correlated with the 3-year survival rate （ P〈0.05 ）. The multiple- factor analysis showed the length of alcohol-inactivated autograft, duration of disease course and neoplasm staging were independent factors affecting the overall survival rate （ P〈0.05 ）. Conclusions Alcohol-inactivated autograft replantation could be an option in reconstruction of bone defects in management of malignant bone tumors. Early diagnosis and treatment could increase the survival rate. The functional results will be improved with the decrease of alcohol-inactivated autograft length and preservation of articular surface. The length of alcohol-inactivated autograft, duration of disease course and neoplasm staging are independent factors affecting the overall survival rate.