儿童骨肉瘤保肢手术方式选择的文献分析

Literature analysis on the selection of limb salvage surgery for osteosarcoma in children

目的 基于数据挖掘探究儿童(≤14岁)骨肉瘤保肢手术方案,为儿童保肢手术决策提供参考。方法 以“骨肉瘤,保肢”“Osteosarcoma、bone sarcoma、malignant bone tumor、osteogenic sarcoma、osteogenic sarcomas、Limb salvage、limb sparing”为关键词,在外文数据库检索到742篇文献,在中文常用数据库检索出960篇文献,经阅读标题、摘要、全文二次筛选最终纳入23篇文献,将涉及骨肉瘤、保肢、儿童作为研究对象,删除重复报告的病例,收集患者的性别、年龄、发病部位、并发症、手术方式、MSTS评分等,进行统计分析。结果 本研究纳入169例,年龄2~14岁,平均10.4岁,随访8~204个月,平均57个月。股骨113例,胫骨56例。169例行瘤段切除,其中假体重建60例,生物重建109例,重建方式包括:同种异体骨移植54例,自体+异体骨复合移植41例,灭活回植10例,带血管蒂腓骨移植4例。11岁以下儿童行:瘤段切除自体+异体骨复合移植,常见并发症包括骨折、骨不连、感染、假体松动等。11~14岁儿童行:瘤段切除同种异体骨移植,常见并发症包括:骨折、骨不连、感染、假体松动、切口裂开等。84例(89例次)出现手术并发症,其中重建骨骨折(17/89,19.10%)、骨不连(9/89,10.11%)、感染(11/89,12.36%)、假体松动(6/89,6.74%)、切口裂开(5/89,5.62%)是常见的并发症。并发症发生率:瘤段切除假体置换(31/60,51.7%),瘤段切除同种异体骨移植(27/54,50.0%),瘤段切除灭活再植(3/11,27.3%),瘤段切除自体+异体骨复合移植(20/36,55.6%)。不同手术方式的并发症发生率差异无统计学意义(χ^(2)=3.441,P=0.328)。术后肢体功能MSTS评分:11岁以下儿童(25.42±4.47)分,11~14岁儿童(25.62±3.19)分,差异无统计学意义(F=0.058,P=0.810)。结论 儿童肢体骨肉瘤切除后重建并发症多、肢体功能欠佳,11岁以下儿童推荐自体+异体骨复合移植,11~14岁儿童推荐同种异体骨移植。

Objective To explore the limb salvage surgery plan for children(≤14 years old)with osteosarcoma,and to provide references for children's limb salvage surgery decision-making based on data mining.Methods A total of 742 articles were searched in Pubmed database and 960 articles were searched in Chinese database based on key words including osteosarcoma,bone sarcoma,malignant bone tumor,osteogenic sarcoma,osteogenic sarcomas,limb salvage and limb sparing.23 articles were selected for the final study after reading titles,abstracts and full texts.Osteosarcoma,limb salvage and children were selected as subjects,repeated cases were deleted,and patients'sex,age,location,complications,operation methods and MSTS scores were collected and statistically analyzed.Results A cohort of 169 patients was enrolled in this study.The age of onset ranged from 2 to 14 years(mean:10.4 years).The follow-up ranged 8 to 204 months(mean:57 months).There were 113 cases in the femur and 56 cases in the tibia.169 patients underwent segmental tumor resection,including prosthesis reconstruction(n=60)and biological reconstruction(n=109).The reconstruction methods included allogeneic bone transplantation(n=54),autogenous and allogeneic bone transplantation(n=41),inactivated replantation(n=10)and vascular pedicled fibula transplantation(n=4).Children under 11 years old underwent tumor segment resection,autogenous and allogeneic bone grafting.Common complications included fracture,bone nonunion,infection,prosthesis loosening and so on.Children aged 11-14 years old underwent segmental resection and allogeneic bone transplantation.Complications included fracture,nonunion,infection,prosthesis loosening,incision dehiscence and so on.84 patients had 89 kinds of operative complications,including reconstructed bone fracture(19.10%),nonunion(10.11%),infection(12.36%),loosening of prosthesis(6.74%)and incision rupture(5.62%).Incidence of complications:segmental resection and prosthesis replacement(31/60,51.7%),allogeneic bone transplantation(27/54,50.0%),segmental resection,inactivation and replantation(3/11,27.3%),segmental resection,autologous and allogeneic bone transplantation(20/36,55.6%).There was no significant difference in the incidence of complications among different surgical methods(χ^(2)=3.441,P=0.328).The MSTS score of postoperative limb function was(25.42±4.47)in children under 11 years old and(25.62±3.19)in children aged 11-14 years old,and there was no significant difference between the children under 11 years old and 11-14 years old.Conclusions There are many complications with poor limb function after resection of limb osteosarcoma in children.Autologous and allogeneic bone transplantation is recommended for children under 11 years old,and allogeneic bone transplantation is recommended for children aged 11-14 years old.