计算机导航辅助技术应用于恶性骨肿瘤保留关节精确切除的长期随访

Long-term effects of computer assisted orthopaedic surgery in precise tumor resection and joint-sparing for limb with malignant bone tumors

目的评价计算机导航辅助技术应用于恶性骨肿瘤保留关节精确切除的长期随访结果。方法回顾分析2008年9月至2015年7月北京积水潭医院采用计算机导航技术辅助下保留关节重建术治疗的31例股骨远段、胫骨近段和胫骨远段恶性肿瘤患者的病历资料。其中男19例,女12例,年龄10~48岁,中位年龄为19岁。病变位于股骨干2例、股骨远段干骺端22例、胫骨近段干骺端6例和胫骨远段干骺端1例。全部患者术前均行穿刺活检,病理诊断为骨肉瘤20例、软骨肉瘤4例、尤因肉瘤3例、梭形细胞肉瘤2例、皮质旁肉瘤1例和上皮样血管内皮瘤1例。全部患者术前均行CT和MRI检查,经计算机导航系统进行术前设计,明确病灶侵袭的髓内范围和骨外范围,设计截除瘤骨的范围并进行标记,截骨长度为80.0~390.0 mm,中位长度为180.0 mm,肿瘤距离关节表面距离10.0~80.0 mm,中位距离37.5 mm;术中在计算机导航系统指引下依照术前设计截断瘤骨,保留关节及韧带组织,完成个体化订制人工假体的置换和大段异体骨的移植。结果 31例患者全部按术前计划完成手术,术后肿瘤标本经病理学结果验证均达到广泛切除。全部病例均得到随访,随访时间24.0~108.0个月,中位随访时间52.5个月。存活28例,肺转移4例,病死3例,局部软组织复发2例。美国骨肿瘤学会(MSTS)评分结果显示,术后肢体功能恢复66.7%~100%,中位功能恢复90.0%。术后感染5例,1例异体骨不愈合再行手术植骨,2例假体机械失效,2例截肢,最终保肢率93.5%。结论计算机导航辅助技术引导实施骨肿瘤精准切除具有可行性,其肿瘤学评价安全可靠,经保留关节后重建可使患肢获得良好的功能恢复。

】 Objective To evaluate the effects of computer navigation assisted accurate resection of malignant bone tumor . Methods Thirty-one patients with malignant bone tumors treated by surgical resections and joint-sparing reconstructions with assistance of the image-guided computer navigation between September 2008 and July 2015 were evaluated. There were 19 males and 12 females with a median age of 19 years （ ranged from 10 to 48 years）. Tumors were located at femoral diaphysis in 2 cases, distal femur metaphysis in 22 cases, proximal tibia in 6 cases and distal tibia in one case. The pathological diagnosis were osteosarcoma in 20 cases,chondrosarcoma in 4 cases,and others in 7 cases. Pre-operative CT and MR of each patient and bone tumor models were performed. The pre-operation planning for each patient were performed with the navigation system software that included conforming the tumor surgical margin, designing of resection and reconstructions with custom-made joint-sparing prosthesis and allograft. Intra-operatively, the registration and matching the operative anatomy to the virtual image generated by the navigation system software were performed. Then the surgical processes were performed according the pre-operation planning. The median scope of the resected tumor was 180.0 mm（ 80. 0-390. 0 mm） . The median distance between tumors resection margin and the joint was37.5 mm（ 10.0-80.0 mm）. Results The tumor precision resections of all cases were done as pre-operation planning and joint-sparing reconstructions with custom-made prosthesis in 23 cases and allograft in 8 cases. All the resected specimens showed a safe and clear margin. All cases were followed up for 24.0-108.0 month with a median of 52. 5 months. Twenty-eight cases survived, 3 cases died and 2 cases recurred in local soft tissue. According to the Musculoskeletal Tumor Society （ MSTS） score, the recovery of limb function were 6 6 .1% - 100% with a median of 90%. The postoperative complications included infection in 5 cases, allograft nonunion in one case, artificial prosthetic mechanical failure in 2 cases and amputation in 2 cases. The eventually limb salvage rate was 93. 5%. Conclusion The navigation system is feasible, safe and reliable for the precision tumor resection and realization of joint-sparing reconstruction for the patients with bone tumor near joints.