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[目的]探讨胫骨近端恶性骨肿瘤广泛切除手术技巧、重建方法与临床疗效。[方法]胫骨近端恶性骨肿瘤病人45例,男27例,女18例,平均年龄28岁(12~62)岁。肿瘤类型:骨肉瘤25例,恶性骨巨细胞瘤7例,软骨肉瘤6例,恶性纤维组织细胞瘤、纤维肉瘤各3例,淋巴瘤1例。手术取膝关节前内侧切口30例,膝关节前外侧切口15例,肿瘤累及上胫腓关节时一并切除腓骨上段13例,肿瘤侵入膝关节内行关节外广泛切除2例,部分瘤段骨灭活复合型假体5例,切断结扎胫前血管28例。本组病例均采用国产定制肿瘤型假体重建,软组织重建采用腓肠肌内侧头肌瓣移位42例,腓肠肌外侧头肌瓣移位3例,部分胫骨假体较长的病例联合应用胫骨前肌肌瓣覆盖假体下段前方。骨肉瘤、恶性纤维组织细胞瘤病人行新辅助化疗。[结果]45例患者随访时间平均为4.6年(8个月~9年),4例局部复发,6例肺部转移,1例恶性纤维组织细胞瘤患者术后6年发生L3椎体转移,行全脊椎整块切除术。假体相关并发症包括假体周围感染3例,1例行清创、置管冲洗后治愈,2例截肢;假体脱位3例,假体松动2例,假体断裂1例,假体周围骨折1例,均行切开复位、假体翻修或骨折内固定术。膝关节平均活动度92°(50°~120°),伸膝延迟平均4.4°(0°~20°);按照MSTS肢体功能评分标准,所保留肢体平均功能恢复率为76.7%。[结论]胫骨上端恶性骨肿瘤的广泛切除与重建要求较高,安全的手术边界,规范的切除技术,常规应用腓肠肌内侧头或外侧头肌瓣移位覆盖假体前方并重建伸膝装置,必要时联合应用胫骨前肌肌瓣覆盖假体下段,方可保障保肢术达到较好的疗效。
[Objective] To explore the technique, reconstruction method and clinical curative effect of extensive resection of proximal tibial malignant bone tumor. [Method] 45 patients with proximal tibial malignant bone tumor, 27 males and 18 females, with an average age of 28 years (range, 12 to 62 years). Tumor types: osteosarcoma in 25 cases, malignant giant cell tumor in 7 cases, chondrosarcoma in 6 cases, malignant fibrous histiocytoma, fibrosarcoma in 3 cases, 1 case of lymphoma. 30 cases of anterior medial kyphosis and 15 anterolateral knee anterior knee were surgically removed. Thirteen cases of upper fibula were excised when the tumor involved upper tibiofibular joint. The tumor invaded the knee joint extensively excision in 2 cases, Live composite prosthesis in 5 cases, cut off the anterior tibial artery in 28 cases. This group of patients were made using custom-made tumor-type prosthesis reconstruction, soft tissue reconstruction using the gastrocnemius muscle flap in 42 cases, the lateral gastrocnemius muscle flap in 3 cases, some tibial prosthesis longer cases combined application of tibialis anterior muscle The flap covers the lower part of the prosthesis. Osteosarcoma, malignant fibrous histiocytoma neoadjuvant chemotherapy. [Results] The average follow-up time of 45 patients was 4.6 years (ranged from 8 months to 9 years), 4 cases of local recurrence, 6 cases of lung metastasis and 1 case of malignant fibrous histiocytoma occurred L3 vertebral metastasis 6 years after operation. Line of the whole spine lump resection. Prosthesis-related complications included 3 cases of periprosthetic infection, 1 case of debridement, 2 cases of amputation after catheter flushing, 3 cases of prosthesis dislocation, 2 cases of prosthesis loosening, 1 case of prosthesis rupture, 1 case of prosthesis 1 case of fracture, all underwent open reduction, prosthesis revision or internal fixation of fracture. The average knee mobility was 92 ° (50 ° -120 °) and extension of the knee was 4.4 ° (0 ° ~ 20 °). According to MSTS physical function score, the average functional recovery rate was 76.7%. [Conclusion] The extensive resection and reconstruction of malignant bone tumors in the upper tibia requires high and safe surgical boundaries and standard resection techniques. It is necessary to shift the medial or lateral cranial muscle flap of the conventional gasotomy in front of the prosthesis and reconstruct the knee extensor device Joint application of the anterior tibialis anterior muscle flap cover the lower part of the prosthesis to ensure the limb salvage surgery to achieve a better effect.