累及腓骨近端原发恶性肿瘤的保肢手术治疗

Limb salvage for primary malignant tumors involving the proximal fibula

[目的]回顾性分析累及腓骨近端原发恶性肿瘤患者的病历资料,探讨其保肢技术,总结其肿瘤学结果、并发症及术后功能情况。[方法]2002年10月~2014年12月,共有14例累及腓骨近端原发恶性肿瘤患者于本院接受保肢治疗,男9例,女5例;年龄9~61岁,平均23.20岁。骨肉瘤9例,软骨肉瘤2例,尤文肉瘤2例,纤维肉瘤1例。14例患者均首诊于本院,术前均行穿刺活检明确病理,均符合并接受保肢手术治疗,其中9例骨肉瘤患者接受了4~6周期新辅助化疗(术前2周期),化疗方案以阿霉素、顺铂、大剂量氨甲喋呤、异环磷酰胺为主。依据Enneking分期,处于ⅡA期病例4例,采用Malawer-Ⅰ型切除。ⅡB期病例10例采用Malawer-Ⅱ型切除。[结果]随访时间18~164个月,平均36.20个月。5例术后局部复发,其中Malawer-Ⅱ型切除的2例(2/10),Malawer-Ⅰ型切除的3例(3/4)。4例患者死于肺转移,其中Malawer-Ⅱ型切除的2例(2/10),Malawer-Ⅰ型切除的2例(2/4)。所有患者经膝关节股二头肌肌腱及外侧副韧带止点重建后,膝关节功能均稳定。对于腓总神经切除的患者佩戴踝关节外固定支具行走。多数患者疼痛缓解,不影响日常生活活动。国际骨肿瘤协会(musculoskeletal tumor society,MSTS)评分14~26分.平均21.9分(73%)。[结论]累及腓骨近端原发恶性肿瘤,由于其解剖学特点,多数发现时已处于Enneking分期ⅡB期,选择保肢技术时,应尽量获得足够的手术边界,以期获得良好的肿瘤学结果。

[Objective] To investigate the technique, outcome, complications and postoperative function of limb salvage surgery for primary malignant tumors involving the proximal fibula. [Methods] A total of 14 patients with primary malignant tumors involving the proximal fibula, including 9 males and 5 females aged 9 to 61 years with a mean of 23.20 years, received limb-salvage treatment in our hospital from October 2002 to December 2014. Osteosarcoma was previously suspected in our hospital for all of the 14 patients, however, puncture biopsy revealed 9 cases of osteosarcoma, 2 cases of chondrosarco- ma, 2 cases of Ewing＇ s sarcoma, as well as 1 case of fibrosarcoma. All patients accepted the limb salvage surgery, including 9 cases receiving 4-6 cycles of neoadjuvant chemotherapy （doxorubicin, cisplatin, high-dose methotrexate and ifosfamide, 2 cycles before surgery） . According to Enneking＇ s staging, 4 patients were in Ⅱ A period and received Malawer type Ⅰ resection, while the remaining 10 patients fell within Ⅱ B period and received Malawer-type Ⅱ resection. [Results] All patients were followed up for 18 to 164 months with an average of 36.20 months. Local recurrence occurred in 5 cases, in- cluding 2 cases of Malawer type Ⅱ of resection （2/10）, 3 cases of Malawer type Ⅰ resection （3/4） . Four patients died of lung metastasis, including 2 cases of Malawer type Ⅱ resection （2/10）, 2 cases of Malawer type Ⅰ recection （2/4） . After femoral biceps tendon and the lateral collateral ligament reconstruction, knee stability regained in all patients. For the patients with common peroneal nerve resection, ankle external fixation brace was used to help walk. Pain relief was achieved in most patients, and the activities of daily living was not affected. Musculoskeletal Tumor Society （MSTS） score demonstrated 14 to 26 points, with an average of 21.9 points （73%） . [Conculusion] Primary malignant tumors involving the proximal fibula, due to its anatomical features, has been found in the Enneking staging Ⅱ B period most of the time. In limb salvage, sufficient surgical borders should be gained to obtain good oncology results.