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目的报道侵犯胫骨与腓骨间肌群及胫骨后、外侧骨皮质的胫骨近段骨肉瘤患者采用改良膝前内侧入路的手术技术,并评估假体重建的疗效。方法 2004年7月至2013年3月,收治21例胫骨近段后外侧受累的骨肉瘤患者,男9例,女12例,Enneking分期2例II A期,19例II B期,年龄12~47岁,平均24.4岁。所有患者均接受新辅助化疗及采用改良的膝前内侧手术入路完整切除肿瘤,并采用肿瘤假体重建。术后早期评估并发症,后期随访采用MSTS评估疗效,评估膝关节屈伸度数及股四头肌肌力,分析肺转移率、死亡率及5年生存率。结果术后早期并发症包括腓总神经麻痹2例(术后3个月恢复),胫骨前方局部皮肤浅表坏死1例(术后1个月恢复)。随访5~138个月,平均66.6个月。1例失访,8例发生肺转移,7例最终死亡,1例胸腔镜下切除单发肺转移灶。局部复发2例,分别在初次手术后5、6个月时,行大腿中段截肢术,所有随访病例中无血管损伤或下肢血管危象,无假体松动或断裂。术后膝关节活动范围平均101.0°(95%IC,91.7°~110.3°),2例膝关节伸直受限20°。股四头肌肌力:术后6个月18例5级,2例4级。14例未死亡病例最后随访时MSTS平均28.5分(95%IC,27.2~29.8)。Kaplan-Meier法5年生存率为71.4%(95%IC,52.1%~90.7%)。结论改良的膝前内侧入路适用于胫骨近端后方或外侧皮质受累的骨肉瘤患者,当肿瘤侵犯胫骨后方或胫腓骨间肌群时,疗效满意。该手术技术结合新辅助化疗是治疗胫骨近端骨肉瘤II B期胫骨后、外侧皮质破坏的可选方法之一。
Objective To report the surgical technique of improving the medial approach of the knee anterior to the posterior tibial osteosarcoma of the posterior cortical bone and the tibia and fibula, and evaluate the effect of prosthesis reconstruction. Methods From July 2004 to March 2013, 21 patients with posterior lateral tibial involvement of osteosarcoma were enrolled in this study. There were 9 males and 12 females with Enneking staging of 2 cases of stage II A, 19 cases of stage II B, 47 years old, average 24.4 years old. All patients underwent neoadjuvant chemotherapy and had a complete resection of the tumor with a modified knee anterior approach and were reconstructed with a tumor prosthesis. Postoperative early assessment of complications, late follow-up MSTS assessment of efficacy, assessment of knee flexion and extension quadriceps muscle strength, analysis of lung metastasis, mortality and 5-year survival rate. Results Early postoperative complications included peroneal nerve paralysis in 2 cases (3 months postoperatively), superficial necrosis of the skin in 1 anterior tibia (recovered at 1 month after operation). Followed up for 5 ~ 138 months, an average of 66.6 months. One patient lost follow-up, eight patients had lung metastases, seven patients eventually died, and one patient underwent thoracoscopic resection of a single lung metastasis. Local recurrence was performed in 2 cases. The middle thigh amputation was performed at 5 and 6 months after the first operation. No vascular injury or vascular crisis was observed in all follow-up cases. No loosening or rupture occurred. The knee range of motion was 101.0 ° on average (95% IC, 91.7 ° -110.3 °) and 2 cases of knee extension were restricted to 20 °. Quadriceps muscle strength: 6 cases after 18 cases of 5, 2 cases 4. MSTS averaged 28.5 points (95% IC, 27.2-29.8) at the final follow-up of 14 non-fatal cases. The 5-year Kaplan-Meier survival rate was 71.4% (95% IC, 52.1% -90.7%). Conclusion The modified anterior knee approach is suitable for osteosarcoma patients with cortical involvement in the posterior or lateral cortex of the proximal tibia. The results were satisfactory when the tumor infiltrated the posterior tibial or inter-tibiofibular muscle. The surgical technique combined with neoadjuvant chemotherapy is one of the alternative methods for the treatment of posterior lateral tibial and lateral cortical disruption of proximal tibial osteosarcoma IIB.