股骨纤维结构不良外科治疗的疗效分析

Analysis of surgical outcome for the fibrous dysplasia in the femur

背景:股骨纤维结构不良由于严重程度不同,病变范围差异较大,手术治疗尚缺乏统一原则。目的:探讨不同手术方式治疗股骨纤维结构不良的临床疗效,分析比较影响股骨纤维结构不良手术治疗远期疗效的独立危险因素。方法方法:回顾性分析2000年1月至2016年9月于我中心接受手术治疗的82例患者(84处股骨病灶)的病例资料。收集的临床数据包括:基本数据(性别、诊断时年龄、病灶处初次骨折的年龄),初诊时的主要症状,受累部位(单发型或多发型),股骨病灶部位和病理结果。手术相关数据:手术时间,失血量,植骨类型,内固定方式(髓内固定和髓外固定),早期并发症(感染和血肿)。随访相关数据:相关并发症(是否出现骨折及恶变),影像学资料和末次随访时患者功能评分。结果:3处病灶(3/84,3.6%)住院期间出现早期伤口并发症,其中2处为切口感染,1处为切口血肿,均经伤口清创后愈合。10处病灶采用髓内固定,64处病灶采用髓外接骨板固定。髓内固定组早期切口并发症发生率(2/10,20%)明显高于髓外接骨板固定组(1/64,1.6%,P<0.001)。82例患者中66例获得末次随访,随访比例为80.5%,中位随访时间为47.1个月。1例出现深部感染,1例出现局部复发。随访期间无恶变病例出现。伴有"牧羊拐"畸形组(n=8)和无畸形组(n=58)末次MSTS功能评分分别为(29.1±1.1)分和(29.8±0.6)分,"牧羊拐"畸形组功能明显差于无畸形组(P=0.012)。病理骨折和骨纤类型不是影响预后功能的影响因素。结论:初次骨折时患者年龄是随访期间再次骨折的预测因素,尤其是年龄小于18岁者。"牧羊拐"畸形是影响术后功能的主要危险因素。髓内固定和髓外固定方式均可提供足够的生物学稳定,并在中期随访过程中可获得相同的预后。

Background：Because of varied severity of the fibrous dysplasia in the femur and great difference in the extent of this disease,there is no uniform principle in surgical treatment for it.Objective：To assess the prognosis and complications of different surgical managements and graft types for the fibrous dysplasia,and to evaluate the factors associated with the fracture in patients with fibrous dysplasia and wound complication and refracture after surgery during mid-term followup.Methods：Between January 2000 and September 2016,a total of 82 patients with 84 lesions in the femurs were recruited with the diagnosis of fibrous dysplasia established based on a combination of clinical history,physical examination,radiographic findings and histopathology analysis.The following diagnostic data were collected：baseline demographic features （sex,age at diagnosis,age at the first fracture）,initial presenting symptoms,affected bone sites （monostotic or polyostotic fibrous dysplasia）,site in femur and histological results.The data associated with surgery included surgery time,blood loss,graft type,internal fixation and early wound complications （infection and hematoma）.Monitoring data were also recorded：skeletal events （fracture or malignancy）,radiological image during the follow-up and the function at the last follow-up.Resuits：Three lesions （3/84,3.6%） developed the early wound complication in the hospital,including two wound infections and one hematoma.Furthermore,the rate of early wound complication in the intramedullary nail group was statistically higher than that in the plate group （20% vs 1.6%,P〈0.001）.Eventually,66 patients （80.5%） were followed up with an median duration of 47.1 months.One suffered from the deep infection and local recurrence occurred in another patient.In this seties,no malignant transformation occurred.The MSTS score was 29.1 ± 1.1 and 29.8± 0.6 in the groups with and without shepherd＆#39;s crook deformity,respectively （P=0.012）.Pathologic fracture and the type of fibrous dysplasia were not the influence factors of prognosis.Conclusions：Age at the fi-st fracture is the predictor of refracture in the patients with fibrous dysplasia,especially in those aged less than 18 years old.Furthermore,the shepherd＆#39;s crook deformity is the crucial risk factor of surgical outcome.Both intramedullary nail and extramedullary plate can provide sufficient stability with the same prognosis during the midterm follow-up.