带血管蒂自体腓骨头骨骺移植重建儿童肱骨近端原发恶性肿瘤切除后骨缺损

Vascularized fibular epiphyseal transfer for reconstruction of bone defect after resection of primary proximal humerus tumor in children

目的儿童肱骨近端恶性肿瘤切除后重建仍存在挑战。评估带血管蒂腓骨头骨骺移植重建儿童肱骨近端原发恶性肿瘤切除后骨缺损手术可行性、并发症、术后功能及该手术的适应证。方法回顾分析2009年5月至2018年5月,因肱骨近端恶性肿瘤接受该手术的11例患者,男9例,女2例,年龄4.6~13.5岁,平均(9.0±2.45)岁。骨肉瘤10例,Ewing肉瘤1例。11例随访13~118个月,中位随访时间72个月,平均(66.0±35.4)个月。结果随访期末8例无瘤生存,3例因多发转移死亡,5年生存率72.7%。术后未出现感染及伤口不愈合。移植骨愈合时间2.8~6.2个月,平均(3.9±1.2)个月。未出现移植骨骨折及内固定失效。骨骺闭合前,移植骨最多纵向生长1~11 mm,中位值每年1.5 mm,平均(2.9±3.1)mm。未观察到移植骨肥大增粗表现。无肩关节脱位,患者肩关节外展10°~40°,平均(28.2±10.1)°,前屈10°~65°,平均(33.6±15.8)°。MSTS评分平均65%,失分主要原因是手部无法上举,但患者对手术满意度均较高。2例出现腓总神经麻痹,术后半年均自行恢复。所有患者术后均可正常行走。结论带血管蒂自体腓骨头骨骺移植重建儿童肱骨近端原发恶性肿瘤切除后骨缺损手术后,移植骨可长期存活,可有效保留患者肘关节以远的功能,患者接受度高。

Objective Reconstruction after proximal humeral malignant tumor resection remains a challenge in children.The aim of this study is to evaluate the feasibility,complications,postoperative function,and indications of vascularized fibular epiphyseal transfer for reconstruction of bone defects after resection of primary malignant tumor of proximal humerus in children.Methods From May 2009 to May 2018,11 patients underwent proximal humeral malignant tumor resection,including 9 males and 2 females.The mean age was(9.0±2.45)years(range:4.6-13.5 years).There were 10 cases of osteosarcoma and 1 case of Ewing’s sarcoma.The median and mean follow-up time of 11 patients was 72 months and 66 months,respectively(range:13-118 months).Results At the latest follow-up,8 patients survived without disease and 3 died of multiple metastasis.The 5-year survival rate was 72.7%.There was no infection or non-union of incision.The average healing time of the autograft was(3.9±1.2)months(range:2.8-6.2 months).No graft fracture or internal fixation failure occurred.Before epiphyseal closure,the median longitudinal growth of the transplanted bone was 1.5 mm(range:1-11 mm)per year,with an average of(2.9±3.1)mm.Hypertrophy or thickening of the bone graft was not observed.No dislocation of shoulder joint was found.The average abduction of the shoulder joint was(28.2±10.1)°(range:10°-40°),flexion(33.6±15.8)°(range:10°-65°).The average MSTS score was 65%.The main MSTS malfunction was that the hand could not be raised,but the patients were satisfied with the results.There were 2 cases of common peroneal nerve paralysis,which recovered spontaneously half a year after operation.All patients could walk normally after operation.Conclusions Vascularized fibular epiphyseal transfer for reconstruction of bone defects after resection of primary proximal humerus malignant tumor can achieve long survival of the grafts in children.The technique is acceptable and could effectively preserve the limb function beyond the elbow joint.