青少年长骨恶性肿瘤长节段骨缺损的重建技术

Reconstruction for long segment bone defect of long bone malignant tumor in teenagers

目的探讨青少年四肢长骨恶性肿瘤切除后长节段骨缺损修复重建的方法及其疗效评价。方法回顾性分析2015年4月至2019年10月共10例进行骨缺损修复重建的四肢长骨超长病灶骨恶性肿瘤患儿病例资料,其中男4例,女6例,年龄10.2岁(范围6~16岁)。骨肉瘤7例,尤文肉瘤3例;肱骨肿瘤2例,股骨肿瘤7例,胫骨肿瘤1例。肿瘤切除后骨缺损占病变骨全长的比例为80.9%(范围71.4%~89.3%)。考虑青少年涉及骨骺生长问题,手术在保证肿瘤扩大切除的前提下,采用自体腓骨移植、传统假体结合钢板、3D打印设计保留关节骨骺的超长假体,并在假体与骨结合端做3D打印骨小梁的骨长入处理,两端保留骨骺的短力臂设计辅助钢板及交锁螺钉增强稳定性。主要观察X线片及CT检查评估假体重建稳定性及骨连接端3D打印处理处骨长入情况,同时评估患者术后功能评分评价疗效。结果 10例均顺利完成手术,术中无神经、血管损伤等并发症发生。随访5~58个月,平均随访22.9个月。1例术后2年复查X线片示移植腓骨有骨吸收迹象,内固定位置良好无明显异常;2例术后1年半至2年内出现辅助钢板断裂,给予更换断裂钢板目前内固定良好。按照国际保肢学会的评估标准进行评分:2例肱骨骨肉瘤术后评分分别为23、26分,平均24.5分;4例股骨骨肉瘤及3例股骨尤文肉瘤评分分别为26、25、19、30、27、24、28分,平均25.6分;1例胫骨骨肉瘤评分为26分;均获得比较满意的治疗效果。本组10例肿瘤体积自110~367 cm3,平均224.5 cm3;病变与近侧骨端的距离平均为5.2 cm(范围0~11.3 cm);与远侧骨端的距离平均为4.2 cm(范围0~8.7 cm);。规范新辅助化疗后30%患者达到部分缓解,70%患者达到疾病稳定。保肢治疗效果良好,目前均无复发病例。结论利用3D打印与传统机加工技术相结合,制作保留骨骺的个体化长节段假体在骨恶性肿瘤保肢治疗中的合理应用可以达到良好的治疗效果。

Objective To explore the method and curative effect evaluation of repairing and rebuilding the long segmental bone defect after resection of long bone malignant tumors in adolescents.Methods Reviewed our experience in 10 patients.Among them,4 were male and 6 were female.The age was 10.2 years old(range,6-16 years old).Including 7 cases of osteosarcoma,3 cases of Ewing's sarcoma;2 cases of humerus tumors,7 cases of femoral tumors,and 1 case of tibial tumors-who presented between April 2015 and October 2019,in which the proportion of bone defect account for 71.4%-89.3%of the total length of diseased bone after tumor resection,with an average value of 80.9%.Considering the epiphyseal growth of young people,on the premise of ensuring enlarged tumor resection,we use traditional fibula autograft and prosthesis combined with steel plate,3D printing design to retain the super-prosthesis of the epiphysis,and 3D printing bone trabecular was processed for the sake of making it grow successfully into the binding part of prosthesis and bone as we expect,simultaneously,the design of the short-force arm retaining the bilateral epiphysis can assit the steel plate and interlocking screws to enhance the stability.Results The operation was completed successfully,and there were no complications such as nerve and blood vessel injury during the operation.After follow-up of 4-8 months,with an average follow-up of 22.9 months.One patient's review of X-ray film after 2 years of the operation showed that the transplanted fibula had a sign of bone resorption,and the internal fixation was in it's original position without obvious abnormalities.Two cases'auxiliary steel plates had fractured within one and a half to two years after surgery.With replacing the fractured steel plates,the internal fixation was good until now.According to the evaluation standards of the International Society of Limb Salvation:2 cases of humerus osteosarcoma were respectively scored 23 points,26 points,an average of 24.5 points;4 cases of femoral osteosarcoma and 3 cases of femoral Ewing's sarcoma respectively scored 26 points and 25 points,19 points,30 points,27 points,24 points,28 points(average,25.6 points);1 case of tibial osteosarcoma scored 26 points;all obtained relative satisfying treatment results.Conclusion The combination of 3D printing and traditional machining techniques to produce an individualized long segmental prosthesis that preserves the epiphysis which applicated in the limb salvage treatment of bone malignant tumors can achieve excellent therapeutic effect.