保留踝关节的自体瘤骨灭活再植重建胫骨下段骨肉瘤切除后骨缺损二例报道并文献复习

Abstract

目的 探讨应用自体瘤骨灭活再植技术重建胫骨下段骨肉瘤切除后骨缺损的操作过程中,保留踝关节功能的非融合手术效果及早期随访情况.方法 对 2 例接受规范术前化疗的胫骨远端骨肉瘤患者实施自体瘤骨灭活再植手术,本组病例未采取常规踝关节融合,而是应用人工韧带重建等方法保留了踝关节功能.操作流程:完整切除胫骨远端肿瘤、65 ℃、20% 高渗盐水灭活 30 min 后原位回植、对侧自体腓骨置于髓腔中心、钢板内固定、LARS 韧带重建内踝软组织、下胫腓关节融合.术后随访患者并发症及骨愈合情况,应用 MSTS 评分评估术后功能.同时计算机检索 1997~2017 年,Pubmed、中国知网、万方数据库等公开发表的文献,并同时配合手工检索已公开发表的骨科学术论文,将其纳入文献一并进行讨论.结果 2 例灭活胫骨与宿主骨均实现完全愈合,平均愈合 6 个月 ( 4 个月、8 个月 ).随访期内未见肿瘤复发、未出现深部感染.患者无局部疼痛症状,行走功能及踝关节屈伸正常.MSTS-93 评分平均 95%;检索文献发现,目前国内外共有12 篇文献报道了外科治疗胫骨远端恶性骨肿瘤的研究.结论 非融合的踝关节重建可以提供良好的早期功能.65 ℃、20% 高渗盐水灭活 30 min 是一种简单、经济、有效的灭活技术.骨内活性蛋白的保存不仅有利于骨愈合,同时还有可能促进关节软骨的自身修复.

Objective To present the surgical techniques and early functional outcomes of the ankle joint preservation with recycling autograft for osteosarcoma of the distal tibia. Methods Two patients with osteosarcoma of the distal tibia received neoadjuvant chemotherapy, ankle joint preservation surgery using recycling autograft. Non-arthrodesis technique was applied in all patients. The tumor was resected. The local site was devitalized by 20 % sterile saline at 65 ℃ for 30 mins. The recycling bone was implanted back into the defect with a non-vascularized fibular strut graft. Plate, nail and artificial ligament were used for stabilization of the tibia and ankle. Patients were assessed clinicoradiologically by bone union, infection and complication. Functional outcomes were estimated according to Musculoskeletal Tumor Society ( MSTS ) scores; Pubmed, Chinese Nafional Knowledge Infrastructue ( CNKI ), Wanfang Dctabase, were searched for related articles published in the past 20 years ( 1997 - 2017 ). Results Complete healing was achieved at a median time of 6 months ( 4 and 8 months ) in 2 patients. All patients had no pain, no limitation in daily activities. No evidence of local recurrence and deep infection were found. The average functional score was 95% according to MSTS-93 scoring system; Distal tibia maligrant bone tumor researches were described in 12 articles. Conclusions Ankle joint preservation with recycling autograft can achieve good early function recovery in the treatment of the distal tibia osteosarcoma. Devitalization of the tumor-bearing bone is effective in 20% sterile saline at 65 ℃ for 30 mins. The structural bone and the preserved osteoinductivity of the protein may improve bone union, and cartilage self-repair.